Patient information: Alcohol use — when is drinking a problem? (Beyond the Basics)
- Mark D Aronson, MD
Mark D Aronson, MD
- Editor-in-Chief — Primary Care (Adult); Hospital Medicine
- Section Editor — General Medicine
- Professor of Medicine
- Harvard Medical School
According a national survey in the United States, more than half of all Americans age 12 and older reported being current drinkers of alcohol; this translates to an estimated 135.5 million current drinkers. For most of them, drinking alcohol is controlled and safe. Still, 59.7 million persons (almost one quarter) reported being binge drinkers in the 30 days prior to the survey and 17 million people reported heavy drinking .
Most people have a hard time distinguishing when "normal drinking" becomes problem drinking. How do you know how much is too much, particularly when a small to moderate amount of alcohol might be good for you? (see "Patient information: Risks and benefits of alcohol (Beyond the Basics)").
In general, drinking is considered a problem when it starts to adversely affect a person's personal or professional life, or when the person loses control over his or her drinking (see 'Definitions of drinking problems' below).
This topic will explain how healthcare providers determine if a person has a drinking problem. It also offers some screening tools you can use on yourself or a relative or friend. Topics that discuss the treatment of alcohol problems are available by subscription (see "Psychosocial treatment of alcohol use disorder" and "Pharmacotherapy for alcohol use disorder" and "Medically supervised alcohol withdrawal in the ambulatory setting" and "Determining appropriate levels of care for treatment of substance use disorders" and "Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis").
WHO IS AT RISK FOR DRINKING PROBLEMS?
Experts have yet to identify why some people develop problems with alcohol, but they do know that certain factors can increase a person's risk. For instance:
●Alcohol use disorder runs in families, and certain genes make people more vulnerable to drinking problems. In fact, people who have a sibling, parent, or child who abuses alcohol have three to four times the average risk of developing a drinking problem.
●While problem drinking can affect men and women of all ages and backgrounds, it is more common among men than women and is most common among those aged 18 to 25 .
However, women can have alcohol-related problems at lower drinking levels than men. If a man and a woman of the same weight drink the same amount of alcohol, the woman will have a higher level of alcohol in her blood, putting her at greater risk for harm .
●Alcohol abuse is common in people older than 65 and can be especially dangerous for them; alcohol can interact with medications and is responsible for many fall-related injuries.
●In young people, alcohol and drug use can lead to car crashes, suicide and homicide . In addition, people who begin drinking at an early age are four times more likely to develop alcoholism than those who begin drinking at or after age 21.
●Having another mental health problem, such as severe anxiety, depression, or a personality disorder, increases the risk of abusing alcohol. By some estimates, 37 percent of those with a drinking problem also have a mental health condition . That's important because treating these problems is often an integral part of overcoming alcohol addiction.
DEFINITIONS OF DRINKING PROBLEMS
Experts use many terms to describe different types of drinking problems. We will describe the terms alcohol intoxication, alcohol use disorder, problem drinking, and binge drinking.
Alcohol intoxication — Alcohol intoxication occurs when drinking excess alcohol leads to inappropriate behavior and impaired judgment. Being intoxicated can cause slurred speech, loss of coordination, unsteady walking or running, difficulty paying attention or remembering, confusion, or coma.
Alcohol use disorder — Alcohol use disorder is the medical term for alcohol addiction or what most people think of as alcoholism. Alcohol use disorder can be mild to severe. People who have the disorder have two or more of the following problems. The more of these they have, the more severe their disorder.
●They end up drinking more than they planned to, or they drink longer than they planned to.
●They wish they could cut down on alcohol, but they can’t.
●They spend a lot of time trying to get alcohol, getting drunk, or recovering from being drunk.
●They crave or have a strong desire or urge to drink.
●Because of their alcohol use, they often don’t do things that are expected of them, such as go to work or school, remember family events, and clean their home.
●They keep drinking even if it causes or worsens problems in their relationships or interactions with other people.
●They stop or cut back on important social, work, or fun activities they used to do.
●They keep drinking even in situations where it is dangerous to do so (such as while driving).
●They keep drinking even when they know they have a physical or mental problem that was probably caused or made worse by their alcohol use.
●They need to drink more and more to get the same effects they used to get with less use. Or they get less effect from using the amount that used to get them drunk. This is called “tolerance.”
●They have “withdrawal symptoms” if they stop drinking alcohol after drinking for a long time. Withdrawal symptoms can include:
●Sweating or a racing heart
●Insomnia (not being able to sleep)
●Nausea or vomiting
●Seeing, feeling, or hearing things that aren’t really there (this is called having hallucinations)
Problem drinking — Some people do not fit the criteria for alcohol use disorder, but are at risk for accidents and problems resulting from drinking too much. A significant proportion of patients seen in emergency departments or trauma centers for intentional and unintentional injuries are problem drinkers.
Problem drinkers may be moderate drinkers, heavy drinkers, or binge drinkers. The definition of these terms is based on the number of servings of alcohol that the person drinks per occasion and how often the person drinks.
What is one drink? — A standard "drink" in the United States contains about 0.6 fluid ounces or 14 grams of "pure" alcohol (figure 1), and is the equivalent of:
●12 ounces of regular beer
●8-9 ounces of malt liquor
●5 ounces of wine
●1.5 ounces of 80 proof distilled spirits
These examples may not accurately reflect actual servings, however. A mixed drink, for example, can be the equivalent of one to three or more standard drinks, depending on the recipe. Also, the alcohol content for different types of beer, wine, or malt liquor can vary greatly.
Moderate drinkers — Healthy people who drink moderately have a relatively low risk of developing an alcohol problem. Moderate drinking is defined as:
●Women: No more than one drink per day
●Men: No more than two drinks per day
●People 65 and older: No more than one drink per day
People who stay within these "low-risk" drinking limits can still have problems if they drink too quickly, have health problems, or are taking certain prescription medications. Even moderate amounts of alcohol can impact balance, judgment, and the ability to drive, even in the absence of feeling "buzzed" or "high" .
Heavy drinkers — People who drink heavily have a significantly increased risk of developing alcohol problems. Heavy drinking is defined as:
●Women: More than seven drinks per week or three drinks per occasion
●Men: More than 14 drinks per week or four drinks per occasion
Binge drinkers — People who binge drink also have a significant risk of developing an alcohol problem. Binge drinking is defined as drinking at a single occasion (generally within about two hours):
●Women: Four or more drinks
●Men: Five or more drinks
The binge drinker is able to go days without drinking at all. However, binge drinkers cannot limit their drinking once they have a drink. With increasing heavy drinking days over time, the risk of developing alcohol abuse or dependence grows.
SCREENING AND DIAGNOSIS OF DRINKING PROBLEMS
When trying to determine whether a person has a problem with alcohol, healthcare providers focus on three key things:
●Have you lost control of your drinking?
●Have you developed tolerance or other signs of addiction?
●Has alcohol contributed to problems such as the loss of a job, legal troubles, or problems in relationships?
Still, distinguishing normal from problematic drinking requires the person to share information about their drinking and its effects on them.
Screening questionnaires — Providers sometimes use one of several questionnaires that are designed to identify people who may have a drinking problem. Such questionnaires ask specific questions that have been studied and shown to help predict when a person has a problem with alcohol use. In addition, some patients may feel more comfortable providing information about drinking when asked as part of a questionnaire, or knowing that such questions are asked of all patients.
Screening questionnaires are better at detecting alcohol use disorder than questions about the quantity or frequency of drinking. That's important, because alcohol use disorder has less to do with the amount of alcohol a person drinks and more to do with the effects that drinking has on their life.
Screening questionnaires are not intended to establish a diagnosis of alcohol use disorder. Rather, they identify people who should be further assessed by their clinician to determine if alcohol is a problem for them, and if they need treatment.
Some screening tools work better than others in specific groups. One of the more universally-applicable tests is described below. Other tests have been designed specifically for college students, women, and pregnant women, among other populations. A more extensive list of screening tests is available (see "Screening for unhealthy use of alcohol and other drugs in primary care").
Alcohol Use Disorder Identification Test — The Alcohol Use Disorder Identification Test (AUDIT) asks about the amount of alcohol you consume, as well as your experience in using alcohol. A sample version of the AUDIT questionnaire is available at http://pubs.niaaa.nih.gov/publications/arh28-2/78-79.htm.
CONSEQUENCES OF DRINKING PROBLEMS
There are a number of serious consequences of drinking alcohol excessively:
●Excessive alcohol consumption is a leading preventable cause of death in the United States.
●Drinking alcohol increases the risk of traffic accidents, suicide, drowning, and other serious injuries.
●Alcohol use continues to be the leading cause of injuries treated in trauma centers and emergency departments .
●Alcohol-related liver disease may lead to end-stage liver disease (cirrhosis) and death.
●Alcohol increases the risk of certain cancers of the mouth, esophagus, throat, liver, and breast.
TREATMENT OF DRINKING PROBLEMS
People who have a drinking problem have a number of treatment options at their disposal, including counseling and medications.
●Counseling often involves meeting with a therapist, counselor, or physician to talk. For some people, brief interventions have been shown to be very successful, especially when combined with medications. Others may benefit from more prolonged counseling.
●The medications used in treating alcohol use disorder help people who are going to alcohol counseling and a peer support group to reduce their drinking.
●In addition to formal treatment, many healthcare providers recommend participating in social support groups, such as Alcoholics Anonymous.
Can I stop drinking on my own? — Many people successfully overcome drinking problems on their own. However, people with alcohol dependence should not attempt to cut down or stop drinking without the help of a healthcare provider. Suddenly reducing alcohol intake can cause life-threatening withdrawal symptoms. Medical supervision is an essential part of safe recovery in this group.
Experts use different terms to describe different types of problems with alcohol use. In general, drinking can be called problematic if it leads to negative consequences in a person's life.
Depending on the severity of the problem, drinking problems can also cause tolerance, physical dependence, and a loss of control over drinking. If left unchecked, problem drinking can lead to illness, bodily harm, and even death. Fortunately, effective treatments are available.
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient information: Alcohol use — when is drinking a problem? (The Basics)
Patient information: Cirrhosis (The Basics)
Patient information: Alcohol poisoning (The Basics)
Patient information: Fetal alcohol syndrome (The Basics)
Patient information: Controlling your blood pressure through lifestyle (The Basics)
Patient information: Marijuana use and addiction (The Basics)
Patient information: Toxic hepatitis (The Basics)
Patient information: Antisocial personality disorder (The Basics)
Patient information: Cocaine use disorder (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Screening for unhealthy use of alcohol and other drugs in primary care
Pharmacotherapy for alcohol use disorder
Medically supervised alcohol withdrawal in the ambulatory setting
Management of moderate and severe alcohol withdrawal syndromes
Overview of the chronic neurologic complications of alcohol
Overview of the risks and benefits of alcohol consumption
Psychosocial treatment of alcohol use disorder
Pathogenesis of alcoholic liver disease
Determining appropriate levels of care for treatment of substance use disorders
The following organizations also provide reliable health information.
●National Library of Medicine
●National Institute on Alcohol Abuse and Alcoholism (NIAAA)
●US Department of Health and Human Services
●World Health Organization
●National Institute on Drug Abuse (NIDA)
●Substance Abuse and Mental Health Services Administration (SAMHSA)
- Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.
- NIAAA (2009). Rethinking Drinking: Alcohol and your health. NIH Publication No. 09-3770. National Institutes of Health, U. S. Department of Health and Human Services. Available at www.RethinkingDrinking.niaaa.nih.gov/.
- Gentilello LM. Alcohol interventions in trauma centers: the opportunity and the challenge. J Trauma 2005; 59:S18.
- Morse RM, Flavin DK. The definition of alcoholism. The Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine to Study the Definition and Criteria for the Diagnosis of Alcoholism. JAMA 1992; 268:1012.
- Maier RV. Controlling alcohol problems among hospitalized trauma patients. J Trauma 2005; 59:S1.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.