Epidemiology of Alcohol Problems in the United States

1 Epidemiology of Alcohol Problems in the United States NIAAA Social Work Education Module 1 (revised 3/04) 2 Objectives A. Describe demographic characteristics and historical trends of alcohol use, alcohol abuse/dependence and other alcohol-related problems B. Identify the relationship between level of alcohol consumption and health effects C. Recognize the implications of utilizing epidemiological data for early interven-tion and prevention of alcohol problems, and for evaluating intervention impact 3 Epidemiologic Approach to Alcohol Problems  An ecological model etiology, natural history  Addresses  Identifies  Study interaction of vulnerability, risk, and resilience factors of alcohol use, abuse, and dependence in communities, populations 4 Epidemiologic Rates  Incidence Rate = The rate at which new cases occur in a population during a specific period (e.g., over one year) Prevalence Rate = The proportion of a cases that exist in a population at a point in time  Differing Measures across Studies “New Case” can be defined as:  5 Age or year of first use or first intoxication versus  Age of onset of alcohol dependence (age of first experience of any clinical criterion symptoms for diagnosis) versus  Age of occurrence of the third dependence symptom or age when symptoms first “cluster” (2 or more symptoms in a year) 6 Standard Drink Measure 7 Defining Alcohol Consumption  Prior to 1970, per capita consumption = total alcohol beverage sales total population over age 15 years  Since 1970, per capita consumption = total alcohol beverage sales total population over age 14 years  The 1997 per capita consumption was 2.18 gallons of ethanol per person 8 At Risk Drinking by Age and Gender Population group Per week  Men  Women Per occasion > 5 drinks > 3-4 drinks > 1 drink Source: NIAAA, 1995  Elders (65+ ) > 14 drinks > 7 drinks > 7 drinks Drinking Patterns (Defined according to 9 quantity & frequency of alcohol consumption) Abstainer: has never drank or drinks < once/yr Less may or may not drink 5 or more drinks at least once/yr drinks at least once a week and may or may not drink 5 or more drinks at one sitting week and has 5 or more drinks at one sitting at least once per week Frequent: drinks 1-3 times/month and Frequent: Frequent Heavy Drinker: drinks at least once a Drinking Episodes Defined (National Household Survey)  Binge 10 Drinking as 5 or more drinks per occasion alcohol use as 5 or more drinks for 5 or more days per month ©2002 Microsoft Corporation.  Heavy Drinking Episodes Defined A 11 (NIAAA Advisory Council Task Force) drinking “binge” is a pattern of drinking that brings blood alcohol concentrations (BAC) to 0.08 or above.  Typical adult males: 5 or more drinks in about 2 hours  Typical adult females: 4 or more  For some individuals, the number of drinks needed to reach “binge” level BAC is lower Drinking Episodes Defined 12 (NIAAA Advisory Council Task Force) drinking is distinct from:  “risky” drinking (reaching a peak BAC between .05 gm% and .08 gm%)  a “bender” (2 or more days of sustained heavy drinking)  Binge Drinking Episodes Defined  People 13 (NIAAA Advisory Council Task Force) with risk factors for the development of alcoholism have increased risk with any alcohol consumption, even that below a “risky” level.  For pregnant women, any drinking presents risk to the fetus.  Drinking by persons under the age of 21 is illegal.  “Binge drinking is clearly dangerous for the drinker and society.” 14 At Risk or Problem Use above established cut-off limits AND  No current problems associated with drinking OR  Alcohol use in risky situations  Drinking 15 Definition of Alcohol Abuse Maladaptive alcohol use causes clinically important distress or impairment, shown in a single 12-month period by one or more of the following:  Failure to carry out major obligations at work, home or school because of repeated alcohol use Repeated use of alcohol even when it‟s physically dangerous to do so.   Repeated experience of legal problems  Continued alcohol use despite knowing that it has caused or worsened social or interpersonal problems. 16 Definition of Alcohol Dependence Maladaptive alcohol use causes clinically important distress or impairment, shown in a single 12-month period by three or more of the following: or withdrawal Amount/duration of use greater than intended. Unsuccessful efforts to control or reduce use Spending much time using alcohol, recovering from its effects, or trying to obtain it. Tolerance or abandoning important work, social or leisure activities because of alcohol use. Continued alcohol use despite knowing that it has probably caused ongoing physical or psychological problems. Reducing 17 Historical Trends: 1850-1997 3 2.5 2 1.5 1 0.5 0 Gallons Ethanol Spirits Wine Beer Year Source: Nephew et al., 1999 Prevalence of Lifetime Alcohol Use by Age and Gender 90 80 70 60 50 40 30 20 10 0 18 Percent Male Female 18-24 25-34 35-44 Age Groups 45-55 55+ 19 National Trends Liters Ethanol Consumed 18 16 14 12 10 8 6 4 2 0 1970 1980 1990 Country Source: NIAAA, 1997a 20 Age Trends: Alcohol Use 90 80 70 60 Percent 50 40 30 20 10 0 1993 1994 1995 8th 10th 12th 1996 1997 Source: Johnston et al., 1998 21 Age Trends: Intoxication 70 60 50 Percent 40 30 20 10 0 1991 1992 1993 1994 1995 1996 1997 8th 10th 12th Source: Johnston et al., 1998 22 Age Trends: Heavy Use in Past 30 Days 35 30 25 Percent 20 15 10 5 0 1991 1992 1993 1994 1995 1996 8th 10th 12th 1997 Source: Johnston et al., 1998 Prevalence of Lifetime Alcohol Dependence (DSM-IV) 25 20 Percent 23 15 10 5 0 Male Female 18-24 25-34 35-44 45-55 Age Groups 55+ Source: SAMHSA, 2000a Prevalence of Alcohol Use (Men) and Dependence by Age 90 80 70 60 50 40 30 20 10 0 24 Percent Use Dependent 18-24 25-34 35-44 45-55 55+ Age Groups Prevalence of Alcohol Use (Women) and Dependence by Age 25 70 60 50 Percent 40 30 20 10 0 18-24 25-34 35-44 45-55 55+ Use Dependent Age Groups 26 Alcohol Use & Aging Populations National Household Survey on Drug Abuse, 2000 1.6%of elders report heavy drinking in past 30 days  Aging primary care patients 15% male, 12% female abuse alcohol  Community sample 2.2 to 9.6%of elders abuse alcohol  Hospitalized adults >40: 21%abused alcohol  SAMHSA TIP Series, „98 Up to 17%of older adults are affected by alcohol and prescription drug problems  Additional Risks Related to Alcohol Use and Aging  Elderly 27 individuals are more likely to be affected by chronic illness and use of medications. and prescription drug problems are frequently:    Alcohol Under-identified Under-estimated Under-diagnosed Under-treated 28 Age and Gender Interactions 70 60 50 40 30 20 10 0 Any Use Binge Heavy Percent 18 -2 18 -2 26 + e m al al M m al Fe al e e e M Fe 26 + 5 5 Source: SAMHSA, 1999a Past Month Alcohol Use by Ethnicity: Ages 18-25 70 60 50 40 30 20 10 0 k n W hi te Bl ac ia n As ia nd isp an ic s 29 Percent Any Use Binge Heavy Am .I Source: SAMHSA,2000a H Past Month Alcohol Use by Ethnicity: Ages 26 or Older 60 50 Percent 30 40 30 20 10 0 k n W hi te Bl ac ia n As ia nd isp an ic s Any Use Binge Heavy Am .I H Source: SAMHSA,2000a Use of Alcohol and Other Drugs: 1999 Ages 18–25 90 80 70 60 50 40 30 20 10 0 31 Percent Lifetime Past Year Past Months lco A ol h ob T o cc a rij a M a an u C e in a oc ti o o ip in cr c s lu re l a P H s en g n n oi er H Source: SAMHSA,2000a Use of Alcohol and Other Drugs: 1999 Ages 26 and Older 100 90 80 70 60 50 40 30 20 10 0 ho lco A l T o cc a ob ar M a an iju oc C e in a H a cin llu o s en g r sc re P tio ip n H n oi er 32 Percent Lifetime Past Year Past Months Source: SAMHSA,2000a Reported Past Year Substance Dependence by Age, 1999 10 9 8 7 6 5 4 3 2 1 0 ho lco A l ar M a an iju Co e in ca H a cin llu s en og r sc e Pr n tio ip H in ro e D c+ Al g ru 33 Percent age 12-17 age 18-25 26 or older Source: SAMHSA,2000a Adolescent Risk Factors Risk Factors  Negative 34 Increased Odds Ratio  1.6  1.7 mother  Negative interaction with father  Parental alcohol dependence  Parents dislike friends  Heavy drinking friends  Daily cigarette smoking interaction with - 4.6 - 4.0  2.52  3.71  15.5  15.8 Source: Kuperman et al., 2001. Adolescent Risk Factors (continued) Risk Factors abuse  Other drug abuse  Dropping out of school  ADHD  Conduct disorder  Marijuana 35 Increased Odds Ratio  27.1  19.8  6.5  5.0  13.5 Source: Califano and Booth, 1998 Problems Reported by Alcohol Users (past year) 10 9 8 7 6 5 4 3 2 1 0 Health Psychological 36 12-<18 18-25 26-34 35+ Percent Source: SAMHSA,1999a 37 Alcohol and Violence  Alcohol is related to both aspects of violence -- perpetration and victimization were drinking in: of homicides • 60% of sexual offences • 37% of assaults • 27% of females and 57% of males involved in marital violence • 13% of child abuse cases Source: Roizen, 1997) • 86%  Offenders 38 Alcohol and Violence (continued) Roizen, 1993 Alcohol is associated with: Miczek et al., 1993 Identified alcohol in: 13%-50% of offenders in rape cases  6%-36% of victims in rape cases  35%-65% of rape cases (6 studies)  ~50% of incest cases (2 studies)  20%-83% of family violence cases (3 studies)  10%-83% of homicides (6 studies)  33%-57% of felonies (2 studies)  39 Alcohol and Violence (continued)  Risk factors for becoming violent: • • • History of violence Multiple drug use Co-morbid psychiatric disorder  Rates for alcohol-related violence hard to find: • • Rates of alcohol involvement vary across studies making comparison difficult Hard to establish a causal relationship due to other factors (e.g., interaction between personality factors and alcohol) Alcohol, Drug, and Violent Events Related to Arrest 60 50 40 40 Percent 30 20 10 0 Source: Nunes-Dinis & Weisner, 1997 Alcohol Drug Violence Alcohol and Drug Use: 12 Months of Arrests in Northern California 70 60 50 41 Percent 40 30 20 10 0 Alc. Frequent Alc. Infreq. Drug Weekly Drug Monthly Source: Nunes-Dinis & Weisner, 1997 42 Alcohol-Related Hospitalizations  Hospital • discharges (1997): • Alcohol-related diagnosis was first-listed (primary) diagnosis for 20.2 per 10,000 population aged 15 and older All listed alcohol-related diagnosis was 64.5 per 10,000 population  Alcohol-related morbidity episodes not appearing as a first-listed (primary) diagnosis = 69% Alcohol-Related Hospitalizations (continued) Disorder dependence syndrome  Alcohol psychosis  Cirrhosis of the liver  Alcohol abuse, nondependent  Alcohol 43 Percent 49% 22% 20% 9% Age-Adjusted Liver Cirrhosis Mortality U.S. 1910-1996 25 44 Rates per 100,000 20 15 10 5 0 Male Female 19 10 19 20 19 30 19 40 19 50 19 60 19 70 19 75 19 80 19 85 19 90 19 95 19 96 Source: Saadatmand et al., 1999 Vulnerability to Alcohol-Related Liver Disease  Genetic Factors   45   Dietary Factors Gender Hepatitis C Level of Alcohol Intake Source: NIAAA, 2001b Alcohol-Related Cirrhosis by Race and Gender (Age-Adjusted, 1996) 46 14 12 10 8 6 4 2 0 ed ed Re l ifi Un sp ec sp ec ifi at ed Rates per 100,000 Hisp-M White-M Black-M Hisp-F White-F Black-F Al c O th er Source: Saadatmand et al., 1999. Alcohol Consumption Among U.S. Pregnant & Child-bearing Aged Women 60 50 percent 47 40 30 20 10 0 19 91 19 95 19 99 Pregnant All women Sources: SAMHSA,1999a; CDC, 1997 Frequent Drinking Among U.S. Pregnant & Child-bearing Aged Women 14 12 10 48 Percent 8 6 4 2 0 Pregnant All women 19 91 19 95 Source: CDC, 1997. Binge Drinking Among U.S. Pregnant & Child-bearing Aged Women 20 18 16 14 12 10 8 6 4 2 0 49 Percent Pregnant All women 19 91 19 95 Sources: SAMHSA,1999a; CDC , 1997 19 99 Reported Rates of Fetal Alcohol Syndrome, U.S. 1979-1993 8 7 6 5 4 3 2 1 0 50 Rates per 10,000 Birth 19 79 19 81 19 83 19 85 19 87 19 89 19 91 19 92 Source: CDC, 1995a 19 93 51 Prenatal Alcohol Exposure  How many drinks can a pregnant women consume without harm to the fetus? estimated 550,000 to 750,000 U.S. children are born exposed to drugs/alcohol each year risk of child maltreatment (abuse, neglect) and out of home placement  An  Increased ©2002 Microsoft Corporation 52 Risks of Fetal Alcohol Exposure Low birth weight  Prematurity  Small for gestational age (SGA)  Failure to thrive (FTT)  Neurobehavioral symptoms  Infectious disease  Sudden Infant Death Syndrome (SIDS)  Fetal Alcohol Syndrome (FAS)  Other Fetal Exposure Effects  Compromised developmental outcomes  Compromised Developmental Outcomes  53 Many unknowns to predict specific outcome  Certain physical problems may persist  Some problems not immediately apparent  Secondary problems may emerge  Structured and nurturing environment may compensate and promote development  Regular developmental evaluation needed  Need early identification of social, language, cognitive, and motor developmental problems 54 Children Prenatally Exposed Developmental patterns birth to 15 months characterized by:       Unpredictable sleep patterns Feeding difficulties Irritability Atypical social interaction Delayed language development Poor fine motor development ©2002 Microsoft Corporation Children Prenatally Exposed (continued)   Atypical 55 Toddlers (16-36 months): social interaction  Minimal play strategies  Preschoolers (3-5 years): Easy loss of control ©2002 Microsoft Corporation Mood swings Hyperactivity/short attention span Difficulty transitioning between activities Difficulty processing auditory/visual info Children Prenatally Exposed (continued)  School • 56 aged to adolescence: No conclusive research on long-term biological or constitutional effects of drug/alcohol exposure Greater risk of maltreatment, learning disabilities, behavior problems ©2002 Microsoft Corporation • Alcohol Death Rates by Ethnicity 57 (Age-Adjusted), 1979-1997 30 Rates per 100,000 25 20 15 10 5 0 White-M White-F Other-M Other-F 9 97 1 1 98 1 3 98 1 5 98 1 7 98 1 9 98 1 1 99 1 3 99 1 5 99 1 7 99 1 Source: Hoyert et al., 1999 Rates per 100,000 100 150 200 250 300 50 0 He art dise a se s er Ca nc bro vas cul ar Pul mo na ry Pne um oni a Dia be Ca rA ccid e nt s O th er A ccid e nt s Alz he i me r's Sui cid e Liv er dise a se Ho mic ide te s Ce re Male Age-Adjusted Death Rates for 10 Leading Causes, U.S. (1997) Female 58 Source: Hoyert et al., 1999 59 Age-Adjusted Death Rates for Causes Other Than Cancer, Heart, or Stroke, U.S. (1997) 45 40 35 30 25 20 15 10 5 0 Male Female Rates per 100,000 s s s s e e e ia ry r' te id nt nt id n as a e e e e c o ic ise on id id ui m im ab i d S om cc cc lm eu he D r H e A A lz Pu Pn iv r r A e a L C th O Source: Hoyert et al., 1999 Age-Adjusted Death Rates by Cause, Ages 25-64 (1997) Rates per 100,000 300 250 200 150 100 50 0 60 25-44 M 45-64 M 25-44 F 45-64 F H ea r se di t s se a s s e e r r e a IV te la nt id id ni as ce e e c c e u o H i s b d an ui m sc m ia di ci a C S u o D ov H ne er Ac r v P eb Li r Ce Source: Hoyert et al., 1999 Age-Adjusted Death Rates by Causes Other than Cancer, Heart, or Stroke, Ages 25-64 (1997) 60 61 Rates per 100,000 50 40 30 20 10 0 25-44 M 45-64 M 25-44 F 45-64 F a ni o m eu Pn e et b ia D s Ac s nt e id c e id c ui S ive L e as ise rd H e id ic m o H IV Source: Hoyert et al., 1999 62 Drug Abuse Deaths 1995-1998 Number of Cases in Thousand 8 7 6 5 4 3 2 1 0 1995 1996 1997 1998 Male Female Source: SAMHSA, 2000 63 Drug-Related Deaths by Age (1996) 7000 6000 6399 Number of Deaths 5000 4000 3000 2090 2000 1000 0 6-17 yrs 18-25 26-34 35+ 825 124 Source: SAMHSA, 1997 Medical Examiner Mention of Drugs, 6-17 Year Old Decedents (n=124) Category Mentioned:   64 # of % total mentions episodes 52 26 23 22 10 41.9 21.0 18.6 17.7 8.1    Marijuana/hashish Cocaine Alcohol in combination Opiates Diazepam Source: SAMHSA, 1997 Alcohol Involvement in Emergency Department Episodes 65  35% of drug episodes (1999) involved a mention of alcohol-in-combination events per 100,000: in combination 81 69 36 35 Source: SAMHSA, 1999b  Alcohol  Cocaine  Marijuana  Opiates  Rate Traffic Alcohol-Related Fatalities, 1977-1999 100 90 80 70 60 50 40 30 20 10 0 1977 Traffic Crash Fatality Alcohol Fatality 66 In Thousands 1985 1990 1991 1993 1995 1997 1999 Source: Yi et al., 2001 Alcohol Involvement in Accidental Death, Homicide, and Suicide 100 90 80 70 60 50 40 30 20 10 0 e g ia Fir nin rm e n/ ow ur oth Dr B p Hy all F 67 Positive Alcohol Intoxicated Percent g h ot de de nin unsh ras ici ici o C Su om ois G ar H P C Source: Smith et al. , 1999 Alcohol and Trauma by Injury Type Number of Trauma Patients 68 900 800 700 600 500 400 300 200 100 0 Ca r St ab bi ng G un sh ot ll le yc Fa or c Not Intoxicated Intoxicated n de str ot M Pe Source: NIAAA, 1997 Bl un t ia 69 Alcohol and Trauma, by Age Number of Trauma Patients 900 800 700 600 500 400 300 200 100 0 18-24 25-34 35-44 45-54 55+ Not Intoxicated Intoxicated Source: NIAAA, 1997 Relative Risk Over 21 Years, Alcohol Consumption & Mortality (Scottish Men) 4 3.5 3 2.5 2 1.5 1 0.5 0 e as se di t r St ke o Al e lr o oh c e at l d l Al c e us a 70 Percent 1-7 drinks/wk 8-14 drinks/wk 15-21 drinks/wk 22-34 drinks/wk 35+ drinks/wk H ea r Source: Hart et al, 1999. Alcohol and Mortality: 11-Year Follow-up, Adults Age 50+ (16,304 Danish Men & Women) 71 90 80 70 60 50 40 30 20 10 0 Men 50-60 Men 65+ Women 50-60 Women 65+ Percent < k /w 1 1 k /w -6 7 k /w 3 -1 k /w 7 -2 14 k /w 1 -4 28 42 k /w + Source: Gronbaek et al., 1998 DHHS & USDA Dietary Guidelines for Alcohol Consumption 72 Women- Moderate drinking, no more than 1 drink/day Men- Moderate drinking, no more than 2 drinks/day Children Adolescents Should not drink at all Pregnant women Adults Unable to control drinking  Recovering  On certain meds  Family history of alcoholism  Should not drink at all One Day Census of Clients in Substance Treatment by Age 1200 1000 Thousands 73 800 600 400 200 0 1987 65+ 45 - 64 21 - 44 18 - 20 Under 18 Source: SAMHSA, 1997 1989 1990 1991 1992 1993 1995 74 Appendices Additional Materials Available for Incorporating into Classroom Presentations Per Capita Consumption, 1935-98 75 Per Capita Consumption, 1977-98 76 Percent Changes in Per Capita Consumption, 1977-1998 77 Total Per Capita Consumption: Ethanol by State, 1997 US total== 2.18 U.S. total 2.18 78 DC 1.99 or below 2.00 to 2.24 1.99 or below 2.252.24 2.49 to 2.00 to 2.25 to 2.502.49 over or 2.50 or over 79 U.S. Drinking Patterns Abstain 40% Dependent 5% At Risk or Problem 20% Low Risk 35% Source: National Longitudinal Alcohol Epidemiologic Survey, 1992. Principal diagnosis of discharges with alcohol mentioned (1997) 6.8% 15.3% 80 Alcoholic psychoses Alcohol dependence syndrome Cirrhosis, with mention of alcohol Cirrhosis, without mention of alcohol Nondependent abuse of alcohol Nonalcohol-related first-listed diagnosis 3.7% 2.5% 3.0% 68.7% Average deaths with explicit mention of alcohol: 1986-1990 81