Volume 4, Issue 2 | June 2012
Alcoholism Isn’t What It Used To Be
The realization dawned gradually as researchers analyzed data from NIAAA’s 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). In most persons affected, alcohol dependence (commonly known as alcoholism) looks less like Nicolas Cage in Leaving Las Vegas than it does your party-hardy college roommate or that hard-driving colleague in the next cubicle.
“We knew from the 1991–1992 National Longitudinal Alcohol Epidemiologic Study that alcohol dependence is most prevalent among younger adults aged 18 to 29,” says Bridget Grant, Ph.D., Ph.D., chief of NIAAA’s Laboratory Epidemiology and Biometry. “However, it was not until we examined the NESARC data that we pinpointed age 22 as the mean age of alcohol dependence onset.” Subsequent analysis by Ralph Hingson, Sc.D., director, Division of Epidemiology and Prevention Research, showed that nearly half of people who become alcohol dependent do so by age 21 and two-thirds by age 25.
The NESARC surveyed more than 43,000 individuals representative of the U.S. adult population using questions based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association (APA). Published in 1994, DSM-IV recognizes alcohol dependence by preoccupation with drinking, impaired control over drinking, compulsive drinking, drinking despite physical or psychological problems caused or made worse by drinking, and tolerance and/or withdrawal symptoms.
Meanwhile, findings continue to accumulate to challenge past perceptions of the nature, course, and outcome of alcoholism. Among those findings:
• Many heavy drinkers do not have alcohol dependence. For example, even in people who have 5 or more drinks a day (the equivalent of a bottle of wine) the rate of developing dependence is less than 7 percent per year.
• Most persons who develop alcohol dependence have mild to moderate disorder, in which they primarily experience impaired control. For example, they set limits and go over them or find it difficult to quit or cut down. In general, these people do not have severe alcohol-related relationship, health, vocational or legal problems.
• About 70 percent of affected persons have a single episode of less than 4 years. The remainder experience an average of five episodes. Thus, it appears that there are two forms of alcohol dependence: time-limited, and recurrent or chronic.
• Although 22 is the average age when alcohol dependence begins, the onset varies from the mid-teens to middle age.
• Twenty years after onset of alcohol dependence, about three-fourths of individuals are in full recovery; more than half of those who have fully recovered drink at low-risk levels without symptoms of alcohol dependence.
• About 75 percent of persons who recover from alcohol dependence do so without seeking any kind of help, including specialty alcohol (rehab) programs and AA. Only 13 percent of people with alcohol dependence ever receive specialty alcohol treatment.
“These and other recent findings turn on its head much of what we thought we knew about alcoholism,” according to Mark Willenbring, M.D., director of NIAAA’s Division of Treatment and Recovery Research. “As is so often true in medicine, researchers have studied the patients seen in hospitals and clinics most intensively. This can greatly skew understanding of a disorder, especially in the alcohol field, where most people neither seek nor receive treatment and those who seek it do so well into the course of disease. Longitudinal, general population studies such as the NESARC permit us to see the entire disease continuum from before onset to late-stage disease.”
To Willenbring, these realizations call for a public health approach that targets at-risk drinkers and persons with mild alcohol disorder to prevent or arrest problems before they progress. NIAAA is addressing this need with tools to expand risk awareness (http://rethinkingdrinking.niaaa.nih.gov) and inform secondary prevention and primary care screening (http://www.niaaa.nih.gov/guide).
New criteria to guide clinicians in diagnosis and treatment await decisions by the DSM-V committee, expected about 2012. Both Dr. Grant and Howard Moss, M.D, associate director for clinical and translational research, represent NIAAA on that committee.
“NIAAA’s goal now and for the foreseeable future is to develop and disseminate research-based resources for each stage of the alcohol use disorder continuum, from primary prevention to disease management,” according to acting NIAAA director Ken Warren, Ph.D.