# Presentation: 045159

## Alcohol Problems andHigh School Students

*Dan Hungerford, DrPH*
**Epidemiologist**
**National Center for Injury Prevention and Control**
**Centers for Disease Control and Prevention**

## Prevention Strategies

**Universal**    a total population
**Selective**      a high-risk subpopulation
**Indicated**      high-risk individuals

**Notes:**
Universal  
Policies, programs and messages aimed at preventing or delaying the misuse of alcohol

Examples          GA: No sales of alcohol on Sunday
                             Special taxes on Alcohol-containing beverages

Selective
Prevention strategies that target subsets of the total population that are deemed to be at risk for substance abuse by virtue of their membership in a particular population segment. Targets the entire subgroup regardless of the degree of risk of any individual within the group. An individual's personal risk is not specifically assessed or identified and is based solely on a presumption given his or her membership in the at-risk subgroup. 

Examples:                 Special programs at universities targeting fraternities
                                   or  athletes.

Indicated
Indicated prevention strategies are designed to prevent the onset of substance abuse in individuals who do not meet DSM-IV criteria for addiction, but who are showing early danger signs, such as falling grades and consumption of alcohol.  They exhibit risk factors that increase their chances of developing an alcohol abuse problem. 

The mission of indicated prevention is to identify individuals who are exhibiting early signs of substance abuse and other problem behaviors associated with substance abuse and to target them with special programs. 

In order to ID high-risk individuals, screening is involved.
                  Public health screening:  not assessment, not diagnosis.

## Types of Drinkers

**Types of Drinkers**

***Alcohol Dependent***

**Low- Risk & Abstaining**

***4 %***

***25%***

*** ******71%***

***Risky & Harmful ***

**Notes:**
So here’s what the spectrum of alcohol use looks like. 

We’ve got ~ 70% of the population at low risk of future harm because they don’t drink at all or they don’t drink very much.  

We’ve got ~ 30% of the population that drinks at risky levels. This group can be broken into two categories.
  Those who have very serious alcohol-related problems. They are essentially addicted and can   be formally diagnosed as alcohol dependent.

  Those who drink at levels that are high enough to reliably predict future alcohol-related harm and those who have already experienced alcohol-related harm. However, no one in this group is addicted. 

Let’s look at this spectrum in greater detail.  

## How do we identify and help high-risk individuals?

## Proxies for Alcohol Problems

**Alcohol dependence symptoms **
**Alcohol-related Harm**
**Hazardous Drinking **

**Notes:**
When we screen individuals, we looks at these three proxies to determine if they have a problem and how serious that problem might be.  

substance dependence
a psychiatric disorder characterized by 
neuroadaptation (tolerance and withdrawal)
impaired control over substance use
increased salience of drug seeking 
substance abuse: one or more in last 12 months
recurrent failure to fulfill obligations 
recurrent use in physically hazardous situations
recurrent substance-related legal problems
continued use despite persistent substance-related social or intepersonal problems
don’t meet substance dependence criteria

NB
	HARM—e.g., physical, legal, social, 
		injuries
		legal consequences
		loss of friendship, alienation of family

	SYMPTOMS—not dependence itself.  NOT A DIAGNOSIS. A RISK FACTOR.
		Eye Opener
		Inability to stop drinking once started
		Inability to fulfill normal obligations

## Inability to stop drinking

Tolerance 

Morning drinking

Amnesia  

Shakiness

Salience

- Tolerance
- Morning drinking
- Amnesia
- Shakiness
- Salience

**Alcohol Dependence Symptoms**

**Notes:**
Symptoms Not a Diagnosis of alcohol dependence. 

All of the can be graded by frequency, which helps get a sense of 
     a) whether someone is dependent (addicted)
     b) how severe that addiction is.   

Alcohol Dependence Indicators
Experiencing the following situations is not necessarily problematic, but researchers feel that these types of experiences are indicative of alcohol dependence.
1.	Once I started drinking it was difficult for me to stop before I became completely intoxicated.
2.	I sometimes kept on drinking after I had promised myself not to.
3.	I deliberately tried to cut down or quit drinking, but I was unable to do so.
4.	I was afraid I might be an alcoholic.
5.	Sometimes I have needed a drink so badly that I couldn’t think of anything else.
6.	I have skipped a number of regular meals while drinking.
7.	I have often taken a drink the first thing when I got up in the morning.
8.	I have taken a strong drink in the morning to get over the effects of last night’s drinking.
9.	I have awakened the next day not being able to remember some the things I had done while drinking.
10.	My hands shook a lot the morning after drinking.
11.	I need more alcohol than I used to, to get the same effect as before.
12.	Sometimes I have awakened during the night or early morning sweating all over because of drinking.
13.	I stayed intoxicated for several days.
Scoring:   1 per question that applies
1-2 	minimal problematic drinking
  3	moderate problematic drinking
 4	severe problematic drinking
10Hilton ME.  Drinking patterns and drinking problems in 1984: results from a general population survey.  Alcoholism: Clinical and Experimental Research 11(2): 167-175, 1987.

## Drinking-related Harm

| Medical Problems  | illness, injury, disability |
| --- | --- |
| Social Problems   
 | behavior that threatens relationships |
| Work Problems | absenteeism, tardiness, 
poor	performance |
| Legal problems | DUI, Fights, Theft  |

**Notes:**
Work Problems
Absenteeism
Tardiness
Poor performance 
Poor interpersonal communication
Poor work relationships
    no promotion;  no raise;  no job
Social Problems
undesireable social that behavior threatens relationships
Medical Problems  illness limits regular activities, injury to self and others, motor vehicle crashes, violence: fights, murder, suicide attempts
Legal Problems
drinking when driving
disorderly behavior
fights
theft

## Recommended Drinking Limits

|  | Men | Women |
| --- | --- | --- |
|     On any day                 | ≤ 4 | ≤ 3  |
|     In a typical week | ≤ 14 | ≤ 7 |

-      NIAAA, *Helping Patients Who Drink Too Much: A Clinician’s Guide, *2005

**Notes:**
What is the threshold for hazardous drinking?  

## Diagnosable Alcohol Use Disordersby Drinking Pattern

| Drinking Pattern  | Prevalence |
| --- | --- |
| Exceeds weekly limit only |      8% |
| Exceed daily limit only  |    20% |
| Exceeds weekly and daily limits | ≈ 50% |

-      NIAAA, *Helping Patients Who Drink Too Much: A Clinician’s Guide, *2005

**Notes:**
The denominator for these percentages is drinkers (29% plus 22%), not the whole population.

1 out of 12 drinkers who exceed only the weekly limit are DSM diagnosable.
1 out of   5 drinkers                     “                    daily limit               “
1 out of   2 drinkers                     “                     both limits             “

So these limits are not as low as you might think.  
We could raise the limits and the prevalence would be higher for each drinking pattern. 
However, we wouldn’t be identifying as many people early in their drinking career. 
We’d be waiting for them to become diagnosable. 

These limits make a great deal of sense as a population threshold for risky drinking.  

## Binge Drinking, Current Drinkers

- Naimi et al, *JAMA*, 2003

**Notes:**
BRFSS,  >= 5 drinks on at least one occasion in past 30 days. 
>= 18, noninstitutionalized
Note: % is for current drinkers.  

Many in younger group too early in drinking career to be alcoholic. 
But not too young to be driving or in an alcohol related car crash. 
Inexperienced drivers + ETOH (decreased coord and cog function, increased risk taking)  =    increased mortality & morbidity

## Prevalence of Alcohol Dependence among Binge Drinkers

- New Mexico, *BRFSS*, 2002

- Dependent 8%

- Non-dependent 92%

**Notes:**
However, most binge drinkers are not dependent. 

## Binge Drinking & Harm

**Unintentional injuries****  ****	****	****      **(Anda, JAMA, 1988)
**Violence****  ****	****	****	****	****      **(Rossow, *Addiction*, 1996)
**Meningitis **** ****	****	****	****      **(Imrey, *Am J Epidemiol*, 1996)
**Sexually transmitted diseases****    **(Lauchli, *AEP*, 1996**)**
**Myocardial infarction****  ****	****	****      **(Rehm, *Am J Epidemiol*, 2001)
**SIDS****  ****	****	****	****	****      **(Iyasu, *JAMA*, 2002)
**Unintended Pregnancy****  ****	****      **(Naimi, *Pediatrics*, 2003)
**Impaired driving****  ****	****	****      **(Naimi, *JAMA*, 2003)

## Have you even ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs?

Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? 

Do you ever use alcohol or drugs while you are by yourself Alone. 

Do you ever Forget things you did while using drugs or alcohol

Do your Family or Friends ever tell you that you should cut down on your drinking or drug use? 

Have you even gotten into Trouble while you were using alcohol or drugs? 

- Do you ever use alcohol or drugs to **R**elax, feel better about yourself, or fit in?
- Do you ever use alcohol or drugs while you are by yourself **A**lone.
- Do you ever **F**orget things you did while using drugs or alcohol
- Do your **F**amily or **F**riends ever tell you that you should cut down on your drinking or drug use?
- Have you even gotten into **T**rouble while you were using alcohol or drugs?

**Screening: CRAFFT **

**Notes:**
Standard self-report methods not useful in School settings. 

Demand characteristics of the screening setting as important as the instrument.

Violation of school rules probably best. 

## Screening, Brief Intervention, andReferral to Treatment	(SBIRT)

**S****	***≠ case finding; everyone; risk factors*
**BI****	***onsite;**** ****5 to 30 minutes; drink less or stop*
***R******	****as needed; facilitated*
***T******	******  ****prevalence; offsite; build motivation*

**Notes:**
The following recommendations will be more useful if readers will refer to a common definition of screening, brief intervention, and referral to treatment (SBIRT). Screening is different from case finding. In case finding, a clinician evaluates patients who appear to have a medical or psychological condition to arrive at a diagnosis. The goal is diagnosis and the target is the individual patient. In screening, program staff use a screening instrument with every member of a predefined group of patients to identify and measure risk factors for a condition. Screen-positive patients receive an intervention to decrease that risk. Depending on the condition and risk factors of interest, screen-positive status may or may not lead to a diagnostic evaluation. The goal is quantifying risk and the target is a predefined group.  
In most medical clinics, the prevailing practice is case finding: to address alcohol-related problems only for patients who appear to have them. However, this practice does not identify the majority of patients with alcohol problems because in many alcohol-related conditions, the role of alcohol is not obvious. Another important consideration is the relationship of the screening instrument to the condition of interest. For example, blood alcohol concentrations are appropriate to identify the degree to which patients are intoxicated; self-report questionnaires are appropriate to identify the level of usual alcohol consumption, alcohol-related harm, or the symptoms of alcohol dependence,. 
The term brief intervention is defined many ways in the published literature and, historically, can include three or four separate counseling sessions. However, for the purposes of these recommendations, brief intervention is defined as a post-screening interaction between a patient and specially trained staff, who do not need advanced professional counseling credentials. The interaction occurs during the medical visit or hospitalization and can last from 5 minutes to 20 minutes or more. For patients with less severe problems, the focus of the intervention is to motivate them to decrease or stop drinking. For patients who have problems severe enough to warrant more extensive treatment, the focus of the brief intervention may be to increase patients’ motivation to seek more intensive treatment.  The brief intervention may also include efforts to ensure patients will be able to access appropriate specialized services.

## What is a brief intervention?

*** *****Present screening results**
** ****Identify risks & discuss consequences**
** ****Provide medical advice**
** ****Solicit patient commitment**
** ****Goal: reduced drinking or abstinence**
** ****Give advice and encouragement**
** ****Refer to specialized treatment? **