Alcohol use is legal for persons age 21 and older, and the majority of people who drink do so without incident. However,

there is a continuum of potential problems associated with alcohol consumption. Alcohol is the most used intoxicating

substance in the United States—82 percent of people age 12 and older have used alcohol at least once in their lifetimes.

And nearly half of all Americans age 12 and older—an estimated 109 million people—have used alcohol in the past

month (Substance Abuse and Mental Health Services Administration 2002).

How Do We Define “Alcohol Problem”?

The term alcohol problem refers to any problem related to alcohol use that may require some type of intervention or

treatment. Alcohol problems vary in duration (that is, they are acute, intermittent, or chronic) and severity (that is, ranging

from mild to severe). People who drink may, on occasion, consume alcohol at levels that pose a risk for alcohol-related

problems. Such risky drinkers typically experience mild or moderate intermittent alcohol problems. More severe chronic

problems may be experienced by persons clinically diagnosed with alcohol abuse or alcohol dependence (Institute of

Medicine 1990). Some characteristics that may affect a client’s development of alcohol problems or treatment of these

problems include his or her age, cultural background, and mental or physical health, including disabilities.

Risky Drinking

A significant proportion of problems related to alcohol use occur in persons who are not alcohol dependent but who

engage in risky drinking (Institute of Medicine 1990; National Institute on Alcohol Abuse and Alcoholism 2000).

Although risky drinking is not a clinically defined condition with quantifiable symptoms, it is typically defined as

consuming alcohol in a way that may pose a risk of physical or emotional harm to the drinker or others but has not

produced effects that would result in a diagnosis of alcohol abuse or dependence problems (Babor and Higgins-Biddle

2000). Risky drinking includes heavy or excessive drinking, such as binge drinking

(drinking four or more drinks on a single occasion for females and five or more drinks for

males) (National Institute on Alcohol Abuse and Alcoholism 2000). It also includes

drinking in situations that increase the risk of harm, such as before or while driving, while

pregnant, or while taking certain prescription medications (e.g., certain sedatives) (Fiellin et

al. 2000). Identifying risky drinking behavior may lead to the early detection and prevention

of the more serious problems of alcohol abuse and dependence. 

Alcohol Abuse

A person who frequently engages in risky drinking may have a more severe alcohol

problem—alcohol abuse. A recognized medical condition, alcohol abuse is the regular use

of alcohol despite recurrent adverse consequences. A diagnosis of alcohol abuse is made

when someone exhibits one or more of the following within a 12-month period:

n Recurrent alcohol use resulting in a failure to fulfill obligations at work, school, or home

n Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an

automobile when impaired by alcohol use)

n Recurrent alcohol-related legal problems

n Continued alcohol use despite having persistent or recurrent social or interpersonal

problems caused or exacerbated by alcohol use (American Psychiatric Association 1994).

April 2003, Volume 2 Issue 1

Substance Abuse in Brief

2 Alcohol Dependence

2 Factors That May

Contribute to Alcohol

Dependence

3 Consequences of

Problem Alcohol Use

4 Detection and

Treatment of Alcohol

Use Problems

5 References

6 Providing Treatment

Referrals

6 What You Can Do 

To Raise Awareness

6 National Alcohol

Screening Day

...continued on page 2

What You Should Know About Alcohol Problems

Inside
2

April 2003

Substance Abuse in Brief

Alcohol abuse, although problematic, usually does not progress to dependence. In fact, a recent study found that 5 years

after being diagnosed with alcohol abuse, only 3.5 percent of abusers met the criteria for alcohol dependence (Schuckit

et al. 2001).

Alcohol Dependence

The most severe problem is alcohol dependence, also referred to as alcoholism or alcohol addiction. In 2001 an

estimated 5.4 million people age 12 and older were dependent on alcohol (Substance Abuse and Mental Health Services

Administration 2002). Alcohol dependence is a chronic disease with discrete definable symptoms. An individual has

become alcohol dependent when he or she experiences three or more of the following in a 12-month period:

n Tolerance: the need for increasing amounts of alcohol to reach intoxication.

n Withdrawal: the occurrence of physical symptoms when heavy alcohol use is reduced or stopped. Its symptoms may

include tremors, sweating, a high pulse rate, nausea or vomiting, insomnia, and anxiety. Severe withdrawal may

induce transient hallucinations or grand mal seizures.

n Drinking larger amounts or drinking over a longer period than was intended.

n A persistent desire or unsuccessful efforts to cut down on or control alcohol use.

n Spending a great deal of time obtaining, using, or recovering from the effects of alcohol use.

n Giving up or reducing social, occupational, or recreational activities because of alcohol use.

n Using despite having knowledge of persistent or recurring physical or psychological problems that were caused or

exacerbated by alcohol use (American Psychiatric Association 1994).

Alcohol dependence is a persistent condition. Approximately two-thirds of persons who are alcohol dependent will still

be dependent in 5 years (Schuckit et al. 2001). 

Factors That May Contribute to Alcohol Dependence

Alcohol dependence is influenced by both genetic and environmental factors. Persons with a family history of

dependence have a higher chance of lifetime dependence than those without such a history (U.S. Department of Health

and Human Services 2000). In addition, researchers have identified genes that influence people’s susceptibility to

alcohol dependence; however, hereditary influences alone do not predict a future of alcohol dependence. Environmental

factors also play a significant role. For example, the child of a parent who is dependent on alcohol may be genetically

predisposed to alcohol dependence but may effectively thwart it through education, self-monitoring, and social support

(National Institute on Alcohol Abuse and Alcoholism 1995). Conversely, neurochemical changes in the brain caused by

repeated abuse of substances such as alcohol can lead to neurological substance dependence, even if the individual has

no genetic vulnerability to addiction disorders (Center for Substance Abuse Treatment 1999).

Preventing drinking among youth is important, not only because drinking alcohol is illegal for persons younger than age

21, but also because postponing the onset of alcohol use decreases the likelihood of developing dependence later in life.

About 40 percent of those who start drinking at age 15 or younger develop alcohol dependence at some point; for those

who start drinking at age 21 or older, the figure is approximately 10 percent (see figure 1) (Grant and Dawson 1997).

Several factors may help discourage or at least postpone alcohol use. Parental support, communication, and monitoring

are significantly related to whether adolescents drink, the amount they drink, and the frequency of their drinking.

Adolescents’ drinking behavior is also related to their friends’ acceptance or rejection of drinking and whether their

friends drink (National Institute on Alcohol Abuse and Alcoholism 1997).
April 2003

Substance Abuse in Brief

3

Consequences of Problem Alcohol Use

Identifying and eliminating problem drinking behaviors are important for many reasons. Problem alcohol use of any

degree of severity may disrupt family and social relationships and lead to psychological problems, violence and

aggression, and legal problems. Problem alcohol use is also linked to an increased risk of injuries, including those

resulting from automobile crashes, falls, and fires. Not only does the risk of injury increase with the amount of alcohol

consumed, but this risk begins to rise at relatively low levels of consumption. Problem drinking may also contribute to

unsafe sex practices leading to an increased incidence of HIV/AIDS, hepatitis, and other sexually transmitted diseases.

Finally, higher levels of alcohol consumption are associated with a greater risk of negative health effects, including a

weakened immune system, tuberculosis, coronary heart disease, stroke, liver cirrhosis, and cancer (National Institute on

Alcohol Abuse and Alcoholism 2000).

The most recent calculation of the overall economic costs of alcohol problems was estimated by the National Institute on

Alcohol Abuse and Alcoholism at more than $184 billion in 1998 (see figure 2). More than 70 percent of these costs

were attributed to productivity losses ($134.2 billion) caused by impaired workplace and household productivity related

to alcohol use, worktime lost by incarcerated offenders and victims of alcohol-related crime, and alcohol-related

premature death. Other economic costs of alcohol problems include healthcare expenditures related to the prevention and

treatment of alcohol abuse and dependence and the medical consequences of alcohol consumption ($26.3 billion),

administrative and property damage costs from alcohol-related motor vehicle crashes ($15.7 billion), criminal justice

system costs stemming from alcohol-related crime ($6.3 billion), fire destruction attributable to alcohol use ($1.5

billion), and alcohol-related social welfare expenditures ($0.5 billion) (National Institute on Alcohol Abuse and

Alcoholism 2000).

Figure 1. Percentage of Adults Diagnosed With Lifetime Alcohol Dependence

by Age at First Alcohol Use

Source: Grant and Dawson 1997.

Age at First Alcohol Use

Percent
April 2003

Substance Abuse in Brief

Detection and Treatment of Alcohol Use Problems

Prevention of and early intervention in alcohol problems are important to reduce their consequences and related social

and economic costs. Alcohol screening attempts to identify both risky drinkers and drinkers who are experiencing

symptoms of alcohol abuse or dependence. Screening tools range from brief self-administered questionnaires to lengthy

clinician-administered interviews. Screening for co-occurring mental disorders is also essential for planning an effective

intervention.

Once an alcohol problem has been identified, it should be treated appropriately. Not only do affected individuals

experience different types of alcohol problems; each individual has different characteristics, strengths, and weaknesses

that should be considered when assessing what treatment methods are most appropriate. A comprehensive and effective

assessment should provide a detailed description of the kind of alcohol problem experienced by a particular individual 

at a specific time (Institute of Medicine 1990).

In general, persons identified as risky drinkers—those experiencing mild or moderate alcohol problems—may benefit

most from brief interventions, which usually incorporate counseling and education sessions that provide practical advice

and build skills (Babor and Higgins-Biddle 2000; Institute of Medicine 1990). Typically used by a primary care

provider, brief interventions are designed to reduce alcohol use, thus minimizing the risk of developing alcohol-related

problems (Fleming and Manwell 1999). Research has shown that brief interventions are effective in reducing drinking

and related problems (Babor and Higgins-Biddle 2000).

Brief interventions are insufficient for persons diagnosed with alcohol dependence. These persons may benefit more

from intensive treatment approaches, which can include psychological, pharmacological, social, and medical services.

The primary goal of all treatment programs should be to eliminate alcohol use as a factor contributing to physical,

emotional, and social problems (Institute of Medicine 1990).

4

Figure 2. Estimated Econonic Costs of Alcohol Abuse

in the United States, 1998 (in billions of dollars)

Source: National Institute on Alcohol Abuse and Alcoholism 2000.

Healthcare

Expenditures

14% ($26.3)

Motor Vehicle

Crashes 

9% ($15.7)

Crime

3% ($6.3)

Other

1% ($2.0)

Productivity Losses

73% ($134.2)
5

April 2003

Substance Abuse in Brief

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington,

DC: American Psychiatric Association, 1994.

Babor, T.F., and Higgins-Biddle, J.C. Alcohol screening and brief intervention: Dissemination strategies for medical

practice and public health. Addiction 95(5):677–686, 2000.

Center for Substance Abuse Treatment. The science of addiction: Simplified. Substance Abuse in Brief. Rockville, MD:

Substance Abuse and Mental Health Services Administration, July 1999.

Fiellin, D.A.; Reid, M.C.; and O’Connor, P.G. Screening for alcohol problems in primary care: A systematic review.

Archives of Internal Medicine 160(13):1977–1989, 2000.

Fleming, M., and Manwell, L.B. Brief intervention in primary care settings: A primary treatment method for at-risk,

problem, and dependent drinkers. Alcohol Research & Health 23(2):128–137, 1999.

Grant, B.F., and Dawson, D.A. Age at onset of alcohol use and its association with DSM-IV alcohol abuse and

dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse

9:103–110, 1997.

Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy

Press, 1990.

National Institute on Alcohol Abuse and Alcoholism. The Genetics of

Alcoholism, Alcohol Alert 18. Bethesda, MD: National Institutes of

Health, 1995. 

National Institute on Alcohol Abuse and Alcoholism. Youth Drinking:

Risk Factors and Consequences, Alcohol Alert 37. Bethesda, MD:

National Institutes of Health, 1997.

National Institute on Alcohol Abuse and Alcoholism. 10th Special

Report to the U.S. Congress on Alcohol and Health. Bethesda, MD:

National Institutes of Health, 2000.

Schuckit, M.A.; Smith, T.L.; Danko, G.P.; Bucholz, K.K.; Reich, T.; and

Bierut, L. Five-year clinical course associated with DSM-IV alcohol

abuse or dependence in a large group of men and women. American

Journal of Psychiatry 158(7):1084–1090, 2001.

Substance Abuse and Mental Health Services Administration. Results

From the 2001 National Household Survey on Drug Abuse: Volume II,

Technical Appendices and Selected Data Tables. Rockville, MD: U.S.

Department of Health and Human Services, 2002. Available at

www.samhsa.gov/oas/nhsda/2k1nhsda/PDF/vol2cover.pdf [accessed

November 26, 2002].

U.S. Department of Health and Human Services. Healthy People 2010,

Volume I. Washington, DC: U.S. Government Printing Office,

November 2000. 

Substance Abuse in Brief is produced under

contract number 270-99-7072 by Johnson,

Bassin & Shaw, Inc., and The CDM Group,

Inc., for the Substance Abuse and Mental

Health Services Administration’s (SAMHSA’s)

Center for Substance Abuse Treatment (CSAT).

This publication transmits information about

substance abuse and its treatment to health 

and human service professionals whose work

is affected by alcohol and illicit drug use.

Edwin M. Craft, Dr.P.H., LCPC, is the

alternate Government Project Officer and 

the SAMHSA editor of this publication.

An electronic version of Substance Abuse in

Brief is available online at www.csat.samhsa.gov

under publications. If you wish to reference 

or reproduce this issue, citation of this

publication is appreciated. Recommended

Citation: Center for Substance Abuse

Treatment. What You Should Know About

Alcohol Problems. Substance Abuse in Brief,

April 2003, Volume 2 Issue 1.

Substance Abuse in Brief
6

Substance Abuse in Brief in Brief

What You Can Do To Raise Awareness

n Employers: Provide educational materials about potential alcohol use problems

and institute employee assistance programs. Visit www.workplace.samhsa.gov for

more information.

n Faith-Based Communities: Provide training to clergy so that they understand the

nature and signs of potential alcohol use problems and can provide referrals to

community treatment resources. The Substance Abuse Resource Guide: Faith

Communities (available online at www.ncadi.samhsa.gov) provides additional

resources.

n Educators: Provide parents and students with information on drinking. Lesson

plans, activities, and parent information for fifth graders are available online at

www.ncadi.samhsa.gov. The publication Keeping Your Kids Drug-Free (available

online at www.ncadi.samhsa.gov/govpubs/phd884/default.pdf) also provides

valuable information for parents.

National Alcohol Screening Day

The National Alcohol Screening Day (NASD) program, the Nation’s only large-scale

screening and early intervention program for alcohol problems, has screened more than

50,000 individuals since its inception in 1999. Screenings are conducted at communitybased healthcare facilities, primary care offices, and colleges. NASD is held annually in

April and is organized by the nonprofit organization Screening for Mental Health, Inc.,

with major support from the National Institute on Alcohol Abuse and Alcoholism, the

Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention. 

For more information, visit www.mentalhealthscreening.org or contact Screening for

Mental Health, Inc., at 781–239–0071 or info@mentalhealthscreening.org.

The Substance Abuse and

Mental Health Services

Administration provides

information about local

treatment programs

(1–800–662–HELP). In

addition, the Substance

Abuse Treatment Facility

Locator (www.findtreatment.

samhsa.gov) provides a

searchable directory of 

more than 11,000 alcohol 

and drug treatment programs.

April 2003

Providing Treatment

Referrals