U.S. Department of Health

& Human Services 

National Institutes of Health 

National Institute on Alcohol Abuse 

and Alcoholism 

Number 76 July 2008 

ALCOHOL AND
 

OTHER DRUGS
 

Drug and alcohol dependence often go hand in hand. Research 

shows that people who are dependent on alcohol are much 

more likely than the general population to use drugs, and people 

with drug dependence are much more likely to drink alcohol 

(1). For example, Staines and colleagues (2) found that, of 248 

alcoholics seeking treatment, 64 percent met the criteria for 

a drug use disorder at some point in their lifetime. 

Patients with co-occurring alcohol and other drug use disorders 

also are likely to have more severe dependence-related problems than those without combined disorders—that is, they 

meet a higher number of diagnostic criteria for each disorder 

(three out of seven criteria are required to meet the diagnosis 

of dependence) (3). People with co-occurring alcohol and 

other drug use disorders are more likely to have psychiatric 

disorders such as personality, mood, and anxiety disorders; 

they are more likely to attempt suicide and to suffer health 

problems (3). People who use both alcohol and drugs also are 

at risk for dangerous interactions between these substances. 

For example, a person who uses alcohol with benzodiazepines, 

whether these drugs are prescribed or taken illegally, is at 

increased risk of fatal poisoning (3). 

This Alcohol Alert features the latest research on alcohol and 

other drug use disorders, examining the frequency with which 

these disorders occur and overlap, evidence for common 

genetic risk factors, and how co-occurring disorders can be 

most effectively diagnosed and treated. 

Epidemiology: How Common 

Is Alcohol and Other Drug 

Addiction? 

How common is alcohol and other drug use, and how often 

do alcohol and drug use disorders co-occur? To answer these 

questions, the National Institute on Alcohol Abuse and 

Alcoholism (NIAAA) conducted the National Epidemiologic 

Survey on Alcohol and Related Conditions (NESARC), one 

of the largest surveys of its kind ever performed. It examined 

the prevalence of alcohol and other drug use and abuse in 

the United States. According to NESARC, 8.5 percent of 

adults in the United States met the criteria for an alcohol use 

disorder, whereas 2 percent met the criteria for a drug use 

disorder and 1.1 percent met the criteria for both. People 

who are dependent on drugs are more likely to have an alcohol use disorder than people with alcoholism are to have a 

drug use disorder. Young people ages 18–24 had the highest 

rates of co-occurring alcohol and 

other drug use disorders (see figure). 

Men were more likely than women to 

have problems with alcohol, drugs, 

or the two substances combined (1). 

Because many people suffer from 

both alcohol and drug dependence, 

scientists speculate that these disorders 

“ Because many people suffer from both 

alcohol and drug dependence, scientists 

speculate that these disorders may have 

some common causes and risk factors.” 
Prevalence of alcohol and drug use disorders by age in the United States 

8.4

0.5

.4

1.5

7.0

2.1

0.8 0.2

0.0

4.6

.0 0.3

20

18–24 25–44 45–64 65+

Age

Pre alence of Disorder (%)

Any alcohol use disorder

ny drug use disorder

Co-morbid disorders

10

Source: 2001–2002 NESARC 

may have some common causes and risk factors, as 

described below. 

The Genetics of Alcohol and 

Other Drug Use Disorders— 

Shared Risk Factors? 

Research has established that some of the risk for addiction 

to both drugs and alcohol is inherited. Children of alcoholics are 50 to 60 percent more likely to develop alcohol 

use disorders than people in the general population (4). 

Similarly, children of parents who abuse illicit drugs may be 

45 to 79 percent more likely to do so themselves than the 

general public (5–7). This suggests that some of the risk 

factors for alcohol and other drug use are rooted in genetics, 

though studies of specific families have not proven a genetic 

contribution. 

Researchers believe that some of the same genes that increase 

a person’s risk for problems with alcohol also might put him 

or her at greater risk for drug dependence. Moreover, those 

same genes might increase the risk for other psychiatric 

problems, such as conduct disorder and adult antisocial 

behavior (i.e., externalizing behaviors) (8). 

Much of the most compelling evidence for this apparent 

genetic link is based on twin and adoption studies.1 For 

example, in 2003, Kendler and colleagues (9) analyzed data 

from the Virginia Twin Registry. They compared rates of 

alcohol, drug, and other externalizing disorders in identical 

and fraternal twins. They found that, in identical twins, 

when one twin was dependent on alcohol or on drugs, the 

second twin was much more likely (than a second fraternal 

twin) to have a problem with drugs or alcohol or to have 

an externalizing disorder. The study suggested that certain 

genes put people at risk for both alcohol and other drug use 

disorders, as well as externalizing disorders, whereas other 

genes put people at risk for specific types of disorders. These 

disorder-specific genes often are linked to how the body 

breaks down (or metabolizes) specific drugs and alcohol (8). 

Diagnosing Substance Use 

Disorders: Barriers and 

Challenges 

An accurate diagnosis is the first step toward treatment and 

recovery. However, diagnosing people with drug and alcohol disorders can be complicated, especially when these disorders occur concurrently. There are barriers to diagnosis: 

For example, patients may be unwilling to talk about their 

addiction, and clinicians may be unaware of the signs and 

symptoms of abuse and dependence. 

Clinicians should screen patients for alcohol and other drug 

use disorders in a systematic, step-by-step fashion. One 

resource that can help is NIAAA’s publication Helping 

Patients Who Drink Too Much: A Clinician’s Guide. The Guide 

takes clinicians through a series of steps, outlining what 

questions to ask patients. It presents information—such as 

defining a standard drink and the recommended daily and 

weekly drinking limits—that can help both clinicians and 

1 Adoption studies compare the risk of alcoholism in biological relatives with the risk in 

adoptive relatives of alcoholics (e.g., an adopted-away child of an alcoholic parent). Twin 

studies compare the risk of alcoholism in pairs of twins reared in the same environment, 

examining both identical twins (i.e., twins who share 100 percent of their genes) and fraternal twins (i.e., twins who share, on average, only 50 percent of their genes). 

2
 
 

 

patients identify problem-drinking behaviors. (For more information on the Guide, see the resources section of this Alert.) 

Clinicians also may screen patients for drug problems using 

instruments such as the Drug Abuse Screening Test (DAST) 

or the CAGE Adapted to Include Drugs (CAGE–AID), 

or using a urine drug test (3). Clinicians should take a full 

history of any patient suspected of having a problem with 

drugs, asking, for example, about which drugs are used, age 

of first use, pattern of use, consequences of use, attempts 

to quit, and treatment history. It also is crucial to evaluate 

patients for signs of intoxication or withdrawal. Clinicians 

should assess the patient’s psychiatric history, medical history, family history, and social and developmental history. 

With this information, clinicians will be better equipped to 

determine whether the patient fits the DSM–IV–TR2 criteria for substance abuse or dependence (3). 

Despite careful screening, however, some substance use disorders go undetected. Patients often misreport their substance use because of the stigma associated with an alcohol 

or other drug use disorder diagnosis, or they may fear legal 

reprisals. To address these fears, clinicians should make sure 

patients know the scope of confidentiality required by law. 

Clinicians also should make an effort to be empathic, 

accepting, and nonjudgmental; to ask questions in a direct 

and straightforward manner; and to deal with their own 

discomfort regarding drug use so as not to communicate 

their anxiety to their patients (3). 

Although not as common, some patients overreport their 

substance use. For example, a patient suffering from 

untreated or inadequately treated pain may exaggerate 

his or her use of opiates in order to obtain methadone or 

buprenorphine (drugs used to treat opioid addiction) to 

alleviate that pain. Such patients would benefit from treatment by a pain specialist (3). 

Additionally, clinicians may fail to recognize substance use 

disorders because they do not routinely screen for substance 

use, especially in patients who do not look like “typical substance users.” According to NESARC data, there is no typical substance user; problem alcohol and drug use occurs in 

people across genders, age-groups, and ethnic backgrounds 

(3). It is important that clinicians evaluate all patients for 

substance use disorders. 

2 Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. 

American Psychiatric Association, 2000. 

THE TERMINOLOGY OF ADDICTION
 

In the American Psychiatric Association’s (APA’s) latest revision of the Diagnostic and Statistical Manual of Mental Disorders 

(DSM–IV–TR), substance use disorders fall into two categories: substance abuse and substance dependence. A person can be 

diagnosed with abuse only if he or she does not fit the criteria for dependence, and a person who meets the criteria for 

both abuse and dependence is diagnosed with dependence. According to the APA, a dependent person cannot control his 

or her substance use; substance dependence is “a cluster of cognitive, behavioral and physiological symptoms indicating 

that the individual continues use of the substance despite significant substance-related problems” (23). 

Some scientists believe that, rather than thinking about abuse and dependence as distinct phenomena, it might be 

more useful to consider a broader concept of “addiction.” In a recent study, Saha and colleagues (24) found that alcohol problems occur on a continuum rather than falling into the categories of abuse and dependence. They suggest 

that having two diagnostic categories may be misleading. 

Additionally, O’Brien and colleagues (25) argue that the term “dependence” itself might create confusion, because it 

has more than one meaning. In the DSM–IV–TR, drug and alcohol dependence involve chronic, relapsing, and 

compulsive substance use associated with addiction. However, the term dependence can simply refer to changes in 

the body and brain that cause signs of withdrawal but which are not necessarily associated with addiction—changes 

which might, for example, occur in patients who are taking pain medication or antidepressants as prescribed for legitimate medical reasons. Because of such ambiguity, clinicians may be reluctant to prescribe substances such as pain 

medications that can lead to physical dependence (23). 

The term “addiction” also has disadvantages, however. As noted by Drs. Henry Kranzler and T.-K. Li in NIAAA’s 

journal Alcohol Research & Health (23), addiction carries a stigma that might make clinicians less likely to use this 

term for fear of alienating their patients. Additionally, like the term “alcoholism,” addiction is so widely used in such 

different contexts that its meaning is imprecise and unclear (23). 

3
 
Clinicians also may have problems interpreting the 

DSM–IV–TR criteria, making it difficult to accurately 

diagnose substance use disorders. As described in the 

accompanying sidebar, the DSM–IV–TR uses terminology 

that may be confusing. Some clinicians confuse physical 

dependence on a substance (i.e., experiencing withdrawal) 

with the DSM–IV–TR diagnosis of substance dependence. 

In fact, the vast majority of people who meet criteria for 

alcohol dependence do not experience withdrawal symptoms when they abruptly discontinue drinking. Additionally, 

some patients whose substance use is hazardous or harmful 

may not meet the criteria for substance abuse (3). Such 

patients still should be evaluated and considered for an 

intervention aimed at reducing their drinking or otherwise 

modifying their behavior. 

Treatment 

Behavioral therapies 

For most patients, the most effective treatment approaches 

combine behavioral treatments (i.e., motivation enhancement therapy [MET] and cognitive-behavioral therapy 

[CBT]) and pharmacological treatments. MET seeks to 

motivate patients who are resistant to treatment, and CBT 

gives people the skills to reduce their drinking or to abstain 

from drinking. Contingency management interventions are 

another tool. These interventions center on rewarding positive behavior. Behavioral therapy also is an important tool 

for helping patients comply with medication regimens (10). 

For more information on behavioral therapies, see Volume 

1 of the Project Combine monograph series, listed in the 

resources section of this Alert. 

Pharmacotherapies 

In addition to behavioral therapy, pharmacotherapies can 

help patients to curb their use of alcohol and other drugs. 

This section explores traditional and new medications available to treat alcohol and drug dependence. Volume 2 of 

the Project Combine monograph series provides additional 

information on medication management (see the resources 

section of this Alert). 

Disulfiram. Disulfiram interferes with the breakdown of 

alcohol. When a person taking disulfiram drinks alcohol, 

it causes a buildup of acetaldehyde—a toxic byproduct of 

alcohol—in the body. This causes a variety of unpleasant 

effects, including reddening or flushing of the face and 

neck, nausea, and nervousness. The U.S. Food and Drug 

Administration (FDA) approved disulfiram in 1949 for the 

treatment of alcohol use disorders (10). In a study of 600 

male veterans, overall, disulfiram had no effect on long-term 

abstinence (11). Among individuals who drank, however, 

the active dosage of the medication (250 mg/day) reduced 

the number of days the subjects spent drinking. Disulfiram 

can cause potentially serious effects when combined with 

alcohol, so the patient’s goal must be abstinence (10). 

Patients who respond well to disulfiram tend to be older, 

with greater social stability and motivation for recovery; 

they tend to have a longer drinking history, attend Alcoholics 

Anonymous meetings, and be free of alcohol-related dementia 

and other cognitive problems (12,13). 

Disulfiram may be useful in treating cocaine addiction, 

both by producing an adverse reaction similar to that produced with alcohol and by reducing the euphoria associated 

with the drug (10). Successful treatment with disulfiram 

requires strict adherence to the medication regimen— 

patients who take disulfiram must be highly motivated to 

continue treatment. 

Naltrexone. Naltrexone blocks the activity of a class of 

molecules (i.e., opiate receptors). These molecules are 

involved in relaying chemical messages in the brain that are 

involved in addiction. In addition to an oral form, the FDA 

has approved a long-acting, injectable form of naltrexone 

for the treatment of alcohol dependence (10). Research 

shows that naltrexone reduces the risk of relapse in heavy 

drinkers; however, there is less evidence that it reduces the 

number of drinking days or that it helps patients to maintain total abstinence (14,15). 

Studies also have shown that naltrexone may be useful in 

treating drug use disorders, including opioid and cocaine 

dependence (16). Naltrexone has been approved by the 

FDA for the treatment of opioid dependence; however, 

because it can cause acute withdrawal from opiates (potentially making the patient feel very ill), patients should be 

drug-free for at least 7 days before beginning treatment. 

Additionally, patients should be warned that if they return 

to using opiates heavily, they run the risk of death because 

naltrexone will reduce their tolerance to opiates and put 

them at risk for overdose (10). 

Acamprosate. Acamprosate also affects 

certain chemical messengers (i.e., neurotransmitters) in the brain (10). Although 

the FDA approved acamprosate for 

the treatment of alcohol dependence, 

research with this medication has produced mixed results. European studies 

(17–19) have shown that acamprosate 

not only reduces the risk of heavy 

“In addition to behavioral therapy, 

pharmacotherapies can help patients 

to curb their use of alcohol and 

other drugs.” 

4
 
drinking, but nearly doubles the likelihood that patients 

will achieve abstinence. These studies suggest that acamprosate is most useful in patients who develop alcohol 

dependence later in life, who do not have a family history of 

alcohol dependence, and who display physical dependence 

and higher than usual levels of anxiety (20). It is important 

to note that other studies show that acamprosate is no more 

effective than placebo (21,22). 

Anticonvulsant medications. Topirimate has been shown 

to be an effective treatment for alcohol dependence and 

may be beneficial for cocaine dependence treatment. Other 

anticonvulsants, including carbamazepine and valproate, 

also have shown some effectiveness in treating alcohol use 

disorders, and they may be especially useful in patients with 

co-occurring alcohol dependence and bipolar disorder (10). 

Serotonergic and other medications. Although studies are 

scarce, some research has shown that medications which 

target other mechanisms in the brain (selective serotonin 

reuptake inhibitors [SSRIs], atypical antipsychotic medications, or lithium) may be useful in treating substance use 

disorders. The medications appear to be particularly useful 

for treating certain subgroups of alcohol-dependent patients, 

based on the age of onset of problem drinking (10). 

Conclusion 

Addictive disorders represent a major health issue both in 

the United States and worldwide. Because alcohol and drug 

dependence are likely to co-occur, exploring how alcohol 

addiction may relate to and interact with other addictions 

is important. Current research is exploring the underlying 

causes of addiction, and why alcohol and other drug use 

disorders co-occur so frequently, as well as how behavioral 

and drug therapies can best treat these disorders. There is 

no “magic bullet” for treating addiction—no treatment will 

work for everyone in every situation. More research is needed 

to identify effective treatments for different populations, 

especially youth, older people, and patients with co-occurring 

psychiatric disorders. Such research is vital to better understand the mechanisms and course of addiction as well as its 

diagnosis and treatment. 

References 

(1) Falk, D.; Yi, H.-y.; and Hiller-Sturmhöfel, S. An Epidemiologic Analysis of CoOccurring Alcohol and Drug Use and Disorders: Findings From the National 

Epidemiologic Survey of Alcohol and Related Conditions (NESARC). Alcohol 

Research & Health 31(2):100–110, 2008. (2) Staines, G.L.; Magura, S.; Foote, J.; et 

al. Polysubstance use among alcoholics. Journal of Addictive Diseases 20:53–69, 

2001. PMID: 11760926. (3) Arnaout, B., and Petrakis, I. Diagnosing Co-Morbid Drug 

Use in Patients With Alcohol Use Disorders. Alcohol Research & Health 

31(2):148–154, 2008. (4) McGue, M. The behavioral genetics of alcoholism. Current 

Directions in Psychological Science 8:109–115, 1999. (5) Agrawal, A., and Lynskey, 

M. The genetic epidemiology of cannabis use, abuse and dependence. Addiction 

101:801–812, 2006. PMID: 16696624. (6) Kendler, K.S.; Jacobson, K.C.; Prescott, 

C.A.; and Neale, M.C. Specificity of genetic and environmental risk factors for use and 

abuse/dependence of cannabis, cocaine, hallucinogens, sedatives, stimulants, and 

opiates in male twins. American Journal of Psychiatry 160:687–695, 2003. PMID: 

12668357. (7) Tsuang, M.T.; Bar, J.L.; Harley, R.M.; and Lyon, M.J. The Harvard Twin 

Study of Substance Abuse: What we have learned. The Harvard Review of Psychiatry 

9:267–279, 2001. PMID: 11600486. (8) Dick, D.M.; and Agrawal, A., The genetics of 

alcohol and other drug dependence. Alcohol Research & Health 31(2):111–118, 2008. 

(9) Kendler, K.S.; Prescott, C.A.; Myers, J.; and Neale, M.C. The structure of genetic 

and environmental risk factors for common psychiatric and substance use disorders in 

men and women. Archives of General Psychiatry 60:929–937, 2003. PMID: 12963675. 

(10) Arias, A.J., and Kranzler, H. Treatment of co-occurring alcohol and other drug use 

disorders. Alcohol Research & Health 31(2):155–167, 2008. (11) Fuller, R.K.; 

Branchey, L.; Brightwell, D.R.; et al. Disulfiram treatment of alcoholism: A Veterans 

Administration cooperative study. JAMA: Journal of the American Medical Association 

256(11):1449–1455, 1986. PMID: 3528541. (12) Fuller, R.K., and Gordis, E. Does 

disulfiram have a role in alcoholism treatment today? Addiction 99(1):21–24, 2004. 

PMID: 14678055. (13) Suh, J.J.; Pettinati, H.M.; Kampman, K.M.; and O’Brien, C.P. 

The status of disulfiram: A half of a century later. Journal of Clinical 

Psychopharmacology 26(3):290–302, 2006. PMID: 16702894. (14) Bouza, C.; 

Angeles, M.; Munoz, A.; and Amate, J.M. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: A systematic review. Addiction 

99(7):811–828, 2004. PMID: 15200577. (15) Srisurapanont, M., and Jarusuraisin, N. 

Opioid antagonists for alcohol dependence. Cochrane Database of Systematic 

Reviews (1):CD001867, 2005. PMID: 15674887. (16) Schmitz, J.M.; Stotts, A.L.; 

Rhoades, H.M.; and Grabowski, J. Naltrexone and relapse prevention treatment for 

cocaine-dependent patients. Addictive Behavior 26(2):167–80, 2001. PMID: 

11316375. (17) Bouza, C.; Angeles, M.; Munoz, A.; and Amate, J.M. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: A systematic review. Addiction 99(7):811–828, 2004. PMID: 15200577 2008. (18) Chick, J.; 

Lehert, P.; and Landron, F. Does acamprosate improve reduction of drinking as well as 

aiding abstinence? Journal of Psychopharmacology 17(4):397–402, 2003. (19) Mann, 

K.; Lehert, P.; and Morgan, M.Y. The efficacy of acamprosate in the maintenance of 

abstinence in alcohol-dependent individuals: Results of a meta-analysis. Alcoholism: 

Clinical and Experimental Research 28(1):51–63, 2004. PMID: 14745302. (20) 

Verheul, R.; Lehert, P.; Geerlings, P.J.; et al. Predictors of acamprosate efficacy: 

Results from a pooled analysis of seven European trials including 1485 alcoholdependent patients. Psychopharmacology (Berl) 178(2–3):167–173, 2005. PMID: 

15322728. (21) Mason, B.J.; Goodman, A.M.; Chabac, S.; and Lehert, P. Effect of oral 

acamprosate on abstinence in patients with alcohol dependence in a double-blind, 

placebo-controlled trial: The role of patient motivation. Journal of Psychiatric Research 

40(5):383–393, 2006. PMID: 16546214. (22) Anton, R.F.; O’Malley, S.S.; Ciraulo, 

D.A.; et al. Combined pharmacotherapies and behavioral interventions for alcohol 

dependence: The COMBINE study: A randomized controlled trial. JAMA: Journal of the 

American Medical Association 295(17):2003–2017, 2006b. PMID: 16670409. (23) 

Kranzler, H., and Li, T.-K. What is Addiction? Alcohol Research & Health 31(2):93–95, 

2008. (24) Saha,T.D.; Chou, S.P.; and Grant, B.F. Toward an alcohol use disorder continuum using item response theory: Results from the National Epidemiologic Survey on 

Alcohol and Related Conditions. Psychological Medicine 36:931–941, 2006. (25) 

O’Brien, C.P.; Volkow, N.; and Li, T.-K. What’s in a word? Addiction versus dependence in DSM-V. American Journal of Psychiatry 163:764–765, 2006. PMID: 16648309. 

5
 
R e s o u r c e s 

Source material for this Alcohol Alert originally appeared in Alcohol Research & Health, 

Volume 31, Number 2, 2008. Articles in that issue explore the causes, diagnosis, and 

treatment of alcohol and other drug addiction. Other resources include: 

▲

Helping Patients Who Drink Too Much: A Clinician’s Guide. The Guide is a screening tool 

that helps clinicians recognize and diagnose alcohol use disorders. It is available in 

book form and as an accredited electronic-learning course. 

▲

Project Combine,Volume 1. Combined Behavioral Intervention Manual: A Clinical 

Research Guide for Therapists Treating People With Alcohol Abuse and Dependence. 

Highlights the use of Combined Behavioral Intervention, an intensive treatment 

that combines several previously evaluated interventions. 

▲

Project Combine,Volume 2. Medical Management Treatment Manual: A Clinical 

Research Guide for Medically Trained Clinicians Providing Pharmacotherapy as Part 

of the Treatment for Alcohol Dependence. Describes the use of medical management and brief counseling sessions to enhance medication adherence and abstinence from alcohol. 

The Clinician’s Guide, the Project Combine manuals, and full-text articles from each issue of Alcohol Research & 

Health are available on the NIAAA Web site at www.niaaa.nih.gov. Subscriptions to Alcohol Research & Health 

are available from the Superintendent of Documents for $25.Write to New Orders, Superintendent of 

Documents, P.O. Box 371954, Pittsburgh, PA 15250–7954; or fax 202/512–2250. 

Full text of this publication is available on NIAAA’s World Wide Web site at www.niaaa.nih.gov. 

All material contained in the Alcohol Alert is in the public domain and may be used or reproduced 

without permission from NIAAA. Citation of the source is appreciated.
 

Copies of the Alcohol Alert are available free of charge from the National Institute on Alcohol Abuse and Alcoholism
 

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