What’s Old is New Again
Two drug-related issues have received a lot of public and media attention recently: the dramatic rise in deaths from opioids, and the growing legalization of marijuana in several states with expectations of more states still to come.
While not trivializing those serious drug problems, we should recognize that alcohol remains the most harmful of drug problems, getting worse in some respects, even while there is some good news. As the fourth leading preventable cause of death, excessive drinking costs the US some $223.5 billion annually (which works out to about $1.90 per drink consumed as of 2006). With nearly 90,000 deaths attributable to excessive drinking, more than 2.5 million years of potential life are lost annually (Stahre, Roeber, Kanny, Brewer, & Zhang, 2014).
Most recently, Grant et al. (2015) reported that twelve-month and lifetime prevalence of alcohol use disorders (AUDs) were 13.9 percent and 29.1 percent, representing nearly 33 million people and 68 million people respectively, revealing a significant increase in AUDs over the past decade. Additionally, heavy drinking is a growing problem among young adults and “emerging adulthood is becoming an increasingly vulnerable period for AUD onset” as the authors report (Grant et al. 2015).
But there is some good news! In its recent Report to the Congress on the Prevention and Reduction of Underage Drinking, SAMHSA (2013) reported a 26.7 percent decline in past-month alcohol use and a 35 percent drop in binge drinking among twelve- to seventeen-year-olds over the years 2004–2012. Yet the downside is that girls are catching up with boys, and 35 percent of twenty-year-olds binged at least once in the past month. In fact, an estimated 92 percent of all alcohol consumed by youth is in the form of binge drinking.
What do we make of these trends? It’s hard to know for sure, but we do know that adult drinking has an impact on youth drinking and other problems, and therefore we should expect over the long-term that adult drinking patterns will continue to harm youth, both directly and indirectly. For example, the Adverse Childhood Experiences (ACE) studies clearly established that certain parental behaviors—including child abuse and neglect, violence, separation and divorce, and alcohol problems—increase the likelihood that those children will develop a wide range of social and health problems, including early onset of drinking and, over time, alcohol dependence. The ACE studies have been widely cited to support increased efforts to reduce negative influences on children, especially in the mental health field.
In a major study Anda and colleagues (2002) observed that growing up with alcohol abusing parents substantially increased the risk of each adverse experience as well as the risk of multiple adverse experiences. They note:
Our findings suggest that prevention of child abuse, domestic violence, and other forms of household dysfunction that are common in alcoholic families will depend on advances in identification and treatment of alcoholic parents . . . and on clinicians’ inquiring about parental alcohol abuse and the long-term effects of adverse childhood experiences, with which both alcohol abuse and depression are strongly associated (Anda et al., 2002).
In addition to the ACE studies, other research has shown that adult drinking—and the policies that influence it—has an impact on underage drinking. The SAMHSA Report to Congress (2013) notes that:
Children of parents who binge are twice as likely to binge themselves and to meet alcohol dependence criteria. Whether through genetics, social learning or cultural values and community norms, researchers have repeatedly found a correlation between youth drinking and the drinking practices of parents.
Yet, despite the evidence that parental excessive alcohol use has a powerful negative influence on youth, there has been relatively little focus on problem drinking among adults in national efforts to reduce underage drinking.
As Anda, one of the original ACE researchers, recently stated, “Prevention is best done by reducing the intergenerational transmission of ACEs by reducing the exposure to mental illness and substance abuse or reducing the severity of the exposure among children. Over time, this will reduce the prevalence of adult problem drinking in the generations to come. I take the long view on this” (personal communication, August 1, 2015).
The long view necessarily involves efforts to reduce child exposure to substance abuse, especially alcohol, to reduce adverse exposures to problem drinking per se as well as to the all too frequent consequences of problem drinking such as physical and verbal abuse, parental separation or divorce, and family dysfunction.
Thus, the evidence suggests that reducing adult excessive drinking will have an impact on youth drinking, which in turn will have an influence on those youth when they become adults and, in turn, parents themselves.
So how do we make progress? Traditionally, screening, treatment, and prevention are the tools we use to reduce problem drinking. Let’s review their practice and impact.
Screening and brief intervention has been shown to be not only effective, but cost-effective, in reducing problem drinking among adults. In primary care settings, studies have shown that brief counseling for nondependent excessive drinkers reduces total alcohol consumption and binge drinking, reduces alcohol-related health outcomes, and is cost-saving, according to a systematic review of the research literature (CDC, 2014b). Major public health organizations have recommended routine screening and brief intervention, especially among younger, heavy-drinking populations, particularly young males.
How is screening working? Not so well, it appears. Several studies have shown that despite the evidence and the recommendations from authoritative medical and public health groups, screening and brief intervention are not widely put into practice. For example, a study published in Preventing Chronic Disease reported that relatively few problem drinkers are ever counseled about their drinking problems, even though most problem drinkers have health insurance and see a primary care professional routinely (Town, Naimi, Mokdad, & Brewer, 2006). The findings suggest that low rates of alcohol screening, including among heavy drinkers, result primarily from missed screening opportunities rather than a lack of access to preventive services.
But for those who are alcohol dependent and who would benefit from treatment, how many are actually receiving treatment? Fewer than one might expect. According to the Substance Abuse and Mental Health Services Administration (SAMHSA) based on data from 2013, of 17.3 million people aged twelve or older with past-year alcohol dependence or abuse, only 6.3 percent actually received treatment, with another 3.1 percent who perceived a need for treatment but did not receive it (2014). So, more than nine of ten individuals with alcohol dependence or abuse did not perceive a need for, or receive, treatment for their problem drinking.
Grant et al. (2015) notes that there are key barriers to getting problem drinkers into treatment, including attitudes about stigma, concern over effectiveness, and cost. Therefore, despite effectiveness of treatment with it increasingly being covered by insurance due to the Affordable Care Act, treatment is seriously underutilized, and until it gets to scale cannot make a major dent in our nation’s drinking problem by itself.
So how about prevention? After decades of research, we now know that environmental approaches—that is, altering the physical, social, and economic environments related to alcohol—can reduce problem drinking. Many studies, and systematic reviews of those studies, have concluded that policies to increase the price of alcohol through taxation, reducing access to alcohol through decreasing alcohol outlet density, and cutting back hours and days of sales, dramshop liability, and overservice law enforcement initiatives, can have a major positive effect. Likewise, maintaining a minimum age twenty-one purchase age, together with effective enforcement strategies, can reduce underage drinking (CDC, 2014a).
These policy approaches have been well researched and have been endorsed by a wide range of public health groups, and are included in the Surgeon General’s National Prevention Strategy, which includes specific targets as well as evidence-based interventions shown to be effective (US Department of Health and Human Services, 2011). Yet because changing alcohol policies is a controversial issue, there has not been widespread adoption of the more powerful interventions.
Clearly no one approach is going to be sufficient to reduce the consequences of excessive adult drinking on our nation’s youth. We have evidence-based approaches to prevention, intervention, and treatment, but they are not yet sufficiently to scale to make an appreciable difference. With more than 73 million youth ages zero to seventeen, and knowing that one in four children is, or will be, living in a family setting where alcohol is a serious problem, we have to do better.
Indeed, what’s old is new again. Parental drinking does matter, and how frequently and how much they drink can influence the physical and mental health of their children for a lifetime.
Anda, R. F., Whitfield, C. L., Felitti, V. J., Chapman, D., Edwards, V. J., Dube, S. R., & Williamson, D. F. (2002). Adverse childhood experiences, alcoholic parents, and later risk of alcoholism and depression. Psychiatric Services, 53(8), 1001–9.
Centers for Disease Prevention and Control (CDC). (2014a). Preventing excessive alcohol consumption. Retrieved from http://www.thecommunityguide.org/alcohol/index.html
Centers for Disease Prevention and Control (CDC). (2014b). Vital signs: Alcohol screening and counseling. Retrieved from http://www.cdc.gov/vitalsigns/alcohol-screening-counseling/index.html
Grant, B. F., Goldstein, R. B., Saha, T. D., Chou, S. P., Jung, J., Zhang, H., . . . Hasin, D. S. (2015). Epidemiology of DSM-5 alcohol use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry, 72(8), 757–66.
Town, M., Naimi, T. S., Mokdad, A. H., & Brewer, R. D. (2006). Health care access among US adults who drink alcohol excessively: Missed opportunities for prevention. Preventing Chronic Disease: Public Health Research, Practice, and Policy. Retrieved from http://www.cdc.gov/pcd/issues/2006/apr/05_0182.htm
Substance Abuse and Mental Health Services Administration (SAMHSA). (2013). Report to the Congress on the Prevention and Reduction of Underage Drinking, June 2015. Retrieved from https://www.stopalcoholabuse.gov/media/ReportToCongress/2014/report_main/report_to_congress_2013.pdf
Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Behavioral health barometer, United States, 2014. Retrieved from http://www.samhsa.gov/data/sites/default/files/National_BHBarometer_2014/National_BHBarometer_2014.pdf
Stahre, M., Roeber, J., Kanny, D., Brewer, R. D., & Zhang, X. (2014). Contribution of excessive alcohol consumption and years of potential years life lost in the United States. Preventing Chronic Disease: Public Health Research, Practice, and Policy. Retrieved from http://www.cdc.gov/pcd/issues/2014/13_0293.htm
US Department of Health and Human Services (2011). National prevention strategy. Retrieved from http://www.surgeongeneral.gov/priorities/prevention/strategy/index.html