Alcohol Use in Adults

Peter D. Friedmann, M.D., M.P.H.

N Engl J Med 2013; 368:365-373January 24, 2013DOI: 10.1056/NEJMcp1204714

Comments open through January 29, 2013

Article

References

Citing Articles (4)

Comments (2)

Letters

See Key Clinical Points

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

A 57-year-old man with a history of alcohol dependence comes for an annual examination. He reports that he has reduced his drinking to two beers two to three times per week and has not had five or more drinks on any occasion or any adverse consequences for the past 2 years. He states that he drinks “for his health” and that “it is under control.” How should his case be assessed and managed?

The Clinical Problem

Alcohol contributes to 79,000 deaths and $223.5 billion in societal costs annually in the United States.1,2 Almost 9% of U.S. adults (approximately 13% of those who drink) meet the criteria for an alcohol-use disorder3 (Table 1Table 1

Checklist of DSM-IV-TR Criteria for Alcohol-Use Disorders.)4,5; the prevalence of alcohol-use disorders is higher in clinical settings.5 Alcohol consumption can have adverse social, legal, occupational, psychological, and medical consequences. The risk of harmful consequences and disability exists on a continuum6 (Figure 1Figure 1

Continuum of Risk Associated with Alcohol Use and Possible Clinical Responses.). Risk drinking is defined as an average of 15 or more standard drinks per week or 5 or more on an occasion for men and 8 or more drinks weekly or 4 or more on an occasion for women and people older than 65 years of age.5 A standard drink (i.e., 12 oz of beer, 5 oz of wine, or 1.5 oz of 80-proof liquor) contains 14 g of ethanol. High average consumption or frequent heavy drinking can be clinically silent yet have adverse health and social consequences7,8 (see Fig. S1 and S2 in the Supplementary Appendix, available with the full text of this article at NEJM.org). Continued drinking despite adverse consequences constitutes an alcohol-use disorder4 (Table 1). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), differentiates abuse from dependence,4 but recent research suggests that they represent one disorder, which the proposed taxonomy for the DSM-5 would consolidate into a single spectrum.9 At the severe end of the spectrum, chronic, severe dependence is a recurring brain disorder characterized by loss of control over drinking, drinking despite harm, daily or near-daily drinking, a compulsion to drink (“craving”), tolerance, withdrawal, and substantial disability. Despite observational studies that suggest that drinking lowers cardiovascular risk, the possibility of confounding raises concerns about recommending alcohol for heart health.10 Definitive data from trials are lacking to prove the cardiovascular benefits of alcohol, and the harms associated with alcohol are well established7 (Fig. S1 and S2 in the Supplementary Appendix). For example, beverage alcohol is a carcinogen, and even light drinking is associated with increased risks of oropharyngeal, esophageal, and breast carcinomas.11 For people with a prior alcohol-use disorder, young adults at low risk for cardiovascular disease, women who are pregnant or trying to conceive, people with conditions that are caused or exacerbated by alcohol (Table S1 in the Supplementary Appendix), and people who are going to operate a vehicle or machinery, the risks of drinking outweigh any supposed health benefits.

Key Clinical Points

Alcohol Use In Adults

Consuming 15 or more standard drinks per week or 5 or more on an occasion, for men, or 8 or more drinks weekly or 4 or more on an occasion, for women and people older than 65 years of age, confers a risk of alcohol-related harm.
Drinking at these risk levels can be clinically silent, so clinicians should screen adults with validated questionnaires about consumption.
When risk drinking is suspected, the clinician should, at a minimum, assess the consumption pattern, adverse consequences (including alcohol-related health problems and criteria for an alcohol-use disorder), and readiness to change drinking.
Brief interventions can reduce alcohol consumption and adverse consequences in risk drinkers without alcohol dependence.
Pharmacotherapy with brief medical-management counseling can reduce heavy drinking in persons with alcohol dependence.
Clinicians should monitor and manage risk drinking and alcohol-use disorders longitudinally.