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Lloyd I. Sederer, MD

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Problem Drinking

Posted: 10/09/09 07:50 PM ET

How many times have you seen on TV or read in the paper of a DUI (driving under the influence) to later find out this person has offended before? Someone is killed every 22 minutes in the USA from an alcohol related crash. Someone is injured in an alcohol related crash on average every minute -- 500,000 people each year in the USA -- and one third of MVAs are associated with intoxication. Yet, we are more active about the health impact of passive smoking than we are about the (passive) victims of drunk driving. But DUIs are only a small part of the consequences of problem drinking.

Crime, including domestic violence and rape, is frequently perpetrated under the influence. Rates of sexually transmitted diseases such as HIV/AIDS, syphilis and gonorrhea, escalate when alcoholic disinhibition is at work. Pregnant women with problem drinking are at higher risk to deliver babies with fetal alcohol syndrome and a host of developmental delays and disabilities. Eighty percent of fire and drowning accidents involve heavy drinking. Alcoholism produces brain atrophy, peripheral nerve disorders, liver disease and pancreatitis, among other health problems. Sure, we have all read that a glass of wine promotes a healthy heart. But three glasses of wine or a six pack actually increases risk of hypertension, diabetes, even breast cancer.

Estimates of the criminal and health impacts of problem drinking are surely underestimated since often the diagnosis is not made, or disguised in order to protect someone or get insurance companies to pay for medical care in emergency rooms, hospitals and doctors' offices. What's more, we don't measure the cost, in terms of suffering, lost productivity and other costs, to family members - nor the often tragic consequences to those injured by cars and crimes as a result of alcohol abuse. Still, global studies (such as by the World Health Organization) attribute alcohol to have about 5% of the global burden of disease and injury (2004). In this country, the cost of alcohol related problems is $186 billion each year.

But this testy problem is not without proven strategies for improvement. What works from a public health point of view is making alcohol less available and more expensive; banning alcohol advertising; and lowering the legal levels of alcohol while driving -- and regularly stopping drivers (sobriety checkpoints). When France and Sweden restricted alcohol advertising it was challenged by the European Commission and the challenge failed. You may want to know that there is little evidence of the effectiveness from media campaigns such as "responsible drinking" (though alcohol manufacturers like to use this method), nor of marketing limitations that are self-imposed by the alcohol industry. Designated driver campaigns when studied have not shown effectiveness.

At the individual person level, researchers have demonstrated we have an effective means of identifying and intervening with people with problem drinking through a simple query by a doctor, nurse or other health professional when a patient comes for a medical visit. Called SBIRT (Screening Brief Intervention and Referral for Treatment) this is done by talking about drinking (counseling) and has shown remarkable impact. The simple, first step (screening) in SBIRT asks three questions: 1) On any day in the last month, have you ever had more than 4 drinks (men) or more than 3 drinks (women)?; 2) Think about your typical week, on average, how many days per week do you drink alcohol?; and 3) On a typical drinking day, how many drinks do you have? Responses above specified levels have the clinician provide brief counseling and referral if the person is ready.

Unhealthy drinking goes down dramatically, just like smoking, when people hear from their doctors that drinking a lot is unhealthy, that their doctors are concerned about the potential of drinking on their health, and they are given opportunities to consider and take action.

Results from a nation-wide SBIRT study of more than 600,000 patients showed nearly 40% of heavy drinkers cut down or stopped drinking six months after screening and brief counseling. A study in a large urban hospital found that brief alcohol counseling of injured patients reduced re-injury and re-hospitalization by about 50%. Medical procedure codes now exist so primary care doctors can bill for SBIRT. In other words, we have a simple, low burden, effective means of helping large numbers of problem drinkers. Studies of mandatory treatment, in fact, show far less robust effects than SBIRT (though this could represent differences in the severity of the problem).

Problem drinking is all too common. Solutions are clear and proven. But their use is rare. The safety, health and economic costs of problem drinking are legion. We can make a difference and we are hardly paying attention.

The opinions expressed herein are solely my own as a psychiatrist and public health advocate.

Lloyd I Sederer, MD, written with Eric Goplerud, PhD, Director of the Center for Integrated Behavioral Health Policy at George Washington University Medical Center.