Module1Epidemiology-1

8/3/2019 Module1Epidemiology-1

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Epidemiology of Alcohol Problems

in the United States

NIAAA Social Work Education

Module 1

(revised 3/04)


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Objectives

A. Describe demographic characteristics andhistorical trends of alcohol use, alcoholabuse/dependence and other alcohol-related

problemsB. Identify the relationship between level of

alcohol consumption and health effects

C. Recognize the implications of utilizing

epidemiological data for early interven-tion andprevention of alcohol problems, and forevaluating intervention impact


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Epidemiologic Approach to Alcohol

Problems

An ecological model

Addresses etiology, natural history

Identifies interaction of vulnerability,

risk, and resilience factorsStudy of alcohol use, abuse, and

dependence in communities, populations


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Epidemiologic Rates

Incidence Rate= The rate at which new

cases occur in a population during aspecific period (e.g., over one year)

Prevalence Rate= The proportion of acases that exist in a population at apoint in time


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Differing Measures across Studies

New Case can be defined as:

Age or year of first use or first intoxication versus

Age of onset of alcohol dependence (ageof first experience of any clinical criterionsymptoms for diagnosis)

versus Age of occurrence of the third dependence

symptom or age when symptoms firstcluster (2 or more symptoms in a year)


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Standard Drink Measure


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Defining Alcohol Consumption

Prior to 1970, per capita consumption =

total alcohol beverage sales

total population over age 15 years

Since 1970, per capita consumption =total alcohol beverage sales

total population over age 14 years

The 1997 per capita consumption was2.18 gallons of ethanol per person


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Source: NIAAA, 1995

At Risk Drinking by Age and

Gender

Population group

Men

Women

Elders (65+ )

Per week Per occasion

> 14 drinks > 5 drinks

> 7 drinks > 3-4 drinks

> 7 drinks > 1 drink


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Drinking Patterns (Defined according toquantity & frequency of alcohol consumption)

Abstainer: has never drank or drinks < once/yr

Less Frequent: drinks 1-3 times/month andmay or may not drink 5 or more drinks at leastonce/yr

Frequent: drinks at least once a week and may

or may not drink 5 or more drinks at one sittingFrequent Heavy Drinker: drinks at least once a

week and has 5 or more drinks at one sitting atleast once per week


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Drinking Episodes Defined(National Household Survey)

Binge Drinking as 5 or more drinks per

occasion

Heavy alcohol use as 5

or more drinks for 5 ormore days per month

2002 Microsoft Corporation.


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Drinking Episodes Defined(NIAAA Advisory Council Task Force)

A drinking binge is a pattern ofdrinking that brings blood alcohol

concentrations (BAC) to 0.08 or above.Typical adult males: 5 or more drinks in

about 2 hours

Typical adult females: 4 or moreFor some individuals, the number of

drinks needed to reach binge levelBAC is lower


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Binge drinking is distinct from:

risky drinking (reaching a peakBAC between .05 gm% and .08gm%)

a bender (2 or more days ofsustained heavy drinking)


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People with risk factors for thedevelopment of alcoholism have increased

risk with any alcohol consumption, eventhat below a risky level.

For pregnant women, any drinkingpresents risk to the fetus.

Drinking by persons under the age of 21 isillegal.

Binge drinking is clearly dangerous for the

drinker and society.


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At Risk or Problem Use

Drinking above established cut-off limits

AND No current problems associated with

drinking

ORAlcohol use in risky situations


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Definition of Alcohol Abuse

Failure to carry out majorobligations at work,home or school because

of repeated alcohol use Repeated use of alcohol

even when its physicallydangerous to do so.

Repeated experience oflegal problems

Continued alcohol use

despite knowing that ithas caused or worsenedsocial or interpersonalproblems.

Maladaptive alcohol use causes clinically importantdistress or impairment, shown in a single 12-monthperiod by one or more of the following:


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Definition of Alcohol Dependence

Tolerance or withdrawalAmount/duration of use

greater than intended.Unsuccessful efforts to

control or reduce useSpending much time

using alcohol, recoveringfrom its effects, or trying

to obtain it.

Reducing or abandoningimportant work, social orleisure activities becauseof alcohol use.

Continued alcohol usedespite knowing that ithas probably causedongoing physical orpsychological problems.

Maladaptive alcohol use causes clinically importantdistress or impairment, shown in a single 12-monthperiod by three or more of the following:


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Historical Trends: 1850-1997

0

0.5

1

1.52

2.5

3

Year

GallonsEthanol

SpiritsWine

Beer

Source: Nephew et al., 1999


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Prevalence of Lifetime Alcohol

Use by Age and Gender

0

1020

30

40

50

60

70

80

90

Percent

18-24 25-34 35-44 45-55 55+

Age Groups

Male

Female


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National Trends

02468

101214

1618

Country

LitersE

thanolCons

umed

1970

19801990

Source: NIAAA, 1997a


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Age Trends:Alcohol Use

0

1020

30

40

50

60

70

80

90

1993 1994 1995 1996 1997

Percent

8th

10th

12th

Source: Johnston et al., 1998


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Age Trends: Intoxication

0

10

20

30

40

50

60

70

1991 1992 1993 1994 1995 1996 1997

Percent

8th

10th

12th



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Age Trends: Heavy Use in Past 30

Days

0

5

10

15

20

25

30

35

1991 1992 1993 1994 1995 1996 1997

Percent

8th

10th

12th



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Prevalence of Lifetime Alcohol

Dependence (DSM-IV)

05

10

15

20

25

Percent

18-24 25-34 35-44 45-55 55+Age Groups

MaleFemale

Source: SAMHSA, 2000a


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Prevalence of Alcohol Use

(Men) and Dependence by Age

0

1020

30

40

50

6070

80

90

Percent

18-24 25-34 35-44 45-55 55+

Age Groups

Use

Dependent


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Prevalence of Alcohol Use

(Women) and Dependence by Age

0

10

20

30

40

50

60

70

Percent

18-24 25-34 35-44 45-55 55+

Age Groups

Use

Dependent


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Alcohol Use & Aging Populations

National HouseholdSurvey on DrugAbuse, 2000

1.6%of elders reportheavy drinking inpast 30 days

Aging primary carepatients

15% male, 12%female abuse alcohol

Community sample

2.2 to 9.6%of eldersabuse alcohol

Hospitalized adults >40:

21%abused alcohol

SAMHSA TIP Series, 98

Up to 17%of older adultsare affected by alcoholand prescription drugproblems


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Additional Risks Related to Alcohol

Use and Aging

Elderly individuals are more likely to be

affected by chronic illness and use ofmedications.

Alcohol and prescription drug problems

are frequently: Under-identified

Under-estimated

Under-diagnosed

Under-treated


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Age and GenderInteractions

0

10

20

30

4050

60

70

Male

18-25

Female

18-25

Male

26+

Female

26+

Percent Any Use

Binge

Heavy

Source: SAMHSA, 1999a


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Past Month Alcohol Use by

Ethnicity:Ages 18-25

0

10

20

30

40

50

60

70

Whit

es

Black

Am.In

dian

Asian

Hisp

anic

Percent Any Use

Binge

Heavy

Source: SAMHSA,2000a


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Past Month Alcohol Use by

Ethnicity:Ages 26 or Older

0

10

20

30

40

50

60

Whit

es

Blac

k

Am.In

dian

Asian

Hisp

anic

Percent Any Use

Binge

Heavy



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Use of Alcohol and Other Drugs:

1999 Ages 1825

0102030405060708090

Alco

hol

Toba

cco

Mar

ijuana

Coca

ine

Hallu

cinog

ens

Presc

riptio

n

Hero

in

Percen

t

Lifetime

Past Year

Past Months



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Use of Alcohol and Other Drugs:

1999 Ages 26 and Older

010

2030405060708090

100

Alcohol

Toba

cco

Mariju

ana

Cocaine

Hallu

cinogens

Prescrip

tion

Heroin

Percent

Lifetime

Past Year

Past Months



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Reported Past Year Substance

Dependence by Age, 1999

0123456

789

10

Alcohol

Mariju

ana

Cocaine

Hallu

cinogens

Prescrip

tion

Heroin

Alc+Dr

ug

Percent

age 12-17

age 18-25

26 or older



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Source: Kuperman et al., 2001.

AdolescentRisk Factors

Risk Factors

Negative interaction with

motherNegative interaction with father

Parental alcohol dependence

Parents dislike friendsHeavy drinking friends

Daily cigarette smoking

1.6 - 4.6

1.7 - 4.0

2.52

3.7115.5

15.8

IncreasedOdds Ratio


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Source: Califano and Booth, 1998

Adolescent Risk Factors(continued)

27.119.8

6.5

5.013.5

Increased

Odds RatioRisk Factors

Marijuana abuseOther drug abuse

Dropping out of school

ADHDConduct disorder


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Problems Reported by Alcohol

Users (past year)

0

12

3

4

5

67

8

9

10

Health Psychological

Percent

12-


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Alcohol and Violence

Alcohol is related to both aspects ofviolence -- perpetration and victimization

Offenders were drinking in: 86% of homicides

60% of sexual offences

37% of assaults 27% of females and 57% of males involved

in marital violence

13% of child abuse cases Source: Roizen, 1997)


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Alcohol and Violence (continued)

Roizen, 1993

Alcohol isassociated

with:

13%-50% of offenders in rapecases

6%-36% of victims in rape cases

Miczek et al.,1993

Identifiedalcohol in:

35%-65% of rape cases (6 studies)

~50% of incest cases (2 studies)

20%-83% of family violence cases(3 studies)

10%-83% of homicides (6 studies)

33%-57% of felonies (2 studies)


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Risk factors for becoming violent: History of violence

Multiple drug use Co-morbid psychiatric disorder

Rates for alcohol-related violence hard to find: Rates of alcohol involvement vary across studies

making comparison difficult Hard to establish a causal relationship due to

other factors (e.g., interaction between personalityfactors and alcohol)

Alcohol and Violence (continued)


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Alcohol, Drug, and Violent

Events Related to Arrest

0

10

20

30

40

50

60

Percent

Alcohol

Drug

ViolenceSource: Nunes-Dinis & Weisner, 1997


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Alcohol and Drug Use: 12 Monthsof Arrests in Northern California

0

10

20

30

40

50

60

70

Percent

Alc. Frequent

Alc. Infreq.

Drug Weekly

Drug MonthlySource: Nunes-Dinis & Weisner, 1997


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Alcohol-Related Hospitalizations

Hospital discharges (1997):

Alcohol-related diagnosis was first-listed

(primary) diagnosis for 20.2 per 10,000population aged 15 and older

All listed alcohol-related diagnosis was 64.5per 10,000 population

Alcohol-related morbidity episodes notappearing as a first-listed (primary)diagnosis = 69%


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Alcohol-Related Hospitalizations(continued)

Disorder Percent

Alcohol dependence syndrome 49%

Alcohol psychosis 22%

Cirrhosis of the liver 20%

Alcohol abuse, nondependent 9%


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Age-Adjusted Liver CirrhosisMortality U.S. 1910-1996

0

5

10

15

20

25

1910

1920

1930

1940

1950

1960

1970

1975

1980

1985

1990

1995

1996

Ratesper100

,000

Male

Female

Source: Saadatmand et al., 1999


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Vulnerability to Alcohol-Related

Liver Disease Genetic Factors

Dietary Factors Gender

Hepatitis C

Level of Alcohol Intake

Source: NIAAA, 2001b


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02468

101214

AlcR

elated

Othe

rspecifi

ed

Unspecifi

ed

Ratesper

100,000 Hisp-M

White-M

Black-M

Hisp-F

White-F

Black-F

Alcohol-Related Cirrhosis by Raceand Gender (Age-Adjusted, 1996)

Source: Saadatmand et al., 1999.


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Alcohol Consumption Among U.S.Pregnant & Child-bearing AgedWomen

0

10

20

30

40

50

60

1991

1995

1999

percent

Pregnant

All women

Sources: SAMHSA,1999a; CDC, 1997


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Frequent Drinking Among U.S.

Pregnant & Child-bearing AgedWomen

0

2

4

6

8

1012

14

1991

1995

Percent

Pregnant

All women

Source: CDC, 1997.


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Binge Drinking Among U.S.Pregnant & Child-bearing AgedWomen

02

468

101214

161820

1991

1995

1999

Percent

Pregnant

All women

Sources: SAMHSA,1999a; CDC , 1997


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Reported Rates of Fetal Alcohol

Syndrome, U.S. 1979-1993

01

2

3

4

5

6

7

8

1979

1981

1983

1985

1987

1989

1991

1992

1993

Ratesper10,0

00Birth

Source: CDC, 1995a


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Prenatal Alcohol Exposure

How many drinks can apregnant women consume

without harm to the fetus?An estimated 550,000 to 750,000

U.S. children are born exposedto drugs/alcohol each year

Increased risk of childmaltreatment (abuse, neglect)and out of home placement 2002 Microsoft Corporation


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Risks of Fetal Alcohol Exposure

Low birth weight

Prematurity Small for gestational

age (SGA)

Failure to thrive (FTT)

Neurobehavioralsymptoms

Infectious disease

Sudden Infant DeathSyndrome (SIDS)

Fetal AlcoholSyndrome (FAS)

Other Fetal Exposure

Effects Compromised

developmentaloutcomes

53

d l l


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Compromised DevelopmentalOutcomes

Many unknowns to predict specific outcome

Certain physical problems may persist

Some problems not immediately apparent Secondary problems may emerge

Structured and nurturing environment maycompensate and promote development

Regular developmental evaluation needed

Need early identification of social, language,cognitive, and motor developmental problems

54


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Children Prenatally Exposed

Developmental patterns birth to 15months characterized by:

Unpredictable sleep patterns

Feeding difficulties

Irritability

Atypical social interaction Delayed language development

Poor fine motor development 2002 MicrosoftCorporation

55


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Toddlers (16-36 months):

Atypical social interaction

Minimal play strategies

Preschoolers (3-5 years):Easy loss of control

Mood swingsHyperactivity/short attention spanDifficulty transitioning between activitiesDifficulty processing auditory/visual info

Children Prenatally Exposed(continued)

2002 Microsoft Corporation

56

hild ll d


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School aged to adolescence: No conclusive research on

long-term biological orconstitutional effects ofdrug/alcohol exposure

Greater risk of maltreatment,learning disabilities, behaviorproblems

Children Prenatally Exposed(continued)

2002 Microsoft Corporation

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Alcohol Death Rates by Ethnicity(Age-Adjusted), 1979-1997

0

5

10

15

20

25

30

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

Ratesper100,000

White-M

White-F

Other-M

Other-F

Source: Hoyert et al., 1999

58

A Adj t d D th R t f


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Age-Adjusted Death Rates for10 Leading Causes, U.S. (1997)

0

50

100

150

200

250

300

Heart

dis

eases

Cancer

Cerebrovascular

Pulmonary

Pneum

onia

Diabe

tes

Car

Accid

ents

Oth

erAccid

ents

Alzheim

er's

Suicid

e

Liv

erd

isease

Homicid

e

Ratesper100,000 Male

Female


59


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Age-Adjusted Death Rates for Causes Other

Than Cancer, Heart, or Stroke, U.S. (1997)

0

51015202530

354045

Pulm

onary

Pneumo

nia

Diabete

s

CarA

ccid

ents

Othe

rAccide

nts

Alzheim

er's

Suici

de

Liverdise

ase

Homi

cide

Ratesper10

0,000

Male

Female


60

A Adj t d D th R t b


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Age-Adjusted Death Rates byCause, Ages 25-64 (1997)

0

50

100

150

200

250

300

Hea

rtdise

ases

Canc

er

Cere

brov

ascu

lar

Pneu

mon

ia

Diab

etes

Acci

dent

s

Suic

ide

Live

rdise

ase

Hom

icid

eH

IV

Ratesper10

0,000

25-44 M

45-64 M25-44 F

45-64 F


61


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Age-Adjusted Death Rates by Causes Otherthan Cancer, Heart, or Stroke, Ages 25-64(1997)

0

10

20

30

40

50

60

Pneu

monia

Diab

etes

Accid

ents

Suici

de

Liver

disea

se

Homi

cide

HIV

Ratesper100

,000

25-44 M

45-64 M

25-44 F

45-64 F


62


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Drug Abuse Deaths 1995-1998

0

1

2

3

4

5

6

7

8

1995 1996 1997 1998

NumberofCasesinThousand

Male

Female

Source: SAMHSA, 2000

63


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Drug-Related Deaths by Age (1996)

124

825

2090

6399

0

1000

2000

3000

4000

5000

6000

7000

6-17 yrs 18-25 26-34 35+

NumberofDe

aths


64


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Medical Examiner Mention of Drugs,

6-17 Year Old Decedents (n=124)


Category Mentioned:

Marijuana/hashish

Cocaine

Alcohol in combination

Opiates

Diazepam

# of % totalmentions episodes

52 41.9

26 21.0

23 18.6

22 17.7

10 8.1

65

Al h l I l t i


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Alcohol Involvement inEmergency Department Episodes

35% of drug episodes (1999) involved amention of alcohol-in-combination events

Rate per 100,000:

Alcohol in combination 81

Cocaine 69Marijuana 36

Opiates 35

Source: SAMHSA, 1999b

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Traffic Alcohol-Related Fatalities,

1977-1999

0

10

20

30

40

50

60

70

80

90

100

1977 1985 1990 1991 1993 1995 1997 1999

InThousand

s

Traffic Crash

Fatality

Alcohol Fatality

Source: Yi et al., 2001

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Alcohol Involvement in AccidentalDeath, Homicide, and Suicide

01020

30405060

70

8090

100

Burn/Fire

Hypot

hermia

Drow

ning Fall

Poison

ing

Gunsh

ot

Homic

ideSui

cide

CarC

rash

Percen

t

Positive Alcohol

Intoxicated

Source: Smith et al. , 1999

68Alcohol and Trauma by


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Alcohol and Trauma byInjury Type

0

100

200

300

400500

600

700

800

900

Car

Moto

rcyc

leFa

ll

Stabb

ing

Guns

hot

Pede

strian

Blun

tumberofTraumaPatients

Not Intoxicated

Intoxicated

Source: NIAAA, 1997

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Alcohol and Trauma, by Age

0

100

200

300

400

500600

700

800

900

18-24 25-34 35-44 45-54 55+

NumberofTraumaPatients Not Intoxicated

Intoxicated

Source: NIAAA, 1997

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Relative Risk Over 21 Years, AlcoholConsumption & Mortality (Scottish Men)

0

0.5

1

1.5

2

2.5

3

3.5

4

Heartdise

ase

Stroke

Alcoholr

elated

Allc

ause

Percent

1-7 drinks/wk

8-14 drinks/wk

15-21 drinks/wk

22-34 drinks/wk35+ drinks/wk

Source: Hart et al, 1999.

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Alcohol and Mortality: 11 Year Follow up


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Alcohol and Mortality: 11-Year Follow-up,

Adults Age 50+(16,304 Danish Men & Women)

010

20

30

40

5060

70

80

90


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DHHS & USDA Dietary Guidelinesfor Alcohol Consumption

Women- Moderate drinking, no more than 1 drink/day

Men- Moderate drinking, no more than 2 drinks/day

ChildrenAdolescents Should not drink at allPregnant women

Adults Unable to control drinking Recovering On certain meds Family history of alcoholism

Shouldnot drinkat all

73


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One Day Census of Clients in

Substance Treatment by Age

0

200

400

600

800

1000

1200

1987 1989 1990 1991 1992 1993 1995

Thousands 65+

45 - 64

21 - 44

18 - 20

Under 18

Source:

SAMHSA,

1997

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Appendices

Additional Materials Available forIncorporating into Classroom

Presentations

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Per Capita Consumption, 1935-98

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Per Capita Consumption, 1977-98

77Percent Changes in Per Capita


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Percent Changes in Per CapitaConsumption, 1977-1998

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Total Per Capita Consumption:


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Total Per Capita Consumption:Ethanol by State, 1997

1.99 or below

2.00 to 2.24

2.25 to 2.49

2.50 or over

U.S. to tal = 2.18

DC

1.99 or below2.00 to 2.242.25 to 2.492.50 or over

US total = 2.18

79


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U.S. Drinking Patterns

Source: National Longitudinal Alcohol Epidemiologic Survey, 1992.

Abstain 40% Dependent 5%

Low Risk 35%At Risk or

Problem 20%

80

Principal diagnosis of discharges


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Principal diagnosis of dischargeswith alcohol mentioned (1997)

6.8%

15.3%

3.7%

2.5%

3.0%

68.7%

Alcoholic psychoses

Alcohol dependencesyndrome

Cirrhosis, withmention of alcohol

Cirrhosis, withoutmention of alcohol

Nondependent abuseof alcohol

Nonalcohol-related

first-listed diagnosis

81Average deaths with explicit


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Average deaths with explicitmention of alcohol: 1986-1990

Module1Epidemiology-1

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