The Epidemiology of Alcohol Use, The Epidemiology of Alcohol Use, Abuse and DependenceAbuse and Dependence

Deborah Hasin, Ph.D.Deborah Hasin, Ph.D.Columbia UniversityColumbia University

New York State Psychiatric InstituteNew York State Psychiatric Institute

What is Epidemiology?What is Epidemiology?

Descriptive epidemiologyDescriptive epidemiology: The distribution of health : The distribution of health conditions and diseases in populationsconditions and diseases in populations– Purposes: to identify time trends, groups at special risk, need for Purposes: to identify time trends, groups at special risk, need for

policies and servicespolicies and services

PrevalencePrevalence: : Proportion of cases in a total populationProportion of cases in a total population

IncidenceIncidence: : Proportion of new cases developing in a specific time Proportion of new cases developing in a specific time among those without the disease at the outsetamong those without the disease at the outset

Analytic epidemiologyAnalytic epidemiology: Investigation of potential causes/risk : Investigation of potential causes/risk factors (genetic variants, contextual circumstances) of illness, factors (genetic variants, contextual circumstances) of illness, often done through:often done through:– Retrospective comparison of cases to non-casesRetrospective comparison of cases to non-cases

– Prospective study of disease developmentProspective study of disease development

First things first: not all drinking is badFirst things first: not all drinking is bad

Reasons for drinking include Reasons for drinking include enhanced sociability, enhanced sociability, enjoyment, festivitiesenjoyment, festivities

In many countries, drinking In many countries, drinking alcohol is normative alcohol is normative

Light to moderate drinking is Light to moderate drinking is protective against protective against cardiovascular disease and cardiovascular disease and mortalitymortality

Alcohol in excess – Alcohol in excess – a major public health problema major public health problem

Excess alcohol consumption Excess alcohol consumption 33rdrd largest largest cause of U.S. cause of U.S. preventable mortalitypreventable mortality (Mokdad et al., 2000)(Mokdad et al., 2000)

Excess alcohol consumption Excess alcohol consumption 55thth largest largest cause of cause of preventable disability worldwidepreventable disability worldwide ((EzzatiEzzati et al., 2002) et al., 2002)

Excess alcohol consumption and alcohol use disorders Excess alcohol consumption and alcohol use disorders aassociated with:ssociated with:

Accidents, traffic fatalities, domestic violenceAccidents, traffic fatalities, domestic violenceFetal Alcohol SyndromeFetal Alcohol SyndromeNeuropsychological impairment Neuropsychological impairment Poor medication adherence, e.g., HIVPoor medication adherence, e.g., HIVEconomic costs and lost productivityEconomic costs and lost productivityPsychiatric comorbidity, functional disabilityPsychiatric comorbidity, functional disability

Total per capita ethanol consumption, United Total per capita ethanol consumption, United States, 1790-1978 States, 1790-1978

Source: ME Lender and JK Martin, Drinking in America: A History, Free Press:NY, 1982.Note: For prohibition years (1920-30), amounts adapted from WJ Rorabaugh, The Alcoholic Republic: An American Tradition (NY, 1979).

Total per capita ethanol consumption, United Total per capita ethanol consumption, United

States, 1935–2005States, 1935–2005

Age-adjusted death rates of liver cirrhosis by sex Age-adjusted death rates of liver cirrhosis by sex (death registration States, 1910-1932, and United (death registration States, 1910-1932, and United

States, 1933-2004)States, 1933-2004)

Total and alcohol-related traffic fatality rates per Total and alcohol-related traffic fatality rates per 100,000 registered vehicles, United States, 1982-100,000 registered vehicles, United States, 1982-

20042004

Monitoring the Future (MTF) study Monitoring the Future (MTF) study Drunk (past 30 days) Drunk (past 30 days)

and disapprove of heavy drinkingand disapprove of heavy drinking

Image Removed – Awaiting Copyright Permissions

Total per capita consumption in gallons of Total per capita consumption in gallons of ethanol by State, United States, 2005ethanol by State, United States, 2005

Total Alcohol Consumption by Country, 2002Total Alcohol Consumption by Country, 2002High-consumption countries (WHO)High-consumption countries (WHO)

RankRank CountryCountry Litres pure alcoholLitres pure alcohol22 UgandaUganda 18.5718.57

55 UkraineUkraine 15.5815.58

66 Russian FederationRussian Federation 15.2315.23

77 South KoreaSouth Korea 14.8414.84

88 IrelandIreland 14.7214.72

1818 ZimbabweZimbabwe 13.4613.46

1919 FranceFrance 13.3413.34

2020 United KingdomUnited Kingdom 13.2913.29

2121 GermanyGermany 13.1813.18

3636 PolandPoland 10.9410.94

Total Alcohol Consumption by Country, 2002Total Alcohol Consumption by Country, 2002Intermediate-consumption countries (WHO)Intermediate-consumption countries (WHO)

RankRank CountryCountry Litres pure alcoholLitres pure alcohol4848 JapanJapan 9.69.6

4949 United StatesUnited States 9.589.58

5353 AustraliaAustralia 9.179.17

5454 South AfricaSouth Africa 9.129.12

5757 SwedenSweden 8.988.98

5959 BrazilBrazil 8.768.76

6868 ThailandThailand 7.717.71

7171 IcelandIceland 7.627.62

7777 Dominican RepublicDominican Republic 7.457.45

9999 EthiopiaEthiopia 5.515.51

Total Alcohol Consumption by Country, 2002Total Alcohol Consumption by Country, 2002Low-consumption countries (WHO)Low-consumption countries (WHO)

RankRank CountryCountry Litres pure alcoholLitres pure alcohol110110 CongoCongo 4.54.5

113113 TurkeyTurkey 4.094.09

121121 North KoreaNorth Korea 3.483.48

125125 IsraelIsrael 3.283.28

130130 VietnamVietnam 2.872.87

139139 IndiaIndia 2.172.17

153153 MoroccoMorocco 1.451.45

165165 EgyptEgypt 0.640.64

174174 PakistanPakistan 0.310.31

183183 Afghanistan Afghanistan 0.030.03

Wave of attacks on Iraqi alcohol sellers

Shops selling alcohol have become targets in a wave of attacks. BBC World News, July 22, 2004

Substance Availability Can Change

Substance availability throughout the world can change rapidly, as a result of changes in government regulation, taxation, confiscation, wars, religious conflicts, marketing efforts, etc.

Factors affecting risk of heavy drinking and alcohol use disordersFactors affecting risk of heavy drinking and alcohol use disorders

Availability – temporal, geographical

Price, laws, advertising

Parental, peer influences

Stress

Religiosity

Cognition, Personality

Comorbidity

Genetics

External Macro

Internal Micro

Subjective Reactions

Measurement issues in alcohol consumptionMeasurement issues in alcohol consumption

Per capita consumption usually shows higher consumption Per capita consumption usually shows higher consumption than surveysthan surveysMany factors affect survey reports of alcohol, including Many factors affect survey reports of alcohol, including – ethanol content of different drinks ethanol content of different drinks

– non-standardized drink sizes non-standardized drink sizes

– amounts poured in different circumstances amounts poured in different circumstances

– time frame coveredtime frame covered

– Context of questions in the survey Context of questions in the survey

Survey methods do adequate job, but new methods under Survey methods do adequate job, but new methods under investigation to improve survey reports of alcohol consumption investigation to improve survey reports of alcohol consumption (Greenfield & Kerr,2008)(Greenfield & Kerr,2008)

DSM-IV Alcohol DependenceDSM-IV Alcohol Dependence

MMaladaptive drinking leading to clinically significant aladaptive drinking leading to clinically significant impairment or distress, shown by 3+ of the following in impairment or distress, shown by 3+ of the following in the same 12-month periodthe same 12-month period::

1.1. Drinking more or longer than intendedDrinking more or longer than intended2.2. Persistent desire or unsuccessful efforts to cut down or Persistent desire or unsuccessful efforts to cut down or

stopstop3.3. A great deal of time spent on drinking or getting over its A great deal of time spent on drinking or getting over its

effectseffects4.4. Important activities given up or reduced because of Important activities given up or reduced because of

drinkingdrinking5.5. Continued drinking despite knowledge of a serious Continued drinking despite knowledge of a serious

physical or psychological problemphysical or psychological problem6.6. ToleranceTolerance7.7. Withdrawal, or drinking to avoid or relieve drinkingWithdrawal, or drinking to avoid or relieve drinking

Alcohol Dependence SyndromeAlcohol Dependence Syndrome(Edwards and Gross, 1976)(Edwards and Gross, 1976)

Dependence concept based on close Dependence concept based on close observation of patientsobservation of patients

The concept: a combination of physiological and The concept: a combination of physiological and psychological processespsychological processes

Dimensional rather than yes or noDimensional rather than yes or no

Bi-axial distinction of core alcohol dependence Bi-axial distinction of core alcohol dependence syndrome from its consequences the basis for syndrome from its consequences the basis for dependence/abuse dependence/abuse

DSM-IV Alcohol AbuseDSM-IV Alcohol Abuse

NNot dependent, ot dependent, and and maladaptive drinking leading to maladaptive drinking leading to clinically significant impairment or distress, shown by 1 clinically significant impairment or distress, shown by 1 + of the following+ of the following::

1.1. Continued use despite social/interpersonal problemsContinued use despite social/interpersonal problems

2.2. Hazardous use (e.g., driving when impaired by alcohol)Hazardous use (e.g., driving when impaired by alcohol)

3.3. Frequent drinking leading to failure to function in major Frequent drinking leading to failure to function in major rolesroles

4.4. Legal problemsLegal problems

National Epidemiologic Survey on Alcohol and National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave 1: 2001-2002Related Conditions (NESARC) Wave 1: 2001-2002

National sampleNational sampleN= 43,093N= 43,093Response rate 81%Response rate 81%NIAAA & NIDA NIAAA & NIDA sponsoredsponsoredHousehold, group Household, group residentsresidentsOversamples Blacks, Oversamples Blacks, Hispanics, young Hispanics, young adults (18-24 yrs)adults (18-24 yrs)DSM-IV diagnosesDSM-IV diagnosesIn-person interviewsIn-person interviews

Alcohol Use Disorders and Associated Alcohol Use Disorders and Associated Disabilities Interview ScheduleDisabilities Interview Schedule (AUDADIS)(AUDADIS)

Grant et al., Ruan et al., Grant et al., Ruan et al., Drg Alch DepDrg Alch Dep 1995; 2003 2008 1995; 2003 2008

Fully structured, designed for lay interviewersFully structured, designed for lay interviewers

Coverage: Major Axis I disorders and all Axis II disordersCoverage: Major Axis I disorders and all Axis II disorders

Family history of alcohol, drug, antisocial and depressive disordersFamily history of alcohol, drug, antisocial and depressive disorders

Treatment utilizationTreatment utilization

Medical problemsMedical problems

Overall functioningOverall functioning

Early and adult stressful eventsEarly and adult stressful events

DiscriminationDiscrimination

Current and Lifetime Prevalence DSM-IV Alcohol Abuse and Dependence

Current Lifetime

Alcohol abuse 4.7 17.8

Alcohol dependence 3.8 12.5

Any alcohol disorder 8.5 30.3

Hazard Rates for Age at Onset of DSM-IV Alcohol Abuse and

Dependence

Image Removed – Awaiting Copyright Permissions

Average age at onset and durationAverage age at onset and duration

Alcohol AbuseAlcohol Abuse Onset: Onset: 22.5 years22.5 years

Duration: Duration: 32.9 months32.9 months

Alcohol DependenceAlcohol Dependence Onset: Onset: 21.9 years21.9 years

Duration: Duration: 44.1 months44.1 months

Number of lifetime episodesNumber of lifetime episodes

Most (72.0%) had Most (72.0%) had only oneonly one episode episode

Of those with >1 episode of Alcohol AbuseOf those with >1 episode of Alcohol Abuse

Mean number episodes 5.2Mean number episodes 5.2

Of those with >1 episode of Alcohol DependenceOf those with >1 episode of Alcohol Dependence

Mean number episodes 5.1Mean number episodes 5.1

Current DSM-IV Alcohol Use Disorders Current DSM-IV Alcohol Use Disorders by Genderby Gender

12.4

6.9

5.44.9

2.6 2.3

0

2

4

6

8

10

12

14

Any alcohol usedisorder

Alcohol abuse Alcohol dependence

Male

Female

Pre

vale

nce

(%

)

Lifetime DSM-IV Alcohol Use Disorders Lifetime DSM-IV Alcohol Use Disorders by Genderby Gender

42.0

24.6

17.419.5

11.5

8.0

0

5

10

15

20

25

30

35

40

45

Any alcohol usedisorder

Alcohol abuse Alcohol dependence

Male

Female

Pre

vale

nce

(%

)

Prevalence of lifetime DSM-IV alcohol Prevalence of lifetime DSM-IV alcohol dependence by birth cohort and genderdependence by birth cohort and gender

5.1

5.8

4.0

3.3

2.1

3.8

6.4

3.6

2.4

4.0

0

1

2

3

4

5

6

7

White NativeAmerican

Hispanic Black Asian

Abuse

Dependence

Current DSM-IV Alcohol Abuse and Dependence by Race-Ethnicity

Pre

vale

nce

(%

)

20.3

22.9

11.5 12.2

5.6

13.8

20.1

8.4

6.0

4.0

0

5

10

15

20

25

White NativeAmerican

Hispanic Black Asian

Abuse

Dependence

Lifetime DSM-IV Alcohol Abuse and Dependence by Race-Ethnicity

Pre

vale

nce

(%

)

4.54.0

2.9

2.2

3.2

5.5

6.26.6

0

1

2

3

4

5

6

7

8

$0-19,999 $20,000-34,999 $35,000-$69,999 $70,000+

Dependence

Abuse

Current DSM-IV Alcohol Dependence and Abuse by Income

Pre

vale

nce

(%

)

Disability by diagnosis, and by number of Disability by diagnosis, and by number of dependence criteriadependence criteria

Image Removed – Awaiting Copyright Permissions

Treatment RatesTreatment Rates Current DSM-IV Abuse and Dependence Current DSM-IV Abuse and Dependence

1991-1992 and 2001-20021991-1992 and 2001-2002

13.8

12.1

4.4

3.1

0

2

4

6

8

10

12

14

16

NLAES 1991-1992 NESARC 2001-2002

Alcohol Dependence

Alcohol Abuse

Tre

atm

ent R

ates

(%

)

Treatment RatesTreatment Rates Lifetime DSM-IV Abuse and Dependence Lifetime DSM-IV Abuse and Dependence

1991-1992 and 2001-20021991-1992 and 2001-2002

23.5 24.1

9.27.0

0

5

10

15

20

25

30

NLAES 1991-1992 NESARC 2001-2002

Alcohol Dependence

Alcohol Abuse

Tre

atm

ent R

ates

(%

)

Most Common Alcohol Treatment/Help Seeking Settings Among Individuals with Current Alcohol Abuse or

Dependence

Treatment/Help Seeking Setting

Alcohol Abuse

Alcohol Dependenc

e

Physician or other health care professional 0.6% 6.7%

12-step program 2.0% 7.4%

Rehabilitation program 0.7% 4.3%

DSM-V issues concerning DSM-V issues concerning dependencedependence

Alcohol dependence is a highly reliable, valid alcohol Alcohol dependence is a highly reliable, valid alcohol diagnosis, however:diagnosis, however:

– Should a Should a severityseverity indicator of dependence be added, as indicator of dependence be added, as has been used in small-sample/low-frequency genetics has been used in small-sample/low-frequency genetics studies (studies (Hasin et al., 2002; Heath et al., 2001Hasin et al., 2002; Heath et al., 2001)?)?

– Should Should drinking leveldrinking level be added as a criterion or as an extra be added as a criterion or as an extra requirement (Li et al., 2007), e.g., Project COMBINE? requirement (Li et al., 2007), e.g., Project COMBINE? (Anton (Anton et al., 2006)et al., 2006)

– Can biological Can biological endophenotypesendophenotypes be identified that would aid be identified that would aid in the diagnosis, e.g., the COGA study? in the diagnosis, e.g., the COGA study? (Hesselbrock et al., (Hesselbrock et al., 2001; Edenberg et al., 2004)2001; Edenberg et al., 2004)

DSM-V issues concerning abuseDSM-V issues concerning abuse

Alcohol abuse is less clear Alcohol abuse is less clear

– Keep abuse as it is now? Keep abuse as it is now?

– Diagnose it independently from dependence?Diagnose it independently from dependence?

– Combine abuse and dependence criteria (Saha et Combine abuse and dependence criteria (Saha et al., 2006)?al., 2006)?

– Drop abuse entirely on the assumption that it is Drop abuse entirely on the assumption that it is just a prodromal phase of dependence?just a prodromal phase of dependence?

Evidence for dependence as continuous Evidence for dependence as continuous condition with graded severity: NESARCcondition with graded severity: NESARC

National Epidemiologic Survey on Alcohol and National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave 2: 2004-2005Related Conditions (NESARC) Wave 2: 2004-2005

National sampleNational sampleN= 34,653N= 34,653Cumulative response rate Cumulative response rate 70.2%70.2%Covered period since Wave Covered period since Wave 1 interview, incorporting 1 interview, incorporting information from Wave 1 information from Wave 1 through computerized through computerized interviewinterviewAdded additional diagnoses, Added additional diagnoses, risk factors and risk factors and consequences of alcohol consequences of alcohol and other disordersand other disordersDSM-IV diagnosesDSM-IV diagnosesIn-person interviewsIn-person interviews

Incidence of alcohol use disordersIncidence of alcohol use disorders (Grant et al., Molecular Psychiatry 2008)(Grant et al., Molecular Psychiatry 2008)

First time studied in the U.S. general populationFirst time studied in the U.S. general population

– One-year incidence rates (cases per 100 person-years at One-year incidence rates (cases per 100 person-years at risk) of alcohol dependence and abuse were among the risk) of alcohol dependence and abuse were among the highest of all disorders: 1.70 for dependence, 1.02 for abusehighest of all disorders: 1.70 for dependence, 1.02 for abuse

– Demographic predictors similar to those previously shown Demographic predictors similar to those previously shown for prevalence (male, unmarried, younger) for prevalence (male, unmarried, younger)

– Strongest psychiatric predictors: Drug disorders, borderline Strongest psychiatric predictors: Drug disorders, borderline personality disorder, bipolar disorder, generalized anxiety personality disorder, bipolar disorder, generalized anxiety disorderdisorder

Relapse of alcohol dependence Relapse of alcohol dependence (Dawson et al., Alch Clin Exp Rsch 2007)(Dawson et al., Alch Clin Exp Rsch 2007)

First time studied in the U.S. general populationFirst time studied in the U.S. general population

– 1,772 had current alcohol dependence at Wave 1 and were re-1,772 had current alcohol dependence at Wave 1 and were re-interviewed at Wave 2interviewed at Wave 2

– Type of remission predicted likelihood of relapseType of remission predicted likelihood of relapse

– Three types: high-risk drinker (according to Clinician’s Guide), low Three types: high-risk drinker (according to Clinician’s Guide), low risk drinker, abstainerrisk drinker, abstainer

– In respondents aged 35+, symptom recurrence differed significantly In respondents aged 35+, symptom recurrence differed significantly by remission status at Wave 1: 51.0% in high-risk drinkers, 27.2% by remission status at Wave 1: 51.0% in high-risk drinkers, 27.2% in low-risk drinkers, and 7.3% in abstainers. in low-risk drinkers, and 7.3% in abstainers.

– Risk of relapse did not differ significantly by Wave 1 remission Risk of relapse did not differ significantly by Wave 1 remission status in respondents aged 34 or lessstatus in respondents aged 34 or less

SummarySummary

Alcohol consumption, abuse and dependence show Alcohol consumption, abuse and dependence show much variability by time, geographic location and much variability by time, geographic location and individual characteristicsindividual characteristics

Risk is affected by many factors, from availability and Risk is affected by many factors, from availability and laws to personal experiences to geneslaws to personal experiences to genes

All of this variability potentially points out directions for All of this variability potentially points out directions for policy and the investigation of etiologypolicy and the investigation of etiology

Much more needs to be done to understand these Much more needs to be done to understand these factors fully, and NESARC data are available to factors fully, and NESARC data are available to stimulate further studiesstimulate further studies

AcknowledgementsAcknowledgements

Bridget Grant, Ph.D., Ph.D.Bridget Grant, Ph.D., Ph.D.Katherine Keyes, M.P.H. Katherine Keyes, M.P.H. Fred Stinson, Ph.D. Fred Stinson, Ph.D.

NIAAA and NIDA for the NESARC dataNIAAA and NIDA for the NESARC data

Current support: R01 AA013654, Current support: R01 AA013654, K05 AA014223K05 AA014223, , R01 DA018652, R01 DA018652, New York State Psychiatric New York State Psychiatric InstituteInstitute

Contact information for Dr. Hasin: Contact information for Dr. Hasin: dsh2@columbia.edudsh2@columbia.edu