Pitting Prevention Against Treatment: Putting the Patient at Risk

How much alcohol is too much to drink safely? A commonly heard phrase within the 12-step community is: “One drink is too many and 1000 drinks is not enough.” However, that phrase is also used to depict the problems of alcoholics. The definition of an alcoholic remains problematic, if not controversial - it is not defined by the number of drinks a person consumes, even though there are specific recommendations promulgated by federal agencies - those recommendations are guidelines.  The question is what happens when a person exceeds those guidelines. That question is a most important one.

A recent paper by Esser et al, published in the journal Preventing Chronic Disease contends that most excessive drinkers (90%) do not meet the criteria for alcohol dependence and thus are unlikely candidates for alcohol use disorder treatment.^[i] The authors arrived at their conclusion by examining a pooled cohort of individuals found in the National Survey on Drug Use and Health from 2009, 2010, and 2011 by way of a restricted-use data set created for the purpose of looking at the prevalence of alcohol dependence among excessive drinkers. The authors defined excessive drinking as “binge drinking, heavy drinking, any past 30-day drinking by respondents aged 18 to 20; or any past 30 day alcohol consumption by pregnant women."

In addition to the definition of excessive drinking, the authors noted in the introduction of their paper the observation that there are 88,000 deaths each year due to excessive alcohol consumption and that the cost to the US was an estimated $223.5 billion in 2006 alone. Furthermore, they observed that half of the deaths and three quarters of the economic costs were due to binge  drinking. They also noted that binge drinking is associated with a myriad of health and social problems. They then introduced the substance of their article with the unreferenced assertion that “it is often assumed that most excessive drinkers are alcohol dependent.” However, the authors conclude that they are not. So, if they are not alcohol dependent, then it follows that emphasizing treatment is misplaced. The authors reserved alcohol use disorder treatment for those who meet criteria for alcohol dependence. Their paper made no reference to the DSM-IV-TR diagnostic category of alcohol abuse disorder.

Thus, on one hand excessive drinking is a problem that leads to bigger problems, but on the other hand, it is not a problem that warrants treatment, according to Esser et al, because treatment appears to be indicated only if alcohol dependence can be codified using the DSM criteria. The authors offer no support for their conclusion that treatment for excessive drinking is not indicated. Their theory was, however, widely mentioned in the popular media, print, TV and online.

The Esser, et al article  was widely circulated in the mass media with reports appearing in the New York Times,^[ii] the Washington Post,^[iii] CBS,^[iv] USA Today,^[v] The Daily Beast,^[vi] and even on Saturday Night Live.^[vii] The titles for the mass media reports varied slightly and included: “Heavy Drinkers Are Rarely Alcoholics,” “Most Binge Drinkers Are Not Actually Alcoholics,” and “Vast Majority of Americans Who Drink Excessively Are Not Alcoholics, New CDC Study Shows.”

The mass media converted “alcohol dependence” used in the CDC journal into a readily understood synonym, “alcoholic”. The Saturday Night Live skit stated “a new government report concludes that 90% of people who drink excessively are not alcoholics and can change their behavior easily, which is exactly what an alcoholic would say.”^[viii]

The headlines appeared to reassure heavy drinkers, binge drinkers and excessive drinkers that all is well in the bottle. From a public health perspective, the question is whether in releasing this study, the CDC inadvertently promoted excessive drinking by reassuring those who drink too much that they are not alcoholics. The focus of both the article and the ensuing media messages seem to be on the label of “alcoholic” rather than the consequences of excessive drinking.

Esser, et al. contend that the National Survey on Drug Use and Health used criteria from the DSM-IV to define dependence. Thus, a person who answered the questions had to meet any three of seven criteria for a diagnosis. However, had the authors included the abuse category, their data analysis would have been different, as only one criterion needed to be met.

In DSM-IV, recurrent alcohol use that resulted in a failure to fulfill a major role or obligation, or poor work performance related to alcohol use would be sufficient to make a diagnosis of alcohol abuse, but not alcohol dependence. Recurrent alcohol use in situations in which it is physically hazardous would also be sufficient to make a diagnosis of alcohol abuse. The other two categories of recurrent alcohol use in the DSM-IV would be legal problems or continued use despite adverse consequences. By ignoring the alcohol abuse diagnostic category, Esser, et al. ignored real consequences of excessive drinking; they also avoid the question of whether treatment might benefit those who did not meet the criteria for dependence, but who had recurrent problems from their excessive alcohol consumption.

It should be noted that the generalizations made by Esser, et al. resulted from viewing excessive drinkers uniformly in the three categories used to pursue their analysis. However, as Cook and Moore note in their paper on the economics of alcohol abuse and alcohol control policies, there are wide differences in quantity of alcohol consumed among the excessive drinkers; they contend that the purchase and consumption of alcohol are highly concentrated, thus the top 10% of drinkers consume more than half of all alcohol.^[ix]

This was picked up by the Washington Post, which translated the Cook and Moore concept of the top 10 percenters into the following: “The top 10 percent of American drinkers - 24 million adults over age 18 - consume, on average, 74 alcoholic drinks per week. That works out to a little more than four-and-a-half 750 ml bottles of Jack Daniels, 18 bottles of wine, or three 24-can cases of beer. In one week. Or, if you prefer, 10 drinks per day.”^[x] Most would consider this, at least, to be excessive drinking, if not for reasons of psychosocial decrements in function, at least because of the toxic effects of excessive chronic alcohol consumption.

The authors of the CDC paper attempt to interpret the new DSM-5 in the context of DSM-IV’s alcohol dependence, stating that: “[T]he new Diagnostic and Statistical Manual of Mental Disorders, Version 5 (DSM-5) defines a spectrum of alcohol use disorders, and based on these diagnostic criteria, alcohol dependence would be classified as a severe alcohol use disorder.” This conclusion is a mis-interpretation of the DSM-5.

The DSM-5 lists 11 criteria for an alcohol use disorder. It then qualifies the diagnosis of alcohol use disorder by requiring a severity framework. The spectrum of severity is defined as follows: Mild: the presence of 2 to 3 symptoms; Moderate: the presence of 4 to 5 symptoms; Severe: the presence of 6 or more symptoms. In short, the DSM-IV diagnosis of alcohol dependence, which requires only 3 criteria, is not synonymous with DSM-5’s severe alcohol use disorder. All that is needed in the current DSM-5 diagnostic spectrum is at least 2 of the listed criteria--just two.^[xi] The DSM-5 appears to envision a graduated spectrum, allowing both the patient and the clinician to assess what is needed and indicated. It is clear from the discussion within DSM-5, that its authors believed that whatever intervention chosen should be appropriate and proportionate.

While the authors of the CDC paper contend that their findings suggest that most excessive drinkers are unlikely to need addiction treatment, they do not define addiction treatment. Furthermore, even after acknowledging the myriad of economic and social costs associated with excessive drinking, the authors find little need for individual level intervention, preferring, instead, population level interventions, such as increasing alcohol taxes, regulating outlet density and dram shop liability.

The odd part of the recommendations for population level interventions in lieu of individual level intervention is the recognition by the CDC Community Preventive Services Task Force (CPSTF) that evidence gaps are associated with the population level interventions mentioned by Esser, et al. For instance, additional research is recommended to determine whether changes in alcohol prices differentially affect drinking behavior and health outcomes for subgroups of the population.^[xii] 

Furthermore, with regard to regulating outlet densities, little is known about the impact of density changes relative to baseline density levels; there is a lack of research, according to the CPSTF, on the impact of reducing outlet density.^[xiii] State and local governments have enacted various caps on financial liability of servers and managers in dram shop cases, the CPSTF admits, necessitating the need for more research on the effectiveness of dram shop liability given these efforts to limit liability.^[xiv]

It is not clear why Esser, et al. find treatment to be superfluous in addressing the public health problem of excessive drinking. The authors are correct in noting that excessive drinking is linked to a host of problems for the individual and for society. Thus, the dichotomy should not be one of dependence or non-dependence, but one of the complications associated with excessive drinking. If problems related to drinking are experienced at the individual level, then the solutions should be pursued not simply at the population level, but also at the individual level. The determining factor should not be simply a matter of how many problems an individual is experiencing, but the impact of those problems on the health and well-being of that individual, that individual’s family and that individual’s community. Both the DSM-IV diagnosis of alcohol abuse and the DSM-5 diagnostic framework embracing a severity framework would require an individual assessment of the problems associated with excessive drinking, not a retreat into labels which at the community level reveal little.

Pitting prevention strategies against treatment strategies is unnecessary and counterproductive. The excessive drinker requires an appropriate assessment to determine the appropriate course of action. Focusing on labels in lieu of an appropriate assessment allows the affected individual to deny that problems exist. Treatment strategies run the gamut from mere advice, brief counseling, facilitated self-change, addiction-focused behavioral therapy, pharmacotherapy, to long-term care management.^[xv] The outcomes of treatment are of paramount importance. Determining what works for which person is essential; this concept is well known in the treatment of hypertension, diabetes, asthma, and other chronic conditions. It is no less important for excessive drinking.

Esser et al. also make a strong assertion that being poor is associated with alcohol dependence, but being middle class is not. This point was picked up by the mass media. Yet, the paper reports that being educated and middle class is associated with binge drinking. Thus, it appears that the authors have ignored a practical reality in the excessive drinking vs. dependence discussion--if you are well-educated and middle class, your problems manifest themselves differently than if you are poor. That should not be a surprise.

Other than the pharmacological criteria associated with dependence (or alcohol use disorder in DSM-5 parlance), the other criteria are psychosocial decrements of function. The CDC paper notes that binge drinking was most common among those with annual family incomes of $75,000 or more, while alcohol dependence was more common among those with family incomes of less than $25,000. When a person’s family income is $75,000 or more, it is much less likely that their psychosocial decrements of function would be manifest, experienced or acknowledged. The American Community Survey reports that the median family income in the United States for 2011 was $51,324. Purchasing power plays a role in the psychosocial realm of things. In addition, the types of employment that occur with higher incomes probably offer greater refuge to the excessive drinker who has problems associated with excessive drinking, thus making the impact of the excessive drinking less obvious.

Making alcohol dependence or alcoholism the province of the poor ignores the reach of this public health problem. It only allows those who are excessive drinkers but currently well off financially to distance themselves from the consequences of their drinking while disparaging those who are poor and also excessive drinkers.

The National Survey on Drug Use and Health (NSDUH) is a cohort analysis, not a longitudinal analysis. While possible, it is not likely that the same individuals will be surveyed over time. Nevertheless, age cohorts suggest that excessive drinking diminishes over time by cohort. Thus, those 18-25 years of age have different drinking patterns from those 45-64 years of age. However, the NSDUH data do not reveal how many of those who drink excessively in the 18-24 year cohort persist in drinking in their later years. Pooling data from multiple years cannot answer that question. The data do raise the possibility that different solutions might work for different age cohorts. Furthermore, there are other cohorts and mitigating factors, e.g., gender, race, ethnicity, and geography. The pooled data of the published paper could not address the needs of these multifaceted dimensions.

The author’s proposed solutions to excessive drinking might appear to some as simplistic. These solutions alone might work well for children and many adolescents, but not for many adults. Alcohol is relatively inexpensive to make. While strong prevention strategies are always desirable, such solutions that target the availability of alcohol will not work for everyone in every context. In fact, such solutions might actually encourage the access to alcohol from other sources and excessive alcohol consumption. Wine can be made from kits in a basement. Moonshine has a history of being an alternative to “legitimate” distillation products. Retailers will sell what their customers demand. Wholesalers will use their resources to achieve the best return on investment possible. Increasing taxes can create a volatile situation, generating resistance from many quarters for many reasons, including the observation that the impact falls disproportionately on the poor.^[xvi]

If highly restrictive environmental solutions survive legal and legislative challenges, inappropriate production of alcohol may result. This would lead to other health problems resulting from inappropriate production of alcohol by either inexperienced or unscrupulous purveyors of unregulated drinking alcohol. Thus, shifting policies to bypass the individual in favor of population strategies begs the question.

A truly comprehensive strategy would include enhanced alcohol treatment strategies, as well as appropriate population based strategies, not the reduction of treatment in pursuit of prevention strategies targeted to high consumers suggested by the authors of the paper. Such a strategy would recognize the heterogeneity of the alcohol consuming population and target the various subgroups with approaches that are designed to effect change in consumption behaviors.

Mark Willenbring of Alltyr Clinic in Saint Paul, Minnesota, notes that “The goal of treatment depends upon the nature, extent, severity of the disorder. In place of the ’one size fits all’ approach initially developed for people with severe, relapsing AUD, an individualized approach that takes patient preference into account is required. Coexisting conditions or circumstances are also important determinants of the therapeutic approach and methods used.”^[xvii]

The authors of this paper have done the public a disservice in suggesting that the excessive drinker, the binge drinker and the heavy drinker are not after all “alcoholics” and do not need treatment. The data set from which they drew their conclusions do not support their conclusions. Furthermore, the analysis done did not really focus on treatment or prevention strategies, but only on a secondary data analysis of a large nationally representative data set. Yet, as the headlines from the mass media response to the paper demonstrate, the public message got quickly distorted to mean that excessive drinking is not a problem at the individual level, but could be a problem at the population level.

The authors create their own paradox by saying in their introduction that excessive alcohol consumption leads to problems for individuals and society and then suggesting that because such individuals do not meet the criteria of DSM-IV, they are not alcoholics; it is not the label “dependence” or “alcoholic” that defines the solution to the problem of excessive drinking.

While the authors do recognize that primary care providers can play a critical role in discussing alcohol consumption with presenting patients after appropriate screening, relying only on screening to have substantial impact seems unreasonably hopeful. The meta message of the article for clinicians, patients, consumers, and policy makers is that the problem of excessive alcohol consumption is not a problem for all. After reading a paper that suggests that one who is not alcohol dependent but who is an excessive drinker cannot benefit from treatment, the authors leave the primary care provider with few options to engage the excessive drinker. The mixed message of the paper undermines any attempt to mobilize a patient’s willingness to change as it diverts attention from the problems of drinking to the label of the drinker.

Nevertheless, screening and brief intervention is a worthy effort for primary care clinician involvement. It may save lives of people who otherwise view occasional heavy drinking as not warranting intervention by either them or their healthcare professional. Health care professionals need to do a better job of asking questions and giving advice that could be live saving, e.g., do you ever drink 5 or more drinks in an evening, and/or CAGE items in which a yes to ANY of those items precipitates Ask, Assess (further), Advise, and then refer if appropriate.

The issue of denial with regard to substance use disorders is well established in the popular psyche. The quip from Saturday Night Live cited above captures that point. Furthermore, the very data set from which the authors derived their analysis and conclusion reveals that over 90% of the individuals who met criteria for substance use disorders requiring treatment perceived no need for treatment and make no effort to get treatment.^[xviii] Minimizing the complexity of excessive drinking is not helpful.

In conclusion, the problem of excessive drinking will not be resolved by asserting without foundation that substance abuse treatment is unnecessary. This problem cannot be resolved by getting lost in the labels, ignoring the specific needs of individuals while searching for a more global solution. Furthermore, it does not help pitting the middle class against the poor: this does a disservice to both groups. Solutions to excessive drinking need to occur at both the individual level and the population level; they need to be culturally appropriate, gender specific, and economically sensitive. The phenomenon of excessive drinking should be seen as a continuum where appropriate solutions are applied at the appropriate point along that continuum. Prevention strategies and treatment strategies belong in that mix of solutions. It should not be an either/or proposition. The labels of “alcohol dependence,” “excessive drinker,” “heavy drinker,” ” binge drinker,” “risky drinkers,” “alcoholic,” or whatever should not be controlling for the public health community; the needs of the patient, the family and the community should be. By minimizing the impact of excessive drinking, we put the patient at risk for all of the well-known consequences from such drinking.

A version of this article was first published in Alcoholism & Drug Abuse Weekly, December 8, 2014 and may be accessed at www.alcoholismdrugabuseweekly.com.