"About 14 million Americans—almost 10 percent of adults—meet diagnostic criteria for alcohol abuse and alcoholism," writes Secretary Shalala in the foreword. While the proportion of adults with these medical disorders has been similar each time that problem prevalence surveys have been conducted, other epidemiologic measures show change: Abstention has increased and heavy drinking has decreased among U.S. adults. Per capita alcohol consumption, which peaked during the 1980s, in 1993 reached the lowest level since 1964. Increased health concerns, less tolerant attitudes toward drinking, and increased social and legal sanctions against drinking and driving are possible reasons for these changes, the report suggests.
Drinking patterns and problem prevalence vary substantially by gender, age, ethnicity, and among discrete subgroups of these broad classifications. As in past reports, the rate of alcohol abuse and alcoholism among men is almost three times that for women. Separate analyses show that, although per capita consumption since 1980 has declined less markedly among women, men continue to drink more and report more alcohol-related problems than women. Heavy drinking, alcohol abuse, and alcoholism are most prevalent among 18- through 29-year-olds of both genders and least prevalent among persons aged 60 and older. Although heavy drinking and monthly and daily alcohol use among high school seniors have declined since the 1980s, the decline is less among college-bound seniors, and binge drinking is a widespread problem on college campuses.
Alcohol-related morbidity and mortality remain significant problems. As many as 44 percent of more than 40,000 traffic crash fatalities each year involve alcohol and, although such crashes are decreasing, young drivers continue to be over-represented in drinking driving deaths. Liver cirrhosis, on the decline since 1973, remains the 11th leading cause of death, and heavy drinking contributes to other leading killers: heart disease, stroke, and certain cancers.
The population distribution of alcohol disorders and other alcohol damage provides clues for understanding how that damage can be mediated by individual attributes and environmental influences. The Ninth Special Report describes these interactions in eleven chapters on genetic, psychological, and sociocultural influences on alcohol use and abuse; actions of alcohol on the brain; neurobehavioral effects of alcohol consumption; effects on health and body systems; effects on fetal and postnatal development; effects on behavior and safety, the economic aspects of alcohol use and related problems, prevention; treatment; and health services research. Produced by the National Institutes of Health's National Institute on Alcohol Abuse and Alcoholism with guidance from a distinguished editorial advisory board and contributions from some of the world's foremost alcohol researchers, the 450-page referenced volume is a resource for researchers, treatment and prevention practitioners, and policy makers.
Across the alcohol research spectrum, the report documents new gains from the 25-year Federal investment in alcohol research. Since the previous report, geneticists using animal models have identified several quantitative traits including alcohol preference, alcohol sensitivity, and severity of withdrawal that are believed to underlie a drinker's response to alcohol. Systematic efforts are underway in large human populations with high alcoholism prevalence to detect and map the specific genes involved in alcoholism susceptibility, determine how gender and other factors modify that susceptibility, and identify the biological and psychological factors that influence the relationship between primary gene products and drinking behavior.
"The alcohol field is uniquely poised to take full advantage of the tools and techniques of today's science to fully explore biobehavioral linkages," says National Institutes of Health Director Harold Varmus, M.D., in the report preface. "This exploration will add significantly to our overall understanding of other diseases where biology and behavior are so closely intertwined."
The relationship of the brain to behavior is the focus of neuroscience research, where scientists are characterizing the many cellular and molecular mechanisms by which alcohol produces immediate and long-term changes in CNS activity. Unlike other psychotropic drugs that work through a single receptor, alcohol affects many cellular sites and processes including neurotransmitter receptors, cell membranes, intracellular mechanisms, and gene expression to produce intoxication, tolerance, dependence, and withdrawal—all behaviors potentially mediated by pharmacologic agents. In addition to naltrexone, the anticraving medication approved in 1994 for use in alcoholism treatment, NIAAA researchers are evaluating other anticraving medications, detoxification agents, alcohol-sensitizing agents, and medications for use in patients with coexisting psychiatric disorders. Effectively combining behavioral and pharmacologic therapies for different patient types is a focus of current research.
The Ninth Special Report introduces several new applications for alcohol research, including the recently tested and proved AMPS program, a resistance education program for high-risk 6th grade students that demonstrated positive results through grade 12, and Project Northland, a community-based intervention that reduced the onset of alcohol use, drinking prevalence, and the combination of cigarette and alcohol use among 6th, 7th, and 8th grade students. Researchers also demonstrated that reduced blood alcohol level laws for young drivers reduce single-vehicle nighttime crashes, with the greatest effect achieved by zero tolerance laws. According to NIAAA Director Enoch Gordis, M.D., "Our researchers are conducting controlled trials in prevention and have shown not only that social and regulatory policies can be researched but that the application of research findings to policy can save lives."
Recently validated research applications for clinical practice include behavioral therapies to prevent relapse and brief interventions for use by primary care professionals to help nondependent problem drinkers curtail drinking. NIAAA's health services research program also aims to improve the accessibility, quality, effectiveness, and cost-effectiveness of prevention and treatment.
Bound copies are available for $11 by written request to NIAAA, P.O. Box 10686, Rockville, Maryland 20849-0686.