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    Problematic alcohol consumption is not a benign condition that resolves with age.
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    Putting it all together …
    4. Parietal and frontal regions were under-activated in alcohol dependent young women relative to controls
    *Differential sensitivity: These regions may be particularly sensitive to ethanol effects
    *Developmental differences: Parietal and frontal regions may be affected earlier in the course of alcohol dependence
    -we know that these are the last regions to myelinate during human brain development – into adolescence and ages at which youth may well be drinking harmful amounts
    Consistent with adult studies in that decrements in functioning are apparent in group comparisons; not severe; not in all subjects
    Developmental differences: less impairment of cognitive flexibility; less severity; but drinking before myelination & pruning are complete may cause more damage but may allow possibility for future recoverability with abstinence
  • <number>
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    Putting it all together …
    4. Parietal and frontal regions were under-activated in alcohol dependent young women relative to controls
    *Differential sensitivity: These regions may be particularly sensitive to ethanol effects
    *Developmental differences: Parietal and frontal regions may be affected earlier in the course of alcohol dependence
    -we know that these are the last regions to myelinate during human brain development – into adolescence and ages at which youth may well be drinking harmful amounts
    Consistent with adult studies in that decrements in functioning are apparent in group comparisons; not severe; not in all subjects
    Developmental differences: less impairment of cognitive flexibility; less severity; but drinking before myelination & pruning are complete may cause more damage but may allow possibility for future recoverability with abstinence
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    Figure legend. The triangle schematically displays the spectrum of alcohol use, from abstinence or no use and lower risk use, which are the most common patterns of alcohol use, to risky use, problem drinking, and the less common but more severe alcohol use disorder diagnoses. In progressing from lower risk use through dependence, consumption and consequences increase. Clinicians and public health practitioners should be concerned with the categories encompassed by the dashed line, unhealthy alcohol use.
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    The Prevention Paradox – where to target interventions - consider both shape of the consumption function and optimal points of intervention (mode; tail; or shift the curve to the left)
    Single distribution or distribution of consumption theory: French social scientist Sully Ledermann (1956). ‘Ledermann argued that a single function, a lognormal curve, provides an accurate estimate for the distribution of alcohol consumption in any society. Given the addictive properties of alcohol, some might have expected alcohol distribution to be bimodal, with one peak level among moderate or "social" drinkers and a second peak level among those who are physically dependent on alcohol. Contrary to this expectation, Ledermann found a unimodal distribution which is continuous and highly skewed. Perhaps the most controversial aspect of Ledermann's work is the contention that the dispersion of this distribution is relatively invariate and can be estimated from the mean.’ (Single, E 1992, The Myth of the Single Distribution; Guest lecture presented at Simon Fraser University May 26, 1992, Canadian Centre on Substance Abuse, viewed 08 Feb 2002, <http://www.ccsa.ca/docs/sfu.htm>)
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    Consuming 5 or more drinks is associated with a variety of bad outcomes in numerous epidemiological studies.
    Although a discussion of these studies is beyond the scope of this talk, it’s worth noting that these 5+ relative risks are considerable, ranging from 2-10.
    To put this in perspective, most of these relative risks have a magnitude that surpasses the relative risk for myocardial infarction among those with hypertension.
    Furthermore, although there is a dose-response relationship between the number of drinks and bad outcomes, even drinking 5 drinks is associated with significantly increased risk.
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  • (lowered BAC limits, enforce traffic safety measures, random breath testing, and legal and medical interventions for repeat DUIs)
  • [ powerpoint (4.3mb) ]

    1. 1. Alcohol -Alcohol - Health and Economic ImpactsHealth and Economic Impacts Richard A. Yoast, Ph.D., DirectorRichard A. Yoast, Ph.D., Director AMA Dept. of Public Policy & Primary PreventionAMA Dept. of Public Policy & Primary Prevention Tuesday, September 16,2008Tuesday, September 16,2008 American Council on Alcohol ProblemsAmerican Council on Alcohol Problems National Meeting, Springfield ILNational Meeting, Springfield IL
    2. 2. Who drinks? What are the impacts?What are the impacts?
    3. 3. NSDUH Survey, 2002 Alcohol - the Drug of Choice Among 12-20 Year Olds 0 5 10 15 20 25 30 35 40 45 8th 10th 12th Grade Percentusinginpastmonth Alcohol Cigarettes Marijuana
    4. 4. Drinking among Americans 12 or older (2007) NSDUH • 51.1% are current drinkers (last 30 days) = est. 126.8 million people • 56.6% of males, 46 % of females • (ages 18 to 25: 57.1% of females, 65.3% of males) • 3.5% of 12 or 13 year olds • 14.7% of 14 or 15 year olds • 29.0% of 16 or 17 year olds • 50.7% of 18 to 20 year olds • 68.3% of 21 to 25 year olds • Binge drinking (last 30 days): 23.3% = 57.8 million people • Heavy drinking: 6.9% = 17 million people • Current adult use decreased with age: • 63.2% of ages 26 to 29 • 47.6 % of ages 60 to 64 • 38.1% of ages 65 or older.
    5. 5. U.S. Youth 2005 YRBS Sizeable youth population engaging in risky alcohol-related behaviors (last 30 days) - 43.3% grades 9 -12 (50% of 12th graders) had at least one drink - 25.5% binged (5 or more drinks in a row) - 28.5% rode 1 or more times with drinking driver - 9.9% (19.2% of 12th grade males) drove after drinking - 23.3% of currently sexually active students drank or used other drugs before last sexual intercourse [CDC MMWR June 9, 2006]
    6. 6. Underage Drinking Negative consequences costs the US: $62 billion per year (medical costs, lost productivity & quality- of-life costs due to motor-vehicle crashes, violence, property crime, suicide, burns, drowning, fetal alcohol syndrome, high-risk sex, poisonings, psychoses & dependency treatment). [Miller TR, Levy DT, Spicer RS, Taylor DM. Societal costs of underage drinking. J Studies Alcohol and Drugs 67: 519-528, 2006.]
    7. 7. Acute Health and Safety Consequences of Alcohol Use in the Younger Population • alcohol poisoning • motor vehicle crashes • risky sexual behaviors • suicide attempts • drowning • other drug use • significant contributor to injury in adolescence • a role in more than 50% of traumatic brain injuries in adolescents • violence
    8. 8. Early Onset - Not Benign • Age at which young people begin using alcohol has decreased over the last 35 years; • On average, youths now take their first drink at the age of 12 years.
    9. 9. Early Alcohol Involvement – • associated with poorer behavioral measures of thinking abilities of youth. • Memory • Learning Strategies • Visual Spatial Abilities • Attention • associated with under activation in several brain regions during cognitive tasks (frontal and prefrontal,parietal, cingulate)
    10. 10. Alcohol and Neuroanatomical Findings with Youth • Smaller hippocampus in adolescence • Greater responsivity to alcohol cues • Score worse than non-users on vocabulary, general information, memory, memory retrieval and at least three other tests • Significant neuro-psychological deficits exist in early to middle adolescents (ages 15 and 16) with histories of extensive alcohol use
    11. 11. Alcohol-related chronic symptoms or medical conditions in youth • Appetite changes • Weight loss • Eczema • Headaches • Sleep disturbance • Serum enzymatic markers of liver damage are elevated in alcohol- abusing adolescents.
    12. 12. What Do We Need to Learn? • Are these deficits permanent? • How long do they last? • Can we speed recovery? • To what extent are neurocognitive and neuroanatomical differences present before alcohol use starts? • Which children are most vulnerable to these adverse alcohol consequences? • Withdrawal may impact different abilities than use.
    13. 13. Youth/young adult drinking Alcohol a leading contributor to the main cause of death—injury —for people under age 21 (ca. 5,000 deaths/yr related to underage drinking) - result of motor-vehicle crashes, unintentional injuries from other causes, homicides, and suicides. Faden V.B., Goldman M. (Co-Chairs), NIAAA Interdisciplinary Team on Underage Drinking Research. Alcohol development in youth – a multidisciplinary overview: The scope of the problem. Alc Res & Health 28(3):111-120, 2004/2005.
    14. 14. Drinkers: Less Active BrainsDrinkers: Less Active Brains •• Comparing two 20 year old females. Top view of brain, two inchesComparing two 20 year old females. Top view of brain, two inches above earsabove ears Note differences in back of brain Note differences in back of brain Healthy Control Alcohol-Dependent Colored areas show active brain areas during memory task.Colored areas show active brain areas during memory task.Colored areas show active brain areas during memory task.
    15. 15. College Age Drinkers: Reduced Brain Function College Age Drinkers: Reduced Brain Function Healthy Controls Alcohol Dependent Spatial Working Memory response Simple Attention response Source: Tapert SF, Brown GG, Kindermann SS, Cheung EH, Frank LR, Brown SA (2001). fMRI Measurement of Brain Dysfunction in Alcohol-Dependent Young Women. Alcoholism: Clinical and Experimental Research. 25 (2):236-245.
    16. 16. Neurocognitive Impact of Alcohol Pre-natal: fetal alcohol effects Middle Adolescence: fewer learning strategies, memory impairment Late Adolescence: attentional decrement, visuospatial impairment Adults: Prolonged abuse has harmful to liver, lungs, pancreas, kidneys, endocrine system, immune system, cardiovascular system, and brain.
    17. 17. BUT - • If drinking onset is delayed by 5 years, a child’s risk of serious alcohol problems later in life is reduced by 50%.
    18. 18. Alcohol Drinking Patterns • Binge drinking • For women, 4 or more drinks during a single occasion. • For men, 5 or more drinks during a single occasion. • Heavy drinking • For women, more than 1 drink per day on average. • For men, more than 2 drinks per day on average. • Excessive drinking includes heavy drinking, binge drinking or both.
    19. 19. Dietary Guidelines for Americans If you drink alcoholic beverages, do so in moderation, For women: no more than 1 drink/day (7/week) For men: no more than 2 drinks/day (14/week)
    20. 20. Dietary Guidelines for Americans Those who should not drink any alcohol: • Pregnant or trying to become pregnant. • Taking prescription or over-the-counter medications that may cause harmful reactions when mixed with alcohol. • Under the age of 21. • Recovering from alcoholism or unable to control amount. • Have medical condition that may be worsened by alcohol. • Driving, planning to drive, or participating in other activities requiring skill, coordination, and alertness.
    21. 21. Immediate Health Risks of Excessive Use • Unintentional injuries: traffic injuries, falls, drownings, burns, firearm injuries. • Violence, including intimate partner violence (2/3 of incidents) and child maltreatment. • Risky sex: unprotected, multiple partners,increased risk of sexual assault – can lead to unintended pregnancy or sexually transmitted diseases. • Miscarriage & stillbirth: lifelong physical & mental birth defects among children • Alcohol poisoning: unconsciousness, low blood pressure & body temperature, coma, respiratory depression, or death.
    22. 22. health problems that might be alcohol induced • cardiac arrhythmia • dyspepsia • liver disease • depression or anxiety • insomnia • trauma
    23. 23. Signs of possible alcohol problems chronic illness that isn't responding to treatment as expected, such as: • chronic pain • diabetes • gastrointestinal disorders • depression • heart disease • hypertension
    24. 24. Long-Term Health Risks of Excessive Use Development of chronic diseases, neurological impairments & social problems: • Neurological problems, including dementia, stroke and neuropathy. • Cardiovascular problems, including myocardial infarction, cardiomyopathy, atrial fibrillation and hypertension. • Cancer of the mouth, throat, esophagus, liver, colon, and breast - risk increases with increasing amounts of alcohol. Risks greatly increased among smokers.
    25. 25. Long-Term Health Risks of Excessive Use Liver diseases, including: • Alcoholic hepatitis. • Cirrhosis - among 15 leading causes of all deaths in US • For persons with Hepatitis C virus, worsening of liver function & interference with treatment medications used Other gastrointestinal problems, including pancreatitis and gastritis Social problems, including unemployment, lost productivity, family problems, street violence, alcoholic riots
    26. 26. The Shape of U.S. Drinking Some overviews
    27. 27. 27 Hazardous U.S. Alcohol Consumption 0 20 40 60 80 100 2.5 5 10 20 30 40 50 60 70 80 90 100 Highest Volume Percentile of Drinkers Lowest Volume PercentofTotal Wine Spirits Beer Rogers & Greenfield, 1999
    28. 28. 28 Drinking Volume Partitioned by 6 Contexts 14% 24% 14%4% 25% 19% Restaurants Bars Parties Public Places Home, with Friends Home, "Quietly" TOTAL 21% 7% 17% 16% 3% 37% HAZARDOUS 1984 & 1995 National Alcohol Surveys; Clark, 1988; Greenfield et al, 2000
    29. 29. Major costs of alcohol (1990) Total cost: $98.6 BILLION Health care: $10.7 billion Indirect costs: $70.2 billion: • Mortality: $33.6 billion • Morbidity: $36.6 billion Crime: $5.8 billion Auto crashes: $3.9 billion Incarceration: 4.8 billion
    30. 30. Economic Costs of alcohol and other drug abuse are increasing; $277 billion in 1995 Sources: Rice et al. 1990; Robert Wood Johnson Foundation, 1993; National Institute on Drug Abuse & National Institute on Alcohol Abuse and Alcoholism, March 1998. Billion Dollars $70.3 $85.8 $98.6 $148.0 $44.1 $58.3 $66.9 $97.7 $109.8 $166.5 $0 $50 $100 $150 $200 $250 $300 1985 1988 1990 1992 1995 Drugs Alcohol
    31. 31. Alcohol in Primary Care • Patients with all stages of alcohol problems frequently seen in clinical settings (McDonald, 2004). • Patients screened in 22 primary care practices: 9% at-risk drinkers, 8% problem drinkers, 5% alcohol-dependent. ( Manwell 1998): • Binge drinkers compared to other primary care patients: higher rates of related problems (injury, hypertension), 1.5 times more primary care visits, higher per patient costs (psychiatry, emergency room, drugs) (Mertens 2005)
    32. 32. Alcohol, Injury & Acute Care • Emergency Departments ~ 110 million visits/yr, ~⅓ are injuries alcohol problems: 15 to 30% • Trauma Centers ~ 3½ million visits/yr, all are injuries alcohol problems: 40 to 60% Dan Hungerford, CDC
    33. 33. The Spectrum of Alcohol UseThe Spectrum of Alcohol Use heavy severe consumption none none consequences Risky Lower risk Alcohol Use Disorders Alcohol Use Disorders Abstinence Harmful, abuse Problem Alcoholism Dependence Unhealthy Use
    34. 34. Age at Onset of DSM-IV Alcohol Dependence Percentageineachagegroupwhodevelop first-timealcoholdependence Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 5 10 15 18 21 25 30 35 40 45 50 Age Percentageineachagegroupwhodevelop first-timealcoholdependence Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003 0.0% 0.2% 0.4% 0.6% 0.8% 1.0% 1.2% 1.4% 1.6% 1.8% 5 10 15 18 21 25 30 35 40 45 50 Age
    35. 35. 44.5% 27.9% 27.6% Alcohol Only Drugs Only Drugs & Alcohol REASONS FOR DRUG TREATMENT: 72% involve alcohol Source: Treatment Episode Data Set, DHHS/SAMHSA, Sept 2000
    36. 36. Distribution curve, e.g. consumption of a drug Number of people Level of consumptionLow High Many Few
    37. 37. The main problem Binge DrinkingBinge Drinking
    38. 38. 39 Binge Drinking, Current Drinkers 0 10 20 30 40 50 60 70 18-20 21-25 26-34 35-54 55+ Age Group (years) BingePrevalence(%) Male Female Naimi et al, JAMA, 2003
    39. 39. 40 Alcohol Dependence among Binge Drinkers – example New Mexico New Mexico, BRFSS, 2002 Dependent 7% Non-dependent 93%
    40. 40. 19 25 56 Nonbingers Infrequent Bingers Frequent Bingers Percent of Alcohol Consumed by Frequent Bingers, Infrequent Bingers, and Nonbingers Adults 21+ Years Old Source: National Household Survey, 1998 Frequent bingers: 6% of population, drink 56% of the alcohol Overall, bingers: 16% of population, drink 75% of the alcohol
    41. 41. Binge Drinking, by Average Alcohol Consumption, 2001 48%52% Moderate Drinkers Heavy Drinkers 73% 27% Moderate Drinkers Heavy Drinkers Binge Episodes Binge Drinkers
    42. 42. 5+ Drinks Especially Increase Bad Outcomes Impaired driving (Naimi, JAMA, 2003) Unintentional injuries (Anda, JAMA, 1988) SIDS (Iyasu, JAMA, 2002) Violence (Rossow, Addiction, 1996) Unintended Pregnancy (Naimi, Pediatrics, 2003) Sexually transmitted diseases (Lauchli, AEP, 1996) Myocardial infarction (Rehm, Am J Epidemiol, 2001) Meningitis (Imrey, Am J Epidemiol, 1996)
    43. 43. Risk of Injury, by Usual Number of Drinks 0 5 10 15 20 25 0 1 2 3 4 5 6 7 8 9+ Usual Number of Drinks PopulaitonPercentage 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 ProbablityofGettingInjured Population Percent Get hurt or injured College Alcohol Survey, 1999
    44. 44. Obstacles to change & A New FrameworkA New Framework
    45. 45. Structural Obstacles • Alcohol not treated as a drug, food or carcinogen - by law FDA can’t review or control alcohol • Federal Trade Commission - protection of youth?: • uses alcohol industry data on advertising to kids • youth “prevention” campaign uses alcohol industry materials • Government & private foundations rarely fund research on alcohol industry, rarely support advocacy • No national media campaign since 1980’s/ except DUI • Government agencies fear reprisals if they counter industry economic interests or messages • Courts consistently support industry rights to free speech over parental rights and needs of children – unrestricted advertising
    46. 46. Common Misperceptions: • Most understand alcoholism is a disease, but don’t know that like diabetes and other chronic diseases, it can be treated and controlled if not cured & may be relapsing • Don’t understand concept of alcohol problems as amenable to change – we look only for alcoholism and see the rest as social, not health problems • myths about alcoholics applied to all problem drinkers]
    47. 47. Common Misperceptions: • Old information: no effective treatment, prevention doesn’t work, drinking never changes for better or worse, laws have no impact • Many hold beliefs fostered by alcohol industry, mass media & culture: ‘problems due to individual choice & irresponsibility’ – ‘failure to change is individual failure’ – ‘alcohol problems are not health problems -only social, personal failings’
    48. 48. Obstacles • Medical and public health communities fail to address alcohol use disorders as mainstream health issue – focus on individuals, social disruption, particular alcohol problems – rarely as larger health problem • Media & government focus only on social, not health impacts. • Heavy publicity for research on positive health impacts of alcohol (are they finding what they’re looking for?) - summarized by media as “drinking is good for you”
    49. 49. Underlying dynamics • Much of public health communityMuch of public health community accepts alcohol industry “expertise” inaccepts alcohol industry “expertise” in determining and discussing healthdetermining and discussing health issuesissues –– legitimizes their self interestlegitimizes their self interest & perspectives on problems& perspectives on problems • Alcohol industry and the policies they support focus on individual choice & punishment – ignore their own role, environmental, even governmental roles in promoting problems
    50. 50. Consequences • physician & other health professional paralysis leading to inaction and silence (lacking clear medical/health framework; rely on own feelings, behaviors, experience) • Alcohol problems & research treated as discreet, unconnected issues (DUI, FAS/FAE, alcoholism, violence, injury) – not usually part of most medical practice concerns • Alcohol is a leading preventable cause of cancer and violence – often ignored • Alcohol related violence, injury, death are notAlcohol related violence, injury, death are not seen as expressions of health or drug problems-seen as expressions of health or drug problems- attributed to individual excess, misbehavior orattributed to individual excess, misbehavior or accidentaccident
    51. 51. Furthermore, the alcohol industry • especially emphasizes intent, personal responsibility, personal enjoyment of intoxication, and lower risk situations • ignores alcoholism, alcohol use disorders, negative consequences of any type save impaired driving, connections between these problems and their products and behaviors
    52. 52. A better framework for thinking. Research (J-curve) makes it clear that • For some people, some times, in some situations, low level alcohol use is relatively risk free and might be beneficial • For everyone, risk & harm rise with the level of consumption (volume, frequency) • In some people, some situations, some occasions - any use is risky and more consumption even more harmful
    53. 53. But over all: Regardless of why, when, where or how someone drinks, whatever they think or choose to do, alcohol • always acts as a drug, • is a carcinogen, and • consumption is never risk free. Alcohol’s impact on the body is systemic and no one and no organs are free of its impacts – however small. The most common forms of health problems related to alcohol are not due to, related to or even precursors of alcoholism (dependence) – binge drinking affects more people and is a better indicator of problems, and is amenable to change
    54. 54. All alcohol associated problems - • Are connected (impaired driving, FAS/FAE, violence, accidents and injury, dependence, binge drinking, underage drinking, football riots, domestic violence, vandalism, etc., etc.) – • Related to alcohol consumption • Related to alcohol’s impact on the body (especially the brain) (In that sense it’s like tobacco and many illicit drugs.) For some people, some situations, some health conditions and some circumstances or occasions, risk begins from the initial intake of alcohol and harm rises with consumption (amount, frequency).
    55. 55. A health framework for alcohol: In most people’s daily lives, the times at which they can drink at low risk levels and the circumstances under which they can do so are extremely limited Many can never drink without high-risk Everyone’s consumption carries a risk for the drinker and the non-drinker (of causing harm to themselves, the people around them and the society they live in. The greater the consumption (amount, frequency, number of drinkers), the greater the potential for harm.
    56. 56. European Charter - Ethical principles 1. All people have the right to a family, community and working life protected from accidents, violence and other negative consequences of alcohol consumption. 2. All people have the right to valid impartial information and education, starting early in life, on the consequences of alcohol consumption on health, the family and society. 3. All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages.
    57. 57. European Charter - Ethical principles 4. All people with hazardous or harmful alcohol consumption and members of their families have the right to accessible treatment and care. 5. All people who do not wish to consume alcohol, or who cannot do so for health or other reasons, have the right to be safeguarded from pressures to drink and be supported in their non-drinking behaviour.
    58. 58. Summary of 10 strategies for alcohol action 1. Educate people, beginning in early childhood, of the health, family and social consequences of alcohol consumption and effective measures to prevent or minimize harm 2. Promote public, private & work environments protected from accidents, violence & other negative consequences of alcohol consumption. 3. Establish & enforce effective anti-drink-driving laws. 4. Promote health by controlling availability & influencing alcohol prices (e.g. through taxes). 5. Strictly control (keeping existing limitations or bans) direct & indirect alcohol advertising - ensure that no advertising specifically addresses young people (e.g., by linking of alcohol to sports).
    59. 59. 10 strategies for alcohol action 6. Ensure access to effective treatment & rehabilitation with trained personnel, for people with hazardous or harmful alcohol consumption and their family members. 7. Foster awareness of ethical and legal responsibility among those marketing or serving alcohol, strictly control product safety, implement measures against illicit production & sale. 8. Enhance society’s capacity to deal with alcohol through training of professionals in different sectors, & strengthening community development and leadership. 9. Support nongovernmental organizations and self- help movements - specifically those aiming to prevent or reduce alcohol-related harm. 10. Formulate broad-based programs in Member States, with clear outcome targets and indicators; monitor progress; ensure periodic updating based on evaluation.
    60. 60. • Enforce MLDA • Restrict hours or days of sale • Restrict the number of sales outlets • Increase alcohol taxes • Implement effective countermeasures for alcohol impaired driving reverse • Implement advertising restrictions U.S. Best Practices – Comprehensive Approach
    61. 61. 6262
    62. 62. 6363 Representation of Environmental Model
    63. 63. For More Information Contact Richard Yoast, Ph.D. richard.yoast@ama-assn.org