On average 15.1 percent of U.S. drivers 18 or older drove while legally intoxicated at least once in the past year. The 2008 data release is the first time a projection of drunk driving in the nation has been compiled.

The report was based on state level information on DUI and DWI incidents and pervasiveness, as well as data from the National Surveys on Drug Use and Health. The combined number of drivers surveyed over a three year period totaled 127,283.

The National Highway Traffic Safety Administration reports that there were about 16,700 traffic related deaths in 2004 involving a driver under the influence of alcohol.

The SAMHSA report also revealed that about 5% of adult drivers drove under the influence of illicit drugs, including marijuana, cocaine, inhalants, hallucinogens, heroin and prescription drugs used nonmedically.

SAMHSA Administrator Terry Cline hopes the report highlights the scope and nature of national issue of driving under the influence, and helps direct resources and prevention efforts. The full report is available at http://oas.samhsa.gov/2k8/stateDUI/stateDUI.cfm.

State Estimates of Driving Under the Influence of Alcohol and Illicit Drugs in the Past Year among Current Drivers Aged 18 or Older: Average of 2004-2006

SOURCE: Office of Applied Studies, Substance Abuse and Mental Health Services Administration. National Survey on Drug Use and Health, 2004-2006

SAMHSA is a public health agency within the Department of Health and Human Services. The agency is responsible for improving the accountability, capacity and effectiveness of the nation's substance abuse prevention, addictions treatment, and mental health services delivery system.

National Institute on Alcohol Abuse and Alcoholism

No. 5 PH 270 August 1989

----------------------------------------------------------------------

Alcohol Withdrawal Syndrome

The alcohol withdrawal syndrome is a cluster of symptoms observed in persons who stop drinking alcohol following continuous and heavy consumption. Milder forms of the syndrome include tremulousness, seizures, and hallucinations, typically occurring within 6-48 hours after the last drink. A more serious syndrome, delirium tremens (DTs), involves profound confusion, hallucinations, and severe autonomic nervous system overactivity, typically beginning between 48 and 96 hours after the last drink (Victor 1983). Estimates vary on the incidence of serious consequences of alcohol withdrawal. Regardless of actual incidence, recent evidence suggests that it may be important to treat everyone who is suffering from alcohol withdrawal.

In a classic study that has shaped our understanding of alcohol withdrawal for many years, Isbell et al. (1955) found that alcohol-related seizures occur only after stopping heavy drinking. In a recent study that looked primarily at seizures, Ng et al. (1988) challenged Isbell's concept and reported that the risk of first seizure is related to current alcohol use rather than to withdrawal. They concluded, based on self-reports given retrospectively by seizure patients, that the relationship of alcohol use to seizures is causal and dose-dependent. However, emerging neurophysiological findings lend support to Isbell's interpretation of withdrawal.

In the central nervous system, ethanol (in concentrations high enough to intoxicate humans) interferes with the processes that tell certain nerve cells to activate or become excited (Hoffman et al. 1989; Lovinger et al. 1989). It also enhances those processes that tell certain nerve cells to be restrained (Suzdak et al. 1986). Thus, ethanol acts as a nonspecific biochemical inhibitor of activity in the central nervous system. During withdrawal, a person's central nervous system experiences a reversal of this effect: Excitatory processes are enhanced while inhibitory processes are reduced (Morrow et al. 1988). Such changes can result in overactivation of the central nervous system when alcohol is withdrawn.

Clinical researchers have measured this overactivation in patients (Linnoila et al. 1987). Even patients with moderately severe alcohol withdrawal can experience sympathetic nervous system overactivity and increased production of the adrenal hormones cortisol and norepinephrine. Both of these hormones can be toxic to nerve cells. Moreover, cortisol can specifically damage neurons in the hippocampus (Sapolsky et al. 1986)--a part of the brain that is thought to be particularly important for memory and control of affective states. Thus, repeated untreated alcohol withdrawals may lead to direct damage to the hippocampus.

Ballenger and Post (1978) did a retrospective chart review that led them to postulate that repeated inadequately treated withdrawals could produce future withdrawals of increased severity. These authors suggested that this phenomenon may be analogous to kindling as described in the animal literature. In kindling, repeated, weak (subthreshold), electrical or pharmacological stimulation of certain parts of the central nervous system leads to increased sensitivity; an animal eventually exhibits behavioral changes (including seizures) that are more severe on each occasion. The implication is that repeated untreated withdrawals from alcohol have a cumulative effect and create more serious future withdrawals. Only a minority of chronic alcoholics develop a seizure disorder, so an inherited vulnerability may be involved. Many investigators (e.g., Linnoila et al. 1987) now believe that chronic alcoholics who cannot maintain abstinence should receive pharm acotherapy to control withdrawal symptoms, thereby reducing the potential for further seizures and brain damage.

In a recent review of pharmacological treatments for alcohol intoxication, withdrawal, and dependence, Liskow and Goodwin (1987) concluded that the drugs of choice for treating withdrawal are the benzodiazepines--e.g., the longer-acting benzodiazepines chlordiazepoxide (Librium) and diazepam (Valium) or the shorter-acting benzodiazepines oxazepam (Serax) and lorazepam (Ativan).

Physicians traditionally have used benzodiazepines by administering decreasing doses over the period of alcohol withdrawal. Rosenbloom (1988) recommends this approach, suggesting the use of intermediate half-life benzodiazepines (such as lorazepam), or even shorter half-life drugs (such as midazolam), because these drugs do not linger in the system and allow for doses to be easily titrated to the parent's response. However, Sellers et al. (1983) introduced a different approach. At the start of treatment, doses of diazepam are given every 1 to 2 hours until withdrawal symptoms abate. Because diazepam has a long half-life and produces a psychoactive metabolite (desmethyldiazepam) with an even longer half-life, there is usually no need for further medication. This strategy, called "loading dose," simplifies treatment, protects against seizures, and eliminates possible reinforcement of drug-seeking behavior in parents who otherwise might receive additional medication for relief of symptoms.

Other agents, such as the beta-blocker propranolol (Sellers et al. 1977), the beta-blocker atenolol in combination with oxazepam (Kraus et al. 1985), and the alpha-2-adrenoreceptor agonist clonidine (Manhem et al. 1985; Robinson et al. 1989), have been tested and shown to alleviate some symptoms of the withdrawal syndrome, but there is no clear evidence of their efficacy in preventing seizures (Liskow and Goodwin 1987). Potential drugs for future use are calcium channel blockers (Koppi et al. 1987) and carbamazepine, which are now in the early stages of evaluation (Butler & Messiha 1986).

Most clinicians use medications to diminish the symptoms of alcohol withdrawal. However, Whitfield et al. (1978) reported success with nondrug detoxification of a group of ambulatory patients with uncomplicated alcoholism. The treatment consisted of screening and providing extensive social support during withdrawal. The authors concluded that nondrug detoxification offers a reduced need for medical staff, a shortened detoxification period, and no sedative interference with a patient's alertness for participating in an alcohol treatment program.

Several researchers have developed scales for assessing the severity of the alcohol withdrawal syndrome: the Total Severity Assessment and Selected Severity Assessment (Gross et al. 1973), the Abstinence Symptom Evaluation Scale (Knott et al. 1981), and the Clinical Institute Withdrawal Assessment Scale [CIWA] (Shaw et al. 1981) Originally developed as research tools for studying treatment efficacy, such scales are now finding clinical use. Foy et al. (1988) demonstrated that a modified version of the CIWA can assist in guiding treatment and predicting patients at risk for severe alcohol withdrawal. Such scales also may be helpful when monitoring the adequacy of a loading dose of medication. However, rating procedures are not infallible, and an occasional patient will have a more severe reaction than the scale predicts. Rating procedures cannot replace the clinical judgment of medical staff.

One final point deserves mention. A recent study by Hayashida et al. (1989) compared outpatient with inpatient detoxification. The research concluded that outpatient medical detoxification is "an effective, safe, and low-cost treatment for patients with mild-to-moderate symptoms of alcohol withdrawal." However, the data from this study indicate that inpatient detoxification was more effective than outpatient detoxification: At the 6-month followup those treated as inpatients reported significantly greater improvement in their drinking behavior, despite having been measured as more impaired than the outpatient group at the time of admission. This point is not emphasized in the report. Whereas outpatient detoxification may be cheaper for some alcoholics, it is not clear to what extent serious comorbidities, which may be undetected outside a hospital setting, may lead to more severe and expensive problems later.

----------------------------------------------------------------------

Alcohol Withdrawal Syndrome-- A Commentary by
NIAAA Director Enoch Gordis, M.D.

A variety of techniques exist for managing alcohol withdrawal, some that involve pharmacotherapy with sedatives and some that do not. Based on current literature, it appears that it is probably safe to treat mild withdrawal without drugs. However, research on treating alcohol withdrawal is just beginning to accumulate. Recent research findings show a potential for central nervous system damage to patients who experience repeated withdrawals and suggest that all patients exhibiting alcohol withdrawal symptoms receive pharmacotherapy. As evidence increases, it may well be that pharmacotherapy becomes the recommended choice in all withdrawal cases. Therefore, it is vital that clinicians keep abreast of the literature to ensure that their patients receive the most up-to-date care.

When using sedatives to treat alcohol withdrawal, understanding the relative advantages and disadvantages of different drug administration techniques is important. Administering an initial dose of a long-acting benzodiazepine, like diazepam, with repeated doses every 2 hours until symptoms subside, then stopping the drug, simplifies treatment and frees patients and staff to focus on the recovery process, not drug dosage schedules. However, this method could cause problems if sedation is found to complicate an existing medical condition, such as chronic obstructive pulmonary disease, because the drugs, or their metabolites, remain in the body for several days. On the other hand, by giving repeated doses of a short-acting benzodiazepine (e.g., oxazepam), probably for several days, if complications to medical conditions are found, the drugs can be easily stopped due to their rapid elimination by the body. But this regimen is less easily managed because medication must be given around the clock, and it could result in the patient and staff attending to the drug-taking regimen rather than to recovery.

In deciding which drug administration technique to use for individual patients, there is no substitute for a thorough medical evaluation. There is a welcome trend toward using the CIWA and other clinical scales for measuring withdrawal syndrome severity and for guiding drug treatment decisions; their use should be encouraged. However, no scaling instrument is infallible. Withdrawal severity scales should be used to complement, not replace, a thorough clinical evaluation of the patient's medical status.

----------------------------------------------------------------------

NOTE: The following ERRATA appeared in Alcohol Alert No. 8. It is shown here for clarity.

ERRATA: Dr. M. Hayashida has notified NIAAA that Alcohol Alert No. 5, entitled "Alcohol Withdrawal Syndrome," contained incorrect information about his study comparing the effectiveness and costs of inpatient and outpatient detoxification (Hayashida, M.; Alterman, A.; McLellan, A.; et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-to-moderate alcohol withdrawal syndrome. New England Journal of Medicine 320(6): 358-365,1989). The last paragraph of the Alert erroneously reported that data from the study provide evidence that inpatient detoxification was more effective than outpatient detoxification. However, an accurate interpretation of the study would have suggested that some significant differences were noted between the two groups at a 1-month followup, favoring inpatient detoxification (a group that was more impaired by some drinking measures at admission), but that no differences were observed at a 6-month followup.

----------------------------------------------------------------------

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service * National Institutes of Health

----------------------------------------------------------------------

PHILADELPHIA, Nov 14 (Reuter) - A new method for identifying problem drinkers can lead to earlier, more effective treatment and could double the number of people receiving help, researchers said on Thursday. 11-14-96

The method, tested with success in Cambridge, Ontario, relies on indirect questioning to identify potential drinking problems and a modest level of "lifestyle counseling" to limit alcohol use.

"We could markedly reduce the cost of alcohol abuse in the U.S.A. by implementing a very simple system like the one that we've applied," said Yedi Israel, a professor at Thomas Jefferson University's medical school and lead author of a research report on the method. "If you are a (alcohol) dependent person, it's like a declaration of independence."

In the United States, where only about one million of an estimated 10 million problem drinkers are receiving treatment, another one million people yearly could be helped through the new screening and treatment techniques, Israel said.

The report is to be published in the Nov. 15 issue of "Alcoholism: Clinical and Experimental Research." It was based on a study of 15,000 people in Cambridge, a city of 90,000.

The method begins with a series of four questions asked of patients in their doctors' waiting rooms on whether they have had any injuries or fights in the previous five years. This is based on research showing about half of all injuries are alcohol-related and other research showing both doctors and patients resist screening techniques in which every patient is asked directly about alcohol abuse, Israel said.

In addition, he said, doctors often are not trained in treating alcohol problems and share with their patients an aversion, because of the stigma, to referring people to alcohol-treatment professionals until it is too late.

"We have not had systems that allow intervention early on where the patient -- the problem drinker -- doesn't have to define herself or himself as alcoholic," he said. "Alcoholism is not a disease in the early stages but it ends up being a disease at the very end, where the person doesn't have absolute control over drinking."

Patients in the study were asked in the waiting-room questionnaire whether they had broken or dislocated any bones or joints, been injured in a traffic accident, received a head injury or been in a fight or assault. Those who answered "yes" to two or more questions -- about one in seven -- were then asked by their doctors about their alcohol consumption and any alcohol-related problems.

About 3.5 percent of the total number of patients were identified as problem drinkers. In this way, doctors were able to identify 70 percent of the problem drinkers that could be expected in a group of this size, the study said.

Patients who qualified for treatment and accepted were then given either three hours of counseling over a year with a trained nurse or simple advice to reduce their drinking.

Those who received the counseling, which helped drinkers to identify and control situations in which they were likely to drink, showed significant declines in alcohol consumption and related problems. Those who received simple advice reported that they drank less often but that physical and social problems related to drinking did not decline.

Israel said the screening method is inexpensive, less than $1 per patient, and predicted its use would increase. It will be implemented in the Philadelphia area though the Jefferson health system and he has been teaching it to a New York health maintenance organization with 22 million members, he said.

15:47 11-14-96

Adults who are considering drinking alcoholic beverages should have only low-risk drinking as a goal, if they choose to drink. The lowest risk is not to drink, which should always be acceptable. Adult women who elect to drink should limit their consumption to no more than one drink per day. Men who elect to drink should limit their consumption to no more than two drinks per day. Underage youth should not drink.

These circumstances place drinkers at high risk for health, social, and/or legal consequences:

If underage;
If pregnant, nursing, or trying to conceive;
If driving or engaging in other activities that require attention, judgment or skill;
If taking medication that interacts with alcohol;
If recovering from alcohol or other drug dependence;
If drinking to intoxication;
If drinking cannot be done in moderation.

Although not specifically addressed by the guideline, alcohol use also is contrindicated for people with certain medical conditions such as peptic ulcer. The existence of spearate guidelines for men and women reflects research findings that women become more intoxicated than men a the equivalent dos of alcohol due to the size of their bodies in relationship to men.

Reference
Dietary Guidelines for Americans, Department of Health and Human Services and Department of Agriculture (1992)

This bibliography presents a selection of the ARF Library materials on the topic of addictions. Please consult your workplace/community libraries and information services to obtain these materials.

Baugh, James R. Recovering From Addiction: Guided Steps Through the Healing Process. New York: Insight Books. RC 533 .B28 1990

Breeden, Joann E. Love, Hope and Recovery: Healing the Pain of Addiction. Nevada City, CA: Blue Dolphin Publishing, Inc., 1993. RC 564 .B734 1994

Browne Miller, Angela. Gestalting Addiction: The Addiction-Focused Group Therapy of Dr. Richard Louis Miller. Norwood, NJ: Ablex Publishing Corp., 1993. RC 564 .B775 1993

Browne Miller, Angela. Transcending Addiction and Other Afflictions: Lifehealing. Norwood, NJ: Ablex Publishing Corp., 1993. RC 533 .B76 1993

Burns, John. The Answer to Addiction: The Path to Recovery From Alcohol, Drug, Food, And Sexual Dependencies. New York: Crossroad. RC 564 .B8723 1990

Carey, Sylvia. Jolted Sober: Getting to the Moment of Clarity in the Recovery From Addiction. Los Angeles, CA: Lowell House. RC 564 .C368 1989

Corey, Michael A. Kicking the Drug Habit: A Comprehensive Self-Help Guide to Understanding the Drug Problem and Overcoming Addiction. Springfield, Ill.: Charles C. Thomas. RC 564 .C684 1989

Cretchen, Dorothy. Steering Clear: Helping Your Child Through the High-Risk Drug Years. Minneapolis: Winston Press, 1982. 110p. HV 5824 .Y68 C73 1982

Daley, Dennis C. Kicking Addictive Habits Once and for All: A Relapse-Prevention Guide. Lexington, MA: D.C. Heath and Co., 1991. RC533 .D34 1991

Davies, John Booth. The Myth of Addiction. New York: Harwood Academic Publishers, 1992. RC 566 .D37 1992

Ditzler, James, Joyce Ditzler and Celia Haddon. Coming Off Drugs. London: MacMillan, 1986. 183p. RC 564 .D57 1986

Dixon, Annas. Dealing With Drugs. London: BBC Books, 1987. 208p. HV 5801 .D425 1987

The Dual Disorders Recovery Book: A Twelve Step Program for Those of us With Addiction and an Emotional or Psychiatric Illness: What we Used to be Like, What Happened, and What we are Like Now. Center City, MN: Hazelden, 1993. RC 564 .D836 1993

Engs, Ruth. Alcohol and Other Drugs: Self Responsibility. Bloomington, Indiana: Tichenor Pub., 1987. 387p. HV 5801 .E65 1987

Finnegan, John. Recovery From Addiction: A Comprehensive Understanding of Substance Abuse With Nutritional Therapies for Recovering Addicts and Co-Dependents. Berkeley, CA: Celestial Arts, 1990. RC 564 .F56 1990

Geide, Ray. Beyond Addiction: A Step-By-Step Guide to the Spiritual Principles of Addiction and Recovery. Dexter, KS: Dexter Publishing. RC 533 .G44 1991

Geller, Anne and M.J. Territo. Restore Your Life: A Living Plan for Sober People. New York: Bantam, 1992. RC 564 .G368 1992

Goodwin, Donald. Alcoholism: The Facts. Oxford, UK: Oxford University Press, 1994. RC 565 .G638 1994

Grof, Christina. The Thirst for Wholeness: Attachment, Addiction and the Spiritual Path. San Francisco, CA: Harper, 1993. RC 564 .G76 1993

Hodgson, Ray, and Peter Miller. Selfwatching: Addictions, Habits, Compulsions: What to Do About Them. New York: Facts on File, 1982. 224p. RC 564 .H6 1982

Jill, S. and Brian S. Learning to Live Again: A Guide for the Recovering Addict. Bradenton, FL: Tab Books, 1991. RC 564.29 .J55 1991

Kearney, Robert J. Within the Wall of Denial: Conquering Addictive Behaviors. New York: W.W. Norton & Co., 1996. RC 564 .K368 1996

Kinney, Jean and Gwen Leaton. Loosening the Grip: A handbook of Alcohol Information. St. Louis, MO: Mosby-Year Book, Inc., 1991. HV 5035 .K566 1991

Krivanek, Jara A. Addictions. Sydney; Boston: Allen & Unwin. HV 5822 .H4 K74 1988

Lawson, John. Friends You Can Drop: Alcohol and Drugs. Boston: Quinlan Press, 1986. 214p. HV 5060 .L374 1986

Luciani, Joseph J. Healing Your Habits: Introducing Directed Imagination, a Successful Technique for Overcoming Addictive Problems. San Diego, CA: LuraMedia, 1990. RC 533 .L83 1990

Mann, Marty. Marty Mann's New Primer on Alcoholism: How People Drink, How to Recognize Alcoholics, and What to Do About Them. New York: Holt, Rinehart Winston, 1981. 239p. HV 5035 .M36 1981

Michaelson, Peter. Secret Attachments: Exposing the Roots of Addictions and Compulsions. Naples, FL: Prospect Books, 1993. RC 533 .M33 1993

Mumey, Jack. The Joy of Being Sober. Chicago: Contemporarybooks, 1984. 214p. HV 5275 .M85 1984

O'Brien, Robert et al. The Encyclopedia of Drug Abuse. New York: Facts on File, Inc., 1992. HV 5804 .O24 1992

Peele, Stanton. Diseasing of America: Addiction Treatment Out of Control. Lexington, Mass.: Lexington Books, 1989. RC 564 .P424 1989

Peele, Stanton. The meaning of addiction: compulsive experience and its interpretation. Lexington, Mass.: Lexington Books, 1985. RC 564. P45 1985.

Peele, Stanton. The Truth About Addiction and Recovery. New York: Simon & Schuster, 1992. RC 564 .P439 1992

Peele, Stanton. Visions of addiction: major contemporary perspectives on addiction and alcoholism. Lexington, Mass: Lexington Books, 1988. HV 5801. V53 1988.

Plagenhoef, Richard L. and Carol Adler. Why am I Still Addicted?: A Holistic Approach to Recovery. Blue Ridge Summit, PA: TAB Books, 1992. RC 564 .P53 1992

Pleshette, Janet. Overcoming Addictions. Northamptonshire, UK: Thorsons. RC 564 .P63 1989

Podsadowski, Alan. Recovery From Addiction: A Guidebook for the Journey. North Vancouver, BC: West Coast Alternatives Society, 1993. RC 564 .R4285 1993

Preston, Andrew and Andy Malinowski. The Detox Handbook: A Users Guide to Getting Off Opiates. Dorset, UK: Island Press, 1994. RC 566 .P734 1994

Psychiatry and the Addictions. Abington, UK: Carfax Publishing. RC 533 .P78 1989

Recovering From Addiction: A Guidebook for the Journey. North Vancouver, B.C.: West Coast Alternatives Society, 1993. RC 564 .R4285 1993

Rogers, Ronald and C. Scott McMillin. The Healing Road: Treating Addictions in Groups. New York: W.W. Norton & Co. RC 564 .R64 1989

Rosselini, Gayle and Mark Worden. Of Course You're Anxious: Healthy Ways to Deal with Worry, Fear, and Stress in Recovery. Center City, MN: Hazelden, 1990. RC 564 .R667 1990

Sanchez-Craig, Martha. Saying When: How to Quit Drinking or Cut Down: An ARF Self-Help Book. Toronto: Addiction Research Foundation, 1993. RC 565 .S2627 1993

Schuckit, Marc Alan. Educating Yourself About Alcohol and Drugs: A People's Primer. New York: Plenum Press, 1995. RC 564 .S333 1995

Sourcebook of Substance Abuse and Addiction, ed. Lawrence S. Friedman. Baltimore, MD: Williams & Wilkins, 1996. HV 5801 .S639 1996

The TRY Book: What You Can Do About Alcohol and Drug Abuse: The Responsibility is Yours. Victoria, B.C.: Alcohol and Drug Program, 1988. HV 5801 .T78 1988

Twerski, Abraham J. Addictive Thinking: Understanding Self-Deception. Center City, MN: Hazelden, 1990. RC 533 .T93 1990

Tyrer, Peter. How to Stop Taking Tranquillizers: Overcoming Common Problems. London: Sheldon Press,1986. 96p. RC 568 .T7 T87 1986

Understanding Substance Abuse & Treatment, eds. George Pratsinak and Robert Alexander. Laurel, MD: American Correctional Association, 1992. HV 8836.5 .U53 1992

Washton, Arnold M. Step Zero: What to do When You Can't Fake it Anymore: Getting to Recovery. Center City, MN: Hazelden, 1991. RC 564 .W374 1991

Washton, Arnold M. Willpower's Not Enough: Understanding and Recovering From Addictions of Every Kind. New York: Harper & Row. RC 533 .W37 1989

Please send your comments and suggestions to:

Addiction Research Foundation Library
33 Russell Street
Toronto, Ontario
Canada M5S 2S1
internet: http://www.isdweb.arf.org

[07/96 addict.bib]

National Institute on Alcohol Abuse and Alcoholism

No. 12 PH 294 April 1991

----------------------------------------------------------------------

Assessing Alcoholism

The goal of assessment is to determine personal characteristics that can influence the treatment of a patient's alcohol problem. Once a person has been referred for alcohol treatment, clinicians use assessment techniques to characterize the problem and to plan treatment (1,2).

Assessment comprises at least four important tasks: 1) to aid in the formal diagnosis of the patient's alcohol problem; 2) to establish the severity of the alcohol problem; 3) to guide treatment planning; and 4) to define a baseline of the patient's status, to which his or her future conditions can be compared (3). Assessment is an ongoing, interactive process, used to evaluate a patient's progress and adjust treatment.

Questions answered by assessment include the following: Can withdrawal be accomplished without medications? Is outpatient treatment appropriate? If inpatient treatment is desirable, should the setting be psychiatric or alcohol-specific in nature? What would be an appropriate mix of choices taken from the variety of therapies? How has the patient's status changed during the course of treatment, and what problem areas remain?

A variety of methods are involved in comprehensive patient assessment, including medical examinations, clinical interviews, and formal instruments (questionnaires or tests). Each has specific strengths, and the approaches complement each other as they address the four goals stated above.

Every patient entering alcoholism treatment presents a unique combination of medical and psychological characteristics (4-7). Clinical interviews are valuable, and it is unlikely that there will ever be an adequate substitute for the experienced and skillful clinician. Nevertheless, the clinician's perception and judgment can be enhanced by the application of formal assessment instruments. Formal instruments relating to alcohol problems can be used to assess beliefs about the effects of drinking, levels of alcohol dependence, high-risk drinking situations, and resources that will aid in recovery. General psychological instruments can be used to assess personality, cognition, and neuropsychological characteristics.

Most alcoholism assessment instruments are standardized, self-administered questionnaires (or tests). These instruments offer comprehensiveness, consistency, ease of administration, and low cost. Standardized instruments provide a quantitative scale of alcohol problems, which can be useful, for example, when attempting to measure the patient's current need for treatment and future progress. In addition, formal instruments tend to be highly valid (they measure meaningful dimensions of alcoholism) and reliable. They also offer the clinician norms, by which the patient can be quantitatively compared to peers. And finally, some patients may place greater confidence in treatment strategies based on results of standardized tests rather than on clinical judgment alone.

Clinicians can choose from more than 100 assessment instruments in constructing a battery of tests tailored to the needs of a particular patient (see, for example, 8-14). Some instruments are protected by copyright, but can be obtained and used by paying a small royalty fee. Many are available free of charge.

To make a formal diagnosis of alcoholism, the clinician might use a test such as the alcohol section of the Structured Clinical Interview for DSM-III-R (SCID). The SCID is an extensive interview which must be administered by a trained clinician. The alcohol section of the SCID can be administered in about 15 minutes. The SCID reflects the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R) to arrive at a formal diagnosis (15). To make a quick estimate of the patient's psychiatric condition, the clinician might employ a short screening instrument such as the Brief Psychiatric Rating Scale, or BPRS, which can be administered in about 5 minutes (16). Should the BPRS suggest possibly severe psychiatric problems, the clinician might then administer the SCID in its entirety.

To establish the severity of the patient's alcohol problem, the clinician might use an instrument such as the Addiction Severity Index, or ASI (9). The ASI is a structured, 40-minute interview designed to assess the severity of adjustment problems in seven areas: medical, legal, psychiatric, drug abuse, alcohol abuse, employment, and family. The patient answers questions related to the number, extent, and duration of difficulties in each of these areas.

To help individualize treatment, the clinician might employ an instrument such as the Alcohol Use Inventory, or AUI (8,17). The AUI assesses the patient on the basis of three domains: perceived benefits of drinking, drinking styles, and consequences of drinking. Answers to test questions in these domains offer helpful suggestions in planning treatment. A recent version of the AUI comprises 228 questions, and can be self-administered in 40 to 60 minutes.

While some patients require medication to help them withdraw from alcohol, many others do quite well with the assistance of social support, emotional reassurance, and frequent "reality reorientation." The Clinical Institute Withdrawal Assessment Scale (CIWA) is an example of an instrument designed to help clinicians choose the best strategies for treating the patient's withdrawal (10,18). The CIWA employs a "check off" format to uncover signs and symptoms of alcohol withdrawal. Two recent studies found the CIWA to be helpful in identifying the risk of severe withdrawal and the need for medication (19,20).

A growing area of interest in alcoholism treatment deals with identifying emotional, cognitive, and social factors that may precipitate drinking. If such prompting, or "high risk," circumstances can be accurately gauged, treatment can incorporate interventions to teach the patient the skills to cope with them. The Inventory of Drinking Situations (21) and the Alcohol Expectancy Questionnaire (22) are examples of promising instruments being used in this area.

To establish a baseline to which future improvement or deterioration of the patient may be compared, the clinician might use an instrument such as the ASI, noted earlier. The measures cited here are examples of a wide range of instruments, some or all of which might be helpful to patients.

Many factors must be considered in choosing and employing assessment instruments to obtain treatment-relevant information (23). In the course of treatment, the timing and sequencing of tests are important issues. For example, an early test might help determine if the patient will require detoxification. Subsequent tests might assess collateral or contributing psychological problems and suggest interventions and treatment. Later tests might measure the progress of the patient and assist in selection of after-care interventions.

Many patients will show cognitive improvement during the few weeks after drinking has stopped, in which case the clinician must be especially alert to the timing of tests. In addition, certain limitations of patients will affect the administration of tests--indeed, the greater the patient's impairment, the greater the demand for skill on the part of the interviewer. The timing and selection of tests depends not only on the course of the patient's progress, but also on the needs of the treatment facility. In choosing and using instruments, administrators and clinicians consider cost, staff capacity, and their own treatment models.

Assessment techniques can provide benefits other than those for which they a re specifically designed. For example, the administration of instruments can suggest the seriousness and concern for individual patients of a program. This can encourage patients to stay with or return to treatment (2,24).

----------------------------------------------------------------------

Assessing Alcoholism--A Commentary by
NIAAA Director Enoch Gordis, M.D.

Assessment is a valuable tool for alcoholism treatment, and the use of formal assessment instruments as a standard part of all alcoholism treatment programs is recommended.

Although formal assessment cannot replace an experienced clinician's judgment, standardized tests and questionnaires can supplement clinical wisdom in important ways. For example, an assessment instrument can provide important baseline data for measuring individual patient progress, can aid in making patient/treatment-match decisions, or, in the press of a busy day, can help prevent clinical staff from omitting things of importance at intake. Even programs in which only one mix of treatment is offered can use formal assessments to highlight aspects of a patient's life that need the most help. Formal assessment also can provide standardized patient outcome data that can be used to justify reimbursement and validate the effectiveness of program components.

The number of programs that currently use any type of assessment instrument is low, although there are many advantages to such use. Many programs are concerned that using an assessment instrument may require extensive staff training or time that should be spent in patient care. However, all competent programs perform some kind of assessment, whether it involves a clinician's initial interview with a patient or the use of a formal assessment instrument. In many cases, a portion of the time currently used to conduct initial patient interviews can be devoted to formal assessment without interfering with patient care. Moreover, the variety of instruments that are now available permits a program to tailor assessment to its individual staff and schedule.

----------------------------------------------------------------------

Representative Sources for Assessment Instruments:

(1) Marketing Services, Department 898, Addiction Research Foundation, 33 Russell St., Toronto, Ontario, Canada M5S2S1.(2) Psychological Assessment Resources, Inc., 16204 North Florida Ave., Lutz, FL 33549-6130.(3) Western Psychological Services, 12031 Wilshire Blvd., Los Angeles, CA 90025-1251.

----------------------------------------------------------------------

All material contained in the Alcohol Alert is in the public domain and may be used or reproduced without permission from NIAAA. Citation of the source is appreciated.

Copies of the Alcohol Alert are available free of charge from the Scientific Communications Branch, Office of Scientific Affairs, NIAAA, Willco Building, Suite 409, 6000 Executive Boulevard, Bethesda, MD 20892-7003. Telephone: 301-443-3860.

----------------------------------------------------------------------

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service * National Institutes of Health

Getting the Facts

For many people, the facts about alcoholism are not clear. What is alcoholism, exactly? How does it differ from alcohol abuse? When should a person seek help for a problem related to his or her drinking? The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has prepared this booklet to help individuals and families answer these and other common questions about alcohol problems. The information below will explain alcoholism and alcohol abuse, symptoms of each, when and where to seek help, treatment choices, and additional helpful resources.

----------------------------------------------------------------------

A Widespread Problem

For most people, alcohol is a pleasant accompaniment to social activities. Moderate alcohol use--up to two drinks per day for men and one drink per day for women and older people (A standard drink is one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits) -- is not harmful for most adults. Nonetheless, a substantial number of people have serious trouble with their drinking. Currently, nearly 14 million Americans--1 in every 13 adults--abuse alcohol or are alcoholic. Several million more adults engage in risky drinking patterns that could lead to alcohol problems. In addition, approximately 53 percent of men and women in the United States report that one or more of their close relatives have a drinking problem.

The consequences of alcohol misuse are serious--in many cases, life-threatening. Heavy drinking can increase the risk for certain cancers, especially those of the liver, esophagus, throat, and larynx (voice box). It can also cause liver cirrhosis, immune system problems, brain damage, and harm to the fetus during pregnancy. In addition, drinking increases the risk of death from automobile crashes, recreational accidents, and on-the-job accidents and also increases the likelihood of homicide and suicide. In purely economic terms, alcohol-use problems cost society approximately $100 billion per year. In human terms, the costs are incalculable.

----------------------------------------------------------------------

What Is Alcoholism?

Alcoholism, which is also known as "alcohol dependence syndrome," is a disease that is characterized by the following elements:

• Craving: A strong need, or compulsion, to drink.
• Loss of control: The frequent inability to stop drinking once a person has begun.
• Physical dependence: The occurrence of withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking. These symptoms are usually relieved by drinking alcohol or by taking another sedative drug.
• Tolerance: The need for increasing amounts of alcohol in order to get "high."

Alcoholism has little to do with what kind of alcohol one drinks, how long one has been drinking, or even exactly how much alcohol one consumes. But it has a great deal to do with a person's uncontrollable need for alcohol. This description of alcoholism helps us understand why most alcoholics can't just "use a little willpower" to stop drinking. He or she is frequently in the grip of a powerful craving for alcohol, a need that can feel as strong as the need for food or water. While some people are able to recover without help, the majority of alcoholic individuals need outside assistance to recover from their disease. With support and treatment, many individuals are able to stop drinking and rebuild their lives. Many people wonder: Why can some individuals use alcohol without problems, while others are utterly unable to control their drinking? Recent research supported by NIAAA has demonstrated that for many people, a vulnerability to alcoholism is inherited. Yet it is important to recognize that aspects of a person's environment, such as peer influences and the availability of alcohol, also are significant influences. Both inherited and environmental influences are called "risk factors." But risk is not destiny. Just because alcoholism tends to run in families doesn't mean that a child of an alcoholic parent will automatically develop alcoholism.

----------------------------------------------------------------------

What Is Alcohol Abuse?

Alcohol abuse differs from alcoholism in that it does not include an extremely strong craving for alcohol, loss of control, or physical dependence. In addition, alcohol abuse is less likely than alcoholism to include tolerance (the need for increasing amounts of alcohol to get "high"). Alcohol abuse is defined as a pattern of drinking that is accompanied by one or more of the following situations within a 12-month period:

• Failure to fulfill major work, school, or home responsibilities;
• Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;
• Recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk;
• Continued drinking despite having ongoing relationship problems that are caused or worsened by the effects of alcohol.

While alcohol abuse is basically different from alcoholism, it is important to note that many effects of alcohol abuse are also experienced by alcoholics.

----------------------------------------------------------------------

What Are the Signs of a Problem?

How can you tell whether you, or someone close to you, may have a drinking problem? Answering the following four questions can help you find out. (To help remember these questions, note that the first letter of a key word in each of the four questions spells "CAGE.")

• Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

One "yes" response suggests a possible alcohol problem. If you responded "yes" to more than one question, it is highly likely that a problem exists. In either case, it is important that you see your doctor or other health care provider right away to discuss your responses to these questions. He or she can help you determine whether you have a drinking problem and, if so, recommend the best course of action for you.

Even if you answered "no" to all of the above questions, if you are encountering drinking-related problems with your job, relationships, health, or with the law, you should still seek professional help. The effects of alcohol abuse can be extremely serious--even fatal--both to you and to others.

----------------------------------------------------------------------

The Decision To Get Help

Acknowledging that help is needed for an alcohol problem may not be easy. But keep in mind that the sooner a person gets help, the better are his or her chances for a successful recovery.

Any reluctance you may feel about discussing your drinking with your health care professional may stem from common misconceptions about alcoholism and alcoholic people. In our society, the myth prevails that an alcohol problem is somehow a sign of moral weakness. As a result, you may feel that to seek help is to admit some type of shameful defect in yourself. In fact, however, alcoholism is a disease that is no more a sign of weakness than is asthma or diabetes. Moreover, taking steps to identify a possible drinking problem has an enormous payoff--a chance for a healthier, more rewarding life.

When you visit your health care provider, he or she will ask you a number of questions about your alcohol use to determine whether you are experiencing problems related to your drinking. Try to answer these questions as fully and honestly as you can. You also will be given a physical examination. If your health care professional concludes that you may be dependent on alcohol, he or she may recommend that you see a specalist in diagnosing and treating alcoholism. You should be involved in making referral decisions and have all treatment choices explained to you.

----------------------------------------------------------------------

Getting Well

Alcoholism Treatment

The nature of treatment depends on the severity of an individual's alcoholism and the resources that are available in his or her community. Treatment may include detoxification (the process of safely getting alcohol out of one's system); taking doctor-prescribed medications, such as disulfiram (Antabuse®) or naltrexone (ReViaTM), to help prevent a return to drinking once drinking has stopped; and individual and/or group counseling. There are promising types of counseling that teach recovering alcoholics to identify situations and feelings that trigger the urge to drink and to find new ways to cope that do not include alcohol use. Any of these treatments may be provided in a hospital or residential treatment setting or on an outpatient basis.

Because the involvement of family members is important to the recovery process, many programs also offer brief marital counseling and family therapy as part of the treatment process. Some programs also link up individuals with vital community resources, such as legal assistance, job training, child care, and parenting classes.

Alcoholics Anonymous

Virtually all alcoholism treatment programs also include meetings of Alcoholics Anonymous (AA), which describes itself as a "worldwide fellowship of men and women who help each other to stay sober." While AA is generally recognized as an effective mutual help program for recovering alcoholics, not everyone responds to AA's style and message, and other recovery approaches are available. Even those who are helped by AA usually find that AA works best in combination with other elements of treatment, including counseling and medical care.

Can Alcoholism Be Cured?

While alcoholism is a treatable disease, a cure is not yet available. That means that even if an alcoholic has been sober for a long while and has regained health, he or she remains susceptible to relapse and must continue to avoid all alcoholic beverages. "Cutting down" on drinking doesn't work; cutting out alcohol is necessary for a successful recovery.

However, even individuals who are determined to stay sober may suffer one or several "slips," or relapses, before achieving long-term sobriety. Relapses are very common and do not mean that a person has failed or cannot eventually recover from alcoholism. Keep in mind, too, that every day that a recovering alcoholic has stayed sober prior to a relapse is extremely valuable time, both to the individual and to his or her family. If a relapse occurs, it is very important to try to stop drinking once again and to get whatever additional support is needed to abstain from drinking.

Help for Alcohol Abuse

If your health care provider determines that you are not alcohol dependent but are nonetheless involved in a pattern of alcohol abuse, he or she can help you:

• Examine the benefits of stopping an unhealthy drinking pattern.
• Set a drinking goal for yourself. Some people choose to abstain from alcohol, while others prefer to limit the amount they drink.
• Examine the situations that trigger your unhealthy drinking patterns, and develop new ways of handling those situations so that you can maintain your drinking goal.

Some individuals who have stopped drinking after experiencing alcohol-related problems choose to attend AA meetings for information and support, even though they have not been diagnosed as alcoholic.

----------------------------------------------------------------------

New Directions

With the support of NIAAA, scientists at medical centers and universities throughout the country are studying alcoholism. The goal of this research is to develop more effective ways of treating and preventing alcohol problems. Today, NIAAA funds approximately 90 percent of all alcoholism research in the United States. Some of the more exciting investigations include:

• Genetic research: Scientists are now studying 3,000 individuals from several hundred families with a history of alcoholism in order to pinpoint the location of genes that influence vulnerability to alcoholism. This new knowledge will help identify individuals at high risk for alcoholism and also will pave the way for the development of new treatments for alcohol-related problems. Other research is investigating the ways in which genetic and environmental factors combine to cause alcoholism.
• Treatment approaches: NIAAA also sponsored a study called Project MATCH, which tested whether treatment outcome could be improved by matching patients to three types of treatment based on particular individual characteristics. This study found that all three types of treatment reduced drinking markedly in the year following treatment.
• New medications: Studies supported by NIAAA have led to the Food and Drug Administration's approval of the medication naltrexone (ReViaTM) for the treatment of alcoholism. When used in combination with counseling, this prescription drug lessens the craving for alcohol in many people and helps prevent a return to heavy drinking. Naltrexone is the first medication approved in 45 years to help alcoholics stay sober after they detoxify from alcohol.

In addition to these efforts, NIAAA is sponsoring promising research in other vital areas, such as fetal alcohol syndrome, alcohol's effects on the brain and other organs, aspects of drinkers' environments that may contribute to alcohol abuse and alcoholism, strategies to reduce alcohol-related problems, and new treatment techniques. Together, these investigations will help to prevent alcohol problems; identify alcohol abuse and alcoholism at earlier stages; and make available new, more effective treatment approaches for individuals and families.

----------------------------------------------------------------------

Resources

For more information on alcohol abuse and alcoholism, contact the following organizations:

Al-Anon Family Group Headquarters
1600 Corporate Landing Parkway
Virginia Beach, VA 23454-5617
Internet address: http://www.al-anon.alateen.org

Makes referrals to local Al-Anon groups, which are support groups for spouses and other significant adults in an alcoholic person's life. Also makes referrals to Alateen groups, which offer support to children of alcoholics.

Locations of Al-Anon or Alateen meetings worldwide can be obtained by calling the toll-free numbers Monday through Friday, 8 a.m.-6 p.m. (e.s.t.):

U. S.: (800) 344-2666
Canada: (800) 443-4525

Free informational materials can be obtained by calling the toll-free numbers (operating 7 days a week, 24 hours per day):

U. S.: (800) 356-9996
Canada: (800) 714-7498

Alcoholics Anonymous (AA) World Services
475 Riverside Drive, 11th Floor
New York, NY 10115
(212) 870-3400
Internet address: http://www.alcoholics-anonymous.org

Makes referrals to local AA groups and provides informational materials on the AA program. Many cities and towns also have a local AA office listed in the telephone book.

National Council on Alcoholism and Drug Dependence (NCADD)
12 West 21st Street
New York, NY 10010
(800) NCA-CALL
Internet address: http://www.ncadd.org

Provides phone numbers of local NCADD affiliates (who can provide information on local treatment resources) and educational materials on alcoholism via the above toll-free number.

National Institute on Alcohol Abuse and Alcoholism
Scientific Communications Branch
6000 Executive Boulevard, Suite 409
Bethesda, MD 20892-7003
(301) 443-3860
Internet address: http://www.niaaa.nih.gov

Makes available free informational materials on all aspects of alcoholism, including the effects of drinking during pregnancy, alcohol use and the elderly, and help for cutting down on drinking.

Prepared: November 1996

As Americans face tougher times from a slowing economy, they are consuming more alcohol, Reuters reported Jan. 12.

"People are drinking more, because people tend to drink more during tough times,'' said JP Morgan beverage analyst John Faucher. "That fits into the current environment, both from a September 11 standpoint as well as from an economic standpoint."

Typically, sales of alcohol increase during recessions. According to industry figures, spending on liquor has risen in recent months. Data also shows that more people are consuming alcohol at home rather than in restaurants.

"I would agree with the theory that people have been drinking more," said Davenport & Co. analyst Ann Gurkin, who follows a number of beverage companies.

Industry watchers also note that consumers are buying "top-shelf" liquors. Marketers speculate that people are trying to give themselves a relatively low-priced luxury like a single malt Scotch or bottle of champagne, while foregoing a vacation or a new car.

"People continue to trade up for the most part," said Gray Ottley of Silver Creek Distillers.

See Article