Alcoholism - Part V

Turning the Improbable
Into the Exceptional!
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
Since its founding in 2003, The Advocacy Foundation has become recognized as an effective
provider of support to those who receive our services, having real impact within the communities
we serve. We are currently engaged in community and faith-based collaborative initiatives,
having the overall objective of eradicating all forms of youth violence and correcting injustices
everywhere. In carrying-out these initiatives, we have adopted the evidence-based strategic
framework developed and implemented by the Office of Juvenile Justice & Delinquency
Prevention (OJJDP).
The stated objectives are:
1. Community Mobilization;
2. Social Intervention;
3. Provision of Opportunities;
4. Organizational Change and Development;
5. Suppression [of illegal activities].
Moreover, it is our most fundamental belief that in order to be effective, prevention and
intervention strategies must be Community Specific, Culturally Relevant, Evidence-Based, and
Collaborative. The Violence Prevention and Intervention programming we employ in
implementing this community-enhancing framework include the programs further described
throughout our publications, programs and special projects both domestically and
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Dedication
______
Every publication in our many series’ is dedicated to everyone, absolutely everyone, who by
virtue of their calling and by Divine inspiration, direction and guidance, is on the battlefield dayafter-day
striving to follow God’s will and purpose for their lives. And this is with particular affinity
for those Spiritual warriors who are being transformed into excellence through daily academic,
professional, familial, and other challenges.
We pray that you will bear in mind:
Matthew 19:26 (NIV)
Jesus looked at them and said, "With man this is impossible,
but with God all things are possible." (Emphasis added)
To all of us who daily look past our circumstances, and naysayers, to what the Lord says we will
accomplish:
Blessings!!
- The Advocacy Foundation, Inc.
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The Transformative Justice Project
Eradicating Juvenile Delinquency Requires a Multi-Disciplinary Approach
The way we accomplish all this is a follows:
The Juvenile Justice system is incredibly overloaded, and
Solutions-Based programs are woefully underfunded. Our
precious children, therefore, particularly young people of
color, often get the “swift” version of justice whenever they
come into contact with the law.
Decisions to build prison facilities are often based on
elementary school test results, and our country incarcerates
more of its young than any other nation on earth. So we at
The Foundation labor to pull our young people out of the
“school to prison” pipeline, and we then coordinate the efforts
of the legal, psychological, governmental and educational
professionals needed to bring an end to delinquency.
We also educate families, police, local businesses, elected
officials, clergy, and schools and other stakeholders about
transforming whole communities, and we labor to change
their thinking about the causes of delinquency with the goal
of helping them embrace the idea of restoration for the young
people in our care who demonstrate repentance for their
mistakes.
1. We vigorously advocate for charges reductions, wherever possible, in the adjudicatory (court)
process, with the ultimate goal of expungement or pardon, in order to maximize the chances for
our clients to graduate high school and progress into college, military service or the workforce
without the stigma of a criminal record;
2. We then enroll each young person into an Evidence-Based, Data-Driven Restorative Justice
program designed to facilitate their rehabilitation and subsequent reintegration back into the
community;
3. While those projects are operating, we conduct a wide variety of ComeUnity-ReEngineering
seminars and workshops on topics ranging from Juvenile Justice to Parental Rights, to Domestic
issues to Police friendly contacts, to CBO and FBO accountability and compliance;
4. Throughout the process, we encourage and maintain frequent personal contact between all
parties;
5 Throughout the process we conduct a continuum of events and fundraisers designed to facilitate
collaboration among professionals and community stakeholders; and finally
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6. 1 We disseminate Quarterly publications, like our e-Advocate series Newsletter and our e-Advocate
Quarterly electronic Magazine to all regular donors in order to facilitate a lifelong learning process
on the ever-evolving developments in the Justice system.
And in addition to the help we provide for our young clients and their families, we also facilitate
Community Engagement through the Restorative Justice process, thereby balancing the interesrs
of local businesses, schools, clergy, elected officials, police, and all interested stakeholders. Through
these efforts, relationships are rebuilt & strengthened, local businesses and communities are enhanced &
protected from victimization, young careers are developed, and our precious young people are kept out
of the prison pipeline.
This is a massive undertaking, and we need all the help and financial support you can give! We plan to
help 75 young persons per quarter-year (aggregating to a total of 250 per year) in each jurisdiction we
serve) at an average cost of under $2,500 per client, per year.*
Thank you in advance for your support!
* FYI:
1. The national average cost to taxpayers for minimum-security youth incarceration, is around
$43,000.00 per child, per year.
2. The average annual cost to taxpayers for maximun-security youth incarceration is well over
$148,000.00 per child, per year.
- (US News and World Report, December 9, 2014);
3. In every jurisdiction in the nation, the Plea Bargain rate is above 99%.
The Judicial system engages in a tri-partite balancing task in every single one of these matters, seeking
to balance Rehabilitative Justice with Community Protection and Judicial Economy, and, although
the practitioners work very hard to achieve positive outcomes, the scales are nowhere near balanced
where people of color are involved.
We must reverse this trend, which is right now working very much against the best interests of our young.
Our young people do not belong behind bars.
- Jack Johnson
1 In addition to supporting our world-class programming and support services, all regular donors receive our Quarterly e-Newsletter
(The e-Advocate), as well as The e-Advocate Quarterly Magazine.
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The Advocacy Foundation, Inc.
Helping Individuals, Organizations & Communities
Achieve Their Full Potential
…a collection of works on
Alcoholism
Evidence-Based Solutions at the Grassroots Level
Part V
“Turning the Improbable Into the Exceptional”
Atlanta
Philadelphia
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John C Johnson III
Founder & CEO
(878) 222-0450
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www.TheAdvocacyFoundation.org
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Biblical Authority
______
1 Corinthians 10:13-14
13
No temptation has overtaken you except what is common to mankind. And God is
faithful; he will not let you be tempted beyond what you can bear. But when you are
tempted, he will also provide a way out so that you can endure it.
James 4:7-10
7
Submit yourselves, then, to God. Resist the devil, and he will flee from you. 8 Come
near to God and he will come near to you. Wash your hands, you sinners, and purify
your hearts, you double-minded. 9 Grieve, mourn and wail. Change your laughter to
mourning and your joy to gloom. 10 Humble yourselves before the Lord, and he will lift
you up.
15
and call on me in the day of trouble;
I will deliver you, and you will honor me.”
Psalm 50:15
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Table of Contents
…a collection of works on
Alcoholism
Evidence-Based Solutions at the Grassroots Level
Part V – Alcoholism
______
Biblical Authority
I. Introduction: Alcohol Use Disorder (AUD)…………………………… 17
II. The Alcohol Use Disorder Identification Test (AUDIT)…………….. 41
III. Addictive Personalities………………………………………………… 47
IV. Alcohol-Related Traffic Crashes in the U.S…………………………. 59
V. Alcohol in Family Systems……………………………………………. 69
VI. Alcoholics Anonymous ……………………………………………….. 79
VII. Recovery Approach……………………………………………………. 95
VIII. References……………………………………………………………… 105
Attachments
A. Alcohol Use Disorder Identification Test (AUDIT)
B. The Genetics of Alcohol and Other Drug Dependence
C. AUDIT Testing Guidelines
Copyright © 2018 The Advocacy Foundation, Inc. All Rights Reserved.
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I. Introduction
Alcoholism, also known as Alcohol Use Disorder (AUD), is a broad term for any
drinking of alcohol that results in mental or physical health problems. The disorder was
previously divided into two types: alcohol abuse and alcohol dependence. In a medical
context, alcoholism is said to exist when two or more of the following conditions is
present: a person drinks large amounts over a long time period, has difficulty cutting
down, acquiring and drinking alcohol takes up a great deal of time, alcohol is strongly
desired, usage results in not fulfilling responsibilities, usage results in social problems,
usage results in health problems, usage results in risky situations, withdrawal occurs
when stopping, and alcohol tolerance has occurred with use. Risky situations
include drinking and driving or having unsafe sex, among other things. Alcohol use can
affect all parts of the body, but it particularly affects the brain, heart, liver, pancreas,
and immune system. This can result in mental illness, Wernicke–Korsakoff syndrome,
an irregular heartbeat, cirrhosis of the liver, and an increase in the risk ofcancer, among
other diseases. [3][4] Drinking during pregnancy can cause damage to the baby resulting
in fetal alcohol spectrum disorders. Women are generally more sensitive then men to
the harmful physical and mental effects of alcohol.
Environmental factors and genetics are two components that are associated with
alcoholism, with about half the risk attributed to each . A person with a parent or sibling
with alcoholism is three to four times more likely to become an alcoholic
themselves. Environmental factors include social, cultural, and behavioral influences.
High stress levels, anxiety, as well as inexpensive cost and easy accessibility to alcohol
increase the risk. People may continue to drink partly to prevent or improve symptoms
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of withdrawal. After a person stops drinking alcohol, they may experience a low level of
withdrawal lasting for months. Medically, alcoholism is considered both a physical and
mental illness. Questionnaires and certain blood tests may both detect people with
possible alcoholism. Further information is then collected to confirm the diagnosis.
Prevention of alcoholism may be attempted by regulating and limiting the sale of
alcohol, taxing alcohol to increase its cost, and providing inexpensive
treatment. Treatment may take several steps. Due to medical problems that can occur
during withdrawal, alcohol detoxification should be carefully controlled. One common
method involves the use of benzodiazepine medications, such as diazepam. This can
be either given while admitted to a health care institution or occasionally while a person
remains in the community with close supervision. Mental illness or other addictions may
complicate treatment. After detoxification support such asgroup therapy or support
groups are used to help keep a person from returning to drinking. One commonly used
form of support is the group Alcoholics Anonymous. The
medications acamprosate, disulfiram, ornaltrexone may also be used to help prevent
further drinking.
The World Health Organization estimates that as of 2010 there were 208 million people
with alcoholism worldwide (4.1% of the population over 15 years of age). In the United
States about 17 million (7%) of adults and 0.7 million (2.8%) of those age 12 to 17 years
of age are affected. It is more common among males and young adults, becoming less
common in middle and old age. It is the least common in Africa at 1.1% and has the
highest rates in Eastern Europe at 11%. Alcoholism directly resulted in 139,000 deaths
in 2013, up from 112,000 deaths in 1990. A total of 3.3 million deaths (5.9% of all
deaths) are believed to be due to alcohol. It often reduces a person's life expectancy by
around ten years. In the United States it resulted in economic costs of $224 billion USD
in 2006. Many terms, some insulting and others informal, have been used to refer to
people affected by alcoholism; the expressions include tippler, drunkard, dipsomaniac,
and souse. In 1979, the World Health Organization discouraged the use of "alcoholism"
due to its inexact meaning, preferring "alcohol dependence syndrome".
Signs and Symptoms
Early signs
The risk of alcohol dependence begins at low levels of drinking and increases directly
with both the volume of alcohol consumed and a pattern of drinking larger amounts on
an occasion, to the point of intoxication, which is sometimes called "binge drinking".
Young adults are particularly at risk of engaging in binge drinking.
Long-Term Misuse
Alcoholism is characterized by an increased tolerance to alcohol–which means that an
individual can consume more alcohol–and physical dependence on alcohol, which
makes it hard for an individual to control their consumption. The physical dependency
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caused by alcohol can lead to an affected individual having a very strong urge to drink
alcohol. These characteristics play a role decreasing an alcoholic's ability to stop
drinking. Alcoholism can have adverse effects on mental health, causing psychiatric
disorders and increasing the risk of suicide. A depressed mood is a common symptom
of heavy alcohol drinkers.
Warning signs
Warning signs of alcoholism include the consumption of increasing amounts of alcohol
and frequent intoxication, preoccupation with drinking to the exclusion of other activities,
promises to quit drinking and failure to keep those promises, the inability to remember
what was said or done while drinking (colloquially known as "blackouts"), personality
changes associated with drinking, denial or the making of excuses for drinking, the
refusal to admit excessive drinking, dysfunction or other problems at work or school, the
loss of interest in personal appearance or hygiene, marital and economic problems, and
the complaint of poor health, with loss of appetite, respiratory infections, or increased
anxiety.
Short-Term effects
Physical
Drinking enough to cause a blood alcohol
concentration (BAC) of 0.03–0.12%
typically causes an overall improvement
in mood and possible euphoria (a "happy"
feeling), increased self-confidence and
sociability, decreased anxiety, a flushed,
red appearance in the face and impaired
judgment and fine muscle coordination. A
BAC of 0.09% to 0.25%
causes lethargy, sedation, balance
problems and blurred vision. A BAC of
0.18% to 0.30% causes profound
confusion, impaired speech (e.g. slurred
speech), staggering, dizziness and
vomiting. A BAC from 0.25% to 0.40%
causes stupor,
unconsciousness, anterograde amnesia, vomiting (death may occur due to inhalation of
vomit (pulmonary aspiration) while unconscious and respiratory depression (potentially
life-threatening). A BAC from 0.35% to 0.80% causes a coma (unconsciousness), lifethreatening
respiratory depression and possibly fatal alcohol poisoning.
With all alcoholic beverages, drinking while driving, operating an aircraft or heavy
machinery increases the risk of an accident; many countries have penalties for drunk
driving.
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Long-Term Effects
Having more than one drink a day for women or two drinks for men increases the risk of
heart disease, high blood pressure, atrial fibrillation, and stroke. Risk is greater in
younger people due to binge drinking, which may result in violence or accidents. About
3.3 million deaths (5.9% of all deaths) are believed to be due to alcohol each
year. Alcoholism reduces a person's life expectancy by around ten years and alcohol
use is the third leading cause of early death in the United States. No professional
medical association recommends that people who are nondrinkers should start drinking
wine. Long-term alcohol abuse can cause a number of physical symptoms,
including cirrhosis of the liver, pancreatitis, epilepsy, polyneuropathy, alcoholic
dementia, heart disease, nutritional deficiencies, peptic ulcers and sexual dysfunction,
and can eventually be fatal. Other physical effects include an increased risk of
developing cardiovascular disease, malabsorption,alcoholic liver disease, and cancer.
Damage to the central nervous system and peripheral nervous system can occur from
sustained alcohol consumption. A wide range of immunologic defects can result and
there may be a generalized skeletal fragility, in addition to a recognized tendency to
accidental injury, resulting a propensity to bone fractures.
Women develop long-term complications of alcohol dependence more rapidly than do
men. Additionally, women have a higher mortality rate from alcoholism than
men. Examples of long-term complications include brain, heart, and liver damage and
an increased risk of breast cancer. Additionally, heavy drinking over time has been
found to have a negative effect on reproductive functioning in women. This results in
reproductive dysfunction such as anovulation, decreased ovarian mass, problems or
irregularity of the menstrual cycle, and early menopause. Alcoholic ketoacidosis can
occur in individuals who chronically abuse alcohol and have a recent history of binge
drinking. The amount of alcohol that can be biologically processed and its effects differ
between sexes. Equal dosages of alcohol consumed by men and women generally
result in women having higher blood alcohol concentrations (BACs), since women
generally have a higher percentage of body fat and therefore a lower volume of
distribution for alcohol than men, and because the stomachs of men tend to metabolize
alcohol more quickly.
Psychiatric
Long-term misuse of alcohol can cause a wide range of mental health problems.
Severe cognitive problems are common; approximately 10 percent of all dementia
cases are related to alcohol consumption, making it the second leading cause
of dementia. Excessive alcohol use causes damage to brain function, and psychological
health can be increasingly affected over time. Social skills are significantly impaired in
people suffering from alcoholism due to the neurotoxic effects of alcohol on the brain,
especially the prefrontal cortex area of the brain. The social skills that are impaired
by alcohol abuse include impairments in perceiving facial emotions, prosody perception
problems and theory of mind deficits; the ability to understand humor is also impaired in
alcohol abusers. Psychiatric disorders are common in alcoholics, with as many as 25
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percent suffering severe psychiatric disturbances. The most prevalent psychiatric
symptoms are anxiety and depression disorders. Psychiatric symptoms usually initially
worsen during alcohol withdrawal, but typically improve or disappear with continued
abstinence. Psychosis, confusion, and organic brain syndrome may be caused by
alcohol misuse, which can lead to a misdiagnosis such as schizophrenia. Panic
disorder can develop or worsen as a direct result of long-term alcohol misuse.
The co-occurrence of major depressive disorder and alcoholism is well
documented. Among those with comorbid occurrences, a distinction is commonly made
between depressive episodes that remit with alcohol abstinence ("substance-induced"),
and depressive episodes that are primary and do not remit with abstinence
("independent" episodes). Additional use of other drugs may increase the risk of
depression. Psychiatric disorders differ depending on gender. Women who have
alcohol-use disorders often have a co-occurring psychiatric diagnosis such as major
depression, anxiety, panic disorder, bulimia, post-traumatic stress disorder (PTSD),
or borderline personality disorder.
Men with alcohol-use disorders more often have a co-occurring diagnosis
of narcissistic or antisocial personality disorder, bipolar disorder, schizophrenia, impulse
disorders or attention deficit/hyperactivity disorder (ADHD).
Women with alcoholism are more likely to experience physical or sexual assault, abuse
and domestic violence than women in the general population, which can lead to higher
instances of psychiatric disorders and greater dependence on alcohol.
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Social Effects
Serious social problems arise from alcoholism; these dilemmas are caused by the
pathological changes in the brain and the intoxicating effects of alcohol. Alcohol abuse
is associated with an increased risk of committing criminal offences, including child
abuse, domestic violence, rape, burglary and assault. Alcoholism is associated with loss
of employment, which can lead to financial problems. Drinking at inappropriate times
and behavior caused by reduced judgment can lead to legal consequences, such as
criminal charges for drunk driving or public disorder, or civil penalties
for tortious behavior, and may lead to a criminal sentence. An alcoholic's behavior and
mental impairment while drunk can profoundly affect those surrounding him and lead to
isolation from family and friends. This isolation can lead to marital conflict and divorce,
or contribute to domestic violence. Alcoholism can also lead to child neglect, with
subsequent lasting damage to the emotional development of the alcoholic's
children. For this reason, children of alcoholic parents can develop a number of
emotional problems. For example, they can become afraid of their parents, because of
their unstable mood behaviors. In addition, they can develop considerable amount of
shame over their inadequacy to liberate their parents from alcoholism. As a result of this
failure, they develop wretched self-images, which can lead to depression.
Alcohol Withdrawal
As with similar substances with a sedative-hypnotic mechanism, such
as barbiturates and benzodiazepines, withdrawal from alcohol dependence can be fatal
if it is not properly managed. Alcohol's primary effect is the increase in stimulation of the
GABA A receptor, promoting central nervous system depression. With repeated heavy
consumption of alcohol, these receptors are desensitized and reduced in number,
resulting in tolerance and physical dependence. When alcohol consumption is stopped
too abruptly, the person's nervous system suffers from uncontrolled synapse firing. This
can result in symptoms that include anxiety, life-threatening seizures, delirium tremens,
hallucinations, shakes and possible heart failure. Other neurotransmitter systems are
also involved, especially dopamine, NMDA and glutamate.
Severe acute withdrawal symptoms such as delirium tremens and seizures rarely occur
after 1-week post cessation of alcohol. The acute withdrawal phase can be defined as
lasting between one and three weeks. In the period of 3–6 weeks following cessation
increased anxiety, depression, as well as sleep disturbance, is common; fatigue and
tension can persist for up to 5 weeks as part of the post-acute withdrawal syndrome;
about a quarter of alcoholics experience anxiety and depression for up to 2 years.
These post-acute withdrawal symptoms have also been demonstrated in animal models
of alcohol dependence and withdrawal. A kindling effect also occurs in alcoholics
whereby each subsequent withdrawal syndrome is more severe than the previous
withdrawal episode; this is due to neuroadaptations which occur as a result of periods of
abstinence followed by re-exposure to alcohol. Individuals who have had multiple
withdrawal episodes are more likely to develop seizures and experience more severe
anxiety during withdrawal from alcohol than alcohol-dependent individuals without a
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history of past alcohol withdrawal episodes. The kindling effect leads to persistent
functional changes in brain neural circuits as well as to gene expression. Kindling also
results in the intensification of psychological symptoms of alcohol withdrawal. There are
decision tools and questionnaires which help guide physicians in evaluating alcohol
withdrawal. For example, the CIWA-Ar objectifies alcohol withdrawal symptoms in order
to guide therapy decisions which allows for an efficient interview while at the same time
retaining clinical usefulness, validity, and reliability, ensuring proper care for withdrawal
patients, who can be in danger of death.
Causes
A complex mixture of genetic and environmental factors influences the risk of the
development of alcoholism. Genes that influence the metabolism of alcohol also
influence the risk of alcoholism, and may be indicated by a family history of
alcoholism. One paper has found that alcohol use at an early age may influence
the expression of genes which increase the risk of alcohol dependence. Individuals who
have a genetic disposition to alcoholism are also more likely to begin drinking at an
earlier age than average. Also, a younger age of onset of drinking is associated with an
increased risk of the development of alcoholism, and about 40 percent of alcoholics will
drink excessively by their late adolescence. It is not entirely clear whether this
association is causal, and some researchers have been known to disagree with this
view.
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Severe childhood trauma is also associated with a general increase in the risk of drug
dependency. Lack of peer and family support is associated with an increased risk of
alcoholism developing. Genetics and adolescence are associated with an increased
sensitivity to the neurotoxic effects of chronic alcohol abuse. Cortical degeneration due
to the neurotoxic effects increases impulsive behavior, which may contribute to the
development, persistence and severity of alcohol use disorders. There is evidence that
with abstinence, there is a reversal of at least some of the alcohol induced central
nervous system damage. The use of cannabis was associated with later problems with
alcohol use. Alcohol use was associated with an increased probability of later use of
tobacco, cannabis, and other illegal drugs.
Availability
Alcohol is the most available, widely consumed, and widely abused recreational
drug. Beer alone is the world's most widely consumed alcoholic beverage; it is the thirdmost
popular drink overall, after water and tea. It is thought by some to be the oldest
fermented beverage.
Gender Difference
Based on combined data from SAMHSA's 2004–2005 National Surveys on Drug Use &
Health, the rate of past-year alcohol dependence or abuse among persons aged 12 or
older varied by level of alcohol use: 44.7% of past month heavy drinkers, 18.5% binge
drinkers, 3.8% past month non-binge drinkers, and 1.3% of those who did not drink
alcohol in the past month met the criteria for alcohol dependence or abuse in the past
year. Males had higher rates than females for all measures of drinking in the past
month: any alcohol use (57.5% vs. 45%), binge drinking (30.8% vs. 15.1%), and heavy
alcohol use (10.5% vs. 3.3%), and males were twice as likely as females to have met
the criteria for alcohol dependence or abuse in the past year (10.5% vs. 5.1%).
Genetic Variation
Genetic differences that exist between different racial groups affect the risk of
developing alcohol dependence. For example, there are differences between African,
East Asian and Indo-racial groups in how they metabolize alcohol. These genetic
factors partially explain the differing rates of alcohol dependence among racial
groups. The alcohol dehydrogenase allele ADH1 B*3 causes a more rapid metabolism
of alcohol. The allele ADH1 B*3 is only found in those of African descent and certain
Native American tribes. African Americans and Native Americans with this allele have a
reduced risk of developing alcoholism. Native Americans, however, have a significantly
higher rate of alcoholism than average; it is unclear why this is the case. Other risk
factors such as cultural environmental effects e.g. trauma have been proposed to
explain the higher rates of alcoholism among Native Americans compared to alcoholism
levels in caucasians.
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A genome-wide association study of more than 100,000 human individuals identified
variants of the gene KLB, which encodes the transmembrane protein β-Klotho, as highly
associated with alcohol consumption. The protein β-Klotho is an essential element
in cell surface receptors for hormones involved in modulation of appetites for simple
sugars and alcohol.
Definition
Diagnosis
Misuse, problem use, abuse, and heavy use of alcohol refer to improper use of alcohol,
which may cause physical, social, or moral harm to the drinker. The Dietary Guidelines
for Americans defines "moderate use" as no more than two alcoholic beverages a day
for men and no more than one alcoholic beverage a day for women. Some drinkers may
drink more than 600 ml of alcohol per day during a heavy drinking period. The National
Institute on Alcohol Abuse and Alcoholism (NIAAA) defines binge drinking as the
amount of alcohol leading to a blood alcohol content (BAC) of 0.08, which, for most
adults, would be reached by consuming five drinks for men or four for women over a
two-hour period. According to the NIAAA, men may be at risk for alcohol-related
problems if their alcohol consumption exceeds 14 standard drinks per week or 4 drinks
per day, and women may be at risk if they have more than 7 standard drinks per week
or 3 drinks per day. It defines a standard drink as one 12-ounce bottle of beer, one 5-
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ounce glass of wine, or 1.5 ounces of distilled spirits. Despite this risk, a 2014 report in
the National Survey on Drug Use and Health found that only 10% of either "heavy
drinkers" or "binge drinkers" defined according to the above criteria also met the criteria
for alcohol dependence, while only 1.3% of non-binge drinkers met the criteria. An
inference drawn from this study is that evidence-based policy strategies and clinical
preventive services may effectively reduce binge drinking without requiring addiction
treatment in most cases.
Alcoholism
The term alcoholism is commonly used amongst laypeople, but the word is poorly
defined. The WHO calls alcoholism "a term of long-standing use and variable meaning",
and use of the term was disfavored by a 1979 WHO expert committee. The Big
Book(from Alcoholics Anonymous) states that once a person is an alcoholic, they are
always an alcoholic, but does not define what is meant by the term alcoholic in this
context. In 1960, Bill W., co-founder of Alcoholics Anonymous (AA), said:
We have never called alcoholism a disease because, technically speaking, it is not a
disease entity. For example, there is no such thing as heart disease. Instead there are
many separate heart ailments, or combinations of them. It is something like that with
alcoholism. We did not wish to get in wrong with the medical profession by pronouncing
alcoholism a disease entity. We always called it an illness, or a malady—a far safer
term for us to use. In professional and research contexts, the term "alcoholism"
sometimes encompasses both alcohol abuse and alcohol dependence, and sometimes
is considered equivalent to alcohol dependence. Talbot (1989) observes that alcoholism
in the classical disease model follows a progressive course: if a person continues to
drink, their condition will worsen. This will lead to harmful consequences in their life,
physically, mentally, emotionally and socially.
Johnson's Typologies
Johnson (1980) explores the emotional progression of the addict’s response to alcohol.
He looks at this in four phases. The first two are considered "normal" drinking and the
last two are viewed as "typical" alcoholic drinking. Johnson's four phases consist of:
1. Learning the mood swing. A person is introduced to alcohol (in some cultures this
can happen at a relatively young age), and the person enjoys the happy feeling it
produces. At this stage, there is no emotional cost.
2. Seeking the mood swing. A person will drink to regain that feeling of euphoria
experienced in phase 1; the drinking will increase as more intoxication is required
to achieve the same effect. Again at this stage, there are no significant
consequences.
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3. At the third stage there are physical and social consequences, i.e., hangovers,
family problems, work problems, etc. A person will continue to drink excessively,
disregarding the problems.
4. The fourth stage can be detrimental, as Johnson cites it as a risk for premature
death. As a person now drinks to feel normal, they block out the feelings of
overwhelming guilt, remorse, anxiety, and shame they experience when sober.
Milam & Ketcham's Physical Deterioration Stages
Other theorists such as Milam & Ketcham (1983) focus on the physical deterioration that
alcohol consumption causes. They describe the process in three stages:
1. Adaptive stage – The person will not experience any negative symptoms, and
they believe they have the capacity for drinking alcohol without problems.
Physiological changes are happening with the increase in tolerance, but this will
not be noticeable to the drinker or others.
2. Dependent stage – At this stage, symptoms build up
gradually. Hangover symptoms from excessive drinking may be confused with
withdrawal symptoms. Many addicts will maintain their drinking to avoid
withdrawal sickness, drinking small amounts frequently. They will try to hide their
drinking problem from others and will avoid gross intoxication.
3. Deterioration stage – Various organs are damaged due to long-term drinking.
Medical treatment in a rehabilitation center will be required; otherwise, the
pathological changes will cause death.
DSM and ICD
In psychology and psychiatry, the DSM is the most common global standard, while in
medicine, the standard is ICD. The terms they recommend are similar but not identical.
Organization
APA's DSM-
IV
Preferred
term(s)
"alcohol abuse"
and "alcohol
dependence"
Definition
alcohol abuse = repeated use despite
recurrent adverse consequences.
alcohol dependence = alcohol
abuse combined
with tolerance, withdrawal, and an
uncontrollable drive to drink. The term
"alcoholism" was split into "alcohol abuse"
and "alcohol dependence" in 1980's DSM-
III, and in 1987's DSM-III-R behavioral
symptoms were moved from "abuse" to
"dependence". It has been suggested
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WHO's ICD-
10
"alcohol harmful
use" and
"alcohol
dependence
syndrome"
that DSM-V merge alcohol abuse and
alcohol dependence into a single new
entry, named "alcohol-use disorder".
Definitions are similar to that of the DSM-IV. The
World Health Organization uses the term "alcohol
dependence syndrome" rather than
alcoholism. The concept of "harmful use" (as
opposed to "abuse") was introduced in 1992's
ICD-10 to minimize underreporting of damage in
the absence of dependence. The term
"alcoholism" was removed from ICD between
ICD-8/ICDA-8 and ICD-9.
The DSM-IV diagnosis of alcohol dependence represents one approach to the definition
of alcoholism. In part, this is to assist in the development of research protocols in which
findings can be compared to one another. According to the DSM-IV, an alcohol
dependence diagnosis is: "maladaptive alcohol use with clinically significant impairment
as manifested by at least three of the following within any one-year period: tolerance;
withdrawal; taken in greater amounts or over longer time course than intended; desire
or unsuccessful attempts to cut down or control use; great deal of time spent obtaining,
using, or recovering from use; social, occupational, or recreational activities given up or
reduced; continued use despite knowledge of physical or
psychological sequelae." Despite the imprecision inherent in the term, there have been
attempts to define how the word alcoholism should be interpreted when encountered. In
1992, it was defined by the National Council on Alcoholism and Drug
Dependence (NCADD) and ASAM as "a primary, chronic disease characterized by
impaired control over drinking, preoccupation with the drug alcohol, use of alcohol
despite adverse consequences, and distortions in thinking." MeSH has had an entry for
"alcoholism" since 1999, and references the 1992 definition.
AA describes alcoholism as an illness that involves a physical allergy :28 (where "allergy"
has a different meaning than that used in modern medicine.) and a mental
obsession. The doctor and addiction specialist Dr. William D. Silkworth M.D. writes on
behalf of AA that "Alcoholics suffer from a "(physical) craving beyond mental control". A
1960 study by E. Morton Jellinek is considered the foundation of the modern disease
theory of alcoholism. [113] Jellinek's definition restricted the use of the word alcoholism to
those showing a particular natural history. The modern medical definition
of alcoholism has been revised numerous times since then. The American Medical
Association uses the word alcoholism to refer to a particular chronic primary disease.
Social Barriers
Attitudes and social stereotypes can create barriers to the detection and treatment of
alcohol abuse. This is more of a barrier for women than men. Fear of stigmatization may
lead women to deny that they are suffering from a medical condition, to hide their
drinking, and to drink alone. This pattern, in turn, leads family, physicians, and others to
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e less likely to suspect that a woman they know is an alcoholic. In contrast, reduced
fear of stigma may lead men to admit that they are suffering from a medical condition, to
display their drinking publicly, and to drink in groups. This pattern, in turn, leads family,
physicians, and others to be more likely to suspect that a man they know is an alcoholic.
Screening
Several tools may be used to detect a loss of control of alcohol use. These tools are
mostly self-reports in questionnaire form. Another common theme is a score or tally that
sums up the general severity of alcohol use.
The CAGE questionnaire, named for its four questions, is one such example that may
be used to screen patients quickly in a doctor's office.
Two "yes" responses indicate that the respondent should be investigated further.
The questionnaire asks the following questions:
1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to
steady your nerves or to get rid of a hangover?
The CAGE questionnaire has demonstrated a high effectiveness in detecting alcoholrelated
problems; however, it has limitations in people with less severe alcohol-related
problems, white women and college students.
Other tests are sometimes used for the detection of alcohol dependence, such as
the Alcohol Dependence Data Questionnaire, which is a more sensitive diagnostic test
than the CAGE questionnaire. It helps distinguish a diagnosis of alcohol dependence
from one of heavy alcohol use. The Michigan Alcohol Screening Test(MAST) is a
screening tool for alcoholism widely used by courts to determine the appropriate
sentencing for people convicted of alcohol-related offenses, driving under the
influence being the most common.
The Alcohol Use Disorders Identification Test (AUDIT), a screening questionnaire
developed by the World Health Organization, is unique in that it has been validated in
six countries and is used internationally. Like the CAGE questionnaire, it uses a simple
set of questions – a high score earning a deeper investigation. The Paddington Alcohol
Test (PAT) was designed to screen for alcohol-related problems amongst those
attendingAccident and Emergency departments. It concords well with the AUDIT
questionnaire but is administered in a fifth of the time. Certain blood tests may also
indicate possible alcoholism.
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Genetic Predisposition Testing
Psychiatric geneticists John I. Nurnberger, Jr., and Laura Jean Bierut suggest that
alcoholism does not have a single cause—including genetic—but that genes do play an
important role "by affecting processes in the body and brain that interact with one
another and with an individual's life experiences to produce protection or susceptibility".
They also report that fewer than a dozen alcoholism-related genes have been identified,
but that more likely await discovery. At least one genetic test exists for an allele that is
correlated to alcoholism and opiate addiction. Human dopamine receptor genes have a
detectable variation referred to as the DRD2 TaqI polymorphism. Those who possess
the A1 allele (variation) of this polymorphism have a small but significant tendency
towards addiction to opiates and endorphin-releasing drugs like alcohol. Although this
allele is slightly more common in alcoholics and opiate addicts, it is not by itself an
adequate predictor of alcoholism, and some researchers argue that evidence for DRD2
is contradictory.
Urine and Blood Tests
There are reliable tests for the actual use of alcohol, one common test being that
of blood alcohol content (BAC). These tests do not differentiate alcoholics from nonalcoholics;
however, long-term heavy drinking does have a few recognizable effects on
the body, including:
Macrocytosis (enlarged MCV)
Elevated GGT
Moderate elevation of AST and ALT and an AST: ALT ratio of 2:1
High carbohydrate deficient transferrin (CDT)
With regard to alcoholism, BAC is useful to judge alcohol tolerance, which in turn is a
sign of alcoholism.
However, none of these blood tests for biological markers is as sensitive as screening
questionnaires.
Prevention
The World Health Organization, the European Union and other regional bodies, national
governments and parliaments have formed alcohol policies in order to reduce the harm
of alcoholism. Targeting adolescents and young adults is regarded as an important step
to reduce the harm of alcohol abuse. Increasing the age at which licit drugs of abuse
such as alcohol can be purchased, the banning or restricting advertising of alcohol has
been recommended as additional ways of reducing the harm of alcohol dependence
and abuse. Credible, evidence based educational campaigns in the mass media about
the consequences of alcohol abuse have been recommended. Guidelines for parents to
prevent alcohol abuse amongst adolescents, and for helping young people with mental
health problems have also been suggested.
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Management
Treatments are varied because there are multiple perspectives of alcoholism. Those
who approach alcoholism as a medical condition or disease recommend differing
treatments from, for instance, those who approach the condition as one of social choice.
Most treatments focus on helping people discontinue their alcohol intake, followed up
with life training and/or social support to help them resist a return to alcohol use. Since
alcoholism involves multiple factors which encourage a person to continue drinking,
they must all be addressed to successfully prevent a relapse. An example of this kind of
treatment is detoxification followed by a combination of supportive therapy, attendance
at self-help groups, and ongoing development of coping mechanisms. The treatment
community for alcoholism typically supports an abstinence-based zero
tolerance approach; however, some prefer a harm-reduction approach.
Detoxification
Alcohol detoxification or 'detox' for alcoholics is an abrupt stop of alcohol drinking
coupled with the substitution of drugs, such as benzodiazepines, that have similar
effects to prevent alcohol withdrawal. Individuals who are only at risk of mild to
moderate withdrawal symptoms can be detoxified as outpatients. Individuals at risk of a
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severe withdrawal syndrome as well as those who have significant or acute comorbid
conditions are generally treated as inpatients. Detoxification does not actually treat
alcoholism, and it is necessary to follow up detoxification with an appropriate treatment
program for alcohol dependence or abuse to reduce the risk of relapse. Some
symptoms of alcohol withdrawal such as depressed mood and anxiety typically take
weeks or months to abate while other symptoms persist longer due to persisting neuroadaptations.
Alcoholism has serious adverse effects on brain function; on average it
takes one year of abstinence to recover from the cognitive deficits incurred by chronic
alcohol abuse.
Psychological
Various forms of group therapy or psychotherapy can be used to deal with underlying
psychological issues that are related to alcohol addiction, as well as provide relapse
prevention skills. The mutual-help group-counseling approach is one of the most
common ways of helping alcoholics maintain sobriety. Alcoholics Anonymous was one
of the first organizations formed to provide mutual, nonprofessional counseling, and it is
still the largest. Others include Life Ring Secular Recovery, SMART Recovery, Women
For Sobriety, and Secular Organizations for Sobriety. Rationing and moderation
programs such as Moderation Management and Drink Wise do not mandate complete
abstinence. While most alcoholics are unable to limit their drinking in this way, some
return to moderate drinking. A 2002 US study by the National Institute on Alcohol Abuse
and Alcoholism (NIAAA) showed that 17.7 percent of individuals diagnosed as alcohol
dependent more than one year prior returned to low-risk drinking. This group, however,
showed fewer initial symptoms of dependency. A follow-up study, using the same
subjects that were judged to be in remission in 2001–2002, examined the rates of return
to problem drinking in 2004–2005. The study found abstinence from alcohol was the
most stable form of remission for recovering alcoholics. A long-term (60 year) follow-up
of two groups of alcoholic men concluded that "return to controlled drinking rarely
persisted for much more than a decade without relapse or evolution into abstinence."
Medications
In the United States there are four approved medications for alcoholism: disulfiram, two
forms of naltrexone, and acamprosate. Several other drugs are also used and many are
under investigation.
Benzodiazepines, while useful in the management of acute alcohol withdrawal, if
used long-term can cause a worse outcome in alcoholism. Alcoholics on chronic
benzodiazepines have a lower rate of achieving abstinence from alcohol than
those not taking benzodiazepines. This class of drugs is commonly prescribed to
alcoholics for insomnia or anxiety management. Initiating prescriptions of
benzodiazepines or sedative-hypnotics in individuals in recovery has a high rate
of relapse with one author reporting more than a quarter of people relapsed after
being prescribed sedative-hypnotics. Those who are long-term users of
benzodiazepines should not be withdrawn rapidly, as severe anxiety and panic
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may develop, which are known risk factors for relapse into alcohol abuse. Taper
regimes of 6–12 months have been found to be the most successful, with
reduced intensity of withdrawal.
Acamprosate may stabilise the brain chemistry that is altered due to alcohol
dependence via antagonising the actions of glutamate, a neurotransmitter which
is hyperactive in the post-withdrawal phase. By reducing excessive NMDA
activity which occurs at the onset of alcohol withdrawal, acamprosate can reduce
or prevent alcohol withdrawal related neurotoxicity. Acamprosate reduces the risk
of relapse amongst alcohol dependent persons.
Disulfiram (Antabuse) prevents the elimination of acetaldehyde, a chemical the
body produces when breaking down ethanol. Acetaldehyde itself is the cause of
many hangover symptoms from alcohol use. The overall effect is severe
discomfort when alcohol is ingested: an extremely fast-acting and long-lasting
uncomfortable hangover. This discourages an alcoholic from drinking in
significant amounts while they take the medicine.
Naltrexone is a competitive antagonist for opioid receptors, effectively blocking
the effects of endorphins and opioids. Naltrexone is used to decrease cravings
for alcohol and encourage abstinence. Alcohol causes the body to release
endorphins, which in turn release dopamine and activate the reward pathways;
hence when naltrexone is in the body there is a reduction in the pleasurable
effects from consuming alcohol. Evidence supports a reduced risk of relapse
among alcohol dependent persons and a decrease in excessive
drinking. Nalmefene also appears effective and works by a similar manner.
Calcium Carbimide works in the same way as disulfiram; it has an advantage in
that the occasional adverse effects of disulfiram, hepatotoxicity and drowsiness,
do not occur with calcium carbimide.
The Sinclair method is a method of using naltrexone or another opioid antagonists to
treat alcoholism by having the person take the medication about an hour before they
drink alcohol, and only then. The medication blocks the positive reinforcement effects of
ethanol and hopefully allows the person to stop drinking or drink less.
Evidence does not support the use of selective serotonin reuptake
inhibitors (SSRIs), tricyclic antidepressants (TCAs), antipsychotics, or gabapentin.
Dual Addictions and Dependences
Alcoholics may also require treatment for other psychotropic drug addictions and drug
dependences. The most common dual dependence syndrome with alcohol dependence
is benzodiazepine dependence, with studies showing 10–20 percent of alcoholdependent
individuals had problems of dependence and/or misuse problems of
benzodiazepine drugs such as valium or clonazopam. These drugs are, like
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alcohol, depressants. Benzodiazepines may be used legally, if they are prescribed by
doctors for anxiety problems or other mood disorders, or they may be purchased
as illegal drugs "on the street" through illicit channels. Benzodiazepine use increases
cravings for alcohol and the volume of alcohol consumed by problem
drinkers. Benzodiazepine dependency requires careful reduction in dosage to
avoid benzodiazepine withdrawal syndrome and other health consequences.
Dependence on other sedative-hypnotics such as zolpidem andzopiclone as well
as opiates and illegal drugs is common in alcoholics. Alcohol itself is a sedativehypnotic
and is cross-tolerant with other sedative-hypnotics such asbarbiturates,
benzodiazepines and non-benzodiazepines. Dependence upon and withdrawal from
sedative-hypnotics can be medically severe and, as with alcohol withdrawal, there is a
risk of psychosis or seizures if not managed properly.
Epidemiology
The World Health Organization estimates that as of 2010 there are 208 million people
with alcoholism worldwide (4.1% of the population over 15 years of age). Substance use
disorders are a major public health problem facing many countries. "The most common
substance of abuse/dependence in patients presenting for treatment is alcohol." In
the United Kingdom, the number of 'dependent drinkers' was calculated as over 2.8
million in 2001. About 12% of American adults have had an alcohol dependence
problem at some time in their life. In the United States and Western Europe, 10 to 20
percent of men and 5 to 10 percent of women at some point in their lives will meet
criteria for alcoholism. Estonia had the highest death rate from alcohol in Europe in
2015 at 8.8 per 100,000 population.
Within the medical and scientific communities, there is a broad consensus regarding
alcoholism as a disease state. For example, the American Medical Association
considers alcohol a drug and states that "drug addiction is a chronic, relapsing brain
disease characterized by compulsive drug seeking and use despite often devastating
consequences. It results from a complex interplay of biological vulnerability,
environmental exposure, and developmental factors (e.g., stage of brain
maturity)." Alcoholism has a higher prevalence among men, though, in recent decades,
the proportion of female alcoholics has increased. Current evidence indicates that in
both men and women, alcoholism is 50–60 percent genetically determined, leaving 40–
50 percent for environmental influences. Most alcoholics develop alcoholism during
adolescence or young adulthood. 31 percent of college students show signs of alcohol
abuse, while six percent are dependent on alcohol. Under theDSM's new definition of
alcoholics, that means about 37 percent of college students may meet the criteria.
Prognosis
Alcoholism often reduces a person's life expectancy by around ten years. The most
common cause of death in alcoholics is from cardiovascular complications. There is a
high rate of suicide in chronic alcoholics, which increases the longer a person drinks.
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Approximately 3–15 percent of alcoholics commit suicide, and research has found that
over 50 percent of all suicides are associated with alcohol or drug dependence. This is
believed to be due to alcohol causing physiological distortion of brain chemistry, as well
as social isolation. Suicide is also very common in adolescent alcohol abusers, with 25
percent of suicides in adolescents being related to alcohol abuse. Among those
with alcohol dependence after one year, some met the criteria for low-risk drinking, even
though only 25.5 percent of the group received any treatment, with the breakdown as
follows: 25 percent were found to be still dependent, 27.3 percent were in partial
remission (some symptoms persist), 11.8 percent asymptomatic drinkers (consumption
increases chances of relapse) and 35.9 percent were fully recovered—made up of 17.7
percent low-risk drinkers plus 18.2 percent abstainers. In contrast, however, the results
of a long-term (60-year) follow-up of two groups of alcoholic men indicated that "return
to controlled drinking rarely persisted for much more than a decade without relapse or
evolution into abstinence." There was also "return-to-controlled drinking, as reported in
short-term studies, is often a mirage."
History
Historically the name "dipsomania" was coined by German physician C. W. Hufeland in
1819 before it was superseded by "alcoholism". That term now has a more specific
meaning. The term "alcoholism" was first used in 1849 by the Swedish physician
Magnus Huss to describe the systematic adverse effects of alcohol. Alcohol has a long
history of use and misuse throughout recorded history. Biblical, Egyptian and
Babylonian sources record the history of abuse and dependence on alcohol. In some
ancient cultures alcohol was worshiped and in others, its abuse was condemned.
Excessive alcohol misuse and drunkenness were recognized as causing social
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problems even thousands of years ago. However, the defining of habitual drunkenness
as it was then known as and its adverse consequences were not well established
medically until the 18th century. In 1647 a Greek monk named Agapios was the first to
document that chronic alcohol misuse was associated with toxicity to the nervous
system and body which resulted in a range of medical disorders such as seizures,
paralysis, and internal bleeding. In 1920 the effects of alcohol abuse and chronic
drunkenness led to the failed prohibition of alcohol in the United States, a nationwide
constitutional ban on the production, importation, transportation, and sale of alcoholic
beverages that remained in place until 1933. In 2005 alcohol dependence and abuse
was estimated to cost the US economy approximately 220 billion dollars per year, more
than cancer and obesity.
Society and Culture
The various health problems associated with long-term alcohol consumption are
generally perceived as detrimental to society, for example, money due to lost laborhours,
medical costs due to injuries due to drunkenness and organ damage from longterm
use, and secondary treatment costs, such as the costs of rehabilitation facilities
and detoxification centers. Alcohol use is a major contributing factor for head
injuries, motor vehicle accidents (due to drunk driving), domestic violence, and assaults.
Beyond the financial costs that alcohol consumption imposes, there are also significant
social costs to both the alcoholic and their family and friends. For instance, alcohol
consumption by a pregnant woman can lead to fetal alcohol syndrome, an incurable and
damaging condition. Estimates of the economic costs of alcohol abuse, collected by the
World Health Organization, vary from one to six percent of a country's GDP. One
Australian estimate pegged alcohol's social costs at 24% of all drug abuse costs; a
similar Canadian study concluded alcohol's share was 41%. One study quantified the
cost to the UK of all forms of alcohol misuse in 2001 as £18.5–20 billion. All economic
costs in the United States in 2006 have been estimated at $223.5 billion.
Stereotypes of alcoholics are often found in fiction and popular culture. The "town
drunk" is a stock character in Western popular culture. Stereotypes of drunkenness may
be based on racism or xenophobia, as in the fictional depiction of the Irish as heavy
drinkers. Studies by social psychologists Stivers and Greeley attempt to document the
perceived prevalence of high alcohol consumption amongst the Irish in America. Alcohol
consumption is relatively similar between many European cultures, the United States,
and Australia. In Asian countries that have a high gross domestic product, there is
heightened drinking compared to other Asian countries, but it is nowhere near as high
as it is in other countries like the United States. It is also inversely seen, with countries
that have very low gross domestic product showing high alcohol consumption. In a
study done on Korean immigrants in Canada, they reported alcohol was even an
integral part of their meal, and is the only time solo drinking should occur. They also
believe alcohol is necessary at any social event as it helps conversations start.
Caucasians have a much lower abstinence rate (11.8%) and much higher tolerance to
symptoms (3.4±2.45 drinks) of alcohol than Chinese (33.4% and 2.2±1.78 drinks
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espectively). Also, the more acculturation there is between cultures, the more
influenced the culture is to adopt Caucasians drinking practices. Peyote, a psychoactive
agent, has even shown promise in treating alcoholism. Alcohol had actually replaced
peyote as Native Americans’ psychoactive agent of choice in rituals when peyote was
outlawed.
Topiramate
Research
Topiramate, a derivative of the naturally occurring sugar monosaccharide D-fructose,
has been found effective in helping alcoholics quit or cut back on the amount they drink.
Evidence suggests that topiramate antagonizes excitatory glutamate receptors, inhibits
dopamine release, and enhances inhibitory gamma-aminobutyric acid function. A 2008
review of the effectiveness of topiramate concluded that the results of published trials
are promising, however, as of 2008, data was insufficient to support using topiramate in
conjunction with brief weekly compliance counseling as a first-line agent for alcohol
dependence. A 2010 review found that topiramate may be superior to existing alcohol
pharmacotherapeutic options. Topiramate effectively reduces craving and alcohol
withdrawal severity as well as improving quality-of-life-ratings.
Baclofen
Baclofen, a GABAB receptor agonist, is under study for the treatment of alcoholism. A
2015 systematic review concluded that there is insufficient evidence for the use of
baclofen for withdrawal symptoms in alcoholism. There is tentative data supporting
baclofen in alcohol dependence however further trials are needed as of 2013.
Ondansetron
Ondansetron, a 5HT3 antagonist, appears to have promise as a treatment.
High Functioning Alcoholics
A High-Functioning Alcoholic (HFA) is a person who maintains jobs and relationships
while exhibiting alcoholism.
Statistics from the Harvard School of Public Health indicated that 31 percent of college
students show signs of alcohol abuse and 6 percent are dependent on alcohol. Doctors
hope that the new definition will help identify severe cases of alcoholism early, rather
than when the problem is fully developed.
Many HFAs are not viewed as alcoholics by society because they do not fit the common
alcoholic stereotype. Unlike the stereotypical alcoholic, HFAs have either succeeded
or over-achieved throughout their lifetimes. This can lead to denial of alcoholism by the
HFA, co-workers, family members, and friends. Functional alcoholics account for 19.5
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percent of total U.S. alcoholics, with 50 percent also being smokers and 33 percent
having a multigenerational family history of alcoholism.
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II. The Alcohol Use Disorder
Identification Test
The Alcohol Use Disorders Identification Test (AUDIT) is a ten-question test
developed by a World Health Organization-sponsored collaborative project to determine
if a person may be at risk for alcohol abuse problems. The test was designed to be used
internationally, and was validated in a study drawing patients from six countries. Several
research studies have found that the AUDIT screening tool is a reliable and valid
measure in identifying alcohol abuse problem behaviors and it has been found to be a
valid indicator for severity of alcohol dependence. There is some evidence that the
AUDIT works in adolescents and young adults; it appears less accurate in older adults.
It appears well-suited for use with college students, and also with women and members
of minority groups.
The AUDIT alcohol consumption questions (AUDIT-C) is a 3-question screening test for
problem drinking which can be used in a doctor's office.
The Alcohol Use Disorders Identification Test (AUDIT), developed in 1982 by the World
Health Organization, is a simple way to screen and identify people at risk of alcohol
problems.
1. How often do you have a drink containing alcohol?
(0) Never (Skip to Questions 9-10)
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you
are drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9
(4) 10 or more
3. How often do you have six or more drinks on one occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
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(4) Daily or almost daily
4. How often during the last year have you found that you were not able to stop
drinking once you had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed to do what was normally
expected from you because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
6. How often during the last year have you been unable to remember what
happened the night before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
7. How often during the last year have you needed an alcoholic drink first thing
in the morning to get yourself going after a night of heavy drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
8. How often during the last year have you had a feeling of guilt or remorse
after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
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9. Have you or someone else been injured as a result of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
10. Has a relative, friend, doctor, or another health professional expressed
concern about your drinking or suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
Add up the points associated with answers. A total score of 8 or more indicates harmful
drinking behavior.
______
Reliability and Validity of The Alcohol Use Disorders Identification
Test - Consumption In Screening For Adults With Alcohol Use
Disorders And Risky Drinking In Japan.
BACKGROUND
Asian Pac J Cancer Prev. 2014;15(16):6571-4.
Abstract
Alcohol is well established as a risk factor for cancer development in many organ sites.
To assess the reliability and validity of the Alcohol Use Disorders Identification Test -
Consumption (AUDIT-C) for detecting alcohol use disorders or risky drinking in
Japanese adults the present study was conducted.
MATERIALS AND METHODS
A test-retest method was applied with a 2-week interval with 113 health care
employees. The κ coefficient, Cronbach's coefficient alpha, Spearman's correlation
coefficient, and intra-class correlation coefficient (ICC) were determined and the validity
of the AUDIT-C was analyzed using the data from a nationwide survey on adult alcohol
use conducted in 2008 (n=4,123).
RESULTS
The reliability of the AUDIT-C score was high (??coefficient=0.63, Cronbach's
alpha=0.98, correlation coefficient=0.95, and ICC=0.95). According to the likelihood
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atio and Youden index, appropriate cutoffs for the AUDIT-C were ≥ 5points in men and
≥4 points in women. The sensitivity and specificity of these cutoffs for identifying ≥8
points on the AUDIT were 0.88 and 0.80, respectively, for men (positive likelihood ratio
[LR+]=4.5) and 0.96 and 0.87, respectively, for women (LR+=7.7). The sensitivity and
specificity of the cutoffs for identifying ≥ 12 points on the AUDIT were 0.90 and 0.84,
respectively, for men (LR+=5.8) and 0.93 and 0.94, respectively, for women
(LR+=15.8). The sensitivity and specificity of the cutoffs for identifying ≥ 16 points on the
AUDIT were 0.93 and 0.80, respectively, for men (LR+=4.7) and 0.92 and 0.98,
respectively, for women (LR+=55.6). With higher scores on the AUDIT, the specificity
decreased and false-positives increased. The appropriate cutoffs for identifying risky
drinking were the same for both genders.
CONCLUSIONS
The reliability and validity of the AUDIT-C are high, indicating that it is useful for
identifying alcohol use disorders or risky drinking among the general population in
Japan, a group at high risk of cancer development.
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III. Addictive Personalities
An addictive personality refers to a particular set of personality traits that make an
individual predisposed to developing addictions. This hypothesis states that there may
be common personality traits observable in people suffering from addiction. Alan R.
Lang of Florida State University, author of an addiction study prepared for the United
States National Academy of Sciences, said, "If we can better identify the personality
factors, they can help us devise better treatment and can open up new strategies to
intervene and break the patterns of addiction."
Description
Experts describe the spectrum of behaviors designated as addictive in terms of five
interrelated concepts: patterns, habits, compulsions, impulse control disorders, and
physical addiction.
Biological Factors
Sensation-seeking has been studied as having a strong relationship with addictive
personalities.
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Psychological Factors
Alan R Lang has done much research on personality traits that play into addiction.
While his research found that there is no single set of traits that is definitive of an
“addictive personality", he did find several “significant personality factors”. These main
factors are:
impulsivity
value on nonconformity combined with weak commitment to socially valued goals
for achievement
sense of social alienation and tolerance for deviance
heightened stress and lack of coping skills
Some advocate for the existence of an “addictive belief system” that leads people
towards being more likely to develop addictions. This system is rooted incognitive
distortions like “I cannot make an impact on my world” and other maladaptive attitudes
like “I am not good enough.” These core beliefs, often very black and white thinking, set
up the person to develop the many traits common in the addictive personality, such
as depression and emotional insecurity. Cognitive and perceptual styles also have been
shown to play a role in addictions. People with addictions and addictive personalities
tend to have an external locus of control, and they also have an increased tendency
towards field dependence. However, it is unclear whether these are causative traits or
simply personality traits that tend to be found in people with addictions.
Environmental Factors
Specific genes predispose people to drug addiction—it's one of the behavioral disorders
most strongly correlated with genetic makeup—but environmental factors, especially
trauma and mistreatment in childhood, also correlate strongly with addiction. Examples
such as physical or sexual abuse, and unpredictable expectations and behavior of
parents, increase a person's risk for developing addiction.
Interaction of Biopsychosocial Factors
In looking at these traits separately, it is also necessary to look at them all together. For
example, psychological traits related to addictive personality include depression, poor
self-control, and compulsive behavior, which are all also linked to neurotransmitter
deficiencies, showing both a psychological and biological basis for these traits and
behaviors. Likewise, there is a gene/environment connection in that individuals selfselect
into different environments. This self-selection is based partially on personality
traits, and the selected environments may or may not include increased risk for
addictive behaviors. An individual might seek out environments where addictive
substances are more readily available, which can also explain how addictions in these
people can cross from one to another.
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Signs and Symptoms
People who suffer from an addictive personality spend excessive time on a behavior or
with an item, not as a hobby but because they feel they have to. Addiction can be
defined when the engagement in the activity or experience affects the person’s quality
of life in some way. In this way, many people who maintain an addictive personality
isolate themselves from social situations in order to mask their addiction.
People that face this issue are currently defined to have a "brain disease" as promoted
by the National Institute on Drug Abuse and other authorities. People who experience
addictive personality disorders typically act on impulses and cannot deal with delayed
gratification. At the same time, people with this type of personality tend to believe that
they do not fit into societal norms and therefore, acting on impulses, deviate from
conformity to rebel. People with addictive personalities are very sensitive to emotional
stress. They have trouble handling situations that they deem frustrating, even if the
event is for a very short duration.
The combination of low self-esteem, impulsivity and low tolerance for stress causes
these individuals to have frequent mood swings and often suffer from some sort
of depression. A coping mechanism to deal with their conflicting personality becomes
their addiction and the addiction acts as something that the person can control when
they find it difficult to control their personality traits.
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People with addictive personalities typically switch from one addiction to the next. These
individuals may show impulsive behavior such as excessive caffeine consumption,
Internet use, eating chocolate or other sugar-laden foods, television watching, or even
running.
Extraversion, self-monitoring, and loneliness are also common characteristics found in
those who suffer from addiction. Individuals who score high on self-monitoring are more
prone to developing an addiction. High self-monitors are sensitive to social
situations; they act how they think others expect them to act. They wish to fit in, hence
they are very easily influenced by others. Likewise, those who have low self-esteem
also seek peer approval; therefore, they participate in "attractive" activities such as
smoking or drinking to try to fit in.
People with addictive personalities find it difficult to manage their stress levels. In fact,
lack of stress tolerance is a telltale sign of the disorder. They find it difficult to face
stressful situations and fight hard to get out of such conditions. Long-term goals prove
difficult to achieve because people with addictive personalities usually focus on the
stress that comes with getting through the short-term goals. Such personalities will often
switch to other enjoyable activities the moment that they are deprived of enjoyment in
their previous addiction.
Addictive individuals feel highly insecure when it comes to relationships. They may often
find it difficult to make commitments in relationships or trust their beloved because of
the difficulty they find in achieving long-term goals. They constantly seek approval of
others and as a result, these misunderstandings may contribute to the destruction of
relationships. People suffering from addictive personality disorder usually
undergo depression and anxiety, managing their emotions by developing addiction to
alcohol, other types of drugs, or other pleasurable activities.
An addict is more prone to depression, anxiety, and anger. Both the addict's
environment, genetics and biological tendency contribute to their addiction. People with
very severe personality disorders are more likely to become addicts. Addictive
substances usually stop primary and secondary neuroses, meaning people with
personality disorders like the relief from their pain.
Personality Traits and Addiction
Addiction is defined by scholars as “a reliance on a substance or behavior that the
individual has little power to resist.” Substance-based addictions are those based upon
the release of dopamine in the brain, upon which the range of sensations produced by
the euphoric event in the brain changes the brain’s immediate behavior, causing more
susceptibility for future addictions. Behavior-based addictions, on the other hand, are
those that are not linked to neurological behavior as much and are thus thought to be
linked to personality traits; it is this type of addiction that combines a behavior with a
mental state and the repeated routine is therefore associated with the mental state.
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Alan R. Lang, a psychology professor at Florida State University, wrote in a study that
the continuing search for the personality traits that play a part in the development of
addictions are important for the broader fight against addiction. Identifying the
different personality traits will help in the long term when it comes to the treatment of
addiction, the strategies to intervene, and how to break the pattern of addiction. With
addictive tragedies becoming prevalent in communities around the United States,
scientists are asking questions about the aspects of psychological makeup and how
they contribute to addiction. They also want to know if there are common threads that
are in all addictions, from hard drugs to cigarettes and from gambling
to overeating. Through the information that already exists on the personality's role in
addictions, with a lot of emphasis on drugs and alcohol, a study from the National
Academy of Sciences says that there is no single set of psychological characteristics
that pertain to all addictions. The study did show, however, that there are common
elements between all addictions.
Substance Addiction
Common Forms of Addictive Behavior
One form of addiction is substance addiction. This is different from substance abuse in
that abuse of a substance is not really definable while substance addiction is a
behavioral addiction where there is an overwhelming involvement with the use and
buying of drugs or alcohol. It is a mental dependence or addiction to a substance but
not a physical addiction, although it can lead to a physical addiction in the end.
Gambling
Another common addiction that may attract those with addictive personalities
is gambling. When an addict behaves mindlessly and irresponsibly while gambling, it
can grow to be a bigger problem. A gambler with an addictive personality goes through
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three stages. The first is the "winning phase" in which the person can still control his or
her own behavior. Second comes the "losing phase" where the individual starts to
gamble alone, borrowing cash and gambling large sums of money, compiling debt
which he or she may not be able to pay off. Finally, the "desperation phase" of the
addictive behavior gambler is when the person takes further risks, may engage in illegal
loans and activities and even experience depression or attempt suicide.
Eating Disorders
Addictive personality behaviors even include eating disorders, such
as anorexia, bulimia and compulsive overeating. There are many external factors that
also contribute to disordered eating behavior, but for some it can develop into
a pathology quite similar to addiction. Those with anorexia nervosa channel their
success into this one goal: losing weight. Once a person starts dieting, it is very difficult
for him or her to quit. This is similarly true for those suffering from bulimia. A person is
said to have bulimia when he or she binges on large amounts of food and then
prevents digestion by purging (laxatives, vomiting, water pills, etc.). With compulsive
eating, the person has a compulsive urge or craving to eat and will eat even when not
hungry. This addictive behavior often results in obesity.
Compulsive Buying
Another form of addictive personality is compulsive buying disorder. Compulsive buying
is different from regular consumers and different from hoarding because it is about the
process of buying. It is not about the items bought. In fact, these items are usually never
used and are just put away. They are bought purely for the sake of buying. People who
are addicted to buying describe it as a high or say that it gives them a buzz. Often,
when someone suffering from this is depressed, they will go out and buy items to make
themselves feel better. However, compulsive buying has negative effects which include
financial debt, psychological issues, and interpersonal and marital conflict. To those
who suffer from compulsive buying, to them, the act is the same as using a drug.
People who suffer from compulsive buying usually suffer from another disorder. One
study found that 20% of compulsive buyers also suffer from an eating disorder. Other
disorders that go hand in hand include mood disorders, depression, and anxiety. Like
people with other addictions, people with compulsive buying problems tend to get
confused by their feelings and tend to tolerate aversive psychological states (e.g., bad
moods) poorly. Compulsive buying may lead to these psychological problems because
sufferers become dependent on the high they experience while buying. Compulsive
buying puts the person in a positive mood at the time. But afterwards, the person feels
intense guilt and anxiety for their purchases. Treatment for compulsive buying, at this
point in time, only includes cognitive behavioral therapy. One way to prevent compulsive
buying is education. One study found that adolescents who have taken a class or
course about financial education and planning were less likely to impulsively buy
products.
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Cell Phone Use
Another form of addictive personality is problematic cell phone use. A recent study
indicates that people who are addicted to their cell phones share common traits with
those who suffer from an addictive personality. Characteristics such as self-monitoring,
low self-esteem, and peer approval-motivation are commonly found in those who are
addicted to their cell phones as well as those who suffer from any other addiction such
as alcoholism. Despite personality characteristics leading to addictive tendencies, cell
phones themselves can partly be blamed for causing addiction. Improvements in cell
phones such as GPS, music players,cameras, web browsing, and e-mail can make
them an indispensable instrument to an individual. Technological advancements
reinforce the over-attachment people have to their cell phones, thus contributing to
addictive personality.
Internet and Computer Use
A more recent addiction that is being looked into is Internet addiction (also known as
pathological Internet use). This addiction has become more prevalent in younger
generations as computer technologies advance. When people suffer from internet
addiction they are unable to control their use of the Internet. This can lead to
psychological, social, school and work difficulties.
Those addicted to the internet may be drawn to social networking sites, online games or
other sites. Symptoms of this addiction include the following: mood changes, excessive
time spent online, perceived social control while online, and withdrawal when away from
the computer.
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Tanning
Another form of behavior that is still being investigated is obsessive sun tanning as a
behavioral addiction. In a recent study, researchers have proved that many frequent
tanners demonstrate signs and symptoms adapted from substance abuse or
dependence criteria. Many people who admit to being frequent tanners say they tan to
look good, feel good, and to relax. People who partake in excessive tanning are usually
completely aware of the health risks associated with it, just like addicted smokers are
completely aware of the health risks of smoking. The health hazards are even more
severe for high-risk age groups such as teenagers and young adults. Due to the fact
that the health risks do not deter tanners from their habit, they are exhibiting selfdestructive
behavior that resembles the characteristics of those who suffer from
substance abuse.
Frequent tanners have said a primary reason why they participate in artificial tanning is
to experience the "feel good" feeling tanning salons have to offer. Researchers have
found that ultraviolet (UV) radiation from tanning beds offers mood-enhancing effects
that act as a treatment for seasonal affective disorder(SAD). SAD is when a person
exhibits minor depression during seasonal changes, such as during the winter
months. Ultraviolet radiation has been proven to increase the level of melatonin in the
body. Melatonin plays a key role in sleep patterns and is suggested to reduce anxiety
levels. Thus, those who go tanning experience a sense of relaxation afterwards. This
sensation is what possibly drives tanners to continue tanning regardless of the health
risks. More research needs to be done, but many researchers are beginning to add
tanning to the list of addictive processes.
Exercise
Exercise provides benefits for our bodies, but to some people, the benefits turn into
health hazards. To some exercisers, rigorous physical activity becomes the central
aspect of their lives. When a preoccupation with exercise has become routine, a person
is considered addicted to exercise or exercise dependent. A study done shows why
people may become addicted to exercise, especially running. One of the reasons
people become addicted to exercise is because of the release of moodenhancing
chemicals known as endorphins. Endorphins increase the sensation of
pleasure, which is why people feel good about themselves after they exercise.
Endorphins are also responsible for the "runner's high." Recent studies have lent weight
to the alternative theory that the addictive appeal of exercise is due to the production of
endocannabinoids, naturally produced chemicals that bind to the brain's CB1 receptor,
rather than to endorphin production. Those who suffer from exercise addiction will go
through physical and emotional withdrawals in the absence of exercise, just like a
person who is addicted to other substances, such as drugs or alcohol. Although in many
cases, running is a better alternative than substance abuse. The findings in this study
conclude that there is a link between negative addiction to running and interpersonal
difficulties, which is common in other addictive behaviors as well.
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Relation to Leadership
When people are seeking a leader they look for qualities
like honesty, intelligence, creativity, and charisma, but a leader also needs to be driven
and be willing to challenge certain ideas and practices. The fact is that the psychological
profile of a great leader is a compulsive risk-taker. It has been realized that what is
sought in leaders is often the same kind of personality found in addicts, whether they
are addicted to alcohol, drugs, or sex. The reason that this connection exists is
because pleasure is a motivator that is central to learning. Dopamine can be artificially
created by substances that carry a risk for addiction, like cocaine, heroin,
nicotine and alcohol. People with risk-taking and obsessive personality traits, which are
often found in addicts, can be useful in becoming a leader. For many leaders, it is not
the case that they are able to do well in spite of their addiction; rather, the same brain
wiring and chemistry that make them addicts serve them well in becoming a good
leader.
Treatment
When treating addictive personalities, the primary or presenting addiction needs to be
treated first. Only once the behavior is under control can the person truly begin to do
any of the therapeutic work necessary for recovery.
Common forms of treatment for addictive personalities include cognitive behavioral
therapy, as well as other behavioral approaches. These treatments help patients by
providing healthy coping skills training, relapse prevention, behavior interventions,
family and group therapy, facilitated self-change approaches, and aversion
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therapy. Behavioral approaches include using positive reinforcement and behavioral
modeling. Along with these, other options that help with treating those who suffer with
addictive personality include social support, help with goal direction, rewards, enhancing
self-efficacy and help teaching coping skills.
Another important skill to learn in treatment, which can be overlooked, is self-soothing.
People with addictive personalities use their addictions as coping mechanisms when in
stressful situations. However, since their addictions do not actually soothe them, so
much as they provide momentary relief from anxiety or uncomfortable emotions, these
individuals feel the need to use their addiction more often. Thus, self-soothing and other
mindfulness-based interventions can be used for treatment because they provide
healthier coping mechanisms once the addictive behavior has been removed. These
strategies relate to the use of dialectical behavior therapy, another useful technique.
DBT provides ways to tolerate distress and regulate emotions, both of which are
challenging to someone with an addictive personality. DBT may not be the most
effective treatment for all substance abusers, but there is evidence that it is helpful for
most alcoholics and addicts, as well as in eating disorders, and those with co-occurring
conditions.
Another form of treatment that has been considered for people with addictive
personalities who tend towards substance abuse is medication. A medication called
Disulfiram was created in 1947. This pill was used for alcoholics and would cause
adverse effects if combined with alcohol. This medication is still used today but two
others have been made to help treat alcohol dependence
(Acamprosate and Naltrexone). Along with alcohol addictions, Naltrexone is also used
for opioid addiction. Although these medications have proven results in decreasing
heavy drinking, doctors still have to consider the patients' health and the risky side
effects when prescribing these medications.
Controversy
There is an ongoing debate about the question of whether an addictive personality
really exists. There are two sides of this argument, each with many levels and
variations. One side believes that there are certain traits and dimensions of personality
that, if existent in a person, cause the person to be more prone to developing addictions
throughout their life. The other side argues that addiction is in chemistry, as in how the
brain’s synapses respond to neurotransmitters and is therefore not affected by
personality. A major argument in favor of defining and labeling an addictive personality
has to do with the human ability to make decisions and the notion of free will. This
argument suggests human beings are aware of their actions and what the
consequences of their own actions are and many choose against certain things
because of this. This can be seen in that people are not forced to drink excessively or
smoke every day, but it is within the reach of their own free will that some may choose
to do so. Therefore, those with addictive personalities are high in neuroticism and hence
choose to engage in riskier behaviors. The theory of addictive personalities agrees that
there are two types of people: risk-takers and risk-averse. Risk-takers enjoy challenges,
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new experiences and want instant gratification. These people enjoy the excitement of
danger and trying new things. On the other hand, risk-averse are those who are by
nature cautious in what they do and the activities they involve themselves in. It is the
personality traits of individuals that combine to create either a risk-taker or risk-averse
person.
Some people believe that claiming that there is such thing as an addictive personality
belittles the types and significance of many tough addictions. Others also argue that by
placing a label on the type of people that have addictions, this stereotypes people and
denies that addiction can happen to anyone. Some people who agree with this
argument believe that claiming an addictive personality may be used as an excuse by
some who do not use drugs, and are hence not addicted, to explain why they are not
addicted to drugs and other people are.
Other arguments against this theory of addictive personalities is that it is very
deterministic. By labeling someone with an addictive personality, one may think that
there is no way to change the outcome and that he or she will inevitably develop
addictions. Also, this label may cause many to believe that there is no way to change
this or treat addictions, which, according to many researchers and doctors, is untrue.
...
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IV. Alcohol-Related
Traffic Crashes in the U.S.
Alcohol-related traffic crashes are defined by the United States National Highway
Traffic Safety Administration (NHTSA) as alcohol-related if either a driver or a nonmotorist
had a measurable or estimated BAC of 0.01 g/dl or above.
This statistic includes any and all vehicular (including bicycle and motorcycle) accidents
in which any alcohol has been consumed, or believed to have been consumed, by the
driver, a passenger or a pedestrian associated with the accident. Thus, if a person who
has consumed alcohol and has stopped for a red light is rear-ended by a completely
sober but inattentive driver, the accident is listed as alcohol-related, although alcohol
had nothing to do with causing the accident. Furthermore, if a sober motorist hits a
drunk pedestrian, the accident is also listed as alcohol-related. Alcohol-related
accidents are often mistakenly confused with alcohol-caused accidents. Some have
criticized the NHTSA for compiling this statistic since it may give the impression that
drunk drivers cause a much higher percentage of accidents and does not accurately
reflect the problem of drunk driving in the United States.
Nationally, 31% of all drivers involved in fatal accidents during 2013 are known to have
been intoxicated according to theblood alcohol concentration (BAC laws) of their
state. This number is based on a systematic examination of the official records of each
and every accident involving a fatality during that year in the US. However, a majority of
fatalities resulting from car accidents involving alcohol are from sober drivers who are
hit by drunk drivers.
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The higher number (about 40%) commonly reported refers to accidents defined as
alcohol-related as estimated by the National Highway Traffic Safety Administration.
Each year, The Century Council, a national non-profit organization funded by a group
of alcohol manufacturers, compiles a document of alcohol-related traffic fatalities.
Between 1991 and 2013, the rate of alcohol-related traffic fatalities (ARTF) per 100,000
population has decreased 52% nationally, and 79% among youth under 21.
Mothers Against Drunk Driving (MADD)
Mothers Against Drunk Driving (MADD) is a nonprofit organization in the United
States and Canada that seeks to stop drunk driving, support those affected by drunk
driving, prevent underage drinking, and strive for stricter impaired driving policy,
whether that impairment is caused by alcohol or any other drug. The Irving, Texas–
based organization was founded on September 5, 1980, in California by Candace
Lightner after her 13-year-old daughter, Cari, was killed by a drunk driver. There is at
least one MADD office in every state of the United States and at least one in each
province of Canada. These offices offer victim services and many resources involving
alcohol safety. MADD has claimed that drunk driving has been reduced by half since its
founding.
Positions
According to MADD's website, "The mission of Mothers Against Drunk Driving is to stop
drunk driving, support the victims of this violent crime and prevent underage
drinking." Generally MADD favors strict policy in a variety of areas, including an
illegal blood alcohol content of .08% or lower and using stronger sanctions for DUI
offenders, including mandatory jail sentences, treatment for alcoholism and other
alcohol abuse issues, ignition interlock devices, and license suspensions; maintaining
the minimum legal drinking age at 21 years; mandating alcohol breath-testing ignition
interlock devices (IIDs) for everyone convicted of driving while legally impaired.
MADD's founder, Candace Lightner left the group in 1985. In 2002, as reported by The
Washington Times, Lightner stated that MADD "has become far more neoprohibitionist
than I had ever wanted or envisioned … I didn't start MADD to deal with
alcohol. I started MADD to deal with the issue of drunk driving".
History
On May 3, 1980, Cari Lightner, a 13-year-old girl, was killed by a drunken hit-and-run
driver at Sunset and New York Avenues in Fair Oaks, California. The 46-year-old driver,
who had recently been arrested for another DUI hit-and-run, left Cari's body at the
scene. Cari's mother, Candace (Candy) Lightner, organized Mothers Against Drunk
Driving and subsequently served as its founding president. A 1983 television movie
about Lightner garnered publicity for the group, which grew rapidly.
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In the early 1980s, the group attracted the attention of the United States
Congress. Senator Frank Lautenberg (D-NJ) did not like the fact that youth in New
Jerseycould easily travel to New York to purchase alcoholic beverages, circumventing
New Jersey's law restricting consumption to those 21 years old and older.
The group had its greatest success with the enacting of a 1984 federal law, the National
Minimum Drinking Age Act, that introduced a federal penalty (a 5%—later raised to
10%—loss of federal highway dollars), for states that didn't raise the minimum legal age
for the purchase and possession of alcohol to 21. After the United States Supreme
Court upheld the law in the 1987 case of South Dakota v. Dole, every state and the
District of Columbia made the necessary adjustments by 1988 (but not the territories
of Puerto Rico and Guam). However, in July 2010 Guam raised its drinking age to 21. [13]
In 1985, Lightner objected to the shifting focus of MADD, and left her position with the
organization.
In 1988, a drunk driver traveling the wrong way on Interstate 71 in Kentucky caused a
head-on collision with a school bus. Twenty-seven people died and dozens more were
injured in the ensuing fire. Known as the Carrollton bus disaster, it equaled another bus
crash in Kentucky in 1958 as the deadliest bus crash in US history. In the aftermath,
several parents of the victims became actively involved in MADD and one became its
national president.
In 1989, MADD Canada was founded.
In 1994, The Chronicle of Philanthropy released the results of the largest study of
charitable and non-profit organization popularity and credibility. The study showed that
MADD was ranked as the "most popular charity/non-profit in America of over 100
charities researched with 51% of Americans over the age of 12 choosing "Love" and
"Like A Lot" for MADD.
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MADD released its first "Rating the States" report, grading the states in their progress
against drunk driving, in 1991. "Rating the States" has been released four times since
then.
In 1999, MADD’s National Board of Directors unanimously voted to change the
organization’s mission statement to include the prevention of underage drinking.
In 2002, MADD announced its "Eight-Point Plan". This consisted of:
1. Resuscitating the nation's efforts to prevent impaired driving.
2. Increasing driving while intoxicated (DWI)/driving under the influence (DUI)
enforcement, especially the use of frequent, highly publicized sobriety
checkpoints.
3. Enacting primary enforcement seat belt laws in all states.
4. Creating tougher, more comprehensive sanctions geared toward higher-risk
drivers.
5. Developing a dedicated National Traffic Safety Fund.
6. Reducing underage drinking.
7. Increasing beer excise taxes to the same level as those for spirits.
8. Reinvigorating court monitoring programs.
In a November 2006 press release, MADD launched its 'Campaign to Eliminate Drunk
Driving': this is a four-point plan to completely eliminate drunk driving in the United
States using a combination of current technology (such as alcohol ignition interlock
devices), new technology in smart cars, law enforcement, and grass roots activism.
MADD's national president was Millie I. Webb in 2002. Chuck Hurley became MADD
CEO in 2005. He retired in June 2010 and was replaced by Kimberly Earle, who had
been CEO of Susan G. Komen for the Cure since 2007. Earle left to become the
president of a new foundation of Sanford Health in January 2012, the Edith Sanford
Breast Cancer Foundation. Debbie Weir replaced her as MADD's CEO.
Funding
According to Obama-Coburn Federal Funding Accountability Transparency Act of 2006,
MADD received $56,814 in funds from the federal government in fiscal year 2000, and a
total of $9,593,455 between fiscal years 2001 and 2006.
In 1994, Money magazine reported that telemarketers raised over $38 million for
MADD, keeping nearly half of it in fees. This relationship continues to date.
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In 2001, Worth magazine listed MADD as one of its "100 best charities".
In 2005, USA Today reported that the American Institute of Philanthropy was reducing
MADD from a "C" to a "D" in its ratings. The Institute noted that MADD categorizes
much of its fundraising expenses as "educational expenses", and that up to 58% of its
revenue was expended on what the Institute considered fund-raising and management.
Charity Navigator rated MADD at 63.53 out of 100 on its financial rating scale and 96.00
out of 100 on its accountability and transparency scale for its 2013 fiscal year. MADD
reported that it spent 24.4% of its total expenses on fundraising that year. In 2014
MADD spend over $9 million on fundraising activities according to its 2014 tax return.
Activities and Criticisms
Radley Balko, an advocate for decriminalizing drunk driving, argued in a December
2002 article that MADD's policies are becoming overbearing. "In fairness, MADD
deserves credit for raising awareness of the dangers of driving while intoxicated. It was
almost certainly MADD's dogged efforts to spark public debate that effected the drop in
fatalities since 1980, when Candy Lightner founded the group after her daughter was
killed by a drunk driver," Balko wrote. "But MADD is at heart a bureaucracy, a big one. It
boasts an annual budget of $45 million, $12 million of which pays for salaries, pensions
and benefits. Bureaucracies don't change easily, even when the problems they were
created to address change." Charity Watch gives MADD a "C-" grade.
Drunk Driving Laws
MADD was heavily involved in lobbying to reduce the legal limit for blood alcohol from
BAC .10 to BAC .08. In 2000, this standard was passed by Congress and by 2004,
every state had a legal .08 BAC limit. [32] MADD Canada has called for a maximum legal
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BAC of .05. Although many MADD leaders have supported a lower limit, MADD has not
called for a legal limit of .05 in the United States.
Victim Impact Panels
MADD promotes the use of victim impact panels (VIPs), in which judges require DWI
offenders to hear victims or relatives of victims of drunk driving crashes relate their
experiences. MADD received $5,547,693 in 2010 from VIPs; much of this income was
voluntary donations by those attending as some states do not allow a fee to be charged
to offenders for non-legislative programs. Other states like California and Georgia
require that a fee be paid in order to attend. In California this fee ranges from $25 to $50
depending on the county and in Georgia this fee is $50. Some states in the United
States, such as Massachusetts, permit victims of all crimes, including drunk driving
accidents, to give victim impact statements prior to sentencing so that judges and
prosecutors can consider the impact on victims in deciding on an appropriate sentence
to recommend or impose. The presentations are often emotional, detailed, and graphic,
and focus on the tragic negative consequences of DWI and alcohol-related crashes.
According to the John Howard Society, some studies have shown that permitting victims
to make statements and to give testimony is psychologically beneficial to them and aids
in their recovery and in their satisfaction with the criminal justice system. A New
Mexico study suggested that the VIPs tended to be perceived as confrontational by
multiple offenders. Such offenders then had a higher incidence of future offenses.
Grand Theft Auto
On April 29, 2008 MADD issued a press release criticizing the video game Grand Theft
Auto IV saying it was "extremely disappointed" with the manufacturers. MADD has
called on the ESRB to re-rate the game to Adults Only. They also called on the
manufacturer (Rockstar) "to consider a stop in distribution – if not out of responsibility to
society then out of respect for the millions of victims/survivors of drunk driving.". Players
can drive drunk in Grand Theft Auto IV but doing so makes it harder to drive. The game
also explicitly recommends that the player take a taxi instead of driving, and the
character makes humorous remarks suggesting that it is bad to drive drunk. Ignoring
these will lead to consequences: if any police officer is around while the player is drunk
driving, the player immediately becomes wanted by the police.
Blood Alcohol Content
Prior to the MADD's influence, drunk driving laws addressed the danger by making it a
criminal offense to drive a vehicle while impaired — that is, while "under the influence of
alcohol"; the amount of alcohol in the body was evidence of that impairment. The level
specified at that time — commonly, 0.15% — was high enough to indicate drunkenness
rather than impairment. In part due to MADD's influence, all 50 states have now passed
laws making it a criminal offense to drive with a designated level of alcohol of .08% or
higher.
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Sobriety Checkpoints
MADD writes that “opponents of sobriety checkpoints tend to be those who drink and
drive frequently and are concerned about being caught”.
Radley Balko, opponent of limits on drunk driving and writer for Reason Magazine,
discusses the possible social implications of some of MADD's policies in a 2002 article.
He writes, "In its eight-point plan to 'jump-start the stalled war on drunk driving,' MADD
advocates the use of highly publicized but random roadblocks to find drivers who have
been drinking.".
Beer Taxes
Balko criticizes MADD for not advocating higher excise taxes on distilled spirits, even
though it campaigns for higher excise taxes for beer. He writes, "Interestingly, MADD
refrains from calling for an added tax on distilled spirits, an industry that the organization
has partnered with on various drunk driving awareness projects." MADD writes,
"Currently, the federal excise tax is $.05 per can of beer, $.04 for a glass of wine and
$.12 for a shot of distilled spirits, which all contain about the same amount of
alcohol." Point 7 of MADD's 8-Point Plan is to "Increase beer excise taxes to equal the
current excise tax on distilled spirits".
Breath Alcohol Ignition Interlock Devices
Additionally, MADD has proposed that breath alcohol ignition interlock devices should
be installed in all new cars. Tom Incantalupo wrote: "Ultimately, the group said
yesterday, it wants so-called alcohol interlock devices factory-installed in all new cars.
"The main reason why people continue to drive drunk today is because they can,"
MADD president Glynn Birch said at a news teleconference from Washington, D.C."
Sarah Longwell, a spokeswoman for the restaurant lobbying group American Beverage
Institute, responded to MADD's proposals for ignition interlocks by stating "This interlock
campaign is not about eliminating drunk driving, it is about eliminating all moderate
drinking prior to driving. The 40 million Americans who drink and drive responsibly
should be outraged." She also points out that "Many states have laws that set the
presumptive level of intoxication at .05% and you can't adjust your interlock depending
on which state you're driving in. Moreover, once you factor in liability issues and sharing
vehicles with underage drivers you have pushed the preset limit down to about .02%. It
will be a de facto zero tolerance policy."
A review of devices concluded, "The results of the study show that interlock works for
some offenders in some contexts, but not for all offenders in all situations. More
specifically, ignition interlock devices work best when they are installed, although there
is also some evidence that judicial orders to install an interlock are effective for repeat
DUI offenders, even when not all offenders comply and install a device. California's
administrative program, where repeat DUI offenders install an interlock device in order
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to obtain restricted driving privileges, is also associated with reductions in subsequent
DUI incidents. One group for whom ignition interlock orders do not appear effective is
first DUI offenders with high blood alcohol levels."
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V. Alcohol in Family Systems
Alcoholism in family systems refers to the conditions in families that
enable alcoholism, and the effects of alcoholic behavior by one or more family members
on the rest of the family. Mental health professionals are increasingly considering
alcoholism and addiction as diseases that flourish in and are enabled by family
systems. Family members react to the alcoholic with particular behavioral patterns.
They may enable the addiction to continue by shielding the addict from the negative
consequences of his actions. Such behaviors are referred to as codependence. In this
way, the alcoholic is said to suffer from the disease of addiction, whereas the family
members suffer from the disease of codependence. While it is recognized that addiction
is a family disease, affecting the entire family system, "the family is often ignored and
neglected in the treatment of addictive disease." Each individual member is affected
and should receive treatment for their own benefit and healing, but in addition to
benefitting the individuals themselves, this also helps to better support the
addict/alcoholic in his/her recovery process. "The chances of recovery are greatly
reduced unless the co-dependents are willing to accept their role in the addictive
process and submit to treatment themselves." "Co-dependents are mutually dependent
on the addict to fulfill some need of their own." For example, if the "Chief Enabler" (the
main enabler in the family) will often turn a blind eye to the addict's drug/alcohol use as
this allows for the enabler to continue to play the victim and/or martyr role, while
allowing the addict to continue his/her own destructive behavior. Therefore, "the
behavior of each reinforces and maintains the other, while also raising the costs and
emotional consequences for both."
Alcoholism is one of the leading causes of a dysfunctional family. "About one-fourth of
the U.S. population is a member of family that is affected by an addictive disorder in a
first-degree relative." As of 2001, there were an estimated 26.8 million children of
alcoholics (COAs) in the United States, with as many as 11 million of them under the
age of 18. [9] Children of addicts have an increased suicide rate and on average have
total health care costs 32 percent greater than children of nonalcoholic families.
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According to the American Psychiatric Association, physicians stated three criteria to
diagnose this disease: (1) physiological problems, such as hand tremors and blackouts,
(2) psychological problems, such as excessive desire to drink, and (3) behavioral
problems that disrupt social interaction or work performance.
Adults from alcoholic families experience higher levels of state and trait anxiety and
lower levels of differentiation of self than adults raised in non-alcoholic families.
Additionally, adult children of alcoholics have lower self-esteem, excessive feelings of
responsibility, difficulties reaching out, higher incidence of depression, and increased
likelihood of becoming alcoholics.
Parental alcoholism may affect the fetus even before a child is born. In pregnant
women, alcohol is carried to all of the mother’s organs and tissues, including the
placenta, where it easily crosses through the membrane separating the maternal and
fetal blood systems. When a pregnant woman drinks an alcoholic beverage, the
concentration of alcohol in her unborn baby’s bloodstream is the same level as her own.
A pregnant woman who consumes alcohol during her pregnancy may give birth to a
baby with Fetal Alcohol Syndrome (FAS). FAS (fetal alcohol syndrome) is known to
produce children with damage to the central nervous system, general growth and facial
features. The prevalence of this class of disorder is thought to be between 2-5 per 1000.
Alcoholism does not have uniform effects on all families. The levels of dysfunction and
resiliency of the non-alcoholic adults are important factors in effects on children in the
family. Children of untreated alcoholics score lower on measures of family cohesion,
intellectual-cultural orientation, active-recreational orientation, and independence. They
have higher levels of conflict within the family, and many experience other family
members as distant and non-communicative. In families with untreated alcoholics, the
cumulative effect of the family dysfunction may affect the children's ability to grow in
developmentally healthy ways.
Family Roles
The role of the "Chief Enabler" is typically the spouse, significant other, parent, or eldest
child of the alcoholic/addict. This person demonstrates "a strong tendency to avoid any
confrontation of the addictive behavior and a subconscious effort to actively perpetuate
the addiction." The "Chief Enabler" also often doubles as the "Responsible One," or
"Family Hero" another role assumed by family members of the alcoholic/addict. Both the
"Chief Enabler" and "Responsible One" (aka "Model Child") will take "over [the
alcoholic/addict's] roles and responsibilities." For example, a parent might pay for
expenses and take over responsibilities (i.e. car payments, the raising of a grandchild,
provide room and board, etc.), while a child may provide care for their siblings, become
the "peace keeper" in the home, take on all the chores and cooking, etc. A spouse or
significant other may overcompensate by providing all the care to the children, being the
sole financial contributor to the household, covering up or hiding the addiction from
others, etc. This role often receives the most praise from non-family members, causing
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the individual to struggle to see that it is an unhealthy role which contributes to the
addict/alcoholic's disease as well as the family's dysfunction.
Another role is that of the "Problem Child" or "Scapegoat." This person "may be the
only [one] clearly seen as having a problem" outside of the actual addict/alcoholic.
These children (or adult children of the alcoholic(s)) "gets blamed for everything; they
have problems at school, exhibit negative behavior, and often develop drug or alcohol
problems as a way to act out. Their behavior demands whatever attention is available
from parents and siblings." This often "takes the focus off the parental alcohol problem,"
and the child can be the "scapegoat" under the myth that his/her behavior fuels the
parent's drinking/using. However, this child draws attention from outsiders which may
contribute to the recognition of the family alcohol problem by outsiders.
The "Lost Child" role is identified in this system through children that are "withdrawn,
'spaced-out,' and disconnected from the life and emotions around them." They often
avoid "any emotionally
confronting
issues, [and so
are] unable to form close
friendships or intimate bonds
with others."
Other children, "trivialize things
by minimizing all serious issues
as an avoidance strategy [and]
are well liked and easy to
befriend but are
usually
superficial in all relationships, including those with their own family members." These
children are known as the "Mascot" or "Family Clown."
Prevalence
Based on the number of children with parents meeting the DSM-V criteria for alcohol
abuse or alcohol dependence, in 1996 there were an estimated 26.8 million children of
alcoholics (COAs) in the United States of which 11 million were under the age of 18. As
of 1988, it was estimated that 76 million Americans, about 43% of the U.S. adult
population, have been exposed to alcoholism or problem drinking in the family, either
having grown up with an alcoholic, having an alcoholic blood relative, or marrying an
alcoholic. While growing up, nearly one in five adult Americans (18%) lived with an
alcoholic. In 1992, it was estimated that one in eight adult American drinkers were
alcoholics or experienced problems as consequences of their alcohol use.
Familiality
Children of alcoholics (COAs) are more susceptible to alcoholism and other drug abuse
than children of non-alcoholics. Children of alcoholics are four times more likely than
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non-COAs to develop alcoholism. Both genetic and environmental factors influence the
development of alcoholism in COAs.
COAs perceptions of their parents drinking habits influence their own future drinking
patterns and are developed at an early age. Alcohol related expectancies are correlated
with parental alcoholism and alcohol abuse among their offspring. Problem solving
discussions in families with an alcoholic parent contained more negative family
interactions than in families with non-alcoholics parents. Several factors related to
parental alcoholism influence COA substance abuse including stress, negative affect
and decreased parental monitoring. Impaired parental monitoring and negative affect
correlate with COAs associating with peers that support drug use.
After drinking alcohol, sons of alcoholics experience more of the physiological changes
associated with pleasurable effects compared with sons of non-alcoholics, although only
immediately after drinking.
Compared with non-alcoholic families, alcoholic families demonstrate poorer problemsolving
abilities, both among the parents and within the family as a whole. These
communication problems many contribute to the escalation of conflicts in alcoholic
families. COAs are more likely than non-COAs to be aggressive, impulsive, and engage
in disruptive and sensation seeking behaviors. Alcohol addiction is a complex disease
that results from a variety of genetic, social, and environmental influences. Alcoholism
affected approximately 4.65 percent of the U.S. population in 2001-2002, producing
severe economic, social, and medical ramifications (Grant 2004). Researchers estimate
that between 50 and 60 percent of alcoholism risk is determined by genetics (Goldman
and Bergen 1998; McGue 1999).This strong genetic component has sparked numerous
linkage and association studies investigating the roles of chromosomal regions and
genetic variants in determining alcoholism susceptibility.
Marital Relationships
Alcoholism usually has strong negative effects on marital relationships. Separated and
divorced men and women were three times as likely as married men and women to say
they had been married to an alcoholic or problem drinker. Almost two-thirds of
separated and divorced women, and almost half of separated or divorced men under
age 46 have been exposed to alcoholism in the family at some time.
Exposure was higher among women (46.2 percent) than among men (38.9 percent) and
declined with age. Exposure to alcoholism in the family was strongly related to marital
status, independent of age: 55.5 percent of separated or divorced adults had been
exposed to alcoholism in some family member, compared with 43.5 percent of married,
38.5 percent of never married, and 35.5 percent of widowed persons. Nearly 38 percent
of separated or divorced women had been married to an alcoholic, but only about 12
percent of currently married women were married to an alcoholic.
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Children
Prevalence of Abuse
Over one million children yearly are confirmed as victims of child abuse and neglect by
state child protective service agencies. Substance abuse is one of the two largest
problems affecting families in the United States, being a factor in nearly four-fifths of
reported cases. Alcoholism is more prevalent among child abusing parents. Alcoholism
is more strongly correlated to child abuse than depression and other disorders.
Adoption plays only a slight role in alcoholism in the family. Studies were done
comparing children who were born into a family with an alcoholic parent and raised by
adoptive (non-alcoholic) parents as compared to children born to non-alcoholic parents
and raised by adopted alcoholic parents. The results (in US and Scandinavian studies)
were that those adopted children born of an alcoholic parent (and adopted by nonalcoholic
parents ) developed alcoholism at higher rates as adults.
Correlates
Children of alcoholics exhibit symptoms of depression and anxiety more than children of
non-alcoholics. COAs have lower self-esteem than non-COAs from childhood through
young adulthood. Children of alcoholics show more symptoms of anxiety, depression,
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and externalizing behavior disorders than non-COAs. Some of these symptoms include
crying, lack of friends, fear of going to school, nightmares, perfectionism, hoarding, and
excessive self-consciousness.
Many children of alcoholics score lower on tests measuring cognitive and verbal skills
than non-COAs. Lacking requisite skills to express themselves can impact academic
performance, relationships, and job interviews. The lack of these skills do not, however,
imply that COAs are intellectually impaired. COAs are also shown to have difficulty with
abstraction and conceptual reasoning, both of which play an important role in problemsolving
academically and otherwise.
In her book Adult Children of Alcoholics, Janet G. Woititz describes numerous traits
common among adults who had an alcoholic parent. Although not necessarily universal
or comprehensive, these traits constitute an adult children of alcoholics syndrome (cf.
the work of Wayne Kritsberg).
Coping Mechanism
Suggested practices to mitigate the impact of parental alcoholism on the development
of their children include:
Resilience
Maintaining healthy family traditions and practices, such as vacations, mealtimes,
and holidays
Encouraging COAs to develop consistent, stable, relationships with significant
others outside of the family.
Planning non-drinking activities to compete with alcoholic behaviour and
tendencies.
Professor and psychiatric Dieter J. Meyerhoff state that the negative effects of alcohol
on the body and on health are undeniable, but we should not forget the most important
unit in our society that this is affects the family and the children. The family is the main
institution in which the child should feel safe and have moral values. If a good starting
point is given, it is less likely that when a child becomes an adult, has a mental disorder
or is addicted to drugs or alcohol. According to the American Academy of Child and
Adolescent Psychiatry (AACAP) children are in a unique position when their parents
abuse alcohol. The behavior of a parent is the essence of the problem, because such
children do not have and do not receive support from their own family. Seeing changes
from happy to angry parents, the children begin to think that they are the reason for
these changes. Self-accusation, guilt, frustration, anger arises because the child is
trying to understand why this behavior is occurs. Dependence on alcohol has a huge
harm in childhood and adolescent psychology in a family environment. Psychologists
Michelle L. Kelley and Keith Klostermann describe the effects of parental alcoholism on
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children, and describe the development and behavior of these children. Alcoholic
children often face problems such as behavioral disorders, oppression, crime and
attention deficit disorder, and there is a higher risk of internal behavior, such as
depression and anxiety. Therefore, they are drinking earlier, drinking alcohol more often
and are less likely to grow from moderate to severe alcohol consumption. Young people
with parental abuse and parental violence are likely to live in large crime areas, which
may have a negative impact on the quality of schools and increase the impact of
violence in the area. Paternity alcoholism and the general parental verbal and physical
spirit of violence witnessed the fears of children and the internalization of symptoms,
greater likelihood of child aggression and emotional misconduct. Research on
alcoholism within families has leaned towards exploring issues that are wrong in the
community rather than potential strengths or positives. When researchers conduct
research that helps communities, it can be easier for community members to identify
with the positives and work towards a path of resilience. Flawed research design in
adult children of alcoholics (ACOA) research showed ACOAs were psychologically
damaged. Some flawed research designs include using ACOAs as part of the control
group and comparing them to other ACOAs within the same study. This may have
caused some limitations in the study that were not listed. When comparing ACOAs to
other ACOAs, it is difficult to interpret accurate results that show certain behaviors in the
group studied. Research that has been conducted more recently has used control
groups with non-ACOAs to see whether the behaviors align with prior research. This
research has shown that behaviors were similar between non-ACOAs and ACOAs. An
18 year-long study compared children of alcoholics (COA) to other COAs. In failing to
use non-COAs as controls, we miss an opportunity to see if the negative aspects of a
person are related to having an alcoholic parent, or are they just simply a fact of life. For
example, in Werner’s study, he found that 30% of COAs were committing serious
delinquencies. This data would have been more usable if they had viewed the
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percentage of those committing crimes when compared to non-ACOAs. In a study
conducted in a midwestern university, researchers found that there was no significant
difference between ACOA and non-ACOA students. One of the main differences was
the student’s views on how they connect their past experiences with their current socialemotional
functioning. Students who were ACOAs did not demonstrate issues with their
perspective on their interpersonal issues any more than the non-ACA students.
However, this study did show that there were other underlying problems in the family
structure that may attribute to the perception of not being well adjusted in life.
Due to the flawed research that has been conducted in the past, many stereotypes have
followed ACOAs. ACOAs have been identified as having a variety of emotional and
behavioral problems, such as sleep problems, aggression and lowered selfesteem.
When it comes to being a COA or ACOA, there is still hope. Results showed
that a supportive and loving relationship with one of the parents can counterbalance the
possible negative effects of the relationship with the alcoholic parent. When there is one
alcoholic parent in the household, it helps if the child relies on other family members for
support. It may be the second parent, siblings or members of the extended family.
Having other supportive family members can help the child feel like s/he is not
alone. Younger generations of ACOAs scored more positively, in terms of coping
mechanisms. This may be due to fact that alcoholism is seen more as an illness
nowadays, rather than a moral defect. There has been less victim blaming of alcoholism
on parent’s, because it has now been declared a disease rather than a behavioral
problem. Studies show that when ACOAs use positive coping mechanisms, it is related
to more positive results. When an ACOA approaches their issues, rather than avoids
them, it often relates to having a positive outlook. Studies have shown that ACOAs and
COAs have more compulsive behaviors that may cause the need for higher
achievement. Some ACOAs have shown that the only way to survive is to fend for
themselves. This causes a sense of independence that helps them become more selfreliant.
Because they perceive that independence and hard work as necessary, ACOAs
develop a sense of survival instinct.
Implications for Counselors
Counselors serving ACOAs need to be careful to not assume that the client’s presenting
problems are due solely to the parent’s alcoholism. Exploring the ACOAs life events,
such as the number of alcoholic parents, length of time the client lived with the alcoholic
parent, past interventions, and the role of extended family may help in determining what
the correct method of intervention may be.
Many factors can affect marital and/or parenting difficulties, but there has not been any
evidence found that can link these issues specifically to ACOAs. [44] Research has been
conducted to try to identify issues that arise when someone is a COA. It has been hard
to isolate these issues solely to the fact that the child’s parents are alcoholics. Other
behaviors need to be studied, like dysfunctional family relationships, childhood abuse
and other childhood stressors and how they may contribute to things like depression,
anxiety and bad relationships in ACOAs.
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Counselors serving ACOAs can also help by working on building coping mechanisms
such as creating meaningful relationships with other non-alcoholic family members.
Having other family members who are supportive can help the ACOA feel like they are
not alone. Counselors can also provide some psycho-education on alcoholism and its
effects on family members of alcoholics. Research shows that ACOAs feel less like
blaming their parents for their alcoholism after learning that alcoholism is a disease,
rather than a behavior.
Pregnancy
Prenatal alcohol-related effects can occur with moderate levels of alcohol consumption
by non-alcoholic and alcoholic women. Cognitive performance in infants and children is
not as impacted by mothers who stopped alcohol consumption early in pregnancy, even
if it was resumed after giving birth.
An analysis of six-year-olds with alcohol exposure during the second-trimester of
pregnancy showed lower academic performance and problems with reading, spelling,
and mathematical skills. 6% of offspring from alcoholic mothers have Fetal Alcohol
Syndrome (FAS). The risk an offspring born to an alcoholic mothers having FAS
increases from 6% to 70% if the mother's previous child had FAS.
People diagnosed with FAS have IQs ranging from 20-105 (with a mean of 68), and
demonstrate poor concentration and attention skills. FAS causes growth deficits,
morphological abnormalities, mental retardation, and behavioral difficulties. Among
adolescents and adults, those with FAS are more likely to have mental health problems,
dropping out or be suspended from schools, problems with the law, require assisted
living as an adult, and problems with maintaining employment.
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VI. Alcoholics Anonymous
Alcoholics Anonymous (AA) is an international mutual
aid fellowship [1] founded in 1935
by Bill Wilson and Dr. Bob
Smith in Akron, Ohio. AA's
stated "primary purpose" is
to "stay sober and
help
other alcoholics achieve sobriety". [1][2][3] With
other early members, Bill Wilson and Bob Smith
developed AA's Twelve Step program of spiritual and
character development. AA's initial Twelve Traditions were
introduced in
1946 to help the fellowship be stable and unified while
disengaged
from "outside issues" and influences.
The Traditions recommend that members remain anonymous in public media,
altruistically help other alcoholics, and that AA groups avoid official affiliations with other
organizations. They also advise against dogma and coercive hierarchies. Subsequent
fellowships such as Narcotics Anonymous have adopted and adapted the Twelve Steps
and the Twelve Traditions to their respective primary purposes.
According to AA's 2014 membership survey, 27% of members have been sober less
than one year, 24% have 1–5 years sober, 13% have 5–10 years, 14% have 10–20
years, and 22% have more than 20 years sober. Studies of AA's efficacy have produced
inconsistent results. While some studies have suggested an association between AA
attendance and increased abstinence or other positive outcomes, other studies have
not. A 2006 Cochrane Review both states that "No experimental studies unequivocally
demonstrated the effectiveness of AA or TSF (Twelve step Facilitation) approaches for
reducing alcohol dependence or problems" and that "Severity of addiction and drinking
consequence did not seem to be differentially influenced by [twelve-step programs]
versus comparison treatment interventions, [...] and no conclusive differences in
treatment drop out rates were reported."
The first female member, Florence Rankin, joined AA in March 1937, and the first non-
Protestant member, aRoman Catholic, joined in 1939. The first Black AA group was
established in 1945 in Washington DC by Jim S., an African American physician from
Virginia. AA membership has since spread internationally "across diverse
culturesholding different beliefs and values", including geopolitical areas resistant
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to grassroots movements. Close to 2 million people worldwide are members of AA as of
2016.
AA's name is derived from its first book, informally called "The Big Book", originally
titled Alcoholics Anonymous: The Story of How More Than One Hundred Men Have
Recovered From Alcoholism.
Oxford Group Origins
AA sprang from The Oxford Group, a non-denominational movement modeled
after first-century Christianity. Some members founded the Group to help in maintaining
sobriety. "Grouper" Ebby Thacher was Wilson's former drinking buddy who approached
Wilson saying that he had "got religion", was sober, and that Wilson could do the same
if he set aside objections to religion and instead formed a personal idea of God,
"another power" or "higher power".
Feeling a "kinship of common suffering" and, though drunk, Wilson attended his first
Group gathering. Within days, Wilson admitted himself to the Charles B. Towns
Hospital after drinking four beers on the way—the last alcohol he ever drank. Under the
care of Dr. William Duncan Silkworth (an early benefactor of AA), Wilson's detox
included the deliriant belladonna. At the hospital a despairing Wilson experienced a
bright flash of light, which he felt to be God revealing himself. Following his hospital
discharge Wilson joined the Oxford Group and recruited other alcoholics to the Group.
Wilson's early efforts to help others become sober were ineffective, prompting Dr.
Silkworth to suggest that Wilson place less stress on religion and more on "the science"
of treating alcoholism. Wilson's first success came during a business trip to Akron, Ohio,
where he was introduced to Dr. Robert Smith, a surgeon and Oxford Group member
who was unable to stay sober. After thirty days of working with Wilson, Smith drank his
last drink on 10 June 1935, the date marked by AA for its anniversaries.
While Wilson and Smith credited their sobriety to working with alcoholics under the
auspices of the Oxford Group, a Group associate pastor sermonized against Wilson and
his alcoholic Groupers for forming a "secret, ashamed sub-group" engaged in "divergent
works". By 1937, Wilson separated from the Oxford Group. AA Historian Ernest Kurtz
described the split:
...more and more, Bill discovered that new adherents could get sober by believing in each
other and in the strength of this group. Men [no women were members yet] who had
proven over and over again, by extremely painful experience, that they could not get
sober on their own had somehow become more powerful when two or three of them
worked on their common problem. This, then—whatever it was that occurred among
them—was what they could accept as a power greater than themselves. They did not
need the Oxford Group.
In 1955, Wilson acknowledged AA's debt, saying "The Oxford Groupers had clearly
shown us what to do. And just as importantly, we learned from them what not to do."
Among the Oxford Group practices that AA retained were informal gatherings, a
"changed-life" developed through "stages", and working with others for no material gain,
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AA's analogs for these are meetings, "the steps", and sponsorship. AA's tradition of
anonymity was a reaction to the publicity-seeking practices of the Oxford Group, as well
as AA's wish to not promote, Wilson said, "erratic public characters who through broken
anonymity might get drunk and destroy confidence in us."
The Big Book, the Twelve Steps and the Twelve Traditions
To share their method, Wilson and other members wrote the initially-titled
book, Alcoholics Anonymous: The Story of How More Than One Hundred Men Have
Recovered from Alcoholism, from which AA drew its name. Informally known as "The
Big Book" (with its first 164 pages virtually unchanged since the 1939 edition), it
suggests a twelve-step program in which members admit that they are powerless over
alcohol and need help from a "higher power". They seek guidance and strength through
prayer and meditation from God or a Higher Power of their own understanding; take a
moral inventory with care to include resentments; list and become ready to remove
character defects; list and make amends to those harmed; continue to take a moral
inventory, pray, meditate, and try to help other alcoholics recover. The second half of
the book, "Personal Stories" (subject to additions, removal and retitling in subsequent
editions), is made of AA members' redemptive autobiographical sketches.
In 1941, interviews on American radio and favorable articles in US magazines, including
a piece by Jack Alexander in The Saturday Evening Post, led to increased book sales
and membership. By 1946, as the growing fellowship quarreled over structure, purpose,
and authority, as well as finances and publicity, Wilson began to form and promote what
became known as AA's "Twelve Traditions," which are guidelines for an altruistic,
unaffiliated, non-coercive, and non-hierarchical structure that limited AA's purpose to
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only helping alcoholics on a non-professional level while shunning publicity. Eventually
he gained formal adoption and inclusion of the Twelve Traditions in all future editions of
the Big Book. At the 1955 conference in St. Louis, Missouri, Wilson relinquished
stewardship of AA to the General Service Conference, as AA grew to millions of
members internationally.
Organization and Finances
AA says it is "not organized in the formal or political sense", and Bill Wilson called it a
"benign anarchy". In Ireland, Shane Butler said that AA “looks like it couldn’t survive as
there’s no leadership or top-level telling local cumanns what to do, but it has worked
and proved itself extremely robust.” Butler explained that "AA’s 'inverted pyramid' style
of governance has helped it to avoid many of the pitfalls that political and religious
institutions have encountered since it was established here in 1946."
In 2006, AA counted 1,867,212 members and 106,202 AA groups worldwide. The
Twelve Traditions informally guide how individual AA groups function, and the Twelve
Concepts for World Service guide how the organization is structured globally.
A member who accepts a service position or an organizing role is a "trusted servant"
with terms rotating and limited, typically lasting three months to two years and
determined by group vote and the nature of the position. Each group is a self-governing
entity with AA World Services acting only in an advisory capacity. AA is served entirely
by alcoholics, except for seven "nonalcoholic friends of the fellowship" of the 21-
member AA Board of Trustees.
AA groups are self-supporting, relying on voluntary donations from members to cover
expenses. The AA General Service Office (GSO) limits contributions to US$3,000 a
year. Above the group level, AA may hire outside professionals for services that require
specialized expertise or full-time responsibilities.
Like individual groups, the GSO is self-supporting. AA receives proceeds from books
and literature that constitute more than 50% of the income for its General Service
Office. In keeping with A.A.’s Seventh Tradition, the Central Office is fully selfsupporting
through the sale of literature and related products, and through the voluntary
donations of A.A. members and groups. It does not accept donations from people or
organizations outside of A.A.
In keeping with A.A.’s Eighth Tradition, the Central Office employs special workers who
are compensated financially for their services, but their services do not include
traditional “12th Step” work of working with alcoholics in need. All 12th Step calls that
come to the Central Office are handed to sober A.A. members who have volunteered to
handle these calls. It also maintains service centers, which coordinate activities such as
printing literature, responding to public inquiries, and organizing conferences. Other
International General Service Offices (Australia, Costa Rica, Russia, etc.) are
independent of AA World Services in New York.
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Program
AA's program extends beyond abstaining alcohol. Its goal is to effect enough change in
the alcoholic's thinking "to bring about recovery from alcoholism"through "an entire
psychic change," or spiritual awakening. A spiritual awakening is meant to be achieved
by taking the Twelve Steps, and sobriety is furthered by volunteering for AA and regular
AA meeting attendance or contact with AA members. Members are encouraged to find
an experienced fellow alcoholic, called a sponsor, to help them understand and follow
the AA program. The sponsor should preferably have experience of all twelve of the
steps, be the same sex as the sponsored person, and refrain from imposing personal
views on the sponsored person. Following the helper therapy principle, sponsors in AA
may benefit from their relationship with their charges, as "helping behaviors" correlate
with increased abstinence and lower probabilities of binge drinking.
AA's program is an inheritor of Counter-Enlightenment philosophy. AA shares the view
that acceptance of one's inherent limitations is critical to finding one's proper place
among other humans and God. Such ideas are described as "Counter-Enlightenment"
because they are contrary to the Enlightenment's ideal that humans have the capacity
to make their lives and societies a heaven on earth using their own power and
reason. After evaluating AA's literature and observing AA meetings for sixteen months,
sociologists David R. Rudy and Arthur L. Greil found that for an AA member to remain
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sober a high level of commitment is necessary. This commitment is facilitated by a
change in the member's worldview. To help members stay sober AA must, they argue,
provide an all-encompassing worldview while creating and sustaining an atmosphere of
transcendence in the organization. To be all-encompassing AA's ideology places an
emphasis on tolerance rather than on a narrow religious worldview that could make the
organization unpalatable to potential members and thereby limit its effectiveness. AA's
emphasis on the spiritual nature of its program, however, is necessary to institutionalize
a feeling of transcendence. A tension results from the risk that the necessity of
transcendence, if taken too literally, would compromise AA's efforts to maintain a broad
appeal. As this tension is an integral part of AA, Rudy and Greil argue that AA is best
described as a quasi-religious organization.
Meetings
AA meetings are "quasi-ritualized therapeutic sessions run by and for, alcoholics". They
are usually informal and often feature discussions. Local AA directories list a variety of
weekly meetings. Those listed as "closed" are available to those with a self-professed
"desire to stop drinking," which cannot be challenged by another member on any
grounds. "Open" meetings are available to anyone (nonalcoholics can attend as
observers). At speaker meetings, one or two members tell their stories, while discussion
meetings allocate the most time for general discussion. Some meetings are devoted to
studying and discussing the AA literature.
AA meetings do not exclude other alcoholics, though some meetings cater to specific
demographics such as gender, profession, age, sexual orientation, or culture. Meetings
in the United States are held in a variety of languages
including Armenian, English, Farsi, Finnish, French, Japanese, Korean, Russian, and
Spanish. While AA has pamphlets that suggest meeting formats, groups have the
autonomy to hold and conduct meetings as they wish "except in matters affecting other
groups or AA as a whole". Different cultures affect ritual aspects of meetings, but
around the world "many particularities of the AA meeting format can be observed at
almost any AA gathering".
Confidentiality
US courts have not extended the status of privileged communication, such as that
enjoyed by clergy and lawyers, to AA related communications between members.
Spirituality
A study found an association between an increase in attendance to AA meetings with
increased spirituality and a decrease in the frequency and intensity of alcohol use. The
research also found that AA was effective at helping agnostics and atheists become
sober. The authors concluded that though spirituality was an important mechanism of
behavioral change for some alcoholics, it was not the only effective mechanism. Since
the mid-1970s, a number of 'agnostic' or 'no-prayer' AA groups have begun across the
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U.S., Canada, and other parts of the world, which hold meetings that adhere to a
tradition allowing alcoholics to freely express their doubts or disbelief that spirituality will
help their recovery, and forgo use of opening or closing prayers. There are online
resources listing AA meetings for atheists and agnostics.
Disease Concept of Alcoholism
More informally than not, AA's membership has helped popularize the disease concept
of alcoholism, though AA officially has had no part in the development of such
postulates which had appeared as early as the late eighteenth century. Though AA
initially avoided the term "disease", in 1973 conference-approved literature categorically
stated that "we had the disease of alcoholism." Regardless of official positions, from
AA's inception most members have believed alcoholism to be a disease.
Though cautious regarding the medical nature of alcoholism, AA has let others voice
opinions. The Big Book states that alcoholism "is an illness which only a spiritual
experience will conquer." Ernest Kurtz says this is "The closest the book Alcoholics
Anonymous comes to a definition of alcoholism." In his introduction to The Big Book,
non-member Dr. William Silkworth said those unable to moderate their drinking have
an allergy. Addressing the allergy concept, AA said "The doctor’s theory that we have
an allergy to alcohol interests us. As laymen, our opinion as to its soundness may, of
course, mean little. But as ex-problem drinkers, we can say that his explanation makes
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good sense. It explains many things for which we cannot otherwise account." AA later
acknowledged that "alcoholism is not a true allergy, the experts now inform us." Wilson
explained in 1960 why AA had refrained from using the term "disease":
We AAs have never called alcoholism a disease because, technically speaking, it is not
a disease entity. For example, there is no such thing as heart disease. Instead there are
many separate heart ailments or combinations of them. It is something like that with
alcoholism. Therefore, we did not wish to get in wrong with the medical profession by
pronouncing alcoholism a disease entity. Hence, we have always called it an illness or a
malady—a far safer term for us to use.
Canadian and United States Demographics
AA's New York General Service Office regularly surveys AA members in North America.
Its 2014 survey of over 6,000 members in Canada and the United States concluded
that, in North America, AA members who responded to the survey were 62% male and
38% female.
Average member sobriety is slightly under 10 years with 36% sober more than ten
years, 13% sober from five to ten years, 24% sober from one to five years, and 27%
sober less than one year. Before coming to AA, 63% of members received some type of
treatment or counseling, such as medical, psychological, or spiritual. After coming to
AA, 59% received outside treatment or counseling. Of those members, 84% said that
outside help played an important part in their recovery.
The same survey showed that AA received 32% of its membership from other
members, another 32% from treatment facilities, 30% were self-motivated to attend AA,
12% of its membership from court–ordered attendance, and only 1% of AA members
decided to join based on information obtained from the Internet. People taking the
survey were allowed to select multiple answers for what motivated them to join AA.
Research Limitations
Effectiveness
AA tends to polarize observers into believers and non-believers, and discussion of AA
often creates controversy rather than objective reflection. Moreover, arandomized
study of AA is difficult: AA members are not randomly selected from the population of
chronic alcoholics; they are instead self-selected or mandated by courts to attend AA
meetings. There are two opposing types of self-selection bias: (1) drinkers may be
motivated to stop drinking before they participate in AA; (2) AA may attract the more
severe and difficult cases.
Studies
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Studies of AA's efficacy have produced inconsistent results. While some studies have
suggested an association between AA attendance and increased abstinence or other
positive outcomes, other studies have not. Even meta-analyses and literature
reviews have resulted in widely divergent conclusions.
The 2006 Cochrane Review of eight studies (the studies reviewed were done between
1967 and 2005) measuring the effectiveness of AA found no significant difference
between the results of AA and twelve-step participation compared to other treatments,
stating that "experimental studies have on the whole failed to demonstrate their
effectiveness in reducing alcohol dependence or drinking problems when compared to
other interventions."
A 2014 study by Keith Humphreys, Janet Blodgett and Todd Wagner concluded that
"increasing AA attendance leads to short and long term decreases in alcohol
consumption that cannot be attributed to self-selection." Austin Frakt, writing for The
New York Times, discusses how the study's methodology minimizes outside factors,
such as how motivated the people who succeed at becoming abstinent are.
A meta-analysis by Dr. Lee Ann Kaskutas in 2009 reported that while the evidence base
for twelve step groups from experimental studies was weak, "other categories of
evidence... are overwhelmingly convincing". Specifically, the correlation between
exposure to AA and outcome, the dose-response relationship, and the consistency of
the association were found to be very strong. In other words, the frequency by which
individuals attend meetings appears to have a statistically significant correlation with
maintaining abstinence.
Kaskutas noted two studies which both found that 70% of those who attended twelvestep
groups at least weekly were abstaining from alcohol consumption at follow ups two
and sixteen years later. Those who attended less than once per week showed about the
same success rate as those who didn’t attend meetings. Kaskutas also found AA to
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function consistently with known behavioral change theories and
substantial empirical support for specific mechanisms through which AA facilitates
change.
A preliminary study suggested that "AA prayers" help long-term AA members
reduce cravings for alcohol. The study used a MRI machine to scan how subjects
reacted to images of people drinking. The study randomly assigned the subjects, so that
some subjects saw the images after saying prayers in the Big Book of Alcoholics
Anonymous; others after reading newspaper articles. The people who had just seen the
prayers reported feeling fewer cravings for alcohol; the MRI scans of their brains
confirmed that there was a different reaction.
The Sober Truth
Dr. Lance Dodes, in his 2014 book The Sober Truth, argues that most people who have
experienced AA have not achieved long-term sobriety, making the controversial
argument that research indicates that only 5 to 8 percent of the people who go to one or
more AA meetings achieve sobriety for longer than one year. Gabrielle Glaser used
Dodes' figures to argue that AA has a low success rate in a 2015 article for The Atlantic.
The 5 to 8 percent figure put forward by Dodes is controversial; Thomas Beresford, MD,
writing for the National Council on Alcoholism and Drug Dependence, says that the
book uses "three separate, questionable, calculations that arrive at the 5–8%
figure." This is not the only criticism the book has received. Cornell University clinical
psychiatry professor Richard A. Friedman, in his review for the New York Times,
called The Sober Truth a "polemical and deeply flawed book", noting that it was
designed to promote psychodynamic therapy for addiction, which itself lacks a strong
evidence base.
John F. Kelly, an associate professor atHarvard, as well as Gene Beresin, a professor
at Harvard, feel that the book's conclusion that "[12-step] approaches are almost
completely ineffective and even harmful in treating substance use disorders" is wrong,
noting that "studies published in prestigious peer-reviewed scientific journals have found
that 12-step treatments that facilitate engagement with AA post-discharge [...] produce
about one third higher continuous abstinence rates".
Health-Care Costs
As a volunteer-supported program, AA is free of charge. This contrasts with treatments
for alcoholism such as inpatient treatment, drug therapy, psychotherapy, andcognitivebased
therapy. [90] One study found that the institutional use of twelve-step-facilitation
therapy to encourage participation in AA reduced healthcare expenditures by 45% when
compared to another group that was not encouraged to participate in AA.
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Relationship with Institutions
Hospitals
Many AA meetings take place in treatment facilities. Carrying the message of AA into
hospitals was how the co-founders of AA first remained sober. They discovered great
value of working with alcoholics who are still suffering, and that even if the alcoholic
they were working with did not stay sober, they did. Bill Wilson wrote, "Practical
experience shows that nothing will so much insure immunity from drinking as intensive
work with other alcoholics". Bill Wilson visited Towns Hospital in New York City in an
attempt to help the alcoholics who were patients there in 1934. At St. Thomas
Hospital in Akron, Ohio, Smith worked with still more alcoholics. In 1939, a New York
mental institution, Rockland State Hospital, was one of the first institutions to allow AA
hospital groups. Service to corrections and treatment facilities used to be combined until
the General Service Conference, in 1977, voted to dissolve its Institutions Committee
and form two separate committees, one for treatment facilities, and one for correctional
facilities.
Prisons
In the United States and Canada, AA meetings are held in hundreds of correctional
facilities. The AA General Service Office has published a workbook with detailed
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ecommendations for methods of approaching correctional-facility officials with the
intent of developing an in-prison AA program. In addition, AA publishes a variety of
pamphlets specifically for the incarcerated alcoholic. Additionally, the AA General
Service Office provides a pamphlet with guidelines for members working with
incarcerated alcoholics.
United States Court Rulings
United States courts have ruled that inmates, parolees, and probationers cannot be
ordered to attend AA. Though AA itself was not deemed a religion, it was ruled that it
contained enough religious components (variously described in Griffin v.
Coughlin below as, inter alia, "religion", "religious activity", "religious exercise") to make
coerced attendance at AA meetings a violation of the Establishment Clause of the First
Amendment of the constitution. In 2007, the Ninth Circuit of the U.S. Court of
Appeals stated that a parolee who was ordered to attend AA had standing to sue his
parole office.
[The] American Treatment Industry
In 1949, the Hazelden treatment center was founded and staffed by AA members, and
since then many alcoholic rehabilitation clinics have incorporated AA's precepts into
their treatment programs. 32% of AA's membership was introduced to it through a
treatment facility.
[The] United Kingdom Treatment Industry
A cross-sectional survey of substance-misuse treatment providers in the West Midlands
found fewer than 10% integrated twelve-step methods in their practice and only a third
felt their consumers were suited for Alcoholics Anonymous or Narcotics Anonymous
membership. Less than half were likely to recommend self-help groups to their clients.
Providers with nursing qualifications were more likely to make such referrals than those
without them. A statistically significant correlation was found between providers' selfreported
level of spirituality and their likelihood of recommending AA or NA.
Criticism
Thirteenth Stepping
"Thirteenth-stepping" is a pejorative term for AA members approaching new members
for dates or sex. The Journal of Addiction Nursing reported that 50% of the women that
participated in a survey (55 in all) experienced 13-stepping behavior from others. AA's
pamphlet on sponsorship suggests that men be sponsored by men and women be
sponsored by women.
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Moderation or Abstinence
Stanton Peele argued that some AA groups apply the disease model to all problem
drinkers, whether or not they are "full-blown" alcoholics. Along with Nancy Shute, Peele
has advocated that besides AA, other options should be readily available to those
problem drinkers who are able to manage their drinking with the right treatment. The Big
Book says "moderate drinkers" and "a certain type of hard drinker" are able to stop or
moderate their drinking. The Big Book suggests no program for these drinkers, but
instead seeks to help drinkers without "power of choice in drink."
Cultural Identity
One review of AA warned of detrimental iatrogenic effects of twelve-step philosophy and
concluded that AA uses many methods that are also used by cults. A subsequent study
concluded, however, that AA's program bore little resemblance to religious cults
because the techniques used appeared beneficial. Another study found that the AA
program's focus on admission of having a problem increases deviant stigma and strips
members of their previous cultural identity, replacing it with the deviant identity. A
survey of group members, however, found they had a bicultural identity and saw AA's
program as a complement to their other national, ethnic, and religious cultures.
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Literature
Alcoholics Anonymous publishes several books, reports, pamphlets, and other media,
including a periodical known as the AA Grapevine. Two books are used
primarily: Alcoholics Anonymous (the "Big Book") and Twelve Steps and Twelve
Traditions, the latter explaining AA's fundamental principles in depth. The full text of
each of these two books is available on the AA website at no charge.
Alcoholics Anonymous: the story of how many thousands of men and women
have recovered from alcoholism (multiple PDFs) (4th ed.). 2011. ISBN 1-893007-
16-2. 575 pages. Also available in libraries.
Twelve Steps and Twelve Traditions (multiple PDFs). 2002. ISBN 0-916856-01-
1. 192 pages. Also available in libraries.
"Home Page". The AA Grapevine. Alcoholics Anonymous. ISSN 0362-2584.
Archived from the original on 3 April 2009. Also available in libraries.
Films about Alcoholic Anonymous
AA in Film
My Name Is Bill W. – dramatized biography of co-founder Bill Wilson.
When Love Is Not Enough: The Lois Wilson Story – a 2010 film about the wife of
founder Bill Wilson, and the beginnings of Alcoholics Anonymous and Al-Anon.
Bill W. – a 2011 biographical documentary film that tells the story of Bill Wilson
using interviews, recreations, and rare archival material.
The 13th Step – A 2016 documentary film about sexual predators in Alcoholics
Anonymous.
Films where primary plot line includes AA
A Walk Among the Tombstones (2015), a mystery/suspense film based
on Lawrence Block's books featuring Matthew Scudder, a recovering alcoholic
detective whose AA membership is a central element of the plot.
When a Man Loves a Woman – an airline pilot's wife attends AA meetings in a
residential treatment facility.
Clean and Sober – an addict (alcohol, cocaine) visits an AA meeting to get a
sponsor.
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Days of Wine and Roses – a 1962 film about a married couple struggling with
alcoholism. Jack Lemmon's character attends an AA meeting in the film.
Drunks – a 1995 film starring Richard Lewis as an alcoholic who leaves an AA
meeting and relapses. The film cuts back and forth between his eventual relapse
and the other meeting attendants.
Come Back, Little Sheba – A 1952 film based on a play of the same title about a
loveless marriage where the husband played by Burt Lancaster is an alcoholic
who gets help from 2 members of the local AA chapter. [127] A 1977 TV drama was
also based on the play.
I'll Cry Tomorrow – A 1955 film about singer Lillian Roth played by Susan
Hayward who goes to AA to help her stop drinking. The film was based on
Roth'sautobiography of the same name detailing her alcoholism and sobriety
through AA.
You Kill Me – a 2007 crime-comedy film starring Ben Kingsley as a mob hit man
with a drinking problem who is forced to accept a job at a mortuary and go to AA
meetings.
Smashed – a 2012 drama film starring Mary Elizabeth Winstead. An elementary
school teacher's drinking begins to interfere with her job, so she attempts to get
sober in AA.
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VII. Recovery Approach
Psychological Recovery or Recovery Model or The Recovery Approach to mental
disorder or substance dependence emphasizes and supports a person's potential for
recovery. Recovery is generally seen in this approach as a personal journey rather than
a set outcome, and one that may involve developing hope, a secure base and sense of
self, supportive relationships, empowerment, social inclusion, coping skills,
and meaning. Recovery sees symptoms as a continuum of the norm rather than an
aberration and rejects sane-insane dichotomy.
William Anthony, Director of the Boston
Center for Psychiatric
Rehabilitation
developed a quaint
cornerstone definition of
mental health recovery in
1993. "Recovery is
a deeply personal,
unique
process
of
changing one's attitudes, values, feelings, goals, skills and/or roles. It is a way of living a
satisfying, hopeful, and contributing life even with limitations caused by the illness.
Recovery involves the development of new meaning and purpose in one's life as one
grows beyond the catastrophic effects of mental illness."
Originating from the 12-Step Program of Alcoholics Anonymous, the use of the concept
in mental health emerged as deinstitutionalization resulted in more individuals living in
the community. It gained impetus as a social movement due to a perceived failure by
services or wider society to adequately support social inclusion, and by studies
demonstrating that many people do recover. A recovery approach has now been
explicitly adopted as the guiding principle of the mental health or substance dependency
policies of a number of countries and states. In many cases practical steps are being
taken to base services on a recovery model, although a range of obstacles, concerns
and criticisms have been raised both by service providers and by recipients of services.
A number of standardized measures have been developed to assess aspects of
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ecovery, although there is some variation between professionalized models and those
originating in the psychiatric survivors movement.
History
In general medicine and psychiatry, recovery has long been used to refer to the end of a
particular experience or episode of illness. The broader concept of "recovery" as a
general philosophy and model was first popularized in regard to recovery
from substance abuse/drug addiction, for example within twelve-step programs.
Application of recovery models to psychiatric disorders is comparatively recent. The
concept of recovery can be traced back as far as 1840, when John Perceval, son of one
of Britain's prime ministers, wrote of his personal recovery from the psychosis that he
experienced from 1830 until 1832, a recovery that he obtained despite the "treatment"
he received from the "lunatic" doctors who attended him. But by consensus the main
impetus for the development came from the within theconsumer/survivor/ex-patient
movement, a grassroots self-help and advocacy initiative, particularly within the United
States during the late 1980s and early 1990s. The professional literature, starting with
the psychiatric rehabilitation movement in particular, began to incorporate the concept
from the early 1990s in the United States, followed by New Zealand and more recently
across nearly all countries within the "First World". Similar approaches developed
around the same time, without necessarily using the term recovery, in Italy, the
Netherlands and the UK.
Developments were fueled by a number of long term outcome studies of people with
"major mental illnesses" in populations from virtually every continent, including landmark
cross-national studies by the World Health Organization from the 1970s and 1990s,
showing unexpectedly high rates of complete or partial recovery, with exact statistics
varying by region and the criteria used. The cumulative impact of personal stories
or testimony of recovery has also been a powerful force behind the development of
recovery approaches and policies. A key issue became how service consumers could
maintain the ownership and authenticity of recovery concepts while also supporting
them in professional policy and practice.
Increasingly, recovery became both a subject of mental health services research and a
term emblematic of many of the goals of the Consumer/Survivor/Ex-Patient Movement.
The concept of recovery was often defined and applied differently by
consumers/survivors and professionals. Specific policy and clinical strategies were
developed to implement recovery principles although key questions remained.
Elements of Recovery
It has been emphasized that each individual's journey to recovery is a deeply personal
process, as well as being related to an individual's community and society. A number of
features or signs of recovery have been proposed as often core elements and
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comprehensively they have been categorized
under the concept of CHIME. CHIME is an
abbreviation of Connectedness, Hope and
optimism, Identity, Meaning & Purpose and
Empowerment.
Connectedness and Supportive
Relationships
A common aspect of recovery is said to be the
presence of others who believe in the person's
potential to recover, and who stand by them.
While mental health professionals can offer a
particular limited kind of relationship and help
foster hope, relationships
with friends, family and the community are said
to often be of wider and longer-term
importance. Others who have experienced
similar difficulties, who may be on a journey of
recovery, can be of particular importance.
Those who share the same values and
outlooks more generally (not just in the area of
mental health) may also be particularly
important. It is said that one-way relationships
based on being helped can actually be
devaluing, and that reciprocal relationships and
mutual support networks can be of more value
to self-esteem and recovery.
Hope
Finding and nurturing hope has been described
as a key to recovery. It is said to include not
just optimism but a sustainable belief in oneself
and a willingness to persevere through
uncertainty and setbacks. Hope may start at a
certain turning point, or emerge gradually as a
small and fragile feeling, and may fluctuate
withdespair. It is said to involve trusting, and
risking disappointment, failure and further hurt.
Identity
Recovery of a durable sense of self (if it had
been lost or taken away) has been proposed
as an important element. A research review
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suggested that people sometimes achieve this by "positive withdrawal"—regulating
social involvement and negotiating public space in order to only move towards others in
a way that feels safe yet meaningful; and nurturing personal psychological space that
allows room for developing understanding and a broad sense of self,
interests, spirituality, etc. It was suggested that the process is usually greatly facilitated
by experiences of interpersonal acceptance, mutuality, and a sense of social belonging;
and is often challenging in the face of the typical barrage of overt and covert negative
messages that come from the broader social context. Being able to move on can mean
having to cope with feelings of loss, which may include despair and anger. When an
individual is ready for change, a process of grieving is initiated. It may require accepting
past suffering and lost opportunities or lost time.
Formation of Healthy Coping Strategies and Meaningful Internal Schema
The development of personal coping strategies (including self-management or self-help)
is said to be an important element. This can involve making use
ofmedication or psychotherapy if the patient is fully informed and listened to, including
about adverse effects and about which methods fit with the consumer's life and their
journey of recovery. Developing coping and problem solving skills to manage individual
traits and problem issues (which may or may not be seen as symptomsof mental
disorder) may require a person becoming their own expert, in order to identify
key stress points and possible crisis points, and to understand and develop personal
ways of responding and coping. Developing a sense of meaning and overall purpose is
said to be important for sustaining the recovery process. This may involve recovering or
developing a social or work role. It may also involve renewing, finding or developing a
guiding philosophy, religion, politics or culture. From a postmodern perspective, this can
be seen as developing a narrative.
Empowerment and Building A Secure Base
Building a positive culture of healing is essential in recovery approach. Since recovery is
not synonymous with cure a strong supportive network is required. Appropriate housing,
a sufficient income, freedom from violence, and adequate access to health care have
also been proposed. It has been suggested that home (housing first) is where recovery
may begin. Housing services, if required, need to flexibly involve people and to build on
individuals' personal visions and strengths, instead of "placing" and potentially "reinstitutionalizing"
people. Empowerment and self-determination are said to be important
to recovery for reducing the social and psychological effects of stress.
This can mean developing the confidence for independent assertive decision
making and help-seeking which translates into proper medication and active self care
practices. Achieving social inclusion and overcoming challenging social
stigma and prejudice about mentaldistress/disorder/difference is an important part of
empowerment. This may require recovering detached social skills and identity, making
up for gaps in work historyfor better self-management, etc. [10]
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Concepts of Recovery
Varied Definitions
What constitutes 'recovery', or a recovery model, is a matter of ongoing debate both in
theory and in practice. In general, professionalized clinical models tend to focus on
improvement in particular symptoms and functions, and on the role of treatments, while
consumer/survivor models tend to put more emphasis on peer support, empowerment
and real-world personal experience. Similarly, recovery may be viewed in terms of
a social model of disability rather than a medical model of disability, and there may be
differences in the acceptance of diagnostic "labels" and treatments.
A review of research suggested that writers on
recovery are rarely explicit about which of the
various concepts they are employing. The
reviewers classified the approaches they found in
to broadly "rehabilitation" perspectives, which they
defined as being focused on life and meaning
within the context of enduring disability, and
"clinical" perspectives which focused on
observable remission of symptoms and restoration
of functioning. From a psychiatric
rehabilitation perspective, a number of additional
qualities of the recovery process have been
suggested, including that it: can occur without
professional intervention, but requires people who
believe in and stand by the person in recovery;
does not depend on believing certain theories
about the cause of conditions; can be said to
occur even if symptoms later re-occur, but does
change the frequency and duration of symptoms;
requires recovery from the consequences of a
psychiatric condition as well as the condition itself;
is not linear but does tend to take place as a
series of small steps; does not mean the person
was never really psychiatrically disabled; focuses
on wellness not illness, and on consumer choice.
A consensus statement on mental health recovery from US agencies, that involved
some consumer input, defined recovery as a journey of healing and transformation
enabling a person with a mental health problem to live a meaningful life in a community
of his or her choice while striving to achieve his or her full potential. Ten fundamental
components were elucidated, all assuming that the person continues to be a
"consumer" or to have a "mental disability". Conferences have been held on the
importance of the "elusive" concept from the perspectives of consumers and
psychiatrists.
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One approach to recovery known as the Tidal Model focuses on the continuous process
of change inherent in all people, conveying the meaning of experiences through
water metaphors. Crisis is seen as involving opportunity; creativity is valued; and
different domains are explored such as sense of security, personalnarrative and
relationships. Initially developed by mental health nurses along with service users, Tidal
is a particular model that has been specifically researched. Based on a discrete set of
values (the Ten Commitments), it emphasizes the importance of each person's own
voice, resourcefulness and wisdom. Since 1999, projects based on the Tidal Model
have been established in several countries.
For many, recovery has a political as well as personal implication—where to recover is
to: find meaning; challenge prejudice (including diagnostic "labels" in some cases);
perhaps to be a "bad" non-compliant patient and refuse to accept the indoctrination of
the system; to reclaim a chosen life and place within society; and to validate the
self. Recovery can thus be viewed as one manifestation of empowerment. Such an
empowerment model may emphasize that conditions are not necessarily permanent;
that other people have recovered who can be role models and share experiences; and
that "symptoms" can be understood as expressions of distress related to emotions and
other people. One such model from the US National Empowerment Center proposes a
number of principles of how people recover and seeks to identify the characteristics of
people in recovery.
In general, recovery may be seen as more of a philosophy or attitude than a specific
model, requiring fundamentally that "we regain personal power and a valued place in
our communities. Sometimes we need services to support us to get there".
Recovery from Substance Dependence
Particular kinds of recovery models have been adopted in drug rehabilitation services.
While interventions in this area have tended to focus on harm reduction, particularly
through substitute prescribing (or alternatively requiring total abstinence) recovery
approaches have emphasised the need to simultaneously address the whole of people's
lives, and to encourage aspirations while promoting equal access and opportunities
within society. From the perspective of services the work may include helping people
with "developing the skills to prevent relapse into further illegal drug taking, rebuilding
broken relationships or forging new ones, actively engaging in meaningful activities and
taking steps to build a home and provide for themselves and their families. Milestones
could be as simple as gaining weight, re-establishing relationships with friends, or
building self-esteem. What is key is that recovery is sustained.". Key to the philosophy
of the recovery movement is the aim for an equal relationship between "Experts by
Profession" and "Experts by Experience".
Concerns
Some concerns have been raised about a recovery approach in theory and in practice.
These include suggestions that it: is an old concept; only happens to very few people;
Page 100 of 134

epresents an irresponsible fad; happens only as a result of active treatment; implies a
cure; can only be implemented with new resources; adds to the burden of already
stretched providers; is neither reimbursable nor evidence based; devalues the role of
professional intervention; and increases providers' exposure to risk and liability.
Other criticisms focused on practical implementation by service providers include that:
the recovery model can be manipulated by officials to serve various political and
financial interests including withdrawing services and pushing people out before they're
ready; that it is becoming a new orthodoxy or bandwagon that neglects the
empowerment aspects and structural problems of societies and primarily represents
a middle class experience; that it hides the continued dominance of a medical model;
and that it potentially increases social exclusion and marginalizes those who don't fit
into a recovery narrative.
There have been
specific tensions
between recovery
models and
"evidence-based
practice" models in
the transformation of
US mental health
services based on
the
recommendations of
the New Freedom
Commission on
Mental Health. The
Commission's
emphasis on
recovery has been
interpreted by some
critics as saying that
everyone can fully
recover through
sheer will power and
therefore as giving
false hope and
implicitly blaming
those who may be unable to recover. However, the critics have themselves been
charged with undermining consumer rights and failing to recognize that the model is
intended to support a person in their personal journey rather than expecting a given
outcome, and that it relates to social and political support and empowerment as well as
the individual.
Page 101 of 134

Various stages of resistance to recovery approaches have been identified amongst staff
in traditional services, starting with "Our people are much sicker than yours. They won't
be able to recover" and ending in "Our doctors will never agree to this". However, ways
to harness the energy of this perceived resistance and use it to move forward have
been proposed. In addition, staff training materials have been developed by various
organisations, for example by the National Empowerment Center.
Some positives and negatives of recovery models were highlighted in a study of
a community mental health service for people diagnosed with schizophrenia. It was
concluded that while the approach may be a useful corrective to the usual style of case
management - at least when genuinely chosen and shaped by each unique individual
on the ground - serious social, institutional and personal difficulties made it essential
that there be sufficient ongoing effective support with stressmanagement and coping in
daily life. Cultural biases and uncertainties were also noted in the 'North American'
model of recovery in practice, reflecting views about the sorts of contributions and
lifestyles that should be considered valuable or acceptable.
Assessment
A number of standardized questionnaires and assessments have been developed to try
to assess aspects of an individual's recovery journey. These include the Milestones of
Recovery (MOR) Scale, Recovery Enhancing Environment (REE) measure, Recovery
Measurement Tool (RMT), Recovery Oriented System Indicators (ROSI)
Measure, Stages of Recovery Instrument (STORI), and numerous related instruments.
The data-collection systems and terminology used by services and funders are said to
be typically incompatible with recovery frameworks, so methods of adapting them have
been developed. It has also been argued that the Diagnostic and Statistical Manual of
Mental Disorders (and to some extent any system of categoricalclassification of mental
disorders) uses definitions and terminology that are inconsistent with a recovery model,
leading to suggestions that the next version, the DSM-V, requires: greater sensitivity to
cultural issues and gender; to recognize the need for others to change as well as just
those singled out for a diagnosis of disorder; and to adopt a dimensional approach to
assessment that better captures individuality and does not erroneously imply excess
psychopathology or chronicity.
United States and Canada
National Policies and Implementation
The New Freedom Commission on Mental Health has proposed to transform the mental
health system in the US by shifting the paradigm of care from traditional medical
psychiatric treatment toward the concept of recovery, and the American Psychiatric
Association has endorsed a recovery model from a psychiatric services perspective.
Page 102 of 134

The US Department of Health and Human Services reports developing national and
state initiatives to empower consumers and support recovery, with specific committees
planning to launch nationwide pro-recovery, anti-stigma education campaigns; develop
and synthesize recovery policies; train consumers in carrying out evaluations of mental
health systems; and help further the development of peer-run services. Mental Health
service directors and planners are providing guidance to help state services implement
recovery approaches.
Some US states, such as California (see the California Mental Health Services
Act), Wisconsin and Ohio, already report redesigning their mental health systems to
stress recovery model values like hope, healing, empowerment, social connectedness,
human rights, and recovery-oriented services.
At least some parts of the Canadian Mental Health Association, such as
the Ontario region, have adopted recovery as a guiding principle for reforming and
developing the mental health system.
New Zealand and Australia
Since 1998, all mental health services in New Zealand have been required by
government policy to use a recovery approach and mental health professionals are
expected to demonstrate competence in the recovery model. Australia's National Mental
Health Plan 2003-2008 states that services should adopt a recovery
orientation although there is variation between Australian states and territories in the
level of knowledge, commitment and implementation.
UK and Ireland
In 2005, the National Institute for Mental Health in England (NIMHE) endorsed a
recovery model as a possible guiding principle of mental health service provision and
public education. The National Health Service is implementing a recovery approach in
at least some regions, and has developed a new professional role of Support Time and
Recovery Worker. Centre for Mental Health issued a 2008 policy paper proposing that
the recovery approach is an idea "whose time has come" and, in partnership with the
NHS Confederation Mental Health Network, and support and funding from the
Department of Health, manages the Implementing Recovery through Organisational
Change (ImROC) nationwide project that aims to put recovery at the heart of mental
health services in the UK. TheScottish Executive has included the promotion and
support of recovery as one of its four key mental health aims and funded a Scottish
Recovery Network to facilitate this. A 2006 review of nursing in Scotland recommended
a recovery approach as the model for mental health nursing care and intervention. The
Mental Health Commission of Ireland reports that its guiding documents place the
service user at the core and emphasize an individual's personal journey towards
recovery.
Page 103 of 134

Page 104 of 134

VIII. References
1. https://en.wikipedia.org/wiki/Alcoholism
2. https://en.wikipedia.org/wiki/Alcohol_Use_Disorders_Identification_Te
st
3. http://www.talkingalcohol.com/files/pdfs/WHO_audit.pdf
4. https://www.integration.samhsa.gov/AUDIT_screener_for_alcohol.pdf
5. https://www.ncbi.nlm.nih.gov/pubmed/25169489
6. https://en.wikipedia.org/wiki/Addictive_personality
7. https://en.wikipedia.org/wiki/Alcoholrelated_traffic_crashes_in_the_United_States
8. https://en.wikipedia.org/wiki/Alcoholism_in_family_systems
9. https://en.wikipedia.org/wiki/High-functioning_alcoholic
10. https://en.wikipedia.org/wiki/Alcoholics_Anonymous
11. https://en.wikipedia.org/wiki/Recovery_approach
12. https://pubs.niaaa.nih.gov/publications/arh312/111-118.pdf
Page 105 of 134

Notes
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Page 107 of 134

Page 108 of 134

Attachment A
Alcohol Use Disorder Identification Test
(AUDIT)
Page 109 of 134

AUDIT
Introduction
The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item
screening tool developed by the World Health Organization (WHO) to
assess alcohol consumption, drinking behaviors, and alcohol-related
problems. Both a clinician-administered version (page 1) and a self-report
version of the AUDIT (page 2) are provided. Patients should be encouraged
to answer the AUDIT questions in terms of standard drinks. A chart
illustrating the approximate number of standard drinks in different alcohol
beverages is included for reference. A score of 8 or more is considered to
indicate hazardous or harmful alcohol use. The AUDIT has been validated
across genders and in a wide range of racial/ethnic groups and is wellsuited
for use in primary care settings. Detailed guidelines about use of the
AUDIT have been published by the WHO and are available online:
http://whqlibdoc.who.int/hq/2001/who_msd_msb_01.6a.pdf
http://www.drugabuse.gov/nidamed-medical-health-professionals

The Alcohol Use Disorders Identification Test: Interview Version
Read questions as written. Record answers carefully. Begin the AUDIT by saying
“Now I am going to ask you some questions about your use of alcoholic beverages
during this past year.” Explain what is meant by “alcoholic beverages” by using
local examples of beer, wine, vodka, etc. Code answers in terms of “standard
drinks”. Place the correct answer number in the box at the right.
1. How often do you have a drink containing alcohol?
(0) Never [Skip to Qs 9-10]
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week
2. How many drinks containing alcohol do you have
on a typical day when you are drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9
(4) 10 or more
3. How often do you have six or more drinks on one
occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
Skip to Questions 9 and 10 if Total Score
for Questions 2 and 3 = 0
6. How often during the last year have you needed
a first drink in the morning to get yourself going
after a heavy drinking session?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
7. How often during the last year have you had a
feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
8. How often during the last year have you been
unable to remember what happened the night
before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
4. How often during the last year have you found
that you were not able to stop drinking once you
had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed to
do what was normally expected from you
because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
9. Have you or someone else been injured as a
result of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
10. Has a relative or friend or a doctor or another
health worker been concerned about your drinking
or suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
Record total of specific items here
If total is greater than recommended cut-off, consult User’s Manual.

The Alcohol Use Disorders Identification Test: Self-Report Version
PATIENT: Because alcohol use can affect your health and can interfere with certain
medications and treatments, it is important that we ask some questions about
your use of alcohol. Your answers will remain confidential so please be honest.
Place an X in one box that best describes your answer to each question.
Questions
0 1 2 3 4
1. How often do you have Never Monthly 2-4 times 2-3 times 4 or more
a drink containing alcohol? or less a month a week times a week
2. How many drinks containing 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
alcohol do you have on a typical
day when you are drinking?
3. How often do you have six or Never Less than Monthly Weekly Daily or
more drinks on one monthly almost
occasion?
daily
4. How often during the last Never Less than Monthly Weekly Daily or
year have you found that you monthly almost
were not able to stop drinking
daily
once you had started?
5. How often during the last Never Less than Monthly Weekly Daily or
year have you failed to do monthly almost
what was normally expected of
daily
you because of drinking?
6. How often during the last year Never Less than Monthly Weekly Daily or
have you needed a first drink monthly almost
in the morning to get yourself
daily
going after a heavy drinking
session?
7. How often during the last year Never Less than Monthly Weekly Daily or
have you had a feeling of guilt monthly almost
or remorse after drinking?
daily
8. How often during the last year Never Less than Monthly Weekly Daily or
have you been unable to remem- monthly almost
ber what happened the night
daily
before because of your drinking?
9. Have you or someone else No Yes, but Yes,
been injured because of not in the during the
your drinking? last year last year
10.Has a relative, friend, doctor, or No Yes, but Yes,
other health care worker been not in the during the
concerned about your drinking last year last year
or suggested you cut down?
Total

STANDARD
DRINK
EQUIVALENTS
APPROXIMATE
NUMBER OF
STANDARD DRINKS IN:
BEER or COOLER
12 oz.
12 oz. = 1
16 oz. = 1.3
22 oz. = 2
40 oz. = 3.3
~5% alcohol
MALT LIQUOR
8-9 oz.
12 oz. = 1.5
16 oz. = 2
22 oz. = 2.5
40 oz. = 4.5
~7% alcohol
TABLE WINE
5 oz.
a 750 mL (25 oz.) bottle = 5
~12% alcohol
80-proof SPIRITS (hard liquor)
1.5 oz. a mixed drink = 1 or more*
a pint (16 oz.) = 11
a fifth (25 oz.) = 17
1.75 L (59 oz.) = 39
~40% alcohol
*Note: Depending on factors such as the type of spirits and the recipe, one mixed
drink can contain from one to three or more standard drinks.
http://pubs.niaaa.nih.gov/publications/Practitioner/pocketguide/pocket_guide2.htm

Page 110 of 134

Attachment B
The Genetics of Alcohol
and Other Drug Dependence
Page 111 of 134

The Genetics of Alcohol and
Other Drug Dependence
Danielle M. Dick, Ph.D., and Arpana Agrawal, Ph.D.
Alcohol dependence and dependence on other drugs frequently co-occur, and strong evidence suggests
that both disorders are, at least in part, influenced by genetic factors. Indeed, studies using twins
suggest that the overlap between dependence on alcohol and on other drugs largely results from shared
genetic factors. This common genetic liability, which also extends to antisocial behavior, has been
conceptualized as a general predisposition toward a variety of forms of psychopathology characterized
by disinhibited behavior (i.e., externalizing psychopathology). Accordingly, many of the genetic factors
affecting risk for dependence on alcohol or other drugs appear to act through a general externalizing
factor; however, other genetic factors appear to be specific to a certain disorder. In recent years,
researchers have identified numerous genes as affecting risk for dependence on alcohol and other drugs.
These include genes involved in alcohol metabolism as well as in the transmission of nerve cell signals
and modulation of nerve cell activity (i.e., γ-aminobutyric acid [GABA] and acetylcholinergic
neurotransmission and the endogenous opioid and cannabinoid systems). KEY WORDS: Alcohol and other
drug (AOD) dependence (AODD); co-morbid AOD dependence; genetics and heredity; genetic theory of
AODD; genetic risk factors; AODR genetic markers
This article explores the hypothesis
that certain genetic factors
increase a person’s risk of both
alcohol abuse and dependence and
other drug abuse and dependence. It
first reviews the evidence suggesting
that certain genetic factors contribute
to the development of alcohol and
other drug (AOD) use disorders, as well
as to the development of a variety of
forms of externalizing psychopathology—that
is, psychiatric disorders characterized
by disinhibited behavior, such
as antisocial personality disorder, attention
deficit/hyperactivity disorder, and
conduct disorder. After summarizing
the difficulties associated with, and
recent progress made in, the identification
of specific genes associated with
AOD dependence, the article then discusses
evidence that implicates several
genes in a person’s risk for dependence
on both alcohol and illicit drugs.
Genetic Epidemiology of
AOD Dependence
Alcohol dependence frequently cooccurs
with dependence on illicit
drugs (Hasin et al. 2007). Both alcohol
use disorders (i.e., alcohol abuse
and alcohol dependence) and drug
use disorders (drug abuse and drug
dependence) are influenced by several
factors. For example, family, twin,
and adoption studies 1 have convincingly
demonstrated that genes contribute
to the development of alcohol
dependence, with heritability estimates
ranging from 50 to 60 percent
for both men and women (McGue
1999). Dependence on illicit drugs
only more recently has been investigated
in twin samples, but several
studies now suggest that illicit drug
abuse and dependence also are under
significant genetic influence. In these
studies of adult samples, heritability
estimates ranged from 45 to 79 percent
(for reviews, see Agrawal and
Lynskey 2006; Kendler et al. 2003a;
Tsuang et al. 2001).
Twin studies also can be used to
assess the extent to which the cooccurrence
of disorders is influenced
by genetic and/or environmental
factors. Thus, a finding that the correlation
between alcohol dependence
in twin 1 and drug dependence in
twin 2 is higher for identical (i.e.,
monozygotic) twins, who share 100
1 For a definition of these and other terms, see the glossary,
pp. 177–179.
DANIELLE M. DICK, PH.D., is an assistant
professor of psychiatry, psychology,
and human genetics at the Virginia
Institute for Psychiatric and Behavioral
Genetics, Virginia Commonwealth
University, Richmond, Virginia.
ARPANA AGRAWAL, PH.D., is a research
assistant professor in the Department of
Psychiatry, Washington University, St.
Louis, Missouri.
Vol. 31, No. 2, 2008 111

percent of their genes, than for fraternal
(i.e., dizygotic) twins, who share
on average only 50 percent of their
genes, indicates that shared genes
influence the risk of both alcohol
and drug dependence. The twin studies
conducted to date support the role
of such shared genetic factors. For
example, in the largest twin study
of the factors underlying psychiatric
disorders, Kendler and colleagues
(2003b) analyzed data from the
Virginia Twin Registry and found
that a common genetic factor contributed
to the total variance in
alcohol dependence, illicit drug abuse
and dependence, conduct disorder,
and adult antisocial behavior. This
pattern also has been identified in
several other independent twin studies
(Krueger et al. 2002; Young et al.
2000). Taken together, these findings
suggest that a significant portion
of the genetic influence on alcohol
dependence and drug dependence
is through a general predisposition
toward externalizing disorders, which
may manifest in different ways (e.g.,
different forms of AOD dependence
and/or antisocial behavior) (see figure).
However, some evidence also suggests
that disorder-specific genetic influences
contribute to AOD dependence
(Kendler et al. 2003b). These specific
influences likely reflect the actions
of genes that are involved in the
metabolism of individual drugs.
The idea that alcohol and drug
dependence share a genetic liability
with each other, as well as with other
forms of externalizing psychopathology,
is further supported by electrophysiological
studies recording the brain’s
electrical activity. These studies, which
are conducted using electrodes placed
on the person’s scalp, provide a noninvasive,
sensitive method of measuring
brain function in humans. They
generate a predictable pattern in the
height (i.e., amplitude) and rate (i.e.,
frequency) of brain waves that can
show characteristic abnormalities in
people with certain types of brain
dysfunction. For example, electrophysiological
abnormalities have been
observed in people with a variety of
externalizing disorders as well as in
unaffected children of these people.
These findings suggest that electrophysiological
measurements can be
used as markers of a genetic vulnerability
to externalizing disorders.
One commonly measured electrophysiological
characteristic is the
so-called P3 component of an eventrelated
potential—that is, a spike in
brain activity that occurs about 300
milliseconds after a person is exposed
to a sudden stimulus (e.g., a sound or
light). Researchers have observed that
the amplitude of the P3 component
is reduced in alcohol-dependent people
and their children, suggesting
that this abnormality is a marker for
a genetic predisposition to alcohol
dependence (Porjesz et al. 1995).
However, the abnormal P3 response
is not specific to alcohol dependence
but appears to be associated with a
variety of disinhibitory disorders,
Figure
Alcohol
dependence
Disorderspecific
genes
Drug
dependence
Disorderspecific
genes
Genes
influencing
externalizing
psychopathy
including other forms of drug dependence,
childhood externalizing disorders,
and adult antisocial personality
disorder, again suggesting a shared
underlying predisposition to multiple
forms of AOD dependence and other
externalizing problems (Hicks et al.
2007). 2
Interestingly, electrophysiological
abnormalities are most pronounced
in alcohol-dependent people who also
have a diagnosis of illicit drug abuse
or dependence (Malone et al. 2001).
This observation is consistent with
data from twin and family studies
suggesting that co-morbid dependence
on alcohol and another drug
represents a more severe disorder with
higher heritability than dependence
2 Abnormalities in the P3 response also have been associated
with risk for other psychiatric disorders, such as
schizophrenia (van der Stelt et al. 2004).
Conduct
disorder
Antisocial
personalty
disorder
Schematic representation of a model to illustrate the influence of genetic
factors on the development of alcohol dependence, dependence on other
drugs, and other externalizing disorders (e.g., conduct disorder or antisocial
personality disorder). Some of the proposed genetic factors are
thought to have a general influence on all types of externalizing conditions,
whereas others are thought to have a disorder-specific influence.
112
Alcohol Research & Health

Genetics of AOD Dependence
on one drug alone (Johnson et al.
1996; Pickens et al. 1995). This conclusion
also appears to be supported
by new studies exploring the roles of
specific genes, which are discussed
later in this article.
Identifying Specific
Genes Related to AOD
Dependence
With robust evidence indicating that
genes influence both alcohol dependence
and dependence on illicit
drugs, efforts now are underway to
identify specific genes involved in the
development of these disorders. This
identification, however, is complicated
by many factors. For example, numerous
genes are thought to contribute
to a person’s susceptibility to alcohol
and/or drug dependence, and affected
people may carry different combinations
of those genes. Additionally,
environmental influences have an
impact on substance use, as does gene–
environment interaction (Heath et al.
2002). Finally, the manifestation of AOD
dependence varies greatly among affected
people, for example, with respect to
age of onset of problems, types of
symptoms exhibited (i.e., symptomatic
profile), substance use history, and
presence of co-morbid disorders.
Despite the complications mentioned
above, the rapid growth in research
technologies for gene identification in
recent years has led to a concomitant
increase in exciting results. After suffering
many disappointments in early
attempts to identify genes involved
in complex behavioral outcomes (i.e.,
phenotypes), researchers now are frequently
succeeding in identifying
genes that help determine a variety
of clinical phenotypes. These advances
have been made possible by several
factors. First, advances in technologies
to identify a person’s genetic makeup
(i.e., genotyping technology) have
dramatically lowered the cost of genotyping,
allowing for high-throughput
analyses of the entire genome. Second,
the completion of several large-scale
research endeavors, such as the Human
Genome Project, the International
HapMap Project, 3 and other government
and privately funded efforts,
have made a wealth of information
on variations in the human genome
publicly available. Third, these developments
have been complemented by
advances in the statistical analysis of
genetic data.
Several large collaborative projects
that strive to identify genes involved
in AOD dependence currently are
underway. The first large-scale project
aimed at identifying genes contributing
to alcohol dependence was the
National Institute on Alcohol Abuse
and Alcoholism (NIAAA)-sponsored
Collaborative Study on the Genetics
of Alcoholism (COGA), which was
initiated in 1989. This study, which
involves collaboration of investigators
at several sites in the United States,
examines families with several alcoholdependent
members who were recruited
from treatment centers across the
United States. This study has been
joined by several other gene identification
studies focusing on families
affected with alcohol dependence,
including the following:
• A sample of Southwestern American
Indians (Long et al. 1998);
• The Irish Affected Sib Pair Study of
Alcohol Dependence (Prescott et al.
2005a);
• A population of Mission Indians
(Ehlers et al. 2004);
• A sample of densely affected families
collected in the Pittsburgh area
(Hill et al. 2004); and
• An ongoing data collection from
alcohol-dependent individuals in
Australia.
Importantly, most of these projects
include comprehensive psychiatric
interviews that focus not only on
alcohol use and alcohol use disorders
but which also allow researchers to
collect information about other drug
use and dependence. This comprehensive
approach permits researchers
to address questions about the nature
of genetic influences on AOD dependence,
as discussed below.
More recently, additional studies
have been initiated that specifically
seek to identify genes contributing
to various forms of illicit drug dependence
as well as general drug use
problems (for more information,
see http://www.nida.nih.gov/about/
organization/Genetics/consortium/index.
html). Through these combined
approaches, researchers should be
able to identify both genes with drugspecific
effects and genes with more
general effects on drug use. The
following sections focus on several
groups of genes that have been identified
by these research efforts and
which have been implicated in affecting
risk for dependence on both alcohol
and illicit drugs.
Genes Encoding Proteins Involved
in Alcohol Metabolism
The genes that have been associated
with alcohol dependence most consistently
are those encoding the enzymes
that metabolize alcohol (chemically
known as ethanol). The main pathway
of alcohol metabolism involves
two steps. In the first step, ethanol
is converted into the toxic intermediate
acetaldehyde; this step is mediated
by the alcohol dehydrogenase (ADH)
enzymes. In a second step, the
acetaldehyde is further broken down
into acetate and water by the actions
of aldehyde dehydrogenase (ALDH)
enzymes. The genes that encode the
ADH and ALDH enzymes exist in
several variants (i.e., alleles) that are
characterized by variations (i.e., polymorphisms)
in the sequence of the
DNA building blocks. One important
group of ADH enzymes are
the ADH class I isozymes ADH1A,
ADH1B, and ADH1C. For both
3 The International HapMap Project is a multicountry effort
to identify and catalog genetic similarities and differences in
human beings by comparing the genetic sequences of different
individuals in order to identify chromosomal regions
where genetic variants are shared. Using the information
obtained in the HapMap Project, researchers will be able
to find genes that affect health, disease, and individual
responses to medications and environmental factors.
Vol. 31, No. 2, 2008 113

the genes encoding ADH1B and
those encoding ADH1C, several alleles
resulting in altered proteins have
been identified, and the proteins encoded
by some of these alleles exhibit
particularly high enzymatic activity in
laboratory experiments (i.e., in vitro)
(Edenberg 2007). This suggests that
in people carrying these alleles, ethanol
is more rapidly converted to acetaldehyde.
4 Several studies have reported
lower frequencies of both the ADH1B*2
and ADH1C*1 alleles, which encode
some of the more active proteins,
among alcoholics than among nonalcoholics
in a variety of East Asian
populations (e.g., Shen et al. 1997)
and, more recently, in European populations
(Neumark et al. 1998;
Whitfield et al. 1998).
In addition, genome-wide screens
to identify genes linked to alcoholism
and alcohol-related traits have been
conducted in three independent samples
consisting largely of people of
European descent—the COGA study
(Saccone et al. 2000), the Irish Affected
Sib Pair Study of Alcohol Dependence
(Prescott et al. 2005a), and an
Australian sample (Birley et al. 2005).
These studies have found evidence
that a region on chromosome 4 containing
the ADH gene cluster shows
linkage to the phenotypes studied.
This cluster contains, in addition
to the genes encoding ADH class I
isozymes, the genes ADH4, ADH5,
ADH6, and ADH7, which encode
other ADH enzymes. Polymorphisms
exist for each of these genes, some of
which also have been associated with
alcohol dependence (Edenberg et al.
2006; Luo et al. 2006a,b; Prescott et
al. 2005b).
Interestingly, the effects of these
genes do not appear to be limited
to alcohol dependence. One study
compared the frequency of alleles that
differed in only one DNA building
block (i.e., single nucleotide polymorphisms
[SNPs]) throughout the
genome between people with histories
of illicit drug use and/or dependence
and unrelated control participants.
This study detected a significant difference
for a SNP located near the
ADH gene cluster (Uhl et al. 2001).
More recent evidence suggests that
genetic variants in the ADH1A,
ADH1B, ADH1C, ADH5, ADH6,
and ADH7 genes are associated with
illicit drug dependence and that this
association is not purely attributable
to co-morbid alcohol dependence
(Luo et al. 2007). The mechanism by
which these genes may affect risk for
illicit drug dependence is not entirely
clear. However, other observations 5
also indicate that enzymes involved
in alcohol metabolism may contribute
to illicit drug dependence via pathways
that currently are unknown but
independent of alcohol metabolism
(Luo et al. 2007).
Genes Encoding Proteins Involved
in Neurotransmission
AODs exert their behavioral effects in
part by altering the transmission of
signals among nerve cells (i.e., neurons)
in the brain. This transmission
is mediated by chemical messengers
(i.e., neurotransmitters) that are
released by the signal-emitting neuron
and bind to specific proteins (i.e.,
receptors) on the signal-receiving
neuron. AODs influence the activities
of several neurotransmitter systems,
including those involving the neurotransmitters
γ-aminobutyric acid
(GABA), dopamine, and acetylcholine,
as well as naturally produced compounds
that structurally resemble opioids
and cannabinoids. Accordingly,
certain genes encoding components
of these neurotransmitter systems may
contribute to the risk of both alcohol
dependence and illicit drug dependence.
Genes Encoding the GABA A Receptor.
GABA is the major inhibitory neurotransmitter
in the human central
nervous system—that is, it affects
neurons in a way that reduces their
activity. Several lines of evidence suggest
that GABA is involved in many
of the behavioral effects of alcohol,
including motor incoordination,
anxiety reduction (i.e., anxiolysis),
sedation, withdrawal signs, and preference
for alcohol (Grobin et al.
1998). GABA interacts with several
receptors, and much of the research
on alcohol’s interactions with the
GABA system has focused on the
GABA A receptor. This receptor also is
the site of action for several medications
that frequently are misused and
have high addictive potential, such as
benzodiazepines, barbiturates, opiates,
α-hydroxybutyrates, and other
sedative–hypnotic compounds.
Accordingly, this receptor likely is
involved in dependence on these
drugs as well (Orser 2006).
The GABA A receptor is composed
of five subunits that are encoded by
numerous genes, most of which are
located in clusters. Thus, chromosome
4 contains a cluster comprising
the genes GABRA2, GABRA4, GABRB1,
and GABRG1; chromosome 5 contains
GABRA1, GABRA6, GABRB2, and
GABRG2; and chromosome 15 contains
GABRA5, GABRB3, and GABRG3
(see http:// www.ncbi.nlm.nih.gov/sites/
entrez?db=gene).
Interest in the GABA A receptor
genes on chromosome 4 grew when
this region consistently was identified
in genome-wide scans looking for
linkage with alcohol dependence
(Long et al. 1998; Williams et al.
1999). Subsequently, COGA investigators
systematically evaluated short
DNA segments of known location
(i.e., genetic markers) that were situated
in the GABA A receptor gene
cluster on chromosome 4. These
studies found that a significant association
existed between multiple SNPs
in the GABRA2 gene and alcohol
dependence (Edenberg et al. 2004).
This association has been replicated
in multiple independent samples
(Covault et al. 2004; Fehr et al. 2006;
Lappalainen et al. 2005; Soyka
2007). In addition, the same SNPs in
the GABRA2 gene have been shown to
be associated with drug dependence in
both adults and adolescents (Dick et
4 Rapid acetaldehyde production can lead to acetaldehyde
accumulation in the body, which results in highly unpleasant
effects, such as nausea, flushing, and rapid heartbeat,
that may deter people from drinking more alcohol.
5 For example, the medication disulfiram, which inhibits
another enzyme involved in alcohol metabolism called
aldehyde dehydrogenase 2 (ALDH2) and is used for
treatment of alcoholism, has demonstrated a treatment
effect in cocaine dependence (Luo et al. 2007).
114
Alcohol Research & Health

Genetics of AOD Dependence
al. 2006a), as well as with the use of
multiple drugs in another independent
sample (Drgon et al. 2006).
Variations in the GABRA2 gene
are associated not only with AOD
dependence but also with certain
electrophysiological characteristics
(i.e., endophenotypes) in the COGA
sample (Edenberg et al. 2004). As
reviewed above, these electrophysiological
characteristics are not unique
to alcohol dependence but also are
found in individuals with other forms
of externalizing psychopathology.
This association supports the hypothesis
that the GABRA2 gene generally
is involved in AOD use and/or
externalizing problems. Interestingly,
subsequent analyses investigating the
role of GABRA2 in drug dependence
(Agrawal et al. 2006) found that
the association with GABRA2 was
strongest in people with co-morbid
AOD dependence, with no evidence
of association in people who were
only alcohol dependent. This observation
supports the assertion that
co-morbid AOD dependence may
represent a more severe, genetically
influenced form of the disorder.
Several other GABA A receptor genes
have yielded more modest evidence
of association with different aspects
of AOD dependence. Thus, GABRB3
(Noble et al. 1998) and GABRG3
(Dick et al. 2004) are modestly associated
with alcohol dependence,
GABRA1 (Dick et al. 2006b) is associated
with alcohol-related phenotypes
(e.g., history of alcohol-induced
blackouts and age at first drunkenness),
and GABRG2 (Loh et al. 2007)
is associated with aspects of drug
dependence. These findings await
confirmation in independent samples.
Genes Involved in the Cholinergic
System. The cholinergic system includes
neurons that either release the neurotransmitter
acetylcholine or respond
to it. Acetylcholine generally has excitatory
effects in the human central
nervous system—that is, it affects
neurons in a way that enhances their
activity. It is thought to be involved
in such processes as arousal, reward,
learning, and short-term memory.
One of the receptors through which
acetylcholine acts is encoded by a
gene called CHRM2. In the COGA
sample, linkage was observed between
a region on chromosome 7 that contains
the CHRM2 gene and alcohol
dependence, and subsequent experiments
confirmed that an association
existed between alcohol dependence
and the CHRM2 gene (Wang et al.
2004). This association has been replicated
in a large independent study (Luo
et al. 2005) that also found evidence
that the gene was associated with drug
dependence.
As with the GABRA2 gene described
above, the association between CHRM2
and alcohol dependence in the COGA
sample was strongest in people who
had co-morbid AOD dependence
(Dick et al. 2007). Additional analyses
in the COGA sample have suggested
that CHRM2 is associated
with a generally increased risk of
externalizing disorders, including
symptoms of alcohol dependence and
drug dependence (Dick et al. 2008).
This potential role of CHRM2 in
contributing to the general liability of
AOD use and externalizing disorders
is further supported by findings that
CHRM2, like GABRA2, also is associated
with certain electrophysiological
endophenotypes (Jones et al. 2004).
Genes Involved in the Endogenous
Opioid System. Endogenous opioids
are small molecules naturally produced
in the body that have similar
effects as the opiates (e.g., morphine
and heroin) and which, among other
functions, modulate the actions of
other neurotransmitters. The endogenous
opioid system has been implicated
in contributing to the reinforcing
effects of several drugs of abuse, including
alcohol, opiates, and cocaine.
This is supported by the finding that
the medication naltrexone, which
prevents the normal actions of endogenous
opioids (i.e., is an opioid antagonist),
is useful in the treatment of
alcohol dependence and can reduce
the number of drinking days, amount
of alcohol consumed, and risk of relapse.
Research on the role of the endogenous
opioids in AOD dependence
has centered mainly on a gene called
OPRM1, which encodes one type of
opioid receptor (i.e., the µ-opioid
receptor), although the results so far
have been equivocal. This gene contains
a polymorphism resulting in a
different protein product (i.e., a nonsynonymous
polymorphism) that in
one study was found to bind one of
the endogenous opioids (i.e., β-endorphin)
three times as strongly as the
main variant of the gene (Bond et al.
1998); other studies, however, could
not confirm this finding (Befort et al.
2001; Beyer et al. 2004).
Laboratory studies have suggested
that OPRM1 is associated with sensitivity
to the effects of alcohol (Ray
and Hutchison 2004). In addition,
several studies have reported evidence
of an association between OPRM1
and drug dependence (e.g., Bart et al.
2005). Other studies, however, have
failed to find such an association
(e.g., Bergen et al. 1997), and a combined
analysis of several studies (i.e.,
a meta-analysis) concluded that no
association exists between the most
commonly studied OPRM1 polymorphism
and drug dependence (Arias et
al. 2006). However, this finding does
not preclude the possibility that other
genetic variants in OPRM1 and/or
other genes related to the endogenous
opioid system are involved in risk for
drug dependence. For example, a recent
study determining the genotypes of
multiple genetic variants across the
gene uncovered evidence of association
with OPRM1 and AOD dependence
(Zhang et al. 2006).
Researchers also have investigated
genetic variations in other opioid
receptors and other components of
the endogenous opioid system; however,
the results have been mixed.
One study (Zhang et al. 2007) found
modest support that the genes OPRK1
and OPRD1—which encode the κ­
and δ-opioid receptors, respectively—
are associated with some aspects of
drug dependence. Other researchers
(Xuei et al. 2007) reported evidence
that the genes PDYN, PENK, and
POMC—which encode small molecules
(i.e., peptides) that also bind to opi-
Vol. 31, No. 2, 2008 115

oid receptors—may be associated with
various aspects of drug dependence.
Genes Involved in the Endogenous
Cannabinoid System. Endogenous
cannabinoids are compounds naturally
produced in the body that have a
similar structure to the psychoactive
compounds found in the cannabis
plant and which bind cannabinoid
receptors. The endogenous cannabinoid
system is thought to regulate
brain circuits using the neurotransmitter
dopamine, which likely helps
mediate the rewarding experiences
associated with addictive substances.
The main cannabinoid receptor in the
brain is called CB1 and is encoded by
the CNR1 gene, which is located on
chromosome 6. This gene is an excellent
candidate gene for being associated
with AOD dependence because
the receptor encoded by this gene is
crucial for generating the rewarding
effects of the compound responsible
for the psychoactive effects associated
with cannabis use (i.e., Δ9-tetrahydrocannabinol).
However, the findings
regarding the association between
CNR1 and AOD dependence to date
have been equivocal, with some studies
producing positive results (e.g.,
Zhang et al. 2004) and others producing
negative results (e.g., Herman
et al. 2006). Most recently, Hopfer
and colleagues (2006) found that a
SNP in the CNR1 gene was associated
with cannabis dependence symptoms. 6
Moreover, this SNP was part of several
sets of multiple alleles that are
transmitted jointly (i.e., haplotypes),
some of which are associated with
developing fewer dependence symptoms,
whereas others are associated
with an increased risk for cannabis
dependence. Finally, a recent
case–control study found that multiple
genetic variants in CNR1 were significantly
associated with alcohol
dependence and/or drug dependence
(Zuo et al. 2007).
6 The SNP was not located in one of those gene regions
that encode the actual receptor (i.e., in an exon) but in a
region that is part of the gene but is eliminated during the
process of converting the genetic information into a protein
product (i.e., in an intron).
Conclusions
For both alcohol dependence and
drug dependence, considerable evidence
suggests that genetic factors
influence the risk of these disorders,
with heritability estimates of 50 percent
and higher. Moreover, twin studies
and studies of electrophysiological
characteristics indicate that the risk of
developing AOD dependence, as well
as other disinhibitory disorders (e.g.,
antisocial behavior), is determined at
least in part by shared genetic factors.
These observations suggest that some
of a person’s liability for AOD dependence
will result from a general externalizing
factor and some will result
from genetic factors that are more
disorder specific.
Several genes have been identified
that confer risk to AOD dependence.
Some of these genes—such as GABRA2
and CHRM2— apparently act through
a general externalizing phenotype.
For other genes that appear to confer
risk of AOD dependence—such as
genes involved in alcohol metabolism
and in the endogenous opioid and
cannabinoid systems—however, the
pathways through which they affect
risk remain to be elucidated. Most of
the genes reviewed in this article originally
were found to be associated
with alcohol dependence and only
subsequently was their association with
risk for dependence on other illicit drugs
discovered as well. Furthermore, studies
that primarily aim to identify genes
involved in dependence on certain types
of drugs may identify different variants
affecting risk, underscoring the challenge
of understanding genetic susceptibility
to different classes of drugs.
This review does not exhaustively
cover all genes that to date have been
implicated in alcohol and illicit drug
dependence. For example, several
genes encoding receptors for the neurotransmitter
dopamine have been
suggested to determine at least in part
a person’s susceptibility to various
forms of drug dependence. In particular,
the DRD2 gene has been associated
with alcohol dependence (Blum
et al. 1990) and, more broadly, with
various forms of addiction (Blum et
al. 1996). This association remains
controversial, however, and more recent
studies suggest that the observed association
actually may not involve variants
in the DRD2 gene but variants
in a neighboring gene called ANKK1
(Dick et al. 2007b). Studies to identify
candidate genes that influence dependence
on illicit drugs, but not on
alcohol, are particularly challenging
because of the high co-morbidity
between alcohol dependence and
dependence on illicit drugs. Therefore,
meaningful studies require large
sample sizes to include enough drugdependent
people with no prior history
of alcohol dependence.
The increasingly rapid pace of
genetic discovery also has resulted in
the identification of several genes
encoding other types of proteins that
appear to be associated with alcohol
use and/or dependence. These include,
for example, two genes encoding taste
receptors (i.e., the TAS2R16 gene
[Hinrichs et al. 2006] and the
TAS2R38 gene [Wang et al. 2007])
and a human gene labeled ZNF699
(Riley et al. 2006) that is related to a
gene previously identified in the fruit
fly Drosophila as contributing to the
development of tolerance to alcohol
in the flies. Future research will be
necessary to elucidate the pathways
by which these genes influence alcohol
dependence and/or whether they
are more broadly involved in other
forms of drug dependence. ■
Acknowledgments
Danielle M. Dick is supported by
NIAAA grant AA–15416 and Arpana
Agrawal is supported by National
Institute on Drug Abuse (NIDA) grant
DA–023668. The COGA project is
supported by grant U10–AA–08401
from NIAAA and NIDA.
Financial Disclosure
The authors declare that they have no
competing financial interests.
116
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Genetics of AOD Dependence
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ORSER, B.A. Extrasynaptic GABAA receptors are critical
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PRESCOTT, C.A.; SULLIVAN, P.F.; MYERS, J.M.; ET AL.
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1031, 2006. PMID: 16940975
SACCONE, N.; KWON, J.M.; CORBETT, J.; ET AL.A
genome screen of maximum number of drinks as an
alcoholism phenotype. American Journal of Medical
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2000. PMID: 11054770
SHEN, Y.C.; FAN, J.H.; EDENBERG, H.J.; ET AL.
Polymorphism of ADH and ALDH genes among
four ethnic groups in China and effects upon the risk
for alcoholism. Alcoholism: Clinical and Experimental
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SOYKA, M.; PREUSS, U.W.; HESSELBROCK, V.; ET AL.
GABA-A2 receptor subunit gene (GABRA2) polymorphisms
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TSUANG, M.T.; BAR, J.L.; HARLEY, R.M.; AND LYON,
M.J. The Harvard Twin Study of Substance Abuse:
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Page 112 of 134

Attachment C
AUDIT Testing Guidelines
Page 113 of 134

WHO/MSD/MSB/01.6a
Original: English
Distribution: General
Thomas F. Babor
John C. Higgins-Biddle
John B. Saunders
Maristela G. Monteiro
AUDIT
The Alcohol Use Disorders
Identification Test
Guidelines for Use in Primary Care
Second Edition
World Health Organization
Department of Mental Health and Substance Dependence

WHO/MSD/MSB/01.6a
Original: English
Distribution: General
Thomas F. Babor
John C. Higgins-Biddle
John B. Saunders
Maristela G. Monteiro
AUDIT
The Alcohol Use Disorders
Identification Test
Guidelines for Use in Primary Care
Second Edition
World Health Organization
Department of Mental Health and Substance Dependence

2 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Abstract
This manual introduces the AUDIT, the Alcohol Use Disorders Identification Test, and describes how to
use it to identify persons with hazardous and harmful patterns of alcohol consumption. The AUDIT was
developed by the World Health Organization (WHO) as a simple method of screening for excessive drinking
and to assist in brief assessment. It can help in identifying excessive drinking as the cause of the presenting
illness. It also provides a framework for intervention to help hazardous and harmful drinkers reduce or cease
alcohol consumption and thereby avoid the harmful consequences of their drinking. The first edition of this
manual was published in 1989 (Document No. WHO/MNH/DAT/89.4) and was subsequently updated in
1992 (WHO/PSA/92.4). Since that time it has enjoyed widespread use by both health workers and alcohol
researchers. With the growing use of alcohol screening and the international popularity of the AUDIT,
there was a need to revise the manual to take into account advances in research and clinical experience.
This manual is written primarily for health care practitioners, but other professionals who encounter persons
with alcohol-related problems may also find it useful. It is designed to be used in conjunction with a
companion document that provides complementary information about early intervention procedures, entitled
“Brief Intervention for Hazardous and Harmful Drinking: A Manual for Use in Primary Care”. Together
these manuals describe a comprehensive approach to screening and brief intervention for alcohol-related
problems in primary health care.
Acknowledgements
The revision and finalisation of this document were coordinated by Maristela Monteiro with technical
assistance from Vladimir Poznyak from the WHO Department of Mental Health and Substance Dependence,
and Deborah Talamini, University of Connecticut. Financial support for this publication was provided by
the Ministry of Health and Welfare of Japan.
© World Health Organization 2001
This document is not a formal publication of the World Health Organization (WHO), and all rights are
reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced,
and translated, in part or in whole but not for sale or for use in conjunction with commercial purposes.
Inquiries should be addressed to the Department of Mental Health and Substance Dependence, World
Health Organization, CH-1211 Geneva 27, Switzerland, which will be glad to provide the latest information
on any changes made to the text, plans for new editions and the reprints, regional adaptations and translations
that are already available.
Authors alone are responsible for views expressed in this document, which are not necessarily those of
the World Health Organization.

TABLE OF CONTENTS I
3
Table of Contents
4
Purpose of this Manual
5
Why Screen for Alcohol Use?
8
The Context of Alcohol Screening
10
Development and Validation of the AUDIT
14
Administration Guidelines
19
Scoring and Interpretation
21
How to Help Patients
25
Programme Implementation
Appendix
28
30
32
33
34
A. Research Guidelines for the AUDIT
B. Suggested Format for AUDIT Self-Report Questionnaire
C. Translation and Adaptation to Specific Languages,
Cultures and Standards
D. Clinical Screening Procedures
E. Training Materials for AUDIT
35
References

4 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Purpose of this Manual
This manual introduces the AUDIT, the
Alcohol Use Disorders Identification
Test, and describes how to use it to identify
persons with hazardous and harmful patterns
of alcohol consumption. The AUDIT
was developed by the World Health
Organization (WHO) as a simple method
of screening for excessive drinking and to
assist in brief assessment. 1,2 It can help
identify excessive drinking as the cause
of the presenting illness. It provides
a framework for intervention to help risky
drinkers reduce or cease alcohol consumption
and thereby avoid the harmful
consequences of their drinking. The AUDIT
also helps to identify alcohol dependence
and some specific consequences of harmful
drinking. It is particularly designed for
health care practitioners and a range of
health settings, but with suitable instructions
it can be self-administered or used
by non-health professionals.
The appendices to this manual contain
additional information useful to practitioners
and researchers. Further research
on the reliability, validity, and implementation
of screening with the AUDIT is
suggested using guidelines outlined in
Appendix A. Appendix B contains an
example of the AUDIT in a self-report
questionnaire format. Appendix C provides
guidelines for the translation and
adaptation of the AUDIT. Appendix D
describes clinical screening procedures
using a physical exam, laboratory tests
and medical history data. Appendix E lists
information about available training
materials.
To this end, the manual will describe:
■ Reasons to ask about alcohol
consumption
■ The context of alcohol screening
■ Development and validation of
the AUDIT
■ The AUDIT questions and how
to use them
■ Scoring and interpretation
■ How to conduct a clinical screening
examination
■ How to help patients who screen positive
■ How to implement a screening
programme

WHY SCREEN FOR ALCOHOL USE? I
5
Why Screen for Alcohol Use?
There are many forms of excessive
drinking that cause substantial risk or
harm to the individual. They include high
level drinking each day, repeated
episodes of drinking to intoxication,
drinking that is actually causing physical
or mental harm, and drinking that has
resulted in the person becoming dependent
or addicted to alcohol. Excessive
drinking causes illness and distress to the
drinker and his or her family and friends.
It is a major cause of breakdown in relationships,
trauma, hospitalization, prolonged
disability and early death.
Alcohol-related problems represent an
immense economic loss to many communities
around the world.
AUDIT was developed to screen for
excessive drinking and in particular to
help practitioners identify people who
would benefit from reducing or ceasing
drinking. The majority of excessive
drinkers are undiagnosed. Often they
present with symptoms or problems that
would not normally be linked to their
drinking. The AUDIT will help the practitioner
identify whether the person has
hazardous (or risky) drinking, harmful
drinking, or alcohol dependence.
Hazardous drinking 3 is a pattern of alcohol
consumption that increases the risk
of harmful consequences for the user or
others. Hazardous drinking patterns are
of public health significance despite the
absence of any current disorder in the
individual user.
Harmful use refers to alcohol consumption
that results in consequences to physical
and mental health. Some would also
consider social consequences among the
harms caused by alcohol 3, 4 .
Alcohol dependence is a cluster of
behavioural, cognitive, and physiological
phenomena that may develop after
repeated alcohol use 4 . Typically, these
phenomena include a strong desire to
consume alcohol, impaired control over
its use, persistent drinking despite harmful
consequences, a higher priority given
to drinking than to other activities and
obligations, increased alcohol tolerance,
and a physical withdrawal reaction when
alcohol use is discontinued.
Alcohol is implicated in a wide variety of
diseases, disorders, and injuries, as well as
many social and legal problems 5,6,7 . It is a
major cause of cancer of the mouth,
esophagus, and larynx. Liver cirrhosis and
pancreatitis often result from long-term,
excessive consumption. Alcohol causes
harm to fetuses in women who are pregnant.
Moreover, much more common
medical conditions, such as hypertension,
gastritis, diabetes, and some forms of
stroke are likely to be aggravated even by
occasional and short-term alcohol consumption,
as are mental disorders such as
depression. Automobile and pedestrian
injuries, falls, and work-related harm frequently
result from excessive alcohol consumption.
The risks related to alcohol are
linked to the pattern of drinking and the
amount of consumption 5 . While persons
with alcohol

6 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
dependence are most likely to incur high
levels of harm, the bulk of harm associated
with alcohol occurs among people who
are not dependent, if only because there
are so many of them 8 . Therefore, the
identification of drinkers with various
types and degrees of at-risk alcohol consumption
has great potential to reduce all
types of alcohol-related harm.
Figure 1 illustrates the large variety of
health problems associated with alcohol
use. Although many of these medical
consequences tend to be concentrated in
persons with severe alcohol dependence,
even the use of alcohol in the range of
20-40 grams of absolute alcohol per day
is a risk factor for accidents, injuries, and
many social problems 5, 6 .
Many factors contribute to the development
of alcohol-related problems.
Ignorance of drinking limits and of the
risks associated with excessive alcohol
consumption are major factors. Social
and environmental influences, such as
customs and attitudes that favor heavy
drinking, also play important roles. Of
utmost importance for screening, however,
is the fact that people who are not
dependent on alcohol may stop or
reduce their alcohol consumption with
appropriate assistance and effort. Once
dependence has developed, cessation
of alcohol consumption is more difficult
and often requires specialized treatment.
Although not all hazardous drinkers
become dependent, no one develops
alcohol dependence without having
engaged for some time
in hazardous alcohol use. Given these
factors, the need for screening becomes
apparent.
Screening for alcohol consumption
among patients in primary care carries
many potential benefits. It provides an
opportunity to educate patients about
low-risk consumption levels and the risks
of excessive alcohol use. Information
about the amount and frequency of alcohol
consumption may inform the diagnosis
of the patient’s presenting condition,
and it may alert clinicians to the need to
advise patients whose alcohol consumption
might adversely affect their use of
medications and other aspects of their
treatment. Screening also offers the
opportunity for practitioners to take preventative
measures that have proven
effective in reducing alcohol-related risks.

WHY SCREEN FOR ALCOHOL USE? I
7
Figure 1
Effects of High-Risk Drinking
Aggressive,irrational behaviour.
Arguments. Violence.
Depression. Nervousness.
Cancer of throat and mouth .
Frequent colds. Reduced
resistance to infection.
Increased risk of pneumonia.
Alcohol dependence.
Memory loss.
Premature aging. Drinker's nose.
Weakness of heart muscle.
Heart failure. Anemia.
Impaired blood clotting.
Breast cancer.
Liver damage.
Trembling hands.
Tingling fingers.
Numbness. Painful nerves.
Ulcer.
Vitamin deficiency. Bleeding.
Severe inflammation
of the stomach. Vomiting.
Diarrhea. Malnutrition.
Inflammation of the pancreas.
Impaired sensation
leading to falls.
In men:
Impaired sexual performance.
In women:
Risk of giving birth to deformed,
retarded babies or low birth
weight babies.
Numb, tingling toes.
Painful nerves.
High-risk drinking may lead to social, legal, medical, domestic, job and financial
problems. It may also cut your lifespan and lead to accidents and death from drunken
driving.

8 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
The Context of Alcohol Screening
While this manual focuses on using the
AUDIT to screen for alcohol consumption
and related risks in primary care
medical settings, the AUDIT can be effectively
applied in many other contexts as
well. In many cases procedures have
already been developed and used in these
settings. Box 1 summarizes information
about the settings, screening personnel,
and target groups considered appropriate
for a screening programme using the AUDIT.
Murray 9 has argued that screening might
be conducted profitably with:
To these should be added groups considered
by a WHO Expert Committee 7 to be
at high risk of developing alcohol-related
problems: middle-aged males, adolescents,
migrant workers, and certain occupational
groups (such as business executives,
entertainers, sex workers, publicans, and
seamen). The nature of the risk differs by
age, gender, drinking context, and drinking
pattern, with sociocultural factors playing
an important role in the definition and
expression of alcohol-related problems 6 .
■ general hospital patients, especially those
with disorders known to be associated
with alcohol dependence (e.g., pancreatitis,
cirrhosis, gastritis, tuberculosis,
neurological disorders, cardiomyopathy);
■ persons who are depressed or who
attempt suicide;
■ other psychiatric patients;
■ patients attending casualty and emergency
services;
■ patients attending general practitioners;
■ vagrants;
■ prisoners; and
■ those cited for legal offences connected
with drinking (e.g., driving while intoxicated,
public intoxication).

THE CONTEXT OF ALCOHOL SCREENING I
9
Box 1
Personnel, Settings and Groups Considered Appropriate for a
Screening Programme Using the AUDIT
Setting Target Group Screening Personnel
Primary care clinic Medical patients Nurse, social worker
Emergency room Accident victims, Physician, nurse, or staff
Intoxicated patients,
trauma victims
Physician’s Room Medical patients General practitioner,
Surgery
family physician or staff
General Hospital wards Patients with Internist, staff
Out-patient clinic
hypertension, heart
disease, gatrointestinal
or neurological disorders
Psychiatric hospital Psychiatric patients, Psychiatrist, staff
particularly those
who are suicidal
Court, jail, prison DWI offenders Officers, Counsellors
violent criminals
Other health-related Persons demonstrating Health and human
facilities impaired social or service workers
occupational functioning
(e.g. marital discord,
child neglect, etc.)
Military Services Enlisted men and officers Medics
Work place Workers, especially those Employee assistance staff
Employee assistance having problems with
Programme
productivity, absenteeism
or accidents

10 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Development and
Validation of the AUDIT
The AUDIT was developed and evaluated
over a period of two decades, and
it has been found to provide an accurate
measure of risk across gender, age, and
cultures 1, 2,10 . Box 2 describes the conceptual
domains and item content of the AUDIT,
which consists of 10 questions about
recent alcohol use, alcohol dependence
symptoms, and alcohol-related problems.
As the first screening test designed specifically
for use in primary care settings, the
AUDIT has the following advantages:
■ Cross-national standardization: the
AUDIT was validated on primary health
care patients in six countries 1,2 . It is the
only screening test specifically designed
for international use;
■ Identifies hazardous and harmful alcohol
use, as well as possible dependence;
■ Brief, rapid, and flexible;
■ Designed for primary health care workers;
■ Consistent with ICD-10 definitions of alcohol
dependence and harmful alcohol use 3,4 ;
■ Focuses on recent alcohol use.
In 1982 the World Health Organization
asked an international group of investigators
to develop a simple screening instrument
2 . Its purpose was to identify persons
with early alcohol problems using procedures
that were suitable for health systems
in both developing and developed countries.
The investigators reviewed a variety of
self-report, laboratory, and clinical procedures
that had been used for this purpose
in different countries. They then initiated a
cross-national study to select the best features
of these various national approaches
to screening 1 .
This comparative field study was conducted
in six countries (Norway, Australia, Kenya,
Bulgaria, Mexico, and the United States
of America).
The method consisted of selecting items
that best distinguished low-risk drinkers
from those with harmful drinking. Unlike
previous screening tests, the new instrument
was intended for the early identification of
hazardous and harmful drinking as well as
alcohol dependence (alcoholism). Nearly
2000 patients were recruited from a variety
of health care facilities, including specialized
alcohol treatment centers. Sixty-four percent
were current drinkers, 25% of whom were
diagnosed as alcohol dependent.
Participants were given a physical examination,
including a blood test for standard
blood markers of alcoholism, as well as an
extensive interview assessing demographic
characteristics, medical history, health
complaints, use of alcohol and drugs, psychological
reactions to alcohol, problems
associated with drinking, and family history
of alcohol problems. Items were selected
for the AUDIT from this pool of questions
primarily on the basis of correlations
with daily alcohol intake, frequency of
consuming six or more drinks per drinking
episode, and their ability to discriminate
hazardous and harmful drinkers. Items were
also chosen on the basis of face validity,
clinical relevance, and coverage of relevant
conceptual domains (i.e., alcohol use, alcohol
dependence, and adverse consequences
of drinking). Finally, special attention in item
selection was given to gender appropriateness
and cross-national generalizability.

DEVELOPMENT AND VALIDATION OF THE AUDIT I
11
Box 2
Domains and Item Content of the AUDIT
Domains Question Item Content
Number
Hazardous 1 Frequency of drinking
Alcohol 2 Typical quantity
Use 3 Frequency of heavy drinking
Dependence 4 Impaired control over drinking
Symptoms 5 Increased salience of drinking
6 Morning drinking
Harmful 7 Guilt after drinking
Alcohol 8 Blackouts
Use 9 Alcohol-related injuries
10 Others concerned about
drinking
Sensitivities and specificities of the selected
test items were computed for multiple
criteria (i.e., average daily alcohol consumption,
recurrent intoxication, presence of at
least one dependence symptom, diagnosis
of alcohol abuse or dependence, and selfperception
of a drinking problem). Various
cut-off points in total scores were considered
to identify the value with optimal
sensitivity (percentage of positive cases
that the test correctly identified) and
specificity (percentage of negative cases
that the test correctly identified) to distinguish
hazardous and harmful alcohol use.
In addition, validity was also computed
against a composite diagnosis of harmful
use and dependence. In the test development
samples 1 , a cut-off value of 8 points
yielded sensitivities for the AUDIT for various
indices of problematic drinking that
were generally in the mid 0.90’s.
Specificities across countries and across
criteria averaged in the 0.80’s.
The AUDIT differs from other self-report
screening tests in that it was based on
data collected from a large multinational
sample, used an explicit conceptualstatistical
rationale for item selection,
emphasizes identification of hazardous
drinking rather than long-term dependence
and adverse drinking consequences, and
focuses primarily on symptoms occurring
during the recent past rather than “ever.”

12 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Once the AUDIT had been published, the
developers recommended additional validation
research. In response to this request,
a large number of studies have been conducted
to evaluate its validity and reliability
in different clinical and community
samples throughout the world 10 . At the
recommended cut-off of 8, most studies
have found very favorable sensitivity and
usually lower, but still acceptable, specificity,
for current ICD-10 alcohol use disorders
10,11,12 as well as the risk of future
harm 12 . Nevertheless, improvements in
detection have been achieved in some
cases by lowering or raising the cut-off
score by one or two points, depending
on the population and the purpose of
the screening programme 11,12 .
A variety of subpopulations have been studied,
including primary care patients 13, 14, 15 ,
emergency room cases 11 , drug users 16 ,
the unemployed 17 , university students 18 ,
elderly hospital patients 19 , and persons of
low socio-economic status 20 . The AUDIT
has been found to provide good discrimination
in a variety of settings where these
populations are encountered. A recent
systematic review 21 of the literature has
concluded that the AUDIT is the best
screening instrument for the whole range
of alcohol problems in primary care, as
compared to other questionnaires such as
the CAGE and the MAST.
Cultural appropriateness and crossnational
applicability were important considerations
in the development of the
AUDIT 1, 2 . Research has been conducted
in a wide variety of countries and
cultures 11, 12, 13, 15, 19, 22, 23, 24 , suggesting
that the AUDIT has fulfilled its promise as
an international screening test.
Although evidence on women is somewhat
limited 11, 12, 24 , the AUDIT seems equally
appropriate for males and females. The
effect of age has not been systematically
analyzed as a possible influence on the
AUDIT, but one study 19 found low sensitivity
but high specificity in patients above
age 65. The AUDIT has proven to be
accurate in detecting alcohol dependence
in university students 18 .
In comparison to other screening tests,
the AUDIT has been found to perform
equally well or at a higher degree of accuracy
10, 11, 25, 26 across a wide variety of criterion
measures. Bohn, et al. 27 found a
strong correlation between the AUDIT
and the MAST (r=.88) for both males and
females, and correlations of .47 and .46
for males and females, respectively, on a
covert content alcoholism screening test.
A high correlation coefficient (.78) was
also found between the AUDIT and the
CAGE in ambulatory care patients 26 .
AUDIT scores were found to correlate well
with measures of drinking consequences,
attitudes toward drinking, vulnerability to
alcohol dependence, negative mood states
after drinking, and reasons for drinking 27 .
It appears that the total score on the AUDIT
reflects the extent of alcohol involvement
along a broad continuum of severity.
Two studies have considered the relation
between AUDIT scores and future indicators
of alcohol-related problems and more

DEVELOPMENT AND VALIDATION OF THE AUDIT I
13
global life functioning. In one study 17 , the
likelihood of remaining unemployed over
a two year period was 1.6 times higher
for individuals with scores of 8 or more
on the AUDIT than for comparable persons
with lower scores. In another study 28 ,
AUDIT scores of ambulatory care patients
predicted future occurrence of a physical
disorder, as well as social problems related
to drinking. AUDIT scores also predicted
health care utilization and future risk
of engaging in hazardous drinking 28 .
Several studies have reported on the reliability
of the AUDIT 18, 26, 29 . The results
indicate high internal consistency, suggesting
that the AUDIT is measuring a single
construct in a reliable fashion. A test-retest
reliability study 29 indicated high reliability
(r=.86) in a sample consisting of non-hazardous
drinkers, cocaine abusers, and
alcoholics. Another methodological study
was conducted in part to investigate the
effect of question ordering and wording
changes on prevalence estimates and
internal consistency reliability 22 . Changes
in question ordering and wording did not
affect the AUDIT scores, suggesting that
within limits, researchers can exercise
some flexibility in modifying the order
and wording of the AUDIT items.
With increasing evidence of the reliability
and validity of the AUDIT, studies have
been conducted using the test as a
prevalence measure. Lapham, et al. 23
used it to estimate prevalence of alcohol
use disorders in emergency rooms (ERs)
of three regional hospitals in Thailand.
It was concluded that the ER is an ideal
setting for implementing alcohol screening
with the AUDIT. Similarly, Piccinelli, et
al. 15 evaluated the AUDIT as a screening
tool for hazardous alcohol intake in primary
care clinics in Italy. AUDIT performed
well in identifying alcohol-related disorders
as well as hazardous use. Ivis, et al. 22
incorporated the AUDIT into a general
population telephone survey in Ontario,
Canada.
Since the AUDIT User’s Manual was first
published in 1989 30 , the test has fulfilled
many of the expectations that inspired its
development. Its reliability and validity have
been established in research conducted in
a variety of settings and in many different
nations. It has been translated into many
languages, including Turkish, Greek, Hindi,
German, Dutch, Polish, Japanese, French,
Portuguese, Spanish, Danish, Flemish,
Bulgarian, Chinese, Italian, and Nigerian
dialects. Training programmes have been
developed to facilitate its use by physicians
and other health care providers 31, 32 (see
Appendix E). It has been used in primary
care research and in epidemiological
studies for the estimation of prevalence
in the general population as well as specific
institutional groups (e.g., hospital
patients, primary care patients). Despite
the high level of research activity on the
AUDIT, further research is needed, especially
in the less developed countries.
Appendix A provides guidelines for continued
research on the AUDIT.

14 I
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THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Administration Guidelines
The AUDIT can be used in a variety of
ways to assess patients’ alcohol use,
but programmes to implement it should
first set guidelines that consider the
patient’s circumstances and capacities.
Additionally, care must be taken to tell
patients why questions about alcohol use
are being asked and to provide information
they need to make appropriate
responses. A decision must be made
whether to administer the AUDIT orally or
as a written, self-report questionnaire.
Finally, consideration must be given to
using skip-outs to shorten the screening
for greater efficiency. This section recommends
guidelines on such issues of
administration.
Considering the Patient
All patients should be screened for alcohol
use, preferably annually. The AUDIT
can be administered separately or combined
with other questions as part of a
general health interview, a lifestyle questionnaire,
or medical history. If health
workers screen only those they consider
most likely to have a “drinking problem”,
the majority of patients who drink excessively
will be missed. However, it is important
to consider the condition of the
patients when asking them to answer
questions about alcohol use. To increase
the patient’s receptivity to the questions
and the accuracy of responding, it is
important that:
■
The interviewer (or presenter of the survey)
be friendly and non-threatening;
■
■
The patient is not intoxicated or in need
of emergency care at the time;
The purpose of the screening be clearly
stated in terms of its relevance to the
patient’s health status;
■ The information patients need to
understand the questions and respond
accurately be provided; and
■ Assurance is given that the patient’s
responses will remain confidential.
Health workers should try to establish
these conditions before the AUDIT is
given. When these conditions are not present
or when a patient is resistant, the
Clinical Screening Procedures (discussed in
Appendix D) may provide an alternative
course of action.
Choose the best possible circumstance for
administering the AUDIT. For patients
requiring emergency treatment or in great
pain, it is best to wait until their medical
condition has stabilized and they have
become accustomed to the health setting
where administration of the AUDIT is to
take place. Look for signs of alcohol or
drug intoxication. Patients who have alcohol
on their breath or who appear intoxicated
may be unreliable respondents.
Consider screening at a later time. If this
is not possible, make note of these findings
on the patient's record.
When presented in a medical context
with genuine concern for the patient’s
well being, patients are almost always
open and responsive to the AUDIT questions.
Moreover, most patients answer the
questions honestly. Even when excessive

ADMINISTRATION GUIDELINES I
15
drinkers underestimate their consumption,
they often qualify on the AUDIT
scoring system as positive for alcohol risk.
Introducing the AUDIT
Whether the AUDIT is used as an oral
interview or a written questionnaire, it is
recommended that an explanation be
given to patients of the content of the
questions, the purpose for asking them,
and the need for accurate answers. The
following are illustrative introductions for
oral delivery and written questionnaires:
“Now I am going to ask you some questions
about your use of alcoholic beverages
during the past year. Because alcohol
use can affect many areas of health
(and may interfere with certain medications),
it is important for us to know how
much you usually drink and whether you
have experienced any problems with your
drinking. Please try to be as honest and
as accurate as you can be.”
“As part of our health service it is important
to examine lifestyle issues likely to
affect the health of our patients. This
information will assist in giving you the
best treatment and highest possible standard
of care. Therefore, we ask that you
complete this questionnaire that asks
about your use of alcoholic beverages
during the past year. Please answer as
accurately and honestly as possible. Your
health worker will discuss this issue with
you. All information will be treated in
strict confidence.
This statement should be followed by a
description of the types of alcoholic beverages
typically consumed in the country
or region where the patient lives (e.g., “By
alcoholic beverages we mean your use of
wine, beer, vodka, sherry, etc.”) If necessary,
include a description of beverages
that may not be considered alcoholic,
(e.g. cider, low alcohol beer, etc.). With
patients whose alcohol consumption is
prohibited by law, culture, or religion
(e.g., youths, observant Muslims), acknowledgment
of such prohibition and encouragement
of candor may be needed. For
example, “I understand others may think
you should not drink alcohol at all, but it
is important in assessing your health to
know what you actually do.”
Patient instructions should also clarify the
meaning of a standard drink. Questions
2 and 3 of AUDIT ask about “drinks consumed”.
The meaning of this word differs
from one nation and culture to another.
It is important therefore to mention the
most common alcoholic beverages likely
to be consumed and how much of each
constitutes a drink (approximately 10 grams
of pure ethanol). For example, one bottle
of beer (330 ml at 5% ethanol), a glass
of wine (140 ml at 12% ethanol), and a
shot of spirits (40 ml at 40% ethanol)
represent a standard drink of about 13 g
of ethanol. Since the types and amounts
of alcoholic drinks will vary according to
culture and custom, the alcohol content
of typical servings of beer, wine and spirits
must be determined to adapt the AUDIT
to particular settings. See Appendix C.

16 I
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THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Oral Administration vs.
Self-report Questionnaire
The AUDIT may be administered either as
an oral interview or as a self-report questionnaire.
Each method carries its own
advantages and disadvantages that must
be weighed in light of time and cost constraints.
The relative merits of using the
AUDIT as an interview vs. the self-report
questionnaire are summarized in Box 3.
The cognitive capacities (literacy, forgetfulness)
and level of cooperation (defensiveness)
of the patient should be considered.
If the expectation is that primary care
providers will manage all the care that
patients will receive for their alcohol problems,
an interview may have advantages.
However, if the provider’s responsibility
will be limited to offering brief advice to
patients who screen positive and referring
more severe cases to other services, the
questionnaire method may be preferable.
Whatever decision is made, it must be consistent
with implementation plans to establish
a comprehensive screening programme.
The AUDIT questions and responses are
presented in Box 4 in a format suggested
for an oral interview. Appendix B gives an
example of the self-report questionnaire.
Adaptation should be made to needs of
the particular screening programme as well
as the alcoholic beverages most commonly
consumed in that society. Appendix C provides
guidelines for translation and adaptation
to national and local conditions.
If the AUDIT is administered as an interview,
it is important to read the questions as
written and in the order indicated. By following
the exact wording, better comparability
will be obtained between your
results and those obtained by other interviewers.
Most of the questions in the
AUDIT are phrased in terms of “how
Box 3
Advantages of Different Approaches to AUDIT Administration
Questionnaire
Takes less time
Easy to administer
Suitable for computer administration
and scoring
May produce more accurate answers
Interview
Allows clarification of ambiguous answers
Can be administered to patients with poor
reading skills
Allows seamless feedback to patient
and initiation of brief advice

ADMINISTRATION GUIDELINES I
17
Box 4
The Alcohol Use Disorders Identification Test: Interview Version
Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask
you some questions about your use of alcoholic beverages during this past year.” Explain what is meant
by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of
“standard drinks”. Place the correct answer number in the box at the right.
1. How often do you have a drink containing alcohol?
(0) Never [Skip to Qs 9-10]
(1) Monthly or less
(2) 2 to 4 times a month
(3) 2 to 3 times a week
(4) 4 or more times a week
2. How many drinks containing alcohol do you have
on a typical day when you are drinking?
(0) 1 or 2
(1) 3 or 4
(2) 5 or 6
(3) 7, 8, or 9
(4) 10 or more
3. How often do you have six or more drinks on one
occasion?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
Skip to Questions 9 and 10 if Total Score
for Questions 2 and 3 = 0
6. How often during the last year have you needed
a first drink in the morning to get yourself going
after a heavy drinking session?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
7. How often during the last year have you had a
feeling of guilt or remorse after drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
8. How often during the last year have you been
unable to remember what happened the night
before because you had been drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
4. How often during the last year have you found
that you were not able to stop drinking once you
had started?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
5. How often during the last year have you failed to
do what was normally expected from you
because of drinking?
(0) Never
(1) Less than monthly
(2) Monthly
(3) Weekly
(4) Daily or almost daily
9. Have you or someone else been injured as a
result of your drinking?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
10. Has a relative or friend or a doctor or another
health worker been concerned about your drinking
or suggested you cut down?
(0) No
(2) Yes, but not in the last year
(4) Yes, during the last year
Record total of specific items here
If total is greater than recommended cut-off, consult User’s Manual.

18 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
often” symptoms occur. Provide the
patient with the response categories given
for each question (for example, “Never,”
“Several times a month,” “Daily”). When a
response option has been chosen, it is
useful to probe during the initial questions
to be sure that the patient has
selected the most accurate response (for
example, “You say you drink several times
a week. Is this just on weekends or do
you drink more or less every day?”).
If responses are ambiguous or evasive,
continue asking for clarification by repeating
the question and the response options,
asking the patient to choose the best
one. At times answers are difficult to
record because the patient may not drink
on a regular basis. For example, if the
patient was drinking excessively during
the month before an accident, but not
prior to that time, then it will be difficult
to characterize the “typical” drinking
sought by the question. In these cases it
is best to record the amount of drinking
and related symptoms for the heaviest
drinking period in the past year, making
note of the fact that this may be atypical
or transitory for that individual.
Record answers carefully, making note of
any special circumstances, additional information,
and clinical observations. Often
patients will provide the interviewer with
useful comments about their drinking that
can be valuable in the interpretation of the
AUDIT total score.
Administering the AUDIT as a written questionnaire
or by computer eliminates many
of the uncertainties of patient responses by
allowing only specific choices.
However, it eliminates the information
obtained from the interview format.
Moreover, it presumes literacy and ability
of the patient to perform the required
actions. It may also require less time on
the part of health workers, if patients can
complete the process alone. With time at
a premium for both health workers and
patients, ways of shortening the screening
process merit consideration.
Shortening the Screening Process
Administered either orally or as a questionnaire,
the AUDIT can usually be completed
in two to four minutes and scored in a
few seconds. However, for many patients
it is unnecessary to administer the complete
AUDIT because they drink infrequently,
moderately, or abstain entirely from alcohol.
The interview version of the AUDIT
(Box 4) provides two opportunities to skip
questions for such patients. If the patient
answers in response to Question 1 that no
drinking has occurred during the last year,
the interviewer may skip to Questions 9-10,
responses to which may indicate past problems
with alcohol. Patients who score points
on these questions may be considered at risk
if they begin to drink again, and should be
advised to avoid alcohol. It is recommended
that this skip out instruction only be used
with the interview or computer-assisted
formats of the AUDIT.
A second opportunity to shorten AUDIT
screening occurs after Question 3 has
been answered. If the patient scored 0
on Questions 2 and 3, the interviewer
may skip to Questions 9-10 because the
patient’s drinking has not exceeded the
low risk drinking limits.

SCORING AND INTERPRETATION I
19
Scoring and Interpretation
The AUDIT is easy to score. Each of the
questions has a set of responses to
choose from, and each response has a
score ranging from 0 to 4. In the interview
format (Box 4) the interviewer enters the
score (the number within parentheses)
corresponding to the patient’s response
into the box beside each question. In
the self-report questionnaire format
(Appendix B), the number in the column
of each response checked by the patient
should be entered by the scorer in the
extreme right-hand column. All the response
scores should then be added and recorded
in the box labeled “Total”.
Total scores of 8 or more are recommended
as indicators of hazardous and
harmful alcohol use, as well as possible
alcohol dependence. (A cut-off score of
10 will provide greater specificity but at
the expense of sensitivity.) Since the
effects of alcohol vary with average body
weight and differences in metabolism,
establishing the cut off point for all
women and men over age 65 one point
lower at a score of 7 will increase sensitivity
for these population groups.
Selection of the cut-off point should be
influenced by national and cultural standards
and by clinician judgment, which
also determine recommended maximum
consumption allowances. Technically
speaking, higher scores simply indicate
greater likelihood of hazardous and
harmful drinking. However, such scores
may also reflect greater severity of alcohol
problems and dependence, as well as a
greater need for more intensive treatment.
More detailed interpretation of a patient’s
total score may be obtained by determining
on which questions points were
scored. In general, a score of 1 or more
on Question 2 or Question 3 indicates
consumption at a hazardous level. Points
scored above 0 on questions 4-6 (especially
weekly or daily symptoms) imply the
presence or incipience of alcohol dependence.
Points scored on questions 7-10
indicate that alcohol-related harm is
already being experienced. The total
score, consumption level, signs of dependence,
and present harm all should play
a role in determining how to manage a
patient. The final two questions should
also be reviewed to determine whether
patients give evidence of a past problem
(i.e., “yes, but not in the past year”).
Even in the absence of current hazardous
drinking, positive responses on these
items should be used to discuss the need
for vigilance by the patient.
In most cases the total AUDIT score will
reflect the patient’s level of risk related to
alcohol. In general health care settings
and in community surveys, most patients
will score under the cut-offs and may be
considered to have low risk of alcoholrelated
problems. A smaller, but still significant,
portion of the population is likely
to score above the cut-offs but record
most of their points on the first three
questions. A much smaller proportion
can be expected to score very high, with
points recorded on the dependence-related
questions as well as exhibiting alcohol-related
problems. As yet there has
been insufficient research to establish

20 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
precisely a cut-off point to distinguish
hazardous and harmful drinkers (who
would benefit from a brief intervention)
from alcohol dependent drinkers (who
should be referred for diagnostic evaluation
and more intensive treatment). This
is an important question because screening
programmes designed to identify
cases of alcohol dependence are likely to
find a large number of hazardous and
harmful drinkers if the cut-off of 8 is
used. These patients need to be managed
with less intensive interventions. In
general, the higher the total score on the
AUDIT, the greater the sensitivity in finding
persons with alcohol dependence.
Based on experience gained in a study of
treatment matching with persons who
had a wide range of alcohol problem
severity, AUDIT scores were compared
with diagnostic data reflecting low, medium
and high degrees of alcohol dependence.
It was found that AUDIT scores in
the range of 8-15 represented a medium
level of alcohol problems whereas scores
of 16 and above represented a high level
of alcohol problems 33 . On the basis of
experience gained from the use of the
AUDIT in this and other research, it is
suggested that the following interpretation
be given to AUDIT scores:
■ AUDIT scores of 20 or above clearly
warrant further diagnostic evaluation
for alcohol dependence.
In the absence of better research these
guidelines should be considered tentative,
subject to clinical judgment that
takes into account the patient’s medical
condition, family history of alcohol problems
and perceived honesty in responding
to the AUDIT questions.
While use of the 10-question AUDIT
questionnaire will be sufficient for the
vast majority of patients, special circumstances
may require a clinical screening
procedure. For example, a patient may be
resistant, uncooperative, or unable to
respond to the AUDIT questions. If further
confirmation of possible dependence
is warranted, a physical examination procedure
and laboratory tests may be used,
as described in Appendix D.
■
■
Scores between 8 and 15 are most
appropriate for simple advice focused
on the reduction of hazardous drinking.
Scores between 16 and 19 suggest
brief counseling and continued monitoring.

HOW TO HELP PATIENTS I
21
How to Help Patients
Using the AUDIT to screen patients is only
the first step in a process of helping
reduce alcohol-related problems and risks.
Health care workers must decide what
services they can provide to patients who
score positive. Once a positive case has
been identified, the next step is to provide
an appropriate intervention that meets the
needs of each patient. Typically, alcohol
screening has been used primarily to find
“cases” of alcohol dependence, who are
then referred to specialized treatment. In
recent years, however, advances in screening
procedures have made it possible to
screen for risk factors, such as hazardous
drinking and harmful alcohol use. Using
the AUDIT Total Score, there is a simple way
to provide each patient with an appropriate
intervention, based on the level of risk.
While this discussion will focus on helping
those patients who score positive on the
AUDIT, sound preventative practice also
calls for reporting screening results to
those who score negative. These patients
should be reminded about the benefits of
low risk drinking or abstinence and told
not to drink in certain circumstances,
such as those mentioned in Box 5.
Four levels of risk are shown in Box 6.
Zone I refers to low risk drinking or abstinence.
The second level, Zone II, consists
of alcohol use in excess of low-risk guidelines
5 , and is generally indicated when the
AUDIT score is between 8 and 15. A brief
intervention using simple advice and patient
education materials is the most appropriate
course of action for these patients. The
Box 5
Advise Patients
not to Drink
■
■
■
■
When operating a vehicle or
machinery
When pregnant or considering
pregnancy
If a contraindicated medical
condition is present
After using certain medications,
such as sedatives, analgesics,
and selected antihypertensives
third level, Zone III, is suggested by AUDIT
scores in the range of 16 to 19. Harmful
and hazardous drinking can be managed
by a combination of simple advice, brief
counseling and continued monitoring,
with further diagnostic evaluation indicated
if the patient fails to respond or is suspected
of possible alcohol dependence. The fourth
risk level is suggested by AUDIT scores in
excess of 20. These patients should be
referred to a specialist for diagnostic evaluation
and possible treatment for alcohol
dependence. If these services are not available,
these patients can be managed in
primary care, especially when mutual help
organizations are able to provide community-based
support. Using a stepped-care
approach, patients can be managed first at
the lowest level of intervention suggested
by their AUDIT score. If they do not respond
to the initial intervention, they should be
referred to the next level of care.

22 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Box 6
Risk Level Intervention AUDIT score*
Zone I Alcohol Education 0-7
Zone II Simple Advice 8-15
Zone III
Simple Advice plus Brief Counseling
and Continued Monitoring 16-19
Zone IV Referral to Specialist for Diagnostic 20-40
Evaluation and Treatment
*The AUDIT cut-off score may vary slightly depending on the country’s drinking patterns, the alcohol content of
standard drinks, and the nature of the screening program. Clinical judgment should be exercised in cases where
the patient’s score is not consistent with other evidence, or if the patient has a prior history of alcohol dependence.
It may also be instructive to review the patient’s responses to individual questions dealing with dependence symptoms
(Questions 4, 5 and 6) and alcohol-related problems (Questions 9 and 10). Provide the next highest level of
intervention to patients who score 2 or more on Questions 4, 5 and 6, or 4 on Questions 9 or 10.
Brief interventions for hazardous and
harmful drinking constitute a variety of
activities characterized by their low intensity
and short duration. They range from
5 minutes of simple advice about how to
reduce hazardous drinking to several sessions
of brief counseling to address more
complicated conditions 36 . Intended to
provide early intervention, before or soon
after the onset of alcohol-related problems,
brief interventions consist of feedback of
screening data designed to increase motivation
to change drinking behaviour, as
well as simple advice, health education,
skill building, and practical suggestions.
Over the last 20 years procedures have
been developed that primary care practitioners
can readily learn and practice to
address hazardous and harmful drinking.
These procedures are summarized in Box 7.
A number of randomized controlled trials
have evaluated the efficacy of this approach,
showing consistently positive benefits for
Box 7
Elements of Brief
Interventions
■ Present screening results
■ Identify risks and discuss consequences
■ Provide medical advice
■ Solicit patient commitment
■ Identify goal—reduced drinking or
abstinence
■ Give advice and encouragement

HOW TO HELP PATIENTS I
23
patients who are not dependent on alcohol
36, 37, 38 . A companion WHO manual,
Brief Intervention for Hazardous and
Harmful Drinking: A Manual for Use in
Primary Care, provides more information
on this approach.
Referral to alcohol specialty care is common
among those primary care practitioners
who do not have competency in treating
alcohol use disorders and where specialty
care is available. Consideration must be
given to the willingness of patients to
accept referral and treatment. Many
patients underestimate the risks associated
with drinking; others may not be prepared
to admit and address their dependence.
A brief intervention, adapted to
the purpose of initiating a referral using
data from a clinical examination and
blood tests, may help to address patient
resistance. Follow-up with the patient
and the specialty provider may also
assure that the referral is accepted and
treatment is received.
Diagnosis is a necessary step following
high positive scoring on the AUDIT, since
the instrument does not provide sufficient
basis for establishing a management
or treatment plan. While persons
associated with the screening programme
should have a basic familiarity with the
criteria for alcohol dependence, a qualified
professional who is trained in the
diagnosis of alcohol use disorders 4 should
conduct this assessment. The best
method of establishing a diagnosis is
through the use of a standardized, structured,
psychiatric interview, such as the
CIDI 39 or the SCAN 40 . The alcohol sections
of these interviews require 5 to 10 minutes
to complete.
The Tenth revision of the International
Classification of Diseases (ICD-10) 4 provides
detailed guidelines for the diagnosis
of acute alcohol intoxication, harmful use,
alcohol dependence syndrome, withdrawal
state, and related medical and neuropsychiatric
conditions. The ICD-10 criteria for
the alcohol dependence syndrome are
described in Box 8.
Detoxification may be necessary for some
patients. Special attention should be paid
to patients whose AUDIT responses indicate
daily consumption of large amounts
of alcohol and/or positive responses to
questions indicative of possible dependence
(questions 4-6). Enquiry should be
made as to how long a patient has gone
since having an alcohol-free day and any
prior experience of withdrawal symptoms.
This information, a physical examination,
and laboratory tests (see Clinical
Screening Procedures, Appendix D) may
inform a judgment of whether to recommend
detoxification. Detoxification
should be provided for patients likely to
experience moderate to severe withdrawal
not only to minimize symptoms, but
also to prevent or manage seizures or
delirium, and to facilitate acceptance of
therapy to address dependence. While
inpatient detoxification may be necessary
in a small number of severe cases, ambulatory
or home detoxification can be used
successfully with the majority of less
severe cases.

24 I
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THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Box 8
ICD-10 Criteria for the Alcohol Dependence Syndrome
Three or more of the following manifestations should have occurred together for at
least 1 month or, if persisting for periods of less than 1 month, should have occurred
together repeatedly within a 12-month period:
■ a strong desire or sense of compulsion to consume alcohol;
■ impaired capacity to control drinking in terms of its onset, termination, or levels of
use, as evidenced by: alcohol being often taken in larger amounts or over a longer
period than intended; or by a persistent desire to or unsuccessful efforts to reduce
or control alcohol use;
■ a physiological withdrawal state when alcohol use is reduced or ceased, as evidenced
by the characteristic withdrawal syndrome for alcohol, or by use of the same (or closely
related) substance with the intention of relieving or avoiding withdrawal symptoms;
■ evidence of tolerance to the effects of alcohol, such that there is a need for significantly
increased amounts of alcohol to achieve intoxication or the desired effect, or
a markedly diminished effect with continued use of the same amount of alcohol;
■ preoccupation with alcohol, as manifested by important alternative pleasures or
interests being given up or reduced because of drinking; or a great deal of time
being spent in activities necessary to obtain, take, or recover from the effects of
alcohol;
■ persistent alcohol use despite clear evidence of harmful consequences, as evidenced
by continued use when the individual is actually aware, or may be expected to be
aware, of the nature and extent of harm.
(p.57, WHO, 1993)
Medical management or treatment of
alcohol dependence has been described
in previous WHO publications 41 . A variety
of treatments for alcohol dependence
have been developed and found
effective 42 . Significant advances have
been made in pharmacotherapy, family
and social support therapy, relapse prevention,
and behaviour-oriented skills
training interventions.
Because the diagnosis and treatment of
alcohol dependence have developed as a
specialty within the mainstream of medical
care, in most countries primary care
practitioners are not trained or experienced
in its diagnosis or treatment. In such cases
primary care screening programmes must
establish protocols for referring patients
suspected of being alcohol dependent
who need further diagnosis and treatment.

PROGRAMME IMPLEMENTATION I
25
Programme Implementation
Alcohol screening and appropriate
patient care have been recognized
widely as essential to good medical practice.
Like many medical practices that
achieve such recognition, there is often a
failure to implement effective technologies
within organized systems of health
care. Implementation requires special
efforts to assure compliance of individual
practitioners, overcome obstacles, and
adapt procedures to special circumstances.
Research into implementation
has begun to produce useful guidelines
for effective implementation 43, 44 . Four
major elements have emerged as critical
to success:
■ planning;
■ training;
■ monitoring; and
■ feedback.
Planning is necessary not only to design
the alcohol screening programme but
also to engage participants in the “ownership”
of the programme. Every primary
care practice is unique. Each has established
special procedures suited to its
physical setting, social and cultural environment,
patient population, economics,
staffing structure, and even individual
personalities. Thus, adapting AUDIT
screening to each practice situation must
involve fitting its essential elements into
this context in a way that is most likely to
achieve sustained success. If screening for
other health conditions and risk factors is
already part of standard practice, those
procedures may provide a useful starting
place. However, both policy and procedural
decisions will be required.
It is generally helpful to involve in planning
the staff who will participate in or
be affected by the screening operation.
Participation of persons with diverse perspectives,
experience, and responsibilities
is most likely to identify obstacles and
create ways to remove or surmount
them. In addition, the involvement of
staff in planning yields a sense of ownership
over the resulting implementation
plan. This is likely to increase the commitment
of individuals and the group to follow
the plan and make improvements
along the way that will assure success.
A partial list of implementation issues on
which planning is helpful are presented
in Box 9. An implementation plan should
receive formal approval at whatever
level(s) required before training begins.
Training is essential to preparing a health
care organization to implement its planning.
However, training without a management
decision to implement a screening
programme is likely to be ineffective
and even counter-productive. A training
package has been developed 31 to support
implementation of AUDIT screening
and brief intervention (See Appendix E).
Training should address the critical issues
of why screening is important, what conditions
should be identified, how to use
the AUDIT, and optimal procedures to
assure success. Effective training should
involve staff in a detailed discussion of
their functions and responsibilities within
the new programme plan. It should also

26 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Box 9
Implementation Questions
Which patients will be screened?
How often will patients be screened?
How will screening be coordinated with other activities?
Who will administer the screen?
What provider and patient materials will be used?
Who will interpret results and help the patient?
How will medical records be maintained?
What follow-up actions will be taken?
How will patients needing screening be identified?
When during the patient’s visit will screening be done?
What will be the sequence of actions?
How will instruments and materials be obtained, stored, and managed?
How will follow-up be scheduled?
provide supervised practice in administering
the AUDIT instrument and any other
procedures planned (e.g., brief interventions,
referral, etc.).
In some countries many people, even
medical staff, are accustomed to think
only of alcohol dependence when other
issues related to alcohol are raised. It is
not uncommon for health workers to
believe that people with alcohol problems
cannot be helped unless they “hit
bottom” and seek treatment, and that
the only recourse is total abstinence.
Some people who hold these beliefs may
find a programme of screening and brief
intervention to be fruitless or threatening.
It is critical that special care is taken
to allow such issues to be addressed
openly, frankly, and with attention to the
best scientific evidence. With sound
explanation and patience, most medical
staff will either understand the value of
screening or suspend judgment until
experience allows a determination of its
value.

PROGRAMME IMPLEMENTATION I
27
Monitoring is an effective way to improve
the quality of screening programme
implementation. There are various ways
of measuring the success of an alcohol
screening programme. The number of
screenings performed may be compared
to the number of people presenting who
should have been screened under the
established policy, producing a percentage
of screening success. Recording and
totaling the percentage of patients who
screen positive is also a useful measure
that encourages staff by establishing the
need for the service. Determining the
percentage of patients who received the
appropriate intervention (brief intervention,
referral, diagnosis, etc.) for their
AUDIT score is a further measure of programme
performance. Finally, a small
sample of patients who had screened
positive six to twelve months before
might be surveyed to provide at least
anecdotal evidence of outcome success.
Re-administration of the AUDIT can serve
as the basis for measuring quantitative
outcomes.
Whatever criteria of success are
employed, frequent feedback to all participating
staff is essential for results to
contribute to enhanced programme performance
in the early periods of implementation.
Written reports and discussion
at regular staff meetings will also
provide occasions at which staff can
address any problems that may be interfering
with success.

28 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Appendix A
Research Guidelines for the AUDIT
The AUDIT was developed on the basis
of an extensive six-nation validation
trial 1, 2 . Additional research has been
conducted to evaluate its accuracy and
utility in different settings, populations,
and cultural groups 10 . To provide further
guidance to this process, it is recommended
that health researchers use the
AUDIT to answer some of the following
questions:
■
■
Does AUDIT predict future alcohol
problems as well as the patient’s
response to brief intervention and more
intensive treatment? This can be evaluated
by conducting repeated AUDIT
screening on the same individual. Total
scores can be correlated with various
indicators of future symptomatology. It
would be desirable to know, for example,
whether AUDIT assesses alcoholrelated
problems along a continuum of
severity, whether severity scores increase
progressively among individuals who
continue to drink heavily, and whether
scores diminish significantly following
advice, counseling, and other types of
intervention. A screening test should
not be conceived in isolation from
intervention and treatment. It must be
evaluated in terms of its impact on the
morbidity and mortality of the population
at risk. Its contribution to secondary
and primary prevention is therefore
dependent on the availability of effective
intervention strategies.
What is the sensitivity, specificity and
predictive power of the AUDIT in different
risk groups using different validation
criteria? In future evaluations of the AUDIT
■
screening procedures, careful attention
should be given to the alcohol-related
phenomena to be detected or predicted.
Emphasis should be given to the assessment
of initial risk levels, harmful use,
and alcohol dependence. The demands
of methodologically sound validation
require the use of independent diagnostic
criteria, which themselves have been
validated. Two instruments that may be
useful for this purpose are the
Composite International Diagnostic
Interview (CIDI) and the Schedules for
Clinical Assessment in Neuropsychiatry
(SCAN) 39, 40 . Both of these interviews
provide independent verification of a
variety of alcohol use disorders according
to ICD-10 and other diagnostic systems.
The test could be improved by
focusing on more carefully defined risk
groups and more specific alcohol-related
problems. Specification of cut-off points
is needed for target populations whose
problems are to be the focus of screening
with AUDIT, especially persons with
harmful use and alcohol dependence.
What are the practical barriers to
screening with the AUDIT? Important
constraints on screening tests are
imposed by cost considerations and by
the acceptability of screening to both
health professionals and the intended
target populations. When a screening
test is expensive, the results of a screening
programme may not justify its cost.
This is also true when the procedure is
time consuming, overly invasive, or otherwise
offensive to the target group.
This type of process evaluation should
be conducted with AUDIT.

APPENDIX A I
29
■
■
Can the AUDIT be scored to produce
separate assessments of hazardous use,
harmful use, and alcohol dependence?
If screening can be differentiated into
these separate domains, it may prove
useful for the purpose of evaluating
different educational and treatment
approaches to secondary prevention.
Alternatively, the AUDIT Total Score
provides a general measure of severity
that may be useful for treatment
matching and stepped-care approaches
to clinical management (i.e., providing
the lowest level of intervention that
addresses the patient’s immediate
needs). If the patient does not respond,
the next higher “step” is provided.
Although AUDIT scores in the range of
8 to 19 seem appropriate to brief interventions,
further research is needed to
find the optimal cut-off points that are
most appropriate for simple advice,
brief counseling, and more intensive
treatment.
How can the AUDIT be used in epidemiological
research? The AUDIT may have
applications as an epidemiological tool
in surveys of health clinics, health service
systems, and general population
samples. The AUDIT was developed as
an international instrument but it could
also be used to compare samples drawn
from different national and cultural
groups, with respect to the nature and
prevalence of hazardous drinking,
harmful drinking, and alcohol dependence.
Before this is done it would be
useful to develop norms for various risk
levels so that individual and group scores
■
■
can be compared to the distribution of
scores within the general population.
What is the concurrent validity of the
AUDIT items and total scores when
compared with different “objective”
indicators of alcohol-related problems,
such as blood alcohol level, biochemical
markers of heavy drinking, public
records of alcohol-related problems,
and observational data obtained from
persons knowledgeable about the
patient's drinking behaviour. To the
extent that verbal report procedures
may have intrinsic limitations, it would
be useful to evaluate under what circumstances
AUDIT results are biased or
otherwise invalid. Procedures to increase
the accuracy of AUDIT should also be
investigated.
How acceptable is the AUDIT to primary
care workers? How can screening
procedures best be taught in the context
of educating health professionals?
How extensively are screening procedures
using AUDIT applied once students
or health workers are trained?

30 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Appendix B
Suggested Format for AUDIT Self-Report Questionnaire
In some settings there may be advantages
to administering the AUDIT as a
questionnaire completed by the patient
rather than as an oral interview. Such an
approach often saves time, costs less,
and may produce more accurate answers
by the patient. These advantages may
also result from administration via computer.
The AUDIT questionnaire format
presented in Box 10 may be useful for
such purposes.
interventions. Such material, however,
should be sufficiently coded so as not to
compromise patients' honesty in answering
AUDIT questions.
Use of the skip outs provided in the oral
interview (Box 4 on page 17) is likely to
be too difficult for patients to follow in
a paper administration. However, they
are easily achieved automatically in computerized
applications.
Administrators are encouraged to add
illustrations of local, commonly available
beverages in standard drink amounts.
Question 3 may require modification (to
4 or 5 drinks), depending on the number
of standard drinks required to total 60
grams of pure ethanol (See Appendix C).
Scoring instructions: Each response is
scored using the numbers at the top of
each response column. Write the appropriate
number associated with each answer
in the column at the right. Then add all
numbers in that column to obtain the
Total Score.
Space at the bottom of the form may be
designated “For Office Use Only” to contain
instructions or places to document
actions taken by health workers who
administer the AUDIT or provide brief

APPENDIX B I
31
Box 10
The Alcohol Use Disorders Identification Test: Self-Report Version
PATIENT: Because alcohol use can affect your health and can interfere with certain medications and
treatments, it is important that we ask some questions about your use of alcohol. Your answers
will remain confidential so please be honest.
Place an X in one box that best describes your answer to each question.
Questions 0 1 2 3 4
1. How often do you have Never Monthly 2-4 times 2-3 times 4 or more
a drink containing alcohol? or less a month a week times a week
2. How many drinks containing 1 or 2 3 or 4 5 or 6 7 to 9 10 or more
alcohol do you have on a typical
day when you are drinking?
3. How often do you have six or Never Less than Monthly Weekly Daily or
more drinks on one monthly almost
occasion?
daily
4. How often during the last Never Less than Monthly Weekly Daily or
year have you found that you monthly almost
were not able to stop drinking
daily
once you had started?
5. How often during the last Never Less than Monthly Weekly Daily or
year have you failed to do monthly almost
what was normally expected of
daily
you because of drinking?
6. How often during the last year Never Less than Monthly Weekly Daily or
have you needed a first drink monthly almost
in the morning to get yourself
daily
going after a heavy drinking
session?
7. How often during the last year Never Less than Monthly Weekly Daily or
have you had a feeling of guilt monthly almost
or remorse after drinking?
daily
8. How often during the last year Never Less than Monthly Weekly Daily or
have you been unable to remem- monthly almost
ber what happened the night
daily
before because of your drinking?
9. Have you or someone else No Yes, but Yes,
been injured because of not in the during the
your drinking? last year last year
10.Has a relative, friend, doctor, or No Yes, but Yes,
other health care worker been not in the during the
concerned about your drinking last year last year
or suggested you cut down?
Total

32 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Appendix C
Translation and Adaptation to Specific Languages,
Cultures and Standards
In some cultural settings and linguistic
groups, the AUDIT questions cannot be
translated literally. There are a number of
sociocultural factors that need to be
taken into account in addition to semantic
meaning. For example, the drinking
customs and beverage preferences of certain
countries may require adaptation of
questions to conform to local conditions.
With regard to translation into other languages,
it should be noted that the AUDIT
questions have been translated into Spanish,
Slavic, Norwegian, French, German, Russian,
Japanese, Swahili, and several other languages.
These translations are available by
writing to the Department of Mental
Health and Substance Dependence, World
Health Organization, 1211 Geneva 27,
Switzerland. Before attempting to translate
AUDIT into other languages, interested
individuals should consult with WHO
Headquarters about the procedures to be
followed and the availability of other
translations.
What is a Standard Drink?
In different countries, health educators
and researchers employ different definitions
of a standard unit or drink because
of differences in the typical serving sizes
in that country. For example,
1 standard drink in Canada: 13.6 g of
pure alcohol
1 s drink in the UK: 8 g
1 s drink in the USA: 14 g
1 s drink in Australia or New Zealand: 10 g
1 s drink in Japan: 19.75 g
In the AUDIT, Questions 2 and 3 assume
that a standard drink equivalent is 10 grams
of alcohol. You may need to adjust the
number of drinks in the response categories
for these questions in order to fit the
most common drink sizes and alcohol
strength in your country.
The recommended low-risk drinking level
set in the brief intervention manual and
used in the WHO study on brief interventions
is no more than 20 grams of
alcohol per day, 5 days a week (recommending
2 non-drinking days).
How to Calculate the Content
of Alcohol in a Drink
The alcohol content of a drink depends on
the strength of the beverage and the volume
of the container. There are wide variations
in the strengths of alcoholic beverages
and the drink sizes commonly used in
different countries. A WHO survey 45 indicated
that beer contained between 2%
and 5% volume by volume of pure alcohol,
wines contained 10.5% to 18.9%, spirits
varied from 24.3% to 90%, and cider from
1.1% to 17%. Therefore, it is essential to
adapt drinking sizes to what is most common
at the local level and to know roughly
how much pure alcohol the person consumes
per occasion and on average.
Another consideration in measuring the
amount of alcohol contained in a standard
drink is the conversion factor of
ethanol. That allows you to convert any
volume of alcohol into grammes. For each
milliliter of ethanol, there are 0.79 grammes
of pure ethanol. For example,
1 can beer (330 ml) at 5% x (strength)
0.79 (conversion factor) = 13 grammes
of ethanol
1 glass wine (140 ml) at 12% x
0.79 = 13.3 grammes of ethanol
1 shot spirits (40 ml) at 40% x
0.79 = 12.6 grammes of ethanol.

APPENDIX D I
33
Appendix D
Clinical Screening Procedures
Aclinical examination and laboratory
tests can sometimes be helpful in the
detection of chronic harmful alcohol use.
Clinical screening procedures have been
developed for this purpose 34 . These
include tremor of the hands, the appearance
of blood vessels in the face, and
changes observed in the mucous membranes
(e.g., conjunctivitis) and oral cavity
(e.g., glossitis), and elevated liver enzymes.
Only qualified health workers should
conduct the examination. Several of
the items require explanation in order
to make a reliable diagnosis.
■
■
Conjunctival injection. The condition of
the conjunctival tissue is evaluated on
the basis of the extent of capillary
engorgement and scleral jaundice.
Examination is best conducted in clear
daylight by asking the patient to direct
his gaze upward and then downward
while pulling back the upper and lower
eye-lids. Under normal conditions, the
normal pearly whiteness is widely distributed.
In contrast, capillary engorgement
is reflected in the appearance of
burgundy-coloured vascular elements
and the appearance of a greenish-yellow
tinge to the sclera.
Abnormal skin vascularization. This is
best evaluated by examination of the
face and neck. These areas often give
evidence of fine wiry arterioles that
appear as a reddish blush. Other signs
of chronic alcohol ingestion include the
appearance of 'goose-flesh" on the
neck and yellowish blotches on the skin.
■
■
■
Hand tremor. This should be estimated
with the arms extended anteriorly, half
bent at the elbows, with the hands
rotated toward the midline.
Tongue tremor. This should be evaluated
with the tongue protruding a short
distance beyond the lips, but not too
excessively.
Hepatomegaly. Hepatic changes should
be evaluated both in terms of volume
and consistency. Increased volume can
be gaged in terms of finger breadths
below the costal margin. Consistency
can be rated as normal, firm, hard, or
very hard.
Several laboratory tests are useful in the
detection of alcohol misuse. Serum
gamma-glutamyl transferase (GGT), carbohydrate
deficient transferrin (CDT),
mean corpuscular volume (MCV) of red
blood cells and serum aspartate amino
transferase (AST) are likely to provide, at
relatively low cost, a possible indication
of recent excessive alcohol consumption.
It should be noted that false positives can
occur when the individual uses drugs
(such as barbiturates) that induce GGT, or
has hand tremor because of nervousness,
neurological disorder, or nicotine dependence.

34 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST
Appendix E
Training Materials for AUDIT
Training materials and other resources
have been developed to teach AUDIT
screening and brief intervention techniques.
These include videos, instructor's
manuals, and leaflets.
Resources that can be used to obtain
training to use the AUDIT to screen for
alcohol problems are listed below:
Anderson, P. Alcohol and primary health
care. World Health Organization, Regional
Publications, European Series no. 64, 1996.
Project NEADA (Nursing Education in
Alcohol and Drug Abuse), consists of
a 30 minute video entitled Alcohol
Screening and Brief Intervention and an
Instructor's Manual 31 with lecture material,
role playing exercises, guidelines for
group discussions, and learner activity
assignments. Available through the U.S.
National Clearinghouse on Alcohol and
Drug Information: www.health.org or
call 1-800-729-6686.
Alcohol risk assessment and intervention
(ARAI) package. Ontario, College of Family
Physicians of Canada, 1994.
Sullivan, E., and Fleming, M. A Guide
to Substance Abuse Services for Primary
Care Clinicians, Treatment Improvement
Protocol Series, 24, U.S. Department of
Health and Human Services, Rockville,
MD 20857, 1997.

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Jablenski, A., Regier, D. and Sartorius,
N. SCAN - Schedules for Clinical
Assessment in Neuropsychiatry.
Archives of General Psychiatry
47:589-593, 1990.
41. Heather, N. Treatment approaches
to alcohol problems. Copenhagen,
WHO Regional Office for Europe,
1995 (WHO Regional Publications,
European Series, No. 65).
42. National Institute on Alcohol Abuse
and Alcoholism. 10th Special Report
to the U.S. Congress on Alcohol and
Health. Rockville, MD, 2000.
43. Richmond, R.L. and Anderson, P.
Research in general practice for smokers
and excessive drinkers in Australia
and the UK. III. Dissemination of
interventions. Addiction 89, 49-62,
1994.
44. Babor, T.F. and Higgins-Biddle, J.C.
Alcohol screening and brief intervention:
dissemination strategies for
medical practice and public health.
Addiction 95(5):677-686, 2000.
45. Finnish Foundation for Alcohol
Studies. International Statistics on
Alcoholic Beverages: Production,
Trade and Consumption 1950-1972.
Helsinki, Finnish Foundation for
Alcohol Studies, 1977.

Notes
NOTES I
39

40 I
AUDIT I
THE ALCOHOL USE DISORDERS IDENTIFICATION TEST

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Advocacy Foundation Publishers
Page 115 of 134

Advocacy Foundation Publishers
The e-Advocate Quarterly
Page 116 of 134

Issue Title Quarterly
Vol. I 2015 The Fundamentals
I
The ComeUnity ReEngineering
Project Initiative
Q-1 2015
II The Adolescent Law Group Q-2 2015
III
Landmark Cases in US
Juvenile Justice (PA)
Q-3 2015
IV The First Amendment Project Q-4 2015
Vol. II 2016 Strategic Development
V The Fourth Amendment Project Q-1 2016
VI
Landmark Cases in US
Juvenile Justice (NJ)
Q-2 2016
VII Youth Court Q-3 2016
VIII
The Economic Consequences of Legal
Decision-Making
Q-4 2016
Vol. III 2017 Sustainability
IX The Sixth Amendment Project Q-1 2017
X
The Theological Foundations of
US Law & Government
Q-2 2017
XI The Eighth Amendment Project Q-3 2017
XII
The EB-5 Investor
Immigration Project*
Q-4 2017
Vol. IV 2018 Collaboration
XIII Strategic Planning Q-1 2018
XIV
The Juvenile Justice
Legislative Reform Initiative
Q-2 2018
XV The Advocacy Foundation Coalition Q-3 2018
Page 117 of 134

XVI
for Drug-Free Communities
Landmark Cases in US
Juvenile Justice (GA)
Q-4 2018
Page 118 of 134

Issue Title Quarterly
Vol. V 2019 Organizational Development
XVII The Board of Directors Q-1 2019
XVIII The Inner Circle Q-2 2019
XIX Staff & Management Q-3 2019
XX Succession Planning Q-4 2019
XXI The Budget* Bonus #1
XXII Data-Driven Resource Allocation* Bonus #2
Vol. VI 2020 Missions
XXIII Critical Thinking Q-1 2020
XXIV
The Advocacy Foundation
Endowments Initiative Project
Q-2 2020
XXV International Labor Relations Q-3 2020
XXVI Immigration Q-4 2020
Vol. VII 2021 Community Engagement
XXVII
The 21 st Century Charter Schools
Initiative
Q-1 2021
XXVIII The All-Sports Ministry @ ... Q-2 2021
XXIX Lobbying for Nonprofits Q-3 2021
XXX
XXXI
Advocacy Foundation Missions -
Domestic
Advocacy Foundation Missions -
International
Q-4 2021
Bonus
Page 119 of 134

Vol. VIII
2022 ComeUnity ReEngineering
XXXII
The Creative & Fine Arts Ministry
@ The Foundation
Q-1 2022
XXXIII The Advisory Council & Committees Q-2 2022
XXXIV
The Theological Origins
of Contemporary Judicial Process
Q-3 2022
XXXV The Second Chance Ministry @ ... Q-4 2022
Vol. IX 2023 Legal Reformation
XXXVI The Fifth Amendment Project Q-1 2023
XXXVII The Judicial Re-Engineering Initiative Q-2 2023
XXXVIII
The Inner-Cities Strategic
Revitalization Initiative
Q-3 2023
XXXVIX Habeas Corpus Q-4 2023
Vol. X 2024 ComeUnity Development
XXXVX
The Inner-City Strategic
Revitalization Plan
Q-1 2024
XXXVXI The Mentoring Initiative Q-2 2024
XXXVXII The Violence Prevention Framework Q-3 2024
XXXVXIII The Fatherhood Initiative Q-4 2024
Vol. XI 2025 Public Interest
XXXVXIV Public Interest Law Q-1 2025
L (50) Spiritual Resource Development Q-2 2025
Page 120 of 134

LI
Nonprofit Confidentiality
In The Age of Big Data
Q-3 2025
LII Interpreting The Facts Q-4 2025
Vol. XII 2026 Poverty In America
LIII
American Poverty
In The New Millennium
Q-1 2026
LIV Outcome-Based Thinking Q-2 2026
LV Transformational Social Leadership Q-3 2026
LVI The Cycle of Poverty Q-4 2026
Vol. XIII 2027 Raising Awareness
LVII ReEngineering Juvenile Justice Q-1 2027
LVIII Corporations Q-2 2027
LVIX The Prison Industrial Complex Q-3 2027
LX Restoration of Rights Q-4 2027
Vol. XIV 2028 Culturally Relevant Programming
LXI Community Culture Q-1 2028
LXII Corporate Culture Q-2 2028
LXIII Strategic Cultural Planning Q-3 2028
LXIV
The Cross-Sector/ Coordinated
Service Approach to Delinquency
Prevention
Q-4 2028
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Vol. XV 2029 Inner-Cities Revitalization
LXIV
LXV
LXVI
Part I – Strategic Housing
Revitalization
(The Twenty Percent Profit Margin)
Part II – Jobs Training, Educational
Redevelopment
and Economic Empowerment
Part III - Financial Literacy
and Sustainability
Q-1 2029
Q-2 2029
Q-3 2029
LXVII Part IV – Solutions for Homelessness Q-4 2029
LXVIII
The Strategic Home Mortgage
Initiative
Bonus
Vol. XVI 2030 Sustainability
LXVIII Social Program Sustainability Q-1 2030
LXIX
The Advocacy Foundation
Endowments Initiative
Q-2 2030
LXX Capital Gains Q-3 2030
LXXI Sustainability Investments Q-4 2030
Vol. XVII 2031 The Justice Series
LXXII Distributive Justice Q-1 2031
LXXIII Retributive Justice Q-2 2031
LXXIV Procedural Justice Q-3 2031
LXXV (75) Restorative Justice Q-4 2031
LXXVI Unjust Legal Reasoning Bonus
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Vol. XVIII 2032 Public Policy
LXXVII Public Interest Law Q-1 2032
LXXVIII Reforming Public Policy Q-2 2032
LXXVIX ... Q-3 2032
LXXVX ... Q-4 2032
Page 123 of 134

The e-Advocate Journal
of Theological Jurisprudence
Vol. I - 2017
The Theological Origins of Contemporary Judicial Process
Scriptural Application to The Model Criminal Code
Scriptural Application for Tort Reform
Scriptural Application to Juvenile Justice Reformation
Vol. II - 2018
Scriptural Application for The Canons of Ethics
Scriptural Application to Contracts Reform
& The Uniform Commercial Code
Scriptural Application to The Law of Property
Scriptural Application to The Law of Evidence
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Legal Missions International
Page 125 of 134

Issue Title Quarterly
Vol. I 2015
I
II
God’s Will and The 21 st Century
Democratic Process
The Community
Engagement Strategy
Q-1 2015
Q-2 2015
III Foreign Policy Q-3 2015
IV
Public Interest Law
in The New Millennium
Q-4 2015
Vol. II 2016
V Ethiopia Q-1 2016
VI Zimbabwe Q-2 2016
VII Jamaica Q-3 2016
VIII Brazil Q-4 2016
Vol. III 2017
IX India Q-1 2017
X Suriname Q-2 2017
XI The Caribbean Q-3 2017
XII United States/ Estados Unidos Q-4 2017
Vol. IV 2018
XIII Cuba Q-1 2018
XIV Guinea Q-2 2018
XV Indonesia Q-3 2018
XVI Sri Lanka Q-4 2018
Vol. V 2019
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XVII Russia Q-1 2019
XVIII Australia Q-2 2019
XIV South Korea Q-3 2019
XV Puerto Rico Q-4 2019
Issue Title Quarterly
Vol. VI 2020
XVI Trinidad & Tobago Q-1 2020
XVII Egypt Q-2 2020
XVIII Sierra Leone Q-3 2020
XIX South Africa Q-4 2020
XX Israel Bonus
Vol. VII 2021
XXI Haiti Q-1 2021
XXII Peru Q-2 2021
XXIII Costa Rica Q-3 2021
XXIV China Q-4 2021
XXV Japan Bonus
Vol VIII 2022
XXVI Chile Q-1 2022
Page 127 of 134

The e-Advocate Juvenile Justice Report
______
Vol. I – Juvenile Delinquency in The US
Vol. II. – The Prison Industrial Complex
Vol. III – Restorative/ Transformative Justice
Vol. IV – The Sixth Amendment Right to The Effective Assistance of Counsel
Vol. V – The Theological Foundations of Juvenile Justice
Vol. VI – Collaborating to Eradicate Juvenile Delinquency
Page 128 of 134

The e-Advocate Newsletter
Genesis of The Problem
Family Structure
Societal Influences
Evidence-Based Programming
Strengthening Assets v. Eliminating Deficits
2012 - Juvenile Delinquency in The US
Introduction/Ideology/Key Values
Philosophy/Application & Practice
Expungement & Pardons
Pardons & Clemency
Examples/Best Practices
2013 - Restorative Justice in The US
2014 - The Prison Industrial Complex
25% of the World's Inmates Are In the US
The Economics of Prison Enterprise
The Federal Bureau of Prisons
The After-Effects of Incarceration/Individual/Societal
The Fourth Amendment Project
The Sixth Amendment Project
The Eighth Amendment Project
The Adolescent Law Group
2015 - US Constitutional Issues In The New Millennium
Page 129 of 134

2018 - The Theological Law Firm Academy
The Theological Foundations of US Law & Government
The Economic Consequences of Legal Decision-Making
The Juvenile Justice Legislative Reform Initiative
The EB-5 International Investors Initiative
2017 - Organizational Development
The Board of Directors
The Inner Circle
Staff & Management
Succession Planning
Bonus #1 The Budget
Bonus #2 Data-Driven Resource Allocation
2018 - Sustainability
The Data-Driven Resource Allocation Process
The Quality Assurance Initiative
The Advocacy Foundation Endowments Initiative
The Community Engagement Strategy
2019 - Collaboration
Critical Thinking for Transformative Justice
International Labor Relations
Immigration
God's Will & The 21st Century Democratic Process
The Community Engagement Strategy
The 21st Century Charter Schools Initiative
2020 - Community Engagement
Page 130 of 134

Extras
The Nonprofit Advisors Group Newsletters
The 501(c)(3) Acquisition Process
The Board of Directors
The Gladiator Mentality
Strategic Planning
Fundraising
501(c)(3) Reinstatements
The Collaborative US/ International Newsletters
How You Think Is Everything
The Reciprocal Nature of Business Relationships
Accelerate Your Professional Development
The Competitive Nature of Grant Writing
Assessing The Risks
Page 131 of 134

About The Author
John C (Jack) Johnson III
Founder & CEO
Jack was educated at Temple University, in Philadelphia, Pennsylvania and Rutgers
Law School, in Camden, New Jersey. In 1999, he moved to Atlanta, Georgia to pursue
greater opportunities to provide Advocacy and Preventive Programmatic services for atrisk/
at-promise young persons, their families, and Justice Professionals embedded in the
Juvenile Justice process in order to help facilitate its transcendence into the 21 st Century.
There, along with a small group of community and faith-based professionals, “The Advocacy Foundation, Inc." was conceived
and developed over roughly a thirteen year period, originally chartered as a Juvenile Delinquency Prevention and Educational
Support Services organization consisting of Mentoring, Tutoring, Counseling, Character Development, Community Change
Management, Practitioner Re-Education & Training, and a host of related components.
The Foundation’s Overarching Mission is “To help Individuals, Organizations, & Communities Achieve Their Full Potential”, by
implementing a wide array of evidence-based proactive multi-disciplinary "Restorative & Transformative Justice" programs &
projects currently throughout the northeast, southeast, and western international-waters regions, providing prevention and support
services to at-risk/ at-promise youth, to young adults, to their families, and to Social Service, Justice and Mental
Health professionals” everywhere. The Foundation has since relocated its headquarters to Philadelphia, Pennsylvania, and been
expanded to include a three-tier mission.
In addition to his work with the Foundation, Jack also served as an Adjunct Professor of Law & Business at National-Louis
University of Atlanta (where he taught Political Science, Business & Legal Ethics, Labor & Employment Relations, and Critical
Thinking courses to undergraduate and graduate level students). Jack has also served as Board President for a host of wellestablished
and up & coming nonprofit organizations throughout the region, including “Visions Unlimited Community
Development Systems, Inc.”, a multi-million dollar, award-winning, Violence Prevention and Gang Intervention Social Service
organization in Atlanta, as well as Vice-Chair of the Georgia/ Metropolitan Atlanta Violence Prevention Partnership, a state-wide
300 organizational member, violence prevention group led by the Morehouse School of Medicine, Emory University and The
Original, Atlanta-Based, Martin Luther King Center.
Attorney Johnson’s prior accomplishments include a wide-array of Professional Legal practice areas, including Private Firm,
Corporate and Government postings, just about all of which yielded significant professional awards & accolades, the history and
chronology of which are available for review online. Throughout his career, Jack has served a wide variety of for-profit
corporations, law firms, and nonprofit organizations as Board Chairman, Secretary, Associate, and General Counsel since 1990.
www.TheAdvocacyFoundation.org
Clayton County Youth Services Partnership, Inc. – Chair; Georgia Violence Prevention Partnership, Inc – Vice Chair; Fayette
County NAACP - Legal Redress Committee Chairman; Clayton County Fatherhood Initiative Partnership – Principal
Investigator; Morehouse School of Medicine School of Community Health Feasibility Study - Steering Committee; Atlanta
Violence Prevention Capacity Building Project – Project Partner; Clayton County Minister’s Conference, President 2006-2007;
Liberty In Life Ministries, Inc. – Board Secretary; Young Adults Talk, Inc. – Board of Directors; ROYAL, Inc - Board of
Directors; Temple University Alumni Association; Rutgers Law School Alumni Association; Sertoma International; Our
Common Welfare Board of Directors – President)2003-2005; River’s Edge Elementary School PTA (Co-President); Summerhill
Community Ministries; Outstanding Young Men of America; Employee of the Year; Academic All-American - Basketball;
Church Trustee.
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www.TheAdvocacyFoundation.org
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