Alcohol

Rachel Gonzales-Castaneda

Martin M. Anderson

Alcohol is the most widely used substance in the US. It is readily available and inexpensive. Alcohol is a central nervous system (CNS) depressant that has the ability to increase brain activity in areas that produce endorphins and in those that activate the dopaminergic reward system. In terms of physiology and metabolism, alcohol is a nonionized lipid soluble compound that is completely miscible in water. It is rapidly absorbed from the gastrointestinal tract and is distributed throughout the total body water. It easily penetrates the CNS because of its lipid solubility. Alcohol intoxication by legal definition is a blood alcohol concentration (BAC) of 0.08 g/dL or greater.¹ Physiologically, alcohol intoxication depresses the CNS so that mood, physical, and mental abilities are noticeably changed. Factors that affect alcohol intoxication include body weight/body type, functional tolerance, medication use, illness, and food consumption, as well as the rate of consumption and strength of drink. Given differences in alcohol metabolism by body weight, type, and physiologic mechanisms, alcohol dose in terms of BAC levels will have different intoxication effects on the body (Table 64.1).

The principal ingredient of all alcoholic beverages is ethanol. A standard drink in the US contains approximately 14 g of “pure” ethanol; however, levels of alcohol vary by type of alcoholic beverage.¹ For instance, a standard drink of beer constitutes 12 oz (which contains about 5% alcohol), whereas wine is 5 oz (containing about 12% alcohol), and distilled spirits is 1.5 oz (including about 40% alcohol). Hence, alcohol content for beers, wines, and distilled spirits vary and contain between 3% and 20% alcohol.

EPIDEMIOLOGY OF ALCOHOL USE AMONG ADOLESCENTS AND YOUNG ADULTS

The following highlights the epidemiologic data of alcohol use among adolescents and young adults (AYAs) separately, using standard national survey sources.

Adolescents

Youth Risk Behavior Survey (2013)

The Centers for Disease Control and Prevention’s (CDC’s) Youth Risk Behavior Survey (YRBS) reveals the following trends in alcohol use among high school-aged adolescents in the US.²

Incidence: 18.6% of high school youth in the US reported that they drank alcohol before the age of 13 years (for the first time, other than a few sips).
Lifetime prevalence: 66.2% reported that they ever had at least one drink of alcohol (on at least one day during their life).
Current prevalence: 34.9% reported that they currently drank alcohol (had at least one drink of alcohol on at least 1 day during the past 30 days).
Binge drinking: Binge drinking is defined as excessive alcohol intake within a 2-hour period such that BAC levels reach 0.08 g/dL (the legal limit of intoxication) or more. This typically happens when males consume five drinks or more and when women drink four drinks or more, within a 2-hour period.¹ Research suggests that for 9- to 13-year-old children and girls aged 14 to 17 years, binge drinking should be defined as three or more drinks. For boys, binge drinking should be defined as four drinks or more for those aged 14 or 15 years and five or more drinks for those aged 16 or 17 years. These figures are based on the number of drinks required to reach a BAC of 0.08 g/dL.¹ Data suggest that 20.8% of adolescents reported that they had five or more drinks of alcohol in a row (within a couple of hours on at least 1 day in the past month).

Monitoring The Future (MTF): Data from the 2014 MTF survey reveal lifetime, current, and binge drinking trends across 8th, 10th, and 12th grade levels³:
Lifetime prevalence: The prevalence of lifetime alcohol use for 8th, 10th, and 12th graders combined in 2014 was 40.7%. The percentage reporting ever being drunk in one’s lifetime across all three grade levels was 23.6%.
Current prevalence: Current alcohol use (drinking in the 30-day period prior to the survey) was 9% for 8th graders, 24% for 10th graders, and 37% for 12th graders. Overall, the current prevalence in the past month across the three grades combined in 2014 was 22.6%.

Binge drinking: The proportion of binge drinking (i.e., having five or more drinks in a row at least once in the prior 2 weeks) for 8th, 10th, and 12th graders was 5.1%, 13.7%, and 22.1%, respectively. Overall, the current prevalence of binge drinking during the past month across the three grades combined was 11.7%.

National Survey on Drug Use and Health (NSDUH): Data from the NSDUH (2014) survey also provide current, binge, and heavy alcohol use among adolescents in the US.⁴ The NSDUH defines current (past month) use as at least one drink in the past 30 days; binge use as five or more drinks on the same occasion (i.e., at the same time or within a couple of hours of
each other) on at least 1 day in the past 30 days; and heavy use as five or more drinks on the same occasion on each of 5 or more days in the past 30 days:

TABLE 64.1 Effects of Alcohol Consumption in the Nontolerant Individual

Blood Alcohol Level (g/dL)	Effects
0.02	Reached after approximately one drink; light or moderate drinkers feel some effect—warmth and relaxation
0.04	Most people feel relaxed, talkative, and happy; skin may become flushed
0.05	First sizable changes begin to occur; light-headedness, giddiness, lowered inhibitions, and less control of thoughts may be experienced; both restraint and judgment are lowered; coordination may be slightly altered
0.06	Judgment is somewhat impaired; ability to make rational decisions about personal capabilities is affected (such as being able to drive)
0.08	Definite impairment of muscle coordination and slower reaction time occurs; driving ability becomes suspect; sensory feelings of numbness of the cheeks and lips occur; hands, arms, and legs may tingle and then feel numb (this constitutes legal impairment in Canada and in some US states, e.g., California)
0.10	Clumsiness; speech may become fuzzy; clear deterioration of reaction time and muscle control (this level previously constituted drunkenness in most US states)
0.15	Definite impairment of balance and movement
0.20	Motor and emotional control centers are measurably affected; slurred speech, staggering, loss of balance, and double vision can all be present
0.30	Lack of understanding of what is seen or heard occurs; individuals are confused or stuporous and may lose consciousness
0.40	Usually unconscious; the skin becomes clammy
0.45	Respiration slows and may stop altogether
0.50	Death occurs
From Morrison SF, Rogers PD, Thomas MH. Alcohol and adolescents. Pediatr Clin North Am 1995;42:371-387.

Current use: Of the approximately 24.3 million adolescents in the US, 16.6% had used alcohol in the past month (10.3% to the point of intoxication), with 8.0% meeting criteria for substance abuse/dependence in the past year.³ Data also show that rates of current alcohol use were lowest for youth aged 12 or 13 (2.1%) and increased with age (9.5% for 14- to 15-year-olds and 22.7% for 16- to 17-year-olds).
Binge drinking: Rates of binge alcohol use followed trends similar to current use, with rates lowest for 12- to 13-year-olds (0.8%) and increasing to 4.5% for 14- to 15-year-olds and 13.1% for 16- to 17-year-olds.
Heavy drinking: Heavy alcohol use rates for adolescents aged 12 to 13 and 14 to 15 were less than 1% (0.1% and 0.7%, respectively) and up to 3% for 16- to 17-year-olds.

Young Adults and College Students

MTF: Prevalence of various measures of alcohol use among young adults and college students in the 2014 MTF survey⁵ is as follows:

Lifetime prevalence: Lifetime prevalence of alcohol use for young adults in 2014 increased with age: 72.1% for 19- to 20-year-olds; 85.2% for 21- to 22-year-olds; 88.8% for 23- to 24-year-olds; and 91.1% for 25- to 26-year-olds.
Annual prevalence: The annual prevalence of alcohol use for young adults followed a pattern comparable to those of lifetime rates in 2014: 68.4% for 19- to 20-year-olds; 82.8% for 21- to 22-year-olds; 84.7% for 23- to 24-year-olds; and 87.9% for 25- to 26-year-olds.
Current use: The current rates of alcohol use (past 30 day use) for young adults also escalated with increasing age: 51.5% for 19- to 20-year-olds; 70.5% for 21- to 22-year-olds; 72.7% for 23- to 24-year-olds; and 75.9% for 25- to 26-year-olds.
Binge drinking: The proportion of young adults who reported binge drinking (i.e., having five or more drinks in a row at least once in the prior 2 weeks) was lower for 19- to 20-year-olds (27.2%) compared to 21- to 22-year-olds, 23- to 24-year-olds, and 25 to 26-year-olds (40%, 38%, and 37%, respectively).

National Survey on Drug Use and Health: Trends in alcohol use among young adults in the US from the NSDUH data are summarized below.⁶

Current use: Rate of current alcohol use in 2013 among young adults aged 18 to 25 was 59.6%.
Binge drinking: Rates of binge drinking among young adults ranged from 29.1% among 18- to 20-year-olds to 43.3% for those aged 21 to 25. Figure 64.1 shows that young adults aged 18 to 25 have the highest prevalence of binge drinking in the US (estimated at 37.9%).
Heavy drinking: Rates of heavy alcohol use in 2013 were 8.5% for young adults aged 18 to 20, peaking at 13.1% for those aged 21 to 25. As a whole, heavy alcohol use was reported by 11.3% of young adults aged 18 to 25 years.

American College Health Association

According to 2013 data from the American College Health Association’s National College Health Assessment (NCHA) survey,⁶ the proportion of young adult college students who reported any alcohol use within the last 30 days was 66.8% (67.0% for females and 66.8% for males).

Sociodemographic Trends of Alcohol Use among Youth

Gender and Race

Lifetime Prevalence: The 2013 YRBS data2 show that the prevalence of lifetime alcohol use for females is higher than for males (67.9% versus 64.4%, respectively). Lifetime prevalence of alcohol use was highest among Hispanic/Latino adolescents (72.4%), followed by non-Latino Whites (65.9%) and Blacks (63.4%).

Current Use: Current use of alcohol was slightly higher for female than male adolescents (35.5% versus 34.4%, respectively). Current alcohol use rates in 2013 were higher among Hispanic (37.5%) and non-Latino White (36.3%) compared to Black (29.6%) youth. Data also reveal that alcohol use in the past month was higher among Hispanic female (39.7%) than Black female (31.3%) students and higher among non-Latino White (36.9%) and Hispanic male (35.2%) students than Black male (27.7%) students.

Binge Drinking: According to the YRBS (2013), binge drinking was higher for male than female adolescents (22.0% versus 19.6%, respectively). Binge drinking was highest among Hispanic/Latino youth (22.6%), followed by non-Latino White (23.2%) and Black students (12.4%). Data for young adult college students from the MTF (2014) suggest that since 2005 there has been considerable similarity in daily alcohol use patterns among males and females,
with the exception of the 19- to 22-year-old age-group. Specifically, males in this age-group have higher rates of daily drinking than their female age counterparts (5.6% for males versus 2.4% for females).

FIGURE 64.1 Percentage of current, binge, and heavy drinking by age-groups in the US. Results from the 2013 National Survey on Drug Use and Health: Summary and National Findings.

Puberty

Pubertal timing has been identified as a potential factor in understanding alcohol use among youth. Girls who become physically mature earlier than their same-aged peers are at risk for greater alcohol use than girls who mature on time or are late developing.⁷ The situation for boys is less clear, but there is some evidence that early development may also be linked to increased levels of alcohol consumption among boys.

Consequences of Alcohol Use among Youth

The costs of problematic alcohol consumption in the US are substantial. In 2006, costs of alcohol use were estimated at $224 billion from losses in productivity, health care costs, crime, and other expenses,⁸ with 11% of the costs ($24.6 billion) attributed to underage drinking. Alcohol use among young adults has been related to multiple adverse consequences, affecting individuals, families, communities, and society at large. Mortality tied to alcohol consumption in the US accounts for approximately 88,000 deaths per year, with young people less than 21 years of age accounting for more than 4,300 of those deaths.⁹ Specific factors associated with alcohol mortality and injuries include engaging in high-risk behaviors, driving under the influence, unsafe sexual practices, and criminal behaviors.

Drinking and Driving

According to the 2013 YRBS survey,² 10% of high school-aged youth reported that they “drove after drinking alcohol,” while 21.9% reported riding “with a driver who had been drinking alcohol.” Motor vehicle accidents caused by driving under the influence of alcohol are among the leading causes of injuries for those younger than 21 years old. According to the most recent NCHA data,⁶ 2.2% of college students reported driving after having five or more drinks in the last 30 days and 21.2% of college students reported driving after having any alcohol in the last 30 days. According to the US Department of Health and Human Services, an estimated 5.8% of youth between 16 and 17 and 15.1% of youth 18 to 20 reported driving under the influence of alcohol in 2010. The US Department of Transportation found that a total of 3,115 youth between 13 and 19 died in motor vehicle crashes that year related to alcohol (with 2 out of 3 fatalities being identified as male). Overall, national risk estimates for being seriously injured (including death) while driving under the influence of alcohol are significantly higher among 16- to 20-year-olds¹⁰ compared to other youth groups reported. Approximately 5,244 (66%) of traffic deaths among persons aged 16 to 20 years were alcohol related. In 2010, there were roughly 189,000 emergency department visits by youth under age 21 for injuries and other conditions associated with alcohol consumption, such as DUIs, violence, and other unintentional injuries, such as falls, drownings, etc.¹⁰ According to the NSDUH (2013), roughly 1 in 9 persons aged 12 or older (10.9%) drove under the influence of alcohol at least once in the past year.⁵ Figure 64.2 shows the prevalence of driving under the influence for young persons in the US.¹¹ As shown, young people aged 21 to 25 have the second highest rate (19.7%) of driving under the influence of alcohol among persons aged 16 or older.¹¹

In 2008, more than 100 US college presidents and other higher education officials signed onto the Amethyst Initiative, which calls for a reexamination of the minimum legal drinking age in the US. The current age limit of 21 years in the US is higher than in Canada (18 or 19, depending on the province), Mexico (approximately 18), and most western European countries (typically 16 or 18). The thrust of their argument is that the US minimum legal drinking age policy results in more dangerous drinking than would occur if the legal drinking age were lower and youth were able to learn responsible drinking earlier. However, when examining epidemiologic and morbidity data over the past three decades, from sources such as the US Fatality Analysis Reporting System, MTF surveys, and Vital Statistics Data, lowering the drinking age (from 21 to 18) would result in the following among 18- to 20-year-olds: (1) a 17% increase in nighttime fatal crashes (those most likely to involve alcohol)—the highest percentage of any age-group and (2) a 10% increase in suicides, past-month drinking, and heavy episodic (“binge”) drinking.¹²,¹³,¹⁴

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