Alcohol: the good, the bad and the ugly

Virtually all of us, as medical students, were exposed to the "bad" of alcohol. Our texts provided lists of diseases caused by the direct effects of high-risk alcohol consumption, as well as the effects of acute intoxication, dependence and withdrawal. Our experience in the wards reinforced these descriptions.

In 1997, 3290 Australians (70% men) died of injury and disease caused by high-risk drinking.³ Most of them died of stroke, alcoholic cirrhosis, road injury, suicide, or alcohol dependence. On average, 19 years of life were lost for each person who died of an alcohol-caused condition. At the same time, high-risk drinking was responsible for 72 300 hospitalisations and 403 795 hospital bed-days in Australia; these were predominantly due to falls, alcohol dependence, assaults, or road injuries.³

As medical students, we also witnessed the havoc wrought by alcohol-associated injuries. Between 1990 and 1997, 31% of all driver and pedestrian deaths on Australian roads were alcohol related.⁴ More than 70% of people with serious alcohol-related road injuries were male (compared with 56% of people with serious non-alcohol-related road injuries). More than half these men were between the ages of 15 and 24 years.

The "ugly" was often not seen by medical students. The psychosocial and economic effects of alcohol were rarely spoken about or observed. The annual cost of alcohol misuse in Australia has been estimated at $3.8 billion -- a substantial amount of this is a result of decreased occupational productivity, often a result of hangover-related absenteeism and poor job performance.⁵ It is estimated that 75% of men and women who have consumed alcohol report that they have experienced hangovers at least once, and 15% experience hangovers at least monthly.⁵

The leading causes of burden of disease in 15-24-year-old Australian males include alcohol dependence and harmful use, and three other disorders that are related to alcohol: road traffic accidents, suicide, and self-inflicted injury.⁶

World-wide, alcohol is the fourth leading cause of disability, involving 15.8 million people. In First World regions it is the leading cause, and in Third World regions it is the fourth largest cause, of male disability.⁷

The recently published National Survey of Mental Health and Wellbeing⁸ indicates that most Australians (83% of men and 63% of women) report that they have consumed at least 12 drinks of alcohol in the preceding year, and one in 15 (6.5%) have had an alcohol-use disorder in the past 12 months. More men (9.4%) than women (3.7%) had an alcohol-use disorder in the past 12 months, and this is greatest among 18-34-year-olds (almost 16% of men).

There is considerable comorbidity between alcohol use and other mental disorders.⁸ Forty-eight per cent of Australian women with an alcohol-use disorder also suffer from anxiety, affective or other drug-use disorders, compared with 15% of women without alcohol-use disorder; 34% of men with an alcohol-use disorder have another mental disorder. The relation between alcohol and mental disorders is complex: each may cause the other, or both may be related to some underlying cause.

Alcohol can also have a devastating effect on families -- more than two-thirds of domestic incidents are alcohol related.

Are we making headway against these problems? The initial good news, that since 1978 alcohol consumption in Australia has been progressively falling, is tempered by the slowing of this fall since 1993, and a slight increase in some States. The 1998 National Drug Strategy Household Survey found evidence of increased binge drinking and a softening of attitudes to drinking and driving.

In dealing with the problems of alcohol, we need to be aware of two phenomena:

• Many alcohol-related problems in the community occur in a very large number of people consuming, on a long term basis, above-average but socially acceptable quantities of alcohol, rather than in the much smaller number of persons consuming very large quantities of alcohol.⁹

• Much of the damaging effect of alcohol, particularly in young people, results from episodic (binge) drinking rather than dependent daily consumption of alcohol.

These findings have important public health implications. The first point can be partially but effectively addressed by brief intervention strategies delivered by trained GPs as part of their usual strategies.¹⁰ However, the second point requires a greater public health commitment to responsible social drinking. Linking alcohol taxes to the alcohol content of beverages is one useful strategy.¹¹ Our strategies need to recognise that people can drink acutely in damaging fashion even if their average weekly consumption is less than the NHMRC limits.

Greg Whelan
Professor, Department of Drug and Alcohol Studies
St Vincent's Hospital, and Physician, Turning Point Alcohol and Drug Centre Inc, Melbourne, VIC

Alan T Gijsbers
Physician, Department of Drug and Alcohol Studies
St Vincent's Hospital, and Turning Point Alcohol and Drug Centre Inc, Melbourne, VIC

1. Doll R. The benefit of alcohol in moderation. Drug Alcohol Rev 1998; 17: 353-363.
2. Pols RG, Hawks DV. Is there a safe level of daily consumption of alcohol for men and women? 2nd ed. Canberra: AGPS, 1992.
3. Chikritzhs T, Jonas H, Heale P, et al. Alcohol caused deaths and hospitalisations in Australia, 1990-1997. National Alcohol Indicators Bulletin No. 1, December 1999.
4. Chikritzhs T, Stockwell T, Heale P, et al. Trends in alcohol-related road injury in Australia, 1990-1997. National Alcohol Indicators Bulletin No. 2, May 2000.
5. Wiese JG, Shiplak MG, Browner WS. The alcohol hangover. Ann Intern Med 2000; 132: 897-902.
6. Mathers C, Vos T, Stevenson C. Burden of disease and injuries in Australia. Canberra: Institute of Health and Welfare, 1999.
7. Murray CJL, Lopez AD. The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, Mass: Harvard University Press on behalf of the World Health Organization and the World Bank, 1996.
8. Teesson M, Hall W, Lynskey M, et al. Alcohol and drug use disorders in Australia: implications of the National Survey of Mental Health and Wellbeing. Aust N Z J Psychiatry 2000; 34: 206-213.
9. Kreitman N. Alcohol consumption and the preventive paradox. Br J Addiction 1986; 81: 353-363.
10. Bien TH, Miller WR, Tonigan JS. Brief interventions for alcohol problems: a review. Addiction 1993; 88: 315-336.
11. Richardson J. Alcohol taxes: the case for reform. Med J Aust 1990: 152: 619-620.

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