March 12, 2001

John C. Higgins-Biddle is an assistant professor in the Department of Community Medicine at the Health Center. In this interview, he discusses a national program, known as "Cutting Back", to test screening and brief interventions for "at-risk" drinkers. Higgins-Biddle is co-director of the program, which is underwritten by the Robert Wood Johnson Foundation.

Q: What is meant by 'at-risk' drinking?
A: At-risk drinking is a pattern of regular or occasional alcohol consumption that is hazardous or harmful to one's self or others. The U.S. Department of Agriculture nutrition guidelines have established that high risk or harm increases substantially for men if they consume more than two drinks a day and for women if they drink more than one. The National Institute on Alcohol Abuse and Alcoholism recommends that people 65 and older, regardless of their gender, have no more than one drink a day.

There are also situations and conditions in which people should not consume alcohol at all. People who are alcohol-dependent, who are pregnant or considering getting pregnant, or are taking certain medications should not drink, nor should people who are driving or operating machinery.

Q: How does at-risk drinking differ from alcohol-dependence?
A: The vast majority of at-risk drinkers drink too much occasionally, and that may include people who do it only once a year at New Year's, as well as people who do it on a regular weekly basis or several days a week. People who are alcohol-dependent (often called 'alcoholics'), in contrast, have a diagnosable disorder.

Only 5 percent of the population are alcohol-dependent, while 20 percent are at-risk drinkers. Approximately 35 percent of Americans drink within recommended limits, and 40 percent do not drink or drink so infrequently they can be considered abstainers.

We need a lot more research, but I think ultimately we are going to find that the bulk of the harm associated with alcohol in our society is not caused only by people who are alcoholics. There are about four times as many at-risk drinkers as there are alcoholics. It's simply a matter of the statistics that the at-risk drinkers are going to produce more harm.

Q: What potential harm do drinkers face?
A: More than 100,000 people die every year in this country because of alcohol-related events, and most of them are not people with cirrhosis of the liver. The risks include short-term conditions or injuries that are related to intoxication, and long-term medical problems that result from regular excessive use.

In addition to medical problems - which largely relate to the individual who consumes the alcohol - there are a whole range of alcohol-related problems that affect other people, including spousal abuse, sexual abuse, rape, and other forms of violence.

Q: Attention historically has focused on treating people who are alcohol-dependent. What effect has that had?
A: By focusing primarily on treatment of people who are alcohol-dependent, we have not only ignored the problems related to at-risk drinking, we have also missed important opportunities to prevent people from becoming alcohol-dependent.

Q: How do programs for at-risk drinkers differ from those for people who are alcohol-dependent?
A: In this country, the consensus is that abstinence is the key for people who are alcohol-dependent, and treatments modeled on the Alcoholics Anonymous 12-step program have been very effective.

For at-risk drinkers, more than 40 clinical trials here and abroad have shown that they can be identified relatively easily using a variety of screening questionnaires, and they can be persuaded by brief advice from their doctor or other health care provider to reduce their alcohol consumption significantly.

From the perspective of the whole population, performing brief interventions with at-risk drinkers will over time have a significant effect on reducing the problem in that population. And because brief intervention is relatively inexpensive, it may be a cost-effective approach to dealing with the problem.

Q: You are currently testing a large national screening and brief intervention program called Cutting Back^TM. With all the previous trials, what makes this one different?
A: We've had a large number of very well controlled trials to determine the efficacy of this approach. Now we are trying to determine whether it can actually be implemented effectively in primary care practices within the managed care environment.

Within five sites in Wisconsin, Colorado, New Mexico, Michigan and New Hampshire, more than 45,000 patients were screened and almost 12 percent were positive for at-risk drinking. In one site, patients who received interventions reduced their weekly drinking by 40 percent, compared to a 12 percent reduction among those who did not receive an intervention.

These modest but statistically significant results suggest that screening and brief interventions are likely to provide meaningful reductions over time in alcohol consumption and related problems among primary care and HMO populations.

Used with permission of the Center for the Advancement of Health, Washington, D.C.