Journal of Addictions Nursing, 21:194206, 2010 Copyright International Nurses Society on Addictions ISSN: 1088-4602 print / 1548-7148 online

e DOI: 10.3109/10884602.2010.515692

Factors Associated with Alcohol Use and its Consequences

Marshall Dean Alameida, PhD
San Francisco State University, Nursing, San Francisco, CA, USA

Charlene Harrington, PhD

University of California San Francisco, San Francisco, CA, USA

Mitchell LaPlante, PhD

University of California San Francisco, Social & Behavioral Sciences, San Francisco, CA, USA

Taewoon Kang, PhD

University of California San Francisco, San Francisco, CA, USA

The aim of this study was to examine the self-reported experiences of an adult population living in the community, as they relate to alcohol use and potential negative outcomes (emotional/physical problems, role function problems, drinking and driving, risk behaviors, and alcohol abuse/dependence). Analyses focused on 37,026 individuals that are weighted to the population of 212,686,651 drawn from a large representative cross-sectional survey of the US. populationthe 2003 National Survey on Drug Use and health (NSDUH). Alcohol use of 19 drinks in the past month showed a signicant increase in the odds ratios for most of the study outcomes compared to those who did not drink alcohol. As alcohol use increased, the odds ratios for all of the study outcomes linearly increased. Mental health symptoms and illicit drug use in the past year also signicantly increased the odds ratios for all of the study outcomes. Hispanic and other race reected an increased odds ratio for alcohol caused role function problems, when compared to Caucasians. Higher income and education levels increased the odds ratios for drinking and driving. Negative consequences occur at low levels of self-reported monthly alcohol use, when binge and heavy drinking are not present. An increase in alcohol consumption reects a linear increase in the odds ratios for alcohol related problems. Nursing professionals need to be aware of the importance in educating clients about the risks associated with alcohol consumption. Keywords Alcohol, Community, Co-occurring Disorders, Policy

INTRODUCTION Alcohol abuse is one of the most important social and health problems in the US and worldwide. Negative consequences from alcohol use have been reported on emotional and physAddress correspondence to Dr Marshall Dean Alameida, San Francisco State University, Nursing, 1600 Holloway Avenue, San Francisco, CA, 94132. E-mail: malameid@sfsu.edu

ical wellbeing, and role functions, as well as in risk behaviors, and driving while under the inuence of alcohol. This study involved the examination of secondary data from the National Survey on Drug Use and Health (NSDUH, 2003; US Department of Health and Human Services, 2003) based on a national probability sample. The purpose of this study was to examine the self-reported experiences of an adult population, that is a sample of the civilian, non-institutionalized US population who are 18 years of age and older, as they relate to alcohol use (quantity and frequency measures) and its consequences (exacerbated emotional/physical problems, role function problems, risk behaviors and). Previous studies of alcohol use have utilized differing quantity and frequency measures. For instance, Dawson, Grant, and Hartford (1995) examined two dimensions of alcohol consumption (average daily alcohol intake and the frequency in which individuals drank 5 or more drinks on one occasion) in relation to ve problem domains Their analysis of selected levels of consumption showed a greater odds ratio for the domains of impaired control, continued drinking despite problems, and hazardous drinking when compared to the physiological domains of tolerance and withdrawal. Midanik, Tam, Greeneld and Caetano (1996) found that those individuals with lower alcohol consumption patterns (average of less than or equal to one drink/day) exhibited risks for drunk driving although they had less risk for work-related problems or meeting the criteria for alcohol dependence than heavy drinkers. Additionally, they found that alcohol consumption patterns that include drinking 5 or more drinks on a single occasion increased the risk for drunken driving, work problems and alcohol dependence. Finally, Russell, Light and Gruenwald (2004) utilized the National Health Interview Survey of 1988 to examine levels

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of alcohol use (drinks/drinking day, drinking days/year, heavy drinking rates) and their relationship to 41 alcohol outcome measures within ve cohorts based on gender and age. They found that those persons reporting severe problems drank on average more times per week than those reporting minor problems (3.5 vs. 2.6), averaged more drinks on each drinking occasion (4.7 vs. 2.6), and were more frequent heavy drinkers (58 days/year vs. 1213 days/year). Previous studies also have provided evidence of alcohols relationship to emotional and physical problems as well as role function problems, drinking and driving, and risk behaviors. In regard to emotional problems, affective disorders (major depression, mood disorders), a leading cause of mental health disability, were associated with co-morbid alcohol dependence (LaPlante, 2002) in approximately 30% of bipolar I and 20% of bipolar II patients (Reiger et al., 1990). Grant and Harford (1995) also reported that 13.3% of those individuals 65 years of age and older with a major depressive disorder had an alcohol use disorder compared to 4.5% without a major depressive disorder. It has also been found that schizophrenia, another leading cause of mental health disability (LaPlante, 2002), has a comorbid prevalence for substance abuse or dependence (Reiger et al., 1990) at a higher level than in the general population (47% vs. 16%), with alcohol the most frequently abused or dependent drug. Furthermore, research has identied a relationship between substance abuse or dependence and Post Traumatic Stress Disorder (PTSD) in adolescents that had been physically or sexually assaulted, witnessed violence, or had family members with alcohol or drug abuse and dependence (Kilpatrick, Acierno, Saunders, Resnick, & Best, 2000). Importantly, it has been reported (Kessler et al., 1997) that cooccurring alcohol disorders initiate at a later point in time than at least one other DSM-III-R disorder and that earlier disorders generally more strongly predict alcohol dependence versus alcohol abuse. The National Co-morbidity Study data suggestion that alcohol disorders typically follow another non-substance abuse, mental disorder (Kessler et al., 1994); supports the fact that alcohol use serves as a self-medicating behavior with some individuals who have mental health disorders. Physical problems related to alcohol were identied by Campbell and associates (2006), who reported that alcohol accelerates the progression of liver disease in hepatitis C virus (HCV) infected individuals and negatively affects treatment. In fact, alcohol related liver disease is recognized as a cause for liver transplants (Day et al., 2008), with those that use some alcohol estimated as high as 50% of the population receiving liver transplants and those that drink alcohol in an addictive manner estimated as approximately 10% of this same population. In this regard, there is an expectation that individuals abstain from alcohol use for 6 months prior to receiving a liver transplant (Lucey & Weinrieb, 2009). In terms of coronary artery disease (CAD), a leading cause of disability in developed countries, research on sibling pairs

has reported a sibling pair concordance to CAD with regular alcohol consumption (Hauser et al., 2003). In a study comparing matched controls, the prevalence of congestive heart failure was higher in the alcohol dependence population than in the control group (Mertens, Lu, Parthasarathy, Moore, & Weisner, 2003). Also, Saremi and Arora (2008) reported an association between cardiomyopathy, hypertension, hypertriglyceridemia and stroke with alcohol consumption of three or more drinks each day. These studies suggest a hypothesis that alcohol is a direct or covariate determinant of numerous etiologies, or an antecedent consequence of a debilitating, chronic disorder. Role function problems were investigated by Lipsky, Caetano, Field and Larkin (2005), who found a relationship between alcohol use and intimate partner violence (IPV) with the risk increasing 22% with each weekly, incremental increase of ve drinks by the victims partner. Chermack and Blow (2002) reported that increased alcohol use and the interaction of cocaine, along with other demographic variables, predicted the severity of violence. Additionally, Jennison (2004) found that binge drinkers in college experienced more alcohol related problems and that this pattern of alcohol use was predictive of alcohol abuse and dependence in both genders 10 years later. Risk behavior identies those respondents that drank alcohol and committed acts that placed them in physical danger. Sexual risk behavior such as having multiple sexual partners, not using a condom, and HIV infection has been found to be more frequent with individuals who drink (Castilla, Barrio, Belza, & Fuente, 1999). Wines, Saitz, Horton, Lloyd-Travaglini, and Samet (2004) reported that the odds ratio for a history of suicidal ideation was 2.66 for individuals with an alcohol problem when compared to those without an alcohol problem. Importantly, an alcohol use disorder was found to increase the risk for completed suicide even when controlling for co-morbid, psychiatric disorders (Flensborg-Madsen, Knop, Mortensen, Becker, Sher, & Groenbaek, 2009). Driving under the inuence of alcohol was strongly evidenced in the NSDUH 2003. Butters, Smart, Mann, and Asbridge (2005) found that in the most serious forms of road rage, illicit drugs and alcohol were involved. Dawson (1999) reported that those individuals that met three criteria for heavy drinking comprised only 3.8% of current drinkers but accounted for 36.4% of all impaired driving incidents. This study extends the prior research on quantity and frequency of alcohol use and its consequences. First, it used secondary data from a national survey on alcohol use (2003) for those living in the community in the US to examine the quantity and frequency of self-reported health consequences. The data were based on self-reported alcohol use and experiences related to four potential negative outcomes (emotional/physical problems, role function problems, drinking and driving, risk behaviors). Second, it investigated the relationship of other drug use and mental health symptoms on the study outcomes.

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METHODS This study conducted secondary data analysis on the National Survey on Drug Use and Health (NSDUH, 2003) survey data. The purpose of this study was to examine the self-reported experiences of an adult population living in the community in the US, as they relate to alcohol abuse (quantity and frequency measures) and its consequences (exacerbated emotional/physical problems, role function problems, drinking and driving, and risk behaviors). This article used the Alcohol Dependency Syndrome Model (Edwards & Gross, 1976) as a conceptual framework where alcohol use begins with alcohol intake, with the potential progression to varying levels of disablement. Design The sample design involves a 5-year design process (19992003) with the objective of providing estimates of drug use at the national and state levels. The study sample is a multistage area probability sample for each of the 50 states and the District of Columbia, and has been described in detail elsewhere (U.S. Department of Health and Human Services, 2004). Sample The study population is a sample of the civilian, noninstitutionalized US population who are 12 years of age and older. The sample includes civilian inhabitants of military installations, and those individuals residing in rooming houses, college dormitories, shelters, and group homes. The collection methods included computer-assisted personal interviews as well as audio computer-assisted, self-interviews (U.S. Dept. of Health and Human Services, 2004). In brief, the original NSDUH 2003 sample included 67,784 persons which were reduced to 55,230 with the public use data le due to a sub sampling step that protected respondents condential data. Cases were evaluated for meeting minimum response requirements. The nal weighted screening response rate was 91% with a 77% Computer Assisted Interview (CAI) weighted interview response rate (U.S. Dept. of Health and Human Services, 2004). In this study, respondents 1217 years of age were excluded. Therefore, the study population was comprised of 37,026 individuals that were weighted to the population of 212,686,651. Selected Variables: Alcohol Use Dependent Variables Four potentially negative consequences of alcohol use were examined as dependent variables: (1) emotional/physical problems; (2) role function problems; (3) risk behavior; and (4) drinking and driving. Self-reported emotional/physical problems were dened as an exacerbation to existing problems with emotional or physical function caused by alcohol use (Table 1). Role function problems are dened as problems with work, school, social interaction, or activity functions that are caused by alcohol use (Table 1). Risk behavior identies those respon-

dents that drank alcohol and committed acts that placed them in physical danger (Table 1). Driving under the inuence of alcohol was strongly evidenced in the NSDUH 2003 (Table 1). Selected Variables: Alcohol Use Independent Variables Two quantity and frequency measures of alcohol use were developed as independent variables and compared to no alcohol use. They were (1) past month alcohol levels, and (2) past month average alcohol use. Past Month Alcohol Levels (Table 2): In the National Survey on Drug Use and Health (2003), the alcohol levels were dened as: no use, past month use without binge or heavy use, past month binge use (5 or more drinks on at least one occasion in the past month), and past month heavy use (5 or more drinks on at least 5 or more occasions in the past month). The comparison groups for this those populations that reported alcohol use was those respondents that did not drink alcohol in the past month. Past Month Average Alcohol Use (Table 2): This measure was based on the product of: the number of days an individual drank alcohol times the average number of drinks on each drinking day. The coding created six levels of categories of alcohol use (0, <10, >10-20, >20-30, >30-60 and >60). The comparison groups for those that reported alcohol use was those respondents who did not drink alcohol in the past month. Selected Variables: Non-Alcohol Independent Variables The non-alcohol use independent variables in the analyses included age (1825, 2634, 3549, 5064 compared to those 65 and older), males (comparison group = females), race and ethnicity (non-Hispanic Black, Hispanic and other compared with those who are White), education (high school, some college, college or graduate school compared to those with no high school graduation), employment (comparison group = not employed), incomes by category (comparison group = incomes of less than $10,000 ), health insurance (Medicare or Medicaid, private, both: comparison group = none), mental health symptoms (comparison group = none) and illicit drug use in the past year (comparison group = none). These variables were based on respondents self-reports. Statistical Analysis The regression analyses in this study were conducted on the weighted sample, dened as the nal sampling weight. The results are intended to provide an unbiased estimate for the entire study population due to the fact that the estimated results from the NSDUH 2003 are based on sample survey data rather than complete data for the population the study is intended to represent (U.S. DHHS, 2003). The statistical software used to generate and analyze the study data was SUDAAN. SUDAAN procedures are capable of analyzing data from complex sample surveys and its ability to compute standard errors of ratio estimates, means, totals,

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TABLE 1 Dependent variables descriptive statistics Dependent Variables Response Variables (Symptoms) Alcohol Caused Problems With Emotions/Nerves or Physical Problems Past 12 Months -No Alcohol Emotional or Physical Problems -Yes Alcohol Emotional or Physical Problems Alcohol Caused Problems With Social Role Functions [home/work/school, family/friends, less activities] -No Alcohol Role problems -Yes Alcohol Role Problems Alcohol and Risk Behaviors -No Alcohol and Dangerous Activities -Yes Alcohol and Dangerous Activities Drinking and Driving -No Alcohol and Driving -Yes Alcohol and Driving regression coefcients, and other statistics in accordance with the sample design. The unit of analysis of this study was at the individual level. The weighted sample (212,686,651) was used for all statistical analysis. Logistic regression was used as the analytical method. The odds ratios and the upper and lower bounds of the 95% condence intervals for the odds ratio were reported. The data were reported if they were signicant at probabilities of equal to or less than 0.01. The Goodness of Fit for the logistic regression models were reported as the Cox and Snell R-Squares. RESULTS The dependent variables descriptive statistics are found in Table 1. Of the sample, 10,572,060 respondents report having Estimated Weighted Sample # [212,686,651] (Thousands) Estimated Weighted Sample %

201,567 10,572

95.02 4.98

201,189 10,936 201,326 10,701 138,704 30,711

94.84 5.16 94.95 5.05 81.87 18.13

exacerbated emotional or physical problems in the past 12 months caused by alcohol. Role functions problems were reported by 10,936,360 individuals in the past 12 months. Many individuals who used alcohol reported engaging in risky behaviors. Of the total sample, 10,701,870 reported engaging in dangerous activities after drinking alcohol while alcohol use and driving was reported by 30,711,740 individuals. The alcohol independent variable descriptive statistics are found on Table 2. In the study 97,257,000 individuals (45.73%) did not use alcohol in the past month. Of those that used alcohol, 35,331,304 (16.61 %) reported binge drinking and 15,527,966 (7.30 %) reported heavy alcohol use in the past month. Table 2 shows that 25% of respondents drank less than 10 drinks in the past month; 8.9% drank 1019 drinks in the past month; 5.8%

TABLE 2 Alcohol independent variable descriptive statistics Independent Variables Need Variables (Quantity) -No Alcohol Use Past Month -Alcohol Use Past Month (No Binge or heavy) -Binge Alcohol Use Past Month -Heavy Alcohol Use Past Month -0 Alcohol Drinks Past Month -<10 Alcohol Drinks Past Month ->10 to 20 Alcohol Drinks Past Month ->20 to 30 Alcohol Drinks past month ->30 to 60 Alcohol Drinks past Month ->60 Alcohol Drinks past Month Estimated Weighted Sample # [212,686,651] 97,257 64,569 35,331 15,527 97,257 52,173 18,460 11,898 15,509 11,267 Estimated Weighted Sample % 45.73 30.36 16.61 7.30 47.08 25.26 8.94 5.76 7.51 5.45

198 TABLE 3 Study comparison groups for tables 4 and 5 Variable Alcohol Levels -Use: No Binge/Heavy -Past Month Binge -Past Month Heavy Average Number Drinks Past Month: -Less than 10 ->10 to 20 ->20 to 30 ->30 to 60 ->60 Age -18 to 25 -26 to 34 -35 to 49 -50 to 64 Male Gender Race -Black/African American -Hispanic -Other Education -High School -Some College -College/Grad School Employment Income -$10,000 to $19,999 -$20,000 to $29,999 -$30,000 to $39,999 -$40,000 to $49,999 -$50,000 to $75,000 -$75,000 and Above Insurance -Medicare & Medicaid -Private -Both Mental Health Symptoms Drug Use in Past Year

M. D. ALAMEIDA ET AL.

Comparison Group No alcohol use in the past month.

No alcohol use in the past month.

Age 65 and older.

Female gender. Non-Hispanic White.

Less than high school.

Not employed. Income less than $10,000.

No insurance.

No mental health symptoms. No drug use in the past year.

drank 2029 drinks in the past month; 7.5% drank 3059 drinks in the past month and 5.5% drank more than 60 drinks in the past month. In terms of the dependent variable alcohol use and emotional or physical problems, this study found that alcohol levels (use but no binge or heavy, binge, heavy compared to no drinking) did progressively increase the odds ratios for exacerbation of emotional/physical problems (Table 4: Model 1). In addition, past month alcohol use of less that 10 drinks/past month (compared to no drinking) increased the odds ratios for exacerbation of emotional/physical problems (Table 4: Model 2), with a linear increase in the odds ratios related to an increase in alcohol consumption. Individuals with public insurance (Medicare and Medicaid) had higher odds of alcohol caused or exacerbated emotional or physical problems while those with private insurance had lower odds, compared to those with no insurance, controlling for income (Table 4, Model 1 and Model 2). Having mental health symptoms and drug use in the past year increased the odds of having alcohol related emotional or physical problems. No other factors were signicant in the models. In terms of the dependent variable alcohol and role function problems, Table 4 (Model 1 and 2) shows that the odds of alcohol caused role function problems increased linearly with alcohol used. Individuals that binged in the past month or had heavy alcohol use were 5 to 8 times more likely to have role function problems. Compared to those who did not drink, those who drank less than 10 drinks in the past month were 1.5 times more likely to have role function problems, which increased up to 19 times higher odds for those with 60 or more drinks. Individuals in the age groups of 1825 and 2634 reported signicant role function problems. As expected, male gender increased the odds ratios for role function problems. Although Hispanics had lower alcohol use when compared to Whites in this study (no table shown), surprisingly, they had increased odds ratios of reporting role function problems. Those individuals with private insurance were less likely to have role function problems. Having mental health symptoms increased the odds of having alcohol related role function problems. Finally, illicit drug use in the past year was a predictor that increased the odds ratios for the outcomes of role function problems. As relates to the dependent variable alcohol and dangerous activities, Table 5 (Model 3 and 4) showed a similar pattern as with other problems. Alcohol use (including any use with no binge or heavy use, binge, and heavy use) was associated with an increase in dangerous activities. The odds of dangerous activities increased with each increase in the number of drinks in the past month. Age 18 to 25 was the group most associated with dangerous activities. Mental health symptoms and drug use in the past year also increased the odds of dangerous activities. As relates to the dependent variable alcohol and driving, any alcohol use was associated with driving under the inuence of alcohol and the number of drinks increased the odds of driving while drinking (Table 5 Model 3 and 4). As expected, younger age groups increased the odds ratios for alcohol risk behaviors,

TABLE 4 Logistic regression results for alcohol use and exacerbated emotional/physical or role function problems: P value Signcant at 0.01 Model 1 Model 2

Alcohol Use Patterns 2.784 (2.0853.716) 1.375 (1.0211.853) 5.187 (4.0706.611) 7.989 (5.89410.827) 2.377 (1.7673.197) 6.405 (4.7058.719) 7.074 (5.2449.542) 10.837 (7.91914.829) 19.091 (14.02925.979) 1.374 (0.7152.637) 1.673 (0.8643.242) 1.535 (0.8022.938) 1.096 (0.5612.143) 1.075 (0.8941.294) 0.970 (0.7171.311) 0.883 (0.7071.103) 0.907 (0.6571.252) 0.891 (0.7101.117) 0.982 (0.7831.233) 1.141 (0.8841.472) 1.634 (1.3851.927) 1.108 (0.8531.439) 1.497 (1.2201.837) 1.418 (1.0771.867) 0.87 (0.6921.086) 0.987 (0.7881.237) 0.853 (0.6431.130) 1.945 (1.0013.780) 2.222 (1.1534.284) 1.823 (0.9463.515) 1.327 (0.6662.645) 1.610 (0.8173.174) 1.938 (0.9753.855) 1.694 (0.8663.312) 1.148 (0.5742.298) 0.948 (0.7881.140) 0.989 (0.7281.344) 0.914 (0.7341.139) 0.929 (0.6741.281) 0.882 (0.7031.108) 0.947 (0.7561.186) 1.040 (0.8031.346) 6.425 (4.9218.389) 8.588 (6.08812.116)

Alcohol Caused or Exacerbated Emotional or Physical Problems: Past 12 Months [WS = 202210] Alcohol Caused Role Function Problems: Past 12 Months [WS = 206166]

Alcohol Caused or Exacerbated Emotional or Physical Problems: Past 12 Months [WS = 212140]

Alcohol Caused Role Function Problems: Past 12 Months [WS = 212125]

Alcohol Levels -Use: No Binge/Heavy -Past Month Binge -Past Month Heavy Average Number Drinks Past Month: -Less than 10 ->10 to 20 ->20 to 30 ->30 to 60 ->60 Age -18 to 25 -26 to 34 -35 to 49 -50 to 64

1.546 (1.1782.029) 3.747 (2.7805.050) 5.383 (4.0927.083) 9.157 (6.87712.194) 19.245 (14.72225.157) 2.458 (1.2604.797) 2.745 (1.4215.306) 2.113 (1.0944.083) 1.413 (0.7052.832) 1.442 (1.2261.696) 1.111 (0.8501.451) 1.554 (1.2631.911) 1.426 (1.0921.864) 0.847 (0.6781.060) 0.939 (0.7511.175) 0.761 (0.5761.005) (Continued on next page)

Male Gender

Race -Black/African American -Hispanic -Other Education -High School -Some College -College/Grad School

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200 Model 1 Model 2 Alcohol Caused or Exacerbated Emotional or Physical Problems: Past 12 Months [WS = 202210] Alcohol Caused Role Function Problems: Past 12 Months [WS = 206166] 1.160 (0.9541.410) 0.935 (0.7611.149) 0.866 (0.6811.101) 0.778 (0.5841.037) 0.733 (0.5021.071) 0.619 (0.4240.904) 0.675 (0.4491.105) 1.193 (0.9371.519) 0.761 (0.6340.914) 0.801 (0.4621.389) 2.399 (1.9912.891) 1.839 (1.5892.128) .092429 0.990 (0.7961.231) 0.941 (0.7331.209) 0.822 (0.6211.089) 0.724 (0.4881.075) 0.801 (0.5501.168) 0.890 (0.6091.302) 1.493 (1.1741.899) 0.746 (0.6100.912) 0.833 (0.4611.505) 2.703 (2.2033.317) 1.733 (1.4822.027) .069986 1.033 (0.8561.248) 1.014 (0.8401.223) 0.977 (0.7871.213) 0.931 (0.7241.198) 0.830 (0.6261.100) 0.749 (0.5051.110) 0.857 (0.5881.248) 0.955 (0.6521.398) 1.442 (1.1321.837) 0.749 (0.6130.915) 0.816 (0.4541.464) 2.694 (2.1893.315) 1.704 (1.4551.995) .069668 Alcohol Caused or Exacerbated Emotional or Physical Problems: Past 12 Months [WS = 212140] Alcohol Caused Role Function Problems: Past 12 Months [WS = 212125] 1.189 (0.9791.445) 0.953 (0.7791.167) 0.880 (0.6921.120) 0.774 (0.5781.036) 0.697 (0.4811.011) 0.571 (0.3910.832) 0.619 (0.4120.930) 1.262 (0.9921.605) 0.764 (0.6360.919) 0.812 (0.4681.410) 2.417 (2.0102.906) 1.916 (1.6542.221) .089539

TABLE 4 Logistic regression results for alcohol use and exacerbated emotional/physical or role function problems: P value Signcant at 0.01 (Continued)

Alcohol Use Patterns

Employment

Income -$10,000 to $19,999 -$20,000 to $29,999 -$30,000 to $39,999 -$40,000 to $49,999 -$50,000 to $75,000 -$75,000 and Above Insurance -Medicare & Medicaid -Private -Both Mental Health Symptoms Drug Use in Past Year Cox and Snell R Square

MODEL 3 shows the results of the regression equations that include the following: DEPENDENT VARIABLES [Alcohol Caused or Exacerbated Emotional or Physical Problems: Past 12 Months and Alcohol Caused Role Function Problems: Past 12 Months] with the INDEPENDENT VARIABLES [ALCOHOL LEVELS, Age, Gender, Race, Education, Employment, Income, Insurance, Mental Health Symptoms and Drug Use in past Year]. MODEL 4 shows the results of the regression equations that include the following: DEPENDENT VARIABLES [Alcohol Caused or Exacerbated Emotional or Physical Problems: Past 12 Months and Alcohol Caused Role Function Problems: Past 12 Months] with the INDEPENDENT VARIABLES [AVERAGE NUMBER DRINKS PAST MONTH, Age, Gender, Race, Education, Employment, Income, Insurance, Mental Health Symptoms and Drug Use in past Year].

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and drinking and driving. Overall, the odds ratios for alcohol risk declined with age. Males had increased odds ratios for alcohol use and driving. An increase in education led to increased odds ratios for drinking and driving. Mental health symptoms increased the odds of dangerous activities, and driving while drinking. Illicit drug use in the past year also predicted an increase in the odds ratios for alcohol and risk factors, and alcohol and driving.

Discussion and Policy Implications The most important nding of this study relates to the low levels of alcohol use (19 drinks per month) that increased the odds ratios for adverse outcomes associated with alcohol consumption. These reported levels of alcohol use were lower, when evaluated on a monthly average basis, than those levels recommended by the National Institute on Alcohol Abuse and Alcoholism of up to one drink per day for women and adults 65 years of age and older and two drinks per day for men below the age of 65 (National Institute on Alcohol Abuse and Alcoholism, 2004), and the Dietary Guidelines for Americans of up to one drink per day for women and two drinks per day for men (U.S Department of Health and Human Services, 2005). It is understood that these self-reported levels of past month alcohol consumption (19) do not depict the number of drinks consumed in a specic day due to limitations in the NSDUH 2003, and as recommended by the various agencies. This study also acknowledges that the self reports associated with the alcohol consequences dependent variables were based on a timeframe of the past 12 months and that the alcohol consumption independent variables were based on alcohol consumption reported in the past month. Respondents self-reports, however, in the NSDUH 2003 indicate that alcohol use in the past month without having indulged in either binge or heavy drinking was still a signicant nding in the study that showed increased odds ratios for alcohol caused or exacerbated emotional or physical problems, dangerous activities and driving while under the inuence of alcohol. In addition, binge drinking or heavy drinking in the past month were associated with a signicant increase in the odds ratios for each of the study outcomes: emotional/physical problems, role function problems, risk behaviors, and drinking and driving compared to those that report no alcohol use in the past month. The ndings from this study show the strong relationship between actual levels of alcohol and adverse consequences at a point in time. It is conceivable that individuals who experienced adverse outcomes associated with alcohol use prior to the past month have since reduced their alcohol intake and would not self report these same problems as occurring within the past month. Longitudinal research should be undertaken to understand how individuals who had adverse consequences respond to the negative consequences. Another important nding in the study is that alcohol use and mental health symptoms increased the odds of having alcohol re-

lated emotional or physical problems or role function problems. It also increased the odds of dangerous activities, and driving while drinking, controlling for the amount of alcohol used. Individuals with mental health symptoms may lack awareness about the synergistic effect of mental health symptoms and alcohol. In addition, it was not a surprise that illicit drug use in the past year also increased the odds ratios for all of the study negative outcomes (Kessler et al., 1994). Herd (1993) identied the predictors of alcohol related problems as the frequency of getting drunk, drinking to enhance the effects of drugs, or drinking to offset symptoms of sickness associated with drug use and heavy drinking (Herd, 1993). Male gender increased the odds ratios for role function problems, alcohol risk, and driving under the inuence of alcohol. Studies on drug abuse and dependence have mostly involved men and have lacked a gender focus. Animal studies show that females are more susceptible to developing drug addictions yet the rate of substance abuse and dependence is higher among men than women in human research (Biener, 1987; Fattore, Altea & Fratta, 2008; Hilton, 1987; Kessler et al., 1994; Robbins, 1989). An explanation could reside in role development factors such as social and cultural expectations (Fattore et al., 2008), though it also has been found that the gender gap may be narrowing with younger aged cohorts in measures of alcohol consumption (Keyes, Grant, & Hasin, 2008), and questions arise as to whether gender neutral evaluative scales are specic enough to identify female alcohol symptoms (Nichol, Kreuger, & Iacono, 2007). Importantly, research on psychiatric co-morbidities, neurobiology, etiology and epidemiology has identied differences in gender (Fattore et al., 2008) though additional research is needed that is more specic to evaluating areas such as brain dimorphism, hormones, pharmacokinetics and pharmacodynamics. An increase in income and educational levels led to increased odds ratios for drinking and driving. Although the NSDUH 2003 did not ask whether the amount of alcohol they consumed before driving was in excess of the legal limits or posed safety concerns, even small amounts of alcohol can impair driving. This suggests the need for greater educational efforts targeted to this population. It is important that policy continue to evaluate alcohol related mortality rates due to the reported 24,108 deaths associated with heavy episodic drinking (5 drinks on one occasion in the past 30 days) in 2000 (Rivara, Garrison, Ebel, McCarty, & Christakis, 2004), and because the economic cost of alcohol related morbidity and mortality has been estimated at $55 billion (Harwood, Fountain, & Livermore, 1998). This gure does not, however, address the additional $129 billion for specialty alcohol services, lost productivity due to morbidity, lost earnings due to crime, criminal justice and property damage costs, social welfare administration costs and re damage costs that can be dened as alcohols contribution to social consequences net of mortality cost and the medical cost of morbidity (Harwood et al., 1998). Furthermore, the ndings of Fillmore, Kerr, Stockwell, Chikritzhs, and Bostrom (2006) raise serious questions about

202 Model 3 Alcohol and Risk Behaviors [WS = 206072] 1.481 (1.1031.988) 6.920 (5.2749.080) 11.847 (8.62716.269) 8.458 (7.06410.127) 13.997 (10.97817.846) 1.519 (1.1312.040) 4.727 (3.4406.497) 7.624 (5.65710.276) 12.452 (9.50316.316) 21.503 (15.99028.916) 3.087 (1.4036.795) 2.371 (1.0825.194) 1.565 (0.7203.400) 0.971 (0.4242.222) 1.826 (1.5592.139) 1.057 (0.7951.405) 1.032 (0.8251.292) 0.978 (0.6771.413) 1.028 (0.8191.291) 1.191 (0.9461.499) 1.094 (0.8521.404) 1.435 (1.2841.604) 0.799 (0.6540.977) 0.719 (0.5950.870) 0.860 (0.6781.090) 1.631 (1.3661.947) 1.874 (1.5662.243) 2.070 (1.6882.539) 2.265 (1.4413.559) 2.047 (1.2983.227) 1.639 (1.0542.548) 1.137 (0.7221.791) 4.337 (1.9439.682) 3.289 (1.4867.279) 1.980 (0.9034.342) 1.112 (0.4802.577) 1.652 (1.4011.947) 1.063 (0.7951.420) 1.073 (0.8501.354) 0.988 (0.6891.415) 1.004 (0.8001.259) 1.122 (0.8931.411) 0.962 (0.7501.235) 2.566 (2.1223.103) 7.005 (5.7508.533) 9.271 (7.38911.633) 13.792 (11.31016.819) 19.347 (15.72323.807) 3.208 (2.0075.127) 2.882 (1.7944.630) 2.078 (1.3153.285) 1.302 (0.8132.085) 1.368 (1.2261.526) 0.832 (0.6811.018) 0.777 (0.6420.940) 0.891 (0.7041.128) 1.579 (1.3161.895) 1.736 (1.4402.092) 1.788 (1.4512.204) 2.880 (2.3883.473) Alcohol and Drive Vehicle [WS = 163436] Alcohol and Risk Behaviors [WS = 212028] Model 4 Alcohol and Drive Vehicle [WS = 169416]

TABLE 5 Logistic regression results for alcohol use and dangerous activities or driving or alcohol abuse/dependence. P value Signicant at 0.01

Alcohol Use Patterns & Select Independent Variables

Alcohol Levels -Use: No Binge/Heavy -Past Month Binge -Past Month Heavy Average Number Drinks Past Month: -Less than 10 ->10 to 20 ->20 to 30 ->30 to 60 ->60 Age -18 to 25 -26 to 34 -35 to 49 -50 to 64

Male Gender

Race -Black/African American -Hispanic -Other Education -High School -Some College -College/Grad School

Employment 1.085 (0.8861.328) 1.057 (0.8321.341) 0.944 (0.7271.227) 1.259 (0.9061.749) 0.951 (0.6881.315) 0.746 (0.4621.205) 1.189 (0.9221.532) 1.012 (0.8481.208) 1.086 (0.5921.989) 2.297 (1.9522.704) 1.953 (1.6812.270) .105911 0.923 (0.7631.117) 1.143 (0.9871.324) 0.819 (0.5581.204) 1.641 (1.4711.832) 2.550 (2.2612.876) .213766 1.375 (1.1691.618) 1.714 (1.4322.051) 1.606 (1.3061.975) 1.760 (1.4092.200) 1.599 (1.2811.996) 1.769 (1.3712.284) 1.094 (0.8951.336) 1.066 (0.8401.352) 0.929 (0.7141.208) 1.163 (0.8401.611) 0.858 (0.6191.190) 0.660 (0.4141.054) 1.270 (0.9801.645) 1.016 (0.8491.215) 1.095 (0.5932.021) 2.305 (1.9542.718) 2.032 (1.7482.362) .103837

1.101 (0.9171.322)

1.156 (0.9741.372)

1.140 (0.9511.368)

1.201 (1.0101.429) 1.379 (1.1721.623) 1.719 (1.4382.055) 1.581 (1.2891.940) 1.645 (1.3252.042) 1.475 (1.1811.844) 1.612 (1.2482.082) 0.986 (0.8131.195) 1.140 (0.9861.318) 0.843 (0.5681.251) 1.647 (1.4771.838) 2.600 (2.3142.921) .215521

Income -$10,000 to $19,999 -$20,000 to $29,999 -$30,000 to $39,999 -$40,000 to $49,999 -$50,000 to $75,000 -$75,000 and Above Insurance -Medicare & Medicaid -Private -Both Mental Health Symptoms Drug Use in Past Year Cox and Snell R Square

MODEL 3 shows the results of the regression equations that include the following: DEPENDENT VARIABLES [Alcohol and Risk Behaviors and Alcohol and Driving] with the INDEPENDENT VARIABLES [ALCOHOL LEVELS, Age, Gender, Race, Education, Employment, Income, Insurance, Mental Health Symptoms and Drug Use in past Year]. MODEL 4 shows the results of the regression equations that include the following: DEPENDENT VARIABLES [Alcohol and Risk Behaviors and Alcohol and Driving] with the INDEPENDENT VARIABLES [AVERAGE NUMBER DRINKS PAST MONTH, Age, Gender, Race, Education, Employment, Income, Insurance, Mental Health Symptoms and Drug Use in past Year].

203

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previous research conclusions regarding alcohols protective inuence, when used in moderation. These researchers point out that a systematic misclassication error was committed by including as abstainers many people who had reduced or stopped drinking, a phenomenon associated with aging and ill health. As a result, the lived experiences reported by respondents in this study must be taken into account when developing guidelines for alcohol use. Therefore, policy may be well advised to include additional criteria, such as self reported outcomes related to alcohol use, when developing recommendations. As an example, the Dietary Guidelines for Americans 2005 are predicated on alcohols relationship to mortality, and proles associated with macronutrients and micronutrients, thereby dispelling the importance of evaluating alcohols social consequences.

Nursing Role and Conclusion This study strongly underscores the importance for the nursing profession to become aware of the consequences associated with alcohol use at low levels of consumption, especially since there are an estimated 1.8 million hospital admissions each year that t DSM-IV criteria for an alcohol use disorder (Smothers, Harwood, & Yahr 2003). Unfortunately, it has been reported that documented evidence of an alcohol related disorder was present in only 40%42% of clients who had screened positive for a DSM-IV alcohol related disorder in a separate interview. Furthermore, intervention was provided for only 24% of these clients while referral to treatment occurred with 50%53% (Smothers, Harwood, & Yahr 2003). Given this evidence, the hospital environment must be utilized to evaluate clients for alcohol related problems (Smothers, Harwood, & Yahr, 2004) and nursing must lead. The literature describes the need for alcohol assessment in all practice settings where nursing is present, yet points out the lack of attention to developing protocols and support for nurses to perform in this capacity in emergency rooms (Cherpitel, 2006). In fact, studies associated with nurses performing alcohol assessment and/or intervention are sparse (Hyman, 2006) although brief intervention for alcohol is recognized as a nursing role and ts within nursings accountability toward health screening and promotion. In this regard, Lock, Kaner, Lamont, and Bond (2002) reported on primary care nurses engaging in alcohol assessment, yet stating that they are given little preparation to facilitate this process in terms of formal training as well as in being taught client interaction skills when discussing this sensitive topic. Additionally, a lack of self-efcacy, a fear of losing the nurse-client relationship (Johnsson, Akerlind, & Bendsten, 2005) and the time requirement associated with alcohol assessment and intervention (Holmqvist et al., 2008; Johansson, Akerlind, & Bendsten, 2005) were cited as reasons for nurses ambivalence toward alcohol screening even though they concede its importance (Holmqvist et al., 2008).

The expectation that the nursing profession will receive standardized protocols and organizational support from all health care environments they practice in, as relates to alcohol assessment, is an unrealistic expectation in the foreseeable future. Therefore, it is suggested that the individual nurse assume responsibility for self-directed education in the area of alcohol assessment and incorporate this knowledge into their practice, as they also assume a leadership role in the development of standardized alcohol assessment protocols in their respective practice settings. Alcohol withdrawal instruments such as the Clinical Institute Withdrawal Assessment-Alcohol (CIWA-A) and Clinical Institute Withdrawal Assessment-Alcohol Revised (CIWA-Ar), etc. can be found in the literature. Likewise, the alcohol assessment instruments such as the Cut down, Annoyed by critics, Guilt about drinking, Eye opener in the morning (CAGE), Alcohol Use Disorders Identication Test (AUDIT), and Michigan Alcohol Screening Test (MAST), etc., along with variations of these instruments and others also can be found in the literature. It is incumbent upon the nurse to identify an instrument that has been researched for their client population and care environment, and that has credible psychometric values for instrument validity and reliability. Furthermore, the instruments rationale, strengths and limitations, as well as the methodology for conducting the assessment must be part of the nurses learning. The nurse also should be aware that specic demographic variables play a contributory role in alcohol use and that knowledge of these variables is important in guiding the assessment. For instance, in many cases of alcohol abuse the client may also have a history of a co-morbid psychiatric and/or illicit drug use. Problems related to alcohol may be associated with the clients self-medicating behaviors. In addition, clients take medications that should not be taken with alcohol, or may be older adults whose physiological changes and medication interactions are cause for great alarm when mixed with alcohol. In these circumstances it is important to understand that any amount of alcohol could have adverse consequences for the client. Teaching can also be provided by the nurse in regard to the fact that higher education and income increases the odds ratio for drinking and driving and that male gender presents as a higher likelihood for alcohol related use and problems. The role of the nurse in the process of alcohol assessment involves the nurse-client relationship, requisite knowledge, and interdisciplinary collaboration. As it relates to the nurse-client relationship, the nurse must trust that the therapeutic relationship will survive the alcohol assessment. Requisite knowledge refers to the application of the assessment instrument and the interpretation of results. Interdisciplinary collaboration refers to the dissemination of the assessment ndings and referral of clinical responsibilities to appropriate team members. As an example, this would mean that the Nurse Practitioner, Clinical Nurse Specialist or MD is responsible for the history and physical, detoxication protocols, and diagnostic evaluations such as laboratory tests. The psychiatrist would be responsible for

FACTORS ASSOCIATED WITH ALCOHOL USE AND ITS CONSEQUENCES

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psychiatric evaluations and psychotropic medication management and the social worker would be tasked with treatment referrals. The nurse would generate the referrals to the team members while also monitoring the client for alcohol withdrawal symptoms with the CIWA-A or CIWA-Ar. In this manner, the issues of self-efcacy, fear of losing the nurse-client relationship, lack of organizational protocols and time constraints associated with alcohol assessment can be mitigated, and the nursing role is maximized by allowing for the immediate assessment of alcohol abuse within more nursing practice settings. DECLARATION OF INTEREST The authors report no conicts of interest. The authors alone are responsible for the content and writing of this paper.

REFERENCES
Archer, L., Dawson, D., Grant, B. (1995). What if Americans drank less? The potential effect on the prevalence of alcohol abuse and dependence. American Journal of Public Health, 85, 6166. Biener, L. (1987). Gender differences in the use of substances for coping. In: Barnett, R.C., Biener, L., and Baruch, G.K. (Eds) Gender and stress. pp. 330 349. New York: Free Press. Butters, J., Smart, R., Mann, R., & Asbridge, M. (2005). Illicit drug use, alcohol use and problem drinking among infrequent and frequent road ragers. Drug and Alcohol Dependence, 80, 169175. Campbell, J., Hagan, H., Latka, M. et al. (2006). High prevalence of alcohol use among hepatitis C virus antibody positive injection drug users in three U.S. cities. Drug and Alcohol Dependence, 81, 259265. Castilla, J., Barrio, G., Belza, M., & Fuente, L. (1999). Drug and alcohol consumption and sexual risk behavior among young adults: results from a national survey. Drug and Alcohol Dependence, 56, 4753. Chermack, S., & Blow, F. (2002). Violence among individuals in substance abuse treatment: the role of alcohol and cocaine consumption. Drug and Alcohol Dependence, 66, 2937. Cherpitel, C. (2006). Screening and brief intervention for alcohol problems in the emergency room: is there a role for nursing? Journal of Addictions Nursing, 17, 7982. Dawson, D. (1999). Alternative denitions of high risk for impaired driving: the overlap of high volume, frequent heavy drinking and alcohol dependence. Drug and Alcohol Dependence, 54, 219228. Dawson, D., Grant, B., & Hartford, T. (1995). Variation in the association of alcohol consumption with ve DSM-IV alcohol problem domains. Alcohol Clinical Experimental Research, 19(1), 6674. Day, E., Best, D., Sweeting, R., Russell, R. et al. (2008). Detecting lifetime alcohol problems in individuals referred for liver transplantation for nonalcoholic liver failure. Liver Transplantation, 14, 16091613. Edwards, G., & Gross, M. (1976). Alcohol dependence: provisional description of a clinical syndrome. British Medical Journal, 8(2), 171183. Flensborg-Madsen, T., Knop, J., Mortensen, E. et al. (2009). Alcohol use disorders increase the risk of completed suicideIrrespective of other psychiatric disorders, A longitudinal cohort study. Psychiatry Research, 50(4), 30714. Fattore, L., Altea, S., & Fratta, W. (2008). Sex differences in drug addiction: a review of animal and human studies. Womens Health, 4(1), 5165. Fillmore, K., Kerr, W., Stockwell, T., Chikritzhs, T., & Bostrom, A (2006). Moderate alcohol use and reduced mortality risk: Systematic error in prospective studies. Addiction Research and Theory, 14(2), 101132. Grant, B., & Hartford, T. (1995). Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey. Drug and Alcohol Dependence, 39, 197206.

Harwood, H., Fountain, D., & Livermore, G. (1998). Economic costs of alcohol abuse and alcoholism. Recent Developments in Alcoholism, 14, 307 330. Hauser, E., Mooser, V., Crossman, D., Haines, J., Jones, C., Winkelman, B., Schmidt, S., Scott, W., Roses, A., Pericak-Vance, M., Granger, M., & Kraus, W. (2003). Design of the genetics of early onset cardiovascular disease (GENECARD) study. American Heart Journal, 145, 602613. Herd, D. (1993). Correlates of heavy drinking and alcohol related problems among men and women in drug treatment programs. Drug and Alcohol Dependence, 32, 2535. Hilton, M.E. (1987). Drinking patterns and drinking problems in 1984: Results from a general population survey. Alcoholism, 11, 167175. Holmqvist, M., Bendtsen, P., Spak, F. et al. (2008). Asking patients about their drinking: A national survey among primary health care physicians and nurses in Sweden. Addictive Behaviors, 33, 301314. Hyman, Z. (2005). Brief interventions for high-risk drinkers. Journal of Clinical Nursing, 15, 13831396. Jennison, K. (2004). The short-term effects and unintended long-term consequences of binge drinking in college: a 10-year follow-up study. The American Journal of Drug and Alcohol Abuse, 30, 659684. Johnsson, K., Akerlind, I., & Bendtsen, P. (2005). Under what circumstances are nurses willing to engage in brief alcohol interventions? A qualitative study from primary care in Sweden. Addictive Behaviors, 30, 10491053. Kessler, R., Crum, R., Warner, L., Nelson, C., Schulenberg, J., & Anthony, J. (1997). Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the national co morbidity survey. Archives of General Psychiatry, 54, 313321. Kessler, R., McGonagle, K., Zhao, S. et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 819. Keyes, K., Grant, B., & Hasin, D. (2008). Evidence for closing gender gap in alcohol use, abuse, and dependence in the United States population. Drug and Alcohol Dependence, 93, 2129. Kilpatrick, D., Acierno, R., Saunders, B., Resnick, H., & Best, C. (2000). Risk factors for adolescent substance abuse and dependence: Data from a national sample. Journal of Consulting and Clinical Psychology, 68(1), 1930. LaPlante, M. (2002). The prevalence of mental health disability in adults. Disability Statistics Center, Institute for Health and Aging, University of California, San Francisco. Lipsky, S., Caetano, R., Field, C., & Larkin, G. (2005). Psychosocial and substance-use risk factors for intimate partner violence. Drug and Alcohol Dependence, 78, 3947. Locke, C., Kaner, E., Lamont, S., & Bond, S. (2002). A qualitative study of nurses attitudes and practice regarding brief alcohol intervention in primary health care. Journal of Advanced Nursing, 39(4), 333342. Lucey, M., & Weinrieb, R. (2009). Alcohol and substance abuse. Semin Liver Dis., 29(1), 6673. Martens, J., Lu, Y., Parthasarathy, S., Moore, C., & Weisner, C. (2003). Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO. Archives of Internal Medicine, 163, 25112517. Midanik, L., Tam, T., Greeneld, T., & Caetano, R. (1996). Risk functions for alcohol-related problems in a 1988 U.S. national sample. Addiction, 94, 649663. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Division of Biometry and Epidemiology. Alcohol Epidemiologic Data Directory (2001). CSR Incorporated Washington, DC. Contract No. NO1-AA-8-2014. Nichol, P., Krueger, R., & Iacono, W. (2007). Investigating gender differences in alcohol problems: a latent trait modeling approach. Alcoholism Clinical and Experimental Research, 31(5), 783794. Reiger, D., Farmer, M., Rae, D. et al. (1990). Co morbidity of mental disorders with alcohol and other drug abuse: Results from the epidemiologic catchment area (ECA) study. The Journal of the American Medical Association, 264(19), 25112518.

206

M. D. ALAMEIDA ET AL. sions, United States, 1994. Archives of Internal Medicine, 163, 713 719. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th Edition, Washington, DC: U.S. Government Printing Ofce, January 2005. U.S. Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, Ofce of Applied Studies. NATIONAL SURVEY ON DRUG USE AND HEALTH, 2003 [Computer File]. ICPSR version. Research Triangle Park, NC: Research Triangle Institute [producer], 2004. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2004. Wines, J., Saitz, R., Horton, N., Lloyd-Travaglini, C., & Samet, J. (2004). Suicidal behavior, drug use and depressive symptoms after detoxication: a 2-year prospective study. Drug and Alcohol Dependence, 76S, S21S29.

Rivara, F., Garrison, M., Ebel, B., McCarty, C., & Christakis, D. (2004). Mortality attributable to harmful drinking in the United States, 2000. Journal of Studies on Alcohol, 65(4), 5306. Robbins, C. (1989). Sex differences and psychosocial consequences of alcohol and drug abuse. Journal of Health and Social Behavior, 30, 117130. Russell, M., Light, J., & Gruenewald, P. (2004). Alcohol consumption and problems: the relevance of drinking patterns. Alcoholism: Clinical and Experimental Research, 28(6), 921930. Saremi, A., & Arora, R. (2008). The cardiovascular implications of alcohol and red wine. American Journal of Ther., 15(3), 265277. Smothers, B., Yahr, H., & Ruhl, C. (2004). Detection of alcohol use disorders in general hospital admissions in the United States. Archives of Internal Medicine, 164, 749756. Smothers, B., Yahr, H., & Sinclair, M. (2003). Prevalence of current DSM-IV alcohol use disorders in short-stay, general hospital admis-

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