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Manual of Articles Sections 8 - 18
Alcohol is the most common socially accepted psychoactive substance in use today. In 1998, 45% of women and 59% of men reported alcohol use in the prior month. Although alcohol use is greater among adult men than women, among adolescents, use is approximately equal between genders. In primary care, 10% of female patients and 15% to 20% of male patients are either experiencing or at risk for experiencing alcohol-related problems.
In a general practice, alcoholism prevalence rates approach 20%, similar to rates of other chronic diseases; however, alcoholism continues to be underdiagnosed. Historically, clinicians have identified alcoholism-associated symptoms such as heart disease, cancer, traumatic injury, and depression, but have failed to identify the disease itself. Underdiagnosis persists regardless of ethnicity, race, gender, or socioeconomic status, but the pattern of underdiagnosis is particularly notable in women.
The standard diagnostic definition of alcoholism is the American Psychiatric Association's Diagnostic and Statistical Manual-IV (DSM-IV) criteria (see Table 1). Alcoholism may be characterized as a persistent inability to control drinking coupled with significant negative consequences. Negative consequences include but are not limited to disruptions in interpersonal relationships and economic and legal complications. In 1997, more than 4 million adult women met the diagnostic criteria for alcohol abuse or alcohol dependence compared to approximately 11 million men.
The National Institutes of Alcohol Abuse and Alcoholism defined low-risk drinking for women as no more than one drink per day, two drinks per occasion, seven drinks per week, and no use in risky situations. Women who are considered at-risk drinkers may occasionally exceed the recommended guidelines, but they do not generally experience negative consequences from alcohol use. These women may have a personal or family history of alcohol-related problems but negative results to the CAGE questionnaire.
Women who drink more than recommended (more than seven drinks per week or more than three drinks per occasion), have one to two positive responses to the CAGE questionnaire within a year, and show evidence of alcohol-related medical or behavioral problems are considered problem drinkers. These women meet the DSM-IV criteria for alcohol abuse and often have drinking-related problems such as driving under the influence, job loss, and family disruptions; however, these women do not meet the diagnostic criteria for alcohol dependence.
This distinction is critical because brief interventions with women who are at risk or problem drinkers can result in a reduction in drinking patterns to moderate levels. A metaanalysis of 32 brief intervention studies found that 27% of patients who received brief interventions reported positive changes in their drinking habits.
Physiological differences in the metabolism of alcohol have important implications. Research suggests that women exhibit a “telescoped” or more rapid development of alcoholism with fewer drinking years than do men. Women generally begin to become intoxicated at a later average age than men (26.5 versus 22.7), experience their first drinking problems later than men (27.5 versus 25), and exhibit loss of control over their drinking at a later average age (29.8 versus 27.2).
Women progress faster than do men between first getting intoxicated regularly and first encountering drinking problems (0.9 years versus 2.3 years) and between first losing control of drinking and onset of drinking problems (5.5 years versus 7.8 years). Researchers conclude that the phenomena of telescoping are robust and consistent with other studies.
The morbidity and mortality data on alcoholism reflect this phenomena. Female alcoholics have death rates 50% to 100% higher than those of male alcoholics. Female alcoholics develop alcoholic liver disease at lower levels of intake and over shorter periods of time when compared with men (P ≤ .001).[ 10] In women, liver disease progresses from alcoholic hepatitis to cirrhosis at a faster rate than it does in men. A greater percentage of female alcoholics die from suicide, alcohol-related accidents, circulatory disorders, and cirrhosis of the liver than do men.
Fetal Alcohol Syndrome
According to a national survey, 18.8% of pregnant women reported drinking alcohol during pregnancy. Unfortunately, the incidence of pregnant women drinking alcohol has increased over the past several years. In 1995, 3.5% of pregnant women reported drinking seven or more alcoholic drinks per week or five or more drinks on at least one occasion compared with 0.8% in 1991.
Other Risk Factors
In adolescence, differences in substance abuse between genders appear to be lessening. In a 1996 Massachusetts school survey, 54% of young women in grades 9 to 12 were using alcohol compared with 50% in 1993. Current alcohol use among female 7th and 8th graders rose slightly in 1996 to 28%, nearly equal the rate of use among young men (29%).
Women who are single, divorced, separated, or cohabitating are more likely to have alcohol-related problems than married or widowed women. Women are more likely than men to be influenced by their partner's, sibling's, or close friend's drinking habits. Clinically, an association exists between a partner's drinking behavior and the drinking behavior in women. Men, however, are more likely to have partners who do not abuse alcohol.
Women who have multiple roles have a lower incidence of alcohol problems than do women who experience role deprivation. For example, married women who work outside the home have fewer alcohol-related problems than women who have experienced a role loss, such as women whose children have left home.
Caucasian women are more likely to abuse alcohol followed by Hispanic and then African-American women. Lesbian women appear to have higher rates of alcoholism than do heterosexual women. Women suffering from prescription drug abuse are also more likely to have alcohol-related problems when compared with women who are not abusing prescription drugs.
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