AIMS:We investigated the presence of social inequalities of alcohol use and misuse using educational attainment as an indicator of socio-economic status in 15 countries: Sweden, Norway, Finland, Germany, The Netherlands, Switzerland, Hungary, the Czech Republic, Israel, Brazil, and Mexico.METHODS:Study surveys were independently conducted and the data centrally analysed. Most samples were national. Survey modes and sample sizes varied. The age range was restricted to between 25 and 59 years of age. Socio-economic status was measured by educational level. Multiple logistic regressions were employed to calculate age-adjusted odds ratios for men and women in each country by educational level for current drinking status, heavy drinking (>or=20 g ethanol per day for women, >or=30 g a day for men), heavy episodic (binge) drinking, and alcohol-related problems (using AUDIT).RESULTS:Men and women demonstrated similar patterns in inequalities with regard to current drinking status within a country. In Germany, The Netherlands, France, Switzerland, and Austria higher educated women were most likely to drink heavily, while among men the lower educated were more at risk in most countries. For heavy episodic drinking, almost no significant differences were evident among women, but for men a social gradient was observable with lower educated being more at risk in several countries. Among five countries with data from the AUDIT, men of lower education in Finland, Czech Republic, and Hungary had higher risks to report problems. Nordic countries shared a common pattern in social inequalities as did two Latin American countries, while a mixed picture was observed for middle European countries. Social inequalities in the two Latin American countries display a pattern emerging in other research on developing countries: namely that those in the higher educated groups are more likely to consume alcohol in a risky manner.CONCLUSIONS:Patterns in the distribution of social inequalities are not universal. Social inequalities in alcohol use differ by gender according to alcohol measure used and differ also across groups of countries. These variations should be taken into account when formulating international and cross-cultural alcohol policies.
Aims: First, this paper investigates (i) gender differences in associations of social stratification, family roles, and heavy drinking, and (ii) country differences in these associations. Second, it seeks to explain country differences in the associations of social stratification and family roles with alcohol consumption by societal level variables. Methods: Survey data of 25 to 49-years-old from eight European countries were used. Logistic regressions were used to analyse gender differences in the association between family roles (marriage, having children), social stratification (education, employment), and heavy drinking (>20 g/day for women; 30 g/day for men). Gender differences were tested by means of interactions between gender and social stratification/family roles. Structural measures of work desirability, social welfare, and gender equity were used to explain differences in associations across countries. Results: The associations between social stratification, family roles, and heavy drinking varied across gender and countries. A country's social welfare system was associated with heavy drinking only among women. Women in countries with a strong social welfare system, such as Nordic countries, tended to drink more heavily if employed, having lower formal education, and a non-traditional family role. In countries with weak social welfare systems or work desirability, heavy drinking was associated with high education, while effects of family roles and employment were small. Conclusions: It appeared that the social welfare system and gender equity of a country determines to a large extent how education, employment, and family roles are associated with heavy drinking.
AIMSTo compare drinking habits and to examine differences between drinking cultures in different regions and countries in Europe; to examine gender differences in drinking habits and to compare them over countries.METHODSData consisted of independently conducted, centrally analysed surveys in the general population aged 20-64 years in 14 European countries. Central measures were abstention, frequency and volume of drinking overall and by beverage type, amounts drunk per drinking day, and heavy episodic drinking.RESULTSThere were clear gender differences in all drinking measures, except for wine drinking. Differences between genders were often smaller than average in northern Europe. Gender ratios did not show systematic changes by age, with the exception that young men and women differed less than older men and women in the frequency of heavy episodic drinking. The results on beverage preferences indicate that the distinction among wine/beer/spirits cultures have implicitly been based on male drinking. Our expectation was for more daily light drinking integrated in everyday life in the Mediterranean countries, more heavy episodic drinking associated with weekends and celebrations in the North, with the traditional beer countries somewhere in between. The differences observed were usually in the direction expected. However, no country represented an ideal type of drinking culture, i.e. drinking for 'mood-changing effects' only or for 'nutritional purposes' only; all countries were mixtures of these two extremes.CONCLUSIONSThere were clear and consistent gender differences in all countries, while the differences in drinking between countries and regions were not as obvious.
AIMS:To identify the pattern of gender differences in drinking across societies, and to its association with other societal characteristics.METHODS:The aggregated results of GENACIS project surveys in 29 countries were examined and were compared with other characteristics of these societies.RESULTS:In all the participating societies men's drinking was more prevalent and heavier than women's drinking. Differences between countries in the gender gap in drinking were strongly associated with women's position in society, as well as with modernization. Similar results were obtained for indicators of alcohol's adverse consequences.CONCLUSIONS:Gender differences should be studied not only as individual behaviours, but also as societal traits, associated with other characteristics of the social system.
Aims: This study explored the suitability of the Alcohol Use Disorder Identification Test (AUDIT) for cross-national comparable estimates of problem drinking in general populations. On the item level the focus is on responsiveness to cross-national and gender differences. For the set of items the focus is on intercorrelations between items, indicating to what extent the AUDIT constitutes a scale. Methods: General population surveys from nine European countries were included. Cross-tabulations were used to analyse cross-national and gender differences in scores on the items. Reliability analysis was used to analyse intercorrelations between the items. Results: The items ‘blackouts’ (men and women) and ‘guilt and remorse’ (women) are the most frequently reported consequences. Gender differences tended to be smaller for ‘guilt and remorse’ and ‘concern of others’, and largest for ‘morning drinking’. The reliability analysis shows that in eight of the nine countries frequency of drinking lowers the alpha. Injury and concern of others lead to a lower internal consistency in three countries. Conclusions: There was sufficient variation between countries in the pattern of responses and variation in gender differences to conclude that the set of consequence items was responsive to national and gender differences in problem drinking. Frequency of drinking was not a good indicator of problem drinking. The country differences in item total correlations of consequences might be due to differences in how these items are interpreted. Decisions on which items to include in an instrument to allow comparison of estimates of problem drinking cross-nationally require studies on how these items are interpreted in general populations of different countries.
This paper provides an introduction to a series of articles reporting results from the EU concerted action "Gender, Culture and Alcohol Problems: A Multi-national Study" which examined differences in drinking among women and men in 13 European and two non-European countries. The gender gap in alcohol drinking is one of the few universal gender differences in human social behavior. However, the size of these differences varies greatly from one society to another. The papers in this issue examine, across countries, (1) men's and women's drinking patterns, (2) the prevalence of men's and women's experience of alcohol-related problems, (3) gender differences in social inequalities in alcohol use and abuse, (4) gender differences in the influence of combinations of social roles on heavy alcohol use, and (5) how societal-level factors predict women's and men's alcohol use and problems on a regional and global level. Country surveys were independently conducted and then centralized at one institution for further data standardization and processing. Several results indicated that the greater the societal gender equality in a country, the smaller the gender differences in drinking behavior. In most analyses the smallest gender differences in drinking behaviour were found in Nordic countries, followed by western and central European countries, with the largest gender differences in countries with developing economies.
Scottish mental health legislation permits 'guardianship' for certain mentally impaired individuals, which imposes a requirement on place of residence, access and attendance at specified services for treatment and rehabilitation. The use of guardianship for alcohol-related brain damage increased steeply in the years 1993-1998. Possible explanations include: (1) increased prevalence or diagnosis of these conditions; (2) reduction of hospital beds; (3) a trend towards diminishing family and social support; (4) increased social work involvement in caring for such individuals; (5) increased consideration of the use of guardianship; (6) new private residential services; (7) lack of interest in the condition by existing services. There have been legal and clinical concerns about such individuals under guardianship relating to quality of ongoing clinical assessment, need for specific treatment and for the management of associated psychiatric illness, issues over control of drinking and control of personal finances, uncertainty over the use of restraint, and need for programmes helping the individual's progress towards independent living.
The classic signs of vitamin deficiency only occur in states of extreme depletion and are unreliable indicators for early treatment or prophylaxis of alcoholic patients at risk. Post-mortem findings demonstrate that thiamine (vitamin B1) deficiency sufficient to cause irreversible brain damage is not diagnosed ante mortem in 80-90% of these patients. The causes of vitamin deficiency are reviewed with special attention to the inhibition of oral thiamine hydrochloride absorption in man caused by malnutrition present in alcoholic patients or by the direct effects of ethanol on intestinal transport. As the condition of the patient misusing alcohol progresses, damage to brain, liver, gastrointestinal tract, and pancreas continue (with other factors discussed) to further compromise the patient. Decreased intake, malabsorption, reduced storage, and impaired utilization further reduce the chances of unaided recovery. Failure of large oral doses of thiamine hydrochloride to provide an effective treatment for Wernicke's encephalopathy emphasizes the need for adequate and rapid replacement of depleted brain thiamine levels by repeated parenteral therapy in adequate doses.
Surveys of new long-stay mental hospital patients in Scotland find that 9% have a diagnosis of alcohol-related brain damage, mainly Korsakoff's psychosis (KP), whereas the rate was 5% in the old long-stay patients. The national hospital database shows a rise in rates of KP in figures for discharge diagnosis and for diagnosis of hospital residents during the past three decades. There is an argument for more specialized provision given the significance of this group of patients.
A survey of the use of thiamine in patients at risk from Wernicke-Korsakoff syndrome (WKS) in Scottish specialist neurosurgical units, and a 2-year retrospective study of 218 at-risk patients admitted to a regional neurosurgical unit with a head injury were undertaken. Although responses to the survey indicated otherwise, the study revealed that there was no consistent practice regarding thiamine administration. Overall, 20.6% of patients received thiamine, with an alcohol history being the only factor correlating with thiamine administration. Of known alcoholics and heavy drinkers, 56.1% and 26.2% respectively received thiamine as in-patients; 44.5% of patients received additional carbohydrate loads in the form of i.v. dextrose or parenteral nutrition, but only 28.9% of these received thiamine as well. Although the actual thiamine status of these patients was not known, given the difficulties of diagnosing WKS in the presence of a head injury, the conclusion is that written protocols are needed in units to ensure that head injury patients at risk of WKS receive appropriate thiamine treatment or prophylaxis.
Wernicke's encephalopathy (WE) is both common and associated with high morbidity and mortality and yet there is evidence that appropriate and effective prophylaxis and treatment are often not given. Effective treatment and prophylaxis may only be achieved by use of parenteral vitamin supplements, since oral supplements are not absorbed in significant amounts. Although there are rare anaphylactoid reactions associated with the use of parenteral thiamine preparations, the risks and consequences of inadequate prophylaxis and treatment, in appropriately targeted groups of patients, are far greater. It is therefore proposed that all in-patient alcohol withdrawal should be covered by prophylactic use of parenteral thiamine, that there should be a low threshold for making a presumptive diagnosis of WE, and that there is a need for guidelines to assist physicians in appropriate management of this common clinical problem.
The proportion of patients with Korsakoff psychosis (KP) who have a history of Wernicke's encephalopathy is smaller in recent studies compared to previous studies. Neuropsychological tests, magnetic resonance imaging (MRI), and single photon emission computed tomography were conducted in eight patients with KP, only four of whom had had a documented Wernicke episode. All subjects showed amnesia without intellectual deterioration. MRI abnormalities were seen in each group to the same extent (atrophy of mammillary bodies, to a less extent thalamus and some generalized gyral atrophy). No MRI measure differentiated the groups. Cerebral blood flow showed reduction of flow to the anterior temporal regions bilaterally, extending to the parietal lobes, to the same degree in each group. Despite the small number of patients examined, the study supports the belief that patients with an insidious onset of KP have the same pathology as those with classical Wernicke-Korsakoff syndrome. This raises the question of whether episodes of alcohol withdrawal without adequate thiamine protection result in occasionally subclinical Wernicke's events, followed by a subsequently diagnosable KP.
Results from studies of pharmacotherapies for primary alcoholism are reviewed, including selective serotonin (5-hydroxytryptamine, 5-HT) reuptake inhibitors (e.g. fluoxetine), opiate antagonists (e.g. naltrexone) and dopamine agonists (e.g. bromocriptine). Because there is considerable comorbidity between alcohol dependence, anxiety, and affective disorders, results from studies of medications used to treat these psychiatric disorders are also reviewed, including the 5-HT agonist buspirone and the noradrenergic agent desipramine. The neurobehavioural model of alcohol dependence implies that combinations of medications may lead to more effective treatment; thus, identifying subtypes of alcoholic patients will be important in determining which therapies or combinations of therapy will be most effective in treating alcohol dependence. For example, in an ongoing study, we are attempting to subtype an alcoholic population for treatment selection by measuring endogenous opioid activity. Because endogenous opioids are involved in analgesia, we exposed male and female subjects with alcoholism [some of whom had post-traumatic stress disorder (PTSD)] to cold-induced pain and measured their response before and after administration of naloxone or placebo. The naloxone injection reduced pain response. In addition, women who have PTSD are much more sensitive to stress, which may be related to levels of brain opioid activity.
We investigated the endogenous opioid system and its role in mediating the reinforcing effects of ethanol that lead to high ethanol consumption as a biochemical marker of an individual's vulnerability to excessive ethanol consumption. We performed studies using human subjects with [high risk (HR)] and without [low risk (LR)] a family history of alcoholism to supplement our studies with experimental animals bred selectively for high- or low-ethanol consumption. HR subjects had lower basal plasma beta-endorphin levels as compared with LR subjects, but they had a more pronounced release of beta-endorphin after exposure to ethanol. Findings from animal studies indicated that ethanol-preferring (C57BL/6) mice (analogous to the HR human subjects) had higher levels of hypothalamic beta-endorphin activity than did ethanol-avoiding (DBA/2) mice (analogous to the LR human subjects) under basal conditions. However, the C57BL/6 mice had a more pronounced release of hypothalamic beta-endorphin than did DBA/2 mice after exposure to ethanol. Thus, although hypothalamic beta-endorphin system activity in human and animal models of alcoholism differs under basal conditions, there is enhanced hypothalamic beta-endorphin system activity after exposure to ethanol in both models. We have also performed studies comparing the density and distribution of opioid receptors in brains of ethanol-preferring animals, such as C57BL/6 mice and ALKO-alcohol (AA) rats, and ethanol-avoiding animals, such as DBA/2 mice and ALKO-non-alcohol (ANA) rats. Interestingly, it was observed that in distinct brain regions known to be important for mediating the process of reinforcement, the C57BL/6 mice had a higher density of delta-opioid receptors than the DBA/2 mice, while the AA rats had a higher density of mu-opioid receptors than the ANA rats. Thus, in the ethanol-preferring animals, the increased release of beta-endorphin following exposure to ethanol was associated with a higher density of delta- or mu-opioid receptors in brain regions important for reinforcement, such as the nucleus accumbens and the ventral tegmental area, and may interact with the dopaminergic system and promote ethanol's reinforcing properties, leading to excessive drinking and alcoholism.
Standard treatment for alcohol abuse may include pharmacotherapy to alleviate withdrawal symptoms followed by psychotherapy in inpatient and/or outpatient settings. Treatment goals include abstinence and reduced alcohol consumption. Standard treatment for alcoholism has a high rate of success in Germany; however, for various reasons, only a small percentage of alcoholic patients are admitted to alcoholism treatment programmes. A new drug, acamprosate, could benefit many more alcoholic patients. Several studies indicate that acamprosate reduces the craving for alcohol and enhances abstinence. Acamprosate's effect is dose-dependent and it has a few minor side-effects. In addition, the availability of acamprosate may enable family practitioners to play an increasingly important role in the treatment of alcoholic patients, thus allowing more patients to receive treatment.
Specific laboratory tests can be used to identify patients who are alcohol-dependent. The laboratory values of a number of biological 'markers', including carbohydrate-deficient transferrin, are often elevated in cases of chronic and acute alcohol abuse. Trait markers reflect a predisposition for alcoholism; state markers reflect actual alcohol consumption. It has been suggested that state markers can be subdivided into screening and relapse markers, and even further subdivided into pre-relapse markers, i.e. craving markers. We hypothesize that methanol metabolism and the presence of condensation products in the blood may serve as state and pre-relapse markers for alcoholism. Since the sensitivities and specificities of laboratory screening tests vary, and an absolute marker for alcoholism has yet to be identified, research in the area of biological markers for alcoholism should continue.
The US National Institute on Alcohol Abuse and Alcoholism (NIAAA) recognizes two forms of problematic drinking: 'willful alcohol abuse', a behavioural problem, and 'alcohol dependence', a true medical disorder, which includes a genetic component, that can be scientifically understood and medically treated. Current biomedical research has linked specific neurotransmitters to certain effects of alcohol that are unique to alcoholics. An inadequate flow of information between the victims of alcoholism, researchers, and the public has impeded further exploration of the genetic and neurochemical underpinnings of alcohol dependence. This is due in part to continuing misconceptions about alcohol dependence, not only among the general public, but within the scientific and medical communities as well. Consequently, compared to other diseases, research in alcohol dependence is proceeding with less urgency despite its relatively high economic and social costs. Incorporating the input of recovering alcoholics into future research agendas can help to ensure relevant scientific investigation and the delivery of a more accurate and consistent message to the public with regard to alcoholism.
Studies on the genetic basis of addiction indicate that the tendency to develop alcoholism is inherited. In addition, alcoholism appears to be associated with a specific neurochemical disorder. Research has focused on the mesolimbic system, which is associated with the ability to feel pleasure (i.e. hypothalamic control centres are related to daily survival activities, and the medial forebrain bundle is involved in the positive reinforcement of addictive drugs). Current findings support the hypothesis that a neurochemical deficiency causes alcohol-dependent individuals to drink. Thus, pharmacotherapy may play an important part in treating those who are not helped by psychosocial therapy alone. Future therapies may include agents that block, enhance, or normalize neurotransmitter function as well as genetically engineered agents that could target a specific cause of alcoholism.
Numerous neurotransmitter systems [e.g. dopamine, gamma-aminobutyric acid (GABA), the endogenous opioids, and serotonin (5-hydroxytryptamine, 5-HT)] are involved in the regulation of alcohol consumption. Because 5-HT reuptake inhibitors and opioid antagonists modify the activity of neurotransmitters, it has been hypothesized that they may also mediate the desire to drink alcohol by acting on specific receptors in the brain. Animal studies have shown that concomitant administration of 5-HT and opioid antagonists reduces alcohol consumption; therefore, the combined use of several pharmacotherapies may be the most effective treatment for alcohol dependence.
Animal studies have demonstrated that alcohol changes neurotransmitter concentrations in the brain. These changes in levels of dopamine, serotonin, gamma-aminobutyric acid (GABA), endogenous opioid peptides, and noradrenaline are associated with activation of reward centres in the brain. It is this property of alcohol that is believed to be responsible for the reinforcing effect of alcohol consumption in rats. One class of neurotransmitters, the endogenous opioid peptides, are believed to play an important role in alcohol reinforcement. This view is supported by the reduced preference for alcohol consumption found in rats given an opiate agonist. The widely distributed inhibitory neurotransmitter GABA is also believed to play a fundamental role in mediating the effects of alcohol. A better understanding of the mechanisms that support alcohol dependence in animals offers hope for the development of pharmacological interventions to block these mechanisms, an approach that is now being explored in humans.
