Searching for the Gold Standard
If a person drinks five or more alcoholic beverages every day, is that person an alcoholic? The answer, according to Curators Distinguished Professor of Psychological Sciences Kenneth J. Sher, is maybe, maybe not. Sher was curious about the association between daily drinking and various outcomes but discovered there was very little data available about daily drinking that was distinct from other drinking patterns. He discussed this surprising find with a former graduate student, Álvaro Vergés, now a researcher with Pontificia Universidad Católica in Santiago, Chile.
“There’s almost nothing in the literature specifically regarding daily drinkers, so we were planning on becoming the first to come out with a group characterization of daily drinkers in terms of their patterns of drinking, the consequences of daily drinking, and so on,” says Vergés. “We discovered that not a lot of daily drinkers were actually diagnosable with alcohol dependence, and that was really surprising. We thought there must be something wrong, so we double-checked, and we realized that somehow our diagnostic classification was not capturing these people.”
Vergés says if one were to ask most alcohol researchers what proportion of people who were daily binge drinkers—five or more drinks per day for a man or four or more drinks per day for a woman—would be alcohol dependent, most researchers would say the vast majority are alcohol dependent. However, data from the National Epidemiologic Survey on Alcohol and Related Conditions finds that among binge drinkers, just 174/399 were alcohol dependent.
Moreover, Sher says the American Psychiatric Association recently jettisoned the alcohol dependence diagnosis in favor of a broader category called alcohol use disorder (AUD) in the organization’s most recent Diagnostic and Statistical Manual of Mental Disorders (DSM–5).
Even though alcohol dependence is no longer an official DSM diagnosis, Sher and Vergés still feel it is a conceptually meaningful diagnosis because it captures how important alcohol is to a person “Many people who drink a lot every day do not diagnose, either with a narrow-band diagnosis like alcohol dependence or a broader-band like alcohol use disorder,” Sher says. “It is surprising that a lot of people are still not being diagnosed despite the fact they are drinking at levels that are likely to damage their health.”
Sher says current diagnostic tools do not include consumption. He suggests it might be useful to have companion measures for 1) do you meet criteria for AUD, and 2) how much do you drink? He says that could resolve the fact that heavy drinkers might be damaging their health without having social problems or symptoms of dependence.
“If somebody has a nice, leisurely lifestyle, they might not have any obvious consequences from daily binge drinking,” Sher says. “Typically, we think of compulsion as doing something despite the fact it is being punished by adverse health outcomes or social problems, but if there is no punishment or no consequences, it’s hard to consider the behavior compulsive.”
Altering the Diagnostic Framework
Vergés says the findings show there is a need for a new diagnostic classification. The typical concern is that people are being over-diagnosed, but what they have found is just the opposite.
“The idea is that we not only have false positives but we might also have a lot of false negatives—people who are experiencing some consequences that we are not getting at with the current diagnoses,” he says.
Sher says alcohol researchers need a new type of diagnosis that considers how much alcohol has taken over a person’s life.
“How much do you wake up thinking about it and wondering when you are going to get your next drink?” Sher says. “Could you imagine going to a party and having a good time if you are not drinking? To me that gets at the core of how wet your brain is. Another piece is how much you are drinking, because we know there is a strong relationship with health effects. I think it suggests we want to look at consumption patterns. The problem is we don’t have a gold standard yet, and in a sense what we are trying to do is ask, what would a gold standard look like?”
Vergés is the lead author and Sher a co-author of the recently published paper, “Intensity of Daily Drinking and Its Relation to Alcohol Use Disorder” in the September 2018 issue of Alcoholism: Clinical and Experimental Research.