Binge Drinking isn’t just for College Kids Anymore

Black line art illustration of a drunk man with a beverage.

The typical picture of a binge drinker may look as much like a middle-age man working long hours as it does a college fraternity boy partying late at night.
Doctors are increasingly focusing on that older population after years of placing a higher priority on experimenting adolescents and young alcoholics. Evidence is emerging that high-pressure jobs push millions of people toward binge drinking, and deaths from alcohol abuse escalate as people get older.
A new study from 14 countries published in the British Medical Journal found that people who work more than 48 hours a week are more likely to drink to excess — defined as 14 drinks a week for women and more than 21 for men. And the U.S. Centers for Disease Control and Prevention estimated in a report last week that six people die daily from alcohol poisoning, mainly those ages 35 to 65.
“Drinking is a fast and easy way to shake off work. That’s where the problem comes,” said Cassandra Okechukwu, an assistant professor at Harvard School of Public Health in Boston. “We have defined it and call it risky alcohol use. We aren’t paying as much attention to that as we pay to the definition of alcoholism. We need to pay more attention.”
Numerous studies show regular drinking, as long as it doesn’t turn into a binge, is healthy, especially for the heart. While red wine is generally touted for its health benefits, beer and liquor have also been shown to ward off various medical conditions. Doctors warn against starting to drink or consuming more for the potential health benefits, and point out that excessive consumption can lead to a raft of ailments ranging from cancer to sudden death.
Poisoning Deaths
The numbers on excessive drinking don’t make sense right away, and they puzzle researchers. Young people are still more likely to binge drink — defined as five or more drinks in a few hours for men and four or more for women. People 65 and older who binge drink do it more frequently than other age groups.
The people dying of alcohol poisoning, however, are middle-aged. Three in four are men, the CDC found.
In a 2012 survey by the agency, 71 percent of Americans said they’d had a drink in the past year, while about 56 percent had done so in the past month. There are a small and growing number of people who drink excessively at one sitting, and it’s not clear why, said George Koob, director of the National Institute on Alcohol Abuse and Alcoholism.
“We’re seeing a higher number of drinks per individual,” he said. “What’s growing is the intensity of drinking in a single bout. We are concerned about that. We haven’t figured out how to address it.”
Longer Hours
Working long hours may exacerbate the problem. The study in the BMJ found that people who worked 49 to 54 hours a week and 55 hours a week had an increased propensity of 13 percent and 12 percent, respectively, for risky drinking.
A glass of wine or a beer or two after the work is a common way to take the edge off after a tough day at the office. The problem is when it morphs into something more. For people who already drink, stress at work or home can lead to an even greater reliance on alcohol, said Sandra Brown, a psychology and psychiatry professor who’s vice chancellor for research at the University of California at San Diego.
“People develop tolerance when they drink regularly,” Brown said. “They don’t realize they are drinking more and put themselves in a more dangerous situation.”
Nationwide, alcohol is responsible for 88,000 deaths a year, making it the third-leading cause of preventable death in the U.S.
Liver, Pancreas
For people in their 30s, 40s and 50s, the effects of alcohol can linger much longer than just a nasty hangover. It taxes the liver and the pancreas, and can lead directly to depression.
The damage from drinking can accumulate over a lifetime, with new risk factors appearing in middle age, said Joseph Lee, a medical director at the Hazelden Betty Ford Foundation. And while most people who have trouble drinking show signs when they’re young, that’s not always the case, he said.
“Just because you went through your college frat days unscathed, it doesn’t mean you have a free pass for the rest of your life,” Lee said. “We see a lot of people who always had a risk for addiction that didn’t manifest until something happened, like a promotion to a high-pressure job, a divorce or a death in the family.”
For middle-aged drinkers, the beer pong and drinking games they played when they were younger can simply carry over as they age and try to hold onto their “adolescent joys,” Koob said. They need to realize their brains and bodies have changed, however, and can’t handle it the same.
“When you are young, the pleasurable effects of alcohol are more rewarding and the hangovers are less,” Koob said. “As you get older, there is a switch over where the hangovers become more excruciating and the pleasurable effects become less. That’s when the demons come rushing out of the bottle.”

CVS Will Sell Naloxone Without Prescription in 14 States

CVS announced it will add 12 states to its program to sell the opioid overdose antidote naloxone without a prescription, bringing the total to 14. The company already sells naloxone without a prescription in Massachusetts and Rhode Island.

“Over 44,000 people die from accidental drug overdoses every year in the United States and most of those deaths are from opioids, including controlled substance pain medication and illegal drugs such as heroin,” Tom Davis, Vice President of Pharmacy Professional Practices at CVS, said in a statement. “Naloxone is a safe and effective antidote to opioid overdoses and by providing access to this medication in our pharmacies without a prescription in more states, we can help save lives.”

The states included in Wednesday’s announcement are Arkansas, California, Minnesota, Mississippi, Montana, New Jersey, North Dakota, Pennsylvania, South Carolina, Tennessee, Utah and Wisconsin. Pharmacy boards in these states can make decisions about offering naloxone without a prescription.

“While all 7,800 CVS/pharmacy stores nationwide can continue to order and dispense naloxone when a prescription is presented, we support expanding naloxone availability without a prescription and are reviewing opportunities to do so in other states,” Davis said.

Use of naloxone kits resulted in almost 27,000 drug overdose reversals between 1996 and 2014, according to a government study published earlier this year. Providing naloxone kits to laypersons reduces overdose deaths, is safe, and is cost-effective, the researchers noted.

“U.S. and international health organizations recommend providing naloxone kits to laypersons who might witness an opioid overdose; to patients in substance use treatment programs; to persons leaving prison and jail; and as a component of responsible opioid prescribing,” the researchers wrote in the Morbidity and Mortality Weekly Report.

US Opioid Epidemic Fueled by Prescribing Practices

The United States is facing the worst “man-made epidemic” of opioid abuse in the history of modern medicine, and it is the direct result of poor research and outdated teaching practices, according to a leading pain expert.

“There’s been over 200,000 deaths from prescription opioids and many more hundreds of thousands of overdose admissions, and millions are addicted or dependent on prescription opioids, and while some patients don’t meet the classic definition of opioid use disorder, as many as 30% of patients who are sitting across from you in your office have opioid use disorder or are severely dependent,” Gary Franklin, MD, MPH, vice president of Physicians for Responsible Opioid Prescribing, said during a Webinar sponsored by the Centers for Disease Control and Prevention’s Clinician Outreach and Communication Activity (COCA).

“So this is an extremely serious epidemic, and while I know that taking care of these patients is not an easy thing to do, we need to reduce overdose deaths and admissions, and we have ways to reverse trends which we all need to embrace.”

The most important step toward reversing the epidemic of prescription opioid abuse is to stop prescribing opioids for the wrong indications.

Recent reports have consistently concluded that there are insufficient data on the long-term effectiveness of prescription opioids to support their use in the treatment of chronic pain, but there is clear evidence of a dose-dependent risk for serious harms.

The biggest triggers to the initiation and perpetuation of prescription opioid abuse comes from their use for the treatment of nonspecific musculoskeletal disorders, especially chronic low back pain, headaches, and disorders such as fibromyalgia.

Although there is no proven benefit for their use in these disorders, “people with these indications are on chronic opioids, and they have become disabled, and they are spilling over into social security and disability systems,” Dr Franklin said.

In recognition of this problem, the American Academy of Neurology and a number of states, including Washington, have produced guidelines that advise that in general, opioids should not be routinely used for the treatment of musculoskeletal conditions, headache, or fibromyalgia.

“Not only is there no evidence to support their use in these conditions, there is quite a bit of evidence against doing so, and these are probably the most routine patients we have who are on chronic opioids and who have become dependent and addicted to them in our country,” Dr Franklin said.

Indeed, in a 2008 study conducted by Dr Franklin and colleagues (Spine. 2008;33:199-204), results showed that 14% of workers who sustained a low back injury were disabled at 1 year and that receiving opioids for at least 7 days at a cumulative dose of 150 mg morphine equivalent dose (MED) doubled the risk of being on disability 1 year later, after adjusting for baseline reported pain, function, and injury severity.

Dosing Guidance

The issue of the MED and the risk for an overdose event, either hospitalization or death, is also extremely important in community efforts to reduce the risk for opioid-induced harm.

Recent evidence suggests that there is a dramatic increase in death when opioids are administered at a dose of 100 mg MED ― “but the risk of overdose is also two- to fivefold higher when that same opioid MED runs between 50 and 99 mg MED,” Dr Franklin said.

“So you need to be paying a lot more attention to lower doses of opioids and never go over 100 mg MED.”

This is particularly important for patients who are receiving a combination of an opioid and either a benzodiazepine or another sedative-hypnotic or muscle relaxants, all of which can dramatically add to the risk for opioid harm, even at lower doses of opioids, he added.

Dr Franklin also cautioned that the intermittent use of opioids does not spare patients from overdose and that in doses lower than 100 mg MED, many patients enrolled in Washington State’s Medicaid program have been admitted for opioid overdose even when they were not using opioids on a long-term basis.

Comprehensive guidelines from Washington State on prescribing opioids make it very clear that physicians must proceed with caution when initiating opioid therapy to improve function and pain in patients with chronic pain or when transitioning to the long-term use of opioids.

Before initiating treatment with any opioid, patients should be screened for current or past substance abuse as well as depression.

Clinically Meaningful Improvement

“When you are tracking pain and function, you also have to make sure there is clinically meaningful improvement in both pain and function,” said Dr Franklin.

In Washington State, a clinically meaningful improvement in pain and function means at least a 30% improvement in both.

Physicians also need to track pain and function at every visit so that they can better judge how well the opioid may be working — or not.

Sleep disturbances are common in patients with chronic pain, and physicians need to help patients with various measures to improve sleep hygiene or prescribe a tricyclic antidepressant, which will help with underlying depression as well sleep disturbances, he added.

There are also many nonpharmacologic alternatives to long-term opioid use that are strongly supported by evidence.

Graded exercise is well established as a good treatment modality for chronic pain, as are cognitive-behavioral therapy (CBT), mindfulness-based stress reduction techniques, and various forms of meditation and yoga.

If patients who are currently receiving opioids are scheduled for an elective operation, they should resume their preoperative dose of opioids 6 weeks after surgery.

If they are not receiving opioids at the time of the procedure, patients should be off all opioids within 6 weeks.

And if patients are not improving on opioid therapy, “the ongoing risk from continued treatment outweighs the benefit,” Dr Franklin said.

“And opioids in these patients should be tapered to zero.”

The new guidelines indicate that when tapering opioids, the dose should be reduced by 10% a week, with or without accompanying CBT, inpatient detoxification, or treatment in a pain clinic.

“These patients are losing their lives in our system, and we need to do everything possible to reverse this epidemic and saves lives,” Dr Franklin said.

“And I am glad to say our efforts are paying off, as we have seen a 30% sustained decline in death from overdose in Washington State and a dramatic decline in the proportion of injured workers on chronic opioids as well.”

What Drinking Costs the US every Year

Drinking too much has well-known personal costs—headaches, nausea, and regrettable 4 a.m. text messages.
The Centers for Disease Control has put a figure on how much it costs the American economy: $249 billion.
That includes spending on health care as well as the economic toll of lost productivity, car crashes, crime, and deaths attributable to excessive alcohol consumption.

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The biggest economic drag from tipplers manifests in the workplace. Alcohol cost $77 billion in impaired productivity at work in 2010, according to the CDC’s breakdown published in the American Journal of Preventive Health. Adding in absenteeism and other factors, the total productivity toll from excess drinking approached $90 billion. That’s not counting losses from alcohol-related deaths. The CDC has previously estimated that one in 10 deaths of working-age Americans are caused by too much drinking.
The total cost of excessive drinking to the economy is rising. The last time the CDC made a similar calculation, excess drinking was blamed for $224 billion in costs, estimated for 2006. The increase, about 2.7 percent annually from 2006 to 2010, outpaced inflation. Most of the costs are attributable to binge drinking, and 40 percent of the total is borne by the government.
Measuring such a big and abstract thing as economic damage from drinking is inherently imprecise. If anything, the CDC says its estimates lowball the true cost. It counted only factors in which alcohol was considered the primary cause, so illness or deaths from other causes that drinking may have exacerbated are left out. “Intangible costs like pain and suffering were not included,” the paper noted.
So drink responsibly. The economy will thank you in the morning.

Is Medicine Driving Doctors to Drink?

Between 10% and 15% of US physicians suffer from a substance use disorder, a rate slightly higher than that of the US population as a whole, a recent Medscape article revealed.

But physicians struggling with abuse or addiction differ from other members of the public in one critical respect: They have taken an oath to care for others. However, the article cited two surveys in which physicians who met the criteria for substance abuse and dependence were more likely to say they had committed a major medical error in the previous 3 months than their peers who didn’t meet the criteria.

“When doctors are impaired, everyone suffers,” the article pointed out, including the physicians themselves.

Why do some doctors become hooked? “Medicine attracts many high-achieving, compulsive, perfectionistic individuals who derive a strong sense of self-worth from their jobs,” the article noted. “If a doctor’s commitment morphs into overwork, exhaustion, and a work/life imbalance, alcohol and other drugs may become a dangerous balm.”

Add to that physician access to potent prescription medications, and it’s not hard to understand how some doctors might step over the line. “Whereas alcohol abuse is the most common form of drug abuse for both physicians and the population as a whole, research shows physicians are more likely than the general population to abuse benzodiazepines and opiates,” the article stated.

The article quoted addiction experts who urged doctors with an alcohol or drug abuse problem to get help, offering some suggestions. Doctors who suspect that a colleague is impaired were urged to broach the subject with that individual or at least bring the matter to a hospital wellness committee’s attention as an act of compassion and a patient safety concern.

For a number of doctors who offered comments, the problem of physician addiction and dependence reflected a larger problem with society as a whole.

The reason a lot of people get hooked is because of the sanctimonious ‘all-or-nothing’ attitude of our society,” wrote an orthopedic surgeon. “Why are the numbers so much better in Europe, where 6-year-olds have a thimbleful of wine with Sunday dinner and hit adulthood ‘knowing’ about alcohol?”

“For as much physical, emotional, and economic damage that alcohol causes, it gets hardly any attention; instead, it is advertised and promoted to our youth,” an ophthalmologist remarked. “A shameful, festering wound on the face of our society.”

But other commenters saw the problem as one endemic to medical culture.

“Why do medical professionals often become alcoholics/addicts and then hide it as the disease progresses? I think one reason has to do with the culture of medicine,” an internist opined. “Medicine is all about identifying symptoms and reflexively prescribing substances to alleviate those symptoms. I don’t think we realize what a huge impact that has on us subconsciously over time as healthcare providers. We are expected to be super-human while teaching our patients to take good care of their bodies. We are discouraged from taking time off when we are sick or burnt out, and as the for-profit medical system evolves, we are pushed harder and harder. There is a disconnect between teaching and preaching wellness and the way healthcare providers live themselves. The system is broken.”

“Medicine is uncomfortable discussing and admitting its substance abuse problem,” another doctor wrote. “Case in point: When I was starting to have daily problems that were harder and harder to hide in medical school, no one ever spoke to me in the clear terms I needed to hear. They knew I was drug-seeking for the pills I was addicted to. They knew I was drinking alcohol daily (“they” being MD department heads and advisers, as well as student counselors at the Top 10 medical school I trained at). No one said to me, ‘You have a disease, and it’s called addiction/alcoholism. You need to go to rehab and 12-step meetings to get better.’ Meanwhile, I went to student/faculty events and saw students getting wasted to the point where they could not speak in front of faculty, who thought it was cute and part of normal medical student life.”

Other physicians took the opposite view: that focusing on the minority of physicians who abuse substances misses the larger picture.

“Ten percent of physicians suffer from a substance use disorder,” a surgeon commented. “Ninety percent do not. Thank you for that indirect credit to the majority of us.”

“Is it less interesting to write about how the vast majority of physicians lead productive lives without chemical dependencies?” an orthopedic surgeon wondered.

Several physicians, recovered alcoholics, took personal responsibility for their problem.

Say what you want about ‘stress, perfectionism, compulsion,’ etc., the fact is, I drank alcohol because I am an alcoholic,” wrote an emergency physician, who said he has been sober for 13 years. “I don’t understand what underlies the difference between me and a ‘normal’ person,” he confessed. “Many of my colleagues are just as perfectionistic and compulsive as I am and are doing the same job. They don’t abuse alcohol or drugs. I was very good at trying to hide my drinking, and I got away with it for years. Thank goodness I don’t remember any poor clinical outcomes that resulted from this. In fact, I took some pathetic pride in the fact that I was never drunk on the job. I lived in constant fear of being discovered, and much of the fear was based on my assumption that if I admitted to my addiction, I would have to stop being a doctor. By the time I was finally confronted by hospital administration and tested positive for alcohol during clinical duty, I was so tired of running and hiding that I was actually relieved. I did have to take a few months off for rehab, and I followed guidelines for monitoring by my state medical board. For the past dozen years I have been back to work, and my clinical practice has flourished. I feel better than I ever did prior to my intervention. I am very grateful for all of those people who helped me through the transition away from alcohol.”

A few commenters weren’t buying the reasons that some doctors develop substance use problems.

“There are reasons and there are excuses,” a vascular surgeon remarked. “You list factors contributing to drug and alcohol abuse, but the reason is that some people make bad choices.”

“So now we make excuses for a profession in which persons have lost their way, using words like ‘high-achieving,’ ‘compulsive,’ ‘perfectionist,’ ‘overwork,’ ‘exhaustion,’ and ‘work/life imbalance’ to make the absurd excuse that alcohol and other drugs then become a dangerous balm,” a medical oncologist remarked. “My goodness, no other profession, now or in history, has had these same characteristics? They have only recently been discovered in ONLY the medical profession? How about a dose of ethics, morality, balance, strength of character, and positive outlook in the ‘good’ that doctors can do?”

“Nobody is making excuses!” a radiation oncologist fired back. “And medicine was not singled out. Physicians have the SAME rate of alcoholism as the general population, not significantly higher than dentists or other educated, intense professionals. Look at firefighters and policemen: Their rates of substance abuse are higher. The point is that there is help. Most university-affiliated hospitals have physician health teams that will treat anonymously. I myself have benefitted from this interaction (not for addiction but for burnout), and it was done quietly and effectively. Now that I am much healthier, I no longer feel the need to hide my problems, and have pointed several colleagues in the same direction. The point is not to make excuses. The point is to get appropriate treatment and get better.”

Obama Plan for Opioid Abuse Stresses Prescriber Training

More physicians will receive training on prescribing opioid pain medications as part of a White House initiative against abuse of prescription drugs and heroin use.

President Barack Obama issued a memorandum yesterday requiring federal departments and agencies to provide opioid prescribing education to all “federal prescribers.” This group includes clinicians who are employees or contract workers of the departments of Defense, Health and Human Services (HHS), and Veterans Affairs, as well as residents who primarily work in federal facilities. A White House spokesperson told Medscape Medical News that the Obama administration has yet to come up with an exact head count of how many clinicians would be affected.

The required training must address such topics as principles of pain management, identification of potential substance abuse, and referral for further evaluation and treatment.

In addition, the memorandum orders federal agencies that either directly provide healthcare services or reimburse for them (HHS is an example) to identify barriers that individuals with opioid use disorder might encounter in receiving “medication-assisted treatment” (MAT) such as buprenorphine, which also is an opioid. Considered widely underused, MAT normalizes brain chemistry and relieves craving for opioids without the harmful effects of the abused drug, according to HHS.

The White House also announced that more than 40 provider groups ranging from the American Medical Association to the American Dental Association have committed themselves to get more than 540,000 clinicians trained in opioid prescribing during the next 2 years. Other voluntary goals these groups have set for themselves include:

doubling the number of physicians certified to prescribe buprenorphine from 30,000 to 60,000 during the next 3 years;

doubling the number of providers who prescribe naloxone, which can reverse an opioid overdose; and

doubling the number of providers registered with their state prescription drug monitoring program.

“We obviously need to work with the medical community,” Obama said yesterday at a community forum on opioid abuse and heroin addiction in Charleston, West Virginia, “They’re the front lines on prescribing this stuff. So there’s got to be a sense of responsibility and ownership and accountability there.”

The American Academy of Family Physicians, one of the provider groups involved in the Obama initiative, will do its part by promoting continuing medical education on opioid prescribing, a spokesperson told Medscape Medical News. The academy aims to train 10,000 of its members on how to prescribe the drugs and have another 600 complete overview training on MAT.

Treatment More Important Than Prison

The president’s latest sally against prescription drug abuse and heroin use enlists companies ranging from CBS Television Network to Google to donate airtime and advertising space for a media campaign by the Partnership for Drug-Free Kids. Likewise, the National Basketball Association and Major League Baseball will run public service announcements and the Dr Oz Show will encourage parents to talk with their children about the risks posed by prescription pain medications, heroin, and other drugs.

In one of many public sector actions, HHS will review how patient satisfaction surveys evaluate pain management and how they may influence current practices and opioid prescribing.

West Virginia was an apt setting for Obama to announce new efforts to combat abuse of prescription painkillers and heroin use. He noted that the state has the highest rate of fatal drug overdoses in the nation.

“More Americans now die from drug overdoses than they do from motor vehicle crashes,” he said. “This crisis is taking lives, destroying families, and shattering communities all across the country.”

Obama said fighting this epidemic depends more on getting people with a substance abuse problem into treatment than putting them in prison. That task will be easier, he said, when substance abuse is no longer stigmatized with terms such as “junkie.” Such pejorative language often deters from people from seeking help.

“Part of our goal today is to replace those words with father, daughter, son, friend, or sister, because then you understand there is a human element,” Obama said. “This could happen to any of us.”