We Need To Think About Binge Drinking and Heavy Drinking Too
We recently published an article discussing safe alcohol use versus responsible alcohol use. We wrote that biomedically speaking there is no use of alcohol in any amount that is safe. Citing the World Health Organization from 2022 (“No level of alcohol consumption is safe for our health”, World Health Organization, December 2022) , “We cannot talk about a so-called safe level of alcohol use. It doesn’t matter how much you drink – the risk to the drinker’s health starts from the first drop of any alcoholic beverage. The only thing that we can say for sure is that the more you drink, the more harmful it is – or, in other words, the less you drink, the safer it is”
We did argue that there are many reasons in our culture that one may choose to take the risk including that alcohol-containing beverages provide flavors and sensations that people enjoy—fine wine, craft beer, or distinct distilled spirits, which may be mixed with other flavored, often sweet ingredients, enhanced social situations as alcohol reduces awkwardness, business relationship building, and traditions such as that beer at the ball game. In America there have developed long and lasting relationships between alcohol and social situations.
We further argued that Americans choose to take risk in many ways other than alcohol use. One example is driving an automobile. Driving Test America estimates that in 2021 Americans drove cars and light trucks 3 trillion miles, averaging 2.4 trips per day. These drivers are guided by rules of the road and formal laws that guide their driving behavior. Nonetheless, there were 6.1 million vehicular crashes, resulting in 1.7 million injuries and 39.3 thousand deaths all just in 2021. This analogy falls apart at some point, as all do, but hopefully the point is made that alcohol use is not the only widely popular, risk taking behavior in America.
We discussed moderate alcohol use defined by The Centers for Disease Control (CDC) as two drinks per day and seven per week for men and one drink per day and four for a week for women (alcohol is metabolized differently by gender). A standard drink is 12 ounces of beer at 5% alcohol by volume (ABV), 5 ounces of wine at 12% ABV, or 1.5 ounces of spirits at 40% ABV. We included strategies one might use to manage drinking alcohol in moderation or, if you will, responsibly.
In order to discuss drinking irresponsibly we categorized the U.S. adult population by consumption patterns. The United States Census Bureau estimates that there are 258.3 million adult Americans. The National Institutes for Health estimates that 30% do not use alcohol for a variety of reasons leaving us 180.8 million American adults who use alcohol. The National Institutes for Health (NIH) estimates that there are 40 million Americans with a substance use disorder; alcohol and/or other drug addiction. The Centers for Disease Control (CDC) estimates that there are 43 million binge drinkers who consume toxic amounts in one sitting and do so four times a month. CDC also estimates that there are, separately, 13 million heavy drinkers who drink beyond moderation every week. If we remove these three groups, then we are talking about 84 million Americans who might use alcohol in moderation. Given a couple of counting overlaps let’s make it 100 million adult Americans who drink and do not binge drink, heavy drink or suffer the disease SUD.
The issues surrounding the use of alcohol and other drugs for people with substance use disorder (addiction) are well documented. Although there are those who believe that people with a drug addiction other than alcohol can drink and people with an alcohol use disorder can use other drugs, say cannabis, there is simply no evidence to support those views and ample evidence that these behaviors are contraindicated. What, though, of the 55 million or so binge drinkers and heavy drinkers?
The Centers for Disease Control (CDC) defines binge drinking as a pattern of drinking an amount of alcohol that brings blood alcohol concentration (BAC) up to 0.08 grams of alcohol per deciliter (100 milliliters) of blood. This is the amount of alcohol in the blood to be considered legally impaired. For most adults, that equates to five drinks for men or four drinks for women within a two-hour period. Further, the CDC defines heavy drinking as fourteen standard alcoholic beverages per week for men and seven for women.
In “Binge Drinking”, Matt Smith (“Binge Drinking”, Matt Smith, WebMD, Medically Reviewed by Smitha Bhandari, MD, August 31, 2024) notes that some researchers blame this kind of binge and heavy drinking for more than half of the roughly 88,000 alcohol-related deaths (we believe that number is higher) -- from car crashes, alcohol poisoning, suicide, and violence -- that happen every year.
In “Understanding Binge Drinking” Sarah Bence (Sarah Bence, Very Well Health, February 29, 2024, Medically reviewed by Kashif J. Piracha, MD) defines five distinct types of excessive drinking including:
Binge drinking: Consuming five drinks or more on one occasion for men or four drinks or more on one occasion for women
Heavy drinking: Consuming 15 or more drinks per week for men or eight or more drinks per week for women
High(er)-intensity drinking: Consuming ten drinks or more on one occasion for men or eight drinks or more on one occasion for women
Underage drinking: Any alcohol consumption among people under the legal drinking age of 21
Drinking while pregnant: Any alcohol consumption by a person who is pregnant.
Ms. Bence identifies the primary sign of binge drinking as consuming a large amount of alcohol and acting drunk, usually creating a BAC of 0.08, the amount of alcohol associated with symptoms like trouble thinking, slurred speech, problems with walking and movement, and riskier behavior. She points out that most people who binge drink are not dependent on alcohol. Rather, it is common for binge drinking to occur socially such as at a wedding reception, a house party, or a night out. Further, some people will age out of these risky behaviors or change their patterns associated with life changes such as marriage, parenting or employment.
However, the Prevention Research Institute (“Theory and Foundation; More information on the Lifestyle Risk Reduction Approach”; Prevention Research Institute; 2020) suggests that while there are biologic determinants of addiction there are also lifestyle determinants:
“These researchers note that physiological effects and pharmacokinetics dictate the potential for addiction but do not alone determine which individuals become addicted. Evolving research (e.g., Schuckit, 1998) indicates that this risk lies on a continuum. These findings suggest that each person has a biological threshold for addiction, conceptualized in our programs as a range of distances from a "trigger point.” Persons with increased biological risk start out at a shorter distance from their trigger point, meaning it will take less time and less use to reach it than people born with standard risk. In addition, some people have greatly increased biological risk and they can develop addiction even more rapidly.”
In other words, people who display riskier behaviors with alcohol such as binge drinking and heavy drinking increase their chances of developing substance use disorder.
Whether one goes on to develop a substance use disorder, Ms. Bence identifies negative biomedical and social consequences from binge drinking and heavy drinking including short-term effects such as:
Poor motor control and slower reaction times
Shorter attention span
Dehydration
Sleepiness
Depression
Hostility
Low blood pressure
Slower breathing
Miscarriage or stillbirth in pregnant women, or fetal alcohol spectrum disorders in their babies
Alcohol poisoning, which can lead to vomiting, seizures, a coma, and death
Taking part in risky sexual behavior
Raising the risk of sexual violence
And longer term effects such as:
Weight gain
High blood pressure
Trouble sleeping
Social isolation
Mental health problems
Loss of brain volume in young people
Weakened immune system
Heart disease
Liver problems
Stroke
Higher chances of breast, throat, esophagus, or colon cancer
Clearly, American adults that use alcohol beyond levels of moderate consumption run several risks whether or not they exceed the “trigger point” and qualify as having an addiction. Ms. Brance suggests that binge drinking and heavy drinking behaviors can be changed. She suggests that knowing limits, including what number of drinks qualifies as binge drinking, is an excellent first step in preventing future binge drinking episodes. It can also be helpful to identify and avoid binge drinking triggers, those circumstances in which such behaviors manifest such as in certain settings, around certain people, or when one is feeling a particular emotion. She also suggests that while it can be challenging to talk openly about concerns about binge drinking with trusted friends and family, these people can be a source of support when you say no to an extra drink or ask to hang out in a different environment where one is less likely to want a drink in hand.
The obvious question then is whether the behavioral changes she discusses can be so easily made. The Prevention Research Institute suggests a more aggressive approach and cites five conditions for change:
· Condition One - - people believe that alcohol or drug-related problems could happen to them, and it is the quantity/frequency choices they make that will determine those outcomes
· Condition Two - - people know how to estimate their level of biological risk and what specific quantity/frequency choices are high risk and low risk (see definitions of moderate use above)
· Condition Three - - people perceive, identify and activate social support for making low-risk choices
· Condition Four - - people hold attitudes, beliefs, values and motivations that support making low-risk choices. While these attitudes might seem self-evident to many, binge and heavy drinking occurs when they do not seem self-evident or are not as valued compared to the risky behavior by the heavy drinker
· Condition Five - - people possess the necessary skills to make and maintain low-risk choices. People not only need motivation and support for making low-risk choices; they need to know how to make low-risk choices.
Best estimates from credible sources are that there are fifty to fifty-five million American adults who qualify as binge drinkers or heavy drinkers, and that they do so regularly. These behaviors may overlap with definitions of alcohol use disorder in the Diagnostics and Statistical Manual v. 5 that stresses cravings, loss of control, withdrawal, serious life difficulties due to continued alcohol use and continuing drinking despite those life difficulties. In some cases these differences may not be as meaningful if behavioral change is required. In some cases occasional binge drinking and/or heavy drinking occurs from youthful indiscretion and will change as one matures.
In many, many cases, ongoing binge drinking and heavy drinking reflects a pattern of behavior that is continuous and will eventually cause very serious life difficulties, medical issues or develop into alcohol use disorder. Suggestions for changing these behaviors tend to the simpler versions of drinking less and less often, not associating drinking with social activities or with feelings. The Prevention Research Institute and others suggest that conditions for behavioral change need to be realized. Regardless, there is no doubt that binge drinking and heavy drinking are behaviors that we as individuals, families and a society need to focus on in addition to substance use disorder.
We have argued elsewhere that as a society we focus far too little on addictive and abusive drinking as usually defined as substance use disorder. A great part of our purpose is to normalize discussions about those behaviors, that medical condition, disease, and to provide better, more informed, up to date definitions. Hopefully, through this effort we will engage more people in the discussion, spur more people to action, and improve on our dismal levels of recovery in America.
We do not suggest, however, that all other levels of behavior with alcohol other than those with substance use disorder are safe, responsible or acceptable. In this article we have discussed heavy drinking and binge drinking. Hopefully, we have shed light on these issues as well. Certainly, there are those who will “age out” of these behaviors. Until they do, there is risk to them and others. Perhaps simple outlook changes are all that is required as suggested by Ms. Brance. Perhaps there is more serious attitude change required as suggested by the Prevention Research Institute. If this is the case, then certain of the intervention steps suggested in articles about codependency might be recommended. Regardless, these drinking behaviors are a danger to the individual and those around them and our attention is required here as well.
Gene Gilchrist
March 2025
