Binge drinking

New Year's Eve is traditionally a time when many drink excessive amounts of alcohol. This picture is from a 1912 postcard mailed in the United States.

Binge drinking or heavy episodic drinking is the modern epithet for drinking alcoholic beverages with the primary intention of becoming intoxicated by heavy consumption of alcohol over a short period of time.^[1] It is a kind of purposeful drinking style that is popular in several countries worldwide, and overlaps somewhat with social drinking since it is often done in groups. The degree of intoxication, however, varies between and within various cultures that engage in this practice. A binge on alcohol can occur over hours or last up to several days.^[2] Due to the long-term effects of alcohol misuse, binge drinking is considered to be a major public health issue.^[3]

Binge drinking is associated with a profound social harm, economic costs as well as increased disease burden. Binge drinking is more common in males, during adolescence and young adulthood. Most binge drinkers are not familiar with the risks associated with binge drinking. Heavy regular binge drinking is associated with adverse effects on neurologic, cardiac, gastrointestinal, hematologic, immune, musculoskeletal organ systems as well as increasing the risk of alcohol induced psychiatric disorders.^[4][5] Up to one third of adolescents binge drink^[where?], with six percent reaching the threshold of having an alcohol related substance use disorder.^[6] Approximately one in twenty five women binge drink during pregnancy, which can lead to fetal alcohol syndrome and fetal alcohol spectrum disorders.^[7] Binge drinking during adolescence is associated with traffic accidents and other types of accidents, violent behavior as well as suicide. The more often a child or adolescent binge drinks and the younger they are the more likely that they will develop an alcohol use disorder including alcoholism. A large number of adolescents who binge drink also consume other psychotropic substances.^[8]

Definition

Binge drinking is defined as episodic excessive drinking.^[8] There is currently no world wide consensus on how many drinks constitute a "binge",^[2] but in the USA, the term is often taken to mean consuming five or more standard drinks (male), or four or more drinks (female), on one occasion. ^[9][10] This is colloquially known as the "5/4 definition", and depending on the source the timeframe can vary. In the United Kingdom, binge drinking is defined as drinking more than twice the daily limit, that is, drinking eight units or more for men or six units or more for women (roughly equivalent to five or four American standard drinks, respectively).^[11] Controversy remains on how to best define binge drinking, as some people feel that the official definition is too broad and/or fails to take into account the context in which the drinks are consumed.^[12]

Other, less common definitions are based on blood alcohol concentration (BAC). For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) recently redefined the term "binge drinking" as any time one reaches a peak BAC of 0.08% or higher as opposed to some (arguably) arbitrary number of drinks in an evening.^[13] However, even that definition is not without controversy. One study showed that university students often have numerous different definitions of "binge drinking" depending on their own drinking habits, with drinkers having significantly higher definitions than nondrinkers.^[14] Whatever the numerical definition used, heavy drinking or rapid consumption over a short period of time with the intention of becoming intoxicated is often implied when the term is used colloquially, since one can remain relatively sober if the four or five drinks are spread out widely over the course of a long evening on a reasonably full stomach.^[15]

In the United States, sometimes the term "extreme drinking" or "industrial-strength bingeing" is used to describe a more severe form of (single-evening) binge drinking; it is often defined as ten or more standard American drinks on a single occasion (sometimes as eight drinks for women).^[16][17] If done over 2 to 3 hours, a typical adult would have a peak BAC of at least 0.20%.

Health effects

See also: Long-term effects of alcohol

Acute intoxication, such as binge drinking, and alcoholism are known potent risk factors for suicide.^[18] Binge drinking is commonly associated with damaged and lost friendships, accidents, law-breaking (especially vandalism and violence), arguments, neglect of obligations, and other acts that are later regretted. Binge drinking is also associated with an increased risk of unplanned sex, unprotected sex, unplanned pregnancies, and an increased risk of HIV infection. 10 percent of women and 19 percent of men have reported being assaulted as a result of alcohol. Males who drink more than 35 units of alcohol per week report being physically hurt as a result of alcohol, and 15 percent report physically hurting others as a result of their drinking. Almost 16 percent of binge drinkers report being taken advantage of sexually, and 8 percent report taking advantage of another person sexually as a result of alcohol within a 1 year period. Binge drinking can cause adverse effects on the body including effects on blood homeostasis and its circadian variation, cardiac rhythm, ischaemic heart disease, blood pressure, white blood cell activity, female reproductive hormone levels as well as adverse effects on the fetus. There is also evidence from animal studies that binge drinking causes brain damage.^[19] Binge drinking has been associated with lower abdominal pain in women.^[20] Ketoacidosis can occur in individuals who chronically abuse alcohol and have a recent history of binge drinking.^[21]

Adolescence and young adulthood

The high levels of binge drinking among young people and the adverse consequences which includes increased risk of alcoholism as an adult and liver disease make binge drinking a major public health issue.^[3] Recent research has found that young college binge drinkers who drink 4/5+ drinks on more than 3 occasions in the past 2 weeks are statistically 19 times more likely to develop alcoholism than non-binge drinkers, though the direction of causality remains unclear.^[22] Heavy and regular binge drinking during adolescence is associated with an increased risk of alcoholism. Approximately 40 percent of alcoholics report heavy drinking during adolescence.^[23] Repeated episodes of excessive drinking, especially at an early age, are thought to cause a profound increase in the risk of developing an alcohol-related disorder (ICD-10, harmful use/dependence syndrome). Other risk factors which influence the development of alcohol abuse or alcoholism include, social and genetic factors. Several researchers have found that starting drinking before the age of 15 is associated with a fourfold increased risk for developing alcoholism compared to people who delay drinking until age 20 or later. It has been estimated by some that if the age at which people started drinking could be delayed to age 20, there would be a 50 percent reduction in the number of cases of alcohol use disorder.^[8] However, it is unclear whether this is a causal relationship, or a function of confounding familial (and other) factors associated with both age at first drink and propensity for alcoholism.^[24]

The main cause of death among adolescents as a result of binge drinking is road traffic accidents; a third of all fatal road traffic accidents among 15- to 20-year-olds are associated with drinking alcohol. Cyclists and pedestrians are likely to have less spatial awareness and concentration while travelling after binge drinking and additionally adolescents who binge drink more commonly drink drive or are the passenger of a drunk driver. It has been found that 50 percent of all head injuries in adolescents in the USA are associated with alcohol consumption. Violence and suicide combine to become the third-most-common cause of death associated with binge drinking among adolescents. The suicide risk in adolescents is more than 4 times higher among binge drinkers than non-binge drinking adolescents.^[8]

Earlier sexual activity, increased changing of sexual partners, higher rate of unwanted (teenage) pregnancy, higher rate of sexually transmitted diseases, infertility, alcohol-related damage to the fetus is associated with binge drinking. Female binge drinkers are three times more likely to be victims of sexual assault; 50 percent of adolescent girls reporting sexual assault were under the influence of alcohol or another psychotropic substance at the time.^[8]

Adolescents who regularly participated in binge drinking for several years show a smaller hippocampus brain region, particularly those who began drinking in early adolescence. Heavy binge drinking is associated with neurocognitive deficits of frontal lobe processing and impaired working memory as well as delayed auditory and verbal memory deficits. Animal studies suggest that the neurodegenerative effects of alcohol abuse during adolescence can be permanent,^[8] though whether such outcomes carry over to humans remains unclear.

Central nervous system

See also: Alcohol withdrawal syndrome#Kindling and Kindling (substance withdrawal)

Heavy binge drinkers tend to have delayed auditory and verbal memory and deficits in executive planning function and episodic memory, which are similar to deficits seen in Korsakoff's syndrome. Impairments in spatial working memory and pattern recognition tasks also have been found in heavy binge drinkers. Impulse control is also impaired in binge drinkers, especially female binge drinkers. Additionally, immediate and delayed recall of verbal and visual information is impaired; conversely, semantic organizational ability is better in binge drinkers compared to non-binge drinkers. Studies in adolescents have shown that regular binge drinking may cause long-lasting cognitive impairments, though the threshold needed to produce significant effects remains unclear. Cognitive impairment in adults is also unclear, as one study found no association between binge drinking and cognitive impairment.^[22]

Binge drinking regimes are associated with causing an imbalance between inhibitory and excitatory amino acids and changes in monoamines release in the central nervous system, which increases neurotoxicity and may result in cogitive impairments, psychological problems and in long-term heavy binge drinkers may cause irreversible brain damage in both adolescents and adults.^[25][26]

While several rat studies indicate that alcohol is more toxic during adolescence than adulthood, some researchers believe that it remains unclear whether this is also the case in humans. Though heavy binge drinking adolescent humans show impaired brain activity during memory tests and underdeveloped brain structures compared to adolescents who did not binge drink, they argue that these findings are similar to adult alcoholics who did not abuse alcohol during adolescence.^[27] Extrapolation from animal studies to humans is notoriously difficult,^[28] and a review by the group Choose Responsibility concluded that alcohol's long-term damage to cognitive processes was the same regardless of whether heavy drinking commenced during adolescence or later.^[27]

Pregnancy

Binge drinking is a more important factor rather than average alcohol intake, with regard to the severity of alcohol induced damage to the fetus. Alcohol has definite long-term adverse effects on the fetus, in particular impaired attentional skills and may lead to psychiatric disorders when the child grows up.^[29] Approximately one in five nonpregnant women binge drink and one in twenty five pregnant women binge drink.^[7] Binge drinking during pregnancy is associated with fetal alcohol syndrome, alcohol-related birth defects as well as alcohol-related neurodevelopmental disorders. The affected children after birth can suffer mental retardation and problems with learning, memory, attention, problem solving and problems with mental health and social interactions. Deformities in facial features, skeletal and body organs as well as a smaller head circumference are also sometimes present in these children.^[30][31] Studies in sheep indicate that fetal neurotoxicity induced by alcohol may be due to acidaemia and hypercapnia.^[32] Binge drinking three or more times during pregnancy has been associated with an increased risk of stillbirth.^[25]

Sudden death

Binge drinking is also associated with strokes and sudden death.^[33] Binge drinking increases the risk of stroke by 10 times.^[1] In countries where binge drinking is commonplace, rates of sudden death on the weekend in young adults and middle aged people increase significantly.^[34] The withdrawal phase after an episode of binge drinking is particularly associated with ischaemic stroke as well as subarachnoid haemorrhage and intracerebral haemorrhage in younger men. In individuals who have an underlying cardiac disorder a binge on alcohol increases the risk of silent myocardial ischaemia as well as angina.^[35] Binge drinking has negative effects on metabolism, lipid profile, blood coagulation and fibrinolysis, blood pressure and vascular tone and is associated with embolic stroke and acute myocardial infarction. Due to these risks experts believe that it is extremely important to warn people of the risks of binge drinking.^[36] Binge drinking by people who would otherwise be considered to be light drinkers is associated with an increased risk of cardiovascular problems and mortality.^[37] Binge drinking increases cardiovascular toxicity due to its adverse effects on the electrical conduction system of the heart and the process of atherothrombosis.^[38]

Urinary system

The bladder may rupture if overfilled and not emptied; however, urination can alleviate this problem. This can occur in the case of binge drinkers who have consumed very large quantities, but are not aware, due to stupor, of the need to urinate. This condition is very rare in women, but does occur. Symptoms include localized pain and uraemia (poisoning due to reabsorbed waste). The recovery rate is high, with most fatalities due to septic blood poisoning. A person is more likely to urinate while passed out before the bladder ruptures, as alcohol relaxes the muscles that normally control their bladder.^[39]

Acute hazards

The most common risk of consuming massive quantities of alcohol in a short period of time is a dangerously high blood alcohol level. The result is called alcohol poisoning (overdose), which can be fatal. Choking on (or inhalation of) vomit is also a potential cause of death, as are injuries from falls, fights, motor vehicle and bicycle accidents.

Cause

In adults, binge drinking is more common in people who have never been married, score a grade B or less in education, and is also higher in adults who have little interest in religion.^[22] Culture as well as peer pressure play an important role in driving binge drinking.^[4]

The reasons for binge drinking by children and adolescents include;^[8]

• It's really fun (76%)
• I feel more sociable (65%)
• I feel happy/relaxed (51% each)
• I forget my problems (41%)

Other causes include feeling more grown up and fitting in with peers and to increase the chance of sexual encounters. Some also drink to alleviate stress or anxiety.^[8]

Risk factors for binge drinking among adolescents include; low socioeconomic status, large amount of disposable (pocket) money, sensation/novelty seeking, low self-control, delinquency and having delinquent friends. Other risk factors include: Using alcohol as a coping strategy for emotional problems (more common in adolescent girls), excessive drinking among peers, poor relationship with parents, alcohol abuse by parents, genetic conditions combined with a background of negative environmental factors increase the harmful use of alcohol.^[8] Additionally the risk taking behavior associated with adolescence promotes binge drinking.^[40]

Pathophysiology

Impairments in impulse control in binge drinkers, which is more prominent in female binge drinkers, is due to dysfunction of the frontal lobe. The findings in humans have been largely concordant with animal studies. Such animal studies find that heavy and regular binge drinking causes neurodegeneration in corticolimbic brain regions areas which are involved in learning and spatial memory, such as the olfactory bulb, piriform cortex, perirhinal cortex, entorhinal cortex, and the hippocampal dentate gyrus. A study in rats found that a heavy 2 day drinking binge caused extensive neurodegeneration in the entorhinal cortex with resultant learning deficits. While brain damage from binge drinking is known to occur as a result of binge drinking patterns, it is unclear how long drinking sessions last and how regular binge drinking is done to cause brain damage in humans. One study found that humans who drank at least 100 drinks (male) or 80 drinks (female) per month (concentrated to 21 occasions or less per month) throughout a 3 year period had impaired decision making skills compared to non-binge drinkers. Repeated acute withdrawal from alcohol which occurs in heavy binge drinkers has been shown in several studies to be associated with cognitive deficits as a result of neural kindling; neural kindling due to repeated withdrawals is believed to be the mechanism of cognitive damage in both binge drinkers and alcoholics. Neuronal kindling also leads to each subsequent acute withdrawal episode being more severe than previous withdrawal episodes.^[22]

Blackouts, a form of amnesia which occurs in binge drinkers may be due to suppressed hippocampus function with rebound NMDA (glutamate) activity combined with excessive glucocorticoid release induced by the stress of repeated intoxication followed by acute withdrawal/abstinence is the proposed mechanism of neural kindling leading to neurotoxicity of structures involved in learning and memory within the brain of binge drinkers.^[22] Frontal lobe processing may become impaired as a result of binge drinking with resultant neurocognitive deficits and impaired working memory.^[22]

Alcohol suppresses brain function during intoxication; but upon withdrawal rebound effects occur in the glutamate/NMDA system and with excess glutamate activity glucocorticoid release; due to the repeated intoxication, followed by acute withdrawal a neurotoxic effect develops which damages the central nervous system, leading to persisting impairments in verbal and nonverbal cognitive abilities as well as impairment of spatial orientation. Due to developmental processes occurring during adolescence including myelinization and restructuring of the synapses, adolescents are thought to be more vulnerable to the neurotoxic effects of alcohol.^[8]

Age and genetic factors influence the risk of developing alcohol related neurotoxicity.^[40] Adolescence, especially early adolescence (i.e. before age 15), is a critical and delicate developmental stage for specialised neuronal and synaptic systems mature. This critical developmental stage is where life long adult traits e.g., talents, reasoning and complex skills mature; however alcohol and in particular binge drinking may disrupt and interfere with this developmental process. Adolescence is also a period of development characterised by a high level of novel seeking, thrill seeking and risk taking behaviour and thus alcohol and other drug experimentation and abuse is common.^[41] An adolescent rat study found that a relatively short exposure to high levels of alcohol resulted long-lasting changes in functional brain activity with corresponding abnormalities in EEG brain waves which persisted into adulthood, including persisting disturbances in sleep EEG with a reduction in slow wave sleep. These EEG findings are similar to premature aging. According to one review of the literature, if the developmental stage of adolescence is similar to the developmental stage of the fetus with regard to sensitivity to the neurotoxic effects of alcohol, and if long-lasting or permanent damage to the brain occurs similar to what animal studies suggest, then this represents a major public health issue due to the high levels of alcohol use by adolescents.^[42]

Diagnosis

For the purpose of identifying an alcohol use disorder when assessing binge drinking, using a time frame of the past 6 months eliminates false negatives. For example it has been found that using a narrow 2 week window for assessment of binge drinking habits leads to 30 percent of heavy regular binge drinkers wrongly being classed as not having an alcohol use disorder.^[22] However, the same researchers also note that recall bias is somewhat enhanced when longer timeframes are used.^[22]

Prevention

Binge drinking is considered harmful, regardless of a person's age, and there have been calls for healthcare professionals to give increased attention to their patients drinking habits, especially binge drinking.^[43] Some researchers believe that raising the legal drinking age and screening brief interventions by healthcare providers are the most effective means of reducing morbidity and mortality rates associated with binge drinking.^[44] Programs in the United States have thought of numerous ways to help prevent binge drinking. The Centers for Disease Control and Prevention suggests increasing the cost of alcohol or the excise taxes, restricting the number of stores who may obtain a license to sell liquor (reducing "outlet density"), and implementing stricter law enforcement of underage drinking laws.^[13] There are also a number of individual counseling approaches, such as motivational interviewing and cognitive behavioral approaches, that have been shown to reduce drinking among heavy drinking college students.^[45] In August 2008, a group of college presidents calling itself the Amethyst Initiative asserted that lowering the legal drinking age to 18 (presumably) was one way to curb the "culture of dangerous binge drinking" among college students.^[46] This idea is currently the subject of controversy. Proponents^[47][48] argue that the 21 law forces drinking underground and makes it more dangerous than it has to be, while opponents^[49] argue that lowering the age may only make the situation worse.

Treatment

Due to the risks especially in adolescents, of cognitive impairments and possible irreversible brain damage associated with binge drinking, urgent action has been recommended.^[25] There is some evidence that interventions by employers such as, health and life-style checks, psychosocial skills training and peer referral, can reduce the level of binge drinking.^[50] In the USA brief motivational interventions have shown some benefit in reducing future binge drinking.^[8]

Adolescents who misuse alcohol can benefit from interventions aimed at risk reduction. For more severe cases a psychotherapeutic intervention involving parents or guardians is recommended.^[51] An effective strategy of intervention for adolescents whose binge drinking leads to admission to hospital, e.g. for alcohol poisoning or injury, is manualised brief interventions at the hospital in one to four counselling sessions each lasting 30 to 60 minutes conducted by trained staff. Evaluation of personal pattern of drinking and associated risks and an emphasis on personal responsibility in a non-condescending manner is recommended during the intervention; discussing and informing/educating the adolescent of possible negative short and long-term consequences of drinking is recommended. The setting of goals and rules to achieve those goals is also recommended during intervention with problem binge drinking adolescents.^[8]

Increasing public information and awareness regarding the risks of binge drinking, conducting interviews in emergency departments of young people suspected of harmful drinking patterns and trying to persuade them to accept individual counseling in youth addiction counseling services are effective strategies for reducing the harm of binge drinking. Encouraging recreational training activities such as adventurous training activities such as climbing or driving can be an alternative "natural buzzes" to alcohol misuse. Additionally the provision of educational content about the risks of binge drinking and a risk assessment are beneficial during intervention with young binge drinkers and a referral in the case of an alcohol use disorder for specialised help.^[8]

Epidemiology

Main article: Epidemiology of binge drinking

Binge drinking is more common in men than it is in women. Among students in the USA approximately 50 percent of men and 39 percent of women binge drink. Racial differences exist among binge drinking with Hispanics followed by white people having the highest level of binge drinking. Individuals of African descent have a lower level of binge drinking followed by those of Asian descent. In the case of Asians their low level of binge drinking may be due to the presence of the aldehyde dehydrogenase gene (ALDH2, Chromosome 12) in many (but by no means the vast majority) that results in poor metabolism of alcohol which leads to severe adverse effects such as facial flushing.^[22] Men are more likely to binge drink (up to 81 percent of alcohol binges are done by men) than women and men are also more likely to develop alcohol dependence than women. People who are homozygous for the ALDH2 gene are less likely to binge drink due to severe adverse effects which occur even with moderate amounts of alcohol consumption.

Social and culture

Binge drinking costs the UK economy approximately £20 billion a year; 17 million working days are estimated to be lost due to hangovers and drink-related illness each year. The cost of binge drinking to employers is estimated to be £6.4 billion and the cost per year of alcohol harm is estimated to cost the National Health Service £2.7 billion.^[25] Urgent action has been recommended to understand the binge drinking culture and its aetiology and pathogenesis and urgent action has been called for to educate people with regard to the dangers of binge drinking.^[25]

Centers for Disease Control and Prevention (CDC) released a study in October 2011 that showed that in the United States, binge drinking costs society $223-billion a year, which amounts to $2 per drink. These costs include health care costs for alcohol-related issues, including liver cirrhosis, loss of work productivity, proper damage due to drunk driving, and expenditures related to criminal acts. ^[52]

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Further reading

• MacLachlan, Malcolm and Smyth, Caroline (eds.). Binge Drinking And Youth Culture. Liffey Press (October 15, 2004). ISBN 1-904148-42-5.
• Walters, Scott and Baer, John. Talking with College Students about Alcohol: Motivational Strategies to Reduce Abuse. Guilford Press (October 13, 2005). ISBN 978-1-59385-222-1.
• Wechsler, Henry and Wuethrich, Bernice. Dying to Drink: Confronting Binge Drinking on College Campuses. Rodale Books (August 17, 2002). ISBN 1-57954-583-1.

External links

• Eliminating high-risk drinking: report
• Global Status Report on Alcohol 2004 by the WHO.
• Alcohol Concern Factsheet 20: Binge drinking
• Binge Drinking on College Campuses
• Alcohol time bomb set to explode Australia's binge-drinking
• BBC Headroom: Drinking too much?