ACCORDING TO THE WORLD HEALTH ORGANIZATION, THE U.S.-BASED CENTERS FOR DISEASE CONTROL

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1 ACCORDING TO THE WORLD HEALTH ORGANIZATION, THE U.S.-BASED CENTERS FOR DISEASE CONTROL AND PREVENTION, AND THE CANCER QUALITY COUNCIL OF ONTARIO, ALCOHOL CONSUMPTION IN EXCESS OF LOW-RISK GUIDELINES IS ONE OF THE TOP-FOUR MODIFIABLE RISK FACTORS FOR CHRONIC DISEASE, ALONG- SIDE SMOKING, LACK OF PHYSICAL ACTIVITY, AND OBESITY. 1,2,3 DESPITE THIS, ALCOHOL DOES NOT CURRENTLY ATTRACT THE SAME AMOUNT OF ATTENTION AS THESE OTHER CHRONIC DISEASE RISK FACTORS. With that in mind, this paper sets out to examine the rate of alcohol use among Ontarians, and to consider public policy options with regard to heavy drinking. As discussed below, the rates of heavy alcohol consumption in Canada and in Ontario are very high, and there are serious negative side-effects re port ed among heavy drinkers. Public health programs for preventing heavy drinking among Ontario teenagers and young adults are mostly limited to the Drug Abuse Resistance Education (DARE) initiative, despite the fact that it has proven to be inefficacious, while many other programs have been found to be effective at lowering heavy drinking and binge-drinking behaviours. 4 Extent Of Alcohol Use Alcohol is the most widely used addictive substance in Canada. Though it may not be surprising to learn that almost eight out of 10 (78%) Canadians drink alcohol, given that it is a legal substance and deeply intertwined with many social and cultural behaviours, it is alarming to see that one in 10 Canadians aged 15 and over report symptoms consistent with alcohol dependence. 5,6 In Ontario, surveys show that about 80% of the population reports using alcohol, and of this group, more than 15% report heavy levels of use. 7 Heavy drinking is indicated by the frequent use of alcohol and binge-drinking. Binge-drinking is considered to be the consumption of five or more alcoholic beverages on a single occasion. This is particularly concerning among youth. In 2007, 25% of people in Ontario aged 12 to 19 reported consuming at least five or more drinks on at least one occasion in the previous 12 months. 8 Canada s guidelines for alcohol consumption state that males should not consume more than 15 standard drinks, and females should not consume more than 10 standard drinks in a given week. 9 Heavy consumption involving binge-drinking or in a steady consumption pattern puts a person at risk of negative health effects and addiction. Throughout this paper, the term heavy use of alcohol will be used to signify drinking behaviour on a spectrum ranging from just above the weekly guidelines up to a significantly high use of alcohol, but not including alcohol addiction. Alcohol addiction is a clinically defined condition with specific diagnosis and treatment protocols, and is outside of the scope of this paper, which looks at public health interventions. Ontario Medical Review 21 April 2013

2 When it comes to the heavy use of alcohol, age is perhaps the strongest determinant. Generally, alcohol use increases with age during adolescence, peaks in the mid-to-late 20s, and then subsides. 10 Heavy drinking patterns show a peak among 20 to 24 year-olds for both sexes, with almost half of Canadian males aged 20 to 24 reporting a heavy drinking pattern. 5 The rate of alcohol use among Canadians declines to a total of 3.6% among those 65 years of age and older. Gender also plays a strong role, with men being 2.6 times more likely than women to meet the clinical criteria for alcohol addiction; of those who drink, 25% of men exhibit heavy drinking behaviour compared to 9% of women. 6 Among Ontario public health units, the proportion of heavy drinkers aged 12 to 19 who reported consuming five or more drinks on at least one occasion varied between a high of 65% and a low of 12%. 8 Alcohol is the most commonly used addictive substance among Canada s youth. 8 Some youth are more at risk for heavy alcohol consumption than others, such as runaway or street-involved youth; youth in police custody; adolescents with co-occurring disorders; sexually abused and exploited youth; gay, lesbian, bisexual and questioning teens; and First Nations, Inuit and Métis youth. The increased risk experienced by these youth populations is due to factors such as elevated rates of trauma and loss, sexual and physical abuse and other types of violence, and stigma and racism. 10 In the adult population, alcohol abstinence is more common among First Nations people in Ontario, with only 66% reporting using alcohol in the past year compared to approximately 80% of adults in the general population. However, heavy drinking is also more common among First Nations people, with 16% of those who do drink consuming five or more drinks per occasion, compared to 6% in the general population. 7 These statistics show that while moderate alcohol consumption is common among adults in Ontario, heavy drinking among adults and underage heavy drinking are more widespread than people may think. As a legal and governmentsanctioned substance, alcohol is easy to access and socially acceptable. Drinking culture may contribute to the development of heavy consumption patterns among youth. Heavy drinking goes largely unaddressed, particularly in this age group. The Health Effects Of Alcohol Use As discussed, alcohol is by far the most common addictive substance used by Ontarians, and binge-drinking is common. Since 80% of Ontarians drink alcohol, negative alcohol-related consequences may directly impact a substantial proportion of the population, and indirectly reaches all Ontarians through costs to our health-care system and justice system, rates of violence and crime, and destruction of public property. 5 Patterns of heavy drinking are associated with risk-taking behaviour, which can lead to poorly thought-out decisions resulting in negative outcomes for the individual and his or her family and social network. Consequences associated with heavy drinking include injury, violence, alcohol poisoning, and unplanned and unwanted sexual experiences including unwanted pregnancy, sexual assault, and contracting sexually transmitted infections. 8 Alcohol-related trauma is a significant and preventable cause of death among young Canadians. 8 In the broader population, heavy alcohol consumption can lead to injury, disability, and premature death from events such as car crashes, falls, fires, violent acts such as assault, rape, domestic abuse, child abuse, homicide, poisonings, suicide and many other forms of intentional and unintentional injury, many of which are preventable. 7 Data collected from Ontario for the year 2002 showed that alcohol use accounted for $5.3 billion in direct and indirect costs, or $441 per capita. This amount represented 37.2% of the entire substance-use related costs for the province. 7 In addition to these consequences of drinking-related actions, alcohol may cause or worsen chronic illnesses or symptoms such as insomnia, depression and hypertension, and make older persons more susceptible to falls and conditions such as delirium. 7 Alcohol is related to the development or exacerbation of more than 60 medical conditions through various pathways, including cirrhosis of the liver, various cancers, pancreatic damage, and increased risk for high blood pressure. Binge-drinking can double the risk of acute health events such as ischemic stroke, and can triple the risk of hemorrhagic stroke. 7 Though the vast majority of chronic health conditions are experienced by the person who uses alcohol, women who are heavy alcohol users and are of reproductive age may also cause unintentional harm to a fetus should they become pregnant. One possible outcome of alcohol use during pregnancy is Fetal Alcohol Spectrum Disorder (FASD), which is a leading cause of developmental and cognitive disabilities among Canadian children. In Canada, the incidence of FASD is estimated to be 1 in 100 live births. 7 Finally, many of the human and social impacts of heavy alcohol use are not quantifiable. 7 Heavy drinking affects the individual and his or her family through crisis, disruption, loss Ontario Medical Review 22 April 2013

3 Summary Of Recommendations 1. Prevention programs which include harm reduction components and have been demonstrated in trials to be effective should be implemented in Ontario on a provincewide scale. 2. Some portion of the projected $100 million in additional Liquor Control Board of Ontario (LCBO) revenues should support new harm reduction programs, with an emphasis on preventing negative health outcomes. 3. Secondary and post-secondary school-based substance abuse programs should be implemented to focus on substances that are used most frequently and cause the most harm within these age groups; the number-one substance on both counts is alcohol. 4. Adult-focused programs such as Screening, Brief Intervention, and Referral, Guided Self-Change, Project TrEAT, and Project GOAL should be implemented across Ontario to provide support to a mature population who are not in educational settings. 5. Additional research into the interconnected factors that lead people into heavy drinking behaviours and addiction should be undertaken; research into the connections between trauma, mental illness, and alcohol addiction is needed. 6. Interventions to address substance abuse should work toward preventing and addressing the underlying factors that drive this behaviour, such as sexual and physical violence, trauma, and stigma and discrimination. of income, insecure housing, loss of employment, emotional impact on children and legal costs, among other potential consequences. Loss of employment due to heavy alcohol use can occur as a result of lost work days, increased sick time, reduced productivity, or injury. 7 In some cases, poverty and homelessness can result from these many interconnected consequences. Alcohol And Harm Reduction Programs In the traditional definition, harm reduction addresses the needs of people who use addictive substances, their families, and the communities who may be affected by that use. 7 The clinical harm reduction model accepts that total abstinence from all drug use may not be a realistic goal for some people, particularly in the short term. Some of these programs include harm reduction for illicit drug use, such as methadone treatment and needle exchange programs, or improving co-ordination with health services and other agencies that link drug users to withdrawal management, treatment, counselling and prevention services that they might not otherwise access. 7 Rather than espouse this clinical harm reduction philosophy, this paper will focus on the public health programs that mitigate the harms experienced by an individual and society by preventing or modifying negative behaviours that fall below the clinical threshold for treatment. Public health-based harm reduction programs for alcohol use take a number of forms, and can target specific age groups and drinking behaviours. Since alcohol consumption in Ontario starts for the most part in high school, targeting students with harm reduction programs may contribute to lower rates of binge-drinking and more responsible choices with regard to property, sexual activity, or drinking and driving, for example. 4 Harm reduction programs provide an assetbuilding focus, rather than a focus on punishment or deterrence, aiming to enhance a person s resilience. Resilience is the ability of a person to cope with a situation that cannot be easily changed or is unchangeable (such as a past experience of trauma, or living with a parent who is a heavy user of alcohol). 10 Unfortunately, the most widely implemented harm reduction program, Drug Abuse Resistance Education (DARE), has been found in clinical study to contribute to increases in drug and alcohol use. 4 This may be due to the zero-tolerance stance of this program. Programs that have been found to be effective at reducing heavy drinking behaviour tend to promote moderation and individual goal-setting. Studies have found that people see themselves as more capable and feel more motivated if they are working toward a self-selected goal. 4 Such moderation-focused harm reduction programs allow for the social and cultural role that alcohol plays, while teaching people Ontario Medical Review 23 April 2013

4 about the negative consequences of heavy drinking, bingedrinking, and alcohol addiction. Programs that have been effective among high school students compared to non-intervention control groups include the Life Skills Training Program and Alcohol Misuse Prevention Study (AMPS) in the United States, and School Health and Alcohol Harm Reduction Project (SHAHRP) in Australia. 4 These programs use various methods to encourage social skills related to alcohol moderation, resisting pressure to drink or binge-drink, and reducing the positive expectations surrounding alcohol consumption, while emphasizing the potentially harmful consequences. While alcohol consumption begins in high school, the peak age for heavy consumption in Ontario is the early to mid-20s. This age group drinks most frequently and most heavily, and students at post-secondary institutions are most likely to binge-drink. 4 These behaviours bring with them a greater likelihood of suffering negative consequences of alcohol consumption. The Alcohol Skills Training Program (ASTP) and Brief Alcohol Screening and Intervention for College Students (BASICS) harm reduction programs in the United States have been found to be effective with this group compared to non-intervention control groups. They use strategies such as drinking assessment, education about social norms, skills training, and self-monitoring techniques to reduce harmful consequences experienced by post-secondary students who show heavy drinking behaviours. 4 These programs have been found to significantly lower the drinking quantities of student participants and reduce negative consequences compared to control group peers. The Rutgers Alcohol Problems Inventory found that the positive results of ASTP and BASICS were maintained through a four-year follow-up period. 4 The majority of Ontarians who drink heavily in the peak drinking age group (early to mid-20s) tend toward moderation into their 30s and beyond; heavy alcohol use continues to decline as age progresses toward the senior years. However, for certain individuals, heavy alcohol use as a young person will develop into alcohol addiction, which brings with it many negative consequences on physical health, mental health, employment, and relationships, among other things. Alcohol abstinence programs such as Alcoholics Anonymous are effective for a certain number of people with alcohol addictions, but the strict standard of zero alcohol consumption poses a challenge to many people who are interested in changing their behaviour. Achieving a level of moderation with regard to alcohol consumption is sometimes a more realistic goal, and can significantly reduce harm. The American Medical Association supports the use of two programs aimed at the treatment of heavy drinkers in a primary care setting. Project Trial for Early Alcohol Treatment (TrEAT), for 18 to 64 year olds, and Project Guiding Older Adult Lifestyles (GOAL), for those over 65, use brief physician interventions (giving advice and explaining negative outcomes) to motivate patients to drink with moderation. 4 Both programs have demonstrated significant reductions in average drinks per week, episodes of binge-drinking, and number of hospital stays compared to non-intervention control groups. At the federal level of government, harm reduction has been excluded from the most recent National Anti-Drug Strategy for Canada, which represents a change of direction from the foregoing Canada s Drug Strategy. These strategies focus mainly on illicit drugs, but the omission of harm reduction in the new strategy nonetheless sets the tone for addictions treatment and correctional services. In Ontario, a handful of alcohol harm reduction programs are currently available in various jurisdictions and through various bodies. For example, the Safer Bars program is available through the Centre for Addiction and Mental Health (CAMH), Drugs and Alcohol Hotline administered online by the Ministry of Health and Long-Term Care and ConnexOntario, the Guided Self-Change program is provided through provincial chapters of the Canadian Mental Health Association (CMHA), and the Screening, Brief Intervention, and Referral (SBIR) program is available online from the College of Family Physicians of Canada (CFPC). However, there is no Ontario-wide, consistently accessible, harm reduction program for alcohol use at this time. Secondary Benefits Of Harm Reduction Programs Harm reduction has a number of secondary benefits that accrue to people other than the direct individual who participates in the program. Some of these benefits are clearcut, including cost diversion from the health-care system and justice system, serious and petty crime prevention, and increases in public order and safety. Other less visible benefits include promoting social justice by providing better services for those with histories of trauma, violence, mental illness, or social isolation and stigma, and for whom abstinence programs and criminal sanctions are ineffective; and addressing the social determinants of health by acknowledging that experiences such as abuse and violence in some cases lead to mental illness or addiction in the place of other suitable and accessible outlets for emotional and physical trauma. Ontario Medical Review 24 April 2013

5 Conclusions While discussions about reducing alcohol s negative impacts, or promoting the idea that alcohol can be a harmful substance, are often criticized and likened to the prohibition-era approaches, most modern alcohol policies bear little resemblance to prohibition. In fact, alcohol policy has been supportive of people s right to drink in moderation, but has not been responsive to people s capacity to abuse alcohol. 11 To date, no convincing explanations have been provided for the disjunction between research and prevention practice. Medical evidence clearly indicates that alcohol is a major risk factor in terms of negative health outcomes from a variety of chronic diseases and acute events. However, higher societal priority is given to much lesser risk factors that cause less harm to individuals, families, and society as a whole. 7 Government clearly has a role to play in trying to reduce the harm that alcohol causes. Reducing alcohol consumption will result in health benefits in both the short term and long term. The price of alcohol has been found to be one of the most important determinants of alcohol consumption, especially with youth and young adults. For example, higher beer prices, through taxation, reduced the frequency of youth drinking and the probability of high-risk drinking. 7 As the availability of alcohol in Ontario is strictly controlled, and a significant proportion is sold at government-run stores, opportunities for government-sponsored harm reduction initiatives are sensible. Since the Liquor Control Board of Ontario (LCBO) has a plan to deliver an additional $100 million per year in revenues to the province, these revenues could be used to help support new harm reduction programs, as outlined, with an emphasis on preventing negative health outcomes. 12 Since drinking begins in high school (despite Ontario s legal drinking age of 19 years and older), and 84% of postsecondary students report consuming alcohol, the educational system is an important place to begin harm reduction programming. 7 Secondary school-based substance abuse programs should focus on substances that are used most frequently and cause the most harm within this population. The number-one substance on both counts is alcohol. 10 The OMA recommends that prevention programs which include harm reduction components and have been demonstrated in trials to be effective should be implemented on a wide scale, including to post-secondary students. 10 The most effective harm reduction programs usually rely on the active participation of peers to provide a positive influence. They teach participants to reframe their perceptions and to adopt refusal strategies, while remaining interactive and focused on behavioural learning. 10 Alcohol harm reduction programming among youth and young adults reduces problem drinking behaviour, promotes healthy development, and provides youth with the tools to make informed and healthy choices. 10 Ontario must do more to prevent alcohol abuse in youth and young adults. In addition, the OMA recommends implementing adultfocused programs such as SBIR, Guided Self-Change, Project TrEAT, and Project GOAL across Ontario in order to access a mature population who are not in educational settings. Helping these adults learn moderation in their drinking habits, perhaps as a step toward abstinence, is essential for reducing the negative health and social harms of heavy drinking. The OMA also believes that more research is needed into the interconnected factors that lead people into heavy drinking behaviours and addiction. Increased knowledge about the connection between early academic problems and later substance abuse among students could contribute significantly to the development of early intervention programs that are more effective than current drug and alcohol education strategies. 10 Research into the connections between trauma, mental illness, and alcohol addiction is also needed; though studies have been conducted into this interplay, the many factors and multi-directional patterns of causation require further research. Finally, it is important that while such research is being conducted, prevention efforts focus on addressing the underlying issues of alcohol addiction, rather than just the coping behaviours they elicit. The OMA stresses that interventions to address substance abuse should also work to prevent and address the underlying factors that drive this behaviour, such as sexual and physical violence, trauma, and stigma and discrimination. 10 Permission And Citation The contents of this publication may be reproduced in whole or in part provided the intended use is for non-commercial purposes, and full acknowledgment is given to: Ontario Medical Association 150 Bloor St. West, Suite 900 Toronto, Ontario M5S 3C1 Ontario Medical Association, Mitigating Harm Associated With Alcohol Use Ont Med Rev 2013, April: ISBN: Copyright Ontario Medical Association, Ontario Medical Review 25 April 2013

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