Proposed changes to the psychiatric profession’s diagnostic manual, the DSM-5, have caused a recent uproar, with critics worried that the new label of “alcohol abuse disorder” will overdiagnose young problem drinkers — as many as 40% of college students — who eventually outgrow their dysfunctional behavior. Editors of the DSM-5 countered that the change in definition won’t increase diagnosis, but the whole debate is merely a sideshow. As a member of Harvard University’s Alcohol and Other Drug Services Executive Committee, I know firsthand that drinking among young adults is still a very serious problem that needs treatment.
Whether or not problem drinkers become alcoholics later in life — and there’s evidence that many of them do — we can’t ignore the hard reality that college binge drinking plays a central role in campus deaths, sexual assaults, physical injuries, destruction of property, failing academic performance, unintended pregnancies, STDs, depression, domestic violence and other mental-health problems.
The statistics are truly sobering. Every year, more than 3 million students between ages 18 and 24 drive while drunk. Alcohol accounts for 1,850 annual deaths in that age group, including deaths from car crashes and suicide. Almost 600,000 are injured under the influence of alcohol and another 700,000 have been assaulted by an intoxicated student. Around 400,000 had unprotected sex as a result of intoxication and 100,000 reported being too drunk to give consent for sex. Eleven percent of college drinkers damaged property. A quarter report academic difficulty due to alcohol use, while 150,000 college students have alcohol-related health problems.
Some of these alarming trends have shown significant increases over the 14 years since the National Institute on Alcohol Abuse and Alcoholism began tracking college drinking and its consequences. And these numbers are painfully animated by recent high-profile cases such as the murder of the University of Virginia lacrosse player by her alcohol-abusing ex-boyfriend or the death by alcohol hazing of a Cornell sophomore.
This level of dysfunction alone should provide the cold shower we need where college binge drinking is concerned. Imagine the outcry if prescription drugs or marijuana use caused anywhere near this degree of mayhem. But when it comes to problem drinking, we view the world through rose-colored shot glasses, preferring images of tailgates and graduation parties, not rapes and suicides.
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As to the issue of addiction, the picture gets worse. There’s a clear link between early drinking and a higher lifetime risk of alcoholism, with each earlier year of drinking resulting in greater risk: 47% of people who started drinking at age 14 became alcohol dependent later in life, while only 9% of those who began drinking after age 21 became dependent.
Studies suggest that two factors may be at work. On the one hand, early drinking is often an indicator of an underlying propensity to alcoholism. In other words, people who are genetically or otherwise predisposed to alcoholism — or show traits, like impulsivity, that can contribute to alcoholism — are more likely to want to start drinking sooner than later. This makes intuitive sense.
But it may be that the act of early drinking itself could raise the risk of alcoholism even in people who have no family history of alcoholism or are in other ways no likelier than the later drinkers to become alcoholics. This line of research suggests that the early identification of problem drinking in young people — and the willingness to label it as a problem — may be critical to forestalling alcoholism in later life.
Critics worry that the revised definition will stigmatize young people who meet the criteria for an alcohol disorder — routinely consuming four or five drinks rapidly in a short period of time or blacking out, for example — but who modify their drinking habits in their 20s. The fear is that the more expansive clinical label will force them into rigid treatment models or might even encourage self-fulfilling behavior.
But why are we getting bogged down in debates about diagnostic labels when the real issue is how to reduce harm? Drunk by any other name is still drunk.