Date:October 10, 2018 - 9:00 AM
NIAAA Working Group on High-Intensity Drinking -- Working Group Meeting Panelists:
Nancy Barnett, Ph.D., Associate Dean for Faculty Affairs, Brown University School of Public Health; Professor, Department of Behavioral and Social Sciences, Brown University
Lee Boot, M.F.A., Research Associate Professor and Director of the Imaging Research Center, UMBC
Ian Colrain, Ph.D., President, SRI Biosciences
Elizabeth D'Amico, Ph.D., Senior Behavioral Scientist, RAND Corporation
Neil E. Grunberg, Ph.D., Professor of Military & Emergency Medicine, Medical & Clinical Psychology, and Neuroscience, Uniformed Services University (USU) School of Medicine; Professor, USU Graduate School of Nursing; Director of Research and Development, USU Leader and Leadership Education and Development (LEAD) program
Keith Humphreys, Ph.D., Professor and Section Director for Mental Health Policy, Department of Psychiatry and Behavioral Sciences, Stanford University; Senior Research Career Scientist, VA Health Services Research Center in Palo Alto; Honorary Professor of Psychiatry, Institute of Psychiatry, King's College, London
Kristina Jackson, Ph.D., Professor (Research), Center for Alcohol and Addiction Studies, Brown University
Cathy Lau-Barraco, Ph.D., Associate Professor of Clinical Psychology, Old Dominion University
Mark Nichter, Ph.D., Regents’ Professor and Professor of Anthropology, Public Health, and Family Medicine; Coordinator of the Graduate Medical Anthropology Training Program, University of Arizona
Mimi Nichter, Ph.D., Professor of Anthropology, University of Arizona
Shimei Pan, Ph.D., Assistant Professor, Information Systems Department, UMBC
Summary of introductory comments
In his opening remarks, Dr. George Koob welcomed panelists and expressed his enthusiasm for convening a team of diverse experts to discuss high-intensity drinking: alcohol intake at levels twice or more the threshold for binge drinking. Dr. Aaron White then described recent trends in alcohol use in the United States. Over the past 15 years, overall rates of alcohol use and binge drinking have modestly increased. Just over half of the U.S. population are current drinkers, and nearly half of current drinkers engage in binge drinking. Binge drinking is defined as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08%. This typically occurs after 4 drinks for women and 5 drinks for men—in about 2 hours. Dr. White added that this approximation is less accurate for adolescents, with some adolescent age groups estimated to reach a BAC of 0.08% after only three drinks.
Dr. White also described “movement under the surface” of alcohol use trends. While underage drinking has continued to steadily decline, overall rates of binge drinking across the adult population reflect a 4.8% increase since 2002. However, the prevalence of binge drinking has increased over 25% among adults ages 50-64 and nearly 40% among adults over the age of 65. Similarly, although rates of binge drinking have remained stable among men, a 14% increase was observed in women. Collectively, these data indicate that population-wide alcohol use statistics are not capturing the shifting patterns of deleterious alcohol consumption occurring among subgroups.
Another paradox has recently emerged: during a time in which modest increases in alcohol consumption the U.S. have been observed, alcohol-related harm has increased dramatically. Between 2006 and 2015, alcohol-related emergency department visits increased by more than 60%. Moreover, given that alcohol involvement in deaths is often underreported, alcohol-related harm may also be underestimated in emergency departments.
As Dr. White pointed out, the definition of binge drinking provides a single threshold. Drinkers either reach the threshold or not; the measurement fails to signify the added risks of drinking that surpasses the binge level. Peak number of drinks per occasion is a measure that allows for assessment of high-intensity drinking. Peak drinking levels predict harmful consequences: a recent analysis of high school students found that drinking at two or more times the binge threshold is associated with greater odds for multiple health-risk behaviors. Among college-age individuals (18-22), college students reported slightly higher rates of drinking 5+ or 10+ drinks per occasion within the past two weeks relative to their non-student counterparts. However, non-college-attending youths reported higher rates of drinking 15+ drinks per occasion. The accumulating evidence that Americans are drinking more dangerously suggests a potential increase in high-intensity binge drinking. Unfortunately, few studies collect data on peak number of drinks and how often individuals drink to that level, limiting the information available on this phenomenon.
Early comments from the panel:
Members of the working group were invited to share initial thoughts or comments related to high-intensity drinking. Several panelists had comments about the rates of high-intensity drinking among non-college-attending youth relative to college students. One panelist pointed out that most research focuses on college students and not non-college-attending youth – the group in which the most extreme pattern of problematic drinking (15+ drinks per occasion) is more prevalent. Another panelist agreed that college students have received more attention, perhaps unfairly, due to the interest of college administrators in addressing drinking behavior among their student populations. Panelists added that it is more challenging to locate, engage, and study non-college-attending youth. Another panelist pointed out that non-college youth are not worse than college students with regard to harmful drinking patterns—just equally bad. He added that residential 4-year college students are a good population to study.
A panelist made the point that beyond categorization into groups such as “students” and “non-students”, specific contexts should be considered. Patterns of drinking likely change with the context or venue, and mapping patterns of consumption in different contexts using ecological momentary assessment could identify the “acceptable” (normative) pattern in a given context. This research approach could offer highly relevant information to inform intervention strategies.
The panelists were reminded that although adolescents and emerging adults are an important target for prevention of high-intensity drinking, the efforts of the working group should not be limited to specific age groups. Data indicating increases in alcohol-related emergency department visits in older adults highlight the need to consider adults over the age of 45. Some panelists were surprised by the increases in this age group, but the panel was quick to connect this pattern to the phenomenon of “deaths of despair” described by economists Anne Case and Angus Deaton. Drinking as a coping mechanism may be increasing during a time in U.S. history in which generations are poorer than the preceding generation and life expectancy in certain subgroups is decreasing rather than increasing.
Regarding the reported increase in alcohol-related emergency department visits, a panelist suggested that the increase may be related to co-substance use. Supporting this idea, Dr. White added that individuals are more likely to co-use other drugs as peak alcohol consumption goes up. Co-use of alcohol with other substances such as stimulants and marijuana may also increase negative consequences. Another attendee expressed the need for better data collection during ED visits, suggesting that measuring BACs would be a helpful screening strategy.
Identifying the top causes and drivers of high-intensity drinking
Members of the working group were asked to list potential causes or drivers of high-intensity drinking behavior. One panelist suggested framing the causes as belonging to one of two categories: psychosocial (cultural norms, stereotypes, expectations, benefits, risks) and psychobiological (coping with despair, psychological escape from problems). Another panelist highlighted the challenge of determining cause in a landscape of many interacting factors, suggesting that data mining may be a helpful strategy to uncover unexpected correlations.
Tracking alcohol consumption
Several panelists indicated that lack of awareness of the amount of alcohol an individual has consumed likely contributes to high-intensity drinking in some populations. One panelist noted that varying contexts and measures of alcohol intake make it especially difficult for anyone to track how much they’ve consumed. Recent trends toward greater consumption of distilled spirits among young people may contribute to the problem; alcohol content is likely underestimated in mixed drinks, which often contain multiple spirits. Another panelist pointed out the implications for inaccuracies in research that relies on self-reported alcohol consumption. Dr. Koob agreed that most people are unable to accurately assess their alcohol intake, adding that NIAAA continues to support development of wearable alcohol biosensors. Resulting technologies would be useful not only for research purposes, but also for helping people monitor their drinking more accurately. One panelist expressed concern for potentially dangerous use of real-time feedback among individuals drinking with intent to reach high BACs.
Social media was heavily discussed as both a data tool and a driver of high-intensity drinking. Panelists first described social media as a unique platform for projecting a curated representation of self (often as special or extreme), adding that the influential nature of this presentation may encourage others to go to extremes to present themselves as special. Social media applications provide a quick means of establishing who and what is popular while providing a space to project alcohol-related behavior as normative or “cool”. Panelists added that individuals also learn strategies for drinking on social media and that people are more likely to post or share what they perceive as positive effects of high-intensity drinking rather than negative effects. Other panelists emphasized that several features of social media, such as news feed algorithms and hashtags, may encourage extreme behavior and alter perceived norms.
Shifting the focus to opportunities for social media data collection, another panelist described the computer science tools that may be helpful to identify factors that contribute to high-intensity drinking. Social media data are large-scale, longitudinal, and dynamic. These data offer opportunities to overcome the college versus non-college population gap and allow for context characterization (people, location, occasion), text and image analysis, and hashtag analysis. Another panelist agreed that social media data are robust but cautioned that advertisers have access to these data as well, with implications for targeted marketing toward vulnerable populations.
Social context: Identity, influence, and perceived norms
Social context and identity include specific attitudes toward drinking and substance use. Multiple panelists discussed the role of social context in shaping expectations and perceived consequences of alcohol use. Perceptions of how acceptable and prevalent drinking is and how much one’s closest friends drink establish perceived norms and predict an individual’s drinking. A panelist pointed out that social context can exist on multiple levels, such as within smaller groups at larger events.
Other panelists discussed generational shifts in normative behavior that may contribute to drinking behavior, particularly among young and emerging adults experiencing a protracted adolescence. Young people are now marrying later, living with their parents longer, lengthening their period of socializing/going out with friends, driving less, and not getting full-time jobs – conditions that are likely extending the drinking behavior that previous generations may have outgrown at an earlier stage in life.
Panelists pointed out that expectancies and perceived norms can be corrected through intervention. Social influence can shape not only initiation of use and continued use, but also recovery. For example, social reinforcers contribute to the effectiveness of Alcoholics Anonymous. Thus, although peer influence may be part of the problem, it can also be part of the solution.
Over the course of the meeting, several panelists emphasized the need to study gender and ethnicity as identity factors that may influence high-intensity drinking behavior. One panelist discussed the importance of identifying what is driving recent increases in heavy alcohol use among women, suggesting that hypersexuality and new waves of feminism may be responsible for a shift in perceptions of drinking from “unladylike” to empowering for women. Another panelist agreed that the significance of alcohol consumption varies across different populations.
Drinking with purpose/intent
Several panelists mentioned that drinking alcohol can serve a variety of different purposes, some of which are more likely to lead to high-intensity drinking. For example, individuals may be motivated by pain to consume alcohol for the purpose of self-medication. Indeed, the pain-relieving effects of alcohol emerge at BACs around 0.08% or higher, suggesting that drinking for this purpose could easily reach the level of high-intensity drinking. On the other hand, panelists suggested that some individuals may engage in high-intensity drinking with the goal of intentionally blacking out.
Drinking to increase tolerance was another purpose discussed by multiple panelists. Tolerance may be desirable for individuals participating in drinking games or more generally to promote the image of being able to hold one’s liquor. Other attendees pointed out that tolerance to alcohol is differential; for example, individuals may develop tolerance to sedative effects of alcohol (thus staying awake longer to continue drinking) but are unlikely to develop tolerance for alcohol-related memory impairment. This combination likely contributes to the elevated risk of harm that accompanies high-intensity drinking.
Panelists suggested that purposes of drinking may change across context. For example, many people drink alcohol to be social. Solitary drinking likely serves a very different purpose than social drinking. Multiple panelists agreed that considering an individual’s purpose for drinking would be useful for identifying alternative reinforcement options.
Somewhat related to the concept of drinking for different purposes is the concept of different “types” of drinkers (e.g., those who binge on the weekends versus steady drinkers). The latter classification has not yet proven beneficial in the treatment domain, although advances in personalized medicine may one day allow for treatment directed at specific types of drinking patterns.
Addressing the problem
Members of the working group were encouraged to share thoughts and ideas about strategies for effectively addressing the problem of high-intensity drinking. One panelist encouraged a creative approach for thinking about public health interventions aimed at reducing substance misuse – visualization. Unlike descriptive text, visualization captures nuance, including the sometimes intricate interplay among potential factors, by spatially representing relationships between a comprehensive array of concepts simultaneously. By capturing and contextualizing relationships between hypothesized factors, this strategy may inspire new connections, insights, hypotheses, research methods and interventions to address high-intensity drinking.
Binge vs high intensity drinking
Panelists expressed interest in whether binge drinking and high-intensity drinking are separate phenomena, suggesting that there is something to learn from comparing populations who binge-drink to those who engage in high-intensity drinking. One panelist stated that what differentiates those who binge from those who engage in high-intensity drinking is the decision to continue drinking while intoxicated. He suggested that studying decision-making in intoxicated people might provide helpful information. A few panelists wondered if intention to drink too much distinguished the two drinking patterns.
Is policy enough?
One attendee discussed the role of alcohol policy in curbing high-intensity drinking, listing examples of specific policies that brought about a positive change (e.g., lowering the BAC limit for driving under the influence reduced deaths; raising the minimum legal drinking age reduced underage drinking). He added that it was important to measure the effects of policy changes on binge and high-intensity drinking.
In response, another attendee argued that because high-intensity drinking occurs in a relatively small subset of the population, a more targeted approach may be necessary to counter this behavior. That is, interventions that are tailored to subpopulations engaging in high-intensity drinking may address the issue better than broad policy. However, a panelist countered that policies that generally address alcohol-related problems are also likely to influence high-intensity drinking behavior as well.
Influencing norms and perceived harm
Multiple panelists indicated that a major obstacle for alcohol prevention and intervention efforts is lack of perceived harm. Many individuals who engage in dangerous drinking patterns such as high-intensity drinking do not see the problem in doing so once or twice a week. Similarly, many parents still view underage and college drinking as a harmless rite of passage, and it can be difficult to motivate them to actively curb this behavior.
The panel emphasized that prevention and intervention efforts must be framed with a “hook” that establishes relevance for the target population. For example, when discussing strategies for discouraging alcohol use among middle- and high-school students, panelists indicated that these students are concerned about their friends (and far less concerned about getting in trouble), so messaging that focuses on their relationship with their friends or how their friends could be harmed is more likely to be effective than punishment. Similarly, focusing on alcohol’s effects on memory was a strategy proposed for encouraging college students (who presumably want to succeed in their coursework) to limit intake.
The portrayal of alcohol use in film and television may have great implications for perceived norms and harm. Tolerance to heavy alcohol use is extolled as a virtue in this type of media, and characters who can handle heavy alcohol use are depicted as “cool” and “tough”. Some panelists raised the idea of reducing alcohol’s overwhelming presence in film and TV, as was done with smoking.
Targeting norms through social influence/reinforcement
Multiple panelists described their experiences implementing various intervention programs. One indicated that social diffusion of messaging does occur, suggesting that individuals will hear about a program even if they don’t directly participate. Similarly, a panelist suggested identifying influential people in a network who engage in the targeted behavior, engaging those individuals in an intervention, and measuring the effect on other people. Behavior change in key individuals can affect other people. Similarly, programs that train students to be engaged bystanders who are willing to contribute to change were suggested as a helpful strategy for social diffusion.
Another panelist added that top-down interventions (i.e., those that focus on educating the targeted crowd) are less likely to be effective than more engaging strategies that involve stakeholders at every level. Long-term benefits are greater when the target population is involved first in determining the problem and desired outcomes, followed by critical participatory action research and dissemination research (bottom-up intervention). The restructuring of the DARE program was discussed as an example.
Social media as a platform for prevention and intervention
Although the rise of social media platforms has contributed to the diffuse state of media today, panelists pointed out that the larger landscape of media channels offers more access for purposes of prevention and intervention. Another panelist agreed that social media can be a platform for intervention that offers an advantage of scalability: massive numbers of individuals can be targeted at once. Analysis of social media data can easily identify both individuals at risk for harmful drinking behavior and the opinion leaders who may have influence over at-risk populations. Messaging can easily be customized for different groups, allowing for individualized intervention. Analysis of social media data from individuals who are known to have alcohol-related problems can be used to develop algorithms that predict problems among other individuals.
Finding the right language
In the literature, drinking 8-10+ drinks in one occasion (i.e., over twice the gender-specific thresholds for binge drinking) has been described as “extreme binge” or “high-intensity” drinking. Panelists were asked to consider whether other language may be more appropriate. Dr. Koob expressed the importance of avoiding terminology that sounds appealing (as “extreme binge” might sound) or minimizes the harmfulness of drinking that falls below the defined threshold. He added that NIAAA’s definition of binge drinking has been useful for research purposes and that he would prefer to identify a term with similar heuristic value.
Proposed terms that were discussed include “excessive binge drinking,” “binging at twice the threshold,” “binge drinking 2.0,” “high-volume drinking,” “dark-side drinking,” “high-drinking occasions,” “overdrinking,” and “drinking past the limit.” There was some discussion of the benefits of specific/explicit versus more general language in describing this phenomenon.
Terms focusing on the increased risk for harm were also pitched: “lethal drinking,” “dangerous drinking,” “high-risk drinking,” “dysfunctional drinking,” “disaster-prone drinking,” and “dangerous binging.” One panelist in favor of consequence-focused terminology suggested that an evocative term could be highly effective. “We already have terms for hazardous and harmful drinking,” another panelist pointed out. The panelist then argued that ascribing “danger” to terms for drinking twice the binge threshold could signal that consumption below that level is not dangerous. He suggested that terms that are simply descriptive (i.e., of quantity or intensity) might be a better option.
A panelist suggested value in using different terminology tailored to specific age groups or communities, although another attendee cautioned that this strategy may be difficult and not helpful for research, as trends are constantly evolving and the language changes quickly.
One panelist pointed out that, according to marketing experts, names and logos don’t matter much, as long as they don’t work against the brand. The concept of the brand (distinguishing features that earn a reputation) is more influential, and a neutral term/title may be an easier platform from which to launch a brand.
Ultimately, “high-intensity drinking” as it is currently defined remained the least-contested terminology. Several panelists indicated that focus groups would be a good way to get feedback on the connotation of the various options for terminology that were discussed.
Developing a plan of action
Dr. Koob encouraged the panelists to share published work highlighting effective interventions with the group. He expressed interest in discussing interventions more at a future meeting. One panelist pointed out that effective interventions have already been shown to decrease peak drinking, so we likely already have programs that would target high-intensity drinking. Similarly, another attendee indicated that college-focused interventions are also effective for other populations. Panelists discussed that high-intensity drinking is more likely to occur at specific events or occasions, and that identifying these patterns may provide an opportunity for effectively-timed interventions. Ultimately, panelists agreed that a single strategy was unlikely to produce benefits for the multiple populations engaging in high-intensity drinking, but that multiple targeted efforts could contribute to a greater awareness of the problem.
When discussing a future research agenda for NIAAA, one panelist suggested assessing alcohol-related expectation versus reality in a laboratory bar setting. Another reiterated the need to study decision-making in intoxicated participants. However, great interest was expressed in the need to conduct research to better understand high-intensity drinking within social contexts. Studies could reveal valuable information to understand how people move around in their social context by integrating emerging technologies, including ecological momentary assessment and alcohol biosensors. The strategy of deriving hypotheses from social media data was also discussed. Another panelist wondered if video ethnography would be a useful strategy for understanding the phenomenon.
At the end of the day, panelists agreed it was important to move forward by implementing interventions and collecting new data at once (a simultaneous approach), so as not to delay a response. “We can’t afford to wait for all the necessary research to be done,” one panelist advised.
The table below summarizes various factors that were discussed that may influence high-intensity drinking:
Interactions (action in the interaction)
Social utility/social benefits
Drink size perceptions/misperceptions
Perception of normative behavior
Deaths of despair/economic shifts
Identity (ethnicity, gender, etc)
 Donavan JE (2009) Estimated blood alcohol concentrations for child and adolescent drinking and their implications for screening instruments. Pediatrics Jun;123(6):e975-81.
 2017 NSDUH
 Grucza et al. (2018) Trends in Adult Alcohol Use and Binge Drinking in the Early 21st-Century United States: A Meta-Analysis of 6 National Survey Series. Alcohol Clin Exp Res Oct;42(10):1939-1950.
 White et al. (2018) Trends in alcohol-related emergency department visits in the United States: Results from the Nationwide Emergency Department Sample, 2006 to 2014. Alcohol Clin Exp Res Feb;42(2):352-359.
 Hingson RW and Zha W (2018) Binge drinking above and below twice the adolescent thresholds and health-risk behaviors. Alcohol Clin Exp Res May;42(5):904-913.