Alcohol-related problems touch virtually everyone. I, personally, have lost several colleagues to alcohol use disorder and seen it wreak havoc in many families. The cost of alcohol misuse to society is enormous, and the public is hungry for information about alcohol and its effects on health. As National Institute on Alcohol Abuse and Alcoholism (NIAAA) Director, I regularly get appeals from people desperate to help loved ones find treatment. Colleges and universities call seeking information about how to address binge drinking on their campuses. This is what motivates me as NIAAA Director and a neuroscientist.
NIAAA’s mission is to generate and disseminate fundamental knowledge about the effects of alcohol on health and well-being and apply that knowledge to improve the diagnosis, prevention, and treatment of alcohol-related problems, including alcohol use disorder, across the lifespan. For nearly 50 years, NIAAA has been at the forefront of cutting-edge alcohol research. This work has significantly expanded our understanding of how alcohol affects the brain and body and has led to better interventions to prevent and treat alcohol misuse and related conditions.
Yet more needs to be done. Alcohol misuse still claims the lives of 88,000 Americans each year, making it the fourth-leading preventable cause of death in the United States. Far too many young people see binge and extreme binge drinking—dangerous practices that can have deadly consequences—as rites of passage. And, sadly, alcohol use disorder is still viewed by many as a moral failing or character flaw, rather than a chronic brain disease from which people can, and do, recover. Many people are not aware that there are effective treatments for alcohol use disorder; and personalized treatments are an exciting, attainable goal.
NIAAA’s strategic plan charts our course for the next five years as we seek to address these challenges, recognizing that flexibility will be needed to capitalize on emerging research opportunities, and that collaboration with our stakeholders is key to achieving our goals. Preventing alcohol misuse at all ages; improving the diagnosis of alcohol use disorder and alcohol-induced pathology, such as fetal alcohol spectrum disorders and organ damage; and developing new treatments for these conditions are several of the Institute’s most salient goals. I am optimistic that NIAAA-supported research will pave the way for future breakthroughs that will help more Americans live healthier, more productive lives.
George F. Koob, Ph.D.
National Institute on Alcohol Abuse and Alcoholism
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is the lead Federal agency for research on alcohol and health and the largest funder of alcohol research in the world. NIAAA’s mission is to generate and disseminate fundamental knowledge about the effects of alcohol on health and well-being, and apply that knowledge to improve the diagnosis, prevention, and treatment of alcohol-related problems, including alcohol use disorder (AUD), across the lifespan.
Alcohol misuse refers to drinking in a manner, situation, amount, or frequency that could cause harm to individuals or those around them. It contributes to poor performance at school and work; family trouble; unprotected sex and sexually transmitted diseases; violence; memory blackouts; unintentional injuries, accidents, and overdoses; and organ damage and disease. It can also lead to AUD, a serious condition that affects nearly 16 million people in the United States. The Centers for Disease Control and Prevention estimates that alcohol misuse costs the United States $249 billion per year due to health care expenses, lost workplace productivity, crime, property damage, and other adverse outcomes.
For nearly five decades, NIAAA has supported cutting-edge research to reduce the toll that alcohol misuse takes on human health and well-being. This work has significantly broadened our understanding of the factors that contribute to alcohol-related problems and the mechanisms by which they develop. Once viewed as a moral failing or character flaw, AUD is now widely regarded as a chronic disease of the brain with potential for recovery and recurrence. This shift in perspective, supported by advances in neurobiological research, has helped reduce the stigma associated with AUD, led to more effective interventions, and provided support for integrating prevention and treatment services into mainstream health care.
This strategic plan serves as a roadmap for optimizing the allocation of NIAAA’s resources to areas of alcohol research most likely to benefit from additional support, translating scientific discoveries for the benefit of the public, and continuing to build on NIAAA’s position as the nation’s key source of evidence-based information on alcohol and health. Over the next five years, NIAAA will prioritize the following goals:
Goal 1: Identify Mechanisms of Alcohol Action, Alcohol-Related Pathology, and Recovery. NIAAA will support preclinical and clinical research to generate a more thorough understanding of the fundamental mechanisms through which alcohol exerts its effects on human health and behavior, how patterns of alcohol use interact with genes and the environment in the development and progression of alcohol-related conditions, and the neurobiological mechanisms underlying recovery from alcohol-related pathology.
Goal 2: Improve Diagnosis and Tracking of Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences. NIAAA will support research to improve the diagnosis of alcohol-related diseases, including AUD, fetal alcohol spectrum disorders (FASD), and alcoholic liver disease (ALD). The Institute will also support epidemiological research to track the prevalence, patterns, and trends of alcohol misuse, AUD and co-occurring mental health conditions, and related consequences; elucidate the nature and scope of individual- and population-based differences in substance use and related outcomes; and identify the complex biopsychosocial factors that contribute to these outcomes. This information will be used to guide the development and implementation of interventions for preventing and treating alcohol misuse and its negative repercussions.
Goal 3: Develop and Improve Strategies To Prevent Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences. NIAAA will support research to adapt and evaluate adult alcohol screening for a broader range of settings and populations, evaluate the effectiveness of youth alcohol screening, and develop and evaluate methods for administering alcohol screening in combination with screening for tobacco, marijuana, and other drugs. NIAAA will also prioritize the development of culturally appropriate interventions for preventing alcohol misuse and its consequences, including human immunodeficiency virus (HIV), among individuals at all stages of life.
Goal 4: Develop and Improve Treatments for Alcohol Misuse, Alcohol Use Disorder, Co-Occurring Conditions, and Alcohol-Related Consequences. NIAAA will support research to develop new and improved treatments for AUD and co-occurring mental health conditions, FASD, ALD, and other alcohol-related diseases. The Institute will also support studies to identify factors that facilitate or inhibit recovery from AUD and improve the implementation, accessibility, and use of alcohol treatment and recovery services tailored to the needs of individuals.
Goal 5: Enhance the Public Health Impact of NIAAA-Supported Research. NIAAA will continue to develop initiatives to raise public awareness about the effects of alcohol on health and well-being and about options for preventing and treating alcohol-related problems. The Institute will strengthen collaborations with other Federal agencies; with scientific, professional, and advocacy organizations; and with patient and community groups to develop, disseminate, and encourage the adoption of evidence-based and culturally appropriate resources and strategies to reduce the public health burden of alcohol misuse.
There has never been a better time to accelerate progress toward these goals. The Collaborative Research on Addiction at NIH (CRAN) initiative is fostering synergy among NIAAA, the National Institute on Drug Abuse, and the National Cancer Institute to develop a comprehensive, well-integrated understanding of polysubstance use and addiction that considers common and distinctive features among substances and substance use disorders. The Human Connectome Project and the Brain Research through Advancing Innovative Neurotechnologies (BRAIN) Initiative, in which NIAAA is an active participant, are expected to spur an explosion of knowledge about the structure and function of brain circuits and how the brain affects behavior. New technologies for measuring and modulating brain activity are being developed to translate our understanding of the neurobiology of AUD into new diagnostic and treatment methods. Advances are also being made in the behavioral and social sciences toward understanding the mechanisms of behavior change, and opportunities are ripe for applying this knowledge to the development of interventions for preventing and treating AUD.
Although alcohol-related injury and disease may never be eliminated completely, research has opened new avenues for reducing the adverse consequences of alcohol misuse and AUD. For example, three-dimensional facial imaging technologies hold promise for early identification and treatment of children affected by FASD. Significant progress has also been made in identifying the biological mechanisms by which ALD develops and progresses, and NIAAA is supporting a major initiative to translate these findings into new and improved treatments for alcoholic hepatitis.
Alcohol researchers are beginning to unravel the mysteries of why some people are more likely than others to develop alcohol-related diseases or to respond to behavioral and pharmacological interventions. Continued advances in genomics, along with the Precision Medicine Initiative, a national effort to elucidate how individual variability in genes, environment, and lifestyle contribute to disease, are expected to bring us closer to developing individually tailored interventions for preventing and treating these conditions. Moreover, rapid advances in electronic health technologies are providing opportunities to help individuals monitor their alcohol use and to provide them with personalized resources and support where and when they need it most. Such devices also have the potential to facilitate alcohol research and clinical care.
NIAAA looks forward to working with its partners to capitalize on these and the many other advances being made across the spectrum of alcohol research to reduce the public health burden of alcohol misuse on individuals, families, communities, and society.
Alcohol is part of our society. People use it to celebrate, socialize, relax, and enhance the enjoyment of meals. Nearly 90 percent of adults in the United States report that they drank alcohol at some point in their lifetime, and more than half report drinking in the last month.1 Although most people drink in moderation, nearly 40 percent of U.S. adults drink in excess of the low-risk guidelines established by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).2 (See “Drinking Patterns and Their Definitions.”)
Alcohol misuse has wide-ranging adverse consequences. In the United States, nearly 88,000 people per year die from alcohol-related causes;3 globally, alcohol accounts for 3.3 million deaths—5.9 percent of all deaths—each year.4 Alcohol misuse also contributes to poor performance at school and work; family problems; unprotected sex and sexually transmitted diseases; violence; memory blackouts; unintentional injuries, accidents, and overdoses; and organ damage and disease. It can lead to alcohol use disorder (AUD), a serious chronic condition that affects nearly 16 million people in the United States.5 (See “What Is Alcohol Use Disorder?”) The Centers for Disease Control and Prevention estimates that alcohol misuse, including AUD, costs the United States $249 billion per year due to health care expenses, lost workplace productivity, crime, property damage, and other outcomes.6
NIAAA, a component of the National Institutes of Health (NIH), is the largest funder of alcohol research in the world. For nearly five decades, NIAAA’s extramural research program has supported a diverse portfolio of innovative investigator-initiated research to elucidate the effects of alcohol on health and reduce the burden of alcohol misuse for individuals at all stages of life. This work is complemented by a robust intramural research program that leverages the state-of-the-art resources available at NIH to advance high-risk, high-reward studies in key areas of alcohol science. In addition, through the Collaborative Research on Addiction at NIH (CRAN) initiative, NIAAA is partnering with the National Institute on Drug Abuse and the National Cancer Institute to integrate resources and expertise across NIH to develop a comprehensive, well integrated understanding of substance use, misuse, and addiction that considers the common and distinctive features of addictive substances and substance use disorders (SUDs).
Research supported by NIAAA has spurred tremendous progress in identifying the factors that contribute to alcohol-related problems and the fundamental biological and behavioral mechanisms by which they develop, and it has paved the way for innovative preventive and treatment interventions. Once viewed as a moral failing or character flaw, AUD is now widely regarded as a chronic but treatable brain disease that develops through complex, dynamic interactions among biological, environmental, and developmental factors. This shift in perspective, bolstered by decades of research on the neurobiology of addiction, has helped reduce the stigma associated with AUD and has underscored the need for a multipronged approach to preventing and treating alcohol-related problems, with interventions designed for individuals, families, communities, and society at large.
This strategic plan serves as a roadmap for catalyzing continued progress across the spectrum of alcohol research and translating these advances for the benefit of the public. It highlights NIAAA’s research goals in five key areas:
- Goal 1: Identify Mechanisms of Alcohol Action, Alcohol-Related Pathology, and Recovery
- Goal 2: Improve Diagnosis and Tracking of Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences
- Goal 3: Develop and Improve Strategies To Prevent Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences
- Goal 4: Develop and Improve Treatments for Alcohol Misuse, Alcohol Use Disorder, Co-Occurring Conditions, and Alcohol-Related Consequences
- Goal 5: Enhance the Public Health Impact of NIAAA-Supported Research
Along with the goals outlined above, NIAAA has identified several cross-cutting research themes, which are woven throughout this strategic plan.
Address Alcohol Misuse Across the Lifespan
Human biology and behavior change throughout life; these changes affect drinking patterns and risks for alcohol-related injury and disease. NIAAA has adopted a “lifespan approach” to alcohol research that considers how the emergence and progression of drinking behavior and related outcomes interact with developmental changes and environmental inputs across the lifespan, from the embryonic and fetal stages of development into older adulthood. This perspective guides the identification of life-stage–appropriate strategies for preventing, treating, and facilitating recovery from alcohol problems, as well as tailoring resources to the needs of individuals of all ages.
Address Co-Occurring Conditions
AUD frequently co-occurs with other SUDs and mental health conditions, including major depressive disorder, anxiety disorders, bipolar disorder, antisocial and borderline personality disorders, and post-traumatic stress disorder (PTSD). Individuals suffering from psychiatric comorbidity tend to have a poorer prognosis, higher risk for treatment dropout, less support for sobriety from their families and in the workplace, and a higher risk for suicide. Alcohol misuse also contributes to more than 200 diseases and injury-related health conditions,9 including alcoholic liver disease. In fact, alcohol is involved in nearly half of all liver disease deaths in the United States each year.10 Alcohol misuse frequently co-occurs with human immunodeficiency virus (HIV), contributes to HIV transmission, reduces HIV screening, makes it difficult to follow complex HIV medication regimens, and contributes to or exacerbates other health conditions in HIV-infected individuals. NIAAA will continue to support research to investigate the relationships between AUD and co-occurring conditions and to develop interventions to prevent and treat them.
Reduce Health Disparities
Some groups of people may be more vulnerable to alcohol problems than others. For example, although Native Americans are less likely to drink than white Americans, those who do drink are more likely to binge drink,11 have a higher rate of past-year AUD compared with other racial and ethnic groups,12 and are approximately twice as likely to die from alcohol-related causes than the general American public.13 In addition, Hispanics and blacks who drink are more likely to binge drink than whites who drink,11 but Hispanics with AUD are less likely than whites with AUD to receive alcohol treatment at a specialty facility.14 The lesbian, gay, bisexual, and transgender communities are also important subpopulations to consider. Lesbian and bisexual women are about seven times more likely than heterosexual women to meet criteria for AUD.15 Although rates of alcohol use and AUD among men who have sex with men (MSM) are comparable to rates in the general population, alcohol misuse among MSM is an important public health problem. Alcohol misuse is a known risk factor for HIV, and MSM account for more than half of all new HIV infections each year in the United States.16 NIAAA is committed to ensuring that all people benefit from alcohol research advances and will support studies to better understand health disparities and develop interventions for at-risk groups.
Advance Precision Medicine
Studies investigating how individual variability in genes, environment, and lifestyle contribute to disease are bringing us closer to developing individually tailored interventions for alcohol-related conditions. NIAAA will continue to support research on the factors that contribute to individual variation in alcohol misuse, AUD, and alcohol-related outcomes. The Institute will use that information to guide the development and validation of prognostic and diagnostic biomarkers and personalized interventions for these conditions. These efforts will be aided by the recent expansion of electronic medical records and the development of mobile health technologies, which have the potential to improve the quality and collection of patient data and to provide comprehensive, personalized health care services where and when patients need them.
Strengthen the Biomedical Workforce
Cultivating a talented and diverse research workforce is essential to advancing the frontiers of scientific knowledge and to translating research findings into practice. NIAAA promotes alcohol research training through individual pre- and postdoctoral fellowships, institutional training grants, and career development awards that span the breadth of NIAAA’s research portfolio. Diverse research teams broaden the scope of scientific inquiry, bring creative solutions to bear on complex scientific problems, and encourage research relevant to the health care needs of underserved populations. Programs to identify, recruit, and train scientists from diverse populations, especially those underrepresented in health research, are an important component of NIAAA’s training portfolio.
Serve as a Responsible Steward of Our Nation’s Research Resources
Underpinning NIAAA’s ability to advance innovative science is an unwavering commitment to responsible research stewardship. NIAAA supports efforts to enhance the rigor and reproducibility of research, including ensuring that sex is incorporated as a biological variable into the design, analysis, and scientific reporting of the studies it funds. This is a critical step toward ensuring that everyone, regardless of sex or gender, benefits from alcohol research advances. NIAAA maximizes the use of research resources by forging strategic partnerships with other NIH Institutes, Centers, and Offices; other Federal agencies; academia; industry; and not-for-profit organizations. Such partnerships provide opportunities to share resources and expertise, and to broaden the dissemination of alcohol research findings. Moreover, by encouraging the use of common research metrics and protocols, as well as the sharing, aggregation, and secondary analysis of data, NIAAA hopes to improve the efficiency of alcohol research and stimulate new insight into preventing and treating alcohol-related conditions.
Drinking Patterns and Their Definitions
What Is a Standard Drink?
Many people are surprised to learn what counts as a drink. The amount of liquid in your glass, can, or bottle does not necessarily match how much alcohol is in your drink. Different types of beer, wine, or malt liquor can have very different amounts of alcohol. For example, many light beers have almost as much alcohol as regular beer—about 85 percent as much.
Moderate Alcohol Consumption
According to the Dietary Guidelines for Americans,7 which are intended to help individuals improve and maintain overall health and reduce the risk of chronic disease, moderate drinking is up to one drink per day for women and up to two drinks per day for men.
Low-Risk Drinking for Developing Alcohol Use Disorder
As defined by NIAAA, for women, low-risk drinking is no more than three drinks on any single day and no more than seven drinks per week. For men, it is defined as no more than 4 drinks on any single day and no more than 14 drinks per week. NIAAA research shows that only about 2 in 100 people who drink within these limits have alcohol use disorder. Even within these limits, you can have problems if you drink too quickly or have other health issues.
Alcohol misuse refers to drinking in a manner, situation, amount, or frequency that could cause harm to the users or to those around them. For individuals younger than the legal drinking age of 21, or for pregnant women, any alcohol use constitutes misuse.
NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration levels to 0.08 g/dL (0.08 percent) or higher. This typically occurs after a woman consumes four drinks or a man consumes five drinks in a 2-hour time frame.
The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking for men as drinking five or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days. SAMHSA defines binge drinking for women as drinking four or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days.
Extreme Binge Drinking
Extreme binge drinking, also known as high-intensity drinking, refers to drinking at levels far beyond the binge threshold, resulting in high peak blood alcohol concentrations. Though definitions vary, some studies define extreme binge drinking as 2 or more times the gender-specific binge drinking thresholds (i.e., 10 or more standard drinks for men; 8 or more for women); other studies use a higher threshold that may or may not be gender specific.
SAMHSA defines heavy drinking as binge drinking (based on the SAMHSA binge drinking thresholds described above for men and women) on 5 or more days in the past 30 days.
Certain people should avoid alcohol completely, including those who:
- Are younger than the minimum legal drinking age of 21.
- Are pregnant or trying to become pregnant.
- Have a medical condition that alcohol can aggravate.
- Take medications that interact with alcohol.
- Are driving a vehicle or operating machinery (or plan to do so shortly after drinking).
What Is Alcohol Use Disorder?
Alcohol use disorder (AUD) is a medical condition that doctors diagnose when a patient’s drinking causes distress or harm. It ranges from mild to severe and is characterized by clinically significant impairments in health and social function. To be diagnosed with AUD, a person must meet certain diagnostic criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM).8 The current DSM (DSM-5) integrates the two DSM–IV disorders, alcohol abuse and alcohol dependence, into a single disorder called AUD. Under DSM-5, anyone meeting any 2 of the 11 criteria during the same 12-month period is diagnosed with AUD. The severity of AUD is based on the number of criteria a person meets—mild (2–3), moderate (4–5), or severe (6 or more).
To assess whether someone has AUD, a health care provider may ask him or her some questions. For example, in the past year, have you:
- Had times when you ended up drinking more, or longer, than you intended?
- More than once wanted to cut down or stop drinking, or tried to, but couldn’t
- Spent a lot of time drinking? Or being sick or getting over the aftereffects?
- Experienced craving—a strong need, or urge, to drink?
- Found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
- Continued to drink even though it was causing trouble with your family or friends?
- Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink?
- More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?
- Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout (i.e., forgetting, after drinking, where you were or what you did while drinking)?
- Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
- Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, irritability, anxiety, dysphoria, depression, restlessness, nausea, or sweating? Or sensed things that were not there?
Any of these symptoms may be a cause for concern. The more symptoms one has, the more urgent the need for change.
Identify Mechanisms of Alcohol Action, Alcohol-Related Pathology, and Recovery
Improve Diagnosis and Tracking of Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences
Develop and Improve Strategies to Prevent Alcohol Misuse, Alcohol Use Disorder, and Alcohol-Related Consequences
Develop and Improve Treatments for Alcohol Misuse, Alcohol Use Disorder, Co-Occurring Conditions, and Alcohol-Related Consequences