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HLT 214 - Substance Use and Abuse - Textbook

Chapter 5. Alcohol

Learning Objectives

At the conclusion of this chapter, students will be able to:

  1. Describe demographic characteristics and historical trends of alcohol use, alcohol abuse/dependence and other alcohol-related problems
  2. Identify the relationship between level of alcohol consumption and health effects
  3. Understand patterns of alcohol use, abuse, and dependence in communities, populations
  4. Recognize the social consequences of alcohol use and abuse at individual, family, and community levels
  5. Identifies interaction of vulnerability, risk, and resilience factors


Alcohol, chemically known as ethanol, played many roles throughout history. Alcohols are consumed as beverages where the alcohols specifically consist of 3–40 percent of ethanol by volume. Alcohol used as an anti-freezing agent has a mix of a solution containing ethylene glycol dissolved in water. Alcohol is also used as an antiseptic agent, as fuels in the internal combustion engines, and as preservatives for the specimens in laboratories. An alcoholic beverage is considered a food, because it contributes energy to the diet (7 kcals/gram). A nutrient is a part of food that is used by our cells and metabolized by the body to make all the contributions that our body needs. Alcohol is not considered a nutrient, because it is not needed for the body’s normal functioning. Alcohol removes inhibition and it is considered a social stimulant.  Throughout history, alcohol has been used as a thirst quencher where water is unsafe and as an analgesic to treat aches and pains. Evidentially, beer recipes were found on Babylonian clay tablets thousands of years old. Alcohol was probably known as early as the Stone Age, ten thousand years ago. Probably the first wine was produced by accident through fermentation caused by wild yeast.  Beer production and consumption had to wait until establishment of agriculture. Alcoholic beverages provided a safe alternative to unsafe drinking water. Early alcoholic beverages had relatively low alcohol content, focused more on taste and thirst quenching.  In biblical narratives, drinking water was seldom mentioned whereas drinking wine and beer is and the Scriptures advise against heavy drinking. All ages, even children, drank wine and ale.1 

Alcoholic Beverages:  Beer, Wine, Liquor

Alcohol is nearly always drunk in the form of three major classes of alcoholic beverages: beer, wine, and hard liquor (aka distilled spirits). It is produced through fermentation and distillation.

Alcohol is produced from carbohydrates (CHO). The CHO must be simple sugar, such as maltose or glucose in order for the yeast to use it as food. If the CHO is a starch, such as that found in cereal grains (barley) it must be broken down to simpler forms, or malted.

image showing chemicals that create alcohol not understood by clerk inputting information

Figure 5. Production of Alcohol

Beer is made from malted cereal grains, such as barley, flavored with hops and brewed by slow fermentation. The resulting carbon dioxide is used to carbonate the beer.

Distilled spirits such as whiskey, vodka, or gin are made by distilling the alcohol after fermentation. Distilling separates the alcohol from water and the alcohol is recovered. One method of classifying distilled liquors is as aged or unaged. Aging is the process of storing distilled spirits (or wines) in barrels for a specific period of time. The term age refers to the actual duration of storage, while maturity expresses the degree to which chemical changes occur during storage. The goal of maturation is to remove harsh flavors from the raw alcohol while adding distinct flavor characteristics found in the barrel's wood. Vodka, neutral spirits for use in a variety of products, most gins, and some rums and brandies are unaged. Aged products are predominantly whiskeys and most rums and brandies.

Alcohol content of a beverage is expressed by volume or by weight. Proof of an alcoholic beverage indicates percentage of alcohol content. In the United States, alcohol proof is defined as twice the percentage of Alcohol by volume (ABV).   ABV is a standard measure of how much alcohol (ethanol) is contained in a given volume of an alcoholic beverage (expressed as a volume percent).

Alcohol is considered a drug because it changes the physical & emotional state of a person.  Alcohol is classified as a depressant because it slows down the body systems.

Beauty is in the eye of the beer holder.

bottles of alcohol

Consumption of Alcohol  and Heavy Drinking in the United States

Excessive alcohol consumption includes binge drinking, heavy drinking, and any alcohol use by pregnant women or underage drinkers (anyone younger than 21). Binge drinking is defined as consuming 4 or more drinks on an occasion for a woman or 5 or more drinks on an occasion for a man. Heavy drinking is defined as consuming 8 or more drinks per week for a woman or 15 or more drinks per week for a man. In 2018, more than half of the US adult population drank alcohol in the past 30 days. About 16% of the adult population reported binge drinking, and 7% reported heavy drinking.  In the years 2006–2010, excessive alcohol use is responsible for about 88,000 deaths a year in the United States, including 1 in 10 total deaths among working-age adults aged 20 to 64 years. Alcohol use poses a higher risk for underage drinkers and pregnant women.  Drinking games, such as beer pong, are popular among college students and promote heavy drinking.1,2

Alcohol  consumption rates and the prevalence of heavy drinking are affected by diverse social and environmental factors — urban versus rural residence, gender, age, racial/ethnic background. 

  • Pharmacology of Alcohol- Alcohol depresses the CNS.  It dissolves in lipid membranes, increasing its effects. Identifying a specific receptor mechanism for alcohol is difficult due to alcohol’s diffuse effects on the body but it probably affect the GABA receptors. Alcohol consumption can damage the brain and most body organs, including the heart, liver, and pancreas.  Alcohol primarily affects the CNS, particularly the brain. Areas of the brain that are especially vulnerable to alcohol-related damage include the following: 

  • Cerebral cortex – largely responsible for higher brain functions, including problem-solving and decision-making 

  • Hippocampus – important for memory and learning 

  • Cerebellum – important for movement coordination of muscle movements, maintaining balance, posture, and proprioception (tracking your body's position in space). Alcohol causes neurons in the cerebellum to become disconnected and dysfunctional, which is why drunk driving is so dangerous.  Field Sobriety Tests for drunk driving assess cerebellar function. 

Alcohol is classified as a depressant because it slows down the central nervous system. It  cause a decrease in motor coordination, reaction time and intellectual performance.  At high doses, alcohol  slows down the respiratory drastically and can cause a coma or death. Alcohol cannot be stored and has priority in metabolism. If taken with sedatives, alcohol and sedatives compete for the same metabolic pathways. Liver cannot metabolize the sedatives fast enough. Therefore,  it is particularly dangerous to mix alcohol with other depressants such as sleeping pills . Combining depressants multiplies the effects of both drugs (synergy) and can lead to memory loss, coma or death. 

Absorption- Once ingested, a drink enters the stomach and small intestine, where small    
blood vessels carry it to the bloodstream. Approximately 20% of alcohol is absorbed  through the stomach and most of the remaining 80% is absorbed through the small intestine. Then it is distributed to all tissues of the body. Rate of alcohol absorption varies according to each person’s physiological and  situational factors. Blood receives high   concentration of alcohol.  Blood Alcohol Concentration (BAC) refers to the percent of alcohol (ethyl alcohol or ethanol) in a person's blood stream. A BAC of  10% means that an individual's blood supply contains one-part alcohol for every 1000 parts blood.  Blood Alcohol  Concentration (BAC) equation including alcohol dose and time.  BAC also depends on  gender, body fat percentage, rate of alcohol metabolization. A social drinker who weighs 150 pounds with normal liver function metabolizes about 5-7 grams of alcohol per hour, about half a beer of ¼ of another drink.

When intake of alcohol exceeds liver’s ability to metabolize it, builds up in the bloodstream Breath analysis is a practical  method of measuring BAC.  Small percentage excreted in urine, sweat, expired air (levels in expired air correspond with blood alcohol content → Breathalyzer test). 

Metabolism-Alcohol is metabolized by the liver, where enzymes break down the alcohol. The body metabolizes more than 90% of the alcohol it absorbs. 
Alcohol is metabolized by several processes or pathways. The most common of these pathways involves two enzymes—alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH). These enzymes help break apart the alcohol molecule, making it possible to eliminate it from the body (Figure 6). 

Understanding the rate of metabolism is critical to understanding the effects of alcohol. In general, the liver can process one ounce of liquor (or one standard drink) in one hour. The liver cannot quicken the pace of metabolization.  If you consume more than this, your system becomes saturated, and the additional alcohol will accumulate in the blood and body tissues until it can be metabolized. This is why pounding shots or playing drinking games can result in high blood alcohol concentrations that last for several hours.

chemicals related to the metabolism of alcohol -- clerk does not understand to explain better

Figure 6. Metabolism of Alcohol

What is "one drink"?

Knowing how to count a standard drink is necessary for calculating blood alcohol concentrations. Too often, people underestimate how much they have had to drink because they aren't using standard measurements.

Beer; One drink = one 12-ounce beer. This is normal-strength beer (4% alcohol). Micro-brews and malt liquor have a higher percentage of alcohol (look at the label).

Liquor: One drink = 1.5 ounces of liquor (40% alcohol or 80 proof). This is how much whiskey, vodka, gin, etc. is in a measured mixed drink or in a "shot." Mixed drinks may not be measured and often contain far more than 1.5 ounces of alcohol.

Wine: One drink = 5 ounces of standard wine -- this is most table wines: white, red, rosé, champagne. One drink = 3 ounces of fortified wine -- this is wine with more than 13% alcohol content, such as brandy, cognac or sherry.

Alcohol consumption and social issues

  • 2/3 of all homicides are committed by people who drink prior to the crime
  • 2% to 3%  of the driving population is legally drunk at any one time.
  • 2/3 of all Americans will be involved in an alcohol related vehicle accident in their life
  • The rate of separation and divorce is 7 times greater
  • 40% of family court cases are alcohol problem related
  • Alcoholics are 15 times more likely to commit suicide
  • Accident rates are higher with people who abuse alcohol

Workplace issues

  • It takes one hour for an average person to process one serving of alcohol
  • Impairment in coordination and judgment can be measured with a BAC of .03
  • A person who is legally intoxicated BAC .08 is 6 times more likely to have an accident than a sober person.

Drinking in America

The number of Americans drinking themselves to death has more than doubled over the last two decades.4 In 2017 alone, 2.6% of roughly 2.8 million deaths in the United States involved alcohol. According to the CDC, binge drinkers are consuming more alcohol than they ever before. The number of drinks they’ve knocked back spiked from 472 on average in 2011 to 529 in 2017, or a 12% increase.1-3

Alcohol abuse

Alcohol abuse is defined as the persistent misuse of alcohol. Alcohol abuse is considered an alcohol use disorder (AUD). An alcohol use disorder occurs when a person’s drinking causes them any harm or distress, or legal, financial or social problems. AUD is defined as mild, moderate or severe based on the number of symptoms experienced. Alcohol contributes to the leading causes of death. Combined with tobacco, increases the risk for esophageal and oral cancer. The risk for heart disease, heart arrhythmia, hypertension, stroke, osteoporosis, brain damage, nutritional deficiencies, fetal damage, obesity, colorectal cancer, breast cancer, and other cancers.

Genetics of Alcohol Use Disorder(AUD)

Alcohol use disorder often seems to run in families, Genetics certainly influence our likelihood of developing AUD, genes are responsible for about half of the risk for AUD. The risk is increased fourfold in children of alcoholics. However, genes alone do not determine whether someone will develop AUD. Environmental factors, as well as gene and environment interactions account for the remainder of the risk. Environmental factors can alter the expression of our genes. This field is called epigenetics. Research helps understand more and more how epigenetics can affect our risk for developing AUD.

CAGE Screening

“CAGE” is an acronym formed from the italicized words in the questionnaire (cut-annoyed-guilty- eye-opener). The CAGE is a simple screening questionnaire to id potential problems with alcohol. Two “yes” responses is considered positive for males; one “yes” is considered positive for females.

  • C: Have you ever felt you ought to cut down on drinking?
  • A: Have people annoyed you by criticizing your drinking?
  • G: Have you ever felt bad or guilty about your drinking?
  • E: Have you ever had a drink first thing in the morning as an eye-opener, to steady your nerves or to get rid of a hangover?

Acute Alcohol Effects

Acute Alcohol Effects include physiological, sensorimotor, behavioral effects. As the blood alcohol concentration increases, acute effects increase in number and intensity. Personal experience of degree of intoxication and behavior while intoxicated are affected by psychological and situational factors, alcohol tolerance. Excessive alcohol consumption impairs Sensorimotor skills which are crucial in driving motor vehicles. Alcohol is a major contributor to fatal and nonfatal automobile accidents. A combination of gender, age and alcohol influence’s risk involvement in automobile accident.

Chronic Alcohol Effects

The long-term effects of alcohol abuse include alcoholism, liver disease, pancreatitis, malnutrition and cancer. An alcohol addiction treatment program such as Alcoholics Anonymous (AA), a global community-based program, may help a person quit alcohol and avoid some of the long-term effects it can have.

Chronic Psychological Effects

There is a strong association between excessive alcohol consumption and engaging in physically or sexually aggressive and /or violent behavior. Alcohol and other drugs of abuse may act on brain mechanisms that cause a high-risk individual to engage in aggressive and violent behavior. The co-occurrence of alcohol use and violence is especially prevalent among men 18 to 30 years old. Alcoholism negatively impacts a person’s sense of self-confidence and erodes their self-esteem. When concurrent mental illness, alcohol abuse can make the situation far worse. It can cause a dramatic increase in the intensity of certain mental health symptoms and can put people at risk for a potentially fatal overdose if they mix pharmaceutical medications with alcohol.

Alcohol and Pregnancy

There is no amount of alcohol that's known to be safe to consume during pregnancy. Consumption of alcohol during pregnancy, puts the baby at risk of fetal alcohol syndrome (FAS). FAS is a condition in a child that results from alcohol exposure during the mother's pregnancy. FAS causes brain damage and growth problems and is associated with continued physical problems and below-average intellectual functioning later in childhood. The physical abnormalities may consist of gross deformities that are identifiable at birth. The problems caused by fetal alcohol syndrome vary from child to child, but defects caused by fetal alcohol syndrome are not reversible.

Alcohol Use Disorder

The diagnostic criteria for AUD as revised in DSM-5 present a more streamlined criteria for alcohol use disorder. The DSM-5 criteria have been combined into a single diagnosis of “alcohol use disorder” based on 11 symptoms.

11 Symptoms of Alcohol Use Disorder

  • 1. Alcohol is often taken in larger amounts or over a longer period than was intended.
  • 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
  • 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  • 4. Craving, or a strong desire or urge to use alcohol.
  • 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
  • 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  • 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
  • 8. Recurrent alcohol use in situations in which it is physically hazardous.
  • 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
  • 10. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect; b) A markedly diminished effect with continued use of the same amount of alcohol.
  • 11. Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to criteria A and B of the criteria set for alcohol withdrawal); b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.


The presence of at least two of these symptoms indicates an alcohol use disorder (AUD). The severity of an AUD is graded mild, moderate, or severe:

Mild: The presence of 2 to 3 symptoms.

Moderate: The presence of 4 to 5 symptoms.

Severe: The presence of 6 or more symptoms.

Alcohol abuse has the potential to destroy individuals, disintegrate families, and negatively impact whole communities. Community health education, especially school health education plays an important role in the prevention of alcohol use disorder.5-8

Chapter Review and Discussion Questions

  1. What is a standard drink in the United States?
  2. Define the terms binge drinking, heavy drinking, and Alcohol Use Disorder.
  3. Describe the consequence of excessive alcohol consumption in pregnancy.
  4. Describe the metabolism of alcohol in the human body.
  5. Do all excessive drinkers have an alcohol use disorder? Discuss.