Whatever your specialty or work setting, you’re sure to encounter women who use or abuse alcohol. An estimated 5.3 million women in the United States are heavy drinkers, defined by the Centers for Disease Control and Prevention (CDC) as women who consume eight or more alcoholic drinks per week and men who consume more than 15. Every nurse needs to understand the risks of alcohol use, especially in women, be able to talk to patients about it, and know how to screen patients for problem drinking. Heavy drinking increases the risk of health problems and makes women more likely to become victims of violence or sexual assaults. Health risks increase if the liver or other organs are damaged. Alcohol can cause brain shrinkage and altered brain-cell function, leading to changes in mental function. Women are more susceptible to these changes. Excessive alcohol use is the third leading life-style related cause of death in the United States, accounting for 88,000 deaths yearly. Alcohol abuse and other substance use disorders are the most preventable illnesses and causes of death. (See the box below.)
Alcohol abuse and dependency
Alcohol abuse is a pattern of drinking that’s harmful to oneself or others. The pattern occurs over a 12-month period and causes missed work or school and, in some cases, neglect of childcare responsibilities. The person continues to drink even in dangerous situations, such as driving, or despite ongoing alcohol-related tension with family and friends. Alcohol abuse may lead to arrest for driving while intoxicated or for hurting someone. Alcohol dependence is chronic, progressive, and life-threatening. It’s characterized by frequent incidences of being intoxicated, preoccupation with alcohol, and a focus on getting and drinking more alcohol. Alcohol-dependent individuals can’t limit their alcohol intake despite the adverse consequences of drinking, and they experience withdrawal symptoms when they don’t consume alcohol. Alcohol withdrawal symptoms may start 6 hours after the last drink and peak 24 to 26 hours after the last drink. Tolerance is the body’s response to alcohol’s functional, metabolic, and reinforcement effects. Alcohol-dependent individuals need progressively more and more alcohol to experience the pleasurable effects they previously felt at lower consumption levels. Withdrawal signs and symptoms, such as sweating, increased heart rate, restlessness, shaking, and seizures, motivate them to seek alcohol. These symptoms can raise blood pressure and cause delirium and even death. Negative affective symptoms, such as anxiety, irritability, and dysphoria, occur early in withdrawal, last longer than other symptoms, and are a major cause of relapse. Long-term health consequences Long-term or heavy drinking can lead to dementia, stroke, neuropathy, depression, anxiety, and impaired cognition and memory. It also can exacerbate psychiatric problems. Nerve damage may result from alcohol-related decreases in vitamin B, zinc, and magnesium.
As a registered nurse and case manager in a substance-use disorder clinic that provides outpatient services for military veterans, I’ve seen an increasing number of women in our residential program and outpatient services. The number of women is projected to keep rising at veterans’ facilities. Women now account for 38% of veterans in outpatient mental health and substance abuse treatment. The uptick in women seeking treatment suggests more women are trying to cope with substance use disorders. In terms of treatment and increased health risks, women face barriers that men don’t. Lack of funds and childcare can make it hard for some women to seek treatment. Some are afraid their children will be taken away if they admit to alcohol abuse.
Physiology of alcohol intake in women
Alcohol passes through the GI system, is dispersed in body water, and travels throughout the body. Because women typically weigh less than men, they have less body water and thus experience greater alcohol effects on the brain and organs. Alcohol is absorbed quickly, with 20% absorbed directly through the walls of an empty stomach. It reaches the brain in as little as 1 minute. In the stomach, the alcohol dehydrogenase enzyme begins to break down alcohol, reducing the amount entering the blood by about 20%. Women have less of this enzyme than men, so they experience more toxic alcohol effects as the body breaks it down for elimination. In the GI tract, veins and capillaries carry alcohol-burdened blood to the liver. No cells other than liver cells produce enough of the enzyme to oxidize alcohol at a significant rate. With lower levels of body water and the alcohol dehydrogenase enzyme than men, women absorb more alcohol and consequently suffer more physical damage. What’s more, the incidence of certain cancers, such as breast, GI, and head and neck cancers, is higher among women who drink heavily. Alcohol use also can affect the heart. Although women may drink less than men, alcohol-related heart disease is more common in women than men. Overall, alcohol-related death rates are 50% to 100% higher in women than men.
Alcohol use throughout the lifecycle
The effects of alcohol use vary with a female’s age. Adolescence Drinking before age 15 increases the risk of abusing alcohol or becoming an alcoholic. Adolescents who drink before age 15 are 15 times more likely to abuse alcohol or become alcohol dependent. Studies show that among females ages 12 and older, 46.5% are drinkers; among those ages 14 and 15, 13.8% currently use alcohol; and among those ages 16 to 17, 24.7% currently use alcohol. Drunk driving is the leading cause of teen deaths. Also, the risks of sexual assault and unsafe and unplanned sex rise with alcohol consumption, as do teen pregnancies and sexually transmitted diseases (STDs). These risks make it especially important for school nurses to educate students about the risks of alcohol. Young and middle adulthood Six in ten women of childbearing age (18 to 44) use alcohol; nearly one-third of them binge drink. Binge drinkers are more likely to have unprotected sex and multiple sex partners, which can lead to unintended pregnancy and STDs. Based on data from the 1991-2005 Behavioral Risk Factor Surveillance surveys, the CDC found that alcohol use and binge drinking among women of childbearing age didn’t change significantly from 1991 to 2005. The highest alcohol users were aged 35 to 44 (17.7%), college graduates (14.4%), employed women (13.7%), and unmarried women (13.4%). Women in their 20s and 30s are more likely to drink than older women. Also, ethnicity can influence how and when women drink. Heavy or problem drinking is more common at younger ages in white women but more common during middle age in African-American women. Problems in close relationships may contribute to heavy drinking. Increased drinking is more common in women who have never married, are living unmarried with a partner, are divorced or separated, or who have a husband who drinks heavily. Other risk factors for drinking are depression, stress, and childhood sexual abuse. Health risks of alcohol among women in this age-group include those discussed above, as well as immunosuppression, increased motor vehicle accidents, and fetal alcohol syndrome (FAS) in infants of women who abuse alcohol. Excessive drinking also can affect menstrual cycles and increase the risk of infertility, miscarriage, stillbirth, and premature delivery. (See the box below.)
Alcohol and pregnancy
Between 2002 and 2007, the Substance Abuse and Mental Health Services Administration of the U.S. Health and Human Services Department surveyed 113,000 women ages 18 to 44. It found 10% of respondents had used alcohol during the first trimester of pregnancy and 8% had engaged in binge drinking during that trimester. Alcohol use was lowest in the third trimester, with 6.2% of respondents reporting they’d used alcohol and 1% reporting they’d binged during that time. Second-trimester use was 7.8%. Some postpartum women surveyed said they’d begun using alcohol with a 3-month old infant in the house; 3l.9% used alcohol and 10% binged. On the other hand, Healthy People 2020 reported that from 2010 to 2012, 90.6% of pregnant women surveyed said they’d consumed no alcohol in the previous 30 days. Drinking during pregnancy increases the risk of birth defects, low birth weight, and FAS in infants. FAS can cause physical and cognitive deficits and behavior problems. Severity varies, but many infants with FAS must attend special education classes as children; during adulthood, some will need assistance. Annually, approximately 40,000 infants are born with signs of FAS, at an estimated healthcare cost of $4 billion. Miscarriages and stillbirths also increase with maternal alcohol use. In the United States, 0.5 to 2 cases of FAS occur for every 1,000 births. Other fetal alcohol-spectrum disorders are three times more common than FAS. No amount of alcohol is safe during pregnancy. Studies show about 1 in 20 women drink excessively before they know they’re pregnant. Drinking during the first trimester increases the miscarriage risk. Drinking at any time during pregnancy increases the chance for delivering an infant who will die from sudden infant death syndrome (SIDS). The risk of SIDS increases with first-trimester binge drinking.
Women tend to drink less as they age, although research shows they’re somewhat more likely to drink now than they did in the early 1900s. Drinking may go unreported in older women, who may be reluctant to admit they drink because of the stigma attached. Alcohol use can cause sleep problems, poor appetite, frequent falls, and health problems linked to aging. Risks of alcohol abuse may increase with age. Older women may be taking such drugs as antianxiety agents or antidepressants, which can interact adversely with alcohol. Also, aging reduces the body’s ability to adapt to alcohol. Lower levels of body water lead to a higher concentration of blood alcohol levels with the same amount of alcohol consumed.
How nurses can help women
Nurses tend to spend more time with patients than other healthcare providers, so patients may be more likely to trust them. You can leverage their trust to help them avoid alcohol abuse or to recognize and treat it when present. Keep in mind that no age group or social standing is exempt from alcohol abuse or other substance use disorders. Screen all patients for alcohol use disorders at every visit, provide information as needed, and make appropriate treatment referrals. Several alcohol use screening tools are available. (See the box below.)
Alcohol use screening tools
The CAGE questionnaire and the Alcohol Use Disorders Identification Test (AUDIT) are validated screening tools useful in many settings with a wide range of populations. CAGE has four clinical interview questions and takes only a few minutes to administer. AUDIT is a longer self-administered tool. Research suggests it may be particularly useful when screening women and minorities. CAGE questionnaire for detecting alcoholism Alcohol Use Disorders Identification Test (AUDIT)
Nine of 10 physicians miss alcohol abuse in adults, and four in 10 miss it in teenagers. Women who abuse alcohol are at higher risk for health, social, and financial consequences. Nurses have the opportunity to screen all patients, including women, to detect alcohol problems. For free handouts, toolkits, and posters you can use to reinforce patient education on the risks of alcohol and the need for treatment, visit http://store.samhsa.gov/facet/Issues-Conditions-Disorders/term/Alcohol-Abuse. Selected references CDC. Fact Sheet: Alcohol use and health. Last updated and reviewed March 14, 2014. www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm. Accessed June 15, 2014. CDC. Alcohol Use Among Pregnant and Nonpregnant Women of Childbearing Age – United States, 1991-2005. MMWR Morb Mortal Wkly Rep. 2009 May 22;58(19):529-32. CDC. Excessive alcohol use and risks to women’s health. Last updated and reviewed January 16, 2014. www.cdc.gov/alcohol/fact-sheets/womens-health.htm. Accessed June 3, 2014. CDC. Fact Sheet: Underage Drinking. Updated January 16, 2014. www.cdc.gov/alcohol/fact-sheets/underage-drinking.htm. Accessed June 17, 2014. Corbin W, Scott C, Leeman RF, et al. Early subjective response and acquired tolerance as predictors of alcohol use and related problems in a clinical sample. Alcohol Clin Exp Res. 2013;37(3):490-7. Ewing JA. Detecting alcoholism. The CAGE Questionnaire. JAMA. 1984;252(14):1905-7. Frayne SM, Phibbs CS, Freidman SA, et al. Sourcebook: Women Veterans in the Veterans Health Administration. Volume 2: Sociodemographics and Use of VHA and Non-VA Care. Women’s Health Evaluation Initiative (WHEI). Center for Health Care Evaluation VA HSR&D Center of Excellence. Women’s Health Services; Office of Patient Care Services; Veterans Health Administration; Washington, DC: October 2012. www.womenshealth.va.gov/WOMENSHEALTH/docs/SourcebookVol2_508c_FINAL.pdf. Accessed June 16, 2014. Gonzales K, Roeber J, Kanny D, et al. Alcohol-attributable deaths and years of potential life lost—11 States, 2006–2010. MMWR Morb Mortal Wkly Rep. 2014 Mar 14;63(10):213-6. Healthy People 2020. Maternal, Infant, and Child Health. Healthy People 2020. http://healthypeople.gov/2020/topicsobjectives2020/nationaldata.aspx?topicId=26. Accessed June 15, 2014. Snyder SR, Kivlehan SM, Collopy KT. Withdrawal and the chronic alcohol abuser. Years of drinking can cause big changes and make drying out dangerous. EMS World. 2014;43(4):44-51. Substance Abuse and Mental Health Services Administration. U.S. Dept of Health and Human Services. About FASD. Last updated March 2014. http://fasdcenter.samhsa.gov/aboutUs/aboutFASD.aspx. Accessed June 16, 2014. Substance Abuse and Mental Health Services Administration, U.S. Dept of Health and Human Services. Report to Congress on the Prevention and Reduction of Underage Drinking, November 2012. Rockville, MD: Author. Wilsnack SC, Wilsnack RW, Kantor L. Focus on: women and the costs of alcohol use. Alcohol Res. 2013;35(2):219-28. Laura Mesuda is a nurse manager at the VA Greater West Los Angeles Health Care System in Los Angeles, California.