Interventions for alcohol dependence in Europe: A

missed opportunity to improve public health

Jürgen Rehm, Kevin D Shield, Maximilien X. Rehm, GerritGmel, Ulrich Frick

TU Dresden, CAMH Toronto

Line of argumentation

• Alcohol consumption is high in Europe, with considerable public health burden

• Alcohol dependence plays a key role in creating this burden, with most of it due to heavy drinking

• Treatment interventions for alcohol dependence can reduce the public health burden markedly

• The current alcohol policy strategies should be supplemented by increase of alcohol dependence treatment rates

Total adult per capita alcohol consumption (recorded and unrecorded) in 2005

WHO, 2011

High exposure, high burden of mortality and disease

• For men between ages of 15 and 64, 1 in 7 deaths in 2004 were caused by alcohol (clearly premature deaths given the life expectancy in Europe)

• For women of the same age category, 1 in 13 deaths in 2004 were caused by alcohol

• The proportion are even higher for burden of disease attributable to alcohol (years of life lost to premature deaths or disability)

How many deaths are attributable to alcohol dependence?

5

Alcohol-attributable Alcohol-attributable (net) Heavy drinking Alcohol dependenceMen 16.1% 13.9% 11.1% 10.7%Women 8.5% 7.7% 5.3% 3.7%Total 13.6% 11.8% 9.2% 8.4%

Men Women Total

25

20

15

10

5

0

Per

cent

age

of d

eath

s

Rehm et al. 2012. Alcohol consumption, alcohol dependence, and attributable burden of disease

What does this mean?

• Most of the burden of alcohol stems from heavy drinkers (about 77% of the net burden, 67% of the overall burden), i.e., women drinking >40 g/day and men drinking >60 g/day

• Alcohol dependence accounts for 71% of the net burden and 62% of the total alcohol-attributable burden

• In other words, alcohol dependence causes the majority of mortality burden of alcohol

• For burden of disease in DALYs, this proportion is much higher

6 Rehm et al. 2012. Alcohol consumption, alcohol dependence, and attributable burden of disease

Number of deaths avoided over one year in men by treatment for AD in the EU in 2004 by five different

treatment modalities

Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease

Number of deaths avoided over one year in women by treatment for AD in the EU in 2004 by five different

treatment modalities

Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease

It reduces level of consumption either to abstinence or by sizable reduction of heavy drinking.

Why is alcohol dependence treatment successful?

9

0

10

20

30

40

50

60

0 5 10 15 20

Typical risk curve for alcohol (e.g., liver cirrhosis mortality)

RR for mortality

0

5

10

15

20

25

30

35

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Relative gain in risk for mortality of reducing by three drinks/day for different levels of drinking

Reducing from 14 to 11 drinks per day reduces the mortality risk about 10 times as much as reducing from 3 to 0 drinks/day

Alcohol policy should be supplementedby increasing treatment rates

• Current alcohol policy recommendations by WHO and public health authoritiesare dominated by prevention(WHO best buys: taxation increases, availability restrictions, marketing ban)

• Alcohol policy should additionally comprise changes to increase treatment rates– For ethical reasons, but– also for public health reasons!