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Chapter 2

The psychological, biological and medical dimensions of intoxication and drunkenness

Other respiratory effects [of acute alcohol intoxication] include decreased airway sensitivity to foreign bodies, decreased ciliary clearance and aspiration, and increased risk of bacterial infection with consequent bronchitis and pneumonia. Gastrointestinal effects include nausea, vomiting, diarrhoea, abdominal pain secondary to gastritis, peptic ulcer, and pancreatitis. Prolonged vomiting can lead to hyponatremia. Acute alcohol intoxication can cause a dysfunction of oesophageal, gastric, and duodenal motility and an increase in duodenal type III (propulsive) waves in the ileum; this increased transit of intestinal contents may contribute to diarrhoea. Acute alcohol intoxication can induce acute alcoholic hepatitis, usually in subjects with chronic alcohol abuse and/or in patients affected by alcoholic cirrhosis. Most often the diagnosis is suggested by a history of excessive alcohol abuse in patients with features of hepatic decompensation. Symptoms usually include nausea, vomiting, and abdominal pain. Less frequently, fever, shivering, and jaundice can occur. Zieve syndrome has also occasionally been reported; this consists of hemolytic anemia, jaundice, and hypertriglyceridemia. Finally, acute alcohol intoxication can be found in patients affected by such psychiatric disorders as affective disorders and antisocial personality; suicide or suicidal gestures are also highly associated with alcohol intoxication… (Vonghia et al. 2008; ‘Acute alcohol intoxication’, 563)

Introduction

In this chapter we present a discussion of the ways in which psychological, biological and medical expertise struggle over definitions of intoxication and drunkenness. In these struggles we see different forms of expertise attempting to develop more sophisticated ways to identify, define, measure and quantify states of intoxication and drunkenness. These attempts are characterised by an emphasis on what might be called objective, quantifiable, generalisable, ‘scientific’ measures, and the applications of these in various medical and psychological contexts in which the physical and mental health and safety dimensions of intoxication and drunkenness are of primary interest. What we hope becomes apparent in the discussion that follows is that in spite of an emphasis on calculation, measurement and scientific objectivity, these psychological, biological and medical discussions do not indeed remove ambiguity, uncertainty and imprecision from their debates.

In the first instance we explore the problematic, shifting and contested terrain in which definitions of intoxication, drunkenness and, in the recent past, binge drinking circulate. We then set out to establish the general and particular health and psychological concerns that attach to the problems of intoxication and drunkenness. In this context there are only minor disagreements about some of the physical and mental health and well-being and safety issues associated with states of intoxication and drunkenness. If there is a strong degree of agreement at this level, it tends to disappear when discussion turns to: attempts to calculate and measure levels of intoxication and drunkenness; who is most able to make these calculations; and what measures are most suited to this task. In concluding this chapter we examine the debates about whether individual self-reporting of feelings or experiences of intoxication and drunkenness, or attempts to calculate whether one is intoxicated or not, have much of a role to play in these ‘scientific’ discussions and debates. In this sense the individual and the subjective are seen as more problematic than the generalised and the objective.

Intoxication, drunkenness and bingeing: Same, different, interchangeable?

Intoxication and drunkenness are terms that are used in different ways by different health, medical and psychological professionals and researchers, in changing contexts and for varying affect. In this section we consider some of the most common definitions of intoxication and drunkenness from the perspectives of various experts and specialists in health, medicine and psychology. As we explain below, these terms are often conflated or used interchangeably. In dictionary definitions, intoxication is frequently associated with a kind of poisoning, a biological state. Here, intoxication is defined through direct reference to a state of drunkenness. Likewise, the entry for drunkenness explains that it is related to, or characterised by, intoxication. As such, these circular definitions do not take us far. Often when one of these terms is being used it refers to something quite specific. That is, drunkenness can be seen as broadly characterised by outward behaviour relating to the consumption of a certain amount of alcohol. However, intoxication, while it can have the same connotation is sometimes used differently, for example, when referring to something measurable. Therefore, in the following sections, we note that intoxication is used more often in some areas and drunkenness in others. Our interest here is not to claim that any particular use of these terms is right or wrong but to illustrate the different ways in which these terms are used and understood by different researchers in the same or closely related disciplines.

Intoxication is described by some researchers as ‘a condition that follows the administration of alcohol and results in disturbances in the level of consciousness, cognition, perception, judgement, affect, or behaviour, or other psycho-physiological function and responses’ (Farke and Anderson 2007, 334; see also Babor and Caetano 2005). Here, intoxication is seen as a state that is distinguished from simply drinking alcohol. For example, Johnson et al. (2005, 1139) define ‘alcohol telescoping’ as ‘the rate of self reported movement from regular alcohol consumption to the onset of regular heavy drinking’ and examine it through the use of two questions. The first being ‘the number of years the client used alcohol regularly in lifetime’, and the second, ‘the number of years the client used alcohol to intoxication regularly in lifetime’. The authors argue that comparing responses to these questions makes it ‘possible to construct a telescoping score that reflects the relative speed, in number of years, for an individual to transition from regular use of alcohol to intoxication’ (Johnson et al. 2005, 1143). Important here is the distinction made between ‘regular use’ and ‘intoxication’.

Intoxication has also been defined as acute consumption, alongside alcohol abuse and dependence, hazardous/harmful use, and ‘alcohol use disorder’ (Neumann and Spies 2003). It also often appears in lists of the possible adverse consequences of consuming alcohol. For example, one study explains, that these ‘acute consequences’ of alcohol consumption include ‘intoxication, injuries and accidents, as well as long-term or chronic consequences, such as liver disease, cancer and alcohol dependence’ (Plant 2008, 155). While we might expect that the terms intoxication, drunkenness and binge drinking have distinct meanings and definitions, they are also often used interchangeably. In this sense, even though our primary interest is not with definitions of binge drinking it is important to illustrate how this term informs understandings of intoxication and drunkenness. Binge drinking is an ill-defined concept for researchers, policy makers and the general public. It has been noted that ‘different definitions of binge drinking have been used in the literature, such that heavy drinking, drinking to intoxication, and occasional heavy intake are terms used interchangeably’ (Yang et al. 2007, 186). Hammersley and Ditton (2005, 498), for example, reported that 7 per cent of 291 participants in the UK conflated binge drinking with ‘drinking to drunkenness or intoxication’. In another study binge drinking was described as ‘a drinking occasion leading to intoxication of the drinking person’ (Van Wersch and Walker 2009, 126).

While intoxication and drunkenness are not always distinguished, it has been argued that intoxication is different to binge drinking (Farke and Anderson 2007, 334). There are two main definitions of binge drinking in the health research literature. It is often used to denote a pattern of drinking that occurs over time. Its more common application however, is as a ‘single drinking session leading to intoxication, often measured as having consumed more than X number of drinks in one occasion’ or, ‘a single episode of acute intoxication’ (Herring et al. 2008b, 477).

Participants in a recent study conducted by McMahon et al. (2007, 300) interpreted binge drinking not only in terms of a specified amount of alcohol but also by intent. Here, they found a range of motivations as to why an individual would engage in episodes of heavy drinking, such as, ‘dependence, tension relief and celebration’. In this study, drinking to intoxication was a defining feature of binge drinking. The authors claim that the importance of intoxication was evident in a number of the definitions of binge drinking, ‘drinking beyond personal limits, drinking to get drunk and drinking until physically unable to continue’. While it is not spelled out, the notion of intoxication is implicit in each of these definitions.

Common measures of binge drinking rely primarily on the amount of alcohol consumed. Some researchers in North America, parts of Europe and Australia use the 5+/4+ metric as an indicator of binge drinking, where five or more drinks for males and four or more for females across a two hour time period is considered binge drinking (Wechsler and Kuo 2000). The National Institute on Alcohol Abuse and Alcoholism (US) defines a binge as ‘a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above’ (National Institute on Alcohol Abuse and Alcoholism 2004). Other researchers, mostly in the UK, rely on an 8+/6+ measure. The 8+/6+ metric refers to 8 units/6 units of pure alcohol consumed within a two hour period (1 unit = 10 ml or 8 g of pure alcohol/ethanol; see Hammersley and Ditton 2005). Notwithstanding the relative merits of such guidelines, the lack of a standardised definition of binge drinking makes comparisons across studies difficult (Gill et al. 2007).

There are other problems with these sorts of definitions of binge drinking. Herring et al. (2008a, 498) explain that, ‘it is probably not helpful to lump together those who have drunk anything from eight (men) or six (women) units with those who have drunk considerably more and are extremely intoxicated’. Nonetheless, intoxication is not defined here, and what makes the amount of drinks coupled to binge drinking enough to induce extreme intoxication is unclear. Again, the distinction between binge drinking and extreme intoxication remains ambiguous.

Lange and Voas (2001, 311–315) argue that, ‘especially for men, the traditional 5+ drinks definition of binge drinking… is too low to reflect accurately the drinking events that produce excessive intoxication’. They argue that the current, ‘use of this term [binge] to describe drinking events that do not produce illegal BACs [in relation to drink driving limits] or significant impairment may affect the credibility of responsible-drinking campaigns’. They also suggest that the concept of binge drinking ‘implies excessive drunkenness’ but that current definitions of binge drinking rely on such low BACs that they ‘may not be capturing the “excessive-drunkenness” quality of the term’.

Some researchers argue that binge drinking should be considered ‘a characteristic of the individual, not of the occasion when drinking occurred’ (Wechsler 2000). Wechsler (2000) suggests that binge drinking is not ‘intended to determine if [drinkers] are legally intoxicated at the time’. Instead, he proposes that it is more useful as a gauge for tracking the risk of potential problem-drinkers. Similarly, it is argued that the utility of such a controversial measure for researchers lies in its ‘use as a measure of alcohol-related harm, which recognizes that much of the short-term harm associated with alcohol… arises from single episodes of drunkenness, rather than drinking more than the recommended weekly levels or individual daily drinking (Herring et al. 2008a, 482). However, as Herring et al. (2008a, 483) claim, ‘within the general definition of binge drinking as single drinking session leading to intoxication there is no consensus as to what level of intake constitutes binge drinking’.

Measham (2008, 210) also argues that, ‘varying definitions and measurements of “binge” drinking have led to problems of comparative research with a narrow focus on total units consumed unrelated to the duration of consumption, leading to the technical possibility of a sober binge drinker!’ A further issue here is the problem of using the 5+/4+ measure as shorthand for intoxication when many young people who drink at this level do not exhibit signs of intoxication, or do not present unacceptable BAC measurements (Perkins et al. 2001). In a study with over 1000 college students in the US, Thombs et al. (2003, 323) found that 66.3 per cent of those meeting the 5+/4+ criterion for the night had BAC < 100 mg/dl. They concluded that while a particular BAC measure might indicate moderate drinking, if an individual has consumed more than the 5+/4+ threshold they would be classified as having engaged in heavy episodic drinking ‘at a relatively low BAC’.

A final observation here about the use and meanings of the term binge drinking and the marked lack of agreement about what it is and what should be done about it. In some contexts there is the perception that binge drinking is undertaken by a minority of individuals who undermine the responsible drinking practices of the majority of the population. The issue in these sorts of cultural, social and political contexts is understood in ways that might seek to downplay the extent and consequences of bingeing – or indeed, to highlight these and claim it as being a pressing concern. For example, Measham and Brain (2005, 272), ‘question the [UK] government’s claim that “binge” drinkers are a small and antisocial minority of people drinking in city centres who should not be allowed to derail the planned government policy of liberalisation of licensing hours for the sensible majority’. Suggesting that rates of consumption of alcohol are much higher than what is defined as a binge (using the 8/6 measure), Measham and Brain (2005) argue that binge drinking is not a minority issue, and instead, that this kind of consumption pattern is indicative of a new culture of intoxication. As our discussion indicates, anyone looking for some scientific, objective certainty with which to engage such claims will be unlikely to find it.

The physical and mental health consequences of intoxication and drunkenness

Having surveyed some of the difficulties associated with the slippery definitions of intoxication, drunkenness and binge drinking, we move to a discussion of some of the ways in which these definitions frame a range of physical and mental health and safety concerns.

The aim in what follows is to identify and map some of the ground covered by these concerns. Our list is extensive, but not exhaustive; illustrative, but not detailed. A useful starting point for this purpose can be found in the ways in which the American Psychiatric Association’s (2000) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines intoxication:[1]

The essential feature of Alcohol Intoxication is the presence of clinically significant maladaptive behavioral or psychological changes (e.g., inappropriate sexual or aggressive behavior, mood lability, impaired judgment, impaired social or occupational functioning) that develop during, or shortly after, the ingestion of alcohol (Criteria A and B). These changes are accompanied by evidence of slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, or stupor or coma (Criterion C). The symptoms must not be due to a general medical condition and are not better accounted for by another mental disorder (Criterion D). The resulting picture is similar to what is observed during Benzodiazepine or Barbiturate Intoxication. The levels of incoordination can interfere with driving abilities and with performing usual activities to the point of causing accidents. Evidence of alcohol use can be obtained by smelling alcohol on the individual’s breath, eliciting a history from the individual or another observer, and, when needed, having the individual undertake breath, blood, or urine toxicology analyses.

The DSM (IV) definition is to be consulted as a clinical reference, and is frequently referred to in psychological research literature that is concerned with such things as the impact of intoxication on risk factors/behaviours associated with issues such as suicidal ideation. For instance, the effects of acute alcohol intoxication have been claimed to act as proximal risk factors for suicidal behaviour among alcoholics and non-alcoholics (Hufford 2001). In this instance it is suggested that intoxication affects levels and states of distress and aggression which may turn ‘suicidal ideation into action through suicide specific alcohol expectancies’. Intoxication impairs cognitive processes which would otherwise allow the generation and implementation of alternative coping strategies (Hufford 2001, 797).

The effects of alcohol intoxication on emotional states are also of interest to psychological expertise. Hufford (2001) claims that some level of alcohol intake is thought by many people to be ameliorative to negative emotions and researchers believe this may be true under certain conditions. This model takes into account the ‘biphasic’ effect of alcohol, whereby it can act as both a stimulant and a depressant. Aggression has been shown to be affected by alcohol intake. Yet an individual’s alcohol intake may also be influenced by feelings of aggression. Hufford (2001, 797) argues that the ‘pharmacological effects of alcohol intoxication on attention is one mechanism that can increase the proximal risk of suicidal behaviour’. The effect of intoxication on attention is seen to work by restricting the range of cues perceived in a given situation, and by decreasing one’s ability to meaningfully interpret these cues. That is, alcohol intoxication interrupts processes of inhibition conflict that are usually present when risky behaviours are contemplated.

Some psychological studies have been conducted to better understand the effect of alcohol intoxication on the ways in which men and women interpret signs of sexual advances. These studies are said to be important in understanding such things as so-called ‘date rape’ scenarios. Alcohol has been shown to disrupt higher-order cognitive processing, making intoxicated people more likely to focus on immediate superficial social cues, and therefore encouraging poor decision-making (Abbey et al. 2003). For example, one study showed that intoxicated men are more likely to interpret a man who committed acquaintance rape as less deviant and more typical than did non-drinking men (Abbey et al. 2003). Some psychologists are interested in the possible expectancy effects of a culture that equates alcohol use with sex and violence. That is, some researchers believe that individuals’ expectancies about this link encourage this type of behaviour.

Abbey et al. (2003) outline and discuss three types of studies to examine this link. In one study participants are led to believe they are drinking alcohol but in fact they are not. In another, participants are asked to assess their pre-existing beliefs about alcohol use. Finally, sober participants are required to consider the behaviour of others who have been drinking. In a scenario presented to males in a laboratory, study participants who think they have consumed alcohol, as well as those who were given alcohol, took longer to suggest that a man should stop attempting to force a woman to have sex with him. In the same study both groups of men were also more likely to interpret the woman’s behaviour as sexually aroused than the non-drinkers. The authors report mixed findings from placebo studies.

Another study involved 90 male and 90 female university students in the US who were randomly assigned to drink alcohol, a placebo beverage or a non-alcoholic beverage. They were then read a story of a man and a women who didn’t know each other well drinking together at a party, consensually kissing and ending with the woman saying ‘no’ to the man’s increasingly insistent sexual advances. The participants, who were randomly allocated to drink alcohol, were given 80-proof vodka calculated to achieve a peak BAC of .080 per cent (2.00 g/kg of body weight for men and 1.85 g/kg body weight for women). This amount was chosen because it is sufficient to impair a number of cognitive functions thus providing a definition of intoxication (Abbey et al. 2003, 675).

Results showed that people were more willing to consider the man in the scenario as acting appropriately if they had been allocated to drinking alcohol, approved of casual sex, or interpreted the female character as very sexually aroused. ‘Participants were more likely to perceive the woman in the story as being very sexually aroused when they drank alcohol, when they had strong alcohol expectancies regarding sex and when they frequently drank alcohol on dates’. The findings ‘support the hypothesis that sexual arousal may be a particularly salient cue on which intoxicated individuals are likely to focus their attention’ (Abbey et al. 2003, 675).

A number of other psychological studies report on concerns with the disinhibitory effect of alcohol and risk taking behaviour related to certain criminal, sexual or violent practices: ‘Alcohol produces a pharmacological effect that may be described as disinhibitory, or in other words, related to an increase in behaviours that, due to environmental context, otherwise normally occur at a low rate’ (Lane et al. 2004, 74). The authors caution that ‘despite a well-established epidemiological and clinical relationship between alcohol intoxication and maladaptive risky behaviour, results of laboratory studies seeking to demonstrate such a relationship have not been conclusive’. One laboratory study has shown that, ‘otherwise normal subjects, when intoxicated, showed risk-taking patterns remarkably similar to subjects with a history of maladaptive risky behaviour’ (Lane et al. 2004, 74)

Intoxication can affect cognitive function and interfere with performance on neuropsychological tasks including memory, learning and coordination (Calhoun et al. 2005, 285–288). However, Calhoun et al. propose that there is still much work to be done in mapping acute alcohol use with brain function. Using functional MRI technology the researchers used virtual-reality driving simulations to ‘introduce the participant to a simulated environment rather than a series of tasks, thus allowing for a more realistic experience’. The authors claimed that their study ‘revealed both global and local effects of alcohol’, and that they were able to consider the ‘relationships between behaviour, brain function, and alcohol blood levels’.

A number of health researchers in Australia draw on the National Health and Medical Research Council (NHMRC) drinking guidelines to classify types of drinkers according to risk. These guidelines define short-term alcohol-associated risk in terms of ‘an excessive volume consumed in a single day, and the associated risks are intoxication and impaired judgement leading to accidents, injury and death’ (Reid et al. 2007, 437). Similarly, the 2004 Australian Institute of Health and Welfare Report (2004, 3) defines intoxication as one of three broad categories of problem that may result from excessive alcohol consumption. These problems are summarised in three categories:

  • Alcohol dependence (loss of personal control, withdrawal symptoms, social disintegration, etc);
  • Heavy regular use problems (cirrhosis of the liver, cognitive impairment, pancreas damage, heart and blood disorders, ulcers, etc); and
  • Intoxication and acute alcohol-related problems (alcohol-related violence, risky behaviour, road trauma, injury, etc).

The Australian Bureau of Statistics (ABS) recently published a series of articles describing Australian social trends in relation to alcohol consumption. One, entitled ‘Risk taking by young people’, draws from the 2007 NHMRC guidelines to describe the effects of ‘high risk drinking’ in relation to intoxication in the following way: ‘Short term risky/high risk drinking – often referred to as binge drinking – leads to immediate and severe intoxication’ (ABS 2008). According to this report, the likelihood of falling over or being involved in an accident or some form of violence increases markedly with high-risk drinking. The report specifically identifies young people aged between 15–24 years as the group most likely to experience the negative consequences of intoxication: ‘Of the many alcohol-related disorders present in subjects referred to emergency care departments, acute alcohol intoxication is the most frequent. This condition is present not only in adults but also in adolescents’ (Vonghia et al. 2008, 562). Apparent increases in rates of adolescent hospital admission as a consequence of alcohol intoxication continue to be a significant concern for health professionals and researchers.

The Australian Institute of Health and Welfare Report (2004, 1) also reveals that intoxication provokes the sorts of high risk behaviours that can readily result in the loss of life:

An estimated 31,132 Australians (23,431 or 75% males; 7,703 or 25% females) died from risky and high-risk alcohol use in a period of ten years between 1992 and 2001. The leading causes of death were alcohol liver disease followed by road crash injury, cancer and suicide. These types of deaths reflect a pattern of drinking to intoxication with more people dying from acute rather than chronic effects of alcohol.

In the medical literature the term intoxication is not only associated with physical symptoms but is also linked to injury, trauma and violence. Vonghia et al. (2008) draw on a study conducted by the Australian Institute of Family Studies in 2000 (see Appendix B) to reveal that ‘conditions deriving from acute alcohol intoxication, such as trauma and violence, were responsible for 46% of potential life years lost, twice that from chronic alcohol-related conditions’ (Vonghia et al. 2008, 563). These authors also draw on other studies to claim a relationship between intoxication and violent crimes such as homicide, assault, robbery and sexual offences.

The health consequences of intoxication and drunkenness are things that attract the interest, concern and, often, the moralising of certain sections of the news media. In such accounts a range of statistics are cited as evidence of the damage heavy drinkers are doing to their health (it is not possible to cover them all here). Moreover, the statistics vary from country to country. What is apparent in these settings is the role that the media plays in translating the concerns and findings of psychological, biological and medical research. This popularising of science and the results of scientific research is never direct or unmediated. What is often apparent in media commentary on the health problems that face heavy drinkers is the paternalistic and condescending attitude that is adopted towards certain marginalised groups and populations. The apparent concern in such commentary for the drinker is constantly tinged with a disbelief that people seem ‘unwilling’ to rein their drinking in, ‘even for the sake of their health’, which Cathy Pryor (2008) attributes to the drinker’s ‘confusion’. In one account Anita Chaudhuri (2003) summarises a number of the key concerns regarding the damage drinkers are inflicting on their health:

Drinking many of your weekly alcohol units at one sitting is much more harmful than moderate daily intake, because the toxic effects of excess alcohol put a huge strain on the body’s vital organs. The results of a Scottish study published in the British Medical Journal showed that there was an excess of deaths due to coronary heart disease on Mondays (3.1% above the daily average of deaths). The journal argued that these deaths were partly attributable to weekend binge drinking, which accounts for 40% of all drinking occasions by men and 22% by women in Britain. When you compare that to France, where binge drinking accounts for only 9% of all drinking occasions by men and 5% by women, it is clear that Collins has a point about Brits and bingeing. Alcohol Concern warns that apart from feeling terrible the morning after, there also are several long-term physiological consequences of binge drinking: high blood pressure, risk of liver cancer and cirrhosis, reduced fertility, weight gain, blood-sugar problems, stomach inflammation and bleeding, and increased risk of having a stroke.

In another story Sally Squires (2000) sketches some of the more troubling effects of alcohol on brain neurochemistry:

Some of the brain’s messenger chemicals excite nerve cells; others dull or inhibit them. Among other activities, alcohol affects the most powerful of the inhibitory systems – those involving the neurotransmitter GABA – and that results in a general depression of many kinds of nerve response. Too much alcohol floods neurons and changes gene function of the cells, which in turn appears to alter receptors and results in intoxication, brain-cell death and, if repeated, dependence and alcoholism.

At the same time, somewhat in conflict with these understandings, there is a strong social perception that regulators and policy makers need to adopt a more flexible approach to understanding what constitutes ‘safe drinking’. The need for flexibility was evident in the debates about what constitutes a ‘safe enough’ blood alcohol level for drivers. Here the question becomes: What is ‘moderate’ drinking? What does it mean to drink ‘in moderation’? Writing in the New York Times, Brody (2002) claims that: ‘Studies of tens of thousands of people here and abroad have found that regular moderate alcohol intake diminishes the risk of heart disease and possibly stroke, probably by raising blood levels of protective H.D.L. [high density lipoproteins] cholesterol and estrogenic substances’. Moderate alcohol consumption has also been linked to a reduced risk of dementia in people over 55. The key word here is moderation. For younger adults, moderate is defined as no more than two drinks a day for men and no more than one drink a day for women. But for healthy men and women over 65, the new definition of moderate offered by the National Institute on Alcohol Abuse and Alcoholism is no more than one drink a day and some experts suggest that older women would be wise to cut that amount in half. These definitions are, of course, contested. The Australian news media regularly reports on studies that claim that moderate alcohol consumption can have positive health benefits for the elderly. The Herald Sun, for example, published a number of stories about some of the positive health effects moderate drinking can have (Burstin 2003; see also Cameron 2007). The Sunday Age (2001) reported that while alcohol abuse contributed to the deaths of 3271 people under the age of 64 in 1998, moderate drinking averted the deaths of 5642 people over 64 in the same period. Finally, the Herald Sun highlights the debates concerning the definition of what constitutes drinking in moderation:

Dr [Phillip] Norrie says drinking in moderation means a maximum of four standard drinks a day for a man and two for women… But [Geoff] Munro says these are maximum limits for safe drinking, not recommended daily doses. And people should aim for at least one or two alcohol-free days a week… Men should aim for a weekly maximum 28 standard drinks and women aim for 14 to prevent risk of alcohol-related health problems. (Burstin 2003)

Calculating, measuring and testing: Debates and dilemmas

Many alcohol researchers in the fields of medicine and public health are concerned with identifying people in need of intervention to prevent them doing long term harm to their health (Aalto and Seppä 2007). Reynaud et al. (2001) argue that any form of hospitalisation that occurs as a result of intoxication should be ‘interpreted as a sign of likely harmful alcohol dependency’ (Reynaud et al. 2001, 96). In their analysis these authors confirm our broad distinction that drunkenness refers to outward behaviour, and intoxication is a biological state that can be measured using a range of laboratory and field-based tests. Within these domains the harmful consequences of intoxication or drunkenness are identified through the use of various measurements, such as BAC (blood alcohol content) tests (Hammersley and Ditton 2005; Poulsen et al. 2007), BrAC (breath alcohol content) tests (Barquin et al. 2008; Voas et al. 2006), counting the number of drinks consumed (Hammersley and Ditton 2005), looking at the frequency of drunkenness (Midanik 2003; Schmid et al. 2003; Zaborskis et al. 2006), the number of drinks required to feel drunk (Midanik 2003; Kerr et al. 2006) and self-perceived drunkenness (Midanik 2003; Gustin and Simons 2008; Harrison and Fillmore 2005; Thombs et al. 2003). The variety of such tests is just one indication of the uncertainties and ambiguities associated with measuring levels of alcohol concentration in the body. Of more interest is the sense that a greater dilemma relates to defining the levels of alcohol concentration that indicate or define intoxication. Given these dilemmas, which we describe in more detail later, Table 1 provides one example that sets out to list a range of health, psychological and behavioural symptoms, and the corresponding BAC levels which might trigger these symptoms.

Table 1. Main clinical symptoms in acute alcohol intoxication according to blood alcohol concentration (BAC)

SYMPTOMS

BAC

Impairment in some tasks requiring skill

BAC<50 mg/dl

Increase in talkativeness

(10.9 mmol/l)

Relaxation

Altered perception of the environment

BAC>100 mg/dl

Ataxia

(21.7 mmol/l)

Hyper-reflexia

Impaired judgement

Lack of coordination

Mood, personality, and behavioural changes, nystagmus

Prolonged reaction time

Slurred speech

Amnesia

BAC>200 mg/dl

Diplopia

(43.4 mmol/l)

Dysarthria

Hypothermia

Nausea

Vomiting

Respiratory depression

Coma

BAC>400 mg/dl

Death

(86.8 mmol/l)

 Source: (Vonghia et al. 2008)

This sort of calculation establishes a relationship between a variety of physiological, psychological and behavioural states – some of which are readily identifiable and observable – and a series of thresholds of alcohol concentration in the blood (BAC). At one level, especially in terms of symptoms, this sort of calculation establishes a relationship that is recognisable – even to the non-expert. However, there is much more ambiguity and debate about the levels of BAC at which these symptoms appear.

Blood alcohol content (BAC), as we have indicated, is a way of measuring intoxication in individuals. It represents the amount of ethanol in a given amount of blood and is represented by weight by volume. The most commonly used measurements are grams of ethanol per millilitre of blood (g/ml) used in the US, and milligrams of ethanol per millilitre of blood (mg/ml), used in much of Europe. For example, 0.05 g/ml=50 mg ml (ICAP 2002). While it is tempting to define intoxication and drunkenness by simply counting the number of drinks consumed in a given time frame, it can be argued that understanding these terms is more complicated than that approach allows. A more accurate measure of intoxication necessarily relies on measurement of alcohol in units such as grams or ounces: ‘Without specifying the percentage of alcohol in the beer or wine, an accurate interpretation of a standard drink is impossible’ (Brick 2006, 1285). However, counting drinks is a common way that researchers measure intoxication. In one study undertaken to determine the ‘relative influence of environmental and demographic factors on the drinking behaviour of servers, intoxication frequency was defined by the respondents and measured as a raw score with 10 times per month or more the highest category’ (Nusbaumer and Reiling 2002, 736).

The difficulty in defining intoxication is highlighted in the research of Hammersley and Ditton (2005, 497–498). Their interviewer-completed questionnaire study of 291 people aged 16–25 looked at the quantity and rate of alcohol consumption in licensed premises. In this study they define intoxication as follows: ‘People drinking less than 1 unit per hour are unlikely to be intoxicated, 1–2 units per hour will probably produce moderate intoxication, with BAC increasing over time. Faster rates (2 or more units per hour) are even more likely to result in intoxication with significant behavioural consequences’. They go on to suggest that, ‘men drank more than women, but after adjusting crudely for body size and the recommended upper limits of intake for men and women, men’s and women’s drinking did not differ’. The implication is, ‘that women’s intoxication levels… were equivalent to men’s, but women are not literally drinking as much as men’. Intoxication is not, then, something that can be linked simply to the number of drinks consumed. Using BAC measures Hammersley and Ditton (2005, 495) concluded that drinking:

eight units steadily over 4 hours at 2 units per hour would produce a peak BAC of approximately 60mg% in an average sized man, occurring just after the end of the drinking session. Drinking the same amount of alcohol at twice the speed would achieve a peak BAC of approximately 100mg% by 2.5 hours, at which level most drinkers will be intoxicated.

In different settings these apparently objective calculations and definitions create their own dilemmas. Intoxication and drunkenness are sometimes defined with reference to the legal limit of alcohol for driving (Hammersley and Ditton 2005). That is, one would be considered intoxicated if BAC was above the legal limit for driving. BAC does not readily translate to a certain number of drinks consumed. There are many factors that effect a person’s BAC at measurement, such as length of time between drinks, amount and type of food consumed and the context of consumption (Brick 2006). For example, the so-called ‘hip flask defence’ referred to in Simic and Tasic (2007), or the ‘cognac alibi’ (Simic et al. 2004) is used after a crime (drink driving or road accidents) to indicate that a drink was taken after the fact (say, to calm one’s nerves) and not before. This is a means to mount a defence that drinking alcohol was not the cause of the accident. Simic et al. (2004) explain the complications that arise for prosecutors who must draw upon the expertise of ‘medico-legal experts’ or forensic pathologists and toxicologists to establish blood alcohol levels after the fact. Simic et al.’s (2004, 367) response to these concerns was to develop a more complex and refined calculation of BAC:

It consists of three inter-related phases in which it combines the obtained BAC values, with testimonies of the drunk driving suspect and also witnesses. A specific algorithm was designed for calculating absorption and elimination of consumed alcohol. All the above-mentioned elements and blood-ethanol values calculated according to Widmark’s method were inserted into appropriate cells of MS Excel software in order to calculate BAC in the function of time. The result is a relevant analysis of the drunk driving suspect’s BAC in 5-minute intervals, as well as a graphic representation in chart form. (Simic et al. 2004, 367)

It is possible to imagine that this sort of algorithm may be more complex, but that it does little to clarify the debate about the ways in which intoxication and drunkenness is to be identified or measured. Brick (2006) illustrates some of the complications that may arise in using BAC measures of intoxication. For example, ‘researchers relying upon alcohol test results from a hospital laboratory often neglect to inquire or report whether the results are derived from whole blood, serum, or plasma samples’ (Brick 2006, 1284). This difference matters because ‘a hospital serum alcohol concentration will be higher than a whole BAC drawn from the same patient at the same time’ (Brick 2006, 1284; see also see Miller et al. 1991 in Appendix B). Brick’s discussion identifies a problem with inconsistent reporting of the quantitative measurements of alcohol intake. Here it is clear that definitions of intoxication and drunkenness which rely on quantitative and objective measurements are not always standardised, nor as reliable and precise as their calculations may imply.

The procedures for determining BACs are labour-intensive, time-consuming, expensive and, because of these factors, not always available in all situations (Shin et al. 2008, 194). In the context of hospitalisation for symptoms that are suspected of being related to intoxication, the ‘confirmation of the diagnosis can take as long as 48 [hours], which places the patient at risk for many complications, which include death’ (Shin et al. 2008, 194–195). Again, the context and the particular needs and ends promote different ways to identify and measure intoxication. So, Shin et al. (2008, 201) have developed a laboratory test for intoxication, ‘which use[s] extremely minute quantities of saliva, can be performed with easily obtainable and inexpensive reagents, and these tests can be completed within 30–40 min’.

Given the complexities and costs associated with calculating and measuring BAC, other methods have been developed to meet the needs to identify and determine intoxication. A common way of assessing intoxication levels in the field is by measuring breath alcohol concentration (BrAC). Passive alcohol sensors (PAS) draw in a mix of expired and environmental air in front of a person’s face and have found to be strong predictors of alcohol concentration. Breath analysers have been used in many contexts to monitor drink driving (Voas et al. 2006). These devices enable law enforcement officials to quickly and easily gauge a driver’s alcohol intoxication status with some level of confidence. Voas et al. (2006, 720) cite studies indicating that when police officers have less than one minute to evaluate a driver (before deciding to undertake more thorough drink driving checks) ‘the officer misses approximately 50% of the drivers who are above the legal limit’. PAS, it is argued, allow officers to make more informed decisions about an individual’s intoxication status.

In another study, Poulsen et al. (2007, 514) use a number of variables for measuring the effects of alcohol intoxication on motor performance: ‘To obtain a blood alcohol concentration level (BAC) of 1.5 g/l (32.6 mmol/l) the amount of alcohol given was adjusted individually based on gender, age (A), height in metres (H), weight in kilograms (W), total body water (TBW), breath alcohol concentration (BrAC) and expected metabolism’. In this study, BrAC was measured by Digital Alcohol Detector CA2000
(an FDA approved ‘breathalyser’, available to purchase on the Internet for about US$50 dollars; see also Barquin et al. 2008).

These sorts of volume-based measures have been queried at the level of methodology because they fail to take into account the length of drinking session, time between drinks or other important attributes of the drinking encounter in non-laboratory settings (Hammersley and Ditton 2005; Wright 2006). In other words, as with the use of BAC to measure intoxication, volume-based measurements must be considered in light of other factors such as length of time spent drinking, time between drinks, food consumption (amount and type), body size and alcohol-content. It appears that in order to understand intoxication we must consider alcohol consumption in context. While measures such as the 5+/4+ or 8+/6+ might be useful indicators, they tell us little about the state or experience of intoxication and drunkenness in themselves. From a sociological perspective, there are other aspects that are harder to measure that help to define intoxication and subjective interpretations of drunkenness.

Subjective understandings of intoxication and drunkenness in scientific discourses

We conclude this chapter with a brief overview of the debates and discussions that attach to attempts to develop calculations based in more subjective reporting and accounts of levels of intoxication and drunkenness. Again, there is little consensus about the ability of individuals to do this with accuracy. Some researchers argue that individuals are not reliable in predicting or calculating their own levels of intoxication, that they may, in fact, be ‘unaware that they are intoxicated’ (Gustin and Simons 2008, 606). Yet other researchers have found scenarios in which participants are able to estimate their BAC levels with some accuracy (Thombs et al. 2003). Thombs et al. (2003), in their study of college students in the US, found that those with mid-ranging BACs ranging from 70–90 mg/dl exhibited the greatest accuracy in estimating their BAC; those with lower BACs tended to overestimate their level of intoxication, whereas those with higher BACs tended to underestimate it.

A study by De Visser and Smith (2007, 350–351) examined some of the more qualitative dimensions of the expectations and uncertainties associated with the possibilities of drinking to levels that might produce intoxication. Their account of interviews with 31 young men in London develops and deploys a vocabulary based on the ambivalences related to the expectancies, attitudes and motivations that shape the use and consumption of alcohol:

Expectancies are perceptions of likely outcomes from drinking; attitudes are a product of expectancies and evaluations of these outcomes, and motives reflect a desire to act on attitudes and expectancies in order to achieve or avoid particular outcomes. To illustrate this distinction, an expectancy might be that “Alcohol enhances sociability”; the accompanying attitude might be that “Alcohol is good because it makes people more sociable”, whereas the motive might be “I will drink to be more sociable”. As predicted by theories of health behaviour, outcome expectancies and motives are important correlates of drinking behaviour.

De Visser and Smith (2007, 351) suggest that there is a danger of making the notion of expectancy static. They introduce the idea of the drinker’s dilemma to suggest that the ways in which drinkers understand their drinking is, indeed, a shifting, mobile, uncertain space:

Rather than simply having favourable or unfavourable expectancies and motives, most people are ambivalent about alcohol. Ambivalence is not surprising given the paradoxical effects of alcohol, which may produce positive or negative outcomes at different stages of a single drinking episode. This produces a “drinker’s dilemma”: although drinkers know that alcohol can have both positive and negative consequences, it is difficult for them to predict whether, and at what point, their drinking will lead to net positive or negative outcomes. Thus, outcomes may not be consistent with motives. For example, someone who drinks to be less inhibited but drinks too much may become antisocial, because they are less concerned about the effects of their behaviour.

Developing this idea of the drinker’s dilemma, of the uncertainty and ambiguity that often accompanies drinking, De Visser and Smith (2007, 352) suggest that ‘motives for drinking became reasons for not drinking as the volume consumed increased. For example, positively evaluated confidence accompanying mild intoxication could easily become negatively evaluated arrogance following excessive consumption’. Moreover, drinkers and non-drinkers ‘gave the same range of motives for not drinking. This implies that drinkers and non-drinkers alike have plenty of motives for not drinking, but the addition of more (or more convincing) motives for drinking determines drinking behaviour’.

In their study Morzorati et al. (2002, 1300) developed a hypothesis which suggested that an individual’s family history may influence the subjective interpretation of the effects of alcohol. They designed a study which enabled them to separate participants into groups which differed by family history of alcoholism. They used what is called a BrAC clamp, ‘a method whereby a predetermined steadystate BrAC is achieved and maintained for a prolonged period of time’ to evaluate self-reported subjective effects of alcohol in these two different groups. They argued that ‘the BrAC clamp greatly minimizes the experimental variance in the achieved alcohol concentration and makes possible long intervals at a target BrAC that is nearly identical in all subjects’. Morzorati et al. (2002, 1301) argue that:

The visual analog scales for high and intoxicated consisted of 100-mm lines used to rate current perceptions from “same” (score=100, how the subject felt before alcohol) to “extremely” (score= 200, the biggest effect alcohol has ever had). The subject placed a single vertical slash mark through the line, and the distance (mm) from the left edge was measured. Because the subjects knew there was no alcohol infusion at baseline, the high and intoxicated scores were generally 100 at baseline. (Morzorati et al. 2002, 1301)

Participants were found to feel more intoxicated after alcohol infusion than after the placebo, but the two groups, those with a family history of alcoholism (FHP) and those without (FHN) experienced this differently. For Morzorati et al. (2002, 1303):

A differential family history of alcoholism was reflected in self-reported subjective perceptions of intoxication when BrAC was clamped at 60 mg%. From baseline to the start of the clamping interval, FHP [family history-positive] subjects reported significantly more intense feelings of intoxication compared with FHN [family history-negative] subjects. During maintenance of the clamp, the FHP subjects adapted to the effects of alcohol, and their perceptions of intoxication were no longer distinguishable from those of the FHN subjects. Thus, according to self-reported perceptions of intoxication, FHP subjects developed significant acute tolerance to alcohol, whereas the FHN subjects did not. The response differences between FHP and FHN subjects are not explained by drinking history, because the numbers of drinks and drinking days in the 4-week interval before the study were not different between the family history groups.

Another study asked participants to fill in the Subjective High Assessment Scale; rating the items of subjective feelings of intoxication as changes from baseline. Each SHAS question is scored on a 36-point Likert scale from 0 (no effect) to 36 (extreme effect) for items that reflect both more positive effects of alcohol (high, intoxication, a floating feeling, and so on) and potential negative effects (nauseated, feeling bad, feeling clumsy, and so on) (Schuckit et al. 2004, 1501).

In a number of studies evidence about self-reported drunkenness is determined through a question such as: ‘Have you ever had so much alcohol that you were really drunk?’ Respondents were provided with the following possible answers: ‘No, never (0), Yes, once (1), Yes, 2–3 times (2), Yes, 4–10 times (3), Yes, more than 10 times (4)’ (Schmid et al. 2003; Zaborskis et al. 2006). Self-reporting can take other forms than those described above. In their research Coleman and Cater (2004, 351) were interested in young people’s experience of risky drinking and used a self-report survey to record ‘young people’s experience and frequency of being “very drunk” and the location where this drinking occurred’. They used a questionnaire which defines intoxication without reference to counting drinks. The questionnaire states: ‘By very drunk we mean that you may not have remembered what you’ve been doing, or ended up by being sick, or falling over, or having a hangover, etc.’ They argue that they use this definition of very drunk ‘to reduce the complexity of defining and recalling “units” or “number of drinks” (particularly relevant for unsupervised locations)’, and that it also ‘accounts for individual differences in intoxication thresholds’. Their findings suggest that ‘the increased experience of becoming very drunk is most notable between ages 14–15’ and further, that:

the progression from first experience of drunkenness to more regular drunkenness is relatively swift, illustrating the importance of delaying this first drunken experience as a means of harm reduction. Recording the transition to first drunkenness, alongside first ever alcohol consumption, has commonly been overlooked as an indicator of potential alcohol related harm. (Coleman and Cater 2004, 352)

They also indicate that, ‘younger people aged 14–15, who reported experience of drunkenness, were more likely to report becoming very drunk unsupervised in outdoor, and potentially more harmful, locations’ (Coleman and Cater 2004, 353). In a Danish study of intoxication, debut participants were asked two questions to assess their experience of intoxication: ‘How old were you the first time you drank at least one drink?’ and ‘Have you ever been drunk two days in a row?’ Response categories included: have never drunk alcohol; never been drunk; first intoxication at age 12 or younger; first intoxication at age 13; first intoxication at age 14; first intoxication at age 15–16 (Järvinen and Gundelach 2007).

In order to try to quantify subjective interpretations of intoxication some laboratory studies may administer a known dose of alcohol to participants who then predict their level of intoxication. Harrison and Fillmore (2005, 459–464) explain different ways that this has been measured, such as estimation of BAC; estimating the number of standard drinks participants predicted would bring on a state of intoxication; or a perceived ability to drive after a measured intake of alcohol. They argue that, ‘the dominant finding of this research has been that people tend to be poor estimators of intoxication. In particular, individuals often underestimate their BAC and the amount of alcohol they consume’. Harrison and Fillmore therefore went beyond a measure of the individual’s estimation of BAC to test the accuracy of individual self-report of specific behavioural measures of intoxication. ‘The study found no relationships between drivers’ estimated and actual levels of behavioral impairment… Thus, despite the opportunity to use specific performance experiences to estimate impairment, participants appeared unable to accurately evaluate their performance’. For Harrison and Fillmore ‘self-evaluations of alcohol intoxication are influenced by a host of factors, including interoceptive cues, such as subjective and behavioral changes associated with alcohol use (e.g. sedation, slurred speech, impaired gait)’. Likewise, Moore et al. state that ‘self-report data are not suitable to assess consumption in heavy drinkers’ (Moore et al. 2007, 629).

It has been argued that these measures do not necessarily reflect the same understandings and definitions of intoxication from all respondents. Levitt et al. (2009: 499) argue that single self-report items (for example, ‘To what extent were you drunk?’) in assessing subjective intoxication levels is not adequate because different individuals do not define, perceive, or experience being ‘drunk’ in the same way.

Conclusion

Our purpose in this discussion has not been to question bio-medical and psychological expertise and its attempts to identify the array of possible physiological, psychological and behavioural consequences of intoxication and drunkenness. These often harmful and damaging consequences are manifest in an array of situations, relationships, health and well-being indicators and policy contexts. In many respects some of these consequences are beyond question. But, the ways in which intoxication and drunkenness might be identified, calculated and measured are far from being beyond question. It is the ambivalent, ambiguous and complex nature of these debates that has most concerned us in this chapter. We have begun to map some of these debates so that we can more firmly locate understandings of intoxication and drunkenness in a variety of social, cultural and political contexts. The following chapter continues this move.

Cite this chapter as: Kelly, Peter; Advocat, Jenny; Harrison, Lyn; Hickey, Chris. 2011. ‘The psychological, biological and medical dimensions of intoxication and drunkenness’, in Smashed! The Many Meanings of Intoxication and Drunkenness. Melbourne: Monash University Publishing. pp. 33–55.

Endnote

[1] The influence of the DSM on constructing categories and types of conditions, pathologies, ideas of normal and abnormal behaviours is much debated in the behavioural and social sciences. An examination of these debates is beyond the scope of this discussion.

Smashed! The Many Meanings of Drunkenness and Intoxications - contents

   by Peter Kelly, Jenny Advocat, Lyn Harrison, Christopher Hickey