• Drunkenness and intoxication
• Drunkenness and related problems
• Culture and drunkenness
• Implications for policy and prevention
• Conclusions
• Policy options
• References

Drunkenness is not a drinking pattern but the outcome of drinking patterns that involve the ingestion of substantial amounts of alcohol in a brief period of time. It represents a public health and public order issue and is of considerable importance for the harm minimization approach to alcohol policy because it is associated with a broad range of alcohol-related problems, both acute and chronic. Drunkenness is a behavior found across cultures and geographic borders. In most countries, drunkenness, especially public drunkenness, is generally viewed as a negative behavior.

Drunkenness and intoxication

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Drunkenness is normally understood to be an altered state of being that results from an elevated level of ethanol in the blood (Blood Alcohol Concentration level, BAC)—and hence in the brain and throughout the body. Because alcohol is a psychoactive substance, it affects both consciousness and motor activities: perception, cognition, coordination, and even gross physical movement (see ANNEX 1: The Basics about Alcohol ). According to the World Health Organization’s International Classification of Diseases (ICD-10), “drunkenness” is one aspect of “intoxication” (World Health Organization, 1994). With regard to alcohol, while “intoxication” describes a physiological state, “drunkenness” also involves a strong social and behavioral component.

Alcohol-induced intoxication is often first defined on the basis of symptoms, outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV): slurred speech, loss of coordination, unsteady gait, nystagmus (rapid, jerky eye movement), impaired attention or memory, stupor and, in the extreme, even coma (American Psychiatric Association, 1994).

Although alcohol is a pharmacologically active substance with a direct effect on the central nervous system, its action is nonspecific (Macdonald, 1999; Oscar-Berman, Shagrin, Evert, & Epstein, 1997). Unlike other psychoactive substances, alcohol is not confined to a single neurochemical pathway or brain region. As a result, at different levels of consumption, alcohol produces a range of behavioral changes. At low doses of intake, it is a stimulant, acting on the same pathways that are involved in emotions such as pleasure and euphoria. At higher doses of intake, alcohol acts as a depressant, slowing down the central nervous system and giving rise to symptoms we associate with drunken behavior (e.g., slurred speech, lack of motor coordination, reduced cognitive ability). At extremely high levels, alcohol may become lethal by depressing breathing altogether.

The effects of alcohol at different concentrations in the blood are outlined in the Table 5.1 below (see also MODULE 16: Blood Alcohol Concentration Limits).

Table 5.1. Blood Alcohol Concentration (BAC) Levels and Their Effects

Source: Roldán, Frauca, & Duenas (2003)

Defining "drunkenness"

Defining the precise point at which drunkenness sets in is difficult. Epidemiological studies rarely deal explicitly with drunkenness; drinking patterns variously defined as “heavy,” “excessive,” “risky,” “binge,” or “hazardous” are implicitly equated with inebriation (e.g., Abel & Kruger, 2004; Graham, 2003; Okoro et al., 2004; Paukov, 1994; Pyörälä, 1995; Sastre, Mullet, & Sorum, 2000; Stillwell, Boys, & Marsden, 2004). In these cases, it may be generally assumed that drinks are consumed in relatively rapid succession so that the effect is cumulative.

There is considerable variation among individuals with respect to the point at which they can be considered “drunk.” Factors such as gender, age, size, general health, mood state, use of medication, family and genetic history, or experience with alcohol all play a role in the degree of intoxication and the rate at which it occurs (see ANNEX 1: The Basics about Alcohol).

The differential effects of alcohol at low and high concentrations play a role in risk for alcohol dependence: Heavy drinkers and those with a family history of dependence appear to be more sensitive to its stimulant effects at lower BAC, and less sensitive to alcohol’s effects at higher BAC (see MODULE 8: “At-risk” Populations; see also Evans & Levin, 2003; Thomas, Drobes, Voronin, & Anton, 2004). In addition, drunkenness is also largely a subjective state that cannot easily be defined by the number of drinks consumed (e.g., Harrison & Fillmore, 2005; Viken, Rose, Morzorati, Christian, & Li, 2003).

The only objective assessment of drunkenness is provided by its legal definition for the purposes of certain behaviors, such as alcohol-impaired driving, where definitions in terms of BAC limits leave little room for interpretation (MODULE 16: Blood Alcohol Concentration Limits; International Center for Alcohol Policies, 2002).

For the purposes of harm reduction and prevention, it may be necessary to define two distinct states: one that has been called “simple drunkenness,”` and the other “acute intoxication,” a clinical condition often requiring admission to an emergency room and whose effects may be long-lasting.

Drunkenness and related problems

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Drunkenness is frequently associated with heavy and problematic drinking but is a preventable and avoidable outcome. There are clear implications of drunkenness for health and social problems. Intoxication, particularly if it is repeated, is associated with increased risk in the following areas:

• injury and emergency room admission (Cherpitel, 1996, 1998; Cherpitel, Giesbrecht, & Macdonald, 1999; Roche, Watt, McClure, Purdie, & Green, 2001; Warner, Barnes, & Fingerhut, 2000);
• acute alcohol poisoning (Lahti & Vuori, 2002; Pletcher, Maselli, & Gonzales, 2004; Reuther, Carter, & Rutty, 1998; Woolfenden, Dossetor, & Williams, 2002);
• death due to hypothermia (Andon, 1997; Centers for Disease Control and Prevention, 2005; Finlayson & Hurt, 1998);
• certain cardiovascular problems (Gras et al., 1992; Hillbom, 1998; Rosengren, Wilhelmsen, Pennert, Berglund, & Elmfeldt, 1987; Vogel, 2002);
• neurological problems and dementia (Diamond & Messing, 1994);
• accidents and greater severity of such accidents (Fabbri et al., 2002; Honkanen & Smith, 1990; Lunetta, Penttila, & Sarna, 1998);
• traffic fatalities (Klein & Burgess, 1993; Shih et al., 2003);
• fetal alcohol syndrome and effects (Abel, 1998; Coles, Russell, & Schuetze, 1997).

In addition, heavy drinking patterns and associated drunkenness are also highly correlated with social outcomes that include:

• loss of productivity (Heller & Robinson, 1992; Moore, 1998);
• public disturbance (Giancola, 2004; Ogle & Miller, 2004; Wells, Graham, & West, 2000);
• crime and violence (Harrison & Fillmore, 2005; Hingson, Heeren, & Zakocs, 2001);
• alcohol-impaired driving (Centers for Disease Control and Prevention, 2004).

Culture and drunkenness

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Drunkenness has a strong cultural component (Cameron et al., 2000; Plant & Miller, 2001). In some parts of the world where drinking is commonplace, drunkenness is a relatively rare occasion or is socially rejected as an inappropriate outcome of drinking (Heath, 2000, 1995). This attitude typifies the so-called “Mediterranean” view of drunkenness. Elsewhere, as in the “Nordic” alcohol consumption pattern, drunkenness may be positively valued and actively sought as a desirable outcome of drinking and a goal unto itself (Heath, 2000; MacAndrew & Edgerton, 1969).

In many cultures, drunkenness plays a very specific role. In some cultures, behaviors that accompany inebriation may not so much be due to alcohol itself, but rather to a particular society’s definition of what constitutes permissible behavior under the circumstances (MacAndrew & Edgerton, 1969; Pittman, 1967).

Drunken behavior may be tolerated in some cultures if it is confined to well-defined contexts and occasions (Heath, 2000). In others, the permissibility of drunkenness for some groups but not for others emphasizes class distinction and gender roles (Carstairs, 1979; Pyörälä, 1995). Drunkenness may also be used for purposes of social cohesion or as a “time-out” from usual prevailing social norms, and is often confined to weekends or holidays.

Within a religious context, some groups may regard drunkenness as a shortcut to transcendence, communicating with dead ancestors, or worshipping spirits and other supernatural beings (e.g., Adams, 1995; Leacock, 1979; Trenk, 2001; Schnell, 1997). There are other groups in which drunkenness is used to enhance sociability, demonstrate hospitality or largesse, stimulate or sustain collective work efforts, celebrate special events, or otherwise enhance personal or social wellbeing.

However, drunkenness and intoxication are also correlated with other social and cultural indicators. For example, there is evidence that the incidence of intoxication and related health and social problems are high in regions undergoing socioeconomic transition (e.g., Iliev, Akabaliev, & Avgarska, 2001; Kopp, Skrabski, & Szekely, 2002; Makinen, 2000; Plange, 1998; Walberg, McKee, Shkolnikov, Chenet, & Leon, 1998).

Implications for policy and prevention

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Drunkenness is by and large an undesirable outcome of alcohol consumption that deserves particular attention within the context of prevention and harm reduction. It can be addressed through a focus on the drinking patterns of those who may be particularly likely to become drunk and suffer the outcomes. This approach allows targeted interventions without curtailing the freedom of individuals whose drinking does not put them at risk.

For the purposes of prevention and policy, it may be helpful to differentiate between two types of drunkenness. The first is the outcome of occasional excessive drinking engaged in by otherwise responsible or moderate consumers. There is evidence that these occasional episodes of excess among usually moderate drinkers are a major contributor to the burden of disease related to alcohol consumption through unintended consequences, such as accidents and injuries (e.g., Weitzman & Nelson, 2004).

General prevention approaches that are intended to encourage responsible drinking patterns and prevent the incidence of harm around particular occasions and settings can be effective with this type of drunken behavior. This includes providing education and making drinking venues safer, as well as ensuring the application and enforcement of regulations on drinking and driving.

The second type of drunkenness is the result of alcohol consumption among individuals who may be alcohol-dependent or problem drinkers. For these individuals, more focused interventions are likely to be appropriate and, in many cases, measures directed at the first group may be inadequate (see MODULE 17: Alcohol Dependence and Treatment).

Educational efforts

Alcohol education can be used to provide realistic information about drinking, alcohol’s interaction with the body, and probable outcomes of various drinking patterns (see MODULE 1: Alcohol Education). The provision of guidance and information can help encourage responsible drinking among the general population. However, while education can be a valuable tool in reducing the potential for harm related to various drinking patterns and outcomes (including drunkenness), it may not be a useful approach for individuals who have developed drinking problems and dependence. For them, specific approaches and treatment may be appropriate (see MODULE 17: Alcohol Dependence and Treatment).

Specific guidelines about drinking have been issued by various governmental and other agencies (see MODULE 19: Drinking Guidelines). Some such guidelines explicitly address excessive drinking, but, even for those that do not, avoiding intoxication is the implicit aim. Most guidelines warn against exceeding some low or moderate maximum of drinks in a given day or week. Many also include special recommendations and caveats applicable to certain groups of individuals who, for a variety of reasons, may be at particular risk or especially susceptible to the effects of alcohol and to drunkenness.

Other educational efforts are directed at drinking patterns that result in drunkenness and where drunkenness may well be the desired objective of drinking (see MODULE 6: Binge Drinking). Various efforts have been aimed at changing the drinking culture and expectations about alcohol to discourage intoxication among young people and adult drinkers alike (see MODULE 1: Alcohol Education).

It is important to recognize that educational (or any other) measures around drunkenness must take into account the prevailing drinking culture and context. If efforts to reduce drunkenness and educate individuals about their alcohol consumption are to have an impact, they need to consider the social acceptability and possible social significance of drinking to intoxication and attempt to address these factors.

Safer environments

For most people, drunkenness is a public nuisance and safety concern. Measures that are aimed at reducing drunkenness and related behaviors enjoy a high level of public support. Effective enforcement of public nuisance ordinances and regulations is key to maintaining public safety.

• Drinking environments warrant special attention in efforts to reduce drunkenness. In particular, training those who sell and serve alcohol can reduce the risk for harm and also the incidence of drunkenness. Various approaches have been successfully implemented (see MODULE 4: Responsible Hospitality ).
• Safety in public venues where drunkenness may occur is a more general concern. Monitoring public spaces and implementing measures targeted at violent behavior that may accompany drinking have been implemented in a number of areas (e.g., MODULE 7: Alcohol and Violence; MODULE 14: Public Order and Drinking Environments). Combined with more efficient enforcement measures, this approach may reduce the incidence of drunkenness (e.g., Single, 1997).
• Drinking and driving is a third area in which drunkenness is a cause for concern. Drunk drivers pose a hazard to other drivers, passengers, and pedestrians alike. Efforts aimed at reducing the incidence of alcohol-impaired driving and dealing effectively with drunk drivers are an essential component of policy (see MODULE 15: Drinking and Driving and MODULE 16: Blood Alcohol Concentration Limits).

Targeting “at-risk” groups

Particular groups of individuals may be more likely to engage in drinking patterns that lead to intoxication and face an increased risk for harm (see MODULE 8: “At-risk” Populations). Among these are young people, whose drinking patterns have been of growing concern. While culture and various influences play an important role in shaping young people’s alcohol-related choices, drunkenness among this population remains a serious issue internationally with equally serious and harmful outcomes (MODULE 11: Young People and Alcohol).

Problem drinkers are another at-risk group. Their alcohol consumption may often result in drunkenness and requires approaches that will help identify and address their needs. For some, treatment may be the best solution. For others, behavior modification may be a more appropriate choice (see MODULE 17: Alcohol Dependence and Treatment and MODULE 18: Early Identification and Brief Intervention).

Conclusions

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Drunkenness is the outcome of excessive alcohol consumption and an issue of concern for a wide range of individuals. For most people, intoxication can be a consequence of occasional excessive drinking. For others—for example, those with drinking problems—it may be a habitual state. Policy measures that address drunkenness and efforts to reduce related risks and the potential for harm require attention to both groups.

Interventions against drunken behavior include efforts to make the drinking environment safer and reduce the likelihood of harm in venues and settings where drunkenness may be encountered. They also include efforts to educate consumers about drinking patterns and outcomes. For those whose drinking is problematic, treatment and specialized approaches may be indicated.

Drunkenness is an important public concern that affects all segments of society and has an impact, direct or indirect, on most people. Therefore, measures to address drunkenness are likely to enjoy popular support. However, it is important to recognize prevailing cultural attitudes and views on drunkenness and to tailor prevention and policy in a way that will make them realistic and culturally appropriate.

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