Sarah (pseudonym) was a 20-year-old pre-nursing student who binge drank during her freshman year. By sophomore year, she used alcohol daily and started experiencing blackouts. Her grades suffered and she changed her major. One weekend, Sarah drove while intoxicated and was involved in an accident on a rural road, which killed two people and paralyzed another. She entered an alcohol treatment center as one of her conditions for bail.
Sarah’s example illustrates the consequences of alcohol abuse and dependence and how alcohol misuse can lead to legal problems or death. Although 21 is the legal drinking age, 11% of the alcohol consumed in the United States is by people ages 12 to 20 (Centers for Disease Control and Prevention [CDC], 2011). In addition, excessive alcohol consumption is responsible for more than 4,600 deaths in underage youth annually (CDC, 2011). Since drinking is an established part of campus life and there is acceptance for underage drinking, this article will focus on the issues of alcohol abuse and dependence as well as treatment for college-age youth.
College and Alcohol
Most college campuses are known to be places for students to drink. Sometimes called the “party pathway” (Hamilton & Armstrong, 2012), many students think of drinking as an integral part of the college experience. The National Survey on Drug Use and Health (U.S. Department of Health and Human Services, 2011) indicated that among full-time college students, 63% were drinkers, 42% were binge drinkers, and 15% were heavy drinkers. College youth may be unaware that engaging in heavy drinking may fundamentally change their brains’ reward and stress systems. These changes, in turn, later fuel motivation to reengage in excessive drinking behavior (Becker, 2008). In addition to rewiring brain pathways, excessive alcohol may also lead to serious consequences such as unsafe sexual activity, poor school performance, drunk driving, and physical and sexual assaults (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 2010; Novik, Howard, & Boekeloo, 2011).
A common, dangerous practice on college campuses is the use of high-energy drinks mixed with alcohol. A recent disturbing finding is that mixing energy drinks with alcohol leads consumers to drink greater quantities of alcohol than they would using alcohol by itself (Marczinski, Fillmore, Henges, Ramsey, & Young, 2012). The practices, attitudes, and knowledge about high-energy drinks—with and without alcohol—used by college students enrolled in summer session courses at a large state university have also been documented (Smoyak, Hayat, Lee, Lim, & Nowik, 2012). This study will be described in a future column.
The NIAAA (2010) snapshot of high-risk drinking among college students found that nearly one third met the criteria for a diagnosis of alcohol abuse based on a 12-month retrospective survey about drinking behaviors. According to the American Psychiatric Association (APA, 2000), alcohol abuse is defined as a maladaptive pattern that leads to impairment during a 12-month period manifested by: (a) continued use that results in failure to fulfill obligations at work, school, or home; (b) use in situations where it is physically hazardous; and (c) sustained use despite recurrent social or interpersonal issues caused by effects of alcohol consumption.
Alcohol use disorders are on a continuum, and if alcohol abuse progresses to dependence, even more serious consequences ensue. Alcohol dependence is marked by (a) tolerance (i.e., after continued drinking, larger amounts of alcohol are necessary to produce the same effect); (b) withdrawal (tremulousness, elevated vital signs, and even delirium); (c) consumption in larger amounts over an extended period of time; (d) reduced social, occupation, and recreational activities as a result of usage; and (e) continued use despite knowing that psychological or physical issues are exacerbated by alcohol (APA, 2000).
Hingson, Zha, and Weitzman (2009) reported that 1,825 deaths in 2005 were the result of alcohol consumption that year among college students ages 18 to 24. These numbers are an indication that the consequences of excessive drinking among college youth are more significant than many realize. Unfortunately, there is little evidence that the amendments of the Higher Education Act of 1965, which specifies policies to prevent use of illicit drugs and abuse of alcohol on college campuses, are being enforced (Lipka, 2012). To receive federal funds, colleges and universities must share these prevention policies annually with students and employees, noting specific risks to health as well as campus-based treatment options. However, the U.S. Department of Education’s Office of Inspector General’s (2012) review of the issue says enforcement of these policies has been essentially zero. Therefore, it is likely that a culture change will be necessary before prevention policies become widespread on college campuses. Significant alcohol abuse and dependence will continue for the immediate future.
For alcohol-dependent youth, the goal of treatment is abstinence. There are essentially three phases in the treatment process for alcohol dependence: detoxification, rehabilitation, and maintaining sobriety. In some instances, the detoxification phase may be needed immediately if there is physical dependence, as there is an increased risk for seizure activity, hallucinations, and delirium tremens. During the rehabilitation stage, patients are involved in counseling sessions to equip them with skills to achieve sobriety. Maintaining sobriety requires the individual to be both motivated and develop a strong support system, usually via Twelve-Step meetings and obtaining a sponsor (Blondell et al., 2011).
When those with alcoholism drink, they perceive a derived benefit. Therefore, for perceptions to change, they must understand there is an alternative to substance use. One route to changing perceptions is the use of motivation enhancement therapy, which involves eliciting reasons for drinking, reasons for abstaining, and concerns about consequences of alcohol use. Blondell et al. (2011) found that those enrolled in motivation enhancement therapy (an outgrowth of motivational interviewing, which typically is used to help individuals with alcoholism see there is a problem with alcohol use) were more likely to complete initial treatment and then follow through with treatment aftercare programs, further supporting its use as a valid intervention for substance use disorders.
Relapse Among Young Adults
Alcoholism is a chronic disorder often characterized by relapse, the resumption of drinking after a period of abstinence (APA, 2000). Although a chronic condition, alcoholism is amenable to treatment, much like other chronic diseases (Carr, 2011). Identifying factors associated with relapse among college students is an important strategy; these factors may include financial stressors and academic pressures, as well as environmental cues such as proximity to off-campus bars.
One important factor in helping newly sober individuals is to help them examine their stressors as well as coping techniques. For most college-age youth, stressors include establishing relationships, academic and career aspirations, and finding employment. Vieten, Astin, Buscemi, and Galloway (2010) noted that “chronic stress appears to sensitize the brain reward system, rendering one more vulnerable to addiction” (p. 109). The severity of the stressors and the lack of social support are contributing factors to the quantity and the frequency of alcohol use. Fox, Bergquist, Hong, and Sinha (2007) found that “exposure to stress and to alcohol cues each produced significant increases in alcohol craving, anxiety, and negative emotions and decreases in positive emotions” (p. 395).
Trauma and abuse further complicate recovery. According to the NIAAA (2010) report, alcohol consumption among college students was related to approximately 97,000 cases of sexual assault or date rape each year. Snow and Anderson (2000) noted that “one of the greatest unacknowledged contributors to recidivism in alcoholism and other addictions may be the failure to identify and treat underlying childhood sexual abuse issues” (p. 9). Lee, Lyvers, and Edwards (2008) further emphasized that those who abuse substances and disclose a history of childhood sexual abuse experienced more severe depressions, abused substances to a greater extent, and were more likely to report using substances to deal with negative feelings, further compounding trauma issues.
A history of childhood sexual abuse affects treatment outcomes for those receiving treatment for substance abuse. Boles, Joshi, Grella, and Wellisch (2005) reported that patients with histories of childhood sexual abuse had more severe alcohol and drug problems, were more likely to suffer from psychiatric disorders, had experienced criminal involvement, and had lower levels of posttreatment sobriety. In addition to more severe substance use disorders, clinicians should also assess for a co-occurring disorder such as posttraumatic stress disorder and/or mood disorder and be prepared to address legal issues as well for sobriety to ensue.
Smith (2007) found that women survivors of childhood trauma reported that they also used substances as a means to block or numb the pain they associated with being victimized, but that there were also strategies that prevented relapse. It was important for these recovering women to take action and learn strategies, such as talking to others also in recovery, and learning to identify common feelings such as sadness, loneliness, and frustration as triggers for relapse (Smith, 2007). The need for social support in recovery from trauma and alcoholism is understandable, and establishing new friendships for college-age youth will also promote newly achieved sobriety.
Environmental cues should also be considered when promoting recovery. Young adults are susceptible to peer influences from the alcohol-condoned college environment. According to the NIAAA (2010), an important step to promote a healthier environment around issues of alcohol use and abuse would be a vigorous enforcement of zero-tolerance laws, implementation of alcohol screening, counseling and treatment aimed at students, and developing campus-community partnerships to educate both students and the broader community.
Implications for Practice
Psychiatric nurses will encounter college students in addiction-recovery settings as well as in psychiatric units and mental health clinics. Psychiatric nurses should specifically promote recovery from alcoholism in college-age students by:
- Encouraging students to talk about factors that led to their alcoholism.
- Collaborating with students to recognize factors that lead to alcohol misuse and develop adequate coping skills and systems of support that could potentially guard against relapse.
- Helping students develop the ability to recognize and deal with emotions and establish self-acceptance and self-esteem without relying on approval from others.
- Assessing students for common stressors and co-occurring addictions such as eating disorders and self-injurious behaviors.
- Asking questions during the admission process to decipher if the student has any underlying issues of trauma.
- Teaching students to recognize triggers for relapse such as changes in mood and anxiety levels and anniversaries of significant traumatic events.
- Encouraging students to find people and places close to campus that support recovery such as aftercare programs and Alcoholics Anonymous or Narcotics Anonymous.
The abuse of alcohol among college students is a public health issue that warrants emphasis on prevention strategies aimed at challenging the status quo. Knowledge that treatment, aftercare, and supportive environments maintain sobriety on college campuses is an important message to repeat. In addition, to save lives, college and university campuses should scrutinize their alcohol policies and seek community involvement to curtail the high-risk drinking behavior patterns among students.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
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- Hingson, R.W., Zha, W. & Weitzman, E.R. (2009). Magnitude of and trends in alcohol-related mortality and morbidity among U.S. college students ages 18–24, 1998–2005. Journal of Studies on Alcohol and Drugs, (Suppl. 16), 12–20.
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- Marczinski, C.A., Fillmore, M.T., Henges, A.L., Ramsey, M.A. & Young, C.R. (2012). Mixing an energy drink with an alcoholic beverage increases motivation for more alcohol in college students. Alcoholism: Clinical and Experimental Research. Advance online publication. doi:10.1111/j.1530-0277.2012.01868.x [CrossRef]
- National Institute on Alcohol Abuse and Alcoholism. (2010). Fall semester–A time for parents to revisit discussions about college drinking. Retrieved from http://www.collegedrinking-prevention.gov/media/NIAAA_Back_to_School_Fact_sheet_8_19_10.pdf
- Novik, M.G., Howard, D.E. & Boekeloo, B.O. (2011). Drinking motivations and experiences of unwanted sexual advances among undergraduate students. Journal of Interpersonal Violence, 26, 34–49. doi:10.1177/0886260510362884 [CrossRef]
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- Smoyak, S., Hayat, M., Lee, J., Lim, J. & Nowik, K. (2012). The practices, attitudes and knowledge of college students about high energy drinks, with and without alcohol. Unpublished manuscript. Rutgers University, New Brunswick NJ.
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- U.S. Department of Education, Office of the Inspector General. (2012, March14). Compliance with drug and alcohol abuse prevention programs. Retrieved from http://www2.ed.gov/about/offices/list/oig/aireports/i13l0002.pdf
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