Moderate Drinking, Binge Drinking, and Alcohol-Related Problems

Do Moderate Drinking, Heavy Drinking, and Binge Drinking Cause Harm?

Over the past several decades, most adults around the U.S. and the world have heard from friends or read in an article somewhere that drinking one or two glasses of wine or maybe having a beer or two every evening with dinner is not so bad. In some cases – so the common theme goes – one or two alcoholic beverages with dinner actually improves health.

At face value, that old myth – because evidence shows it is a myth – makes a certain kind of sense. Alcohol can be relaxing – we all know that. And we all need a safe and healthy way to relax and reduce stress – we all know that, too. In addition, various studies show that red wine contains a chemical called resveratrol that may reduce coronary artery disease. The stress-reduction component and the heart health component, combined, gave millions of people the idea we introduce above: a glass or two of red wine with dinner is a good idea.

However, we now know that it’s not a good idea, although moderate alcohol consumption is within a range considered safe by all the expert authorities, including the Centers for Disease Control (CDC). It’s somewhat of a paradox. Consider this recent warning by the CDC, included in the Alcohol and Public Health section of their website:

“Emerging evidence suggests that even drinking within the recommended limits may increase the overall risk of death from various causes, such as from several types of cancer and some forms of cardiovascular disease. Alcohol has been found to increase risk for cancer, and for some types of cancer, the risk increases even at low levels of alcohol consumption (less than 1 drink in a day).”

That puts an entirely different spin on drinking a moderate amount of alcohol every day. And that’s not the only data point that signals the end of this familiar – and incorrect – cultural trope. Again, consider this further clarification of the topic from the CDC, published on the same page as the quote above:

“Although past studies have indicated that moderate alcohol consumption has protective health benefits, recent studies show this may not be true. While some studies have found improved health outcomes among moderate drinkers, it’s impossible to conclude whether these improved outcomes are due to moderate alcohol consumption or other differences in behaviors or genetics between people who drink moderately and people who don’t.”

If we weren’t ready to put this notion to bed for good, a new, long-range study published in the American Journal of Preventive Medicine reveals evidence that will – or should – cause every person who’s a moderate drinker, as well as medical professionals who evaluate alcohol consumption, to reexamine and reconsider most of what they know about the relative risks and rewards of moderate drinking.

The Connection Between Moderate Drinking and Harm Caused by Alcohol

The CDC information above connects low levels of alcohol consumption to serious, chronic, deadly diseases like cancer. That connection is real news for many people, who genuinely believe that moderate or low alcohol consumption is one hundred percent safe. Our Chief Medical Officer, Dr. Chris Johnston, discusses this fact in an article he wrote for the online magazine Medium:

Alcohol Consumption Increases Cancer Risk

We’ve published additional articles on the risks of alcohol consumption, including these:

Excessive Alcohol Use: The Harm It Causes Others

Alcohol Addiction and the Workplace: Missed Days Add Up

For those interested in learning more about alcohol use disorder (AUD), a.k.a. alcohol addiction, please read this article:

What is Alcohol Addiction?

Those articles offer the latest evidence on the consequences of alcohol consumption, whether the consumption is mild, moderate, or heavy. This article narrows that focus to examine the effect of moderate and heavy alcohol consumption on overall health and well-being, with a specific focus on the role of binge drinking in the lives of people who consume moderate levels of alcohol.

Let’s take a close look at the study, called the Midlife Development in the United States Study (the MIDUS study).

What is the MIDUS Study?

The MIDUS study is the core work generated by a group of researchers funded by the John D. and Catherine T. MacArthur Foundation Research Network who launched the Successful Midlife Development Study (MIDMAC) in order to identify the “biomedical, psychological, and social factors” that allow some people to thrive during their adult years.

While the MIDMAC study is a cluster of research efforts that take a broad view of the subject of midlife achievement, the MIUDS study is the centerpiece. Here are the stated goals of the entire research effort:

• Establish and document what really happens to people in their middle years. Researchers sought to identify the who, what, when, where, and why of midlife events.
• Identify the determinative factors in midlife thriving or non-thriving, including sickness, major experiences, culture, family life, and work experiences.
• Study the ways to understand midlife events, with a focus on individual differences.
• Develop physical, psychological, and social metrics to evaluate midlife development.

The MIDUS study – the surveys that generated the core data for the MIDMAC effort – examined overall health and well-being in a U.S. nationally representative sample of adults in the U.S. One important aspect of the study was an in-depth look at alcohol drinking patterns among adults. Researchers were specifically interested in examining the relationship between moderate drinking and binge drinking. They hypothesized that binge drinking patterns among moderate drinkers might predict subsequent problem drinking and alcohol-related problems. They published the result of this sub-study in June 2022 a paper called “Binge Drinking and Alcohol Problems Among Moderate Average-Level Drinkers.”

Here’s how they conducted the study.

The research team:

• Recruited 1,229 current drinkers over ag 30
• Administered two surveys to each participant, at nine-year intervals:
  • Survey 1: 2004-2015
  • Survey 2: 2021-2022
• The surveys measured rates of alcohol consumption for each participant. They asked each survey respondent about:
  • Past month alcohol use, with this question: “During the past month, how often did you drink any alcoholic beverages, on average?”
    • “Yes” answers defined the respondent as a current drinker
  • Next, they asked respondents identified as current drinkers more detailed questions, such as: “On the days when you drank, about how many drinks did you drink on the average?”
    • Researchers defined moderate drinking as:
      • Women: 1 drink a day or less
      • Men: 2 drinks a day or less
    • Researchers defined high drinking as:
      • Women: More than one drink a day
      • Men: More than two drinks a day

Note: People who reported no drinking in the past month were not included in the study. By the measures used in the study, there’s no statistical difference between no drinking and low drinking, when averaged over a week. Therefore, the study focused on moderate and high drinkers.

• To measure differences between regular patterns of drinking and binge drinking, researchers asked participants: “Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on the same occasion?”
• Researchers defined regular drinking as drinking less than 5 drinks on one occasion or less in the past month
• Researchers defined binge drinking as drinking 5 or more drinks on more than one occasion in the past month
• “Yes” answers indicated presence of binge drinking
• “No” answers indicated absence of binge drinking

Note: The definitions above – for moderate, high, and binge drinking – align with criteria defined by the National Institute on Drug Abuse (NIDA), the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Survey on Drug Use and Health (NSDUH).

That’s how they determined how much people drank, which was the first step in the process. To measure harm caused by alcohol or alcohol-related problems, participants answered 7 questions from the Composite International Diagnostic Interview-Short Form (CICD-SF). Here are the questions.

Assessing Harm Caused by Alcohol: CICD-SF

In the past 12 months, have you…

1. Experienced effects of alcohol in a situation that increased the chances of getting hurt?
2. Experienced and emotional or psychological problems from alcohol?
3. Felt a desire to use alcohol that you could not resist?
4. Gone a month or more when you spent a great deal of time using alcohol?
5. Had to use more alcohol to get the same effect?
6. Used much larger amounts of alcohol than intended?
7. Experienced the effects of alcohol at work, school, or caring for children?

Two or more “yes” answers indicated the presence of alcohol-related harm and/or alcohol-related problems.

Now that we know how they got their data on drinking patterns and how they identified any harm caused by alcohol consumption, let’s take a look at the results.

Does Moderate Drinking + Binge Drinking = Problems Related to Alcohol?

The primary question the study sought to answer was whether moderate drinking and binge drinking interact to cause harm to moderate drinkers over time. That’s an important question, because most of us know people who have a drink or two every day (or most days) and have five or more drinks on one occasion around once a month. We also know this fairly typical pattern begins around early adulthood/college age and for some people, continues indefinitely – or at least into the middle years, defined here as over age 30 and under age 65.

Here’s how study participants responded to the first survey, which served as baseline to measure any changes observed in the second survey.

The Results: Big-Picture Numbers

Among 1,229 current drinkers, researchers identified:

• 972 total moderate or heavy drinkers:
  • 925 reported moderate drinking at baseline
  • 47 reported heavy drinking at baseline

Among 1,229 current drinkers, researchers identified:

• 257 total binge drinkers:
  • 182 reported moderate drinking at baseline
  • 75 reported heavy drinking at baseline

Of the 1,229 current drinkers, researchers identified:

• 1,114 showed no presence of alcohol-related problems. Of those:
  • 1,030 reported moderate drinking at baseline
  • 84 reported heavy drinking at baseline
• 101 showed clear presence of alcohol-related problems. Of those:
  • 77 reported moderate drinking at baseline
  • 38 reported heavy drinking at baseline

At 9-year follow up:

• 666 participants showed no presence of alcohol-related problems
  • 606 were moderate drinkers at baseline
  • 60 were heavy drinkers at baseline
• 101 showed clear presence of alcohol-related problems:
  • 80 were moderate drinkers at baseline
  • 71 were heavy drinkers at baseline

That’s essentially raw data, and we recognize that it’s not easy to tease the meaning out of these numbers.

However, there are important facts to glean – and we can help.

First, please notice that at baseline, 95 percent of current drinkers reported moderate drinking. Next, notice that 71 percent of binge drinkers reported moderate drinking, whereas only 29 percent of binge drinkers reported heavy drinking. Finally, note that at baseline, just over 67 percent of participants who reported moderate drinking reported the presence of alcohol-related problems, while in contrast, 33 percent of heavy drinkers reported alcohol-related problems at baseline.

The statistical analysis below expands and helps unravel this data, which is somewhat counterintuitive – but it’s information that’s crucial for everyone to know. We do mean everyone, from regular people on the street, to people in treatment, to professional addictionolgists who see these numbers in real life every day.

The Results: In-Depth Explanation and Analysis

• Moderate drinkers accounted for 85% of alcohol-related problems at 9-year follow-up.
  • Among men:
    • Moderate drinkers accounted for 85% of alcohol-related problems at 9-year follow-up.
  • Among women:
    • Moderate drinkers accounted for 64% of alcohol-related problems at 9-year follow-up.
  • Binge and heavy drinking at baseline predicted the presence of alcohol-related problems at 9-year follow-up.
    • Binge drinkers at baseline had a 40% increased likelihood of increased alcohol problems at 9-year follow-up.
    • Any binge drinking at baseline increased risk of multiple alcohol-related problems at 9-year follow-up by 160%
    • Any heavy drinking at baseline increased risk of multiple alcohol-related problems at 9-year follow-up by 97%
  • Participants who reported regular binge drinking at baseline were 385% more likely to report alcohol-related problems at baseline
  • Participants who reported regular heavy drinking at baseline were 111% more likely to report alcohol-related problems at 9-year follow-up.
  • Binge drinking episodes among moderate drinkers predicted alcohol-related problems at 9-year follow-up more robustly than binge drinking episodes among heavy drinkers.
  • Moderate drinking + binge drinking at baseline increased risk of multiple alcohol-related problems at 9-year follow-up by 439%

That last bullet point is the one we encourage everyone to understand. We’ll explain why in just a moment, and address the rest of the data first.

Drinking Patterns and Long-Term Harm

As we can see in the analysis, any binge drinking and any heavy drinking at baseline were associated with significant problems at 9-year follow-up. That makes sense. Everyone knows heavy drinking and binge drinking can cause serious physical, emotional, and psychological problems. Also, regular binge drinking at baseline increased problems at 9-year follow up and regular heavy drinking at baseline increased problems at 9-year follow up significantly more than any binge/heavy drinking. That also makes sense. More binge/heavy drinking, more problems.

Most of us could have predicted that.

What most of us probably could or would not have predicted was that moderate drinking at baseline – in the amount that for decades most everyone had heard might be good for us – combined with any amount of binge drinking causes more problems and increases risk at 9-year follow up more than any other combination of drinking patterns.

That means that a person who has a glass or two of wine every night and has five drinks on one night at least once a month is at higher risk than a person who drinks more than two drinks every night.

In other words, a person classified as a moderate drinker who binges once a month is at higher risk than a person classified as a heavy drinker who doesn’t binge, and also at higher risk than a heavy drinker who binges.

What This Means in Daily Life

Think about that.

A person who has a couple of glasses of wine with dinner probably doesn’t think they get drunk every night, and probably doesn’t consider themselves a heavy drinker. That person may go out once a month and get drunk – and that seems totally normal to them. And to be honest, it seems totally normal to most of us. That seems like typical behavior. On the other hand, someone who has more than two drinks a night might admit they get drunk most nights and probably also knows they’re a heavy drinker. Whether or not they binge, they likely know heavy drinking isn’t the best health choice – and most of us would agree.

However, the data in this study says the former person is at highest risk of the most long-term harm from alcohol, and the latter person is at less risk of significant long-term harm from alcohol. At risk, certainly, but at less risk than the person most of us would think is not at much risk at all.

That’s what we want everyone to know. A pattern of drinking recently considered benign – with the addition of just one binge episode per month – leads to the greatest risk of harm from alcohol. This is something we can watch for in ourselves, in our friends, and in our families. This is also something mental health professionals and primary care physicians can include in their alcohol screening processes. If everyone works together to identify the highest risk individuals early and get them the help they need sooner rather than later, then we can mitigate the overall, long-term harm caused by alcohol.

That’s an achievable goal – and something to think about.

By A. Brooks Parker, MD, Medical Director, Recovery Works in Cambridge City, Indiana