What is the best approach to manage binge drinking in young adults?

Management of Binge Drinking in Young Adults

Screen all young adults for binge drinking using validated tools and implement brief multicontact behavioral counseling interventions, which reduce heavy drinking episodes by 12% and decrease weekly alcohol consumption by approximately 3.6 drinks at one year. 1

Screening and Assessment

• Use validated screening tools to identify risky drinking patterns, with binge drinking defined as 4+ drinks for women and 5+ drinks for men within approximately 2 hours. 1
• Screen routinely in primary care settings as recommended by the U.S. Preventive Services Task Force, recognizing that even low-frequency binge drinking (less than once monthly) is associated with higher rates of alcohol use disorder. 1, 2
• Assess for co-occurring psychiatric conditions including anxiety, mood disorders, and suicidal ideation, as adolescent substance use frequently co-occurs with these diagnoses. 1
• Evaluate for high-risk consequences including staggering, amnesia, loss of control, aggressiveness, and sexual disinhibition. 3

First-Line Intervention: Brief Behavioral Counseling

Implement brief multicontact behavioral counseling interventions rather than single-session approaches, as multicontact interventions demonstrate superior efficacy in reducing binge drinking. 1

Evidence for Behavioral Counseling:

• Meta-analysis of 7 trials showed a 12% absolute increase in the proportion of adults reporting no heavy drinking episodes after 1 year compared to controls. 1
• In college-age young adults, behavioral counseling reduced heavy drinking episodes by approximately 1 day per month (from baseline of 6-7 days monthly) at 6-month follow-up. 1
• Weekly alcohol consumption decreased by 3.6 drinks per week at 12-month follow-up in adults receiving behavioral interventions. 1

Implementation Approach:

• Use the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) as a structured approach for brief interventions. 4
• Alternatively, implement the five A's approach (Ask, Advise, Assess, Assist, Arrange) in primary care settings. 4
• Provide clear feedback about drinking dangers while emphasizing patient autonomy and responsibility for change. 4

Education and Harm Reduction

Emphasize complete abstinence or responsible alcohol consumption, highlighting that brain development continues until ages 21-25 years and alcohol exposure may impair synaptic maturation and executive functioning. 1, 5

Key Educational Points:

• Explain that the prefrontal cortex (responsible for executive decision-making and impulse control) is not fully developed until 21-25 years of age. 1
• Discuss neurocognitive risks including deficits in attention, information processing, and executive functioning, as well as smaller hippocampal volumes in heavy alcohol users. 1
• Address increased risks of depression, anxiety, sleep disturbance, self-injuries, suicidal behavior, high-risk sexual behavior, and criminal behavior. 1, 5
• Warn that earlier initiation of alcohol use increases risk of developing alcohol use disorder later in life. 1

Safe Drinking Guidelines (if abstinence not achieved):

• For women: No more than 3 drinks per day and no more than 7 drinks per week. 1, 5
• For men aged 65 or younger: No more than 4 drinks per day and no more than 14 drinks per week. 1, 5
• Define standard drink as 12 oz beer, 5 oz wine, or 1.5 oz liquor. 1, 5

Harm Reduction Strategies:

• Eat before and while drinking alcohol to slow absorption. 5
• Stay hydrated with non-alcoholic beverages between drinks. 5
• Set a drink limit before going out and stick to it. 5
• Use designated drivers or alternative transportation when drinking. 5
• Recognize warning signs of alcohol poisoning requiring immediate medical attention. 5

Pharmacotherapy for Alcohol Use Disorder

If behavioral interventions fail and alcohol use disorder develops, add FDA-approved medications in combination with continued counseling. 4

Medication Options:

Naltrexone (50 mg daily):

• Reduces relapse to heavy drinking and drinking frequency. 4
• Decreases likelihood of return to any drinking by 5% and binge-drinking risk by 10%. 4
• Well-absorbed orally with bioavailability of 5-40%; mean elimination half-life of 4 hours for parent drug. 6
• Proven superior in controlled trials, with abstention rates of 51% vs 23% for placebo and relapse rates of 31% vs 60%. 6

Acamprosate (666 mg three times daily):

• Helps maintain abstinence, particularly in recently abstinent patients. 4
• Requires patients to be abstinent from alcohol on day of randomization for efficacy. 7
• Proved superior to placebo in maintaining abstinence across three clinical studies. 7
• Not metabolized by liver; no dose adjustment needed for mild-moderate hepatic impairment. 7
• Contraindicated in severe renal impairment (creatinine clearance ≤30 mL/min). 7

Important Medication Considerations:

• Only 1.6% of Americans with alcohol use disorder receive medications despite strong evidence for efficacy. 4
• Disulfiram should only be used in supervised settings with highly motivated patients. 4
• Monitor for emergence of depression or suicidality when using acamprosate. 7
• Acamprosate does not eliminate or diminish withdrawal symptoms. 7

Mutual Help Groups and Ongoing Support

• Actively encourage engagement with mutual help groups such as Alcoholics Anonymous, as this peer-support model has demonstrated efficacy. 4
• Familiarize yourself with locally available mutual help groups and facilitate patient connections. 4
• Involve family members in treatment when appropriate to strengthen support systems. 4

Critical Pitfalls to Avoid

• Do not use single-session interventions alone, as they are less effective or ineffective compared to multicontact approaches. 1
• Do not dismiss occasional or weekend binge drinking as "typical teenage behavior", as even low-frequency binge drinking (less than once monthly) is associated with harmful drinking and higher likelihood of alcohol use disorder. 1, 2
• Do not prescribe acamprosate to patients with severe renal impairment or without ensuring they are abstinent at baseline, as efficacy was not demonstrated in non-abstinent patients. 7
• Do not overlook co-occurring psychiatric conditions, as adolescent substance use frequently co-occurs with anxiety, mood, psychotic, and disruptive disorders. 1
• Do not assume older definitions of binge drinking apply to younger adolescents, as the standard criterion (4 drinks for women, 5 for men) is thought to be too high for this population. 1

Special Population Considerations

College-age young adults are at particularly high risk due to developmental changes in autonomy, parental control, norms, and attitudes. 8

• Target risky drinking events such as 21st birthdays. 8
• Address enhancement and social drinking motives, which are higher in binge drinkers. 2
• Recognize that sensation-seeking traits increase risk of binge drinking behaviors. 2

Vulnerable populations including homeless youth and LGBTQ adolescents are at higher risk and require targeted screening and intervention. 1