Alcohol - Health and Economic Impacts

Richard A. Yoast, Ph.D., DirectorAMA Dept. of Public Policy & Primary Prevention

Tuesday, September 16,2008American Council on Alcohol ProblemsNational Meeting, Springfield IL

Who drinks?What are the impacts?

NSDUH Survey, 2002Alcohol - the Drug of Choice Among 12-20 Year Olds

Chart2

10.97.94.5

25.217.612.5

38.728.218.2

Alcohol

Cigarettes

Marijuana

Grade

Percent using in past month

Sheet1

Past Month

Grade

8th10th12th

Alcohol10.925.238.7

Cigarettes7.917.628.2

Marijuana4.512.518.2

Sheet1

Alcohol

Cigarettes

Marijuana

Grade

Percent using in past month

Sheet2

Sheet3

Drinking among Americans 12 or older (2007) NSDUH51.1% are current drinkers (last 30 days) = est. 126.8 million people56.6% of males, 46 % of females (ages 18 to 25: 57.1% of females, 65.3% of males) 3.5% of 12 or 13 year olds14.7% of 14 or 15 year olds29.0% of 16 or 17 year olds 50.7% of 18 to 20 year olds68.3% of 21 to 25 year olds Binge drinking (last 30 days): 23.3%= 57.8 million peopleHeavy drinking: 6.9% = 17 million peopleCurrent adult use decreased with age:63.2% of ages 26 to 29 47.6 % of ages 60 to 64 38.1% of ages 65 or older.

U.S. Youth 2005 YRBS Sizeable youth population engaging in risky alcohol-related behaviors (last 30 days) 43.3% grades 9 -12 (50% of 12th graders) had at least one drink25.5% binged (5 or more drinks in a row) 28.5% rode 1 or more times with drinking driver9.9% (19.2% of 12th grade males) drove after drinking23.3% of currently sexually active students drank or used other drugs before last sexual intercourse

[CDC MMWR June 9, 2006]

Underage DrinkingNegative consequences costs the US: $62 billion per year (medical costs, lost productivity & quality-of-life costs due to motor-vehicle crashes, violence, property crime, suicide, burns, drowning, fetal alcohol syndrome, high-risk sex, poisonings, psychoses & dependency treatment).

[Miller TR, Levy DT, Spicer RS, Taylor DM. Societal costs of underage drinking. J Studies Alcohol and Drugs 67: 519-528, 2006.]

Acute Health and Safety Consequences of Alcohol Use in the Younger Populationalcohol poisoningmotor vehicle crashesrisky sexual behaviorssuicide attemptsdrowningother drug usesignificant contributor to injury in adolescencea role in more than 50% of traumatic brain injuries in adolescentsviolence

Early Onset - Not BenignAge at which young people begin using alcohol has decreased over the last 35 years; On average, youths now take their first drink at the age of 12 years.

Early Alcohol Involvement associated with poorer behavioral measures of thinking abilities of youth.MemoryLearning StrategiesVisual Spatial AbilitiesAttentionassociated with under activation in several brain regions during cognitive tasks (frontal and prefrontal,parietal, cingulate)

Alcohol and Neuroanatomical Findings with YouthSmaller hippocampus in adolescenceGreater responsivity to alcohol cuesScore worse than non-users on vocabulary, general information, memory, memory retrieval and at least three other testsSignificant neuro-psychological deficits exist in early to middle adolescents (ages 15 and 16) with histories of extensive alcohol use

Alcohol-related chronic symptoms or medical conditions in youthAppetite changesWeight lossEczemaHeadachesSleep disturbanceSerum enzymatic markers of liver damage are elevated in alcohol-abusing adolescents.

What Do We Need to Learn?Are these deficits permanent?How long do they last?Can we speed recovery?To what extent are neurocognitive and neuroanatomical differences present before alcohol use starts?Which children are most vulnerable to these adverse alcohol consequences?Withdrawal may impact different abilities than use.

Youth/young adult drinking

Alcohol a leading contributor to the main cause of deathinjuryfor people under age 21 (ca. 5,000 deaths/yr related to underage drinking) - result of motor-vehicle crashes, unintentional injuries from other causes, homicides, and suicides. Faden V.B., Goldman M. (Co-Chairs), NIAAA Interdisciplinary Team on Underage Drinking Research. Alcohol development in youth a multidisciplinary overview: The scope of the problem. Alc Res & Health 28(3):111-120, 2004/2005.

Drinkers: Less Active Brains

Comparing two 20 year old females. Top view of brain, two inches above ears

Note differences in back of brain

Healthy Control Alcohol-Dependent

Colored areas show active brain areas during memory task.Source: Tapert SF, Brown GG, Kindermann SS, Cheung EH, Frank LR, Brown SA (2001). fMRI Measurement of Brain Dysfunction in Alcohol-Dependent Young Women. Alcoholism: Clinical and Experimental Research. 25 (2):236-245.

Source: Tapert SF, Brown GG, Kindermann SS, Cheung EH, Frank LR, Brown SA (2001). fMRI Measurement of Brain Dysfunction in Alcohol-Dependent Young Women. Alcoholism: Clinical and Experimental Research. 25 (2):236-245.

College Age Drinkers: Reduced Brain Function

Healthy Controls

Alcohol Dependent

Spatial Working Memory response

Simple Attention response

These are pictures of the brain taken from fMRI. They brain images non-alcoholic and alcoholic youth, a top view looking down, just above ear-level. The warm colors show parts of the brain that were active for the memory task given during the scanning session. Cool colors show parts that were not very active during this task.

You can see that the overall pattern of activation is similar, but not identical, patterns between groups.

Next, youll see a statistical comparison of the alcoholics versus nonalcoholics patterns.

Neurocognitive Impact of AlcoholPre-natal: fetal alcohol effectsMiddle Adolescence: fewer learning strategies, memory impairmentLate Adolescence: attentional decrement, visuospatial impairmentAdults: Prolonged abuse has harmful to liver, lungs, pancreas, kidneys, endocrine system, immune system, cardiovascular system, and brain.

BUT - If drinking onset is delayed by 5 years, a childs risk of serious alcohol problems later in life is reduced by 50%.

Alcohol Drinking PatternsBinge drinking For women, 4 or more drinks during a single occasion. For men, 5 or more drinks during a single occasion. Heavy drinking For women, more than 1 drink per day on average. For men, more than 2 drinks per day on average. Excessive drinking includes heavy drinking, binge drinking or both.

Dietary Guidelines for Americans If you drink alcoholic beverages, do so in moderation, For women: no more than 1 drink/day (7/week) For men: no more than 2 drinks/day (14/week)

Dietary Guidelines for Americans Those who should not drink any alcohol:Pregnant or trying to become pregnant. Taking prescription or over-the-counter medications that may cause harmful reactions when mixed with alcohol. Under the age of 21. Recovering from alcoholism or unable to control amount. Have medical condition that may be worsened by alcohol. Driving, planning to drive, or participating in other activities requiring skill, coordination, and alertness.

Immediate Health Risks of Excessive UseUnintentional injuries: traffic injuries, falls, drownings, burns, firearm injuries. Violence, including intimate partner violence (2/3 of incidents) and child maltreatment. Risky sex: unprotected, multiple partners,increased risk of sexual assault can lead to unintended pregnancy or sexually transmitted diseases. Miscarriage & stillbirth: lifelong physical & mental birth defects among children Alcohol poisoning: unconsciousness, low blood pressure & body temperature, coma, respiratory depression, or death.

health problems that might be alcohol inducedcardiac arrhythmia dyspepsia liver disease depression or anxiety insomnia trauma

Signs of possible alcohol problemschronic illness that isn't responding to treatment as expected, such as: chronic pain diabetes gastrointestinal disorders depression heart disease hypertension

Long-Term Health Risks of Excessive UseDevelopment of chronic diseases, neurological impairments & social problems: Neurological problems, including dementia, stroke and neuropathy.Cardiovascular problems, including myocardial infarction, cardiomyopathy, atrial fibrillation and hypertension.Cancer of the mouth, throat, esophagus, liver, colon, and breast - risk increases with increasing amounts of alcohol. Risks greatly increased among smokers.

Long-Term Health Risks of Excessive UseLiver diseases, including: Alcoholic hepatitis. Cirrhosis - among 15 leading causes of all deaths in US For persons with Hepatitis C virus, worsening of liver function & interference with treatment medications used Other gastrointestinal problems, including pancreatitis and gastritis Social problems, including unemployment, lost productivity, family problems, street violence, alcoholic riots

The Shape of U.S. DrinkingSome overviews

Hazardous U.S. Alcohol Consumption Rogers & Greenfield, 1999

Drinking Volume Partitioned by 6 ContextsTOTAL37%HAZARDOUS1984 & 1995 National Alcohol Surveys; Clark, 1988; Greenfield et al, 2000

Major costs of alcohol (1990)

Total cost: $98.6 BILLIONHealth care: $10.7 billionIndirect costs: $70.2 billion:Mortality: $33.6 billionMorbidity: $36.6 billionCrime: $5.8 billionAuto crashes: $3.9 billionIncarceration: 4.8 billion

Economic Costs of alcohol and other drug abuse are increasing; $277 billion in 1995Sources: Rice et al. 1990; Robert Wood Johnson Foundation, 1993; National Institute on Drug Abuse & National Institute on Alcohol Abuse and Alcoholism, March 1998.Billion Dollars

Alcohol in Primary CarePatients with all stages of alcohol problems frequently seen in clinical settings (McDonald, 2004). Patients screened in 22 primary care practices: 9% at-risk drinkers, 8% problem drinkers, 5% alcohol-dependent. ( Manwell 1998): Binge drinkers compared to other primary care patients: higher rates of related problems (injury, hypertension), 1.5 times more primary care visits, higher per patient costs (psychiatry, emergency room, drugs) (Mertens 2005)

Alcohol, Injury & Acute CareEmergency Departments~ 110 million visits/yr, ~ are injuriesalcohol problems: 15 to 30%

Trauma Centers~ 3 million visits/yr, all are injuriesalcohol problems: 40 to 60% Dan Hungerford, CDC

The Spectrum of Alcohol Useheavysevereconsumption nonenoneconsequences RiskyLower riskAlcohol Use DisordersAbstinenceHarmful, abuseProblemAlcoholismDependenceUnhealthy Use

Age at Onset of DSM-IV Alcohol Dependence

REASONS FOR DRUG TREATMENT: 72% involve alcoholSource: Treatment Episode Data Set, DHHS/SAMHSA, Sept 2000

Distribution curve, e.g. consumption of a drug Number of peopleLevel of consumptionLow HighManyFew

The main problemBinge Drinking

Binge Drinking, Current DrinkersNaimi et al, JAMA, 2003

Alcohol Dependence among Binge Drinkers example New MexicoNew Mexico, BRFSS, 2002Dependent 7%Non-dependent 93%

Percent of Alcohol Consumed by Frequent Bingers, Infrequent Bingers, and NonbingersAdults 21+ Years OldSource: National Household Survey, 1998Frequent bingers: 6% of population, drink 56% of the alcoholOverall, bingers: 16% of population, drink 75% of the alcohol

Binge Drinking, by Average Alcohol Consumption, 2001 Binge EpisodesBinge Drinkers

5+ Drinks Especially Increase Bad OutcomesImpaired driving (Naimi, JAMA, 2003)Unintentional injuries (Anda, JAMA, 1988)SIDS (Iyasu, JAMA, 2002)Violence (Rossow, Addiction, 1996)Unintended Pregnancy (Naimi, Pediatrics, 2003)Sexually transmitted diseases (Lauchli, AEP, 1996)Myocardial infarction (Rehm, Am J Epidemiol, 2001) Meningitis (Imrey, Am J Epidemiol, 1996)

Risk of Injury, by Usual Number of DrinksCollege Alcohol Survey, 1999

Injured II

022.358640273900

19.638352960810.0192

215.994320554620.059

313.471978618630.1008

411.776497118540.1466

59.546479579150.1789

66.364319719460.2427

73.750104401670.3084

82.647623820380.2898

9+4.45168295339+0.3258

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Population

Population Percent

Shifted Pop. Percent

Get hurt or injured

Usual Number of Drinks

Populaiton Percentage

Probablity of Getting Injured

Alcohol Overdose

22.358640273947.99131378940

9.638352960813.47197861860.0044

15.994320554611.77649711850.0016

13.47197861869.54647957910.0056

11.77649711856.36431971940.005

9.54647957913.75010440160.0071

6.36431971942.64762382030.0066

3.75010440164.45168295330.0181

2.64762382030.0127

4.45168295330.0132

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Population Percent

Shifted Pop. Percent

Alcohol Overdose

Usual Number of Drinks

Population Percentage

Probability of Alcohol Overdose

Figure 2. Usual College Student Drinking and Risk of Alcohol Overdose

Sheet1

DrinksPopulation PercentUnplanned SexUnprotected SexGet hurt or injured5+ Problems

112.396.033.231.923.06

220.5612.496.375.97.74

317.3220.738.7610.0814.78

415.1425.1412.5414.6622.85

512.2732.3614.8417.8933.54

68.1836.7619.2624.2738.6

74.8244.3221.9530.8453.17

83.442.2221.5928.9849.2

9+5.7249.6221.0232.5859.43

5+ Problems

22.358640273947.99131378940

9.638352960813.47197861860.0306

15.994320554611.77649711850.0774

13.47197861869.54647957910.1478

11.77649711856.36431971940.2285

9.54647957913.75010440160.3354

6.36431971942.64762382030.386

3.75010440164.45168295330.5317

2.64762382030.492

4.45168295330.5943

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Population Percent

Shifted Pop. Percent

5+ Problems

Usual Number of Drinks

Population Percent

Probability of Experiencing 5+ Problems

Figure 3. Usual Drinking in the College Student Population and Risk of 5+ Alcohol Problems

Sheet5

DrinksPopulationPopulation PercentShifted Pop. PercentAlcohol Overdose

0267722.358640273947.99131378940.380000

111549.638352960813.47197861860.389.638352960813.471978618636.625741251151.1935187505

2191515.994320554611.77649711850.3831.988641109223.552994237121.556836214889.5013781007

3161313.47197861869.54647957910.3840.415935855728.6394387372153.5805562516108.8298672012

4141011.77649711856.36431971940.3847.105988474125.4572788775179.002756201596.7376597344

511439.54647957913.75010440160.3847.732397895318.7505220079181.38311200271.2519836298

67626.36431971942.64762382030.3838.185918316215.8857429216145.106489601660.365823102

74493.75010440164.45168295330.3826.25073081131.161780673299.7527770818118.4147665581

83172.64762382030.3821.1809905621080.4877641360

95334.45168295330.3840.06514657980152.24755700330

11973302.5641025641156.91973607281149.7435897436596.2949970768553.4485926668

0.518633026

Sheet4

DrinksPopulationPopulation PercentShifted Pop. PercentAlcohol Overdose

0267722.358640273947.9913137894000

111549.638352960813.47197861860.00440.42408753030.5927670592

2191515.994320554611.77649711850.00160.25590912890.1884239539

3161313.47197861869.54647957910.00560.75443080260.5346028564

4141011.77649711856.36431971940.0050.58882485590.318215986

511439.54647957913.75010440160.00710.67780005010.2662574125

67626.36431971942.64762382030.00660.42004510150.1747431721

74493.75010440164.45168295330.01810.67876889670.8057546145

83172.64762382030.01270.33624822520

9+5334.45168295330.01320.58762214980

119734.7237367412.8807650547

5/10003/1000

3.12109746932.0750104402

3/10002/1000

Sheet2

DrinksPopulationUnplanned SexUnprotected SexGet hurt or injuredPopulation PercentShifted Pop. Percent5+ Problems

0267722.358640273947.99131378940*.100

111546.033.231.929.638352960813.47197861860.03062.9493360064.1224254573

2191512.496.375.915.994320554611.77649711850.077412.37960410929.1150087697

3161320.738.7610.0813.47197861869.54647957910.147819.911584398214.1096968178

4141025.1412.5414.6611.77649711856.36431971940.228526.909295915814.5424705588

5114332.3614.8417.899.54647957913.75010440160.335432.018892508112.5778501629

676236.7619.2624.276.36431971942.64762382030.38624.566274116810.2198279462

744944.3221.9530.843.75010440164.45168295330.531719.939305103123.6695982628

831742.2221.5928.982.64762382030.49213.02630919570

9+53349.6221.0232.584.45168295330.594326.45635179150

11973178.156953144688.3568779754

178/100088/1000

118.734987054264.6872797127

Sheet3

DrinksPopulationPopulation PercentShifted Pop. PercentGet hurt or injured

0267722.358640273947.9913137894000

111549.638352960813.47197861860.01921.85056376852.5866198948

2191515.994320554611.77649711850.0599.43664912726.9481332999

3161313.47197861869.54647957910.100813.57975444759.6228514157

4141011.77649711856.36431971940.146617.26434477579.3300927086

511439.54647957913.75010440160.178917.07865196696.7089367744

67626.36431971942.64762382030.242715.44620395896.4257830118

74493.75010440164.45168295330.308411.565321974413.728990228

83172.64762382030.28987.67281383110

9+5334.45168295330.325814.50358306190

11973

108.397886912255.3514073332

108/100055/1000

74.656168044841.6224171052

Obstacles to change &A New Framework

Structural Obstacles Alcohol not treated as a drug, food or carcinogen - by law FDA cant review or control alcohol Federal Trade Commission - protection of youth?: uses alcohol industry data on advertising to kids youth prevention campaign uses alcohol industry materialsGovernment & private foundations rarely fund research on alcohol industry, rarely support advocacyNo national media campaign since 1980s/ except DUI Government agencies fear reprisals if they counter industry economic interests or messagesCourts consistently support industry rights to free speech over parental rights and needs of children unrestricted advertising

Common Misperceptions:Most understand alcoholism is a disease, but dont know that like diabetes and other chronic diseases, it can be treated and controlled if not cured & may be relapsing Dont understand concept of alcohol problems as amenable to change we look only for alcoholism and see the rest as social, not health problems myths about alcoholics applied to all problem drinkers]

Common Misperceptions:Old information: no effective treatment, prevention doesnt work, drinking never changes for better or worse, laws have no impactMany hold beliefs fostered by alcohol industry, mass media & culture: problems due to individual choice & irresponsibility failure to change is individual failure alcohol problems are not health problems -only social, personal failings

ObstaclesMedical and public health communities fail to address alcohol use disorders as mainstream health issue focus on individuals, social disruption, particular alcohol problems rarely as larger health problemMedia & government focus only on social, not health impacts.Heavy publicity for research on positive health impacts of alcohol (are they finding what theyre looking for?) - summarized by media as drinking is good for you

Underlying dynamicsMuch of public health community accepts alcohol industry expertise in determining and discussing health issues legitimizes their self interest & perspectives on problemsAlcohol industry and the policies they support focus on individual choice & punishment ignore their own role, environmental, even governmental roles in promoting problems

Consequencesphysician & other health professional paralysis leading to inaction and silence (lacking clear medical/health framework; rely on own feelings, behaviors, experience) Alcohol problems & research treated as discreet, unconnected issues (DUI, FAS/FAE, alcoholism, violence, injury) not usually part of most medical practice concernsAlcohol is a leading preventable cause of cancer and violence often ignoredAlcohol related violence, injury, death are not seen as expressions of health or drug problems-attributed to individual excess, misbehavior or accident

Furthermore, the alcohol industryespecially emphasizes intent, personal responsibility, personal enjoyment of intoxication, and lower risk situations ignores alcoholism, alcohol use disorders, negative consequences of any type save impaired driving, connections between these problems and their products and behaviors

A better framework for thinking. Research (J-curve) makes it clear thatFor some people, some times, in some situations, low level alcohol use is relatively risk free and might be beneficialFor everyone, risk & harm rise with the level of consumption (volume, frequency)In some people, some situations, some occasions - any use is risky and more consumption even more harmful

But over all:

Regardless of why, when, where or how someone drinks, whatever they think or choose to do, alcoholalways acts as a drug, is a carcinogen, and consumption is never risk free. Alcohols impact on the body is systemic and no one and no organs are free of its impacts however small.The most common forms of health problems related to alcohol are not due to, related to or even precursors of alcoholism (dependence) binge drinking affects more people and is a better indicator of problems, and is amenable to change

All alcohol associated problems -Are connected (impaired driving, FAS/FAE, violence, accidents and injury, dependence, binge drinking, underage drinking, football riots, domestic violence, vandalism, etc., etc.) Related to alcohol consumption Related to alcohols impact on the body (especially the brain) (In that sense its like tobacco and many illicit drugs.)For some people, some situations, some health conditions and some circumstances or occasions, risk begins from the initial intake of alcohol and harm rises with consumption (amount, frequency).

A health framework for alcohol:In most peoples daily lives, the times at which they can drink at low risk levels and the circumstances under which they can do so are extremely limited Many can never drink without high-riskEveryones consumption carries a risk for the drinker and the non-drinker (of causing harm to themselves, the people around them and the society they live in.The greater the consumption (amount, frequency, number of drinkers), the greater the potential for harm.

European Charter - Ethical principles1. All people have the right to a family, community and working life protected from accidents, violence and other negative consequences of alcohol consumption. 2. All people have the right to valid impartial information and education, starting early in life, on the consequences of alcohol consumption on health, the family and society. 3. All children and adolescents have the right to grow up in an environment protected from the negative consequences of alcohol consumption and, to the extent possible, from the promotion of alcoholic beverages.

European Charter - Ethical principles

4. All people with hazardous or harmful alcohol consumption and members of their families have the right to accessible treatment and care. 5. All people who do not wish to consume alcohol, or who cannot do so for health or other reasons, have the right to be safeguarded from pressures to drink and be supported in their non-drinking behaviour.

Summary of 10 strategies for alcohol action1. Educate people, beginning in early childhood, of the health, family and social consequences of alcohol consumption and effective measures to prevent or minimize harm 2. Promote public, private & work environments protected from accidents, violence & other negative consequences of alcohol consumption. 3. Establish & enforce effective anti-drink-driving laws. 4. Promote health by controlling availability & influencing alcohol prices (e.g. through taxes). 5. Strictly control (keeping existing limitations or bans) direct & indirect alcohol advertising - ensure that no advertising specifically addresses young people (e.g., by linking of alcohol to sports).

10 strategies for alcohol action6. Ensure access to effective treatment & rehabilitation with trained personnel, for people with hazardous or harmful alcohol consumption and their family members. 7. Foster awareness of ethical and legal responsibility among those marketing or serving alcohol, strictly control product safety, implement measures against illicit production & sale. 8. Enhance societys capacity to deal with alcohol through training of professionals in different sectors, & strengthening community development and leadership. 9. Support nongovernmental organizations and self-help movements - specifically those aiming to prevent or reduce alcohol-related harm. 10. Formulate broad-based programs in Member States, with clear outcome targets and indicators; monitor progress; ensure periodic updating based on evaluation.

U.S. Best Practices Comprehensive ApproachEnforce MLDARestrict hours or days of saleRestrict the number of sales outletsIncrease alcohol taxesImplement effective countermeasures for alcohol impaired driving reverseImplement advertising restrictions

Representation ofEnvironmental Model

For More Information

ContactRichard Yoast, Ph.D.richard.yoast@ama-assn.org

Problematic alcohol consumption is not a benign condition that resolves with age.Putting it all together

4. Parietal and frontal regions were under-activated in alcohol dependent young women relative to controls*Differential sensitivity: These regions may be particularly sensitive to ethanol effects*Developmental differences: Parietal and frontal regions may be affected earlier in the course of alcohol dependence-we know that these are the last regions to myelinate during human brain development into adolescence and ages at which youth may well be drinking harmful amounts

Consistent with adult studies in that decrements in functioning are apparent in group comparisons; not severe; not in all subjectsDevelopmental differences: less impairment of cognitive flexibility; less severity; but drinking before myelination & pruning are complete may cause more damage but may allow possibility for future recoverability with abstinencePutting it all together

4. Parietal and frontal regions were under-activated in alcohol dependent young women relative to controls*Differential sensitivity: These regions may be particularly sensitive to ethanol effects*Developmental differences: Parietal and frontal regions may be affected earlier in the course of alcohol dependence-we know that these are the last regions to myelinate during human brain development into adolescence and ages at which youth may well be drinking harmful amounts

Consistent with adult studies in that decrements in functioning are apparent in group comparisons; not severe; not in all subjectsDevelopmental differences: less impairment of cognitive flexibility; less severity; but drinking before myelination & pruning are complete may cause more damage but may allow possibility for future recoverability with abstinenceFigure legend. The triangle schematically displays the spectrum of alcohol use, from abstinence or no use and lower risk use, which are the most common patterns of alcohol use, to risky use, problem drinking, and the less common but more severe alcohol use disorder diagnoses. In progressing from lower risk use through dependence, consumption and consequences increase. Clinicians and public health practitioners should be concerned with the categories encompassed by the dashed line, unhealthy alcohol use. 44% drink >12/yr, 22% past drnk or