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Better options than self-report of consumption.

In their paper, Pearson et al. point us to a number of weaknesses with the prevailing 4+/5+ definition of heavy episodic drinking: the predictive validity and clinical utility of the 4+/5+ definition is limited; generalizing from college students to older adults and clinical populations is a mistake; there is a lack of cultural and contextual considerations; self-reported drinking is notoriously unreliable and, importantly, linearly related data do not lend themselves to dichotomization [1]. The challenge, then, is to find a measure that captures when drinking leads to impairment, both in people with substance use disorders and those without such disorders. Impairment from drinking takes many forms, both physiological and psychological, and varies for many reasons, including varying levels of tolerance to alcohol. Tolerance again varies both with physiological and psychosocial factors [2,3]. There are well-known problems with self-reported alcohol consumption. In general population surveys 50% response rates are considered good, and among those that respond, under-reporting of consumption is estimated to be approximately 50% [4,5]. In clinical populations it is not clear when patients under-report less: at baseline or at follow-up. More reliable estimates can sometimes be obtained through biochemical markers. These, however, are useful primarily for following total consumption levels, not heavy episodic drinking. One can consider two approaches here. One is to use and develop emerging technologies for more accurate measurement of consumption and, in particular, heavy drinking episodes. Pearson et al. mention transdermal alcohol monitoring as one alternative [6]. Another is to combine portable breathalysers with mobile networks to communicate results [7]. In both cases actual blood alcohol concentration (BAC) levels are obtained, as opposed to estimates based on self-report. These technologies are promising alternatives to obtain event-level data, which could play a significant role in treatment planning and evaluation [8]. The other approach would be to focus on the consequences of drinking. These are the reasons why people seek treatment in the first place: development of dependence, family conflicts, accidents, anxiety, depression and other health effects, and would arguably bemore relevant to measure than drinking in itself. The most proximal consequence is intoxication. Here an alternative to consumption questions, including the 4+/5+ heavy drinking question, is to enquire how often people feel drunk. The subjective experience of intoxication is dependent upon tolerance, but in this approach that would be of less concern, as the aimwould be to assess intoxication as such and its consequences, not what level of consumption leads to intoxication. A better alternative than the 4+/5+ question might then be the ‘Howoften have you had toomuch to drink’ question, where it is understood that intoxication sometimes can be a desired consequence, but not severe intoxication with memory loss, severe hangover, loss of control over behaviour, etc. There is an obvious need to measure patterns of drinking, in addition to the total volume of drinking over a week or month. It has gradually become clearer that a large part of all alcohol problems are caused by heavy drinking occasions. Similarly, in treatment outcome research—given that abstinence only as an outcome measure is inadequate—the importance of monitoring harmful patterns of consumption has also been recognized increasingly. In view of this, the lack of good measurement of heavy episodic drinking is an important failure in this field, and a strong motive for studies where different approaches to measurement are compared.