While rumors continue to fly about what killed Amy Winehouse — the latest suggest that crack and heroin may have been involved — the singer’s parents continue to maintain that she was sober when she died, and that in fact, she died from alcohol withdrawal.
Unlike withdrawal from cocaine, methamphetamine or heroin, alcohol withdrawal can indeed be deadly — but few alcoholics ever experience the most serious consequences of withdrawal. They either do not succeed, or even attempt, quitting alcohol cold turkey, nor are they much hindered in getting enough alcohol, since it is relatively inexpensive.
Only about 5% of alcoholics suffer the DT’s (delirium tremens) from withdrawal that can be associated with deadly seizures. Of that minority, around 5% of cases are deadly if untreated. Treatment typically consists of replacing the alcohol with benzodiazepines, which, like alcohol, calm the brain by acting on the neurotransmitter GABA. These drugs can then be slowly tapered.
Treatment prevents the “shock to the system” that can lead to seizures due to the elimination of a substance on which the brain has become physically dependent. With treatment, withdrawal deaths occur in less than 1 in 2,000 hospitalized patients.
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More commonly, it is the over-consumption of alcohol that kills. Studies find that alcohol is responsible for more than twice as many deaths as overdose from other drugs, though alcohol is often a factor in other drug overdoses as well. It is also more likely than other drugs to be involved in homicide.
But because drinking is so much a part of American and British life — in both religious and celebratory experiences — it’s hard to think about alcohol as a killer or even as a drug.
That’s partly why society tends to worry less about the deadly consequences of alcohol than of those associated with other drugs. We believe the familiar to be safe and the unusual or unknown to be threatening. That also helps explain why, for instance, people fear flying more than they do driving, even though flying is actually safer when you look at the statistics on injury and death.
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Similarly, we fear as-yet-unproven links between chemicals in plastic and birth defects, but devote little attention or funding to prevent the No. 1 known cause of intellectual disability in children: fetal alcohol syndrome.
Much the same way we fear flying because we have no control over the plane, people become anxious over the fact that they have no control over what companies put into baby toys and packaging. But they do have control over their own alcohol consumption, which makes it seem less scary.
Confusing the situation further, moderate consumption of alcohol is actually associated with health benefits — such as reduced risk for heart disease and clot-related stroke — while excessive use can turn deadly.
So how does alcohol usually kill? There is little recent research on the question; the latest study to look at deaths caused directly by alcohol or alcoholism (excluding accidents and homicides) found that there were 23,199 such deaths in the U.S. in 2007.
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A 2004 study by the Centers for Disease Control and Prevention (CDC), which dug more deeply and included more indirect causes of alcohol-related death, found that nearly 76,000 American deaths involved alcohol in 2001. About half of those deaths were related to chronic conditions linked to heavy drinking; the rest were caused by acute incidents like drunk driving accidents and homicides. About three-quarters of those who died from alcohol were men over age 35, but 4,554 people under 21 also died from alcohol-related incidents, mostly accidents.
Here are the top causes of alcohol-related death based on the 2004 CDC research, and the number of people killed:
1. Alcohol-related liver diseases: 19,616
2. Accidents involving transportation (mainly cars): 14,368
3. Injuries including falls, fires, firearms, hypothermia, choking and drowning: 7,716
4. Homicide: 7,686
5. Suicide: 6,995
6. Alcoholism and chronic alcohol abuse, unspecified causes: 5,841
7. Alcohol-related heart disease and stroke: 5,157
8. Overdoses of other drugs, which included alcohol: 3,694
9. Cancer of organs other than liver: 1,625
10. Pancreatitis and other damage to pancreas: 1,261
11. Damage to brain (including some cases of death by withdrawal in alcoholic psychosis or DT’s): 1,033
12. Alcohol poisoning/overdose: 333
While studies that try to tease out causes of death in situations like accidents or homicides may overestimate the role of alcohol, it’s nonetheless clear that heavy drinking is a major cause of mortality — much greater than the illegal drugs combined.
Maia Szalavitz is a health writer at TIME.com. Find her on Twitter at @maiasz. You can also continue the discussion on TIME Healthland’s Facebook page and on Twitter at @TIMEHealthland.
Correction [Aug. 2]: Due to an editing error, this piece originally misstated that few alcoholics experience withdrawal. In fact, withdrawal is common, but the most severe withdrawal is rare. The article has been updated to reflect the correction.