US Sees Dramatic Rise in Alcohol Use, High-Risk Drinking

Batya Swift Yasgur, MA, LSW

August 21, 2017

Alcohol use, high-risk drinking, and alcohol use disorders (AUDs) are on the rise in the United States, especially among women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged, new research shows.

The researchers found that between 2001-2002 and 2012-2013, alcohol use increased by 11.2%, from 65.4% to 72.7%; high-risk drinking increased by 29.9%, from 9.7% to 12.6%; and AUDs increased by 49.4%, from 8.5% to 12.7%.

The increases were greatest among women, older adults, racial/ethnic minorities, and those with lower educational levels and family income.

"We were surprised to find changes in the rates of alcohol use, high-risk drinking, and AUD, which were rather unprecedented," lead investigator Bridget F. Grant, PhD, senior epidemiologist, National Institute on Alcohol Abuse and Alcoholism, told Medscape Medical News.

"What surprised us were the increases across the board — age, race, sex, and education ― but most notably in minorities, women, and the elderly, and we think that the 2008 recession probably had a lot to do with that," she said.

The study was published online August 9 in JAMA Psychiatry.

Major Information Gap

AUDs are "significant contributors to the burden of disease in the United States and worldwide," the authors write, and are "important risk factors for morbidity and mortality."

In light of the grave physical and psychiatric harms of high-risk drinking and AUD, "regular and detailed monitoring of their trends over time is imperative for the health of the nation," they note.

Since the early 2000s, there has been a "lack of current and comprehensive trend data derived from a uniform source on alcohol use, high-risk drinking, and DSM-IV AUD" that "represents a major gap in public health information."

The study presents prevalence data for 2001-2002 and 2012-2013 regarding 12-month alcohol use, 12-month high-risk drinking (defined as drinking in excess of the daily drinking guideline at least weekly in the past 12 months), and 12-month DSM-IV AUD overall and among important sociodemographic subgroups of the US population.

Data were drawn from 43,093 participants in the National Institute on Alcohol Abuse and Alcoholism's 2001-2002 Wave I National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) and 36,309 participants in the 2012-2013 NESARC-III.

The NESARC surveys were nationally representative, face-to-face interviews in which the target population was US adults (aged ≥18 years) residing in households and selected group quarters.

The researchers used the Alcohol Use Disorder and Associated Disabilities Interview Schedule–DSM-IV Version (AUDADIS-IV) in NESARC and the AUDADIS Fifth Edition Version in the NESARC-III to assess 12-month alcohol use.

High-risk drinking was defined as drinking four or more standard drinks on any day for women and five or more standard drinks on any day for men. To be regarded as engaged in high-risk drinking, the individual had to have exceeded the daily drinking limits at least weekly during the prior 12 months.

Participants were regarded as having a DSM-IV AUD diagnosis if they had met criteria for alcohol dependence or abuse during the past 12 months. A diagnosis of dependence required meeting three or more of the seven DSM-IV criteria for dependence. A diagnosis of abuse required meeting one or more of the four criteria for abuse. Respondents with a 12-month abuse or dependence diagnosis were classified as having 12-month AUD.

Notable Increases

The researchers found significant increases in 12-month alcohol use, from 65.4% in 2001-2002 to 72.7% in 2012-2013, which represents a relative increase of 11.2%.

Although significant increases were seen across all sociodemographic subgroups, they were most notable were among women (15.8%), racial/ethnic minorities (from 17.2% among Hispanic to 29.1% among Asian or Pacific Islander individuals), adults aged 65 years or older (22.4%), and respondents with lower educational level and family income (range, 11.7% to 22.3%).

The prevalence of 12-month high-risk drinking likewise increased significantly, from 9.7% in 2001-2002 to 12.6% in 2012-2013, a 29.9% increase in the total population. There were significant increases in high-risk drinking in almost all sociodemographic subgroups except for Native Americans and respondents residing in rural areas.

Changes in high-risk drinking patterns were most notable among women (57.9%), racial/ethnic minorities (from 40.6% among Hispanic to 62.4% among black individuals), adults aged 65 years or older (65.2%), individuals previously married (31.9%), individuals currently married or cohabitating (34.2%), individuals with a high school education and less than a high school education (42.3% and 34.7% respectively), those earning incomes of $19,999 or less (35.1%), and those residing in urban areas (35.1%).

There was an increase in the prevalence of 12-month DSM-IV AUD from 8.5% to 12.7% (change, 49.4%) in the total population. In this outcome too, significant increases in AUD were seen in most subgroups, with notable increases among women (83.7%), racial/ethnic minorities (51.9% for Hispanic and 92.8% for black individuals), adults aged 65 years or older (106.7%), individuals with a high school education and less than a high school education (57.8% 48.6% respectively), those earning incomes of $20,000 or less (65.9%), those living within 200% of the poverty threshold (range, 47.1% to 55.8%), and those residing in urban areas (59.5%).

Among 12-month alcohol users, there were significant increases in the rate of 12-month DSM-IV AUD, from 12.9% in 2001-2002 to 17.5% in 2012-2013 (change, 35.7%). These increases were significant for all subgroups except Native Americans, previously married respondents, and those residing in rural areas.

Notable increases were found among women (59.8%); individuals who were black, Asian or Pacific Islander, or Hispanic (55.8%, 36.2%, and 29.5%, respectively); adults aged 45 to 64 years (61.9%); those aged 65 years or older (75.0%); those who were married or cohabiting (45.1%); those who had a high school education (41.2%); and those who resided in urban areas (44.8%).

Among 12-month high-risk drinkers, the 12-month DSM-IV AUD rate increased from 46.5% in 2001-2002 to 54.5% in 2012-2013, an increase of 17.2%. Increases were significant for most socioeconomic groups.

Most notable were the increases among women (34.7%), individuals who were black or Hispanic (25.7% and 16.8% respectively), respondents aged 45 to 64 years (34.8%), those aged 65 years or older (58.1%), and those residing in urban areas (21.1%).

The authors note that the increase in high-risk drinking of almost 30% (from 9.7% in 2001-2002 to 12.6% in 2012-2013) represents an increase from approximately 20.2 million to 29.6 million Americans.

The 49.4% increase in 12-month DSM-IV AUD rate, from 8.5% to 12.7%, represents an increase of approximately 17.6 million to 29.9 million Americans, which was "much greater" than the corresponding 14.8% increase from 1991-1992 (7.4%) to 2001-2002 (8.5%).

Although the prevalence of AUD among 12-month alcohol users and 12-month high-risk drinkers both increased, the prevalence of AUD among high-risk drinkers was much greater than among 12-month users, "highlighting the critical role of high-risk drinking in the increase in AUD," the investigators write. This underscores the "more important influence of increases in high-risk drinking relative to alcohol use on increases in AUD."

"When we look at alcohol use disorder, which is a very serious disorder, only 10% of the population has sought treatment for this disorder," Dr Grant observed.

"We think more has to be done with public education and educating healthcare practitioners about both the behavioral and pharmacologic treatments available, so that people with problems controlling drinking can seek treatment," she said.

"We also have to do a better job at the mass education level to address stigma and inform people that this is a disease and it is treatable," Dr Grant added.

"Alarming" Findings

In an accompanying editorial, Marc A. Schuckit, MD, professor of psychiatry, University of California, San Diego, calls the increases in AUDs among people less likely to have adequate health coverage"particularly alarming."

The "greater-than-average increases in AUDs and related conditions in individuals with less education and lower education" are noteworthy because "these individuals who drink often cannot afford insurance or might have policies that severely limit or do not cover alcohol-related treatments," he writes.

He also expresses concern regarding the risk to older individuals who are "likely to carry multiple preexisting medical conditions that can be exacerbated by heavier drinking" and are typically taking "multiple medications that can interact adversely with alcohol, with resulting significant and costly health consequences."

The increase in the proportion of women who drink alcohol, the increase in high-risk drinking among women, and the higher 12-month prevalence of AUDs among women "are likely to foreshadow future increases in lost time at work, suboptimal childrearing practices, and children with fetal alcohol spectrum disorders, with potential lifelong impairments in functioning."

He cautions that the proposed cuts to the National Institutes of Health budget being considered in Washington in 2017 are "potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all."

He states that he feels a "personal responsibility to support politicians, regardless of whether they are Democrats, Republicans, or Independents, who recognize the benefits of research, understand the health care crises we face, and are willing to do something about it."

Dr Grant said that the findings have important take-home messages for clinicians.

Although primary care physicians (PCPs) are "doing a better job now in trying to determine if patients have alcohol problems, it is imperative to ask more questions and educate patients regarding available treatments," she said.

She emphasized that if a patient presents with depression, the PCP or psychiatrist should "be proactive in asking about drinking, since the comorbidity between alcohol use and depression is very high."

The study was sponsored by the National Institute on Alcohol Abuse and Alcoholism, with supplemental funding from the National Institute on Drug Abuse, and by a grant to one of the study authors from the National Institutes of Health. The authors and Dr Schukit have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online August 9, 2017. Abstract, Editorial

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