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Alcohol abuse up significantly: ‘public health crisis’ among women, other groups
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Alcohol use disorders, 12-month alcohol use and high-risk drinking is increasing in almost every population group in the United States, according to research recently published in JAMA Psychiatry.
“Lack of current and comprehensive trend data derived from a uniform source on alcohol use, high-risk drinking, and DSM-IV [alcohol use disorder] since the early 2000s represents a major gap in public health information,” Bridget F. Grant, PhD, of the epidemiology and biometry branch of the National Institute on Alcohol Abuse and Alcoholism and colleagues wrote.
To gather more data on the subject, Grant and colleagues analyzed National Epidemiologic Survey on Alcohol and Related Conditions data gathered from April 2001 to June 2002, and National Epidemiologic Survey on Alcohol and Related Conditions III data that were gathered from April 2012 to June 2013. Information from 79,402 participants was included in the analysis.
Researchers defined high-risk drinking as four or more standard drinks on any day for women, five or more standard drinks on any day for men and surpassing those daily drinking limits at least weekly during the past 12 months. An individual had DSM-IV alcohol use disorder if they met one of the four criteria for abuse in the past 12 months and three of the condition’s criteria for dependence.
Grant and colleagues found that between 2001-2002 and 2012-2013, DSM-IV alcohol use disorder increased by 49.4%, 12-month alcohol use increased 11.2% and high-risk drinking increased 29.9%. These behaviors also increased significantly across most sociodemographic subgroups during the period studied with the largest increases among individuals with low family income and educational level, racial/ethnic minorities, older adults, and women.
Researchers also observed increases for the total sample and most sociodemographic subgroups for the occurrence of 12-month DSM-IV alcohol use disorder among 12-month alcohol users, from 12.9% (95% CI, 12.3-17.5) to 17.5% (95% CI, 16.7-18.3). In addition, 12-month DSM-IV alcohol use disorders among 12-month high-risk drinkers from 46.5% (95% CI, 44.3-48.7) to 54.5% (95% CI, 52.7-56.4).
“These increases constitute a public health crisis that may have been overshadowed by increases in much less prevalent substance use — marijuana, opiates and heroin — during the same period,” Grant and colleagues wrote. “The results of this study call for a broader effort to address the individual, biological, environmental and societal factors that influence high-risk drinking and [alcohol use disorder] and their considerable consequences and economic costs to society — $250 billion — to improve the health, safety and well-being of the nation.”
Grant also told Healio Family Medicine the findings should prompt a discussion between doctors and patients about alcohol.
“Primary care physicians should ask detailed information on alcohol use and high risk drinking and alcohol problems of all their patients,” she said in an interview. “This is particularly true in light of the unprecedented increases in high-risk drinking and alcohol use disorder found in this study. [These] doctors should be also familiar with referral venues for substance use treatment facilities.”
Researchers urged medical professionals, the public and policy makers to learn about alcohol use disorder and high-risk drinking, reinforcing the need for treatment, prevention and intervention strategies, and for eliminating the stigma associated with alcohol-related conditions.
In a related editorial, Marc A. Schuckit, MD, of the department of psychiatry at the University of California San Diego, wrote that he was particularly concerned about the more than 100% increase in alcohol use disorders in the United States’ older population, since persons in this group often take several medications that, when taken with alcohol, can cause “significant and costly health consequences.” In addition, he wrote, older populations often have other medical conditions that can be intensified by drinking.
Despite these concerns, Schuckit noted there have been successful initiatives to rein in some alcohol-related consequences, such as a series of videos shown to students that concentrated on the risk factors for heavy drinking. However, he warned strategies that curb alcohol drinking could be in jeopardy since NIH is facing a possible funding cut.
“[These cuts] are potentially disastrous for future efforts to decrease alcohol problems and are likely to result in higher costs for us all,” he wrote, and urged that Grant and colleagues’ findings not be overlooked.
“If we ignore these problems, they will come back to us at much higher costs through [ED] visits, impaired children who are likely to need care for many years for preventable problems, and higher costs for jails and prisons that are the last resort for help for many.” - by Janel Miller
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Ada Stewart, MD
Family physicians constantly diagnose individuals with alcohol use disorders through our screening methods. As family physicians, this is part of our intake process per the U.S. Preventive Services Task Force. We screen every adult that comes into our offices at least once a year.
If a patient comes back positive during a screening, we advise them of the health risks and go through the assessment to see if they’re ready and willing for treatment. Next, we offer them either counseling, or counseling plus medication treatment. Family physicians follow the U.S. Preventive Services Task Force recommendations to screen and then to offer treatment. Every patient at my practice gets asked about their intake of alcohol. We us screening methods such as CAGE questionnaire, AUDIT, or AUDIT-C, or ask the question “How many times in the past 12 months have you had 4 or more alcoholic drinks” (four drinks for women, and 5 drinks for men). If patients are found to not be forthcoming (if we have had documentation of questionable alcohol use through sources such as emergency room or hospital records), then the patient is recommended treatment. Many family physicians have behavioral health integrated in our practices, so we can connect these patients with counselors or provide them with treatment. We either refer them for treatment, but often provide the treatment ourselves.
The important questions to ask are, ‘Have you ever felt you needed to cut down on your alcohol use?’, or ‘Have you ever felt annoyed with individuals when they ask about your alcohol use?’ or ‘Do you feel guilty?’ or ‘Do you use alcohol as an eye opener?’ If a patient answers positive to three or more of such questions, then you need to have the conversation with the patient that for their health’s sake they really need to cut back. Physicians don’t want to be accusatory or make them feel uncomfortable with asking these questions, but you want to give them the advice they need.
For example, I recently had a patient that I counseled to two months ago, regarding her alcohol use. She recognized that she did have a problem, and I told her that for her health it would be best to cut down. I offered resources and treatment options. She didn’t want any inpatient treatment because she could not take time away from work. I also counseled her preventive evaluations such as a colonoscopy because I was concerned that she had anemia and we couldn’t tell if it was tied to the alcohol use or the colon. I also suggested she get a Pap smear. She got her colonoscopy and unfortunately, they found some cancerous polyps, but she came in today to thank me for recognizing that she needed help. She decided she wants to quit drinking and is getting help at the local hospital. She is also working on [quitting] smoking. Being there for our patients can really make a difference, but they also have to be willing to accept the care, and that can be the hardest part.
Regarding stigma, a lot of times people don’t want to recognize that they do have a problem because they are concerned they will get labeled. As family physicians, we need to make sure the patient is comfortable and that no one is accusing them, or making them feel badly for issues that are beyond their control.
The AAFP has a toolkit, called the ‘Addressing Alcohol Use Practice Manual, that is a great resource to help physicians and other health care professionals identify these patients and ensure the whole office team is involved in that care.
Additional resources:
Addressing Alcohol Use Practice Manual: An Alcohol Screening and Brief Intervention Program (Accessed from AAFP’s website Aug. 14, 2017)
Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement (Accessed from AAFP’s website Aug. 14, 2017)
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