Alcohol Use Disorder: Growing Public Health Crisis

Columbia University Irving Medical Center

Nearly one-third of Americans’ alcohol consumption puts them at risk for alcohol dependence. The COVID-19 pandemic, which fueled a spike in heavy drinking, drastically widened the scope of alcohol misuse, along with related health consequences.

A study by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), published recently in the Journal of the American Medical Association, shows that after increasing approximately 2.2% per year over the previous two decades, alcohol-related deaths spiked a whopping 25.5% between 2019 to 2020, totaling nearly 100,000 deaths. Meanwhile, alcohol-associated liver disease deaths increased by 22.4% with alcohol-related traffic deaths increasing by 14%.

“Alcohol use disorder puts health and safety at risk and can ruin lives,” said Nasir Naqvi, MD, PhD, a cognitive neuroscientist focused on translational research on addiction and assistant professor of clinical psychiatry at the Division of Substance Use Disorders at Columbia. We spoke with Dr. Naqvi about the distinction between social drinking and alcohol dependence, which treatments for alcohol use disorder (AUD) are most effective, and the importance of community and support in treating AUD.

What is alcohol use disorder and how prevalent is it?

AUD is a chronic brain disorder resulting from compulsive alcohol consumption, loss of control over alcohol use, and negative emotions (e.g., stress and anger) when not drinking. According to the 2019 National Survey on Drug Use and Health, 14.5 million people ages 12 and older, including 9 million males and 5.5 million females, suffer from AUD.

How do social drinkers differ from individuals with alcohol use disorder?

Social drinkers don’t have the same difficulty controlling or limiting what they drink, while those with AUD tend to struggle with intense cravings and are often unable to predict how much they will drink and when they will stop. People with AUD also tend to experience negative consequences, such as frequent hangovers, as well as increased tolerance to alcohol. Their bodies grow accustomed to the alcohol in their system, requiring them to drink more over time to feel the same effects than they felt when they first began drinking.

What are the signs that it’s time to seek treatment for drinking?

NIAAA defines heavy drinking for men as consuming more than four drinks per day or more than 14 per week; for women, three drinks per day or more than seven per week is defined as heavy drinking. In addition to sex, factors such as weight, age, genetics, metabolism, and overall health, influence how someone will respond to alcohol.

Beyond just statistics, it may be more useful for individuals to examine alcohol-related problem behaviors they may be experiencing, such as strained relationships, struggles at work, and the overall impact to their quality of life (e.g., losing interest in hobbies or health) to determine when it’s time to seek treatment. If you or someone you know is struggling with anxiety and/or depression and drink alcohol to cope, the alcohol may be actually wind up contributing to some of these symptoms. So, if you are seeking professional help for other mental health issues, it is a good time to accurately report your alcohol use to the person trying to help you.

What treatments for AUD are considered most effective?

There are three medications approved by the FDA for treating alcohol dependence: disulfiram, acamprosate, and naltrexone. Disulfiram works by blocking the breakdown of alcohol in the body, which leads to a buildup of a toxic compound that can cause people who drink alcohol while taking the medication to get sick. Naltrexone binds to the endorphin receptors in the body and blocks the effects and feelings of alcohol. Acamprosate reduces the brain’s dependence on alcohol by changing how it produces and releases neurotransmitters. There are also medications such as topiramate, gabapentin, and ondansetron, that are used off-label to treat alcohol dependence that have similar results.

Evidence-based psychotherapies for alcohol use disorder are also effective. They include cognitive behavioral therapy, motivational interviewing, and 12-step support programs, such as AA. Treatments for families of those suffering from AUD to provide assistance to help their loved ones reduce drinking are also on the rise, the most effective being Community Reinforcement and Family Training (CRAFT).

Is there any evidence that people with AUD can become social drinkers (or give up alcohol) successfully through willpower alone?

Yes. The majority of individuals with AUD can alter their drinking behavior without treatment. However, these are individuals who usually have milder problems and do not have a physiological dependence on alcohol, or who are not also suffering from co-occurring mood and/or anxiety disorders.

Explain the importance of Alcoholics Anonymous (AA) and community in treating addiction.

AA is helpful to many individuals with AUD because it’s free, leveraging community support with others who are also struggling with alcohol misuse. For many people, AA is the most effective intervention for reducing drinking. However, because AA operates on the principle of AUD as a disease that requires total abstinence and devotion to a higher power, it may not be appealing to everyone. Also, AA is not considered “treatment” because it’s not a service provided by trained professionals. While this may seem like a limitation of AA, it’s also perhaps its greatest strength since everyone there is on the same level lending to its powerful sense of community and equality.

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