While alcohol consumption may have leveled off in recent years for a variety of reasons, unleashing alcohol’s frightening grip remains a direct danger to millions of Americans and an indirect burden for their families, colleagues and loved ones. And regardless of consumption levels, alcohol-related deaths have surged in the last two decades. This continued threat has medical professionals evaluating how they confront the issue, which they now label alcohol use disorder instead of the traditional tags of alcoholism and alcohol abuse. The good news is that progress is being made, although additional research, greater awareness and more resources are needed to help individuals recover. Dr. Yngvild Olsen of the Substance Abuse and Mental Health Services Administration recently spoke with WellWell to lay out just what’s facing America in terms of alcohol use disorder, how the country’s aging population may be affected and what’s the general prognosis for helping the afflicted get well.
There’s a move to describe alcoholism or alcohol abuse differently. Can you explain why that is?
For many years, people used terms like alcoholism and alcohol abuse and even the diagnoses were called alcohol abuse and alcohol dependence. That was very confusing because there are lots of people who use alcohol who don’t have the diagnosis of an alcohol use disorder, which is now the term that we use. It also became clear many years ago that when we use the word abuse, it carries negative connotations and a lot of stigmas around the behavior and the health condition that people have of alcohol use disorder. In 2013, the American Psychiatric Association, which is the entity that helps to describe all mental health disorders, including addiction-related disorders, developed and redesigned the term and the diagnostic criteria for how we identify the symptoms of people who have an alcohol use disorder. I do now think though that people are slowly recognizing that an alcohol use disorder, is a health condition where people don’t necessarily have control over their use of alcohol. It impacts many different aspects of their lives. It’s not a moral failure because that was what was associated with the term abuse for many years.
What’s the current status of the disorder in the country?
We know that alcohol use is very common. Alcohol use disorder among the people who drink alcohol is less common. And, certainly when you think about just alcohol use, and then we can talk about some of the risk factors for people to develop an alcohol use disorder. With the COVID pandemic, we saw a pretty significant increase. Often people drink alcohol in response to stress and those negative emotions, even though we know that also it is used in lots of social interactions. People use it and drink among friends and parties, et cetera. That’s very well known. But we also know that in a given month, only about 52 percent of adults over 18 drink any alcohol. And that’s according to something called the National Survey on Drug Use and Health that we run every year. But when you look at heavy drinking, like really excessive drinking, that is defined by the National Institute on Alcohol as having more than four drinks on any occasion for women or five drinks on any occasion for men. So that’s what’s called binge drinking. Heavy drinking is then also defined as binging on five or more occasions in the past month. So, when we look at that population of people who engage in that excessive, that really binge or heavy drinking behavior, that they’re about 24 percent of adults binged on alcohol in any given month. And about 6 percent of people have heavy alcohol use. So, when we define alcohol use disorder, some of those individuals who engage in binge or heavy drinking may meet the criteria for a mild or severe alcohol use disorder. We can talk a little bit about how those are defined, but it’s about 11 percent of people over the age of 18 in the U.S. have an alcohol use disorder.
Is that rising or flat?
It’s a little hard to say over the last 10 years, for example, partly because the surveys that we use to measure that statistic have changed in methodology. So, we can’t compare before 2020 to after 2020. But we do know that we have seen a very slight dip in people who have that alcohol use disorder between 2021 and 2023. But again, it’s about that 10 to 11 percent over those past few years.
Is alcohol use disorder psychologically, genetically or environmentally driven?
When we talk about some of the risk factors for developing a substance use disorder, in this case, an alcohol use disorder, the genetic component accounts for about 40 to 60 percent or almost half of that risk. Now, we know that several different genes are involved in that development, but which ones are exactly involved in which specific use disorder, what combination of genes, because it’s probably not just one. There’s still a lot of research happening to identify specifically what are some of those genes and the genetic combinations. But I think it’s important for people to understand that when we say that it runs in families, it can absolutely run in families because of that risk that 50 percent is genetically based. This does not mean that people who have that predisposition from their families are destined to develop an alcohol use disorder. We know that it also is an interaction between genetics and the environment and other things that can happen in people’s lives. So for example, we know that there’s a lot of really great research that has found that people who have high levels of something called adverse childhood experiences—if you have experienced physical or sexual abuse as a child or if you’ve had traumatic events happen to you as a kid—that increases people’s risk of not only starting to use substances early in adolescence, but also then to go on and have a higher risk of developing that substance use disorder, that alcohol use disorder.
People who also have other psychiatric conditions, so depression, anxiety, PTSD, those types of health conditions also increase the risk. And for many people, that combination of depression and alcohol use disorder can also complicate not just the presentation and increases the risk of both, but also complicates treatment. The other piece that we know is that men are at higher risk for developing a substance use disorder than women, although that looks like it now, women are catching up in some of the data that we have. And that depending on some of the genetic predispositions also relates to how alcohol in particular is metabolized in people. So that may not just be that it’s the brain receptor genetics and how people respond to alcohol in their brains, but also just in how alcohol is metabolized in the body by the liver. There are some people from Asian backgrounds, for example, that have a gene that we know metabolizes alcohol differently so that they have a lower risk of developing an alcohol use disorder compared to other racial and ethnic individuals.
We’ve seen recent reports that alcohol-related deaths have doubled in the last two decades, Why is that occurring?
It’s an incredibly important piece to understand. And you’re absolutely right that alcohol-related deaths have gone up and the Centers for Disease Control estimates that alcohol is attributable to mortality in some way and accounts for over 175,000 deaths per year. And that is an increase of about 29 percent in 2021 compared to 2016. Now, some of the reasons why that has happened, I think is it’s not entirely clear. While people may not be drinking necessarily as much as the population is getting older, the people who had been drinking heavily or excessively in the past, as people get older, also metabolize alcohol differently. They have other health conditions that can be exacerbated by long-term use of alcohol. I think that the other piece is that, unlike opioids, that has also been contributing so much to the overdose crisis in this country, the mortality from opioids is much more sudden. Alcohol-related deaths can take some time before all the harmful effects of alcohol accumulate in someone’s body. It can take time to develop liver disease, cancer, heart disease, all those health conditions that alcohol can contribute to. One of the things that we are also really paying a lot of attention to is all of those alcohol-related deaths, people now are using multiple substances at a time, including alcohol. So, it’s not just that alcohol by itself is contributing to some of these deaths, but it can also be part of that polysubstance use that we’re seeing and increases in the polysubstance use among the population.
Do we see a difference in demographic use in terms of age? Are younger people drinking more than they had in the past?
It looks like some of the surveys that we have shown that the younger population now is drinking less and slightly declining, particularly when you look back 30, 40 years that the alcohol consumption in the U.S., particularly among that younger population, has declined.
Is that a matter of awareness or just a general move towards health?
It’s a little hard for me to speculate on exactly why. I think it may be a combination of things. I do think that there has been a recognition around the younger generation that there is a decline in alcohol use, much like tobacco. The other thing that has happened though, which I think is also important to recognize is that cannabis use has gone up among that younger population. And so, now when we’ve had a lot of focus on drinking and driving we need to be thinking about our messaging around the negative social effects of alcohol in addition to the negative health effects that we see now with cannabis use going up.
Is alcohol seen as less harmful than cigarettes and drugs?
It depends on how you ask that question. Because we have seen that in one of the large studies that look at adolescent perceptions of the dangers of various substances is something called monitoring the future study that is run by the National Institute on Health and the National Institute on Drug Abuse. When they’ve looked at high school seniors, for example, that smoking a pack of cigarettes a day was seen as harmful by more students than drinking four servings of alcohol a day. There are also surveys of adults that have shown that people perceive cigarettes to be more harmful than alcohol. But we also now have seen that perceptions of cannabis use as harmful have declined in some of those surveys among adolescents. So again, it’s hard to say whether there’s something that is now being seen as less harmful or more harmful, as all of these social mores change. But I think we do see that between cigarettes, nicotine and alcohol, there have been some changes recently in how people are perceiving the harm of those. I will say you asked the question about whether alcohol is more harmful than nicotine and cigarettes. We know that cigarettes, nicotine, vaping and alcohol all contribute to health problems and public health consequences.
How do you define the differences between having a technical disorder and drinking too much regularly?
Some of the definitions of heavy drinking or binge drinking are based on quantity. The reason we look at the quantity is because those are then associated with the potential for impairment and the potential for associated consequences. So, getting in a car and having an impaired function, reaction time, those types of things, as well as what happens when people then wake up the next morning and they may have blacked out, they may have engaged in some behaviors that they really didn’t, they can’t remember those types of things. We’re talking about what may be a consequence that happens as a result of a binge drinking episode or maybe something that then is more persistent. Alcohol use disorder is not defined by how much one drinks, it’s not the quantity, but it’s really about how it’s impacting a person’s life. And we know that is alcohol use disorder and alcohol addiction is this chronic brain disease where it’s characterized by people compulsively continuing to drink even though it’s causing them harm. Even though they lose control over their drinking, it’s interfering with incredibly important pieces of their life. They may have had several blackouts where they are engaging in risky sexual behaviors or changing personalities so people can get violent. There are a lot of those types of impacts that are then defining alcohol use disorder more so than just alcohol use.
People who have an alcohol use disorder, particularly a severe alcohol use disorder, may have health conditions like liver failure and brain changes that cause memory issues. They may have heart disease and different kinds of cancers, but they’re continuing to drink because it’s this compulsive nature of just in cravings that are unrelenting and nonstop. So, it’s those types of things, they may have gotten arrested, they may have gotten in car crashes, et cetera, but that compulsive nature of that alcohol addiction is really what is the characteristic of the alcohol use disorder.
How many people are in denial over this? And what are the symptoms that you may have a disorder versus drinking too much?
When we look at those diagnostic symptoms, the diagnostic criteria laid out in that are called the Diagnostic Statistical Manual from the American Psychiatric Association. There are 11 criteria that we look at as health professionals. Depending on how many of those criteria a person meets, we then categorize the alcohol use disorder as either mild, moderate or severe. There are some people who may only meet a couple of those criteria; they may have a mild disorder. That sometimes is harder to identify compared to people who have the severe disorder where it is pretty clear that someone’s life is just really significantly and negatively impacted by alcohol. One of the proven public health approaches that was developed within the last 20 to 30 years is something called screening and brief intervention and referral to treatment. It was designed to identify people who may have that hazardous alcohol use disorder that often gets seen in primary care by your primary care physician. In doing the screening and using very standardized screening tools that have been tested across different age ranges and different demographics, you can start to identify whether someone is just not at risk at all for any of these negative consequences or whether they fall into that risky area.
The brief intervention piece really uses techniques to help identify and create awareness on the part of the individual that, maybe I am having a little bit of a problem with alcohol. Maybe some family member has said, I’m worried about your drinking because your personality changes when you drink or you were late to work and you’ve been late to work multiple times because you’re so hungover in the morning. You’ve missed critical family events because of the alcohol and the consequences of drinking a lot. So those are some of the things that people can become aware of around the person even when it is that more subtle milder alcohol use disorder. So that is one thing to pay attention to is when other people around them are starting to be concerned about someone’s alcohol use.
How do we reach people who are in denial that they are drinking too much?
Part of that denial, part of the challenge around people who may have even a mild alcohol use disorder or even a severe one, is that sometimes it is hard for the individual to see the impact that it’s having on their health and the health of the people around them. One of the things I think that screening and brief intervention and this motivational interviewing technique I’ve described is trying to help people see the connections between their drinking and their behavior. You don’t have to be a healthcare professional in order to learn how to do that. And there are several different resources that SAMHSA also helps provide. There are some campaigns that we have called Talk They Hear You, which is an app and some digital materials that people can download on their phone to then help get concrete messages of how you talk to family members, what can you say and express your concerns for things that are happening with that individual. It also has applicability to teachers and schools. And so, the Talk They Hear You campaign has been a good way for folks to be able to get some of those resources to be able to have those conversations. I think the digital age also makes it easier to self-screening. People can go to SAMHSA’s Screen 4 Success, which is a free 10-minute screening that can connect people to resources. I think one of the things that we often find as healthcare professionals is that sometimes when a healthcare provider or someone in your family raises a concern or starts to have that conversation, it may get that person to start thinking about, hmm, maybe I do have a problem. And if it’s then brought up again and again and again, at some point, that person may start to see that connection between their drinking and the consequences of that alcohol use.
What about someone who has a progressively more significant disorder? How are we identifying it?
Many people who have an alcohol use disorder benefit from peer support and having people with lived experience of substance use disorders. So, there are mutual support groups in every community like the Alcoholics Anonymous mutual support group. Those can be helpful for individuals. For individuals who have a severe disorder, often what will happen is that there will be some type of health consequence. They’ll be in an emergency department or they may end up in the hospital as a consequence of whether it is liver disease or they’ve been in an accident or some other issue has arisen. And in those situations, whether it’s in the emergency department or in the hospital or even in a primary care setting or another healthcare setting, that really being able to do that screening and have that screening and brief intervention and then those referrals to treatment baked into the healthcare setting, that’s really important. And that is something that increasingly we have seen also that adoption across those healthcare settings that aren’t necessarily specialty substance use disorder treatment facilities, but really in general healthcare. This recognition that substance use disorders in general have such an incredible impact on people’s health and well-being more broadly than just the alcohol use disorder itself.
What are the health impacts, both physically and mentally?
Alcohol has several different individual health impacts, both in terms of those mental health conditions, that depression that I talked about, anxiety, it often goes along with those. It can make the depression worse. It can exacerbate anxiety. It impacts a whole range of different organs. I’m not going to list all of them, but some of the more frequent ones are the heart. Alcohol contains a lot of calories. It can contribute to obesity, heart disease and other types of metabolic disorders. It can raise people’s blood pressure. And over many years of alcohol use, it can cause heart failure in individuals. It affects your brain. Alcohol can cause seizures. If you’re excessively drinking or even in withdrawal from alcohol, seizures are often a complication that we see. It increases your risk of injury, So we’ve talked about accidents and falls, and particularly in older individuals, falls from alcohol use are very common. There are memory issues that can happen as a result of alcohol, so it can exacerbate and cause a disorder related to memory, as well as liver problems. So, we’ve talked about cirrhosis, which is liver disease. There are a host of different cancers that are associated with alcohol-from breast cancer and esophageal cancers or different kinds of gastrointestinal cancers, liver cancer are big ones. And we know that more than 30,000 Americans die each year from cirrhosis that is caused by alcohol. Finally, it can also really affect people’s sleep.
Alcohol disrupts that deep sleep, that REM sleep cycle that is important. Alcohol withdrawal in particular can also cause dehydration and volume depletion, electrolyte imbalances and disturbances that also then become problematic. And the one thing that I also just really want to make sure to highlight is that alcohol, obviously during pregnancy, is something that has long been known to be a significant issue not only for the mother but also for the developing fetus. Fetal alcohol syndrome is something that I think we don’t necessarily talk enough about and is becoming also increasingly recognized as something that affects a lot of people across the country. And it doesn’t necessarily always result from a mother who has a severe alcohol use disorder. It can depend on when in the pregnancy the woman is drinking, how much at a given time and just various factors.
How do we begin to treat these issues and are these treatments evolving?
We’ve talked about the importance of screening and also that brief intervention piece so that we’re really identifying people who may be at risk for those negative consequences and then helping to intervene early and before something gets much more serious. For people then who have moderate to severe alcohol use disorder, there are some medications along with many of those behavioral interventions. So, using motivational interviewing techniques. That’s a really important piece of that behavioral intervention. And then there’s something called cognitive behavioral therapy, which also helps to provide people with a lot of understanding of how alcohol use disorder can be triggered by all of the various settings and people and things that emotions, for example, trigger those cravings.
That is a very well-tested and well-evidenced approach that really can help people reshape and reset their thinking around alcohol use and provide some different options for how they can then actually manage all of those triggers and those cravings that will happen, but in a different way. And that’s where a lot of this peer support comes in, a lot of the other pieces of social connectedness, social support. I also mentioned the medications. We do have some FDA-approved medications like Disulfiram and Antabuse. Disulfiram is one of those older medications that is designed to essentially make people sick because it interferes with the metabolism of the alcohol in the liver, but it will make people sick if they drink while they’re taking that medication. That isn’t used as much anymore because when people do get sick from taking Disulfiram and then drink or even have any alcohol exposure, that often can land them in the hospital. So, that may be an option for people who are very motivated to completely abstain from alcohol. There’s another medication called Naltrexone that comes in a tablet as well as a monthly injection that was FDA-approved several decades ago really for the prevention of recurrence of alcohol use disorder. And that seems to have some good effect on several different individuals. And then finally, there’s another medication called Acamprosate that people can take to help reduce some of those cravings that they get from alcohol. The challenge with all these medications is that their effectiveness is not as great as we would like, particularly when you compare them to some other medications that we have for other types of substance use disorders. But they can certainly provide some benefit to individuals. There’s not a lot of great evidence of who will do best with which medication. And to some extent, some of the recommendations are that it’s an individualized decision between the individual and their healthcare provider as to which one they might want to try.
Are we evolving better treatments?
There’s always room for more. Disulfiram was the oldest one for a long time. That was really the primary one that we had. And then came along Naltrexone and Acamprosate. There is now some signal that some of the newer obesity-related medications also may have some benefit, particularly for alcohol use disorder. But I think that there’s a lot more research that needs to be done there before we can say that that’s something that we should be adding to our arsenal.
What are the biggest misconceptions tied to this disorder?
One of the biggest misconceptions is that people who have an alcohol use disorder, particularly that moderate to severe form, can stop on their own and that it is something that is their choice. That it’s somehow their fault, their moral failing that they have this use disorder. It is a health condition that has risk factors and it is something where there are significant consequences and mortality related to alcohol use disorder. The other important thing for people to understand is that we have effective treatments. And there’s a lot of interest in looking for additional treatments that can be even more effective than the ones we have currently. Also, recovery happens and people can and do recover from this. Some of the data that we have from SAMHSA is that there are millions and millions of Americans who are thriving and living healthy and productive lives in recovery and experiencing well-being. And so, there is hope. There’s a lot of reason for hope and if people are worried about their family, friend or coworker, there are also resources out there to help support those individuals and to further help their loved ones and help them understand that this is a chronic health condition often that can have recurrences, but the people really can and do recover.
I think one of the things that we’re excited about is that for the first time, we’re launching something called January Substance Use Disorder Treatment Month in January. For the first time, that will be a national month to help raise awareness around what substance use disorders are, including alcohol use disorder and some of the treatment options that are available and what family and friends can do, as well as what the individual can be thinking about. And then also really importantly, what the healthcare professional can do to be a big part of the solution to all of this. And to be able to treat this health condition as the health condition that it is.
About Dr. Yngvild Olsen
Dr. Yngvild Olsen serves as the Director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA). She has a long history of working within the addiction treatment field to expand access to care and enhance quality. She began her career as the Medical Director for the Johns Hopkins Hospital’s outpatient substance use treatment services while a full-time Assistant Professor in the Department of Medicine at the Johns Hopkins School of Medicine. She subsequently served as the Deputy Health Officer for Maryland’s Harford County Health Department, where she led a modernization of publicly funded substance use treatment services in collaboration with state and local partners.
Please visit SAMHSA to learn more.
