Tag: alcohol use disorder

06/25/24

Increasing Your Awareness of Alcohol Misuse

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Here’s a random statistic for you, according to Capital One. Did you know that Americans spent $3.9 billion on alcohol (mostly beer) for the Fourth of July in 2022? So, what’s the problem with that? Well, the CDC published a study in March of 2024 that estimated an average of 138,000 people died annually from alcohol-related causes in 2016-2017, which increased to 178,000 in 2020 to 2021. The causes included motor vehicle accidents, alcohol poisoning, cancer and cirrhosis.

The PBS News Hour said the main factor for this increase was the COVID-19 pandemic. Alcohol became easier to purchase with the rise of home delivery services, according to Dr. Michael Siegel, of Tufts University. The stress, loss of life from the virus, and isolation from family and friends contributed to mental health struggles that led many people to self-medicate with alcohol. He thought this rise in alcohol-related deaths was “most likely to hold steady,” unless the U.S. takes actions like raising taxes on alcohol to bring down consumption, which has worked in other countries. According to NIAAA, the 2022 National Survey on Drug Use and Health (NSDUH) said 29.5 million people over the age of 12 (10.5%) had an alcohol use disorder in the past year.

The CDC has something called ARDI, the Alcohol-Related Disease Impact Application, where you can see national and state estimates of alcohol-related health impacts, including alcohol-attributed deaths, years of potential life lost, and estimates of the proportion of death from various causes attributed to alcohol. For example, in Pennsylvania there were a total of 6,624 deaths due to excessive alcohol use. Among the chronic causes of death, 787 were due to alcoholic liver disease (520 from cirrhosis), 699 due to hypertension in a total of 1,472 deaths caused by heart disease and stroke. Among acute causes of death there were 382 from motor vehicle traffic crashes, 371 from suicide, and 291 from homicide.

The CDC study of deaths from excessive alcohol use from 2016-2021 is here. The study found that the annual number of deaths from excessive alcohol use increased nationally by more than 29% from 2016-2017 to 2020-2021. There were 12,719 deaths from alcoholic liver disease, and 37,317 from heart disease and stroke. Acute causes of death included 15,055 from motor vehicle crashes, and 9,801 from suicides.

There were increases in the alcohol-related deaths for all age groups. The article suggested that over one in eight total deaths of adults aged 20-64 were from excessive alcohol use. Death rates were highest in men and adults aged 50 to 64, but are increasing more rapidly among women and younger adults. See the following graphs taken from the CDC study.

The nearly 23% increase in the deaths from excessive alcohol use that occurred from 2018–2019 to 2020–2021 was approximately four times as high as the previous 5% increase that occurred from 2016–2017 to 2018–2019. Increases in the availability of alcohol in many states might have contributed to this disproportionate increase. During the peak of the COVID-19 pandemic in 2020–2021, policies were widely implemented to expand alcohol carryout and delivery to homes, and places that sold alcohol for off-premise consumption (e.g., liquor stores) were deemed as essential businesses in many states (and remained open during lockdowns). General delays in seeking medical attention, including avoidance of emergency departments for alcohol-related conditions; stress, loneliness, and social isolation; and mental health conditions might also have contributed to the increase in deaths from excessive alcohol use during the COVID-19 pandemic.

The prevalence of binge drinking among adults aged 35-50 was higher in 2022 than in any other year of the past decade, and could contribute to future increases in alcohol-related deaths. Binge drinking is a pattern of drinking that brings your blood alcohol content (BAC) to .08% or higher. This happens when a woman has four or more drinks or a man has five or more drinks within 2 hours. The CDC said most people who binge drink are not dependent on alcohol. Binge drinking is most common among younger adults aged 18-34 and more common among men than women. See the following graph.

A small percentage of adults who drink account for half of the 35 billion total drinks consumed by US adults yearly. Twenty-five percent of binge drinkers do so at least weekly, and 25% consume at least 8 drinks per occasion. Proven strategies to prevent excessive alcohol use and the related harms include: increase alcohol taxes; enforce laws prohibiting alcohol sales to minors; hold retailers accountable for harms the result from illegal serving or selling alcohol; avoid the privatization of alcohol sales; maintain limits on the days and hours when alcohol can be sold; and regulate the density of alcohol retailers. See “Excessive Alcohol Use” by the CDC.

See the following CDC data table for the number of drinks consumed on an occasion when people binge drink (the black circle is for Washington DC):

Older Adults Are Drinking More Alcohol

The rise in drinking is particularly concerning for people 65 and older, with greater health impacts. Dr. George Koob, the director of the National Institute on Alcohol Abuse and Alcoholism, said this is a particular concern for women. He said Baby Boomers (born between 1946 and 1964) have always tended to drink more, as well as use other drugs, “so the percentage of older people who drink is going up.” The number of people who binge drink, develop alcohol use disorder, and die from alcohol is on the rise. This could place an increased burden on our healthcare system, according to Dr. Koob.

Bodily changes as you age make you more susceptible to some of the harms from drinking alcohol. Your tolerance for alcohol drops. People in their 70s aren’t going to react to alcohol in the same way they did in their 30s. There is a decrease in the enzyme that metabolizes alcohol, meaning the response to a drink will be stronger in older people as their metabolism gets slower. There is a reduction in the percentage of water in the bodies of older people, leading to a higher blood alcohol concentration.

There is also a larger impact on the driving performance, reaction time, memory and balance in older than younger drinkers. “Balance is particularly a problem considering that the leading cause of injuries among adults ages 65 and older — and studies suggest falls while intoxicated tend to be more severe.” Ninety percent of older adults are taking at least one medication regularly, and combining them with alcohol can be risky. Dr. Koob said a study found that older adults are more likely to experience depressed breathing than young adults from a combination of alcohol and opioids. And alcohol can weaken the body’s ability to fight off infections, like with COVID-19.

It can be harder to spot problem drinking in older adults who are retired, live alone or socialize less, as the signs are less overt. The current Dietary Guidelines for Alcohol given by the CDC are one drink or less daily for women and 2 drinks or less daily for men. Less is better, according to Dr. Koob:

We believe that people at any age could benefit from stepping back and taking a look at their current relationship with alcohol. We also think that cultivating alternatives to alcohol use for relaxation, socializing, and dealing with stress can result in less alcohol use and better health.

April is Alcohol Awareness Month and older adults are at a heightened rick of alcohol misuse due to a variety of environmental, medical and social factors. See the Alliance for Aging Research for an interview with Dr. Koob. Embedded in the article is a YouTube video of the interview.

11/30/21

Not as a Stand-Alone Therapy

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The pharmaceutical company Alkermes began planning an alcohol dependency awareness campaign before the pandemic, but its launch in May of 2021 coincidently happened to overlap with the publicity of increasing of alcohol use and misuse during the pandemic. Fierce Pharma noted that while all drinking is not problematic, spikes in binge drinking particularly among women, are causes for concern. The Alkermes campaign emphasizes that alcohol dependence is a disease, not a moral failing. The VP and general manager of addiction marketing at Alkermes said, the disease model was useful for people to see problem drinking as a medical condition, “that there are medical criteria that you can assess and look at your own situation and make informed choices.”

The campaign initially centered on a new website that asks on the front page, “Is it time to rethink your relationship with alcohol?” There are personal stories of people’s “journey with alcohol dependence and recovery.” There is a link to a questionnaire developed by the National Institutes of Health (NIH) that was based on the criteria for alcohol dependence outlined in the DSM-IV. Finally, there is a link to “Learn more about a treatment option,” which leads you to a separate website for Alkermes’ addiction drug, Vivitrol. But there is more going on here than just following a breadcrumb trail from a public service campaign to a treatment option for alcohol dependence.

If you follow the link to the Vivitrol website, you are asked if you are ready for the next step in your recovery. What follows is largely a repeat of information that is contained in the medication guide for Vivitrol. Even though this Alkermes ad campaign is aimed to treat alcohol dependence, there is a significant amount of time spent there describing and discussing the risk of opioid overdose and sudden opioid withdrawal. What you won’t find on the website is information on exactly how Vivitrol treats alcohol dependence! Why would a marketing campaign for an alcohol dependence treatment spend so much effort cautioning against how Vivitrol could create safety issues with opioids?

Because Alkermes has been known to gloss over safety risks in its promotion of Vivitrol to treat opioid addiction. Not only is Vivitrol used to treat alcohol dependence, it is also approved as a medication-assisted treatment for opioid use disorder.

The FDA previously cited Alkermes in a warning letter for omitting safety risks in an ad for Vivitrol. “In the letter, the agency said it had contacted the company twice before issuing the warning.” The FDA was concerned enough with Alkermes’ apparent disregard of it previous letters that it also issued a press release that announced this action. The press release said Alkermes had omitted warnings about the most serious risks associated with the drug from promotional materials.

While the print advertisement contains claims and representations about the drug’s benefits, it fails to adequately communicate important warnings and precautions listed in the product labeling, including vulnerability to opioid overdose, a potentially fatal risk.

What you won’t find on the new Vivitrol website or in the Vivitrol medication guide is information on exactly how it treats alcohol dependence and what are the specific concerns in using Vivitrol to treat alcohol dependence. The active ingredient in Vivitrol is naltrexone, which has been used to treat alcohol use disorder for over twenty years. It works by suppressing cravings for alcohol and opioid drugs. It does this by binding to opioid receptors in the person’s brain, which also removes any opioid drugs binding with these receptors and can precipitate sudden opioid withdrawal. The medication guide for Vivitrol cautions that anyone receiving the drug should be opioid-free for at least 7 to 14 days before receiving Vivitrol, since the injection “may cause you to suddenly have symptoms of opioid withdrawal.”

The American Addiction Centers website said the following about naltrexone and naltrexone’s effectiveness:

Individuals with moderate to severe alcohol use disorders [i.e., alcohol dependence] who are using naltrexone may experience withdrawal symptoms if they stop drinking that can be potentially fatal due to the development of seizures. These individuals should consult with an addiction medicine physician or psychiatrist before discontinuing their use of alcohol. Research findings are mixed, but overall, they tend to support the notion that individuals who use naltrexone to treat alcohol abuse reduce the total amount of alcohol they consume and observe a reduction in the number of times they drink alcohol. In addition, heavy drinkers often notice significant reductions in alcohol use. However, the research does not indicate that the use of naltrexone is effective at assisting individuals in remaining totally abstinent, but it does most likely result in a significant reduction in cravings for alcohol and an overall reduction in the amount of alcohol consumed.

Counterintuitively, naltrexone products like Vivitrol are not effective in helping someone abstain from alcohol. But as the American Addiction Centers website noted, it is used in the Sinclair Method to help the individual reduce their alcohol intake. This “treatment” method actually encourages individuals to drink, but only after taking naltrexone before they start drinking. Naltrexone blocks endorphins from being released when alcohol is consumed. Endorphins are naturally occurring opiates in the brain. “When the endorphins are blocked, there is no ‘buzz’ or rewarding experience, and the alcohol doesn’t make you feel the pleasure that drives you to drink excessively.”

The Sinclair Method sees alcoholism as primarily a learned behavior that can be extinguished by naltrexone systematically closing off this reward circuit in the brain. But naltrexone (as ReVia or Vivitrol) does not close the door on how alcohol effects functional impairments, such as a loss of motor coordination, decreased response time, slowed rate of thinking and judgement. ReVia is a tablet or capsule of naltrexone that you take about an hour before you plan to drink and can be skipped if you plan on drinking and want to feel the euphoria from drinking. With Vivitrol, you have some level of naltrexone in your system for up to a month, meaning that the blocking effect when drinking is stronger the closer you are to when you received your Vivitrol shot.

Vivitrol may be effective in reducing your overall alcohol intake when drinking, but it does not seem to be effective in helping you remain totally abstinent. Moreover, if your alcohol intake is substantial enough, and Vivitrol successfully helps you reduce your craving for alcohol and the amount of alcohol you consume too rapidly, using it can result in seizures and other alcohol withdrawal symptoms. If you use or abuse opioids along with drinking alcohol, Vivitrol can also throw you into sudden opioid withdrawal. It also decreases your tolerance level for opioids and makes you vulnerable to opioid overdose, if you use opioids.

Above, I noted where the Alkermes campaign for Vivitrol as a treatment for alcohol dependence emphasized it was a medical condition with criteria that could be assessed by an individual as they make an informed choice on whether Vivitrol was right for them. Alcohol dependence is never just a medical condition. And recovery is not simply learning to abstain or drastically curtail your alcohol use. It is also about making radical changes in your feeling, thinking and behavior around alcohol. To its credit, Alkermes did emphasize that for Vivitrol to be effective, it must be used with other alcohol or drug recovery programs. So, Vivitrol may work in some cases with alcohol abuse, but not as a stand-alone therapy for alcohol dependence.

Remember the final advice Alkermes gives: “Vivitrol may not work for everyone.”

11/9/21

The Unseen Surge of Alcohol Use

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Although the increase in overdose deaths preceded the COVID pandemic, the pandemic seems to have accelerated the trend. In December of 2020, the CDC reported that drug overdose deaths in the U.S. rose 29.4% that year, mostly from illicitly manufactured fentanyl. Overdose deaths involving psychostimulants increased 10 times from 2009 to 2019. This increase was a mixture of opioids and psychostimulants as well as psychostimulants alone. But all the attention on these two drug classes seems to have overlooked the unseen surge of COVID-related increases with another drug—alcohol.

Using death certificate data from the National Center for Health Statistics, White et al found that almost 1 million people died from alcohol-related causes between 1999 and 2017. The number of death certificates mentioning alcohol more than doubled during that time frame. The Director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), George Koob, said:

Alcohol is not a benign substance and there are many ways it can contribute to mortality. The current findings suggest that alcohol-related deaths involving injuries, overdoses, and chronic diseases are increasing across a wide swath of the population. The report is a wakeup call to the growing threat alcohol poses to public health.

The researchers found that nearly half of alcohol-related deaths were from liver disease (31%) or overdoses on alcohol alone or with other drugs (18%). By the end of the study, alcohol-related deaths were increasing among people in almost every age, racial and ethnic group. Death rates increased for women (85%) more than men (35%). Women also appeared to be at a greater risk for several alcohol-related consequences than men—including cardio-vascular disease, liver disease, alcohol use disorder. Dr. Koob said:

Taken together, the findings of this study and others suggests that alcohol-related harms are increasing at multiple levels – from ED visits and hospitalizations to deaths. We know that the contribution of alcohol often fails to make it onto death certificates. Better surveillance of alcohol involvement in mortality is essential in order to better understand and address the impact of alcohol on public health.

The researchers said alcohol-related deaths were highest among males, individuals between 45 and 74 years of age, and non-Hispanic American Indians or Alaska Natives. Rates increased for all age-groups except 16 to 20 and 75 and over. The largest increase was among non-Hispanic White females. These findings confirm the increasing burden of alcohol on public health.

On his blog, William White observed how the alarm over recent drug surges with opioids and methamphetamines could be obscuring surges in alcohol consumption and its related consequences. In addition to the White et al study, William White also referred to Sherk et al, whose researchers found that even light or moderate alcohol consumption increased the risk for a number of health consequences, including cancer, heart disease and traumatic injuries. More than one quarter (27%) of alcohol-related hospital stays were experienced by individuals who drank within the weekly guidelines.

The low-risk drinking guidelines for men were no more than 14 drinks per week and no more than 4 drinks per day. Low risk guidelines for women were no more than 7 drinks per week and no more than 3 drinks per day. Sherk et al concluded drinkers who followed weekly low-risk drinking guidelines were not immune from harm. They suggested guidelines of one drink per day for both sexes. The researchers clearly demonstrated that alcohol abuse and the related consequences were increasing before the COVID pandemic.

Alcohol Abuse and COVID

As stay-at-home orders began in some US states to lessen COVID-19 transmission in March of 2020, Nielsen reported a 54% increase in national sales of alcohol for the week ending Mach 21, 2020. The World Health Organization warned that alcohol use could potentially worsen health vulnerability, risk-taking behaviors, mental health issues and violence. The WHO suggested existing rules and regulations to protect health and reduce the harm caused by alcohol, such as restricting access, should be reinforced during the COVID-19 pandemic. “Any relaxation of regulations or their reinforcement should be avoided.”

Pollard, Tucker and Green looked at “Changes in Adult Alcohol Use and Consequences During the COVID-19 Pandemic in the US.” The data were collected using the RAND Corporation American Life Panel (ALP), a nationally representative, probability-sample panel of 6,000 participants. A sample of 2,615 ALP members ages, 30-to-80, were invited to participate in the baseline survey.

Comparisons before and during the COVID-19 pandemic were made on the number of days participants reported any alcohol use and heavy drinking, and the average number of drinks consumed over the previous 30 days. Heavy drinking was defined as 5 or more drinks for men and 4 or more drinks for women within a couple of hours. Adverse consequences were assessed by the 15-item Short Inventory of Problems associated with alcohol use in the previous 3 months. Comparisons were made overall, and across self-reported sex, age, and race/ethnicity.

These data provide evidence of changes in alcohol use and associated consequences during the COVID-19 pandemic. In addition to a range of negative physical health associations, excessive alcohol use may lead to or worsen existing mental health problems, such as anxiety or depression, which may themselves be increasing during COVID-19. The population level changes for women, younger, and non-Hispanic White individuals highlight that health systems may need to educate consumers through print or online media about increased alcohol use during the pandemic and identify factors associated with susceptibility and resilience to the impacts of COVID-19.

It does seem that concern with overdoses from opioids and methamphetamine in the midst of COVID overshadowed the growing problem with increasing alcohol consumption and its related consequences during the pandemic. William White observed that alcohol use is historically pervasive in the U.S. and “so infused into the cultural water in which we all swim that we fail to see it. That blindness has exacted, and continues to exact, an enormous toll on individuals, families, and communities.” The findings of the above discussed research studies reinforce the need for continued efforts with public and professional alcohol-related education, alcohol treatment resources, screening for alcohol problems and recovery support for individuals and families effected by alcohol use disorders. We cannot let concerns with the pandemic or opioid epidemic draw our attention away from the growing problem with alcohol-related deaths.

10/26/15

Doubling Up Your Drinking

© willeecole | stockfresh.com
© willeecole | stockfresh.com

Would you like to be able to double the amount of alcohol that enters into your bloodstream when you drink? Let’s say you consume the equivalent of two standard drinks containing one ounce of alcohol. Your blood alcohol level (BAL) would double and you would likely exceed the legal driving limits in thirty minutes. Oh, and you would feel drunker as well. Does this sound crazy? Yet that is exactly what happens to someone who has had gastric bypass surgery.

A recent 2015 study, “Effect of Roux-en-Y Gastric Bypass Surgery,” published in JAMA Surgery evaluated the physical and subjective effects of ingested alcohol on individuals who had received a common from of gastric bypass surgery called Roux-en-Y gastric bypass. The find is from a small study of 8 obese women who had undergone the surgery and 9 obese women who had not yet had the surgery. All the women consumed the equivalent of two standard alcoholic drinks or two placebo nonalcoholic drinks in two 10-minute drinking sessions.

HealthDay reported that the researchers measured the blood alcohol concentration (BAC) levels of the participants. “Drunkenness” was measured by matching each participant’s behavior to an “Addiction Research Center Inventory.” BAC levels rose much faster in the bypass group and peaked at levels twice those seen in the non-bypass group. The BAC levels of the bypass group also exceeded legal driving limits for thirty minutes after consuming their second drink. “BAC levels never exceeded legal driving limits among the non-bypass group.”

Feelings of drunkenness were also greater in the bypass group. Using criteria developed by the U.S. National Institute on Alcohol Abuse and Alcoholism, the researchers concluded that just two drinks were the equivalent of a binge-drinking episode with the potential risk of an alcohol use disorder. Dr. Samuel Klein, one of the study’s authors, said:

This surgery literally doubles the amount of alcohol that immediately enters your bloodstream. . . . And it also increases the patient’s long-term risk for alcoholism, because the risk for a binge episode of drinking goes up. And we know that binge drinking increases the risk for going on to develop alcoholism in the future.

Although Klein and his team used a more rigorous methodology than had been used before, the study’s finding isn’t new. Dr. John Morton, chief of bariatric and minimally invasive surgery at the Stanford University School of Medicine, said this was a well-known phenomenon.  “It’s about physiology,” he said. There is an increased sensitivity to alcohol because the surgery removes alcohol receptors in the stomach. These receptors are also found in the liver. “And if you bypass and remove a portion of either of these, you have a change in blood alcohol levels.”

ScienceLine reported on a woman who lost 180 pounds within a year of her gastric bypass surgery in 2009. She started ordering wine in place of dessert at dinner so she wouldn’t sit there ‘”twiddling my fork” while others ate their dessert. The occasional glass of wine became more often and she spent the next two years fighting an alcohol use disorder. She began drinking at home alone, two bottles of wine per occasion. She began hiding bottles from her husband, driving while drunk and blacking out when drinking. She discovered injuries she didn’t remember getting.

A 2012 study, “Prevalence of Alcohol Use Disorders Before and After Bariatric Surgery,” found that while alcohol use disorder (AUD) symptoms were not significantly different one year after the surgery, they were significantly higher in the second postoperative year. The presence of an AUD in the year before surgery substantially increased the odds of an AUD in the first two postoperative years. “Regular alcohol consumption prior to surgery also independently increased the likelihood of postoperative AUD.” One in 8 participants reported consuming at least three drinks per typical drinking day; and 1 in 6 participant said they drank at a hazardous level in the second postoperative year.

A 2013 Swedish study, “Alcohol Consumption and Alcohol Problems After Bariatric Surgery” did a long-term follow up of over 2,00 obese patients who had three types of bariatric surgery: vertical banded gastroplasty (VBG), banding and gastric bypass. The follow up time of the study ranged from 8 to 22 years. Alcohol consumption standards established by the World Health Organization (WHO) were used to assess the risk levels of alcohol consumption during the follow up period.

During the follow up time, 93.1% of the surgery patients and 96.0% of the controls reported alcohol consumption classified as low risk by the WHO. However, in comparison to the control group, the gastric bypass group had an increased risk of alcohol abuse diagnoses, alcohol consumption at least at the WHO medium risk level, and related alcohol problems. VBG also increased the risk of these conditions, while banding was not different from controls.

Another 2013 study, “Substance Use Following Bariatric Weight Loss Surgery,” looked at the course of substance use (alcohol, cigarettes, recreational drugs, and composite substance use), as measured by the Compulsive Behaviors Questionnaire. Participants completed questionnaires preoperatively and 1,3, 6, 12 and 24 months after surgery. There were no significant changes in participant’s reported frequencies of cigarette smoking or recreational drug use. However, there was a significant increase in alcohol use for participants who had undergone RYGB surgery, the same Roux-en-Y gastric bypass as reported above in the 2015 study by .

Because patients have a reduced tolerance for alcohol after RYGB surgery, they may experience the rewarding aspects of alcohol use sooner and more frequently, which may contribute to the increase in frequency of alcohol use after LRYGB surgery.

Steph Yin for ScienceLine noted that many patients are unaware of the risk of an alcohol use disorder when they get gastric bypass surgery. And scientists aren’t clear themselves on why the risk exists. An early theory was that of addiction transfer. People adopt new addictions after weight-loss surgery because they can no longer fulfill their food addictions. However, evidence like that above in “Effect of Roux-en-Y Gastric Bypass Surgery” suggests there may be an anatomical explanation. Namely that metabolic and hormonal changes triggered by gastric bypass leave patients particularly vulnerable to alcohol use disorders. It’s possible, said Yin, that both are right. Or maybe it’s something else entirely. We just don’t know at this point.

According to James Mitchell, a doctor and professor of neuroscience at the University of North Dakota, “Whether it’s addiction transfer or something else going on, we really don’t know at this point.” What is certain is that the high rates of alcohol use disorders in postoperative gastric bypass patients cannot be attributed to chance.