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New Study Reveals Sharp Spike in Alcohol Use Disorders

From the latest version of the largest and most ambitious survey ever done on alcohol, drug, and co-occurring psychiatric disorders – called the National Epidemiologic Survey on Alcohol and Related Conditions, or NESARC-III – a new study published in JAMA Psychiatry reports that nearly 30% of adults in the United States have had an alcohol use disorder (AUD) at some time in their lives. However, only a small percentage seek professional treatment or other help – for instance, from Alcoholics Anonymous. The study also reveals a significant increase in AUDs over the last decade.

How the Study Was Conducted

For NESARC-III, in 2012-2013 more than 36,000 people from all walks of life were asked in face-to-face interviews a battery of questions about their present and past alcohol, drug, and tobacco problems; use of addiction treatment services; and psychiatric disorders. Because NESARC participants are a large representative group of people selected at random, findings from the survey can be generalized.

…more than 36,000 people from all walks of life were asked in face-to-face interviews a battery of questions about their present and past alcohol, drug, and tobacco problems; use of addiction treatment services; and psychiatric disorders.-Anne FletcherThe first NESARC study was conducted in 2001-2002, when the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) was used to assess alcohol and drug problems. DSM-IV divided alcohol and drug disorders into two distinct categories – abuse and dependence, with different criteria for each.

The DSM-5, released in 2013, integrates abuse and dependence into a single disorder – substance use disorder, generally speaking, and according to specific drugs, such as alcohol use disorder and cocaine use disorder. The DSM-5 then categorizes the disorder according to the number of any of 11 criteria a person meets – mild use disorders are defined by 2 to 3 criteria, moderate by 4 to 5, and severe by 6 or more. Criteria include failure to meet work, social, or family obligations because of substance use; continued use despite persistent negative consequences; tolerance (needing more chemical to get the desired effect); regularly taking a substance in larger amounts or over a longer time than intended; devoting a lot of time to getting, using, or recovering from the effects of a substance; withdrawal (physical or mental symptoms if the drug is abruptly stopped); craving; and several others.

Study Findings

The JAMA Psychiatry study, led by the National Institutes on Alcohol Abuse and Alcoholism’s (NIAAA) Bridget Grant, Ph.D., was designed not only to study prevalence of alcohol use disorders (and related drug and mental health problems) using the newer DSM-5 criteria but also to apply the old DSM-IV criteria to participants’ responses (a way of comparing apples to apples) to see if people are experiencing more or fewer alcohol use disorders over the decade between the first NESARC and NESARC-III.

Using the newer DSM-V criteria, Grant and colleagues found that about 14% of adults met AUD criteria during the previous year, while 29% met AUD criteria at some time in their lives. Lifetime prevalences of mild, moderate, and severe AUDs were 8.6%, 6.6%, and about 14%, respectively. In general, men, Native Americans, and lower income people were more likely to have AUDs.

Compiling the Available Information

Certainly, finding that nearly 30% of Americans report having an AUD at some time in their lives is striking. But results from comparisons with past research, as well as other findings from the new study, offer even more cause for concern…

  • Alarmingly, when the researchers applied the same diagnostic criteria (DSM-IV) to both the older and newer NESARC groups (the apples to apples comparison), they found that the percentage of people with AUDs has gone up markedly. Specifically, NESARC participants studied in 2001-2002 reported recent (past-year) and lifetime rates of AUDs of about 9% and 30%, respectively. In contrast, past-year and lifetime AUD rates for those studied in 2012-2013 jumped to nearly 13% and 44%, respectively. Grant and her colleagues suspect that this may reflect increases in heavy alcohol drinking during that period. (They cite other research documenting how much heavy drinking has increased in both men and women over the same decade.)

While some experts expressed concern that the DSM-V would result in more people being unnecessarily diagnosed with an alcohol use disorder – and perhaps coerced to go to treatment or 12-step groups – a study from earlier this year involving the NESARC-III subjects showed that, while past-year prevalence of alcohol use disorders were higher when applying the DSM-5 criteria than when applying DSM-IV criteria, lifetime prevalences were lower under DSM-5.

  • Findings in young adults are particularly alarming. “Especially striking,” say the researchers, is the 7% past-year rate of severe AUDs among 18- to 29-year-olds (about 27% had any AUD), suggesting an urgent need for more effective prevention and intervention efforts among young adults. They note that the average age of onset of an AUD was about 24 for severe AUDs. (People younger than 18 were not included in NESARC.)
  • Not surprisingly, certain psychiatric problems and AUDs were found to go hand-in-hand. Significant associations were found between recent and lifetime AUD and major depressive disorder, specific phobia, bipolar I disorder, as well as antisocial, borderline personality disorders, and other substance use disorders across all levels of AUD severity. (Other psychiatric problems, such as PTSD and generalized anxiety disorder were associated with lifetime AUD as well.) The researchers statistical analyses suggests that common causal factors underlie co-occurring AUDs and certain mental health disorders, which may help to identify risk factors.
  • Finally, the study revealed that the vast majority of people with alcohol use disorders don’t seek treatment or other help – only about 20% of individuals with an AUD do so at some point in their lives. The most common source of help was from 12-step groups, although aid from health practitioners ranked high for those who sought help in the past year, as did rehabs, outpatient clinics, and health care professionals for those who had ever had an AUD.

In the NESARC-III, the mean age at first treatment of DSM-5 AUD was 29.4 years, representing a 3-year lag between the average age at onset (26.2 years) and treatment, suggesting that there’s likely a critical time when individuals might receive some low-intensity help before it “gets really bad.” The researchers briefly address a form of such treatment called brief intervention, but it’s not widely available. Unfortunately, few treatment resources are available for people with mild and for many with moderate AUDs.

…prior NESARC findings show that participation in 12-step groups increases the likelihood of recovery. However, much of formal addiction treatment has not been found to be effective as it’s administered in the U.S..-Anne Fletcher

Grant and her colleagues also refer to “a large body of literature” that supports the effectiveness of treatment (no reference given) and prior NESARC research shows that participation in 12-step groups increases the likelihood of recovery. However, much of formal addiction treatment has not been found to be effective as it’s administered in the U.S., as my findings from Inside Rehab revealed. The groundbreaking 2012 National Center on Addiction and Substance Abuse at Columbia (CASA Columbia) report on the state of addiction treatment titled “Addiction Medicine: Closing the Gap Between Science and Practice” concluded that “the vast majority of people in need of addiction treatment do not receive anything that approximates evidence-based care” and that “only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”

As for the study, the NESARC researchers refer to supporting 12-step participation, although it found a strong positive impact of recent help-seeking that included 12-step participation, it’s worth noting that the majority of individuals who achieved recovery did not access any form of treatment or 12-step participation.

If we want to see fewer substance use disorders out there and, when they do occur, want them to be more effectively resolved, it’s high time we get away from the “party lines.” Refreshingly, in an article by the Associated Press, George Koob, Ph.D., director of NIAAA, was quoted as saying, “There’s a lore that there’s only Alcoholics Anonymous out there, and that’s not true.”

Special acknowledgment goes to Dan Kivlahan, Ph.D., substance use disorder researcher extraordinaire with Seattle VA Medical Center and the University of Washington for his help with this article.

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