Alcohol Use Disorder: A Hidden Epidemic

While opioid use disorder and overdose deaths have received widespread attention in recent years, alcohol use disorder (a.k.a. alcoholism) has long been a hidden but deadly epidemic.

Alcohol was the most prevalent drug involved in drug-related ED visits in 2021 (39.33 percent of all drug-related ED visits), according to a report from the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Drug Abuse Warning Network.

Liver disease is the most widely known illness linked to excessive alcohol use; however, drinking can contribute to heart disease, stroke, and certain cancers such as breast cancer. Nationally, deaths in which alcohol was a contributing factor rose about 25 percent in 2020.

The COVID-19 pandemic exacerbated unhealthy drinking as people sought to cope with stress, loneliness, and isolation. Further, having alcohol delivered increased the likelihood of people drinking at home alone. Currently, 31 states permit alcohol to be delivered to homes. According to the Wall Street Journal, during the pandemic, many states relaxed rules limiting to-go drinks from restaurants and bars, and some allowed delivery of alcohol. Many of those laws have subsequently become permanent.

In my home state of Colorado, alcohol related deaths increased by nearly 30 percent in the first year of the pandemic. All states reported increases of varying degrees.

Some of the pandemic impacts are yet to be seen. In a study published in December 2021 in Hepatology, researchers project that a one-year increase of 21 percent in alcohol consumption during the COVID-19 pandemic will result in 8,000 additional deaths from alcohol-related liver disease, 18,700 cases of liver failure, and 1,000 cases of liver cancer by 2040. In the short term, alcohol consumption changes due to COVID-19 are expected to cause 100 additional deaths and 2,800 additional cases of liver failure by 2023.

Beyond mortality, alcohol use disorder can severely impact one’s health and mental well-being. Frequent or heavy drinking can lead to relationship issues and create problems at work or school. Alcohol depresses the central nervous system and can lead to mental health disorders or even suicidality.

So why is this a hidden epidemic? Why don’t we talk about it more? One reason alcohol use disorder does not get consistent attention as a fatal disease is because alcohol is legal, widely available, and socially acceptable. As someone who rarely uses alcohol, I have been in many social situations where people seemed to think it odd that I was not joining them for a drink. Ironically, this has been the case even among colleagues working in health and behavioral health care.

What should be done?

First and foremost, we need to change our cultural narrative and norms around alcohol. Legal does not necessarily mean safe. We need increased prevention and education about the health risks associated with excessive drinking.

Increased screening in health care and community-based settings would contribute to preventing disease, injury, and other negative consequences of alcohol. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an integrated health approach increasingly used in primary care settings. Screening tools such as the Alcohol Use Disorders Identification Test (AUDIT) or the CAGE 4-item questionnaire can help promote the early identification and treatment of people experiencing alcohol use disorders.

Comprehensive behavioral health care should be accessible and affordable for people with alcohol use disorders. An array of services, including counseling, skill-building, chronic disease self-management techniques, peer services, and support groups, are equally important as treatment for any health conditions brought on by alcohol use disorder. Residential treatment programs may be necessary for people with severe alcohol use disorder. While many states have or are expanding coverage of residential treatment for substance use disorders within their Medicaid programs, insurance barriers to substance use disorder treatment and residential treatment, such as strict medical necessity rules, continue to be prevalent. Increased parity enforcement would help people with alcohol use disorder access needed care.

Oral medications such as disulfiram or naltrexone can reduce the urge to drink, while long-acting injectable medicines such as Vivitrol may make it easier for people with alcohol use disorder to maintain sobriety. In December 2020, the Centers for Medicare & Medicaid Services (CMS)  made medication-assisted treatment coverage mandatory for state Medicaid programs.

Federal and state agencies should conduct additional research to understand the effectiveness of specific public policies to reduce excessive alcohol consumption while simultaneously increasing investment in treatment and recovery services. States could also explore policy solutions such as regulation of alcohol density, increased alcohol taxes, and restrictions on hours or days of sales.

Alcohol-induced deaths are largely preventable. We must act now to stop this hidden epidemic.