Psychologists are tackling the hidden epidemic of excessive alcohol use

Alongside the opioid overdose crisis, another hidden epidemic is quietly raging. Every year in the United States, more people die of alcohol-related causes than from opioids and other drugs. Even before the Covid-19 pandemic, rates of excessive alcohol use were high and getting higher. The stress and isolation of the pandemic appear to have worsened harmful drinking, at least for some groups. Alcohol-related deaths increased more than 25% from 2019 to 2020. Among adults under 65, more people died from alcohol-related causes in 2020 than from Covid-19 (White, A. M., et al., JAMA, Vol. 327, No. 17, 2022opens in new window).

On top of those many deaths, countless other people are impacted by alcohol’s ripple effects: car crashes, increases in violence and assault, riskier sexual behaviors, jobs lost, families fractured, and children’s lives made unstable by a parent’s dependence on a drug that is not just legal but celebrated.

“Alcohol is a very cheap, widely available, and socially acceptable drug,” said Katie Witkiewitz, PhD, director of the Center on Alcohol, Substance Use, and Addictions (CASAA) at the University of New Mexico. Against that backdrop, and the dizzying scale of the problem, efforts to address alcohol misuse can feel like drops in a bucket. But researchers are learning more about identifying people at risk for alcohol use disorder (AUD), opening doors to new paths for prevention. Psychologists are well positioned to make an impact—treating people for addiction and helping to address the stigma, societal beliefs, and mental health struggles that go hand in hand with drinking.

“Alcohol can be a cause of harm, but it’s also a barometer for other issues. Mental health in this country is in meltdown mode,” said Aaron White, PhD, a biological psychologist at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). “It’s common for people to drink excessively in an effort to cope. Alcohol use might be on the death certificate, but what’s often killing people is loss of hope.”

First, some good news. “We’re seeing that rates of alcohol use, which were higher during the pandemic, are coming down,” said Kate B. Nooner, PhD, a professor of psychology at the University of North Carolina Wilmington who studies prevention and treatment of AUD in children exposed to trauma. That reduction comes with a caveat. “Where things were before the pandemic was not good,” she says.

Roughly 29.5 million people in the United States have AUD, according to the Substance Abuse and Mental Health Services Administration. Heavy drinking costs the country more than $249 million annually (Sacks, J. J., et al., American Journal of Preventive Medicine, Vol. 49, No. 5, 2015opens in new window) and causes 232 million missed workdays each year (Parsley, I. C., et al., JAMA Network Open, Vol. 5, No. 3, 2022opens in new window).

Alcohol also takes a human toll. Between 2015 and 2019, excessive alcohol consumption contributed to about 140,000 deaths among adults ages 20 to 64 each year. Those deaths included acute causes like car crashes and alcohol poisoning, as well as chronic conditions such as liver disease or cancer. Put another way, alcohol was a factor in 1 in 8 deaths among 20- to 64-year-olds. And in people ages 20 to 49, 1 in every 5 deaths was related to excessive drinking (Esser, M. B., et al., JAMA Network Open, Vol. 5, No. 11, 2022opens in new window).

Historically, harms from alcohol use were more prevalent in men. Over the last few decades, though, women of all ages have been drinking more (Slade, T., et al., BMJ Open, Vol. 6, No. 10, 2016opens in new window). “Women are catching up to men,” White said. “In fact, among adolescents and college-age young adults, there’s been a recent reversal where a slightly higher percentage of females binge drink than males.”

Older adults, too, have been imbibing more in recent years, with older women in particular showing an upward trend between 2002 and 2018 (White, A. M., et al., Alcohol, Vol. 107, No. 1, 2023opens in new window). During the pandemic, older adults who reported symptoms such as depression and anxiety were more likely to increase drinking than their peers without mental health disorders (Eastman, M. R., et al., International Journal of Environmental Research and Public Health, Vol. 18, No. 8, 2021opens in new window).

Regardless of age or gender, drinking is associated with a host of harms. AUD can range from mild to severe, according to criteria described in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). But drinking can be harmful even for people who don’t meet the criteria for AUD. Excessive alcohol use is defined as more than two drinks a day for men and more than one drink a day for women. Those amounts are based on “standard” drink sizes—12 ounces of beer, 5 ounces of wine, or 1.5 ounces of spirits—which tend to be less than most people pour. Just one drink a day or less can increase the risk of some forms of cancer and heart disease, the Centers for Disease Control and Prevention warns.

Although alcohol can cause harm at low doses, certain patterns of use are more problematic than others. “There is variability in terms of what motivates a person to drink, even from one day to the next,” said Cassandra Boness, PhD, a research assistant professor at the University of New Mexico’s CASAA.

Some alcohol use is driven by so-called enhancement motives: drinking to relax at a party, for instance, or to socialize with friends. In other cases, a person might be driven by coping motives—drinking to reduce negative emotions, or to deal with difficulties like pain and stress. While both drivers can lead to AUD, coping motivations tend to be more often associated with dependence. “Most people who develop AUD aren’t drinking for fun,” said Aaron Weiner, PhD, ABPP, an addiction therapist and president of APA’s Division 50 (Society of Addiction Psychology). “They’re drinking to try to get through the day.”

Worryingly, though not surprisingly, it was coping drinking that tended to increase during the pandemic, Witkiewitz added. Drinking to cope can evolve into habit, and then dependence. “In the short term, people perceive that alcohol provides stress relief. But long term, excessive alcohol use can lead to greater stress, greater depression, and greater need for relief,” she said. “It’s a snowball effect.”

Researchers are making progress toward understanding the factors that put a person at risk of developing AUD. About half of the risk comes from environmental influences. One of the most influential is a history of trauma. Adverse childhood experiences significantly increase the risk of problematic alcohol use in adulthood (Hughes, K., et al., The Lancet Public Health, Vol. 2, No. 8, 2017opens in new window). A large body of research also shows a strong genetic component for AUD. “About 50% of why some people are more likely to develop AUD is due to differences in their DNA,” said Danielle Dick, PhD, director of the Rutgers Addiction Research Center.

The genetic contribution is complex, with thousands of variants that contribute to risk. Most people incorrectly assume that genetic risk is related to the physiology of how a person processes alcohol. “What we’ve learned is that most genes that influence substance use do so via pathways related to things like impulsivity and self-regulation,” Dick said. Those genes are also associated with other outcomes of risky behaviors, such as lung cancer or HIV infections. “If we’re thinking about prevention, we can’t just focus on alcohol. We need to get at the underlying risk factors,” she said.

Using powerful new genotyping technologies, Dick and her colleagues can calculate a polygenic risk score that looks across a person’s genome to create what she calls an index of genetic liability. “We can start to predict who might be at greater risk,” she said.

Other scientists are also investigating underlying factors like inhibitory control, the process by which people control their impulses. Jessica Weafer, PhD, an assistant professor of psychology at the University of Kentucky, is focusing on risk factors in women. “We’re seeing that among heavy drinkers, women actually have greater deficits in inhibition than men,” she said. In ongoing work, she’s exploring whether those deficits may be driven by neural differences or hormonal factors unique to women. “We know a lot about alcohol in general. But if we’re talking about personalized medicine, and all the individual differences in why people drink and how it affects them, there’s a lot we don’t know,” she said. “There are a lot of understudied populations, and we can’t take a one-size-fits-all approach to prevention.”

Researchers continue to hone the ability to identify those at risk of AUD. But tools are already available to intervene based on what is known so far. One example is the PreVenture Program, a brief intervention for teens developed by Patricia Conrod, PhD, a professor of psychiatry at the University of Montreal. The two-session, school-based intervention targets personality risk factors associated with substance use: hopelessness, anxiety, sensitivity, impulsivity, and sensation seeking. In clinical trials conducted in several countries, the intervention was shown to significantly delay and/or reduce drug and alcohol use among adolescents while improving mental health issues that often co-occur with substance misuse (Frontiers in Psychiatry, Vol. 9, 2018opens in new window).

Early interventions such as PreVenture may be particularly helpful for reshaping the underlying traits and behaviors that predispose a person to addiction and other negative outcomes, White noted. “If you start early, you can address the driving factors that can lead to a trajectory of substance use—you can try to heal the expression of genes altered by trauma,” he said. “Interventions that target college-age young adults can help address substance use behaviors, but it’s not the kind of reprogramming you can do at a very young age.”

The peak age for developing AUD tends to be in the mid-20s, though drinking can become problematic at any age. And people of all ages can learn to change their drinking habits. “No one wakes up one day with a sudden onset of AUD,” Dick said. “The encouraging piece is that there are plenty of opportunities to intervene.”

[Related: Why American youth are drinking more alone]

Historically, treatment for substance use has focused on the severe end of the spectrum. Cultural beliefs, too, tend to paint AUD as all or nothing: You have a serious drinking problem, or you don’t. That mindset means people with problematic substance use behaviors might not recognize their risk—and health care providers often miss chances to intervene. “We need to start moving people toward thinking of this as a continuum of alcohol use,” Witkiewitz said. “Pretty much wherever you are on that continuum, there are benefits to drinking less.”

That viewpoint is gaining ground. In 2022, leading addiction experts, including NIAAA director George Koob, PhD, released an opinion paper urging the field to adopt a diagnosis of “preaddiction” for people with mild to moderate substance use disorders (SUDs). Much as the concept of prediabetes improved early intervention for people at high risk of diabetes, the authors argued, a concept of preaddiction could improve diagnosis and treatment for those at risk of AUD and other SUDs (JAMA Psychiatry, Vol. 79, No. 8, 2022opens in new window).

Concepts of treatment are evolving. When people think about AUD treatment, they usually imagine peer-support programs such as Alcoholics Anonymous (AA). Indeed, evidence shows such 12-step programs are effective (Kelly, J. F., et al., Cochrane Database of Systematic Reviews, 2020opens in new window). Yet these programs are hardly the only option. “There are multiple things that can work for treating AUD, including psychological interventions such as cognitive behavioral therapy and motivational enhancement therapy,” said Keith Humphreys, PhD, a professor of psychiatry at Stanford University and former senior policy advisor in the White House Office of National Drug Control Policy. Besides AA, other mutual-help programs, such as SMART Recovery, have been gaining ground. Multiple medications have also been approved to treat alcohol dependence, by reducing cravings or triggering unpleasant side effects if a person drinks.

Beliefs about recovery have progressed, too. In 2022, scientists at NIAAA updated the definition of recovery from AUD. The new definition indicates that a person is “recovered” if remission from AUD and cessation from heavy drinking are achieved and maintained over time (Hagman, B. T., et al., The American Journal of Psychiatry, Vol. 179, No. 11, 2022opens in new window). What’s notably absent from that definition: abstinence. “The research has really moved toward harm reduction, and there’s a greater recognition of that in treatment studies that target nonabstinence as success,” said Witkiewitz.

There is also increasing understanding that a relapse in drinking is part of the process, Nooner added. “The path toward recovery is really not at all linear,” she said. “The more that’s understood and incorporated into treatments, the better—because it gives people hope on their path to recovery.”

When it comes to alcohol use, shifts in perceptions are no small thing. After all, drinking plays a starring role in American society—as both hero and villain. “Alcohol is really glorified in our culture, but at the same time there is so much stigma toward people with AUD. It’s an amazing and terrible dichotomy,” Witkiewitz said. “As mental health professionals, we can do a lot to break down that dichotomy.”

She sees reasons for optimism. More people are experimenting with cutting back, with movements like “dry January” and alcohol-free mocktails becoming mainstream. “It’s a great time for people to explore alternative ways of being social—even for people without AUD. Every time we reduce alcohol we experience better health,” Witkiewitz said.

Psychologists and other health professionals can also advocate for policies that reduce risky drinking. “Fear-based programs that try to scare people away from drinking aren’t effective. What we need are public health measures,” Boness said. Some states are considering policies such as reducing the density of stores that can sell alcohol in a given area, restricting advertising by the alcohol industry, or raising taxes on alcohol sales.

“Like gasoline, people consume more alcohol when it’s less expensive. And alcohol is very cheap in historical terms,” said Humphreys. Alcohol taxes have not kept pace with inflation. “Even without raising taxes, simply indexing alcohol taxes for inflation would result in less drinking—and probably less violence against women,” he said. In a culture where drinking is part of the social fabric, policies to increase taxes or limit advertising might seem like an uphill battle. But it is one worth fighting, Humphreys added—and mental health professionals are well positioned to help advocate for that change. “There was a time when the tobacco industry seemed politically invincible, but when enough deaths and destruction mount up, things can change. And we are losing an awful lot of people to alcohol,” he said.

Psychologists can also make inroads with patients by screening them for alcohol use and helping them address high-risk behaviors. “Screening is vital. It’s a low-hanging fruit for intervening on a bigger scale,” said Boness, who is comedical director of Project ECHO, a free continuing medical education program that provides training and mentoring support for health care providers treating patients with harmful alcohol use and co-occurring medical and psychiatric problems.

Psychologists can do a lot, but they cannot do it all. In people with AUD who stop drinking suddenly, alcohol withdrawal can be dangerous, even deadly. Supervised detoxification should be managed by a physician. Still, psychologists can work with patients to help them consider their alcohol use and take steps to reduce drinking, even if abstinence is not their goal. Clinicians can also address the mental health problems that often coincide with substance use, and draw from their suite of behavior-change techniques to help people develop new coping mechanisms.

Unfortunately, there is often too little training on addiction in psychology graduate programs and ongoing professional development, and many psychologists are reluctant to address AUD. That is a missed opportunity, Humphreys said. “We are the behavior-change profession, and everything we learn about helping people with behaviors—depression, anxiety, weight loss, managing diabetes—is directly applicable to addressing alcohol problems,” he said. “If you do therapy, you have two choices: You can treat alcohol problems explicitly, or you can pretend you’re not treating alcohol problems. But you can’t avoid them.”