Risk Factors: Varied Vulnerability to Alcohol-Related Harm

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    Takeaways

    • Knowing which patient groups are at greater risk for alcohol-related harm can reinforce your efforts to conduct careful screening, assessment, advising, and referral.
    • Risks for alcohol-related harm vary by a wide range of factors, including your patient’s age, gender, sexual minority status, genes, mental health, and exposure to trauma or other stressors.
    • While being cognizant of varied vulnerabilities, it’s best to adopt a “we screen everyone” approach. See the Core articles on screening and practice change.

    A common but misguided stereotype of a person with alcohol-related problems is of someone who is “down and out.” People across all walks of life, however, are vulnerable to developing problematic drinking patterns and alcohol-related harms such as injuries, medical complications, social or interpersonal troubles, and alcohol use disorder (AUD) (see Core article on AUD).

    Here, we briefly describe the variety of alcohol-related risks faced by different patient groups, which we hope will help you spot red flags early and respond accordingly. Nevertheless, alcohol-related harm can happen to anyone, so it is best to adopt a “we ask everyone” approach, which normalizes alcohol screening and may help reduce patient perceptions of being singled out for attention to their drinking. (See Core articles on screening and practice change.)

    A note on drinking level terms in this Core article: Binge drinking brings a person’s blood alcohol concentration to 0.08 percent or more, which typically happens if a woman has 4 or more drinks, or a man has 5 or more drinks, within about 2 hours. Heavy drinking includes binge drinking and has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    What are the risks in different age groups?

    Adolescents: Brain development disruptions, future AUD, and more. Underage drinking remains common. According to a 2018 national survey, about 9% of youths aged 12-17 drank alcohol, and more than half of them, or 5% total, had a binge drinking episode in the past month.1 Drinking alcohol poses considerable risks to adolescents and should not be considered a normal, expected part of teenage life. During adolescence, heavy drinking can disrupt critical brain development patterns by accelerating the volume decline in frontal cortical gray matter that typically occurs in early adolescence,2,3 and by slowing the volume increase in white matter that typically occurs in late adolescence.4 Heavy drinking in adolescence also predicts future AUD, with the earlier the onset of drinking, the greater the AUD risk.5,6

    Moreover, heavy or binge drinking during adolescence is associated with other risky behaviors, including tobacco and drug use, unprotected sex, poor school performance, conduct problems, impaired driving, and suicide.7 Heavy drinking may also be a clue to the presence of depression or anxiety in both adolescents and adults (see below and Core article on mental health issues). Given rising rates of depression and suicidal ideation among adolescents,8 screening adolescents for both alcohol use and mood disorders has become increasingly important.

    Young adults: At greatest risk for AUD. The age range of 18 to the late 20s is the period of emerging or young adulthood. Brain development is still occurring, adult identities are forming, and transitions such as starting college present increased alcohol-related risk and opportunities for intervention. By young adulthood, drinking alcohol is far more prevalent than during adolescence, including among those under age 21 for whom drinking is illegal. A 2019 national survey showed that in the past month, about 36% of those aged 18-20 and about 65% of those aged 21-29 drank alcohol.9 In both age groups, about 60% of those who drank also had binge drinking episodes in the past month.9 Perhaps surprisingly, the prevalence of AUD is highest among those aged 21-29, affecting approximately 1 in 10 of these young adults, compared to those in any other age group.10,11 In addition, the prevalence of heavy drinking is higher among college students than among same-age peers, perhaps because college students may have more opportunities for high-volume drinking and may delay assuming roles of adult responsibility.12 Young adult males in general are more likely to drink heavily than their female peers, but this gender gap has been narrowing since the 1990s13 (see risks by gender, below).

    Late 20s to mid-life adults: “Maturing out” vs. persistent heavy drinking. Many people who drank heavily in their young adult years reduce their drinking substantially over time, a phenomenon known as “maturing out” of heavy drinking.14,15 Maturing out of heavy drinking is often attributed to transitions to adult roles such as marriage, parenthood, and full-time employment that are incompatible with persistent heavy drinking. In contrast, some individuals who drink heavily as young adults persist in this pattern into middle age. Others first develop alcohol problems in middle age. In either case, studies have found that people with AUD commonly seek treatment in their mid-30s to early 50s.16–19

    Older adults: Increased risk of harms. Heavy drinking and AUD are least common among adults aged 65 and older compared to other age groups,10 but rates have been increasing.20,21 A 2019 analysis of national survey data showed that an estimated 1 in 10 adults in this age group had 5 or more drinks (men) or 4 or more drinks (women) on at least one occasion in the past month,21 and an estimated 1 in 50 had AUD in the past year.11 Age-related changes in how the body processes alcohol present added problems since a given dose of alcohol may lead to greater intoxicating effects in older adults compared to younger adults.22–24 The increased sensitivity to alcohol in older adults raises their risk for many health problems, including injuries (commonly from falls), memory problems, liver disease, sleep problems, and overall mortality.25 Moreover, drinking alcohol at any level poses increased risks for older adults because they are more likely than younger people to take medications, many of which have the potential to interact negatively with alcohol.26 (See Core article on medication interactions.)

    What are the risks by gender?

    Narrowing gender gap in consumption. Historically, men have had higher rates of alcohol consumption, alcohol-related consequences, and AUD than women.10,13 A 2019 critical review of national studies conducted since 2008 concluded that this gender gap in heavy drinking and alcohol problems has noticeably narrowed, though trends in alcohol use vary by age group.13 For example, among adolescents and young adults, rates of alcohol consumption, binge drinking, and various alcohol-related harms have declined in both males and females, but more so for males.13 In middle and older adulthood, alcohol consumption, binge drinking, and alcohol-related harms are increasing, but at a faster rate for women than men.13

    Heightened harms in women. Women tend to suffer a variety of harms at lower levels of alcohol exposure than men. For instance, women with AUD perform more poorly than men with AUD on a variety of cognitive tasks, even with fewer years of AUD.27 Women are at greater risk than men for alcohol-related health problems, including liver inflammation, cardiovascular diseases, and certain cancers.28–30 A single serving of alcohol per day is associated with a 10% increase in the risk of breast cancer for women.31 Over the past few decades, rates of alcohol-related emergency department visits, hospitalizations, and deaths from alcohol associated liver disease and other alcohol-related causes have all increased, but at a faster rate for women than men.32–34 And women (as well as men) who drink heavily are at increased risk of being the victim of secondhand harms, such as physical aggression, by others who have been drinking.35

    Increased prevalence of AUD in women of sexual minority status. Among those with sexual minority status such as being gay or lesbian, different drinking patterns and rates of AUD emerge for men and women. Numerous studies have found that the likelihood of heavy drinking or AUD is substantially greater among women who are sexual minorities (based on sexual identity, behavior, or attraction) than among heterosexual women.36–38 However, in contrast, the likelihood of heavy drinking or AUD among gay men is similar to that in heterosexual men.36–38 Note: these studies specifically report on people of sexual minority status, but not gender minority status, such as transgender people. More quality studies are needed on alcohol risks among gender minorities.39

    What are the risks of prenatal alcohol exposure?

    Alcohol can have harmful effects throughout gestation, with heavy drinking thought to be particularly damaging.40,41 Prenatal alcohol exposure can cause lifelong physical, behavioral, and cognitive impairments collectively known as fetal alcohol spectrum disorders (FASD). In a 2018 study of more than 13,000 first-grade children in the U.S., researchers estimated that between 1% and 5% of the children they assessed had FASD.40

    Because no level of alcohol consumption has been found to be safe during pregnancy, obstetric and pediatric guidelines advise abstinence through pregnancy.42–44 Roughly 1 in 10 pregnant women drink, predominantly in the first trimester, and about half of pregnant women who drink report drinking heavily, according to 2015-2018 data.41,45 Alcohol exposure during the first trimester appears to be particularly detrimental, but even low levels of alcohol exposure throughout pregnancy are associated with morphological, cognitive, and motor deficits.41,46,47

    For more information on FASD, see the Core article on medical complications. For guidance for healthcare professionals on FASD prevention, diagnosis, and care, see the resources below.

    What is the risk from genetic vulnerability to AUD?

    Between 50% and 60% of the vulnerability to AUD is inherited48,49 and likely due to variants in many genes, each of small effect size. Different genes confer risk by affecting various biological processes and mental states and traits, including, for example, physiological responses to alcohol and stress, alcohol metabolism, addiction-related neurobiology, and behavioral tendencies such as impulsivity.49 As a few examples:

    • Inherited responses to alcohol. Individuals who can “hold their liquor” may have an inherited low level of response to alcohol (that is, an innate alcohol tolerance) that puts them at increased risk for heavy drinking and AUD.50–53 Your patients may be unaware that being able to “drink people under the table” isn’t protective from alcohol problems, but instead is a reason for caution. In addition, people who experience stimulating rather than sedating effects from alcohol are more likely to drink heavily and develop AUD.54–56
    • Inherited alcohol metabolism. An estimated 36% of people of East Asian descent (Chinese, Japanese, and Korean heritage) carry gene variants that influence the form of liver enzymes responsible for ethanol metabolism (see the Core basics article).57–59 These variants can cause a buildup of acetaldehyde, which leads to facial flushing, nausea, and tachycardia when alcohol is consumed.59 Although this response may limit drinking, in individuals who do drink, these variants carry an increased risk for esophageal cancer, even among people who are lighter drinkers.59–61
    • Inherited vulnerability to different elements of addiction. A 2017 review of genetic studies of AUD summarized numerous additional genetic loci associated with AUD or related traits,48 including, for example, genes related to addiction-related neurotransmitter systems (see Core article on neuroscience).These genetic studies offer promise in achieving a better understanding of the biological mechanisms leading to the development of AUD.

    How does stress put people at risk for AUD?

    A complex interplay of genetic and environmental factors influences both drinking patterns and AUD risk. Among the environmental risk factors for AUD, external stress is one of the most potent.62 Your patients who experienced trauma, particularly in childhood, or an accumulation of significant stressors throughout life, may be prone to heavy drinking patterns and increased AUD risk.62,63 A person’s stress response is influenced by the type of stressor and its intensity, timing, and duration, as well as by the person’s genetic makeup and drinking history. For more information on the complex links between alcohol, stress, and AUD, see NIAAA’s journal issue on stress and alcohol.

    How do mental health conditions affect the risk for AUD (and vice versa)?

    The interplay of genetic and environmental factors can also prompt the development of mental health conditions such as anxiety and depression that raise the risk of developing AUD.16,49,64 At the same time, AUD can cause or worsen anxiety, depression, or other mental health issues. Thus, co-occurrence of AUD and other mental health conditions is common (see Core article on mental health issues). For example:

    • Among people being treated for anxiety disorders, the prevalence of AUD is in the range of 20% to 40%.65,66
    • Among those who have had a major depressive disorder in their lifetime, up to 40% also have had AUD.65
    • Among those with AUD, 30% to 60% have co-occurring post-traumatic stress disorder.65
    • More than 40% of men and nearly half of women with AUD have had another substance use disorder in their lifetime.65
    • Among people with AUD, estimates of the prevalence of sleep disorders range from 36% to 91%.67

    A neuroscience framework for individual differences in risk for AUD

    An assessment framework called the Addictions Neuroclinical Assessment (ANA) has been developed that takes a precision medicine approach by integrating neuroscience, neuroimaging, and clinical data to identify domains of dysfunction that may be relevant to a person’s vulnerability to addiction, to treatment, and to recovery. In the ANA framework, there are three functional domains relevant to addiction (incentive salience, negative emotionality, and executive function), which align with the three stages of the addiction cycle model described in the Core article on neuroscience.68 In a 2019 ANA analysis of individuals who drank heavily, those with AUD reported more executive function deficits, incentive salience, and negative affect, compared with those without AUD.69 Psychiatric disorders associated with deficits in executive function (such as attention-deficit/hyperactivity disorder) or with heightened negative affect (such as depression or anxiety) may increase risk for developing AUD and complicate treatment and prognosis. For more on comorbid psychiatric disorders, see the Core article on mental health issues.

    In closing, risks for alcohol-related harm are influenced by a wide range of factors, and alcohol-related harm can happen to anyone. Thus, it’s best to adopt a “we screen everyone” approach. See the Core articles on screening and practice change for tips to support you and your practice.

    Resources

    Fetal Alcohol Spectrum Disorders

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

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    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Identify age, gender, and genetic risk factors for developing AUD.
    • Review environmental factors contributors increase the risk for AUD.
    • Describe the importance of universal alcohol screening.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writer for the full article, content contributor to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.  

    External Writer

    Deborah Hasin, MD
    Professor of Epidemiology, College of
    Physicians and Surgeons Department of
    Psychiatry, Columbia University, New York, NY

    NIAAA Content Contributor

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    External Reviewers

    Anika A. Alvanzo, MD, MS, FACP, DFASAM
    Managing Partner, Uzima Consulting
    Group LLC, Middle River, MD;
    Eastern Region Medical Director, Pyramid
    Healthcare, Inc., Duncansville, PA

    Geetanjali Chander, MD, MPH
    Professor of Medicine, Johns Hopkins
    University School of Medicine, Baltimore, MD

    H. Westley Clark, MD, JD, MPH
    Dean's Executive Professor of Public Health,
    Santa Clara University, Santa Clara, CA

    Kenneth R. Conner, PsyD, MPH
    Professor, Emergency Medicine and
    Psychiatry,
    University of Rochester Medical Center,
    Rochester, NY

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Bill Dunty, PhD
    Program Director, Division of Metabolism and
    Health Effects and FASD Research Coordinator, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    Kevin Callahan, PhD
    Technical Writer/Editor,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

    Complete CME/CE Post-Test
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