Aug. 23, 2022 – We live in particularly stressful times, and some people turn to alcohol to cope with challenges, from the COVID-19 pandemic to any number of personal stressors.
And the hits just keep coming, as it seems like stressful infectious disease news keeps coming – more people developing long COVID, the monkeypox outbreak, and even polio making a possible comeback. One expert likens this barrage of news to a smoke alarm that never stops chirping.
And though self-treating stress with alcohol is not new, there is evidence the pandemic has raised the stakes.
The danger of turning to alcohol to cope in the short term is the risk of getting alcohol use disorder, which can cause brain changes that make the condition worse over time. The cycle of drinking, abstaining, and relapsing, in fact, can increase the risk for long-term adverse health effects, experts say.
There are solutions and reasons for hope as scientists and clinicians focusing on alcohol use disorder continue to learn more.
A Large-Scale Challenge
Alcohol contributes to more than 200 health conditions and almost 100,000 deaths in the U.S. each year, according to data from the National Institute on Alcohol Abuse and Alcoholism.
An unfair truth is only a minority of people get alcohol use disorder. Others drink and never have problem drinking. That’s not to say there are not other health risks from drinking too much. But only an estimated 6% to 8% of drinkers become dependent, Marisa Roberto, PhD, said at recent lecture on alcohol addiction science and medicine sponsored by the Scripps Research Institute in La Jolla, CA.
That might sound like a small percentage, but alcohol use disorder affects about 15 million Americans each year, putting it on par with an estimated 14.5 million Americans affected by cancer. Also, the National Institutes of Health budget for researching cancer is about 10 times greater than NIH money focusing on alcohol use disorder, said Roberto, a neuroscience researcher and chair of molecular medicine at Scripps.
Even so, Roberto said she is not advocating for universal abstinence.
“Not everyone that likes to drink in a social setting will develop this problem. We need to keep that in mind,” she said. “So, continue to drink your glass of wine with your meal, with your friends, in moderation.”
The COVID-19 pandemic also changed why some people drink alcohol, said Aaron White, PhD, a senior scientific adviser to the director of the National Institute on Alcohol Abuse and Alcoholism.
For example, even before COVID-19 emerged, “We saw a shift beginning in alcohol use among young people away from drinking to socialize and more toward drinking alone and drinking to cope with stress,” White said at a White House event this month that focused on the use of alcohol as a coping mechanism.
“Then, of course, the pandemic started, and everything escalated.”
White and colleagues attracted a lot of attention in March when they published research that showed a jump in alcohol-related deaths in 2020. Alcohol-related deaths increased 25% between 2019 and 2020, according to the research letter, which was published March 18 in TheJournal of the American Medical Association.
Multiple reasons likely drove the higher number of alcohol-related deaths, White and colleagues noted. “Increased drinking to cope with pandemic-related stressors, shifting alcohol policies, and disrupted treatment access are all possible contributing factors.”
Alcohol and Other Drugs
Alcohol use disorder often does not develop on its own. “People with alcohol use disorder are eight times more likely to have another drug use disorder than the general population,” said Carrie D. Wolinetz, PhD, who hosted the White House webinar. Wolinetz is the deputy director for health & life sciences at the White House Office of Science and Technology Policy.
“And alcohol plays a role in around one of five drug overdose deaths,” she said.
Alcohol is a sedative, and sedatives and painkillers can interact, said Cece Spitznas, PhD, senior science policy adviser at the Office of National Drug Control Policy. Data from her organization shows that alcohol-related deaths involving synthetic opioids, like fentanyl, increased by 146% from 2018 to 2021.
“Among people who died with alcohol in their systems,” she said, “76% of them also had a synthetic opioid present.”
“One of the challenges for the research and health community to understand is how all of this is intertwined,” Wolinetz said.
Like an Alarm That Keeps Going Off
Using alcohol to cope with stress after stress can lead to “bit of a trap,” White said. Drinking works “really well at temporarily dampening activity in the brain areas that make us feel afraid,” he explained.
One part of the brain, the amygdala, can signal danger like a smoke alarm. When things feel threatening, the amygdala continuously chirps, he said. Some people turn to alcohol to cope because “we don’t like that [response]. It doesn’t feel good.”
Even so, alcohol “makes a promise it can’t keep,” White said. “The promise is, ‘Hey just drink me, and you won’t have to feel these uncomfortable feelings.’” The problem is “when the alcohol wears off, the smoke alarm gets louder.”
Over time, brain changes can result.
“PTSD is a great example. If you have PTSD and you’ve got high levels of anxiety, fear, and sleep disruption, alcohol might help you initially. But the changes in the brain that happened when you drink regularly actually end up making the symptom of PTSD worse,” White said.
What the Science Shows So Far
A lot of research over the years compares mice, rats, non-human primates, and others given alcohol to animals that have not. Many insights continue to emerge from these studies that could translate into better understanding and treating of alcohol use disorder in people.
For example, a neurotransmitter called GABA is a key player in alcohol addiction, Roberto said. Animals that develop dependency to alcohol have higher levels of GABA moving between neurons in their brains. That is one reason a drug that lowers GABA levels, gabapentin, has shown promise for treating people with alcohol use disorder.
Another substance, corticotropin releasing factor, also plays a role. Blocking its ability to attach to receptors in the brain made a difference in studies. “What you see in the animal, especially in the dependent animal, is that they relax,” Roberto said. “There is less anxiety-like behavior. They drink less.”
Neuroinflammation, or inflammation in the brain, is a more recently identified culprit in alcohol use disorder. “We have found some mechanism where the stress system is very intertwined within your immune signaling from chronic exposure of stress,” Roberto said. “They all work in the brain to increase neuroinflammation.”
Like almost every other discovery in alcohol use disorder, the immune-inflammatory interaction is very complex, she said.
Roberto and her team are evaluating drugs already FDA-approved to treat inflammation to see if they can reduce this neuroinflammation. “This is going to be terrific because it will help us to skip some of the long steps to take a drug from the bench through the bedside.”
In response to a question, Roberto said genetics plays a role in about 40% of alcohol use disorder cases. But it’s complex, and the risk involves multiple gene changes. Again, animal studies help pinpoint what specific gene changes are involved.
A way to avoid over-relying on alcohol to cope with stress is to find another option, White said.
“One of the ways that we should help address problems with alcohol in the country is to make people aware that there are other ways to cope,” he said. “It doesn’t have to be alcohol. Find a relationship with some other strategy for coping with stress and anxiety that doesn’t carry the same risks.”
Social and cultural connections also can help. When people feel connected to their families and have a stronger link to their history and their communities, they tend to be more resilient, White said. “And if they’re more resilient, they tend not to fall into these sorts of traps of leaning on substances that offer quick fixes.”
Health care providers counseling a person at risk for or with alcohol use disorder can also try what’s known as motivational interviewing, said Daniel Calac, MD, chief medical officer of the Indian Health Council and principal investigator of the California Native American Research Centers for Health.
A quick screen for alcohol misuse during routine health care visits – as well as referring anyone identified as at risk for alcohol use disorder to treatment while a patient is in the office – also helps, he said.
Research at the Indian Health Council suggests that working with providers at a behavioral health unit, especially one on site, can also help.
Screen for Mental Health Effects Too
Mental health issues can also be part of the equation, but on an individual level, it can be unclear which comes first, alcohol use disorder or anxiety and/or depression.
“In fact, having a history of alcohol use disorder more than doubles the odds of having depression, PTSD, or other anxiety disorder,” Wolinetz said.
White said that if doctors ask even one question about alcohol use, it could provide insight into that person’s mental health. For example, if a patient reports binge drinking once a month, “you’ll find that they are statistically more likely to have major depression, to be suicidal and/or to misuse opioids.”
“It doesn’t mean that they absolutely do,” White said, “but it means that a simple question about alcohol can actually clue health care practitioners into other aspects of people’s lives.”
Reasons for Hope
“We’ve seen some really encouraging things happening with regard to alcohol and public health,” White said, when asked reasons he might be optimistic at this point.
Before the pandemic, there was a “real groundswell of interest in opportunities for being mindful of one’s drinking, and taking a break, like ‘dry January’ or ‘sober October,’” he said. He applauded the sober curious movement for getting people to think about their drinking and their relationship with it. Growth in low- or non-alcohol products is also encouraging, he said.
“I see changes that are very promising, but they’re just sort of embers right now,” White said. “We’ll have to see what happens.”
Resources for Patients and Providers
The National Institute on Alcohol Abuse and Alcoholism offers online resources for consumers and health care providers.
The Health and Human Services Substance Abuse and Mental Health Services Administration also has a hotline for people having a hard time with mental health or substance use disorders. The free, confidential service provides information and treatment referrals in English and Spanish. The number is 800-662-HELP (800-662-4357), and the line is available 24 hours a day, 7 days a week, every day of the year.
One place to start with general questions about drinking and personal risk for alcohol use disorder is the NIAAA Rethinking Drinking website. The information is designed to help people explore their drinking and figure out if they need support.
For a person who decides they do need help, the NIAAA Alcohol Treatment Navigator is an online resource to help people explore their options and find support services in their area.
“It’s so important that providers who are on the front lines really look to NIAAA and what they have to offer because they do have a great plethora of information on their websites,” Calac said.