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Does the United States have a drinking problem?

Photo Illustration by Michelle Budge

SALT LAKE CITY — While opioid-related deaths dominate recent headlines, even more people died as a result of drinking alcoholic beverages over the last two decades. During that period, close to 1 million Americans died from alcohol-related causes, as overall consumption rose and drinking patterns changed, according to an analysis of U.S. death certificates from 1999 to 2017 by researchers at the National Institute of Alcohol Abuse and Alcoholism.

Alcohol consumption, emergency room visits related to drinking and hospitalizations also increased during that time frame, according to a new study published in the journal Alcoholism: Clinical and Experimental Research.

“I think that drinking is a huge problem and we’ve forgotten about alcohol with the attention on opioids. Alcohol kills more. We haven’t seen it go away,” said Dr. Elizabeth F. Howell, an associate professor of psychiatry at the University of Utah who is board-certified in addiction psychiatry and addiction medicine.

Women drove most of the increase, though they are still much less likely to consume alcohol than men. Women are, however, drinking at higher rates than they were across all adult age categories in those 20 years, while male drinking patterns were comparatively flat. Death rates involving alcohol, in fact, increased 85% for women, compared to 35% for men.

“Men drink a lot more, they drink more often. They drive drunk more, they are injured and die more. They go to the hospital more,” said Aaron M. White, lead author on the study and senior scientific advisor to the director of the National Institute on Alcohol Abuse and Alcoholism. “But women are catching up; the gap is narrowing.”

Mixologist Julian Bernal crafts a cocktail at Wink & Nod, basement-dwelling, speakeasy-like bar, in Boston. Americans are consuming more alcohol per capita now than in the time leading up to Prohibition, when alcohol opponents successfully made the case that excessive drinking was ruining family life.
Charles Krupa, Associated Press

Meanwhile, women are particularly vulnerable to the physical harm associated with alcohol, compared to men, a phenomenon Howell called “telescoping.” It means that “women get in trouble with alcohol faster than men,” from getting addicted to developing medical complications because they have less of an enzyme that helps metabolize alcohol. If drinking had a lifespan, she said, it would be 10 years shorter for women.

The institute study points to a growing body of research that shows alcohol in even moderate amounts increases the risk of breast cancer for women. They also face more risk of developing heart or liver disease, alcohol use disorder and other health problems related to drinking.

Shifting patterns

In 1999, 35,914 death certificates mentioned alcohol. In 2017, the number rose to 72,558. That compares to nearly 70,000 drug-related deaths, including opioids like heroin and fentanyl.

Women ages 55-64 had the highest rate of female alcohol-related deaths, followed by those ages 45-54. The death rate increased for women by 5.2% a year from 2010-2017. In 1999-2010, the annual increase was 2.1%. The highest rate of alcohol-related male deaths is also among those 55 to 64, followed by those 65 to 74.

Experts note that many death certificates don’t mention the role of alcohol, though it is relevant. Of drivers who die in crashes with a blood-alcohol level above 0.08%, a level pretty much everyone considers dangerous, White said, fewer than 1 in 5 death certificates list alcohol as contributing.

Meanwhile, the Centers for Disease Control and Prevention says 1 in 3 deaths from falls involve excessive drinking, but fewer than 2% of those death certificates say it. It’s not a nefarious plot; often someone is taken to the hospital and dies hours later. By that time, the alcohol is not detectable during autopsy, White said.

Patterns of drinking also changed in ways that may be surprising. Beer consumption is down. Wine consumption is up. “Consumption of spirits went up more than anything,” White said.

Industry tracker IWSR said the volume of wine consumption fell slightly in 2019, the first drop since 1994. The Wall Street Journal reported “volumes of ready-to-drink products consumed rose 50%, driven by hard seltzers and canned cocktails. Spirits volumes grew 2.3%, helped by mezcal, tequila, cognac, bourbon and other whiskey. Beer continued to decline, falling 2.3%.”

A bartender at One 11 Kitchen and Bar in Nevada City, California, pours a glass of wine to patrons.
Elias Funez, The Union via AP

While more women — and more older women — are binge drinking, binge drinking has been decreasing among college students for a few years, dropping most in states where marijuana is legal, according to research from Oregon State University. Marijuana use, not surprisingly, has increased significantly in those states.

It’s hard to say what increased marijuana use will bring, said David C. R. Kerr, associate professor of psychological science and a co-author of that study. “We know that marijuana use is not totally distinct from other substances.”

Binge drinking is clearly linked to harm, though, he said, noting more run-ins with the police, sexual assaults and risky behavior involve alcohol. Known negative outcomes with marijuana include poor motivation, less academic achievement and greater risk for driving accidents.

Amid the shifting trends, there’s a bit of encouraging news, if it holds over time, White said: While alcohol use and harm are going up for adults, they are coming down among adolescents — particularly adolescent males. Alcohol use has also declined among those college age, again mostly among males, not females, who are more likely to report drinking and being drunk than are males that age.

Sobering news?

The greatest increase in drinking is among older non-Hispanic white women.

White believes as baby boomers age, they will continue to bring higher levels of alcohol and drug use with them. He said experts expect increases in harm among older drinkers, but it’s possible that if younger cohorts aren’t drinking and harming themselves they could bring a new attitude toward alcohol.

That’s already being seen in different social movements, like Sober October and Dry January. The “sober curious” are taking a time out from alcohol consumption or eschewing it entirely. Boozeless bars are also becoming popular.

“Basically, they’re asking the question, ‘What is this drug again?’” White said. “Why are we drinking it? What do we get from it?”

It’s too soon to predict the change will hold among those who are younger now, said White. But he’s among those hoping that will be the case. “Right now, we’ve got what we’ve got, which is an increase among adults.”

Alcoholism is not determined by how much one drinks, Howell said, but what happens when one drinks, such as loss of consistent control over consumption and continued use of alcohol in the face of adverse consequences.

The biggest risk of becoming alcoholic is genetic, but people don’t necessarily know they carry genetic risk. Trauma is a big risk, as well. And the younger one starts drinking the more the risk increases. One can become an alcoholic at any age and studies suggest the share of people becoming alcoholic when they are older is growing.

Chronic excessive drinking doesn’t spare any organ system, White said. It triggers inflammation and irritates the stomach lining. It alters the brain. “If you just keep doing that over time, the body ends up damaged. Alcohol takes a toll; it is not a nutrient.”

Still, he added, it’s a legal drug for adults as long as they don’t break laws. And at low doses, the risks appear to be smaller, “though they are not zero. The risk goes up the more you drink.”

Howell said some may be able to drink more, others less, without harm. And she notes one little-known risk factor: gastric bypass. People who have had it and drink see greater harm.

Does America have a drinking problem? White ruminates.

“Yes, we have a drinking problem that in some ways is getting worse and in other ways is getting better. It’s getting worse among adults, especially middle-age and older. It’s certainly getting worse among women in general. But the positive component is less drinking among adolescents and young adults. Whether that will lead to fewer problems as they age, we don’t know.”