Alcohol Medical Scholars Program

Sarah L. Pedersen

University of Pittsburgh, Department of Psychiatry

I.  Introduction

A.  Alcohol use is a public health concern (Slide 2)

1.  Heavy drinking is common1

a.  52% current alcohol use (any use in past 30 days)

b.  23% drink > 5 drinks/occas (heavy episodic drinking—HED)                             past 30 days

c.  6% heavy alcohol use (e.g., 5+ drinks on 5+ days) past 30 day

2. Alcohol use: serious and costly (slide 3)

a.  Acute alc. deaths = 44,000 in past year2

b.  Estimated cost = $235 billion /year in USA

c.  $30 billion in health care costs alone

B.  Alcohol use disorder (AUDs) (Slide 4)

1.  Diagnosis associated with health & social problems

2.  Official (DSM-5) criteria (2+ in same 12 months)3

a.  Taken in larger amounts or over longer period

b.  Unsuccessful efforts to cut down or control use

c.  Large amount of time obtaining, using or recovering

d.  Craving or urge to use

e.  Failure to fulfill major role obligations

f.  Continued use despite social problems

g.  Important activities are given up or reduced

h.  Use in situations that may be physically hazardous

i.  Alc. use is continued despite knowledge of health problem

j.  Tolerance (1+ of)

1’.  ↑ amounts to achieve effect

2’.  ↓ effect at same amount

k.  Withdrawal

1’.  Withdrawal syndrome (shakes/anxiety/insomnia/etc)

2’.  Develops if no alc. or drink to prevent

            C. Rates of AUD differ by age, gender, race (Slide 5)

                        1. 7% age 18+ had AUD past year

                        2. Time of heaviest drinking usually 18-25

                        3. Men more likely than women

                        4. Differences across race/ethnic groups

D. Lecture reviews alcohol use and problems in Black Americans (Slide 6)

1.  Rates of use and disorders

2.  Consequences of use

3.  Lower use yet more problems

4.  Historical context

5.  Reasons for use

6.  Treatment (Rx) implications

E.  Will use 2 illustrative cases

1.  Case 1: Mr. B: 32 year old Black man (Slide 7)

                                    a.  Employed computer scientist at local university

                                    b.  Identifies as religious

                                    c.  Lives in predominantly Black neighborhood        

                                    d.  Drinks (~ 3 drinks) with friends most weekend days

                                    e.  Referred for treatment after DUI

                                    f.  No other criminal history

2.  Case 2: Mr. H: 34 year old White man (Slide 8)

                                    a.  Unemployed for past 8 months

                                    b.   Lives in predominantly White suburb

                                    c.   Drinks (~6-7 drinks) at a bar most weekend days

                                    d.   Referred for treatment for major depression

                                    e.   No criminal history

II.  Rates of use and disorders in Blacks

A.  Alc. Use: Blacks < Whites (Slide 10)

1.  44% of Blacks vs. 58% Whites use currently1

2.  20% Blacks vs. 24% Whites HED

B.  Age and racial disparities in alc. use (Slide 11)

1.  Large differences in adolescence and young adulthood

a.  Age 12-17: 10% Blacks vs. 18% Whites drank past 30 days4

b.  Age 18-25: 50% Blacks vs. 68% Whites drank past 30 days5

c.  College: 33% Blacks vs. 60% Whites intoxicated at parties6

2.  Differences in AUD ↓ across age7 (Slide 12)

                a.  Example: Past 12 month alcohol dependence prevalence

            b.  Age 18-29: 6% Black vs. 11% White

            c.  Age 30-44: 3% Black vs. 4% White

            d.  Age 45-64: 3% Black vs. 2% White

C.  Negative consequences differ across groups (Slide 14)

1.  Social consequences: 3X ↑ Black vs. White8

                                    a. Examples include:

                                    b. Arguments with spouse

                                    c. Fights

2.  Liver cirrhosis mortality: 1.3X ↑ Black vs. White9

3.  AUD mortality: 10% ↑ Black compared to other races in US10

4.  Alcohol and drug-related cancers, ↑ Black11

5.  Illness and injury (e.g., ER visits) ↑ Black12

D.  Summary: Blacks < use, > problems (Slide 15)

            1.  Blacks have higher abstention rates

            2.  Lower levels of use

            3. Yet among drinkers more physical, legal and social problems

            4. Health disparities need addressed from historical and current view

III.  Historical context (Slide 17)

A.  Understanding important history is necessary to understand Black drinking

B.  Slave trade and slavery → less drinking for Blacks (Slide 18)

1.  Limited alcohol use in tribal Africa

                                    a. Consumed at religious/secular ceremonies13

                                    b. Small amounts consumed/occasion

                                    c. Intoxication unacceptable at these events

                                    d. Drunkenness viewed as sign of weakness

2.  Slaves became < likely to drink alc.14 (Slide 19)

a.  Owners did not let slaves drink alc.

b.  Slaves did not drink in order to protect themselves

c.  Abstinence is the norm during this time period

B.  Temperance movement: continued low alcohol use for Blacks (Slide 20)

1.  Abstinence became linked with freedom

                                    a. “To keep sober was to strike a blow to slavery.”14

                                    b. Many leaders against slavery and drinking

                                    c. Blacks encouraged to be abstinent

                                    d. Black churches grew and further pushed abstinence

C.  Post-prohibition period: Black alcohol use remained low (Slide 21)

1.  Restricted alcohol use/abstention continued post-slavery

2.  Reflected by records: ↓ Blacks than Whites died from alc. use

3.  Conservative drinking norms persisted

D.  Historical context informs present day (Slide 22)

                        1. Sets stage for why drunkenness is less tolerated in Black communities

                        2. May play continued role in high levels of abstinence

                        3. Important to understand when working with Black pts

                        4.  Allows deeper understanding of current influences

IV.  Reasons for low Black alc. use: current factors

A.  Cultural norms (Slide 25)

1.  Blacks = more conservative drinking norms

2. Alc. not integrated into social events

3.  For example: 80% White ♀ vs 46% Black ♀ drink at restaurants15

4.   If drinking don’t drink to intoxication16

5.   For example, Blacks ↑ criticism for drinking 4+ drinks17

6.  Black parents ↓ approval of alc. use than White parents18

                                    a.  Black parents more closely monitor children19

                                    b. < alcohol in Black homes compared to White homes

B.  Religiosity (Slide 26)

1.  Black ↑ religiosity than White20

a.  92% Black identified as Christian21

b.  Denominations with more conservative alc. views

2.  ↑ religiosity →↓ substance use might explain racial differences

3.  Black churches active in community

a. Preserves historical views on alc. use

b. Provides monitoring for adolescents

c. May be one reason less alc. use in adolescence

C.  Genetics (Slide 27)

1.  Affect alc. metabolism rates è response to alc.

            a.  Two enzymes: ADH and ALDH

            b.  Variants of ADH/ALDH genes can alter alc. metabolism

            c.  Producing stronger responses to alc.

2.  30% African descent may have and ADH variant

            a.  Metabolize alc. differently

                                    a.  Could be protective against heavy alc. use

b.  ↓ family hx of alc. use

c.  ↑ in pulse rate after drinking

d.  ↓ AUDs

V.  Reasons for higher problems among Black compared to White drinkers

A.  Coping and discrimination (Slide 29)

1.  98% Blacks report racist event/ past year22

2.  Racial discrimination=stress and ↓ well being

3.  Drinking to cope23

                                    a. Black drinkers may drink to cope with discrimination

                                    b. ↑ problem drinking over time

4.  ↑ discrimination → ↑ drinking24

                                    a. Inconsistent across studies

                                    b. In part due to how one responds to discrimination

                                    c. Could increase risk over time

B.  Neighborhood and cultural factors (Slide 30)

1.  8X ↑ liquor stores in Black vs. White neighborhoods25

2.  Alc. ↑ store shelf space in Black neighborhoods

3.  Blacks ↑ likely than Whites to drink in public spaces26

C.  Alcohol preference (Slide 31)

                        1.  Blacks more likely to drink liquor

                        2.  Whites more likely to drink beer

                        3.  Differences found in adolescence27

                        4.  Malt liquor > beer = ↑ alc. problems

                        5.  Black men may underestimate alc. content by 31%28

                                    a. Malt liquor contains more alc. than beer

                                    b. Harder to estimate alc. content in mixed drinks

A.  Sensitivity to alc. (Slide 32)

1.  Individual differences in acute response è alc. risk

            a. é sensitivity to rewarding effects è risk

            b. ê    response to negative effects è risk

2.  Blacks may be more sensitive to effects29 (Slide 33)

a.  At same alc. level, Blacks ↑ “up, talkative” compared to Whites

            1. Could indicate risk for alc. problems

            2. Feel more intoxicated, experience more reward from alc.

b.  However, Black women ↑ sedation

            1. Could indicate lower alc. risk

            2. Black women are low alc. users

VI.  Within Black community (Slide 34)

A. Protective factors

1. Parental influence > for Black vs. White youth30

2. Strong ethnic identity ↓ alc. use31

3. Strong Africentric world view ↓ alc. use32

B. Risk factors (Slide 35)

1. Low income → ↑ risk33

2. Male > female34

3. Low income (<$15,000) Black men most at risk35

4. Exposure to violence in the home earlier alc. initiation36

5.  Theoretical model (Zapolski et al., 2013)

            a. ê access to housing, economic security, work, etc.

            b. Regardless of behavior

            c. Heavy drinking cannot cost access

            d. Ex: no job to lose due to drunkenness

Case Studies: Mr. B and Mr. H (Slide 36)

A.   Who is most at risk for an AUD? Who is most at risk for an alc. problem?

B.   Both have protective and risk factors

C.  Mr. B protective: religious, employed

D.  Mr. H protective: lives in White neighborhood

E.  Mr. B risk: male, drinks in public place, lives in Black neighborhood

F.  Mr. H risk: male, HED, unemployed, depressed, no sober support

G.  Mr. H more at risk for AUD. However, Mr. B got DUI

H.  Differential risk of problems as a result of race and context

VI.  Treatment implications

A. Over-represented in substance use treatment settings (Slide 38)

1. 14% of total population

2. 21% of substance treatment population37

3. May feel stigmatized

4. Resist treatment → dropout, no follow-up care

5. Racial profiling may have directly resulted in criminal charge (DUI)

B.  ↓ likely to have access to/utilize healthcare38 (Slide 39)

C. Mistrust of medical professionals38

D. Need to integrate with religious or community leaders

E.  Educate on effects of alc.

VII.  Revisit Case Studies (Slide 40)

A.  Mr. B resistant to psychotherapy initially. Rather meet with pastor

B.  Treatment plan ultimately included pastor

C.  Educational piece about being a Black male drinker

D.  Mr. H diagnosed with AUD

E.  Mr. H treatment focused on ↓ alc. use

F.  Treating comorbid depression

VIII.  Conclusions

A.  Blacks ↓ alc. use yet ↑ alc. problems (Slide 41)

1.  > rates of abstention

2.  > problems among drinkers

3. Overrepresented in treatment

B.  Historical and current factors at play (Slide 42)

1.  A long history shows why Blacks drink less

2.  Cultural views on intoxication

3. However, risk exists among certain Black drinkers

a. Particularly low income men

b. Individuals with sensitivity to rewarding effects of alcohol

C.  Understanding differences can inform treatment (Slide 43)

1. May be helpful to integrate with community or church

2.  Understand resistance to treatment

3. Even moderate drinking may result in problems

4. Standard psychoeducation on alc. use may need modified

D.  More work is needed to decrease health disparities in alc. problems (Slide 44)

1. ↑ treatment access

2. ↑ screening for alc. probs

3. ↑ cultural sensitivity of clinicians

4. Integrate with churches and community groups




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