Alcohol use disorders
Seminar
Summary
Alcohol use disorders consist of conditions characterised by compulsive heavy alcohol use and loss of control over alcohol intake. Alcohol use disorders are some of the most prevalent mental disorders globally, with higher prevalence in high-income countries and lower prevalence in low-income countries.
The recent COVID-19 pandemic was associated with an increase in fully alcohol-attributable mortality, in part triggered by alcohol-specific interactions with stress.
Despite their high prevalence, alcohol use disorders remain undertreated, even though there are scientifically established and cost-effective psychosocial, community, and pharmacological interventions available. In addition, promising new treatment modalities have been developed and are currently being tested.
The two main barriers to better access to evidence-based alcohol use disorder treatment are low availability, due to the absence of government or public funding for such treatment, and stigma.
The first barrier could be overcome by increasing alcohol excise taxation, which currently falls considerably short of covering the social costs of alcohol use. In addition to generating revenues, increasing excise taxation could reduce health-care costs by reducing hospitalisations for all alcohol-attributable conditions, including alcohol use disorders.
Overall, integrated alcohol control policies could improve the prevention of alcohol use disorders, improve access to treatment, and reduce stigma.
The public health importance of alcohol use disorders
Alcohol use disorders remain a public health concern. In 2019, the estimated global prevalence of alcohol use disorder and alcohol dependence among people aged 15 years and older were 7.0% and 3.7%, respectively, which corresponded to about 400 million and 209 million people.
Alcohol use disorder prevalence was about twice as high in men (9.3%) as in women (4.8%), with a similar sex ratio for alcohol dependence (men: 4·9%; women: 2·5%).
Figure 1 and the appendix (p 25) show distinct regional differences for alcohol dependence. Regions were defined by the Global Burden of Diseases, Injuries, and Risk Factors Study.
Eastern Europe had the highest estimated prevalence of alcohol use disorder and alcohol dependence in 2019, followed by tropical Latin America and central Europe.
The prevalence of alcohol use disorder also showed a clear income gradient between countries, highest in high-income countries, which had on average more than twice the prevalence of low-income countries. For each increase of GDP purchasing power parity per capita by international dollars (INT$) 10 000, prevalence of alcohol use disorder increased on average by 0.68% and alcohol dependence increased by 0.34%.
Between 2000 and 2019, global alcohol use disorder and alcohol dependence prevalence declined marginally (from 7.5% to 7.0%, and from 3.9% to 3.7%, respectively), whereas the male–female prevalence ratio remained relatively stable (ie, for alcohol use disorder 1.7 to 1.9 and for alcohol dependence: 1.7 to 2.0).
However, regional trends diverged:
- Rates in eastern Europe remained highest yet fell steadily.
- Rates in tropical Latin America and central Europe remained persistently high.
- Rates in Oceania and most African regions remained low.
- Rates in southern sub-Saharan Africa have increased.
- Other high prevalence regions, including high-income North America and Australasia, showed minimal change.
The high prevalence of alcohol use disorder is linked with high burden of disease, as measured in disability-adjusted life-years lost. In 2019, alcohol use disorders contributed globally the third highest number of disability-adjusted life-years lost among all mental disorders, after depressive and anxiety disorders.
Risk factors for alcohol use disorder and outcomes
The contributors to the development and course of alcohol use disorder are many, such as adverse childhood experiences or trauma, co-occurring psychiatric disorders (eg, depression, anxiety, post-traumatic stress disorder), and social determinants (eg, alcohol availability, cultural alcohol consumption norms).
The aetiology and course of alcohol use disorders are affected by genetic and environmental factors, with approximately 50% of variability in alcohol use disorder risk being heritable and driven by a multitude of genetic variants with small individual effect sizes.
However, complex interactions between genes and the environment are important to consider, as many of the studies within the Collaborative Study on the Genetics of Alcoholism have shown.
Understanding how alcohol use disorder and heavy drinking (usually defined with the use of the European Medicines Agency [EMA] categories of exceeding 60 or 40 g per day for men and women, respectively) interact is important for designing alcohol-related health services and for alcohol control policies in general.
For example, during COVID-19 (2020–21 compared with 2019), several high-income regions (eg, Germany, the UK, the USA, and the European Union) saw double-digit increases in alcohol use disorder and other fully alcohol-attributable deaths, such as alcohol-associated liver cirrhosis, alcohol use disorder, and alcohol poisoning.
In most jurisdictions, these deaths are associated with chronic or episodic heavy alcohol use, a hallmark (not a criterion) of alcohol use disorder, underscoring the strong link between fully alcohol-attributable diseases and alcohol use disorder.
The pandemic-related increase in fully alcohol-attributable mortality occurred even in countries where average alcohol consumption declined or remained stable. For instance, most of the 19 European Union countries with available data showed an average increase of 18% in fully alcohol-attributable mortality compared with 2019, despite reduced population level alcohol consumption in the same timespan (between 2020 and 2021) during COVID-19 pandemic. This observation suggests that the usual strong association between consumption and fully alcohol-attributable disease categories was absent.
This result could be explained by a polarisation in alcohol consumption levels, where people with pre-existing high levels of alcohol use, such as individuals with alcohol use disorder, increased their alcohol intake, whereas most people with non-heavy alcohol consumption decreased their alcohol intake. In other words, people with a history of heavy alcohol use seem to have reacted differently to pandemic stressors.
Indeed, studies of patients with alcohol use disorder found that stressors, such as isolation, were associated with increased relapse.
Increases in fully alcohol-attributable deaths thus seem to suggest that many with severe alcohol use disorder were pushed into acute decompensation with stress-induced increases in alcohol consumption. Similarly, mortality rates of alcohol-associated liver cirrhosis, react quickly to changes in population-level consumption.
The increase in heavy alcohol use, alcohol use disorder, and fully alcohol-attributable mortality was predicted at the beginning of the COVID-19 pandemic, based on previous experiences with economic recessions and natural catastrophes. This association has important consequences for clinical practice and health-care planning: the health-care systems could and should have prepared for the increase in alcohol use disorder. Clearly, most health-care systems, particularly hospitals, concentrated all their efforts on fighting COVID-19 infections, partly at the expense of treating those with mental and addictive disorders. However, the same priority could have been upheld if services for people with heavy alcohol use and/or alcohol use disorder had been offered as online interventions (including solutions based on artificial-intelligence), and interventions delivered over the phone, or if some community-led initiatives had been strengthened (such as peer or mutual support) to cope with the health-care restrictions brought about by the pandemic.
Two conclusions seem evident.
- First, restrictions on availability of alcohol should be upheld or introduced in periods of crisis – unlike many high-income jurisdictions that loosened them during COVID-19 (eg, permitting home delivery of alcohol), thereby aggravating the problem.
- Second, health-care systems should also be prepared for potential increases in heavy alcohol use and alcohol use disorder during such events. However, many such services could be offered online, including artificial-intelligence-based interventions and community-led initiatives (such as peer or mutual support), so that increases in alcohol-attributable harms due to a shortage of traditional health services can be avoided.
Treatment
For a public health approach, treatment needs to be integrated into a continuum of care, beginning with prevention, followed by screening and brief intervention, then formal treatment, and, finally, aftercare. Thus, integrated treatment systems play an important role and treatment coverage becomes an important indicator for successful treatment systems, as reflected in Sustainable Development Goal (SDG) indicator 3.5.1, which tracks coverage of treatment interventions (ie, pharmacological, psychosocial, and rehabilitation and aftercare services) for both alcohol and illicit drugs.
Alcohol use disorder treatment in Thailand
Alcohol use is a major public health issue in Thailand, with a 12-month prevalence of 28.0% for the years 2019–21, disproportionately reported by men compared with women. Alcohol use was the third leading risk factor for disease burden in men, contributing to 14.0% of disability-adjusted life-years lost in 2019.
Alcohol use disorders are the most common mental disorder in Thai adults, with a lifetime prevalence of 18.0% and a one-year prevalence of 8.9% for alcohol use disorder and 4.6% for alcohol dependence in 2019.
Some sources indicate higher rates of alcohol use disorder in individuals with the lowest wealth.
Despite the relatively high prevalence of alcohol use disorders, only 10.0% of adults with alcohol use disorders accessed treatment in 2019, revealing a substantial treatment gap.
Low treatment utilisation stems from insufficient awareness, mistrust in service effectiveness, financial problems, and stigma. High relapse rates among individuals treated pose a major challenge, often due to insufficient continuous aftercare services attributed to inadequate personnel and resources.
To address this issue, Thailand has implemented initiatives. The Alcoholic Beverage Control Act of 2008 mandates health-care support for the treatment and rehabilitation of individuals with alcohol dependency. Screening for alcohol use problems is required by law during antenatal visits, and hospitals must implement systems for individuals aged 15 years and older.
In 2017, the Ministry of Public Health introduced guidelines encompassing four modules:
- Screening and Brief Intervention,
- Treatment and Rehabilitation, the
- Proactive Community Treatment model for alcohol dependence, and
- Care by public health volunteers.
These guidelines emphasise a comprehensive approach, targeting all levels of alcohol use disorder. Tools include the WHO’s Alcohol, Smoking and Substance Involvement Screening Test and its associated brief intervention and self-help strategies. Psychosocial therapies like Motivational Interviewing and cognitive-behavioural therapy are also integral. However, pharmacotherapy options are scarce.
Despite these efforts, relapse rates remain high, with 40% of treated individuals relapsing into alcohol use disorder, exacerbating societal and family challenges.
The PACT model addresses this by integrating proactive community care into Thailand’s District Health System. This programme emphasises treatment, rehabilitation, and supportive services, substantially reducing alcohol consumption and relapse rates while improving participants’ quality of life.
In parallel, alternative treatments, such as telephone counselling, religion-based programmes, and community empowerment initiatives, address cultural and regional needs. These efforts combine evidence-based practices with traditional Buddhist teachings, enhancing their appeal and effectiveness.
In Thailand, community participation is crucial in tackling alcohol problems. Community health volunteers and other community sectors, such as religious institutions, schools, and local government organisations, have trained staff to actively screen individuals, provide initial treatment, and assess withdrawal risks. Model communities show peer support, knowledge sharing, and community-driven rules to prevent alcohol use. Initiatives include religious activities, vocational training, and treatment activities, establishing counselling centres for quitting alcohol in the community, and shops in the village not selling alcohol during Buddhist Lent.
A study found that implementing the integrated care programme in a community hospital yields a net positive value, with the social return of investment ratio ranging from 1.3 to 2.4 baht for every baht invested.
Combining clinical care with culturally sensitive community-driven solutions offers a holistic model for managing alcohol use disorder, addressing immediate health needs and long-term recovery challenges.
Policy implications
Alcohol use disorders remain a major public health problem globally. Despite high prevalence, associated disability, and excess mortality, alcohol use disorders constitute a highly under-treated and severely stigmatised disease category.
Undertreatment has not changed over the past 15 years despite the introduction of the SDG 3.5.1.
Although pharmacotherapy is available with similar effectiveness as other medications for many NCDs, the treatment gap is larger for pharmacological treatments, with less than 10% of people with alcohol use disorder receiving treatment. Within countries, the treatment gap is often larger for people from lower socioeconomic strata; between countries, the gap is larger for less wealthy countries. Accordingly, sizeable clinical and population benefits could be achieved by improving access to psychosocial and pharmacological treatment, including raising the low prescription rates of existing drugs for alcohol use disorder.
A dedicated fund for alcohol treatment would ensure more equitable access and adequate support for all individuals. These resources could be drawn from the alcohol excise taxation revenues collected by governments. Most countries have low taxation rates for alcohol, despite alcohol’s high societal costs, and in sharp contrast to the excise taxation placed on tobacco.
For example, the Lithuanian government has allocated a portion of its tax revenues from alcohol, tobacco, and gambling to the State Public Health Promotion Fund, which finances various health-related activities, including community services for people with alcohol use disorder.
Integrating alcohol use disorder treatment in UHC is essential to address alcohol’s health, social, and economic effects, ensuring equitable access to care, particularly for vulnerable populations. However, the mere presence of a UHC system is insufficient if it is associated with higher stigmatisation, where only wealthier individuals can escape it by accessing private, anonymous treatment, as seen in Russia and other countries. Such a two-tiered system, in which wealthier individuals can avoid stigmatisation via private insurance plans, can harm public systems in the long term by reducing funding, encouraging staff migration to the private sector, lowering quality of care, and exacerbating inequities.
Public financing is essential for countries to make sustainable progress toward UHC. Increasing levels of alcohol excise taxation would not only generate revenue for health and other government services, but would also decrease alcohol consumption and attributable harms, including alcohol-attributable mortality, burden of disease, associated costs, and inequalities.
Examples such as the taxation increases in Russia, Lithuania, South Africa, and the Philippines, support the conclusions of the review by Wagenaar and colleagues that taxation increases are consistently associated with decreases in alcohol-attributable mortality and hospitalisations.
Availability restrictions have also proven to be a cost-effective way to reduce consumption and attributable disease burden.
Alcohol control policies (ie, implementation of measures, which are consistent, structurally connected, and interdependent) seem to be the best way forward for major public health results.
In sum, reducing alcohol use disorders and other alcohol-attributable burden requires a two-pronged approach: increasing alcohol use disorder treatment opportunities and preventing alcohol use disorders through decreased consumption with the use of known effective and cost-effective alcohol control policies.