ALCOHOL USE AMONG BLACK AMERICANS
Sarah Pedersen, Ph.D.
University of Pittsburgh
School of Medicine
© AMSP 2015 1
Alcohol Use is Common
• Past 30 day use:
–52% any use
–23% > 5 drinks/occasion
–6% 5+ drinks on 5+ days© AMSP 2015 2
Alcohol Use is Costly
• 44,000 acute alc. deaths in past year
• $235 billion estimated cost/year in USA
• $30 billion in health care costs© AMSP 2015 3
Alcohol Use Disorder (AUD)• DSM-5 criteria (2+ in 12 months)
– Larger/longer– Unable to cut down/control use – Large amount of time spent– Cravings or urges to use– Failure to live up to obligations– Continued despite social problems– Activities given up– Use in hazardous situations– Continued despite health problems– Tolerance– Withdrawal
© AMSP 2015 4
AUD Rates
• 7% age 18+ had AUD past year
• Heaviest drinking: ages 18-25
• Men more likely than women
• Racial/ethnic group differences
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• Rates of use and disorder
• Consequences of use
• More problems among drinkers
• Historical context
• Current reasons for use
• Treatment implications
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Lecture: Black American Alcohol Use
Case 1: Mr. B• 32 year old Black man • Employed at local university• Religious• Lives in Black neighborhood• Drinks (~3 drinks) with friends• Referred for treatment after DUI• No prior criminal hx
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Case 2: Mr. H
• 34 year old White man
• Unemployed past 8 months
• Lives in White suburb
• Drinks (~6 drinks) at bar
• Referred for depression
• No criminal hx
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• Rates of use and disorder
• Consequences of use
• More problems among drinkers
• Historical context
• Current reasons for use
• Treatment implications
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Lecture: Black American Alcohol Use
Alcohol Use in Black Americans
• Black Americans use less alcohol than Whites
– Current use: 44% Blacks vs. 58% Whites
• Lower rates of heavy episodic drinking
– 20% Blacks vs. 24% Whites© AMSP 2015 10
Differences into Young Adulthood
• Adolescence: Ages 12-17
– 10% Blacks vs. 18% Whites (past 30 days)
• Young adulthood: Ages 18-25
– 50% Blacks vs. 68% Whites (past 30 days)
• College
– 33% Blacks vs. 60% Whites intox.
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Differences in AUD with Age• 12 month AUD dependence prevalence
– Age 18-29
• 6% Blacks vs. 11% Whites
– Age 30-44
• 3% Blacks vs. 4% Whites
– Age 45-64
• 3% Blacks vs. 2% Whites© AMSP 2015 12
• Rates of use and disorder
• Consequences of use
• More problems among drinkers
• Historical context
• Current reasons for use
• Treatment implications
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Lecture: Black American Alcohol Use
Black Drinkers Alc. Problems
• Social consequences– 3X higher for Blacks vs. Whites
• Liver cirrhosis– 1.3X higher for Blacks vs. Whites
• AUD mortality: 10% higher for Blacks– Alcohol-related cancers
– Illness and injury
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Racial Differences Summary
• Blacks are less likely to drink
– Overall lower levels of use
– Varies across age
• Among drinkers
– Blacks have more problems
• Integrating historical context needed
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• Rates of use and disorder
• Consequences of use
• More problems among drinkers
• Historical context
• Current reasons for use
• Treatment implications
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Lecture: Black American Alcohol Use
Important Historical Dates
© AMSP 2013 17
1640’s-1865Slavery in U.S.A.
1861-1865Civil War
1830’s-1930’sTemperance Movement
1919: 18th amendmentProhibition
1933: 21st amendment end of Prohibition
Drinking in Africa (pre-slavery)
• Limited alcohol use in Africa
–Ceremonial
–Small amounts
–Intoxication unacceptable
–Drunkenness = weakness
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Slavery and Alcohol Use
• Slaves limited alcohol use
–Owners prohibited use
–Slaves stayed sober for protection
–Abstinence the norm
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Temperance Movement Era
• Abstinence linked with freedom
• Leaders against slavery and drinking
• Black churches grew
– Pushed abstinence
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Post-Prohibition Period
• Restricted use continued
Blacks died from alcohol than Whites
• Conservative norms
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History Present Day
• Sets stage:
Drunkenness in Black communities
Abstinence
• May inform clinical practice
• Allows perspective on current factors
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• Rates of use and disorder
• Consequences of use
• More problems among drinkers
• Historical context
• Current reasons for use
• Treatment implications
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Lecture: Black American Alcohol Use
Protective Factors
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Black American Drinking Norms• More conservative drinking norms
• Alcohol not in social events– 80% Whites vs. 46% Blacks drink at restaurant
• Avoid intoxication criticism for drinking 4+
disapproval from parents monitoring
alcohol in Black homes
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Religiosity religiosity = alcohol use
religiosity Blacks vs. Whites
– 92% of Blacks identify as Christian
– Denominations with conservative alc. view
• Black churches active in community
– Preserves historical views
– Provides monitoring
– One reason for lower use in Black teens
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Genetics• ADH/ALDH genes = alc. metabolism
– Variants alter rate of metabolism
– Produce stronger response to alcohol
• African heritage: 30% have ADH variant
– Metabolize alcohol differently
family history
pulse rate after drinking
AUD
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Risk Factors
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Discrimination
• 98% report racist event/past year
discrimination =
stress
drinking and drinking to cope
well-being
• Drinking to cope = more alc. problems
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Neighborhood factors
• 8X # liquor stores in Black neighborhoods
convenient store space for alcohol
• Blacks drinking in public space
– Encounter police
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Alcohol Preference
• Black drinkers more likely to drink liquor
– Increased alcohol content
– Mixed drinks hard to estimate amount
– Men may underestimate alc. by 31%
• White drinkers more likely to drink beer
• Differences early in adolescence
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Alcohol Sensitivity
• People respond to alcohol differently
sensitivity to rewarding effects
or
sensitivity to negative effects
• = INCREASED RISK
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Blacks Alcohol Sensitivity
• At same alcohol level:
– Blacks “up, talkative” vs. Whites
• Feel more intoxicated, experience more reward
• Indicates risk for alcohol problems
– Black women sedation: “sluggish”
• Protective against alcohol problems
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Within the Black Community
• Important to move beyond racial groups
• What subgroups are at risk?
• Protective factors:
– Positive parental influence
– Strong ethnic identity
– Strong africentric world view
© AMSP 2015 34
Within Race Risk Factors
• Low income
• Male
• Exposure to violence in home
• Most at risk = low income men
access to housing, work
– Heavy drinking cannot cost access
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Mr. B and Mr. H
• Who is most at risk for AUD? Alc. prob?
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Protective Risk
Mr. B • Religious• Employed
• Male• Drinks in public place• Black neighborhood
Mr. H • White neighborhood • Male• HED• Unemployed• Depressed• No sober support
• Rates of use and disorder
• Consequences of use
• More problems among drinkers
• Historical context
• Current reasons for use
• Treatment implications
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Lecture: Black American Alcohol Use
Overrepresented in Treatment
• 14% of U.S. population
• 21% of treatment population
• Feel stigmatized– Racial profiling
– Did this occur for Mr. B?
– Resist treatment dropout© AMSP 2015 38
Healthcare Access
Healthcare utilization
• Mistrust of medical professionals
• Integrate religious/community
• Educate on alcohol effects
• UD treatment as an alternative to jail
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Case Studies
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Mr. B Mr. H
Resistant to psychotherapyPrefer pastor
Diagnosed with AUD
Treatment plan ultimately included pastor
Treatment focused on decreasing alcohol use
Education about being a Black drinker
Treated comorbid depression
Conclusions
• Complex drinking differences
alcohol use
– Among drinkers: problems
– Overrepresented in treatment
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Conclusions
• Historical factors
– A long history shows less drinking
– Cultural views on intoxication
• Current factors
– Risk exists among Black drinkers
– Particularly low income men
– Sensitivity to alcohol
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Conclusions
• Understanding differences informs tx
– Integrate with community/church
– Understand resistance
– Moderate drinking may cause problems
– Modify standard psychoeducation
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Conclusions
• More work is needed
• Treatment access
• Screening for alcohol problems
• Cultural sensitivity
• Integration with community
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Acknowledgements
• Marc Schuckit, M.D.
• Benjamin Nordstrom, M.D.
• Marcy Gregg
• Alcohol Medical Scholars Program
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