ALCOHOL USE AMONG BLACK AMERICANS Sarah Pedersen, Ph.D. University of Pittsburgh School of Medicine © AMSP 20151

Alcohol Use is Common Past 30 day use: –52% any use –23% > 5 drinks/occasion –6% 5+ drinks on 5+ days © AMSP 20152

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 20153

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 20154

AUD Rates 7% age 18+ had AUD past year Heaviest drinking: ages Men more likely than women Racial/ethnic group differences © AMSP 20155

Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 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 © AMSP 20157

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 © AMSP

Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 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

Differences into Young Adulthood Adolescence: Ages –10% Blacks vs. 18% Whites (past 30 days) Young adulthood: Ages –50% Blacks vs. 68% Whites (past 30 days) College –33% Blacks vs. 60% Whites intox. © AMSP

Differences in AUD  with Age 12 month AUD dependence prevalence –Age % Blacks vs. 11% Whites –Age % Blacks vs. 4% Whites –Age % Blacks vs. 2% Whites © AMSP

Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 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 © AMSP

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 © AMSP

Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP Lecture: Black American Alcohol Use

Important Historical Dates © AMSP ’s-1865 Slavery in U.S.A Civil War 1830’s-1930’s Temperance Movement 1919: 18 th amendment Prohibition 1933: 21 st amendment end of Prohibition

Drinking in Africa (pre-slavery) Limited alcohol use in Africa –Ceremonial –Small amounts –Intoxication unacceptable –Drunkenness = weakness © AMSP

Slavery and Alcohol Use Slaves limited alcohol use –Owners prohibited use –Slaves stayed sober for protection –Abstinence the norm © AMSP

Temperance Movement Era Abstinence linked with freedom Leaders against slavery and drinking Black churches grew –Pushed abstinence © AMSP

Post-Prohibition Period Restricted use continued  Blacks died from alcohol than Whites Conservative norms © AMSP

History  Present Day Sets stage: –  Drunkenness in Black communities –  Abstinence May inform clinical practice Allows perspective on current factors © AMSP

Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP Lecture: Black American Alcohol Use

Protective Factors © AMSP

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 © AMSP

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 © AMSP

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 © AMSP

Risk Factors © AMSP

Discrimination 98% report racist event/past year  discrimination =  stress  drinking and drinking to cope  well-being Drinking to cope = more alc. problems © AMSP

Neighborhood factors 8X # liquor stores in Black neighborhoods –  convenient store space for alcohol Blacks  drinking in public space –Encounter police © AMSP

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 © AMSP

Alcohol Sensitivity People respond to alcohol differently  sensitivity to rewarding effects or  sensitivity to negative effects = INCREASED RISK © AMSP

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 © AMSP

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

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 © AMSP

Mr. B and Mr. H Who is most at risk for AUD? Alc. prob? © AMSP ProtectiveRisk Mr. BReligious Employed Male Drinks in public place Black neighborhood Mr. HWhite 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 © AMSP 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

 Healthcare Access  Healthcare utilization Mistrust of medical professionals Integrate religious/community Educate on alcohol effects UD treatment as an alternative to jail © AMSP

Case Studies © AMSP Mr. BMr. H Resistant to psychotherapy Prefer 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 © AMSP

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 © AMSP

Conclusions Understanding differences informs tx –Integrate with community/church –Understand resistance –Moderate drinking may cause problems –Modify standard psychoeducation © AMSP

Conclusions More work is needed Treatment access Screening for alcohol problems Cultural sensitivity Integration with community © AMSP

Acknowledgements Marc Schuckit, M.D. Benjamin Nordstrom, M.D. Marcy Gregg Alcohol Medical Scholars Program © AMSP