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

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

3. 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

4. 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

5. AUD Rates 7% age 18+ had AUD past year Heaviest drinking: ages 18-25 Men more likely than women Racial/ethnic group differences © AMSP 20155

6. Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 20156 Lecture: Black American Alcohol Use

7. 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

8. 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 2015 8

9. Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 20159 Lecture: Black American Alcohol Use

10. 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 201510

11. 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. © AMSP 201511

12. 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 201512

13. Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 201513 Lecture: Black American Alcohol Use

14. 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 201514

15. 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 201515

16. Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 201516 Lecture: Black American Alcohol Use

17. Important Historical Dates © AMSP 201317 1640’s-1865 Slavery in U.S.A. 1861-1865 Civil War 1830’s-1930’s Temperance Movement 1919: 18 th amendment Prohibition 1933: 21 st amendment end of Prohibition

18. Drinking in Africa (pre-slavery) Limited alcohol use in Africa –Ceremonial –Small amounts –Intoxication unacceptable –Drunkenness = weakness © AMSP 201518

19. Slavery and Alcohol Use Slaves limited alcohol use –Owners prohibited use –Slaves stayed sober for protection –Abstinence the norm © AMSP 201519

20. Temperance Movement Era Abstinence linked with freedom Leaders against slavery and drinking Black churches grew –Pushed abstinence © AMSP 201520

21. Post-Prohibition Period Restricted use continued  Blacks died from alcohol than Whites Conservative norms © AMSP 201521

22. History  Present Day Sets stage: –  Drunkenness in Black communities –  Abstinence May inform clinical practice Allows perspective on current factors © AMSP 201522

23. Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 201523 Lecture: Black American Alcohol Use

24. Protective Factors © AMSP 201324

25. 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 201525

26. 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 201526

27. 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 201527

28. Risk Factors © AMSP 201328

29. Discrimination 98% report racist event/past year  discrimination =  stress  drinking and drinking to cope  well-being Drinking to cope = more alc. problems © AMSP 201529

30. Neighborhood factors 8X # liquor stores in Black neighborhoods –  convenient store space for alcohol Blacks  drinking in public space –Encounter police © AMSP 201530

31. 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 201531

32. Alcohol Sensitivity People respond to alcohol differently  sensitivity to rewarding effects or  sensitivity to negative effects = INCREASED RISK © AMSP 201532

33. 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 201533

34. 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 201534

35. 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 201535

36. Mr. B and Mr. H Who is most at risk for AUD? Alc. prob? © AMSP 201536 ProtectiveRisk Mr. BReligious Employed Male Drinks in public place Black neighborhood Mr. HWhite neighborhood Male HED Unemployed Depressed No sober support

37. Rates of use and disorder Consequences of use More problems among drinkers Historical context Current reasons for use Treatment implications © AMSP 201537 Lecture: Black American Alcohol Use

38. 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 201538

39.  Healthcare Access  Healthcare utilization Mistrust of medical professionals Integrate religious/community Educate on alcohol effects UD treatment as an alternative to jail © AMSP 201539

40. Case Studies © AMSP 201540 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

41. Conclusions Complex drinking differences –  alcohol use –Among drinkers:  problems –Overrepresented in treatment © AMSP 201541

42. 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 201542

43. Conclusions Understanding differences informs tx –Integrate with community/church –Understand resistance –Moderate drinking may cause problems –Modify standard psychoeducation © AMSP 201543

44. Conclusions More work is needed Treatment access Screening for alcohol problems Cultural sensitivity Integration with community © AMSP 201544

45. Acknowledgements Marc Schuckit, M.D. Benjamin Nordstrom, M.D. Marcy Gregg Alcohol Medical Scholars Program © AMSP 201545