Alcohol Disorders

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Prevalence of 12-Month Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder in the United States, 2001-2002 to 2012-2013 Results From the National Epidemiologic Survey on Alcohol and Related Conditions Bridget F. Grant, PhD; S. Patricia Chou, PhD; Tulshi D. Saha, PhD; Roger P. Pickering, MS; Bradley T. Kerridge, PhD; W. June Ruan, MS; Boji Huang, MD, PhD; Jeesun Jung, PhD; Haitao Zhang, PhD; Amy Fan, PhD; Deborah S. Hasin, PhD

IMPORTANCE Lack of current and comprehensive trend data derived from a uniform, reliable, and valid source on alcohol use, high-risk drinking, and DSM-IV alcohol use disorder (AUD) represents a major gap in public health information.

OBJECTIVE To present nationally representative data on changes in the prevalences of 12-month alcohol use, 12-month high-risk drinking, 12-month DSM-IV AUD, 12-month DSM-IV AUD among 12-month alcohol users, and 12-month DSM-IV AUD among 12-month high-risk drinkers between 2001-2002 and 2012-2013.

DESIGN, SETTING, AND PARTICIPANTS The study data were derived from face-to-face interviews conducted in 2 nationally representative surveys of US adults: the National Epidemiologic Survey on Alcohol and Related Conditions, with data collected from April 2001 to June 2002, and the National Epidemiologic Survey on Alcohol and Related Conditions III, with data collected from April 2012 to June 2013. Data were analyzed in November and December 2016.

MAIN OUTCOMES AND MEASURES Twelve-month alcohol use, high-risk drinking, and DSM-IV AUD.

RESULTS The study sample included 43 093 participants in the National Epidemiologic Survey on Alcohol and Related Conditions and 36 309 participants in the National Epidemiologic Survey on Alcohol and Related Conditions III. Between 2001-2002 and 2012-2013, 12-month alcohol use, high-risk drinking, and DSM-IV AUD increased by 11.2%, 29.9%, and 49.4%, respectively, with alcohol use increasing from 65.4% (95% CI, 64.3%-66.6%) to 72.7% (95% CI, 71.4%-73.9%), high-risk drinking increasing from 9.7% (95% CI, 9.3%-10.2%) to 12.6% (95% CI, 12.0%-13.2%), and DSM-IV AUD increasing from 8.5% (95% CI, 8.0%-8.9%) to 12.7% (95% CI, 12.1%-13.3%). With few exceptions, increases in alcohol use, high-risk drinking, and DSM-IV AUD between 2001-2002 and 2012-2013 were also statistically significant across sociodemographic subgroups. Increases in all of these outcomes were greatest among women, older adults, racial/ethnic minorities, and individuals with lower educational level and family income. Increases were also seen for the total sample and most sociodemographic subgroups for the prevalences of 12-month DSM-IV AUD among 12-month alcohol users from 12.9% (95% CI, 12.3%-17.5%) to 17.5% (95% CI, 16.7%-18.3%) and 12-month DSM-IV AUD among 12-month high-risk drinkers from 46.5% (95% CI, 44.3%-48.7%) to 54.5% (95% CI, 52.7%-56.4%).

CONCLUSIONS AND RELEVANCE Increases in alcohol use, high-risk drinking, and DSM-IV AUD in the US population and among subgroups, especially women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged, constitute a public health crisis. Taken together, these findings portend increases in many chronic comorbidities in which alcohol use has a substantial role.

JAMA Psychiatry. 2017;74(9):911-923. doi:10.1001/jamapsychiatry.2017.2161 Published online August 9, 2017.

Editorial page 869

Author Affiliations: Epidemiology and Biometry Branch, National Institute on Alcohol Abuse and Alcoholism, Rockville, Maryland (Grant, Chou, Saha, Pickering, Ruan, Huang, Jung, Zhang, Fan); New York State Psychiatric Institute, New York (Kerridge, Hasin); Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York (Hasin).

Corresponding Author: Bridget F. Grant, PhD, PhD, Epidemiology and Biometry Branch, National Institute on Alcohol Abuse and Alcoholism, 5635 Fishers Ln, Room 3077, Rockville, MD 20852 ([email protected]).

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A lcohol use and specifically high-risk drinking, which of-ten leads to alcohol use disorder (AUD), are signifi-cant contributors to the burden of disease in the United States and worldwide.1-7 High-risk drinking and AUD are im- portant risk factors for morbidity and mortality from fetal al- cohol spectrum disorders,8 hypertension,9 cardiovascular diseases,10-15 stroke,16 liver cirrhosis,17,18 several types of c ancer19-23 and infections,2 4-26 pancreatitis,27, 28 type 2 diabetes,29 and various injuries.30 High-risk drinking and AUD are disabling,31,32 are associated with numerous psychiatric comorbidities33,34 and impaired productivity and interper- sonal functioning, and place psychological and financial bur- dens on society as a whole and on those who misuse alcohol, their families, friends, and coworkers,35-37 as well as through motor vehicle crashes, violence, and property crime.38,39

In view of the seriousness of the numerous physical and psychiatric harms of high-risk drinking and AUD, regular and detailed monitoring of their trends over time is imperative for the health of the nation. Historically, reliable national survey data on alcohol use, high-risk drinking, and AUD were not avail- able before the early 1970s.40 The few national trend surveys conducted between the early 1970s to the early 1990s showed stability or decreases in trends for 12-month alcohol use, vari- ous measures of high-risk drinking, and social consequence and alcohol dependence symptoms.41-44 Between the early 1990s and the early 2000s, 12-month alcohol consumption in- creased from 44.0%45 to 65.4%,46 12-month high-risk drink- ing increased from approximately 8.0%47,48 to 9.7%,49 and DSM-IV50 AUD increased from 7.4%45 to 8.5%.32

Lack of current and comprehensive trend data derived from a uniform source on alcohol use, high-risk drinking, and DSM-IV AUD since the early 2000s represents a major gap in public health information. Tracking patterns of alcohol consumption and AUD is essential to test temporal models of alcohol consumption behaviors and alcohol-related mor- bidity and mortality and to estimate the effectiveness of policy changes related to alcohol use (eg, taxes and treat- ment entitlements). Furthermore, monitoring of alcohol consumption patterns and AUD over time within important sociodemographic subgroups of the US population is critical for planning and targeting prevention and intervention programs.

Accordingly, this study presents data for 2001-2002 and 2012-2013 on the prevalences of 12-month alcohol use, high- risk drinking (defined as exceeding the daily drinking guide- lines at least weekly in the past 12 months), and 12-month DSM-IV AUD overall and among important sociodemo- graphic subgroups of the US population. We used data from the National Institute on Alcohol Abuse and Alcoholism’s 2001- 2002 Wave 1 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)51 and 2012-2013 NESARC-III.52

Methods Sample The 2012-2013 NESARC-III is a nationally representative, face- to-face interview survey of 36 309 US adults 18 years and older

residing in households and selected group quarters,52 with re- spondents selected through multistage probability sampling. The data were collected from April 2012 to June 2013. Pri- mary sampling units were counties or groups of contiguous counties, secondary sampling units were groups of US Census– defined blocks, and tertiary sampling units were households within sampled secondary sampling units within which eli- gible adult respondents were selected, with black, Asian or Pa- cific Islander, and Hispanic individuals oversampled. The household response rate was 72.0%, the person-level re- sponse rate was 84.0%, and the overall response rate was 60.0%, which were comparable with other current US na- tional surveys.53,54 Data were adjusted for oversampling and nonresponse and were weighted to represent the US civilian population based on the 2012 American Community Survey.55

Weighting adjustment compensated for nonresponse.52 In- formed consent was electronically recorded, and respon- dents received $90 for participation. The Combined Neuro- science Institutional Review Board of the National Institutes of Health and Westat Institutional Review Board approved the protocol and informed consent procedures.

The 2001-2002 NESARC was a nationally representative, face-to-face interview survey of 43 093 US adults, described elsewhere in detail.51 The data were collected from April 2001 to June 2002. The target population was the US adult popu- lation 18 years and older residing in households and selected group quarters. Primary sampling units consisted of counties or county equivalents from which eligible adults were selected, with black and Hispanic individuals, and young adults oversampled. The sampling frame response rate was 98.5%, the household response rate was 88.5%, and the person re- sponse rate was 93.0%, yielding an overall survey response rate of 81.0%. Data were adjusted for oversampling and nonre- sponse and were weighted to represent the civilian US popu- lation based on the 2000 Decennial Census.56 The survey pro- tocol, including written informed consent procedures, received full ethical review and approval from the US Census Bureau and the US Office of Management and Budget.

Key Points Question Have the 12-month prevalences of alcohol use, high-risk drinking, and DSM-IV alcohol use disorder increased between 2001-2002 and 2012-2013?

Findings In this study of data from face-to-face interviews conducted in 2 nationally representative surveys of US adults, including the National Epidemiologic Survey on Alcohol and Related Conditions (n = 43 093) and the National Epidemiologic Survey on Alcohol and Related Conditions III (n = 36 309), 12-month alcohol use (11.2%), high-risk drinking (29.9%), and DSM-IV alcohol use disorder (49.4%) increased for the total US population and, with few exceptions, across sociodemographic subgroups.

Meaning Substantial increases in alcohol use, high-risk drinking, and DSM-IV alcohol use disorder constitute a public health crisis and portend increases in chronic disease comorbidities in the United States, especially among women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged.

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Assessments The Alcohol Use Disorder and Associated Disabilities Inter- view Schedule–DSM-IV Version (AUDADIS-IV)57 used in NESARC and the AUDADIS Fifth Edition Version58 used in NESARC-III assessed any 12-month alcohol use with identical questions. Consistent with the US dietary guidelines,59,60 high- risk drinking was defined as drinking 4 or more standard drinks (a drink equals 14 g of pure alcohol) on any day for women and as drinking 5 or more standard drinks on any day for men. In this study, high-risk drinking was defined as exceeding the daily drinking limits at least weekly during the prior 12 months.

An individual was considered to have a DSM-IV AUD di- agnosis if the respondent met criteria for alcohol dependence or abuse in the past 12 months. A diagnosis of dependence re- quired 3 or more of the 7 DSM-IV dependence criteria, and a diagnosis of abuse required 1 or more of the 4 abuse criteria. Respondents with a 12-month abuse or dependence diagno- sis were classified as having 12-month AUD.

Symptom items that assessed DSM-IV AUD diagnoses in NESARC and NESARC-III were virtually identical. However, 3 items were slightly reworded, and 3 additional abuse ques- tions appeared in NESARC-III. Comparisons between DSM-IV 12-month AUD diagnoses with and without the additional ques- tions yielded almost identical prevalences (8.5% and 8.2%, re- spectively, for NESARC and 12.7% and 12.2%, respectively, for NESARC-III), with near-perfect concordance (κ = 0.97 for NESARC and κ = 0.98 for NESARC-III), which suggested that trivial differences between AUD operationalizations were not responsible for the changes reported herein.

The test-retest reliability and validity of AUDADIS alco- hol use, high-risk drinking, and DSM-IV AUD diagnoses are documented in clinical and general population national and international studies.61-71 The reliability and validity of alcohol use, high-risk drinking, and DSM-IV AUD and their associated criteria scales were fair to excellent.

Statistical Analysis Data were analyzed in November and December 2016. Weighted cross-tabulations estimated the prevalence of alco- hol use, high-risk drinking, and DSM-IV AUD in the total sample and in subgroups. For 2001-2002 and 2012-2013, the preva- lences of 12-month DSM-IV AUD among 12-month alcohol us- ers and 12-month DSM-IV AUD among 12-month high-risk drinkers were also examined. To account for the complex sample design of NESARC and NESARC-III, a software pro- gram (SUDAAN, version 11.0; Research Triangle Institute72) was used to produce standard errors of the prevalence estimates for each survey. These data were used to test differences in prevalences between the surveys using 2-sided t tests for in- dependent samples. P < .05 indicated significant differences in the estimates between surveys.

Results 12-Month Alcohol Use Twelve-month alcohol use significantly increased from 65.4% in 2001-2002 to 72.7% in 2012-2013, a relative percentage in-

crease of 11.2% (Table 1). Significant increases, seen across all sociodemographic subgroups, were particularly notable among women (15.8%), racial/ethnic minorities (from 17.2% among Hispanic to 29.1% among Asian or Pacific Islander individu- als), adults 65 years and older (22.4%), and respondents with lower educational level and family income (range, 11.7%- 22.3%).

12-Month High-Risk Drinking The prevalence of 12-month high-risk drinking increased sig- nificantly between 2001-2002 and 2012-2013 from 9.7% to 12.6% (change, 29.9%) in the total population (Table 2). Sig- nificant increases in high-risk drinking were also seen for all sociodemographic subgroups except Native Americans and re- spondents residing in rural areas. Increases were most no- table among women (57.9%), other racial/ethnic minorities (from 40.6% among Hispanic to 62.4% among black individu- als), adults 65 years and older (65.2%), persons previously mar- ried (widowed, divorced, or separated) (31.9%) and married or cohabitating respondents (34.2%), those with a high school education (42.3%) and less than a high school education (34.7%), those earning incomes of $19 999 or less (35.1%), and those residing in urban areas (35.1%).

12-Month DSM-IV AUD The prevalence of 12-month DSM-IV AUD increased signifi- cantly from 8.5% to 12.7% (change, 49.4%) in the total popu- lation (Table 3). Significant increases in AUD were seen in all subgroups except Native Americans and those residing in ru- ral areas. Notable increases were found among women (83.7%), racial/ethnic minorities (51.9% for Hispanic and 92.8% for black individuals), adults 65 years and older (106.7%), those with a high school education (57.8%) and less than a high school edu- cation (48.6%), those earning incomes of $20 000 or less (65.9%), those living within 200% of the poverty threshold (range, 47.1%-55.8%), and those residing in urban areas (59.5%).

12-Month DSM-IV AUD Among 12-Month Alcohol Users Twelve-month DSM-IV AUD among 12-month alcohol users sig- nificantly increased from 12.9% to 17.5% (change, 35.7%) in the total population (Table 4). Increases were significant during this time for all subgroups except Native Americans, respon- dents who were previously married, and those residing in rural areas. Notable increases were found among women (59.8%), those who were black (55.8%), Asian or Pacific Islander (36.2%), or Hispanic (29.5%), adults aged 45 to 64 years (61.9%) and 65 years and older (75.0%), those who were married or cohabiting (45.1%), those who had a high school education (41.2%), and those who resided in urban areas (44.8%).

12-Month DSM-IV AUD Among 12-Month High-Risk Drinkers Twelve-month DSM-IV AUD among 12-month high-risk drink- ers increased 17.2% from 46.5% in 2001-2002 to 54.5% in 2012- 2013 (Table 5). Increases were significant for all sociodemo- graphic subgroups except Native American, Asian or Pacific Islander, previously married respondents, those with less than a high school education, and those residing in rural areas, the

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Northeast, and the Midwest. Notable increases were seen for women (34.7%), those who were black (25.7%) or Hispanic (16.8%), respondents aged 45 to 64 years (34.8%) and 65 years and older (58.1%), and those residing in urban areas (21.1%).

Discussion Between 2001-2002 and 2012-2013, the 12-month preva- lence of alcohol use increased 11.2% in the United States from

65.4% to 72.7%. High-risk drinking increased almost 30% from 9.7% to 12.6%, representing approximately 20.2 million and 29.6 million Americans, respectively. There was a 49.4% in- crease in 12-month DSM-IV AUD during this time from 8.5% to 12.7% (representing approximately 17.6 million and 29.9 mil- lion Americans, respectively), much greater than the corre- sponding 14.8% increase in DSM-IV AUD observed between 1991-1992 (7.4%) and 2001-2002 (8.5%).73 While the preva- lences of AUD among both 12-month alcohol users and 12- month high-risk drinkers increased, the prevalence of AUD

Table 1. Prevalence of and Percentage Change in 12-Month Alcohol Use by Sociodemographic Characteristics, 2001-2002 and 2012-2013

Sociodemographic Characteristic

% (95% CI)

% Change NESARC 2001-2002 (n = 43 093)

NESARC-III 2012-2013 (n = 36 309)a

Total 65.4 (64.3-66.6) 72.7 (71.4-73.9) 11.2

Sex

Men 71.8 (70.6-73.0) 76.7 (75.5-77.9) 6.8

Women 59.6 (58.0-61.1) 69.0 (67.5-70.5) 15.8

Race/ethnicity

White 69.5 (68.2-70.8) 75.3 (73.7-76.9) 8.3

Black 53.2 (51.6-54.9) 66.1 (63.8-68.3) 24.2

Native American 58.2 (53.0-63.4) 73.9 (69.1-78.1) 27.0

Asian or Pacific Islander 48.4 (44.3-52.5) 62.5 (59.4-65.5) 29.1

Hispanic 59.9 (58.1-61.7) 70.2 (68.8-71.7) 17.2

Age, y

18-29 73.1 (71.5-74.7) 80.1 (78.8-81.3) 9.6

30-44 71.9 (70.4-73.4) 79.5 (78.1-80.8) 10.6

45-64 64.3 (62.9-65.7) 71.9 (70.3-73.5) 11.8

≥65 45.1 (43.4-46.8) 55.2 (52.8-57.6) 22.4

Marital status

Married or cohabiting 66.3 (65.0-67.6) 73.1 (71.6-74.5) 10.3

Widowed, divorced, or separated 56.8 (55.3-58.3) 67.2 (65.4-68.9) 18.3

Never married 70.1 (68.5-71.7) 76.6 (75.1-78.0) 9.3

Educational level

Less than high school 46.4 (44.8-47.9) 55.8 (53.5-58.1) 20.3

High school 60.9 (59.5-62.3) 68.0 (66.5-69.5) 11.7

Some college or higher 73.3 (72.1-74.5) 78.3 (77.1-79.5) 6.8

Family income, $

0-19 999 52.4 (51.1-53.6) 64.1 (62.2-65.9) 22.3

20 000-34 999 61.0 (59.5-62.4) 68.5 (66.8-70.1) 12.3

35 000-69 999 68.1 (66.7-69.4) 73.4 (71.8-74.9) 7.8

≥70 000 78.4 (76.8-80.0) 81.0 (79.5-82.4) 3.3

Poverty threshold, %

<100 52.1 (50.4-53.9) 64.3 (62.5-66.0) 23.4

100-200 55.2 (53.8-56.6) 66.4 (64.4-68.3) 20.3

>200 71.3 (70.0-72.5) 77.8 (76.5-79.0) 9.1

Urbanicity

Urban 67.2 (65.8-68.5) 74.0 (72.9-75.1) 10.1

Rural 58.4 (56.5-60.2) 67.9 (64.8-70.9) 16.3

Region

Northeast 70.9 (67.2-74.4) 77.1 (75.3-78.9) 8.7

Midwest 69.9 (68.4-71.4) 76.5 (74.5-78.5) 9.4

South 59.0 (57.2-60.7) 68.2 (66.0-70.4) 15.6

West 66.1 (63.5-68.7) 72.9 (69.8-75.7) 10.3

Abbreviation: NESARC, National Epidemiologic Survey on Alcohol and Related Conditions. a P < .05 for all comparisons for

2001-2002 compared with 2012-2013.

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among high-risk drinkers (46.5% in 2001-2002 and 54.5% in 2012-2013) was much greater than the prevalence of AUD among 12-month users (12.9% in 2001-2002 and 17.5% in 2012- 2013), highlighting the critical role of high-risk drinking in the increase in AUD between 2001-2002 and 2012-2013, which was 49.4%.46-48 The smaller increase in 12-month high-risk drink- ing (21.3%) and the larger increase in 12-month alcohol use (48.6%) seen between the early 1900s and the early 2000s were associated with a much lower increase in AUD (14.9%), again

underscoring the more important influence of increases in high-risk drinking relative to alcohol use on increases in AUD.

Increases shown in 12-month alcohol use and high-risk drinking are consistent with other surveys during the same pe- riod. The National Health Interview Survey showed a 6.0% increase in 12-month alcohol use,74,75 while the National Sur- vey on Drug Use and Health showed a 9.1% increase in 12- month alcohol use.76,77 Trends in drinking 5 or more drinks at least once in the past year increased 17.8% in the National

Table 2. Prevalence of and Percentage Change in 12-Month High-Risk Drinking by Sociodemographic Characteristics, 2001-2002 and 2012-2013

Sociodemographic Characteristic

% (95% CI)

% Change NESARC 2001-2002 (n = 43 093)

NESARC-III 2012-2013 (n = 36 309)

Total 9.7 (9.3-10.2) 12.6 (12.0-13.2)a 29.9

Sex

Men 14.2 (13.4-14.9) 16.4 (15.7-17.3)a 15.5

Women 5.7 (5.3-6.1) 9.0 (8.4-9.7)a 57.9

Race/ethnicity

White 10.0 (9.6-10.5) 12.3 (11.6-13.0)a 23.0

Black 9.3 (8.4-10.4) 15.1 (14.0-16.2)a 62.4

Native American 12.4 (9.6-15.8) 17.4 (13.6-22.1) 40.3

Asian or Pacific Islander 4.6 (3.5-6.0) 7.2 (6.0-8.8)a 56.5

Hispanic 9.6 (8.8-10.6) 13.5 (12.5-14.6)a 40.6

Age, y

18-29 16.9 (15.7-18.2) 19.3 (18.0-20.6)a 14.2

30-44 10.8 (10.1-11.6) 14.8 (14.0-15.7)a 37.0

45-64 7.5 (6.9-8.2) 11.2 (10.5-12.1)a 49.3

≥65 2.3 (1.9-2.8) 3.8 (3.2-4.4)a 65.2

Marital status

Married or cohabiting 7.3 (6.8-7.8) 9.8 (9.2-10.5)a 34.2

Widowed, divorced, or separated 9.1 (8.3-9.9) 12.0 (11.1-13.0)a 31.9

Never married 17.4 (16.3-18.6) 20.3 (19.1-21.5)a 16.7

Educational level

Less than high school 9.5 (8.5-10.6) 12.8 (11.6-14.0)a 34.7

High school 10.4 (9.6-11.1) 14.8 (13.9-15.9) 42.3

Some college or higher 9.5 (9.0-10.0) 11.6 (10.9-12.4) 22.1

Family income, $

0-19 999 11.1 (10.3-12.0) 15.0 (13.9-16.3)a 35.1

20 000-34 999 10.3 (9.5-11.2) 12.6 (11.7-13.7)a 22.3

35 000-69 999 9.3 (8.7-10.1) 12.9 (12.1-13.7)a 38.7

≥70 000 8.4 (7.7-9.2) 10.5 (9.7-11.4)a 25.0

Poverty threshold, %

<100 11.8 (10.8-13.0) 14.2 (12.9-15.5)a 20.3

100-200 9.7 (8.9-10.7) 12.7 (11.7-13.7)a 30.9

>200 9.3 (8.8-9.8) 12.1 (11.4-12.7)a 30.1

Urbanicity

Urban 9.7 (9.2-10.3) 13.1 (12.5-13.7)a 35.1

Rural 9.6 (8.9-10.5) 10.8 (9.9-11.8) 12.5

Region

Northeast 9.3 (8.1-10.7) 12.2 (11.5-12.9)a 31.2

Midwest 11.2 (10.2-12.3) 14.7 (12.9-16.6)a 31.3

South 9.0 (8.4-9.7) 12.1 (11.1-13.1)a 34.4

West 9.7 (8.9-10.5) 11.8 (11.0-12.7)a 21.6

Abbreviation: NESARC, National Epidemiologic Survey on Alcohol and Related Conditions. a P < .05 for 2001-2002 compared

with 2012-2013.

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Health Interview Survey.78 Parallel increases were also seen in per capita alcohol consumption based on alcohol sales data, which rose 6.4%.79 The marked increases in high-risk drink- ing and DSM-IV AUD between 2001-2002 and 2012-2013 also mirror recent sharp increases in morbidity and mortality from diseases and injuries in which alcohol use has a substantial role or deceleration of previously seen declines. Most important, mortality rates of all cardiovascular diseases and stroke de- celerated between 2000-2001 and 2011-2014 after 3 decades of decline.80,81 Morbidity and mortality rates of hypertension

increased,82,83 as did hypertensive emergencies seen in emer- gency departments (EDs).84 Age-specific death rates of liver cirrhosis, especially alcohol-related liver cirrhosis, rose dra- matically between 2009 and 2013 for the first time since the early 1970s.85 Although increases in age-adjusted rates of type 2 diabetes86,87 since 2000 have largely been attributed to more overweight and obesity,88,89 increases in high-risk drinking dur- ing this time may have contributed, an issue that merits fur- ther investigation. During the same period, alcohol-related ED visits associated with falls increased, and the total number of

Table 3. Prevalence of and Percentage Change in 12-Month DSM-IV Alcohol Use Disorder by Sociodemographic Characteristics, 2001-2002 and 2012-2013

Sociodemographic Characteristic

% (95% CI)

% Change NESARC 2001-2002 (n = 43 093)

NESARC-III 2012-2013 (n = 36 309)

Total 8.5 (8.0-8.9) 12.7 (12.1-13.3)a 49.4

Sex

Men 12.4 (11.7-13.1) 16.7 (15.8-17.6)a 34.7

Women 4.9 (4.5-5.3) 9.0 (8.5-9.6)a 83.7

Race/ethnicity

White 8.9 (8.4-9.5) 13.1 (12.3-13.9)a 47.2

Black 6.9 (6.1-7.7) 13.3 (11.9-14.8)a 92.8

Native American 12.1 (9.3-15.6) 16.6 (12.7-21.5) 37.2

Asian or Pacific Islander 4.5 (3.5-5.9) 8.0 (6.7-9.5)a 77.8

Hispanic 7.9 (6.8-9.2) 12.0 (11.1-12.9)a 51.9

Age, y

18-29 16.2 (15.1-17.4) 23.4 (21.9-24.9)a 44.4

30-44 9.7 (9.0-10.5) 14.3 (13.3-15.3)a 47.4

45-64 5.4 (4.9-6.0) 9.8 (9.1-10.5)a 81.5

≥65 1.5 (1.2-1.8) 3.1 (2.6-3.7)a 106.7

Marital status

Married or cohabiting 6.0 (5.6-6.5) 9.7 (9.0-10.3)a 61.7

Widowed, divorced, or separated 8.1 (7.3-9.0) 10.6 (9.8-11.5)a 30.9

Never married 15.9 (14.7-17.1) 22.4 (20.9-23.9)a 40.9

Educational level

Less than high school 7.0 (6.2-8.0) 10.4 (9.3-11.7)a 48.6

High school 8.3 (7.6-9.0) 13.1 (12.2-14.0)a 57.8

Some college or higher 9.0 (8.4-9.6) 13.0 (12.3-13.8)a 44.4

Family income, $

0-19 999 8.8 (7.9-9.7) 14.6 (13.4-15.9)a 65.9

20 000-34 999 8.9 (8.2-9.7) 12.3 (11.3-13.4)a 38.2

35 000-69 999 8.1 (7.4-8.8) 12.3 (11.5-13.1)a 51.9

≥70 000 8.3 (7.6-9.1) 12.0 (11.2-12.8)a 44.6

Poverty threshold, %

<100 9.4 (8.3-10.5) 14.3 (13.0-15.6)a 52.1

100-200 7.7 (6.9-8.5) 12.0 (11.1-12.9)a 55.8

>200 8.5 (8.0-9.0) 12.5 (11.8-13.2)a 47.1

Urbanicity

Urban 8.4 (7.8-8.9) 13.4 (12.8-14.0)a 59.5

Rural 8.8 (8.0-9.7) 10.2 (9.0-11.5) 15.9

Region

Northeast 7.8 (6.7-9.0) 11.9 (10.9-12.9)a 52.6

Midwest 10.6 (9.3-11.9) 14.8 (13.2-16.5)a 39.6

South 7.3 (6.6-8.0) 11.5 (10.5-12.7)a 57.5

West 8.8 (7.9-9.7) 13.3 (12.2-14.5)a 51.1

Abbreviation: NESARC, National Epidemiologic Survey on Alcohol and Related Conditions. a P < .05 for 2001-2002 compared

with 2012-2013.

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care hours doubled, along with the intensity of care (eg, ad- vanced imaging) received.90 Mortality among alcohol- affected drivers who were simultaneously distracted also in- creased between 2005 and 2009 by 63%.91

Increases in high-risk drinking and AUD among women (57.9% and 83.7%, respectively) relative to men (15.5% and 34.7%, respectively) were alarming, consistent with earlier studies92-96 demonstrating a narrowing of the gender gap in these drinking patterns and AUD between 1991-1992 and 2001- 2002. Greater sensitivity to adverse health effects of heavy

drinking among women are potential biological factors influ- encing the convergence of rates between the sexes within the context of increasing rates of high-risk drinking and AUD.97-99

Drinking norms and values have become more permissive among women,100,101 along with increases in educational and occupational opportunities and rising numbers of women in the workforce,102 all of which may have contributed to in- creased high-risk drinking and AUD in women during the past decade. Stress associated with pursuing a career and raising a family may lead to inc reases in high-risk drinking and

Table 4. Prevalence of and Percentage Change in 12-Month DSM-IV Alcohol Use Disorder Among 12-Month Alcohol Users by Sociodemographic Characteristics, 2001-2002 and 2012-2013

Sociodemographic Characteristic

% (95% CI)

% Change NESARC 2001-2002 (n = 43 093)

NESARC-III 2012-2013 (n = 36 309)

Total 12.9 (12.3-17.5) 17.5 (16.7-18.3)a 35.7

Sex

Men 17.2 (16.3-18.2) 21.7 (20.6-22.9)a 26.2

Women 8.2 (7.5-8.9) 13.1 (12.4-13.8)a 59.8

Race/ethnicity

White 12.8 (12.1-13.6) 17.4 (16.4-18.4)a 35.9

Black 12.9 (11.6-14.3) 20.1 (18.2-22.2)a 55.8

Native American 20.8 (16.3-26.0) 22.5 (17.3-28.7) 8.2

Asian or Pacific Islander 9.4 (7.3-11.9) 12.8 (10.9-15.1)a 36.2

Hispanic 13.2 (11.4-15.2) 17.1 (15.9-18.3)a 29.5

Age, y

18-29 22.2 (20.7-23.7) 29.2 (27.5-31.0)a 31.5

30-44 13.5 (12.5-14.6) 17.9 (16.8-19.2)a 32.6

45-64 8.4 (7.6-9.3) 13.6 (12.7-14.6)a 61.9

≥65 3.2 (2.6-4.0) 5.6 (4.8-6.6)a 75.0

Marital status

Married or cohabiting 9.1 (8.5-9.8) 13.2 (12.4-14.1)a 45.1

Widowed, divorced, or separated 14.2 (12.9-15.7) 15.8 (14.7-17.1) 11.3

Never married 22.6 (20.9-24.4) 29.2 (27.6-30.9)a 29.2

Educational level

Less than high school 15.2 (13.4-17.2) 18.7 (16.7-20.9)a 23.0

High school 13.6 (12.4-14.8) 19.2 (18.0-20.5)a 41.2

Some college or higher 12.2 (11.5-13.0) 16.7 (15.8-17.6)a 36.9

Family income, $

0-19 999 16.7 (15.2-18.3) 22.8 (21.2-24.4)a 36.5

20 000-34 999 14.7 (13.5-15.9) 17.9 (16.6-19.3)a 21.8

35 000-69 999 11.8 (11.0-12.8) 16.7 (15.7-17.8)a 41.5

≥70 000 10.6 (9.7-11.5) 14.8 (13.8-15.8)a 39.6

Poverty threshold, %

<100 17.9 (16.1-20.0) 22.2 (20.5-24.0)a 24.0

100-200 13.9 (12.6-15.4) 18.0 (16.9-19.2)a 29.5

>200 11.9 (11.3-12.6) 16.0 (15.2-16.9)a 34.5

Urbanicity

Urban 12.5 (11.7-13.2) 18.1 (17.3-19.0)a 44.8

Rural 15.1 (13.7-16.6) 15.0 (13.5-16.7) -0.7

Region

Northeast 11.0 (9.7-12.4) 15.4 (14.3-16.6)a 40.0

Midwest 15.1 (13.4-17.0) 19.3 (17.3-21.5)a 27.8

South 12.3 (11.3-13.4) 16.9 (15.7-18.2)a 37.4

West 13.2 (12.0-14.6) 18.3 (16.6-20.1)a 38.6

Abbreviation: NESARC, National Epidemiologic Survey on Alcohol and Related Conditions. a P < .05 for 2001-2002 compared

with 2012-2013.

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AUD103,104 among women, results that were consistent with substantial increases in these patterns of alcohol use among married individuals and those residing in urban areas found in this study. A narrowing of the gender gap in high-risk drink- ing and AUD may portend substantial future increases in the types of alcohol-related morbidity and mortality to which women are more vulnerable, especially breast cancer105,106 and liver cirrhosis,17,18,107 as well as increases in fetal alcohol spec- trum disorder and exposure to violence.108 Women are also

more likely than men to take prescription drugs109 that can in- crease the risk of severe adverse reactions when combined with alcohol.

Older adults have had consistently lower rates than oth- ers of alcohol use, high-risk drinking, and AUD over the past 40 years.32,40,45 However, between 2001-2002 and 2012- 2013, increases in alcohol use (22.4%), high-risk drinking (65.2%), and AUD (106.7%) among older adults were substan- tial and unprecedented relative to earlier surveys.73 Older

Table 5. Prevalence of and Percent Change in 12-Month DSM-IV Alcohol Use Disorder Among 12-Month High-Risk Drinkers by Sociodemographic Characteristics, 2001-2002 and 2012-2013

Sociodemographic Characteristic

% (95% CI)

% Change NESARC 2001-2002 (n = 43 093)

NESARC-III 2012-2013 (n = 36 309)

Total 46.5 (44.3-48.7) 54.5 (52.7-56.4)a 17.2

Sex

Men 50.7 (47.9-53.4) 57.4 (55.0-59.8)a 13.2

Women 36.9 (33.4-40.5) 49.7 (46.8-52.6)a 34.7

Race/ethnicity

White 47.3 (44.5-50.0) 56.6 (54.1-59.0)a 19.7

Black 40.4 (35.8-45.2) 50.8 (46.9-54.6)a 25.7

Native American 63.1 (51.0-73.8) 55.2 (41.8-67.9) −12.5

Asian or Pacific Islander 52.5 (38.5-66.2) 55.0 (45.8-64.0) 4.8

Hispanic 42.3 (37.4-47.4) 49.4 (46.0-52.9)a 16.8

Age, y

18-29 56.6 (53.0-60.2) 64.6 (61.0-68.0)a 14.1

30-44 45.0 (41.6-48.4) 52.3 (49.2-55.4)a 16.2

45-64 37.1 (33.0-41.3) 50.0 (47.0-53.0)a 34.8

≥65 19.8 (13.7-27.8) 31.3 (24.8-38.7)a 58.1

Marital status

Married or cohabiting 38.1 (35.1-41.2) 48.6 (45.7-51.5)a 27.6

Widowed, divorced, or separated 50.8 (46.0-55.6) 53.4 (50.0-56.8) 5.1

Never married 55.0 (51.4-58.5) 62.5 (58.9-66.0)a 13.6

Educational level

Less than high school 47.2 (42.0-52.4) 51.4 (46.7-56.1) 8.9

High school 46.6 (42.7-50.5) 55.7 (52.6-58.8)a 19.5

Some college or higher 46.3 (43.7-48.9) 54.6 (52.0-57.3)a 17.9

Family income, $

0-19 999 49.3 (45.4-53.2) 58.8 (55.2-62.4)a 19.3

20 000-34 999 49.6 (45.2-53.9) 55.7 (51.9-59.4)a 12.3

35 000-69 999 43.4 (39.7-47.1) 52.7 (49.4-56.0)a 21.4

≥70 000 44.4 (40.0-48.9) 51.2 (47.3-55.1)a 15.3

Poverty threshold, %

<100 48.7 (43.4-54.0) 58.2 (54.3-62.0)a 19.5

100-200 46.2 (41.7-50.8) 55.2 (51.4-59.0)a 19.5

>200 46.0 (43.5-48.6) 52.9 (50.4-55.4)a 15.0

Urbanicity

Urban 45.5 (43.0-48.0) 55.1 (53.0-57.1)a 21.1

Rural 50.7 (46.2-55.1) 52.2 (47.0-57.4) 3.0

Region

Northeast 46.4 (42.2-50.6) 51.7 (47.6-55.8) 11.4

Midwest 48.6 (43.4-53.9) 54.4 (49.9-58.9) 11.9

South 44.9 (41.3-48.6) 53.8 (50.9-56.7)a 19.8

West 46.4 (41.8-51.2) 58.1 (54.4-61.8)a 25.2

Abbreviation: NESARC, National Epidemiologic Survey on Alcohol and Related Conditions. a P < .05 for 2001-2002 compared

with 2012-2013.

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adults are at higher risk for disability, morbidity, and mortal- ity from many alcohol-related chronic diseases110,111 that have increased over the past 15 years.86,87 Older adults are at par- ticular risk for falls and injuries,112 and the unintentional in- jury death rate,113 ED-treated falls,114 hospitalized fall rates,115

and fall-related traumatic brain injury deaths116 have risen sig- nificantly over the past decade. Alcohol-interactive prescrip- tion medicine use is highly prevalent among older adults,117,118

especially among current drinkers,119 and recent trend data sug- gest that ED visits for adverse drug reactions involving alco- hol use are on the rise.120 Even if the rates among older adults remain stable, the projected increase in the size of this seg- ment of the population (from 40 million in 2010 to 80 million in 2030)121 could produce a substantial increase in the abso- lute number of older adults with high-risk drinking and AUD, w i t h c o n c o m i t a n t i n c r e a s e s i n a l c o h o l - r e l a t e d multimorbidities.122

Between 2001-2002 and 2012-2013, increases in alcohol use, high-risk drinking, and AUD were generally much greater among minorities than among white individuals, results that are con- sistent with substantial increases among individuals with the lowest educational levels and family incomes seen in this study. Wealth inequality between minorities and whites has wid- ened during and after the 2008 recession,123,124 possibly lead- ing to increased stress and demoralization. Adversities that dis- proportionately affect racial/ethnic minorities include family income and educational disparities, unemployment, residen- tial segregation, discrimination, decreased access to health care, and increased stigma associated with drinking.125-127 These dis- parities may have accumulated over recent years, leading to in- creased negative coping behaviors, such as high-risk drinking and the development of AUD.125-131 Reasons for the widening of the racial/ethnic gap in alcohol use, high-risk drinking, and AUD are complex, historically rooted in racial/ethnic discrimi- nation and persistent socioeconomic disadvantage both at the individual and community levels.132-137 Future research is war- ranted to understand the interplay of socioeconomic, psycho- social, cultural, and biological factors that have contributed to the widening of the racial/ethnic gap in alcohol use, high-risk drinking, and AUD in recent years, with particular attention to the development of subracial/subethnic prevention and inter- vention strategies.

Limitations and Strengths Limitations of this study are noted. NESARC and NESARC-III lacked biological testing for substance use. Like other na- tional surveys,53,54 some population segments were not cov- ered in either survey (eg, the homeless and those who are in- carcerated), potentially leading to underestimation of alcohol

use, high-risk drinking, and DSM-IV AUD. AUDADIS interview- ers were not clinicians, but a NESARC-III validation substudy comparing AUDADIS and clinician diagnoses of 12-month AUD showed similar prevalence and good concordance.68 The NE- SARC-III response rate was acceptable (60.1%) but was lower than that of NESARC (81.0%). Weighting that compensated for nonresponse facilitated comparisons between the surveys.51,52

The validity of increases shown between NESARC and NESARC- III is supported by their coherence with the other studies noted above showing increases in alcohol-related indicators over the same period.

These limitations are balanced by the numerous strengths of the Wave 1 NESARC and NESARC-III, including their large sample sizes and detailed measures of alcohol use, high-risk drinking, and DSM-IV AUD that have been extensively tested and validated,61-71 in addition to their rigorous epidemiologic study methods. These 2 surveys are also unique in providing a uniform source of alcohol information and AUD to examine trends over time.

Conclusions Between 2001-2002 and 2012-2013, an increase in alcohol use, high-risk drinking, and AUD occurred in the total US popula- tion and across almost all sociodemographic subgroups, es- pecially women, older adults, racial/ethnic minorities, and the socioeconomically disadvantaged. These increases consti- tute a public health crisis that may have been overshadowed by increases in much less prevalent substance use (mari- juana, opiates, and heroin)138-140 during the same period. Treat- ment rates for AUD remain low (<10%)141 despite the signifi- cant rise in high-risk drinking and AUD and the existence of a broad spectrum of evidence-based and effective behavioral and pharmacological approaches.142-152 The results of this study call for a broader effort to address the individual, biological, en- vironmental, and societal factors that influence high-risk drink- ing and AUD and their considerable consequences and eco- nomic costs to society ($250 billion)153 to improve the health, safety, and well-being of the nation. The development of pre- vention and intervention strategies both at the population level and those targeted at high-risk subgroups of the population identified in this study154-159 will be paramount to achieving this goal. Most important, the findings herein highlight the ur- gency of educating the public, policymakers, and health care professionals about high-risk drinking and AUD,160 destigma- tizing these conditions and encouraging those who cannot re- duce their alcohol consumption on their own, despite sub- stantial harm to themselves and others, to seek treatment.

ARTICLE INFORMATION

Accepted for Publication: May 28, 2017.

Published Online: August 9, 2017. doi:10.1001/jamapsychiatry.2017.2161

Author Contributions: Dr Saha and Mr Pickering had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Grant. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: All authors. Obtained funding: Grant, Chou, Saha, Pickering, Ruan, Huang, Jung, Zhang.

Administrative, technical, or material support: Kerridge, Ruan, Huang, Zhang, Fan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was sponsored by the National Institute on Alcohol Abuse and Alcoholism, with supplemental funding from the National Institute on Drug Abuse, and by grant

Prevalence of Alcohol Use, High-Risk Drinking, and DSM-IV Alcohol Use Disorder Original Investigation Research

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K05AA014223 from the National Institutes of Health (Dr Hasin).

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views and opinions expressed in this report are those of the authors and should not be construed to represent the views of any of the sponsoring organizations or agencies or the US government.

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