The Truth About Alcohol with Dr. George Koob

Show Notes

April is Alcohol Awareness Month, a time to address the stigma around alcohol use disorder, or AUD, and share resources to support those who suffer from this often underdiagnosed and undertreated condition. Among the millions of Americans impacted, older adults remain at heightened risk of alcohol abuse due to a variety of environmental, medical, and social factors.  

Joining us to discuss the risks of alcohol abuse as we age is the Director of the National Institute on Alcohol Abuse and Alcoholism, Dr. George Koob. Dr. Koob is an internationally recognized expert on alcohol and stress and the neurobiology of alcohol and drug addiction.

Episode Transcript

Lindsay Clarke:

Hi everyone. Welcome to This Is Growing Old, the podcast all about the common human experience of aging. My name is Lindsay Clarke. I’m the Senior Vice President of Health Education Advocacy here at the Alliance for Aging Research. April is alcohol awareness month, a time for organizations to use their collective outreach channels and voices to raise awareness about the treatment and prevention of alcoholism and to address the stigma around alcohol use disorders or AUD.

An estimated 29.5 million people, ages 12 and older in the US had AUD in 2021. And older adults remain at heightened risk due to a variety of environmental, medical and social factors. Joining us to discuss the risks of AUD in older adults, is the director of the National Institute on Alcohol Abuse and Alcoholism at the National Institutes of Health, Dr. George Koob. Dr. Koob is an internationally recognized expert on alcohol and stress and the neurobiology of alcohol and drug addiction. He provides important leadership in the national effort to reduce the public health burden associated with alcohol misuse and is a recipient of many prestigious honors and awards for his research. Dr. Koob, thank you so much for joining us today.

Dr. Koob:

You’re most welcome. It’s a pleasure to be here.

Lindsay Clarke:

Well, let’s start off, could you tell us more about the role of NIAAA in combating alcohol related problems, including alcohol use disorder?

Dr. Koob:

So the National Institute on Alcohol Abuse and Alcoholism is in fact, the largest funder of research on alcohol in the world. And our charge is basically to provide evidence-based information about the diagnosis, prevention and treatment of alcohol use disorder, as well as the health effects of largely, the untoward health effects of alcohol.

Lindsay Clarke:

So I’m hoping you can start also by telling our listeners what is encompassed in the term alcohol use disorders. What’s included in that term?

Dr. Koob:

Well, alcohol use disorder now is a spectrum disorder. So it replaces the old words of substance dependence on alcohol, alcohol addiction and effect, alcohol dependence and alcoholism. And so it’s defined largely by 11 criteria outlined by the American Psychiatric Association in the Diagnostic and Statistical Manual, number five. And so there are 11 criteria, they range from, have you ended up drinking more than you intended? To, you wanted to cut down but weren’t able? Do you have craving for alcohol? Did you continue to drink although it was causing trouble with your family or loved ones? And so if you meet two of these, you have a mild alcohol use disorder. If you meet four or five, you’re in the moderate range. I mean anything above two to five, four to five, you’re in the moderate range. And then if you meet four or five and above, you’re in the severe range.

And so probably, if you want to loop it back to alcohol dependence or alcohol addiction, we would argue that meeting criterion four or five and DSM-5 would put you in that category.

Lindsay Clarke:

So is it fair to say then, that the term encompasses what we would’ve traditionally said as misuse or abuse or alcoholism?

Dr. Koob:

Yes. I mean when DSM-4 used to call it abuse and dependence, those two have been merged into alcohol use disorder, much like autism spectrum disorder and many other disorders where there’s a range of symptoms. And we actually like this because it captures early stage problems with alcohol, if you have a mild alcohol use disorder, which we’ve written about recently and called pre-addiction in some sense, and the old term like alcohol addiction, as I said, would fit where you’re in the moderate to severe range of an alcohol use disorder. So we think of it as a spectrum from mild to moderate to severe.

Lindsay Clarke:

And so we know a variety of medical, social and environmental factors are putting everyone at risk, but particularly older adults, at heightened risk of alcohol use disorders. Can you shed some light on some of these risk factors for older adults?

I always say men over 50 shouldn’t climb ladders. Maybe men at any age should not climb ladders, but definitely don’t be drinking and climbing a ladder

Dr. Koob:

Yes, there’s some special issues surrounding the older population. So one of which of course, is changes in the physiology of the body. There’s probably more body fat per kilogram unfortunately because of changes in physiology. There’s the medication interaction. Older populations are engaged in taking many different medications for many different conditions because the body wears down and sometimes we need a little help. And those often interact in not a good way with alcohol and particularly sedative hypnotics, sleeping pills, opioids, which are also can be sedative, but can, two plus two equals five when you start interacting alcohol with sleeping pills and with opioids. And it can be very dangerous and particularly dangerous for the older population because they’re taking many different medications and you really need to check with your doctor about such interactions, or your pharmacist, both should know.

And then there’s the pharmacological effects when you’re older, you’re more prone to coordination problems, alcohol impairs coordination. It’s probably really not a good idea to get behind the wheel when you’ve been drinking when you’re older, or you shouldn’t be getting behind the wheel when you’re drinking at any age. But in the older population it’s even a bigger issue. So falls, I always say men over 50 shouldn’t climb ladders. Maybe men at any age should not climb ladders, but definitely don’t be drinking and climbing a ladder, for example.

Lindsay Clarke:

Sure. And good advice. Are there any chronic conditions? I mean obviously there can be medications to treat some of those chronic conditions which you just spoke of, but are there any chronic conditions themselves that can put older adults at a heightened risk of problems with alcohol?

Dr. Koob:

Well, yeah, heart disease, diabetes problem, elevated liver enzymes, all of these things definitely interact with alcohol, especially if you pass the dietary guidelines of drinking, which in the whole population would be one drink a day for females and two drinks a day for males. So when you get into that range past what the USDA calls moderate drinking, again, the two, males, one, females, then many chronic conditions that you have can be exacerbated by alcohol. I mean alcohol, according to the National Cancer Institute is now responsible for 5% of cancers. And so 200 different diseases interact with alcohol. And as you get older, unfortunately, you’re more likely to have some of those diseases or disorders.

Lindsay Clarke:

That’s really helpful, thank you. And I was looking at some of the data and I didn’t look at the breakdown at all, but it seems that there has been tremendous growth in alcohol use disorders over the course of the pandemic. Is that true? Are we seeing that in older adults across the board?

Dr. Koob:

I don’t know that we have numbers for older adults that are any different than the population in general, but we have seen a big increase in the pathology associated with alcohol during the first year of the pandemic, extended into the second year of the pandemic. So we published a paper from NIAAA, Aaron Whites, the first author, showing that there was a 25% increase in the number of death certificates where alcohol was attributed as the cause of death during the first year of the pandemic.

There’s been increased hospitalizations, increased emergency room visits, spikes in actual drinking, particularly in about 25% of the population, who showed increased drinking. Another group actually showed decreased drinking, but overall, we’re we are picking up increased pathology associated with alcohol, reflecting increased drinking in those that were drinking. And more drinking to cope with the stress associated with the pandemic. And it could be everything from job stress to fear of getting COVID to the isolation that we were suffering because of COVID. So all of these things have contributed to increased stress and we think increased drinking, to cope with that stress.

And we don’t have numbers yet, but that may be even more sensitive in the older population because they don’t have the social interactions and possibly, the Zooms and connections that other people do. So that isolation was particularly acute, I suspect.

Lindsay Clarke:

And I know that as a lot of us are returning to a life that looks a lot more like it did pre-pandemic, there are also a lot of individuals and especially older adults who are at heightened risk of complications from COVID, who are continuing to be isolated in some respect. So I think that’s a great segue into talking about raising awareness during April for Alcohol Awareness Month. What are the signs of alcohol use disorders that people should be looking for in themselves and in loved ones?

Dr. Koob:

Well, I always start with the interaction with other human beings. And so, if there are problems with interactions with family, the older population is less likely to be late for work, but they may be late for appointments that they would normally set up, groups that they participate in. There may be a deterioration in relationships with everyone, caregivers as well as family members, as well as individuals that perhaps, they are caring for. I mean the older population often are involved in philanthropic-like activities and participating in community activities.And maybe there’s a deterioration. That would be probably the first sign that I would pick up on.

But all the symptoms of the alcohol use disorder can come into play if you notice that they’re drinking more than they normally would be drinking. If they’re drinking, if they’re engaged in activities where you could get hurt doing things that are inappropriate for an older person. It could be everything from driving the golf cart wildly to getting in a car and attempting to go down to the market while intoxicated. So all of these are early signs that maybe there’s something not quite right.

Lindsay Clarke:

Can someone have a problem with alcohol, just in terms of quantity of drinks that doesn’t necessarily impact their safety or behavior? They’re still making it to appointments in time, they’re still meeting their obligations. They’re not putting themselves in danger, but just simply the quantity of drinking is too much?

Dr. Koob:

Well, if you’re drinking and you somehow manage to cover all your bases on the other criteria and you’re drinking quite a lot, as you’re older, an early sign would be possibly elevated liver enzymes, which could be picked up by a primary care doc, if they were actually checking. So there could be problems with sleeping for example, is a very sensitive measure of untoward effects caused by alcohol. So if an older person is complaining that their sleeping is disrupted, while everybody, as you get older, your sleeping is disrupted, your topography of sleep changes as you get older. And it’s much easier to have awakings in the middle of the night. Sometimes it’s just physiological. You have to go to the bathroom number one, all right. So those are all things, but if you can’t get back to sleep, and if these problems with sleeping are getting worse and worse, then that’s another flag that should go up about the possibility that maybe someone is overdoing it and overdoing it with the quantity.

There’s this word out there that you could have somebody that’s functional alcohol use disorder. They used to say functional alcoholic, I don’t buy that because what’s functional? They may be putting on a good show in front of everyone, but snapping at their significant other every night and causing big fights at home and you don’t see it, or their children or their grandchildren even. So if we’re talking about the older population. So I look back to that social interaction deterioration is a key thing. Physiological signs like sleeping, abnormal measures coming up when you do your annual physical, those are all things that to look for.

Lindsay Clarke:

Well, and I think you’ve covered what screening looks like, so it’s asking of those questions, it’s doing the blood work. Is there anything else that people should expect to see at their annual visit?

We really need to educate Americans on what is a standard drink.

Dr. Koob:

Well, if the doctors actually just ask one question, which is how much do you drink and how much do your friends drink? That’s a starter. I mean, we just put out in May of last year, the Healthcare Professional Core Resource on Alcohol, it’s on our website and it has everything you need to know about alcohol. If you’re a healthcare professional, ranging from a pharmacist to a nurse practitioner to a clinical psychologist to a primary care doc, to a board certified addiction medicine specialist, any one of those individuals could benefit from that.

But in there, we have a whole section on screening and brief intervention. And you can start with the question I mentioned, or you could start with the AUDIT-C, which is three questions that are used often as a prelude that there’s an alcohol problem. How often do you have a drink containing alcohol? How many standard drinks containing alcohol do you have on a typical day? And how often do you have six or more drinks on one occasion? That’s it. I mean, how long did that take me to say that? And so if a healthcare professional is using the AUDIT-C, it’s a good starter for identifying problematic alcohol use.

And the other issue is that, I’ve been saying this a lot lately, is we really need to educate Americans on what is a standard drink. And that can be found, I’m going to plug these anyway at some point in our discussion, but that can be found on our other website, Rethinking Drinking. And the standard drink is five ounces of wine, 12 ounces of beer, 1.5 ounces of distilled beverage. And you know the old story, “I only have one drink a day.” I think it was a New Yorker cartoon originally, but the glass is the size of a liter bottle. So if I don’t get anything else across, people should learn what a standard drink is and adjust accordingly.

Lindsay Clarke:

That’s a great point, and I think it segues well into my next question because I think some of that is self-awareness too, right? And also being willing to admit and talk to someone when you’re seeing a healthcare professional and they’re asking those questions. So we have a statistic here from the Center for Behavioral Health Statistics and Quality from 2018, saying that only 16.8% of older adults who suffered from alcohol use disorder received treatment. So obviously, being honest about those questions is going to be a key, but what are some of the other barriers to diagnosis and treatment that we should be thinking about?

Dr. Koob:

Well, there are quite a few, and that number for us, is a bit high because we know in the general population is less than 10% get any treatment for alcohol use disorder. So we suspect that its even lower than 16%. So a number of things when doctors, bless their hearts, do screen for alcohol use disorder or alcohol problems, there’s very little intervention part and very little referral to treatment. And we have numbers, data to support that. So 70, 80% are often asked how much they drink, but then the doctor doesn’t do anything about it. So that’s one issue. There are many others. Stigma, people are afraid to get treatment because they’re going to be stigmatized. People are afraid to recommend treatment because of the stigma issue. Another is just lack of knowledge. And that’s why we put out the Healthcare Professional Core Resource. There are three medications approved by the Food and Drug Administration for the treatment of alcohol use disorder. And they are effective.

They’re as effective as a serotonin selective re-uptake inhibitor for major depressive episodes. People don’t know that. People don’t know that naltrexone can help you along the way, and Acamprosate, those are the two that are most likely to be used. But we also have excellent behavioral treatments for alcohol use disorder. Again, lack of knowledge of those. And then, everybody thinks that you either have to go into a 28-day detox or rehab, excuse me, not detox. Do you have to be detoxed? Yes, you do if you have a moderate to severe alcohol use disorder. But everybody thinks that it’s 28-day rehab in a facility that can cost a lot of money, and particularly if they don’t take insurance or it’s Alcoholics Anonymous.

And there are many, many different treatments for alcohol use disorder that are outpatient. Everything from cognitive behavioral therapy to motivational interviewing to a community approach, where everybody gets involved, family therapy as well as some of these other behavioral treatments. And the behavioral treatments are very, very effective, but you have to do them.

Lindsay Clarke:

Well, I’m really glad that you dug into that because I do think most people think of treatment as a time commitment, a financial commitment, something that maybe they can’t envision finding the time or money for. So knowing there’s so many other treatments out there is I think, really important to underscore. I would love to think that every person who’s going in for their annual visit is being asked those questions. And if they need treatment, they’re being referred. But if they’re not, or if they’re in the process of navigating and either they or a loved one seem to need help, where should people start? Where can they go to get that help?

Dr. Koob:

Well, my third plug for NIAAA is that we, a couple of years ago put out what we call the NIAAA treatment navigator. So on there you can find all the things I’ve been talking about. What is alcohol use disorder? It’s a spectrum disorder, but more importantly, you can find out, what are the treatments that are effective for different levels of alcohol use disorder? You can go to an outpatient facility in the evenings, have dinner there and get back home for your family and not miss an hour of work, and still get an effective treatment. And there are counselors that can help you along the way, even if you just have mild symptoms of an alcohol use disorder.

So I think the treatment navigator has that information, but there’s a third piece to it, which is you can actually type in your zip code and find a treatment facility in your area. And maybe they’re not the right one for you, but you can call them and interact with them and they will refer you to other treatment facilities. And we have the SAMSA locator, the Substance Abuse Mental Health Services Administration on there for that, and also the Psychology Today locator. So one more source of useful help, I hope.

Lindsay Clarke:

Just to remind people because I think that’s so critical, especially that those localized resources, what are the URLs they should go to again?

Dr. Koob:

So it just type in NIAAA treatment navigator or go to our website, find our website by typing in NIAAA. N-I-A-A-A-. It’s pretty simple. We’ve updated our website and we welcome feedback on our website because we keep updating the website to make it easier to find things.

Lindsay Clarke:

That’s great. And I would imagine, whether it’s for an individual or for someone who was worried about a loved one, looking up those local resources is a great start on how to have those conversations and find out where to get started. Before we turn to our closing questions, is there anything else that you want people to really be thinking about this April, as we’re talking about Alcohol Awareness month.

I think there’s a lot of change in our culture… where people are reevaluating their relationship with alcohol. And I can only argue that’s a good thing.

Dr. Koob:

Yeah, I mean, basically our argument is that there’s no really safe amount of alcohol. I mean, we know that even the equivalent of one drink a day of alcohol can increase the probability of breast cancer in women. So each person needs to evaluate their relationship with alcohol. The dietary guidelines argue for one drink a day, females, two drinks a day for males, but don’t have those all on a Friday night. I mean, for your week. That’s not helpful either. And it’s not good for your liver, definitely. And so I think there’s a lot of change in our culture with a good bit of emphasis on things like dry January, sober curious, mocktails, dry bars where people are reevaluating their relationship with alcohol. And I can only argue that’s a good thing.

Lindsay Clarke:

Absolutely. I love a good mocktail, and I think that that’s a really important point though, because I think when people talk about and think about drinking responsibly, the assumption of, “Well, it’s one drink a day, and I’m never doing anything dangerous. I’m never putting myself or loved ones in a situation that’s unsafe.” They assume that that’s just fine. So to underscore the health effects of any alcohol at all is really interesting and important. So thank you for that.

So turning away from April and Alcohol Awareness month, two questions we always ask all of our podcast guests. And the first is, when you were a kid, what did you imagine that growing older would be like?

Dr. Koob:

Well, I had a wonderful mother who had a PhD in 1946 and was a professor of English and a writer. But when she got older, first of all, she had to retire early in those days, in Pennsylvania. And I always thought that that was not a good thing for her because she was so active. But when she did get older, she kept telling me, “You’ll see, George when you get old, you’ll see.” And she was right. I have seen.

So I don’t know what my expectations were. I guess I figured that I saw how my mother managed her professional career after she had to retire. And I guess I thought that I would like to continue to be as useful to society as I could be in as I get older. And so I’m trying to continue to do those kind of things. At the same time, I think I had a pretty good idea that all the pieces of my body were not going to work as well as they did when I was younger. And so I tried to avoid climbing on ladders, just to be a good example.

Lindsay Clarke:

Especially after a drink.

Dr. Koob:

And my wife makes sure that I don’t climb ladders either. So I think I had a reasonably realistic expectation that there were going to be challenges. But at the same token, I believe I’ve led a pretty healthy life when it comes to diet and exercise and things of that nature. So that’s a recommendation to everyone. And it’s not too early, it’s never too late, I should say, to take some of those things into consideration.

Lindsay Clarke:

Absolutely. So what do you look forward to most about growing older now?

Dr. Koob:

Well, probably, working with the young people and helping them basically, with no strings attached. I don’t have anything I need to accomplish, so I really enjoy working. I have a lab at the National Institute on Drug Abuse, where we do basic research on alcohol addiction and opioid addiction. And I think I’m going to continue to do that, working with the younger people and helping them along and moving them through their careers. And I look forward to that. And should I ever retire, retire, then I will probably continue to write and synthesize, which I really enjoy doing in the science field. And as long as I can be useful and helpful.

Lindsay Clarke:

Well, we’re grateful for all of the work you’re doing and that it’s making you happy. So you’ll continue to do it for many more years. And thank you for joining us to share all of this important information. I think this was really great for folks to hear, and I hope that people will go to your website to learn more and to find any resources if they need them.

And for everyone listening or watching us online, thank you for listening to This Is Growing Old. If you’re enjoying the show, please subscribe wherever you get your podcast. Have a great day.