Interview with NIAAA Director on Rise in Alcohol Use During COVID-19

Patient Care Online recently spoke with George F. Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) about worrisome trends in alcohol use and mental health in the United States since the beginning of the COVID-19 pandemic.

With images of young adults on Spring Break flouting all COVID-19 precautions still fresh, our conversation began with NIAAA concerns about the impact of prolonged pandemic-triggered stress on this vulnerable population, and branched from there into the effects of population-wide emotional strain on human coping strategies.

George F. Koob, PhD, is director of the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health. Dr Koob is an internationally-recognized expert on alcohol and stress, and the neurobiology of alcohol and drug addiction. As NIAAA director, he oversees a broad portfolio of alcohol research ranging from basic science to epidemiology, diagnostics, prevention, and treatment.

The following has been edited for clarity.

A Conversation with George F Koob, PhD

Patient Care Online: The NIAAA recently put out a statement on its concern about the current – and the potential future – impact of the pandemic conditions on the problem of alcohol misuse among young adults. Was there something in particular that moved you to, in a sense, flash a warning signal now?

George F Koob, PhD: We learned from previous crises that widespread increases in financial stress and fear about the future lead some people to increase their alcohol consumption in an effort to cope. We also know that stress is a common trigger for relapse among people in recovery from substance use disorders. So, we quickly recognized that the pandemic could lead to increases in alcohol consumption, and potentially relapse, at a time when common in-person strategies for coping, treatment and recovery support could become limited.

PCO: Can you give us a sense of how the numbers on alcohol use among young adults that the NIAAA tracks have changed since March of 2020 when the initial pandemic lockdown went into place?

Koob: Based on total sales data, including both on-premise (bars and restaurants) and off-premise (stores and online) locations, it looks like alcohol sales increased roughly 5-10% on average each month in 2020 during the pandemic compared to pre-pandemic numbers. This estimate accounts for the decrease in sales at bars and restaurants, which led to a shift in sales toward brick-and-mortar stores and online services.

Perhaps more important than shifting patterns of sales are shifting patterns of consumption. A growing list of studies suggests that some people, perhaps 20-30% depending on the study, report drinking more during the pandemic. A roughly similar proportion of the population report drinking less. For those drinking more, elevated anxiety and other negative emotions are a common motivator.

PCO: Can you talk a bit about the specific vulnerabilities of young adults during this unprecedented experience, ie, how do pandemic conditions uniquely threaten the well-being of this age group?

Koob: In the decade leading up to the pandemic, self-reported anxiety, suicidal ideation, and clinically diagnosable anxiety and depression, were all increasing quickly among young adults. The percentage of young adults with major depression doubled from 5.2% in 2009 to 10.3% in 2019. In fact, as of 2019, nearly 1 in 3 (29.4%) young adults met criteria for a mental health disorder in the previous year.

And while alcohol use by adolescents and young adults was declining, more young people were drinking alone, which is often associated with an effort to cope and a greater likelihood of developing an alcohol use disorder. When we entered the pandemic, an increasing percentage of our young people were already struggling with anxiety, depression, and other strains on mental health.

Being social is a big part of life, particularly when we’re young. Young adulthood is commonly the stage of life when we’re studying, working, and trying to find a path with meaning and purpose. Maybe even starting a family. It’s much harder to do those things without being able to interact with other people in person.

We suspect the pandemic has taken a big toll on the well-being of young people, in part by taking away momentum and creating a great deal of anxiety about the future. But it will take researchers a while to tell us exactly what impact the pandemic had on the mental health of young adults. One benefit to being young is resilience. Hopefully, our young people will be able to get back on track quickly once this is over.

PCO: Not all young adults are on campuses for learning yet – and there is a large population in this age group that is not pursuing higher education. They are isolated at home, whether with parents or on their own, perhaps out of work. The risks appear to be the same, or even greater for them?

Koob: Yes, that is a good point. Not all young adults go to college, in fact right now it’s around 40%. Young adults are a heterogeneous group and their experiences during COVID have no doubt been heterogeneous as well. For those who have been isolating at home with their families, some have probably enjoyed the chance to spend time with loved ones. But I imagine plenty feel like their quest for autonomy has been put on hold for a little while and their eager for the pandemic to end. Many young adults in the work force are probably experiencing similar increases in financial stress and worry about the future that older adults are. The pandemic has been hard for everyone.

PCO: We have talked about the substantial risks for alcohol misuse and abuse – what about potential deterrents or incentives for moderation? What are the challenges right now?

Koob: Good question. It is important to remind ourselves and the people in our lives that the pandemic will pass. We will return to the aspects of our lives we needed to put on hold during the crisis. Hopefully, before we know it, schools will be open full time and actual in-person interactions at school and work will recommence. It is critical to make good choices regarding our health and well-being while we wait. Those choices should include taking good care of physical well-being, but also our emotional well-being by using healthy, sustainable coping skills—finding healthy ways to relax and cope with feelings of stress and anxiety that are so common during the pandemic.

We know that some people are drinking more during the pandemic in an effort to cope, and that this isn’t a good long-term strategy.

There are also lots of benefits to a person’s taking a break from alcohol and being more mindful of one’s relationship with it. In other words, asking themselves why they drink. When someone understands better what motivates them to drink, they have an opportunity to decide whether they’d like to change the behavior. Some people might realize they were leaning on alcohol to cope with anxiety or to fall asleep. If so, they can use a break from alcohol to cultivate alternatives to drinking.

Other people might conclude they were perfectly happy with their pattern of alcohol use and their reasons for drinking. Either way, the insights gained while being more mindful can help people make the best choices moving forward.

PCO: There is a lot of reference these days to “health care messaging,” much of it around discussing the COVID-19 vaccine. What should messages around alcohol use look like now to this younger age group? To all adults?

Koob: From our standpoint, it is important to recognize that using alcohol to self-medicate emotional misery related to the pandemic, from anxiety and worry to boredom, is a slippery slope. That strategy tends to make things worse in the long run. A recommendation to pursue emotional selfcare is an important health care message during the pandemic. Identify healthy, sustainable strategies for relaxing and having fun.

We need to remember, that while alcohol is legal for adults and readily available, alcohol misuse contributes to over 200 diseases and injuries, accounts for 50% of liver disease, and worsens psychiatric conditions like PTSD and depression.

If one is age 21 years or older, we recommend following the dietary guidelines which are up to 1 drink per day for women or 2 drinks per day for men.

• And some people should avoid alcohol:
  • If they are pregnant or might be pregnant.
  • If they are under the legal age for drinking.
  • If they have certain medical conditions or are taking certain medications that can interact with alcohol.

Also, using the NIAAA Rethinking Drinking website for understanding alcohol is a must.

PCO: And finally, let’s talk about treatment and support. Many of the clinicians in my audience are family or general practitioners – would you have some guidance for them?

Koob: We think it’s important for physicians to recognize that alcohol has a wide range of effects on health, including sleep, heart and liver health, and immune function. Alcohol also interacts with a variety of medications. Excessive alcohol consumption can be the canary in the cage for a variety of both mental and physical health conditions.

The majority of adults interact with a health care provider at least once per year. We think it’s important for physicians to ask patients questions about their alcohol use. Talking with patients about their alcohol use, and recommending further care if need be, might make it possible for patients to get on a healthier trajectory and avoid the long-term consequences of chronic excessive alcohol consumption.

We recommend an approach called Screening Brief Intervention and Referral to Treatment, or SBIRT. A session of SBIRT typically takes about 5-10 minutes and involves a clinician asking a patient questions about their alcohol use using an instrument such as the Alcohol Use Disorders Identification Test (AUDIT). If the clinician feels, based on the test score, that the patient might be drinking too much, they have the option of engaging in brief interventions with the patient or talking with the patient about getting additional help.

The hope is to help the patient avoid the negative health effects of alcohol misuse, or to prevent further damage if they already have an unhealthy relationship with alcohol. Obviously, fewer people are meeting with clinicians face-to-face right now, but there are plenty of options for using telehealth. The defining feature of telehealth is simply that visits are done remotely using technology -- so it could be an appointment via telephone or videoconferencing or even text messaging.

Prior to the pandemic, telehealth was gaining traction, particularly with people who live where doctors’ offices and hospitals are sparse, such as rural America. The COVID-19 pandemic caused a rapid expansion in the use of telehealth, including for addiction treatment and recovery support.

With research funding, NIAAA supports a variety of telehealth projects, including:

• Screening, Brief Intervention and Referral to Treatment (SBIRT) with clinicians by phone or video chat
• Cognitive Behavioral Therapy (CBT) with a clinician or a self-guided approach called CBT4CBT
• Telehealth to address PTSD and alcohol use following sexual assault
• Video-conferencing based motivational interviewing (MI) for alcohol misuse and medication adherence in patients living with HIV

The NIAAA Treatment Navigator explores a variety of effective options and helps users locate treatment options that fit their needs best alcoholtreatment.niaaa.nih.gov

We anticipate a larger role for telehealth for alcohol prevention, treatment, and recovery going forward.