Perspectives on alcohol addiction have shifted over the past century, but has this translated into better engagement with care?

In the past century there have been dramatic shifts in how society perceives alcohol addiction, the kinds of treatments offered, and the accessibility of these treatments. The authors of this paper address for the first time important questions about how four generations of Americans have been both similar and different in terms of accessing care for alcohol use disorder.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

In the past century there have been dramatic socio-cultural, scientific, and political shifts in how alcohol use disorder is perceived, understood, and treated. On the whole, perceptions of alcohol use disorder have moved away from moral models (i.e., people who have alcohol addiction are morally flawed and require punishment) and toward medical models (i.e., people who have alcohol use disorder are in need of treatment for a medical condition). At the same time, stigma has reduced (though much stigma still exists), and modalities of care have broadened from 12-step programs alone to include numerous cognitive and behavioral clinical interventions, as well as FDA-approved medications.

Given these shifts, one might expect that there have been major generational changes in who accesses care for alcohol use disorder, when these individuals access care, and what kind of treatments they seek. While treatment utilization has been explored through studies that have taken snapshots of the United States population at various points in time, to date no study has explored these trends by grouping people by generation. Further, no study has explored how generational factors intersect with sex.

Knowing more about how treatment attendance patterns have changed over time has the potential to provide key insights into shifting (or stationary) attitudes and behaviors related to alcohol use disorder, so that ultimately its negative consequences can be better addressed by improving the quality of, and access to care. In this study, Bourdon and colleagues escribed overall service use across generations in a sample of individuals with alcohol use disorder, while also testing for generational differences in service use and examining if sex differences across generations are have been stable or changing.

HOW WAS THIS STUDY CONDUCTED?

This was a secondary analysis of a dataset that includes 4,405 adults with alcohol use disorder, recruited from an initial sample of their family members who attended alcohol use disorder treatment, the Collaborative Study on the Genetics of Alcoholism. Participants did not receive any intervention per se. Rather, this was an observational study in which participants provided retrospective information about their history of alcohol use problems, as well as details about if, how, when, and where they sought alcohol use disorder treatment. Data were collected between 1990 and 2018. 

All participants met lifetime diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders–5 alcohol use disorder, and were born during the years 1928 to 1996, encompassing the silent generation (born 1928 to 1945), the baby boomers (born 1946 to 1964), generation X (born 1965 to 1980), and the millennial generation (born 1981 to 1996).

The following primary variables of interest were assessed:

Help-Seeking Behaviors. Help-seeking for alcohol problems was based on the question, “Have you ever brought up any problem you might have had with drinking with any professional?” Those responding with ‘yes’ were subsequently asked if they had talked with a psychiatrist, another medical professional, psychologist, another mental health professional, member of the clergy, or another professional, and the age at which they first sought help.

Treatment Utilization. Treatment utilization for alcohol problems was based on the question, “Have you ever been treated for a drinking problem?” Participants saying ‘yes’ were also asked if they received help from AA or other mutual-help group, at an outpatient program for alcohol use problems, at an outpatient program for problems other than alcohol, at an inpatient program for alcohol use problems, as well as when they received treatment and how old they were. Participants who reported they had never received care were asked “Have you ever attended a mutual-help group (like AA) for your drinking?” Those who saying ‘yes’ were asked their age at first attendance and were included in the treatment group for AA or another mutual-help group attendance.

In their analyses, the authors statistically controlled for a number of demographic and other individual factors that could influence findings including, age, race, whether a participant met lifetime criteria for ‘dependence” on cocaine, opiates, sedatives, or stimulants (the authors did not specify whether this referred to Diagnostic and Statistical Manual of Mental Disorders–IV diagnostic criteria of drug dependence, which would be akin to severe substance use disorder in Diagnostic and Statistical Manual of Mental Disorders-5), and maximum lifetime number of Diagnostic and Statistical Manual of Mental Disorders 5 alcohol use disorder symptoms endorsed.

Descriptive statistics for demographics, help-seeking behaviors, and treatment utilization were calculated separately by generation and then subsequently contrasted. The authors explored differences among generations and the effects of sex on: 1) years from birth to first help-seeking behavior, 2) years from first alcohol use disorder onset to first help seeking behavior, 3) years from birth to first treatment utilization, and 4) years from first alcohol use disorder onset to first treatment utilization.

Altogether, 11% of the final sample were of the silent generation, 42% were baby boomers, 25% were generation X, and 22% were millennial. In terms of demographic factors, 45% were female, 55% male, 80% were White, and 20% were Black. Notably, participants of another race/ethnicity (Asian, Pacific Islander, Native American, other) made up 4% of the original sample and for statistical reasons, were removed from the analyses by the authors.

WHAT DID THIS STUDY FIND?

What were the alcohol use disorder characteristics of the sample?

In the study sample, participants were on average 22 years old when they developed alcohol use disorder, with an average time of six years to first help-seeking, and of six years to first treatment utilization. The average age for first help-seeking in the full sample was 28 years, and also 28 years for first treatment.

The silent and baby boomer generation had a higher average number of lifetime alcohol use disorder criteria than did the millennial and X generation. Notably however, rates of ever being diagnosed with drug dependence other than alcohol were equal across generations.

Individuals born more recently are attending treatment and seeking help at younger ages than older generations.

Figure 1.

• Among participants who sought help, age at first help-seeking was younger in each subsequent generation and statistically greater among the two older (silent and baby boomer) than the two younger generations (generation X and millennial).
• While all generations were equally likely to seek help at some point in their lifetime for alcohol problems, millennials were less likely to ever seek help from a ‘psychiatrist/another medical doctor or a psychologist/another mental health professional’ than the other generations.
• There were however no generational differences in the kind of provider individuals first sought help from.
• With all generations considered together, no racial differences were observed in time to first seeking help for alcohol use disorder.

Across generations, younger women are less likely to seek help and attend treatment than younger men – though this gap closes by mid-age.

Figure 2. Bars represent the likelihood of help-seeking for alcohol use problems. If positive, it indicates women are more likely to seek help than men in that age group. If negative, it indicates men are more likely to seek help than women. The value can be interpreted as a percentage. For example, in the “Female < age 20” group, .12 means that women have a 12% higher likelihood of seeking help than men.

• Notably, compared to men in the same age groups, women aged 20 to 29 were 19% less likely to seek help, however, women aged 50+ were actually 82% more likely to seek help.
• For the transition from first onset of alcohol use disorder to help-seeking, men in the silent generation were less likely to seek help compared to boomer men, while women in the silent generation were more likely to seek help than their boomer female counterparts, and millennials six or more years post-onset of alcohol use disorder were less likely to seek help compared to boomers.
• For age at first treatment utilization, women aged 30 or younger were 31% less likely than men to utilize treatment than men of the same age, regardless of generation.
• Lifetime treatment utilization rates did not differ across generations after adjusting for age, though lifetime use of ‘AA/another mutual-help group’ fluctuated over time. Baby boomers and generation X endorsed significantly more mutual-help attendance than the silent and millennial generations.
• As with help-seeking, age at first treatment decreased with each subsequent generation, with generation X and millennials utilizing treatment at younger ages than silent and baby boomer generations.
• Among individuals who utilized treatment, millennials were more likely than the other generations to first utilize ‘AA/another mutual-help group’, outpatient program, or another treatment and less likely to utilize inpatient services.
• Millennials differed as well in that they were less likely than the other generations to combine professional treatment and mutual-help attendance, were more likely to access only professional treatment, and were less likely to attend mutual-help as their only treatment.
• Rates of treatment as a proportion of those who sought help increased with each generation, with more baby boomers, generation X, and millennials utilizing treatment than seeking help only.
• With all generations considered together, individuals identifying as Black took longer to first present to treatment compared to those identifying as White.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

This study retrospectively investigated changes in alcohol use disorder help and treatment seeking in the United States over the course of the last century. Of course, there have been innumerable significant sociocultural, legal, and economic changes have occurred over this time (e.g., prohibition, legal changes in minimum drinking ages, changes in health insurance coverage, changes in drinking norms among women and youth, changes in treatment and recovery mutual-help organization types and availability). The authors of this paper could not account for all of these factors in their analyses; as such, it is not possible to draw firm conclusions from the findings. Nevertheless, the study offers some potential insights that can be followed up in more detail in further work.

Broadly speaking, the researchers found that more recent generations (i.e., generation X and millennials) appear to be using services earlier and are using more mutual-help services. This may in part explain why silent and baby boomer generations were found to have met a higher mean number of lifetime alcohol use disorder criteria than those of generation X and millennials. It could be that individuals from generation X and millennials are seeking treatment earlier in their disorder progression. It is surprising that there were no generational differences in the rate of drug dependence. This runs somewhat contrary to the expectation the because drugs other than alcohol were less available during the early-mid 20th Century, rates of dependence would have been lower.

Observed generational differences  likely reflect social and policy changes that have led to the medicalization of addiction (versus moralization), and the broader range of treatment options available starting around the 1980s, including the rapid growth of addiction focused inpatient rehabilitation facilities. At the same time, it’s possible that the advent of managed care in the 1990s, which greatly reduced access to formal addiction treatment by tightening insurance reimbursement for care, has resulted in many generation X’ers and millennials to seek alcohol use disorder treatment through free mutual-help groups.

Greater mutual-help program involvement among generation X’ers and millennials may also be a function of the fact that the majority of inpatient rehabilitation programs in the United States are 12-step based (i.e., they utilize 12-step mutual-help recovery principles). This finding could reflect the common treatment pathway in the United States in which people complete a 28-day inpatient treatment program, and then attend mutual-help meetings following inpatient discharge. It is also likely that generation X’ers and millennials have benefitted in unknown ways from the Mental Health Parity and Addiction Equity Act of 2008 and Affordable Care Act of 2010 changed the policy landscape once again by requiring that insurance agencies subsidize alcohol use disorder treatment as well as offer prevention, screening, and other services.

It has been repeatedly found that women are less likely than men to utilize services for alcohol use disorder (learn more about women’s addiction recovery). The authors’ findings align with this by showing that younger women are less likely than men to use alcohol use disorder services, regardless of their generation. The authors’ findings, however, also suggest this picture is more nuanced – older women were actually more likely than men to use services. The reasons for this interesting finding are unclear and should be investigated further, but one possibility is that younger women may have greater child-rearing responsibilities which can reduce alcohol use (even among those with AUD) and also reduce the likelihood of treatment seeking whereas older women with AUD may have fewer of those pressures and constraints. 

Findings form this study also highlight potential racial disparities in alcohol use disorder treatment access. While those identifying as Black were similar to Whites in terms of time to help-seeking following developing alcohol use disorder, Black participants took significantly longer to utilize treatment. This could reflect inequities between races in access to insurance and healthcare recourses.

LIMITATIONS

1. This study retrospectively investigated changes in alcohol use disorder help and treatment seeking in the United States over the course of the last century. Innumerable sociocultural and economic changes have occurred over this time that would have influenced alcohol use, and alcohol use disorder help and treatment seeking, making causal interpretation of the results difficult.
2. This study was conducted using a United States sample. Because alcohol use disorder help seeking behaviors and treatment utilization are heavily influenced by the socio-cultural and economic environment, it is likely that these findings do not generalize well to other countries.
3. The minimum legal drinking age has fluctuated in the United States since prohibition from 21 to 18, and then back to 21 in 1984. Also, some states have laws making consumption prior to age 21 illegal, while others have only laws pertaining to purchase prior to age 21. This could have affected estimates and played into causal explanations of differences observed in this study, given the effect of age of onset on alcohol use.

The authors highlight the following limitations:

1. The Collaborative Study on the Genetics of Alcoholism dataset used in this study only ascertains biological sex, not gender identity, which limits the interpretability of some findings.
2. There is limited representation in the Collaborative Study on the Genetics of Alcoholism dataset of Asian, Native American/Alaska Native, Pacific Islander, and those who identify by another race(s). Multiple studies have found racial/ethnic differences in service use as well as gender and race/ethnicity integrations that they were not able to examine in the current study. Relatedly, Hispanic ethnicity was not asked separately, and thus the authors were unable to examine likely sociodemographic and cultural differences between Hispanics and non-Hispanics.
3. The Collaborative Study on the Genetics of Alcoholism study presents a limited number of questions for help-seeking and treatment utilization. Recent work has shown that many types of mutual-help groups contribute to treatment utilization and long-term remission and not explicitly listing all options could have influenced participants’ selection.

BOTTOM LINE

CITATIONS

Bourdon, J. L., Tillman, R., Francis, M. W., Dick, D. M., Stephenson, M., Kamarajan, C., . . . McCutcheon, V. V. (In press). Characterization of service use for alcohol problems across generations and sex in adults with alcohol use disorder. Alcoholism Clinical and Experimental Research, 44(3), 746-757. doi: 10.1111/acer.14290