Alcohol deaths have more than doubled in the US; death certificates are unreliable

the Alcohol Abuse and Alcoholism (NIAAA) division of NIH just released their analysis of US death certificates, finding almost 1 million people died from alcohol-related causes between 1999-2017, with the number of deaths more than doubling from 1999 to 2017 (see https://www.nih.gov/news-events/news-releases/alcohol-related-deaths-increasing-united-states ). For relevant article see alcohol deaths doubling alc clin exp rsch2019 in dropbox, or DOI: 10.1111/acer.14239

Details:

-- number and rate of alcohol-related deaths by age, sex, race, and ethnicity between 1999 - 2017 for people >16yo from the US National Center for Health Statistics, by death certificates

-- deaths were considered to be alcohol-related if alcohol was listed as either an underlying or contributing cause (up to 20 multiple or contributing causes were indicated on the death certificates)

    -- acute alcohol-related causes of death included acute behavioral disorders, finding of alcohol in blood, toxic effects of alcohol, accidental poisonings by an exposure to alcohol, intentional self poisonings by alcohol

    -- chronic causes of death included chronic mental and behaviors disorders due to use of alcohol, alcohol dependent syndrome, alcohol withdrawal, psychotic disorder, amnesic syndrome, alcoholic polyneuropathy, alcoholic myopathy, alcoholic cardiomyopathy, alcoholic gastritis, alcoholic fatty liver, alcoholic hepatitis, alcohol fibrosis/sclerosis/cirrhosis/hepatic failure, alcohol-induced pancreatitis

Results:

--1999: 35,914 deaths, 16.9 per 100,000 people, and 1.5% of 2.4 million deaths

--2017: 72,558 deaths, 25.5 per 100,000 people, and 2.6% of 2.8 million deaths

-- a total of 944,880 alcohol-related deaths were recorded over the course of the study.

    -- males: 76.4% of alcohol-related deaths (male deaths 721, 587 vs 223,293 for females)

    -- but, a greater increase was observed for females (136% in numbers and 85% in age-adjusted rates) vs males (93% in numbers and 39% in age-adjusted rates)

    -- the rate of death increases in females accelerated around 2010 and for males around (it was highest in those age 55-74 in 1999, but was highest in those aged 45 to 55 in 2017; similar age shift in males)

        -- but the largest annual absolute increase was in those aged 25 to 34, a 6% increase from 1999 to 2017

--racial/ethnic groups: rates increased and accelerated for most groups, largest for non-Hispanic white males/females (the latter having the highest average annual increase at 4.4%), but also for Hispanic males, non-Hispanic black males/females

--87% of alcohol-related deaths were from chronic causes (in 2017, 31% were from liver disease); acute causes from around 17% (this % did increase: it was 15% in 1999 and 22% in 2017)

    -- though, not surprisingly, almost 90% of alcohol-related deaths in those 16-20yo were from acute alcohol consumption, with a significant increase in females and no increase in males

        -- also, self-reported past-month drunkenness in 12th graders declined more in males (38% to 20%) than in females (28% to 18%)

Commentary:

-- 70.1% of the population aged 18 and older (173.3 million people) consumed alcohol in 2017

    -- average consumption 3.6 gallons of pure alcohol per drinker, 2.1 standard US drinks per day

-- per capita alcohol consumption increased 8% since 2000

-- prevalence of alcohol use from 2000-2016 increased 4.4%, binge drinking increased 7.7%

    -- these increases were limited to women: 10.1% increase in the prevalence of drinking and 23.3% increase in binge drinking

    -- the increases were larger in people over 50 years old

-- rates of ED visits involving alcohol increased 47.3% between 2006-2014, among persons at least 12 years old (1,223 to 1,803 per 100,000 population)

-- rates of hospitalization related to alcohol increased 51.4%, from 62.5 to 94.6 per 100,000 population

    -- these increases in ED visits and hospitalizations were greater for females and greater in older individuals

-- deaths related to alcohol consumption have increased: between 2000-2015 the rate of deaths from alcohol-related liver cirrhosis increased 35%, from 4.3 to 5.8 per 100,000 population, and the number of deaths has grown 73.7%, from 12,109 to 21,028

-- the CDC estimated the number of alcohol-related deaths between 2006-2010, using death certificate data and the use of alcohol attributable fractions (AAFs), which estimate from prior research the proportion of deaths from various causes that likely involved alcohol, for example:
    -- chronic pancreatitis: AAF 84%
    -- drownings: AAF 34%
    -- death from falls: AAF 32%
    -- it should be noted that the AAFs were derived from research prior to the year 2000 and have not been updated to include new knowledge about the contribution of alcohol to injuries and diseases

-- based on these calculations, the CDC calculated 88,129 alcohol-related deaths per year between 2006-2010
    -- 49,544 deaths resulted from acute causes (car crashes, falls, drownings)
    -- 38,584 from chronic diseases (e.g. liver disease, heart conditions, and cancer)

-- alcohol plays an important role in "deaths of despair" (depression, suicidal ideation, etc: all related to declining quality of life, including reduced mental and physical health, increases in chronic pain, financial difficulties,...). and the increases in women is likely a component of the observation that total mortality in non-Hispanic white persons has increased more in women than men, narrowing of the gender gap in life expectancy
-- and alcohol is often combined with other drugs: there is increased risk of respiratory failure when alcohol is taken with other drugs that depress respiration (eg opioids and benzos). in terms of overdose mortality, alcohol was implicated as a solo agent in 2,358 deaths in 2017, but alcohol was taken in combination with other drugs in 10,596 deaths
    --  alcohol given IV to achieve a blood alcohol concentration of 0.10% reduced ventilation by 28%; and the synergistic effects of alcohol and opioids was more pronounced in those 66-77 yo vs 21-28 yo

--limitations of the above study:
    --this study was based on death certificates, which are often inaccurate: 
        --A study found that from 2005-2011, only one in 6 drunk driving fatalities in which the decedant had a blood alcohol level >0.08% were reported as being alcohol-related (see alcohol underreporting death certif jstudalcdrug2014 in dropbox, or Castle, IJ. J. Stud. Alcohol Drugs, 75, 299–312, 2014)
        --only 1.8% of death certificates noting fatalities from falls in those >65yo were attribubed to alcohol, though the CDC estimates the number is 32% (which in 2017 translates to 9,500 more deaths in those >65yo than recorded on death certificates)
        --and, there has been minimal improvement in death certificate recordings of alcohol for motor vehicle drivers/pedestrians since the mid 1970s

so, this study raises some important issues:
--there was a dramatic increase in alcohol-associated deaths from 1999 to 2017, and this is likely pretty real (at least there did not seem to be much change in the huge under-reporting of deaths from motor vehicle accidents or falls over the past 5 decades, though ??there might be some improvements in reporting alcohol-related chronic diseases, eg with their role in overdoses, or perhaps with liver disease???)
    --my guess is that women who drink alcohol who die from breast cancer are still unlikely to have alcohol on the death certificate, though alcohol does seem to increase the risk by 30-50%
    --similarly for those dying form cardiovascular diseases (including MI, stroke, a fib), hypertension-related diseases, other cancers.
--this increase was pretty strikingly more in women, and this may be the reason that the longevity gap of women to men has decreased
--and, alcohol-related mortality is now increasing more rapidly in those 45-55 yo (a younger group than previously). which all means:
    --there might be a significant increase in numbers and percentages of people who have alcohol-related mortality as our population ages (those >65yo are projected to double from 51 million in 2017 to 95 million in 2060)
    --though the majority of those >50yo see a clinician at least yearly, a 2019 survey by SAMHSA found that only 1 in 4 aged 50-64 and 1 in 5 aged >64 reported being asked by their clinician how often or how much they drink
    -- and older persons overall are more likely to be prescribed meds: 4 of 5 drinkers >65yo are prescribed meds that could negatively interact with alcohol
--which all means that it is really important to ask patients routinely about alcohol consumption, dispel myths about alcohol in moderation being cardioprotective (eg see http://gmodestmedblogs.blogspot.com/2019/05/stroke-risk-lowest-if-zero-alcohol.html , and http://gmodestmedblogs.blogspot.com/2015/02/moderate-alcohol-and-cardioprotection.html ), and routinely try to help people who do drink to stop (use of motivational interviewing is particularly helpful, as well as cognitive-behavioral therapy, mutual support groups, and medications may help). and we should not make assumptions about the elderly in terms of drinking....

Other related prior blogs:
http://gmodestmedblogs.blogspot.com/2018/10/alcohol-as-leading-risk-facor-for-death.html global review finding that alcohol was the leading factor in death in those 15-49yo
http://gmodestmedblogs.blogspot.com/2018/06/alcohol-intake-increases-blood-pressure.html an analysis finding that any intake of alcohol led to increased blood pressure
http://gmodestmedblogs.blogspot.com/2019/07/alcohol-and-breast-cancer.html for analysis of the relation between alcohol and breast cancer
http://gmodestmedblogs.blogspot.com/2019/04/a-bottle-of-wine-week-and-cancer-risk.html compares the cancer risk between a bottle of wine/week and risk from smoking 5-10 cigarettes/week

geoff​

If you would like to be on the regular email list for upcoming blogs, please contact me at gmodest@uphams.org

to get access to all of the blogs:

1. go to http://gmodestmedblogs.blogspot.com/ to see them in reverse chronological order

2. click on 3 parallel lines top left, if you want to see blogs by category, then click on "labels" and choose a category​

3. or you can just click on the magnifying glass on top right, then  type in a name in the search box and get all the blogs with that name in them

please feel free to circulate this to others. also, if you send me their emails, i can add them to the list