Disparities Among Veteran Alcohol Use Disorders

Americans have a long, complicated and mostly social history with alcohol—from copious consumption during the country’s founding to pandemic-era socializing on Zoom happy hours. However, drinking to excess or developing an alcohol use disorder can also be a deeply personal experience. One expert has long sought answers to how genetics may affect your likelihood of developing an alcohol use disorder.

Henry Kranzler, MD, is professor of Psychiatry and the director of the Center for Studies of Addiction at the University of Pennsylvania Perelman School of Medicine. His work has focused on identifying genetic contributors to alcohol misuse and what is known as alcohol use disorder (AUD) to help account for who may be pre-disposed to alcohol misuse and why, along with helping untangle questions around differences in how AUD is diagnosed.

AUD is a brain disorder that encompasses a broader spectrum of conditions, including alcohol abuse, alcohol dependence, alcohol addiction, and alcoholism, according to the National Institutes of Health.

As a medical condition, AUD is characterized by an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. According to a 2021 National Survey on Drug Use and Health, 28.6 million U.S. adults ages 18 and older suffered from AUD that year.

Genetics play a role, with genes responsible for up to half the risk for AUD, according to the NIH. However, the other half of that risk is accounted for by environmental factors, with behaviors such as early childhood adverse experiences (e.g., abuse and neglect) and co-occurring psychiatric disorders (e.g., antisocial personality disorder) contributing to the risk of AUD.

New research from Kranzler sheds light on how diagnoses differ among veterans, given evidence that exposure to trauma, including combat, is a risk factor for heavy drinking and AUD.

Veterans are at greater risk of AUD than the general population because AUD is more common among males and veterans who receive care from Veterans Affairs (VA) are predominantly (~90%) male, a figure that is a match for the overall percentage of male veterans. In addition, according to the National Institute on Drug Abuse, 65 percent of veterans who enter a treatment program report alcohol as the substance they most frequently misuse. This is almost double that of the general population.

However, clinicians and researchers involved in veterans’ care are concerned about providing accurate diagnoses of AUD to patients who most need treatment, and past studies have shown that there are differences in diagnoses along racial and ethnic lines. A new study, published in The American Journal of Psychiatry found that Black and Hispanic military veterans were more likely to be diagnosed with AUD than their white counterparts—even when alcohol consumption levels were the same.

Based on these findings, a team of military and civilian addiction experts, led by Rachel Vickers-Smith, PhD, an epidemiologist at the University of Kentucky, along with several others from Penn Medicine, led by Kranzler, concluded that racial bias might play a role in how clinicians identify AUD at the U.S. Department of Veterans Affairs (VA) and potentially beyond.

“No other factors emerged to explain this discrepancy, which strongly suggests the presence of racial and ethnic biases in the diagnosis of AUD. Efforts are needed to reduce these biases in the diagnostic process for AUD,” said Kranzler, who is also the co-associate director of Research with the VISN 4 Mental Illness Research, Education, and Clinical Center at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.

Investigators analyzed patient data from the Million Veteran Program, a VA initiative that collects genetic, health, lifestyle, and military background information from consenting patients for research purposes. The study covered 700,012 Black, white, and Hispanic veterans.

Investigators measured based on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire, a widely used screening tool for unhealthy alcohol use. The AUDIT-C is scored on a scale of zero to 12 (scores of zero reflect no alcohol use in the past year). Generally, the higher the AUDIT-C score, the more likely it is that the patient’s drinking is affecting their health and safety and that an AUD may be present.

At all but the lowest and highest levels of alcohol consumption, Black men had as high as a 109 percent greater likelihood of an AUD diagnosis than white men. The discrepancy was most pronounced among patients who scored a four on the AUDIT-C screening questionnaire, which is the minimum score indicating the presence of hazardous or harmful drinking in men. At this threshold, white men were just one-third as likely to receive an AUD diagnosis as Black men.

“Regardless of how often they drank or how much they drank, Black men were significantly more likely than Hispanic or white men to receive an AUD diagnosis,” Kranzler said. “Overall, Hispanic men were also more likely to have an AUD diagnosis than white men irrespective of heavy episodic drinking frequency.” Similar differences based on race and ethnicity were seen in females, though they were less pronounced than among men.

Though open questions remain, such as diagnostic trends across other veteran racial or ethnic groups, the research represents an important step toward rooting out bias so practitioners can more equitably identify AUD and help connect veterans suffering from AUD to the care they need.

The next step? Harnessing that advancement to inform better understanding of the diagnostic process and the causes for diagnostic disparities among care providers who evaluate patients for AUD.

“These findings provide the basis for making changes to the diagnostic process for a diverse veteran population,” Kranzler said.

Kranzler notes the importance of examining the causes of these discrepancies. This can be done through studies that include things like interviews with practitioners or recording interactions between practitioners and simulated patients. By uncovering these causes, researchers and addiction experts can adjust screening approaches to drive diagnostics that are more equitable—for AUD and other conditions, both in the VA and other health care settings.

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