Risk Factors For Alcohol Use Disorder

What are the risk factors for alcohol use disorder? Are they genetic, social, environmental or psychological?

Yes, yes, yes and yes. 

Alcohol is the most widely misused substance in America and, according to the National Center For Drug Abuse Statistics, 1-in-10 Americans over the age of 12 qualify as having a mild, moderate or severe Alcohol Use Disorder.

There are many risk factors for Alcohol Use Disorder, including…

    • Genetics and your DNA. The risk of alcohol use disorder is higher for people who have a parent or other close relative who has problems with alcohol. However, it’s important to note that genetics only accounts for approximately half of a person’s overall risk.


    • Underlying mental health conditions such as anxiety disorders, depression or attention-deficit hyperactivity disorder (ADHD). As many as 80% of people with substance use disorders have another co-occurring mental health condition.


    • Adverse Childhood Experiences (ACEs)

    • Cultural and social factors including where you live, who you interact with and how much they drink, the influence of alcohol advertising and marketing on your peer group, culture and societal perceptions and use of alcohol


    • Living in poverty, experiencing racism or discrimination, access to health care services


    • Age of first use. A key finding of Research done by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) was that people who started drinking before age 15 were 50% more likely to become alcohol dependent as adults. The same was true to a lesser extent for those who started drinking between ages 15 and 17.


    • And…(drumroll)…Alcohol is simply an addictive substance. Let’s get real, a huge risk factor for developing alcohol use disorder is just consumption of alcohol. Alcohol is simply an addictive substance. Alcohol physically alters the brain’s chemistry and functioning. Reward and pleasure centers in the brain become overloaded, causing cravings. And once alcohol leaves your body you go into alcohol withdrawal. If you drink alcohol on any regular basis you will likely start drinking it more and more often. 

But here’s the good news about Alcohol Use Disorder

  • 75% of people who struggle with alcohol use disorder recover — their condition improves and substance use no longer dominates their life

  • Alcohol Use Disorder is treatable. In the same way that asthma, high blood pressure, cancer and diabetes are treatable
  • We do recover from mild, moderate and severe alcohol use disorder
  • In fact, once you get through your first year not drinking, the “return to use” rate (because we’re going to stop calling it “relapse”) falls substantially

So how do you get to your first year alcohol-free?

I asked Dr. Nzinga Harrison to share both the risk factors for alcohol use disorder and strategies to help people become part of the 75% of people who do recover. 

Dr. Harrison is a physician with specialties in addiction medicine and psychiatry, the Chief Medical Officer and Co-Founder of Eleanor Health and co-founder of Physicians for Criminal Justice Reform. She’s spent her career focusing on stigma reduction and health equity and is an advocate for leading with empathy in addiction treatment and reframing the way we view and address addiction and the people who are dealing with substance use disorders.

Dr. Harrison advises that we create a holistic recovery plan that addresses all of the risk factors of alcohol use disorder and the tools that help you recover from it, rather than simply focusing on abstinence alone. 

What’s in a holistic recovery plan that supports recovery from alcohol use disorder? 

According to Nzinga “We’re looking for depression and anxiety. Socially, we’re looking to create a strong support system and develop new coping skills. We need to go back to that childhood and find out anything that’s affecting you today that we didn’t realize was affecting you and try to get to that. We’ve got to get your job stress down. We’ve got to work on relationships. It’s important to manage any other physical illnesses you have. Improve your physical health with exercise, sleep and water. All of these things are what drive down the risk of returning to drinking and increase your chances of getting to one year substance free”. 

And we need to reduce the stigma associated with struggling with a substance use disorder so that people seek support early and more often and so that the people around them and the public health system provides recovery resources in the same way that we provide resources to people who are diagnosed with cancer. 

Tune in to hear Casey and Nzinga discuss:

  • The little known fact that 75% of people who struggle with alcohol use disorder recover from it
  • The importance of universal screening and early detection of alcohol use disorder in primary care medicine – in the same way we screen for high blood pressure, diabetes + breast cancer

  • The differences between a biological predisposition and a environmental predisposition in developing alcohol use disorder

  • How to change the way we talk about alcohol use disorder to decrease shame + stigma surrounding it and make it easier to seek recovery resources
  • CAGE: 4 questions that can predict with 77% accuracy if you have a risk of developing a substance use disorder 

The CAGE questionnaire is used to test for alcohol use disorder in adults. 

It’s simply designed to indicate if a problem might exist – not to diagnose you. 

It’s 4 easy questions that relate to your use of alcohol: 

  1. C: Have you ever felt you ought to cut down on your drinking?
  2. A: Have people annoyed you by criticizing your drinking?
  3. G: Have you felt bad or guilty about your drinking?
  4. E: Have you ever had a drink first thing in the morning (eye-opener) to steady your nerves or to get rid of a hangover?  

Resources mentioned in the episode

Recovery from Addiction | Psychology Today 

Why Is Alcohol So Addictive? – Caron Treatment Centers 

The Link Between Early Drinking Age and Alcoholism Risk 

Genetics of Alcohol Use Disorder 

Alcohol Use Disorder: Definition, Symptoms, Traits, Causes, Treatment 

The Role of Adverse Childhood Experiences in Substance Misuse and Related Behavioral Health Problems

Adverse Childhood Events as Risk Factors for Substance Dependence: Partial Mediation by Mood and Anxiety Disorders

10 Adverse Childhood Experiences | Integrative Life Center   

Social and Cultural Contexts of Alcohol Use – PMC 

Alcohol Abuse Statistics [2022]: National + State Data – NCDAS 

CAGE Assessment: A Questionnaire for Substance Abuse 

Ready to drink less + live more?

More About Dr. Nzinga Harrison

Nzinga Harrison, MD is Co-Founder and Chief Medical Officer of Eleanor Health, a tech-enabled, population-based provider of comprehensive, longitudinal, whole-person substance use disorder and mental health care. Prior to co-founding Eleanor Health, Nzinga served as SVP of East Coast Operations and Chief Medical Officer for Anka Behavioral Health Inc., for which she led medical strategy, operations, and quality management for over 70 outpatient and residential mental health, intellectual disability and addictive disease programs. 

A true leader, Dr. Harrison is a shining example of how you can treat addiction from a place of love and care. She is a vocal advocate and activist, placing emphasis on the healthcare system’s responsibility to incorporate trauma-informed interventions aimed at addressing the harms of racism and marginalization faced by many communities in this country.

Stay connected Dr. Nzinga Harrison on Twitter @NzingaMD

Listen to the In Recovery Podcast with Dr. Nzinga Harrison: https://lemonadamedia.com/show/inrecovery/

Learn more about Eleanor Health and how they can help you with mental health or substance use at EleanorHealth.com

Connect with Casey

Take a screenshot of your favorite episode, post it on your Instagram and tag me @caseymdavidson and tell me your biggest takeaway!

Want to read the full transcript of this podcast episode? Scroll down on this page.


Are you looking for the best sobriety podcast for women? The Hello Someday Podcast was created specifically for sober curious women and gray area drinkers ready to stop drinking, drink less and change their relationship with alcohol.

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Risk Factors For Alcohol Use Disorder


people, drink, addiction, relapse, substance use disorder, illness, alcohol use disorder, anxiety, alcohol, person, remission, substance, stigma, adhd, risk, mental health conditions, disorder, breast cancer, year, cancer

SPEAKERS: Casey McGuire Davidson + Dr. Nzinga Harrison


Welcome to the Hello Someday Podcast, the podcast for busy women who are ready to drink less and live more. I’m Casey McGuire Davidson, ex-red wine girl turned life coach helping women create lives they love without alcohol. But it wasn’t that long ago that I was anxious, overwhelmed, and drinking a bottle of wine and night to unwind. I thought that wine was the glue, holding my life together, helping me cope with my kids, my stressful job and my busy life. I didn’t realize that my love affair with drinking was making me more anxious and less able to manage my responsibilities.

In this podcast, my goal is to teach you the tried and true secrets of creating and living a life you don’t want to escape from.

Each week, I’ll bring you tools, lessons and conversations to help you drink less and live more. I’ll teach you how to navigate our drinking obsessed culture without a buzz, how to sit with your emotions, when you’re lonely or angry, frustrated or overwhelmed, how to self soothe without a drink, and how to turn the decision to stop drinking from your worst case scenario to the best decision of your life.

I am so glad you’re here. Now let’s get started.


Hi there. My guest today is Dr. Nzinga Harrison, the host of a podcast I love, In Recovery. So wherever you listen to podcasts, you can search for those previous episodes. She’s also the chief medical officer and co-founder of Eleanor Health and the co-founder of Physicians for Criminal Justice Reform. A true leader, Dr. Harrison is a shining example of how you can treat addiction from a place of love and care. She’s a vocal advocate and activist placing an emphasis on the healthcare system’s responsibility to incorporate trauma informed interventions aimed at addressing the harms of racism, and marginalization faced by many communities in this country. As a physician with specialties in addiction, medicine and psychiatry, who spent her career focusing on stigma reduction and health equity, Nzinga Harrison is uniquely positioned to help people navigate the stress of current events, including from the opioid crisis and COVID to racial violence and systematic injustice, and move from thinking to action with the goal of improving health and society. So welcome to the Hello Someday Podcast.



Thank you, Casey, that was so beautiful. So I definitely heard elements of like my standard bio you can find on the web, but you have it in some beautiful things. Thank you.



Oh, you’re so welcome. I told you that before we did this interview, I was diving into your website and In Recovery podcast, as well as your interviews on previous podcasts, and I was so impressed by how approachable you were, how warm you are, and also just how you break things down into ideas that anyone can understand.



Yeah, I mean, I think it’s so important. We have so much stigma built up around mental health conditions, certainly around addictions and substance use even before it becomes addiction, that it makes us feel like we can’t talk about it. Or when we talk about difficult things, like we being medical professionals, then one of the ways to keep it emotionally safe is to like talk about it and really big, erudite academic terms, right? And like keep space from the emotion. And so I’ve just tried to be super accessible and super warm to like, get to whatever we can get to to help whoever’s in front of me.



Yeah, and the lack of judgment and just kind of keeping it real, I think helps so much, because so many people struggle with their relationship with alcohol or drugs. And for me, it was with alcohol. And it’s not kind of the end of the world. Like it is super common. You are not the only one and it’s often very solvable. Right?



Totally 100%. So, a probably unknown statistic is that 75% of people with addiction, including alcohol use disorder, go on to recover. Like isn’t that a staggering number?



Oh, my God. Okay, tell me what because all anyone talks about is like the relapse rate, you know, in year one, in year two, in year three. So tell me where that comes from, because I actually hadn’t heard that before.



Yeah, this is, it’s so important and so the relapse rate is important. And I always, when I talk about alcohol use disorder or addiction, always try to put it in the same structure as the other chronic medical conditions that we know about. High blood pressure, diabetes, asthma, right? And so I cringe and like break into a sweat and then almost cassette people when they’re like, relapse is part of the disease. One: Yes, that’s true, but to deliver it that way is just mean. Like, don’t you think, Casey? 




So like, if I’m talking to a person with breast cancer, I’m not going to deliver them like relapse is imminent. 




Or relapse is unavoidable because it’s part of the disease. I am going to say, and I don’t know these numbers for breast cancer so I’m just making it up, I am going to say in the first year, the risk of relapse is X percent. And this is what we do to minimize the chance that you land in that group that has a relapse of the breast cancer, than at two years is lower than if three years is lower, like whatever the story is, for breast cancer. This is how we have to tell and then what you actually hear were breast cancer. And I don’t know this number is like an 80% of people get in remission and stay in remission. So then you anchor hope to remission, right, like you don’t hang your expectations on relapse, like we do for substance use disorders. 


And so this statistic was recently released, like in an article, it comes out of NIH, it comes out in IAA, it’s a combination of sources, but 75% of people with substance use disorder recover. And so we do know, right, like the risk of relapse in the first year is higher. Okay. So a lot of that has not to do with the illness itself but so much like how broken the system is that people have to try to get help in. Yeah, we could have those relapse rates so much lower if our system actually wrapped around people in a holistic, compassionate, longitudinal way, the way we do for other illnesses. 


But so what I say to folks is like, listen, okay, if we can get to the first year, the risk of relapse falls substantially. This is how we get to the first year, like, logically, we’re looking for depression, anxiety, socially, we’re looking for support system coping skills, we got to go back to that childhood and find out anything that’s affecting you today that we didn’t realize was affecting you and try to get to that. We got to get your job stress down. We got to work on relationships, right? Like, whatever other physical illnesses you have, we have to be managing those, gotta get exercise and sleep and water. All of these things are what drive down the risk to increase the chance that we get to one year. And then at two years, even lower, three years, even lower, like how do we get you in the 75%. And then at five years, Casey, the risk of relapse falls to that of the general public that never had a substance use disorder.



This is amazing. Yes, yes. Okay. First of all, I love that because I’m at six and a half years. This is amazing. But not only that, I mean, I know for me, and I know I totally want to talk about, which I love, is the idea that you said acquainting to breast cancer stage one, stage two, stage three, early intervention, but when I was trying to stop drinking and clearly was worried about my relationship with it, trying to moderate didn’t work, was having the gray out flush, blackouts, hangovers, all the things. I didn’t even consider it quote unquote, relapse. I considered it like, I’m trying to stop drinking. And I only made it to day four, or I made it to day 30 and then I went back. It wasn’t like relapse. I just never really got sober momentum.



Yeah, but you know, and so I appreciate that so much and I think you know, people were like, doctors try to make everything an illness, this is like legitimately neuro biologically psychologically, okay, like, if anybody wants to fight like meet me in the street, we can fight right? Before like, legitimately, we’re dealing with a chronic illness. The problem is that the symptoms look like our personality, right? The symptoms are interpersonal, the symptoms are in our behaviors, the symptoms are in the choices we make. And so it can be really hard for people to understand that those are symptoms of your illness, not who you are. And so it gets to that narrative that you were having. That was like this isn’t relapse, which in medicine, any recurrence of symptoms after a period of stability, that’s the definition of relapse, right? So like you have diabetes, your blood sugar has been controlled, your blood sugar is out of control, that is a relapse of your diabetes, not the person. The diabetes, right? You have cancer, you’re in remission, cancer recurs, that is a relapse of the cancer. And so like that narrative that you are having, like, I only made it two days, it’s not a relapse, I didn’t get sober momentum is taking that on as you as opposed to like, this is a recurrence of the symptoms. 


But you’re right, we don’t call it like we consider it active if it’s within a month. So all of the attempts that you’re making, same thing, if I was controlling your blood pressure, if I can’t get normal blood pressures for like a month, I can’t say we made it to stability, right. And so that same kind of concept, and then we mark early remission at three months, and ardently here. For substance use disorder, we have diagnostic criteria, there are 11. And you have to meet three of them to meet diagnostic criteria for substance use disorder. So a person can still be drinking, and be in remission from a substance use disorder, that does not work for everybody that did not work for you. Right, so for you, your illness severity was such that complete abstinence has to be the recovery pathway for you. There are different recovery pathways, but we look at those diagnostic criteria. And if you don’t meet three, for three months, that’s when we call it early remission. And his symptoms recur. That’s when the illness has relapsed, not the person because I’m not the person, the illness, and then if we can get to one year of remission, that’s when like risk of relapsing starts to significantly fall.



Will you tell me like you said, it is absolutely a disease. Anyone who wants to debate me on this, happy to do it. We are just in, I love how you break it down. So it’s so understandable. Tell me why.



One, I love how you like made my, you made my threat to your listening audience so sweet, you’re like to challenge me, I was like, meet me in the street, we can invite. Anyone wants to challenge me? Yes. So this is how I make my case for substance use disorders during chronic medical conditions. So first of all, every chronic medical condition we have has biological, psychological, social, also cultural political inputs, right. So biologically, you’re born with your DNA. You have inherited things from your biological family that come in your DNA. When we look at high blood pressure, type two diabetes, asthma, when we look at the genetic component of that illness, your risk for developing that illness that is just due to your DNA, like born with it, it’s 40 to 55%. When we look at addictions, it’s 40 to 55%. When we look at relapse and remission rates for chronic medical conditions, again, asthma, diabetes, high blood pressure, and you look at the rate of relapse of that illness at one year after discharge from a hospital, so symptoms were significant enough that you had to go inpatient. A year later, what percent have experienced a relapse of their illness, it hovers right 45 to 55%. Addiction 45 to 55%, literally performs exactly the same. 


We live neuro biologically, the chemicals in our brains and bodies that are involved in addiction evolved in my blood pressure, involved in asthma, involved in diabetes, it’s all the same chemicals, right? So like, when it’s all the same chemicals, and it’s all the same nervous system, and it’s all the same genetic component, and it’s all the same relapse rate like it, that’s the duck, if it walks like a duck and quacks like a duck, it’s a duck. And so when I, you know, like lay it out and the charts and you can see addiction and actually is a little bit more what we call heritable. So a little bit more of your risk is coded in your DNA than for those other chronic conditions. And when I show the relapse rates of those other conditions, I say like, you know, oh, I don’t want to say this number wrong, but it’s some devastatingly high number of Americans that don’t believe addiction is treatable. Yeah, simple, the statistic, it’s like over 80% I don’t want to say the number wrong. So I don’t have in my head like devastatingly high, even though 75% of people will recover from.



Talk to me, Casey. 


Right. And then also like, do you think asthma is not treatable? Yeah. Because the relapse rate is the same. Yeah. Or do you think cancer is not treatable? Or do you think diabetes is not treatable, right? And so it’s just because we have this stigma, and this really just errants wrong concept that starts with not understanding addiction as a chronic medical condition.



And so what about I mean, I’m just, of course, thinking to myself, because that was my thing, like, no one in my family drank like I did, right. And I know you said 45 to 50, or 60% is hereditary. I started drinking heavily in college, I was on the women’s rugby team, which is like a crash course in binge drinking, all my friends drank. And I had underlying anxiety and post quitting drinking undiagnosed mood disorder. Is that like, not everyone has parents or siblings or grandparents who drink a ton like I do?



100%. So 40 to 60% coded in your DNA, specifically for that alcohol use disorder.


Okay. So not for anything else.



60 to 40%, then environmental life experiences, right? That is equal 40 to 60, and 60 to 40 is equal. Now, what put you on unequal footing? I bet if you look back in your family, you can see that anxiety. 


Oh, yeah. 


Can that mood disorder? Yeah, right. And so I describe it, like, if you have a room full of people, and you have a group of people who just like only drink occasionally on special occasions, you have people who drink more regularly, you have people who drink regularly, heavily. And then like at the front of that room is a line that’s like this is the line from heavy regular drinking, and then you cross over that line to alcohol use disorder is not that simple. But this is this visual. People who only drink occasionally, don’t have depression, don’t have anxiety, don’t experience trauma growing up, don’t have instability. Have you know, parents that can help teach them healthy coping skills, like all of the things, they may not even be walking towards the line or if they’re walking, they’re walking like super slow Sunday stroll, they probably never going to get to the crossover line. People with a family history of anxiety are walking faster. Yeah. People with a family history of anxiety and alcohol use disorder are walking even faster. Anxiety and mood disorder and alcohol disorder, even faster. anxiety, mood disorder, alcohol use disorder, and then add childhood trauma. Yeah, and then add racism and discrimination, LGBTQ and then add growing up and poverty walking even faster. Yeah, to that line, right. And so the interplay between that 40 to 60%, biological inherited and that 60 to 40%. Environmental is extremely important.



Okay, that makes complete and total sense to me, because women will say to me all the time, but you know, no one in my family drinks the way I do and x, y, z. And, you know, there is like this question of like, is it you know, in terms of things that people believe that are not necessarily true one, it’s not that you just don’t have willpower, or motivation or self discipline or whatever. And it’s also not that, like, you must have had, you know, a family history that you don’t know about or something like that. It’s all the thing.



Again, it’s all the things and yes, you’re so important because people really receive that as a narrative like, and so I must just be making bad choices, which is like another underlying narrative on alcohol use disorders and other addictions which know like, Okay, think of the friend you had, who was the first person in her family to get diagnosed with breast cancer? Yeah, she was by and biological predisposition can come from your DNA. There’s also acquired biological predisposition. Right. So like we’re having, we’re experiencing things biologically in life that are going into our bodies and changing things. And so it’s like, Is it her fault? She has breast cancer? It must be her fault because nobody else in her family had it. So right when nobody comes in that way, nobody thinks that nobody thinks that it is because we don’t have any question about whether breast cancer is an illness.

Casey McGuire Davidson 

Hi there. If you’re listening to this episode, and have been trying to take a break from drinking, but keep starting and stopping and starting again, I want to invite you to take a look at my on demand coaching course, the sobriety starter kit.


The sobriety starter kit is an online self study sober coaching course that will help you quit drinking and build a life you love without alcohol without white knuckling it or hating the process. The course includes the exact step by step coaching framework I work through with my private coaching clients, but at a much more affordable price than one on one coaching. And the sobriety starter kit is ready, waiting and available to support you anytime you need it. And when it fits into your schedule. You don’t need to work your life around group meetings or classes at a specific day or time.

This course is not a 30 day challenge, or a one day at a time approach. Instead, it’s a step by step formula for changing your relationship with alcohol. The course will help you turn the decision to stop drinking, from your worst case scenario to the best decision of your life.

You will sleep better and have more energy, you’ll look better and feel better. You’ll have more patience and less anxiety. And with my approach, you won’t feel deprived or isolated in the process. So if you’re interested in learning more about all the details, please go to www.sobrietystarterkit.com. You can start at any time and I would love to see you in the course 


Yeah. Yeah. I mean, I always think about the support that you get rightly so when you have an illness like breast cancer, but, you know, you post on Facebook, you put pictures of you, during your chemo treatments, you do the walks, you have people delivering meal trains, you have a blog of people update people on your progress, and you’re dealing with substance use, and everybody blames you, and is like, Oh, my God, why do you even do this? You know?



Totally. I always say, like, I dream of the day, where the reflexes to the level of compassion and support that we have for breast cancer, for people to be able to come out and say, I have an addiction. It is easier these days to come out and say, I’m in recovery. I haven’t had a drink in six and a half years. And still some people would be like, Oh, wow, I never, I would have never thought of you. Right? Like that, that thought will still come to people. But at least it’s like you can get positive reinforcement. Oh, my God, congratulations and amazing and all of the things that should be. But when the day, when a person can stand up and say, right now today, I am actively dealing with active alcohol use disorder, I’m struggling, and the troops will rally and the compassion will come and the support will come and you automatically like, you get diagnosed with breast cancer. The infrastructure is already there. Yes. Like I long for this day. For people with addictive disorder. Yeah.



And you have mandatory screening. We were talking about this, like you turn 40 years old, you go into your mammogram, because that’s a medical cut off, right? 


And I’ll take you one step one step even further, Casey, you have a family history of breast cancer, your mammogram starts 10 years before the youngest person develops theirs. 





And not only that, you go into just your annual checkup, and you know, you put your arm up and they check you out and whatever they tell you to do it in your shower. Right 100%.



So like, why are we not taking this same strategy for a condition that we know is way more common? 


Yes, certainly is devastating. 


Right? And the answer is stigma. The answer is we don’t get trained to do it. In medical school, the answer is no licensing or crediting or standard of care. Nobody has told us that this is the standard of care. It should be. This should be.



Yeah. Well, so I want to talk about all the things but you mentioned, I know I could talk to you for hours. Because I’m like learning so much. But you mentioned the lack of training. And I’ve heard you say that you could go through medical school or your rotations without getting any training full stop in addiction medicine or addiction.



100% So to date myself, I’ve been practicing medicine, I graduated medical school 2002. So I’m 20 years in, right, and a lot has changed for the better for sure. But like there’s legislation trying to make it through Congress right now, to mandate addiction training as one of the core skill sets you have to develop before you leave medical school, that it is in progress. Like let’s you know, that standard has not been set.



I did not know that was even in progress. I just heard, gosh, a week or two ago that universal screening is now recommended for anxiety.



So, so slow. Like doesn’t it seem like that would just already be in place, but like yeah, we need universal screening for anxiety. We need universal screening for depression. These are super common. We need universal screening for addiction. And part of that is like can we not wait until we’re stage four? Right? Can we even, can we not wait until we’re stage one? Can we screen and be practicing it’s similar like PD Instructions, right? Like you take your baby to the previous pediatrician 246. I don’t know the intervals 912 every year after that, whatever it is, because pediatricians are looking in anticipation like this is what I expect to be happening right now, if it’s not happening, what is my earliest opportunity to intervene so that we can set this kid up for the best outcomes possible? Can we take that same mindset? Knowing more than 21 million Americans in any given year are going to meet diagnostic criteria for a substance use disorder, can it just be whenever you go to the doctor? Like two questions? We have a PHQ. Two that screens for depression. Two questions. We have a GA D two that screens for anxiety. Two questions. You’ve heard me talk about the CAGE, which screens for substance use disorders for questions. We have a ticks, the ticks is only two questions like if I can’t even get four questions just like let me get to right.



Yeah. So what is CAGE? What is your assessment? 



Yeah, yeah. So CAGE is a research based, validated screening tool. And it’s for questions. And everybody who’s listening, I always tell people, if you ask, if you think to yourself, is my blank a problem? Like I wonder, Is my drinking a problem? I wonder, I’m not using these pain pills and it’s a problem. I wonder like, Am I this is annex, right? Like, if you ask yourself? The answer is yes. Yes, the answer is yes. Now the answer is not that you have a severe substance use disorder, and you need to go to a 30 day rehab. That doesn’t mean that’s the answer. But the answer, at the very least, is that you are at risk for developing a substance use disorder. You have I’m going to talk about this concept of pre addiction, or you have mild, moderate or severe, right. So like, the moment you get any inkling or the moment anybody in your life gets any inkling, the answer is yes. Okay. 


So starting with the answers, yes. Here’s the screener. CAGE is an acronym for questions. C, have you ever thought to yourself, maybe I should cut back on whatever it is? A, Have you ever been annoyed when somebody else mentioned your use pattern to you? G, have you ever felt guilty about the way you were using whatever that is? And E, the cage was initially developed only for alcohol. And now it’s been adapted to include all drugs. And so the E was for eye opener, like, are you waking up in the morning, you have to take a drink first thing in the morning to study your nerves. I use the ESI opener is like you have to smoke a cigarette to get your day started. You have to have a drink or you’re already thinking about it. Even if you didn’t have the drink, you’re already thinking about when I get off work. I’m going to have that glass of wine, right? Or I’m going to smoke that cigarette or I’m going to take that anxiety pill. 


And so C A G Have you ever thought you should cut back? Ever been annoyed? Because people need to get out of my business? Have you ever felt guilty? Because you said you were only going to drink half the bottle? You drink the whole bottle? You have to, you know, you’re thinking about it. First thing when you wake up one yes to any of these four questions 77% of the time. That person has a substance use disorder. It’s mild, moderate, or severe could be anywhere on this spectrum. But 77% of the time, the other 23% of the time, you’ve got to lose over the line. You didn’t jump over the line. Yeah, but your risk is there. And so it’s an opportunity. This is what I tell people: we’re so afraid for somebody to say you have a problem with alcohol, you have a problem with other drugs. We’re so afraid of it. But it is such an amazing opportunity to intervene before your stage four metastatic



Yeah, and I don’t know, almost any woman who can’t check off, you know, two or four of those, like, have you ever thought you should cut back? I mean, I was thinking that I needed to cut back like when I was 22, you know, and I drank too. I was doing poorly but it wasn’t safe. 


Was it safe for you to say out loud to anybody in that environment you were in? I think I might need to cut back?



No and I desperately didn’t want to. I desperately didn’t want to. I’m like hell no, I don’t want to cut back you know, or I God knows I didn’t want to stop drinking completely because I felt like it was like, I would never date, I would never have fun, I would be othered.



Yeah, this is what I said every illness has psychosocial, cultural, political factors. Yeah. And those were your psychosocial factors. And this is what a lot like we have to make it safe. We have to make sober dating cool.



Yes. You know, I mean, we have to make sober rugby the bomb. Oh my god. You know, I mean, like, we have to, we have to, we really, people say like, how do we stop this addiction crisis?



What and I feel like that’s changing. I mean, if you look at sober Instagram or sober TikTok or, I mean it is or like Drew Barrymore and Kelly Ripa coming out or, you know, everyone coming out and saying, I’m stopping drinking, like Chrissy Tegan. I mean, it’s not all about celebrities, but it’s about people being honest about the fact that like, yikes, I was drinking every night, and I decided it wasn’t working for me, you know?



Yeah. It’s so important. And celebrities are huge. Listen, we, you know, we take a lot in from the media that we consume, but is also just as important for you to say it to your girlfriends at dinner on Friday night. You know that I mean, people around us, like, just like making it safe. Yes, I was. It was so cool. I was in New York. It’s now probably two weeks ago for a business dinner. And so they were like, All right, everybody ordering drinks at this business dinner. And so a few people ordered drinks. I ordered a drink, which I usually don’t even order a drink, but I was like, whatever. I ordered a drink and then the person next to me ordered a mocktail, and I was like, This is amazing. Yeah, yeah. And then, so the person next to them ordered a drink, but then the person next to them was like, You know what, I’m into this mocktail thing, like, tell me about the mocktails. And then it ended up more than a quarter of the group ordered mocktails. Now I have no idea of people in recovery, in that bubble? I have no idea. The point was just like, that was such a beautiful, like, Butterfly Effect moment. Yeah, if that one person hadn’t had the agency to order a mocktail, maybe those other three people would have been drinking alcohol that night.



And I feel like when I finally did start talking to people, like I remember, I was like four months sober. And there was this woman who I wanted to be friends with, you know, neighborhood kid, the same age as mine. She worked, you know, whatever. And she invited me to come to a book club. She’s like, you’re gonna love these women. They’re amazing. We read, we drink a lot of wine. And I was like, oh, like deer in the headlights. Because I was like, Oh my God, if I tell her, I don’t drink, she’s gonna not want to be friends with me or whatever. And so I was like, debating with my husband. There’s 17 things I could say. I was like, do I tell her I’m not good at book clubs? Do I tell her like, I have a running club. You know, I didn’t even know what dates it was. And he was like, you don’t drink, tell her you don’t drink. And I was like, This sounds so easy. And I was like, Hey, that sounds great. I’d love to hang out. I actually stopped drinking like four months ago, it just, you know, I feel better without it. So you know, whatever. And she actually said, it gives me anxiety. And then she said, Oh, I totally get that. Actually, I have to keep a close eye on my drinking. I’ve taken breaks. And like, after that I felt so much closer to her. I did not join the book club. But we hung out.



Mm hmm. It’s beautiful. It’s beautiful. Because we think of it’s, you know, we try to think of those things that are like universal human experiences. And struggling with some behavior is a universal human experience. And so when I talk another way that you know, when I’m teaching about addiction, or supporting someone like trying to call out this stigma that so much of what my work is is just like don’t point this at yourself point that at the illness don’t point this entry point. Is it the illness, I’m like, you know, for a person who has never experienced any difficulty with a substance, just think of one behavior you’ve tried to change in your life. And a lot of times, like it’ll be around food or be around diet, it’ll be around exercise, it’ll be around not working as much, honestly, because all of these run through the dopamine pathways, just the same pathway, the addictions read through, right. So like, that’s why it’s a universal human experience. And I’m like, think about how hard it was to, quote, stay on the wagon. Yes. of exercising, or quote, stay on the wagon. Have eating, or quote, stay on the wagon of not working 14 hours a day. And then add all of the biochemical neurobiological aspects of a substance that make it even harder. And people were like, oh, man, yeah,



I get it. Totally, that makes so much sense. Well, you said that the, you know, it’s working its way through the legislation to add this screening. How important do you think it is, like lobbying and big alcohol and money in terms of slowing that down? Because they don’t want you to screen for MediCal? You know?



I mean, you know, I think about it, like, in Vegas, you see, all the big casinos have all around. Like, if you’re having trouble with gambling, it’s like on every slot machine, if you’re having trouble with gambling, here’s the state sponsored line, just give us a call, we’ll help you out. So like, I’m sure casinos didn’t want to put that on their machines. But it is a public health imperative to choose the health of our public over the profits of our corporations. And America does not always do a good job with this. Okay. And I don’t know if it’s just America, this is the experience, like this is world experience, where I have enough to make a comment on it. I’m sure it’s in other parts of the world also. And so it’s up to us to raise our voices to the people who are representing us. Yeah, to drive to drive that. And then I mean, I’m not like all anti Corporation, either. There are plenty of companies with mission and heart, and so that don’t want people to have to die to enjoy their products. And so I think there’s, there’s a way we can, you know, yeah, we can all benefit.



Well, I just saw like last month that doctors are recommending that. Cancer health warnings go on the back of alcohol, not just don’t drink and drive and don’t drink while pregnant. 



Yeah, I think a lot of people, they think cigarettes, they think cancer, you know, what public health education campaigns did that because that was absolutely 100% not the case when I was going oh, yeah, me neither. Oh, totally under appreciate alcohols contribution to risk for cancer. Like they might think liver cancer, liver disease, but like no, all cancers, breast cancer included. 



Yeah, significantly increased by that. I read that 70% of Americans don’t know the risk between out and cancer. Totally.



And in the end, the 30% that do know the risk. I’m just gonna slap my, you know, all my coins on red. And say, I bet the majority of them conjure up heavy drinking risk associated with cancer, not what we would consider regular routine, not concerning drinking. Regular routine, not concerning drinking, increases your risk for developing.



Well, and why wouldn’t they because the American Cancer Society just changed their guidelines right? A year ago to say no amount of alcohol is, you know, okay for cancer risk. Before a year ago, it was one drink a day for women to ferment 14 drinks a week casing? Yeah. And they’re talking five ounce glasses of wine like I did the late you already know.



Exactly. Exactly, exactly. Like even when all these White Claws came out. Then my husband was drinking like a White Claw every day. Like suddenly, I’ll just see like White Claw, White Claw, White Claw. And I was like, Oh, he has no idea that that White Claw has the same alcohol content as a can of beer. And I was like, Do you know that White Claw has the same alcohol content as a can of beer? He was like, what? I was like, yeah. And then he like stopped buying White Claw and drinking them every day because he was like, I would not drink a can of beer every day. Right? But it’s like when you don’t know. You don’t know White Claw, you know, White Claw is delicious. It’s cool. I’m at a party. It’s refreshing. We love sparkling water. It was like sparkling water with a little extra fun stock. 



Yeah, yeah. Well, so tell me, what do you, I know a huge part of what you do is minimizing the stigma around it bringing you know medical facts, bringing stuff out into the open. We’ve talked a lot about it. But if someone’s listening to this and they are you know, answering yes to two or three or one of those cage questions. What do you want them to take away? They’re like two or three things from our conversation.



Yeah, so number one is act now. So if you take that CAGE, and you answer yes to even one of those questions, I want you to treat that the same way you would treat finding a lump in your breast. Wow, you would go somewhere. Right, and you may get there and the gynecologist may say, Oh, this is Fibroadenoma, nothing to worry about, but you would go and get an opinion. And so that’s what I want you to do is go get an opinion where you can get that you can go to your primary care doctor, you can go, if you’re in a religious spiritual institution, you can go to a religious leader, if you have a friend you trust, and you want to bounce it off of them. First, you can go to a friend, neutrals, there are so many online resources now. Right, like, reach out to at least one person and just rip off the band aid and say, I’m concerned, I might need to be concerned, you don’t even have to be concerned. Yeah, just concerned I might need to be concerned is plenty, right. So like, treat it like you would treat finding a lump in your breast. And that’s not just act now. Talk to somebody, get help, get evaluated. That’s number one. 


The second part of that is treat yourself the same way you would treat yourself if you found a lump in your breast. You would not start going down a whole list of reasons why you’re terrible, why your decisions are bad, how you did this to yourself, how you have to hide it for the most part, you wouldn’t, right. And so even though that will probably be part of the reflex just because of the stigma we all get trained into. I want you to actively fight that reflex, actively fight that reflex and say to yourself, I’m concerned, I may have an illness, I need to get evaluated for the illness. I’m concerned I may have an illness, I need to get evaluated for the illness, right and just like undermine kind of that self-inflicted stigma. 


And then number three, same thing. Mental health conditions. Role impacts, yeah, substance use disorders, or mental health conditions. I already threatened to fight your audience once today, so I won’t threaten to fight them again. But if any of all your stuff, alright me on this, right, all of the same neurobiology, all the same neurotransmitters, all the same chemicals, all the same nerve pathways. And so if you’re concerned that you might need to be concerned about your substance use pattern. Please, please, please ask for an evaluation for depression, anxiety and other mental health conditions as well, because 80% of the time, that’s the foundation that’s underlying the development or the risk for development of an addiction, or predicts 80% of the time.



80% of people with substance use disorder have another mental health condition, most frequently depression, anxiety, trauma.



And I’ve also heard I did an episode on ADHD. And I heard that like, 50% of people with ADHD, have a substance use disorder or develop one and they’re five times more likely than the general population to develop a substance use disorder.



That’s right. And the other statistic I want to put next to that is the way we decrease the risk for a person with ADHD. So remember, I said biological is not always genetic, but it’s also other health conditions. This is an example of that so anxiety increases your risk for substance use disorder, most likely alcohol benzo ADHD, increases your risk of substance use disorder usually stimulants, Adderall, cocaine, methamphetamine, etc. The number one way to reduce the risk of a person with ADHD developing a substance use disorder is to identify the ADHD as early as possible and treat it. 


So like my family history, I have a lot of substance use disorder on both sides mom and dad. I have alcohol use disorder on both sides, mom and dad. I have what is most likely undiagnosed ADHD on my mom’s side, definitely depression and anxiety on that side. Also, on my dad’s side, we actually have psychotic disorders. And so when my son first of all, I’ve been training my sons in this like listening to our DNA, right? So like, we have to keep this into consideration. My son was six and started having some out from young, I was like this child may have ADHD like hyperactive, impulsive, fantastic, amazingly fun child, six years old. We took him for a psychological testing, and psychological testing came, ADHD. The number one way I reduce my son’s already pre loaded DNA risk of developing addiction is to treat that ADHD, right. And so we went like hardcore on all of the recommendations that the psychologist made. One to treat ADHD and I told the psychologists, my number one goal for treatment, like academic performance, whatever, I don’t care about it. I need this not to affect his self esteem, or his love for learning. Because those would have been psychological inputs to further increase his risk of addiction, which is already stacked from our DNA. Right. And so it’s like this very whole person, kind of way of thinking about it as the way we reduce our risk.



Yeah. Yeah. And as you said that, I mean, it is amazing how common some of the you know, when you were talking about both sides, your family and this occurs on your mother’s side, and this is prevalent on your father’s side, how common it is. And yet, you know, I know certainly with my grandparents, nobody ever talked about it at all, like it was like the dirty little secret that families don’t share outside the walls of our home.



Right. And you know, what that does completely and utterly removes our power to practice prevention? Yeah, yeah, completely and utterly. And so like, you know, even if I was raising my kids and talking to my family, because everybody’s like, Oh, my God, why are you talking to kids about drugs? Prevention, right, and the other, the other thing we can prevent? Is my kids developing the mindset that people with addiction are somehow bad or inadequate or less important, right? Like, that’s very important, because you want to train them into a compassion mindset. That is a way of practicing prevention as well.



I mean, I was just realizing, as you said, that, that my sister sort of struggled with suicide attempts. When she was growing up. I, you know, didn’t realize that I had anxiety, depression, mood disorder until God six years ago or so, I mean, occasionally in between, but we didn’t find out. She had, you know, incidents in eighth grade and senior high school. I didn’t find out till like, junior year of high school that my dad’s mom had committed suicide. I didn’t know I just knew she died right before they got married. I assumed it was cancer, you know, because like, that’s what you assume. And he, they almost never would have told me the way I found out was I was doing like, a family tree for some Psych class. And I was like, by the way, how’d your mom die? Because I needed to put it on the chart. And he told me and I was like, what? You know?



Yeah, these dirty little secrets kill us. They kill us generation to generation, they kill us. Right? And like, we think it’s so scary. And I don’t want to say we think it’s so scary to talk about because like stigma actually makes it very scary to talk about and consequences real consequences come to people and to families. But it’s like if we can start breaking that, like, you know, you would never see these days you see an obituary and it says the person died by suicide. Are you seeing an obituary? And it says the person died from an overdose? 10 years ago? Never. 


Yeah, never would have.



Family doesn’t shame in the paper. Some people don’t share that right. Like, it just, it just depends. 


So tell us about Eleanor Health and the work you do there.



Eleanor is amazing. So I’m Co Founder and Chief Medical Officer, we started the company back in 2019. And our mission is to help people affected by addiction live amazing lives. And so really trying to take that whole person, compassionate humanity based approach to people and what makes us different from a cool clinical perspective. So like our care model, the way we interact with folks is, we take care of people at all phases of the illness of addiction. And so like, you know, the way I made, I alluded earlier that if our system was better set up, we could get better outcomes. And so we’ve set up a better system and Eleanor and it is, like, right now, you legit have to be staged for addiction to get help. Right. And you have to overcome the barrier of stigma, and then figure out even where in this system do I get help to be able to get help. 


And so at Eleanor, what we do is work with insurance partners, to look to identify people that could benefit from joining the Eleanor community. And then we do proactive outreach. And just say, like, Hey, we’re a healthcare company, we have all kinds of things to offer. We have mental health, we have psychiatry, we have addiction support, we have nurse care managers that help with physical health conditions, we have health coaches, we have care navigators, we have peers, who have their own lives recovery from addiction, like, Would any of this be helpful to you? And so a person who’s drinking a bottle of wine at night, doesn’t quite know if they have a substance use disorder, maybe scary to even think about that, right? Because say, like, hey, yeah, can I talk to one of your coaches? Or Yeah, could I talk to one of your therapists, right? Like, you don’t have to be like, my name is in Nzinga and I’m an alcoholic to get help. And so we can come in any one of those supports and start a relationship. And we’re just there to like, what, what would make an amazing life for you? And then that’s the context that we try to work in, in a longitudinal relationship with all of those different health components.



I love that because I totally agree with you that typically, it’s either you’re on stage for your map, right? So well, you know, I’ve heard doctors and psychiatrists say, or therapist, well, you’re not an alcoholic. And, you know, I’m like, and people are coming to you telling you, they’re worried about their alcohol. Like, how hard is that? Right?



Like, and I mean, this is why like our language, I will always be like, oh, let’s look at the diagnostic criteria. Yeah. That your experience up against the 11. And we’re either gonna land at no diagnosis, mild, moderate, or severe. And even if we land at No, we’re going to start practicing prevention so that we don’t land in mild, moderate or severe view.



You may not know this, I know you talked about 21 million folks, each year sort of an active addiction, I may be getting that stat wrong. But what percent of the American population would you say land somewhere in the spectrum, mild, moderate, severe.



So that 21 million? Are those that land mild to moderate severe? I think what we really need to know is like, what portion land prediction, so like, pretty mild. I don’t have a statistic in my head for you. And part of the reason goes back to what you were saying earlier, which was like seven drinks a week for women and 14 drinks a week for men has been the recommendation. And that recommendation is wrong. Because like if we’re in seven or 14, we’re definitely in pre.



Oh, yeah. Yeah. And for me, that’s laughable. 



But I mean, and that’s like a medical recommendation. Same thing, you know, Casey before, before DSM five, and we’re in DSM four, which is the Diagnostic and Statistical Manual, that’s what we use to diagnose mental health conditions. The diagnosis literally was substance abuse. That’s the medical word like abuse is a crime, okay. Substance Use Disorder is an illness. But like literally the diagnosis that we were writing in charts that we’re training every single behavioral health professional and medical professional in is abuse, like literally driving stigma, with medical diagnosis, literally cutting off our nose for prevention with seven drinks, 14 drinks.



Yeah, well, you know, I mean, can you imagine, you know, the medical recommendations being no more than one cigarette a day for women, no more than two for men. Like it makes it seem like you should be drinking, you know, smoking cigarettes. 


We’re rattling ourselves up, Casey. 


I know, I know. I love it. Well, thank you so much. Honestly, I totally fangirling on you and reached out and I was like, oh my god she’s in. That’s amazing. Tell us where people can find you.



So you can find Eleanor Health at Eleanorhealth.com. Check us out. You can find me on Twitter or Instagram. I’m Nzinga MD, like medical doctor. And then you can just find me on Facebook and LinkedIn with my whole name in Nzinga Harrison



Very cool. And Nzinga is spelled N-Z-I-N-G-A. But of course, I’ll have all the links in the show notes to this podcast. Thank you so much. I truly appreciate it. And I learned so much, especially the percent recovery, or remission. I love that. Thank you.



Thank you so much for having me on. Thank you for having your podcast. You’re making a difference for everybody who listens. I love it.

Casey McGuire Davidson  56:01


Thank you for listening to this episode of The Hello Someday Podcast. If you’re interested in learning more about me or the work I do or accessing free resources and guides to help you build a life you love without alcohol, please visit hellosomedaycoaching.com. And I would be so grateful if you would take a few minutes to rate and review this podcast so that more women can find it and join the conversation about drinking less and living more. 


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