Americans and Alaska Natives (5.7%) relative to whites (5.0%), African Americans (1.8%), and Asian Americans and Pacific Islanders (1.6%). In contrast, among adults, the 12-month prevalence of alcohol use disorder is clearly greater among Native Americans and Alaska
Natives (12.1%) than among whites (8.9%), Hispanics (7.9%), African Americans (6.9%), and Asian Americans and Pacific Islanders (4.5%).
The first episode of alcohol intoxication is likely to occur during the mid—teens. Alcohol- occur prior to age 20 years, but the age at onset of an alcohol use disorder with two or more of the criteria clustered together peaks in the late teens or early to mid 205. The large ma- jority of individuals who develop alcohol-related disorders do so by their late 305. The first evidence of withdrawal is not likely to appear until after many other aspects of an alcohol use disorder have developed. An earlier onset of alcohol use disorder is observed in ado- lescents with preexisting conduct problems and those with an earlier onset of intoxication.
Alcohol use disorder has a variable course that is characterized by periods of remission and relapse. A decision to stop drinking, often in response to a crisis, is likely to be followed by a period of weeks or more of abstinence, which is often followed by limited periods of controlled or nonproblematic drinking. However, once alcohol intake resumes, it is highly develop.
Alcohol use disorder is often erroneously perceived as an intractable condition, per- haps based on the fact that individuals who present for treatment typically have a history of many years of severe alcohol-related problems. However, these most severe cases rep- resent only a small proportion of individuals with this disorder, and the typical individual with the disorder has a much more promising prognosis.
Among adolescents, conduct disorder and repeated antisocial behavior often co-occur with alcohol- and with other substance-related disorders. While most individuals with al- cohol use disorder develop the condition before age 40 years, perhaps 10% have later onset. Age-related physical changes in older individuals result in increased brain suscep- tibility to the depressant effects of alcohol; decreased rates of liver metabolism of a variety of substances, including alcohol; and decreased percentages of body water. These changes can cause older people to develop more severe intoxication and subsequent problems at lower levels of consumption. Alcohol-related problems in older people are also especially likely to be associated with other medical complications.
Environmental. Environmental risk and prognostic factors may include cultural atti- tudes toward drinking and intoxication, the availability of alcohol (including price), acquired personal experiences with alcohol, and stress levels. Additional potential medi- ators of how alcohol problems develop in predisposed individuals include heavier peer substance use, exaggerated positive expectations of the effects of alcohol, and suboptimal ways of coping with stress.
Genetic and physiological. Alcohol use disorder runs in families, with 40%-60% of the variance of risk explained by genetic inﬂuences. The rate of this condition is three to four times higher in close relatives of individuals with alcohol use disorder, with values highest for individuals with a greater number of affected relatives, closer genetic relationships to the affected person, and higher severity of the alcohol-related problems in those relatives.
A significantly higher rate of alcohol use disorders exists in the monozygotic twin than in the dizygotic twin of an individual with the condition. A three- to fourfold increase in risk has been observed in children of individuals with alcohol use disorder, even when these have the disorder.
Recent advances in our understanding of genes that operate through intermediate characteristics (or phenotypes) to affect the risk of alcohol use disorder can help to identify individuals who might be at particularly low or high risk for alcohol use disorder. Among the low-risk phenotypes are the acute alcohol-related skin ﬂush (seen most prominently in