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Alcohol, stress, and glucocorticoids: From risk to dependence and relapse in alcohol use disorders
Open accessAbstract
In this review, we detail the clinical evidence supporting the role of psychological and physiological stress in instrumental motivation for alcohol consumption during the development of mild to moderate alcohol use disorders (AUDs) and in the compulsive, habitual alcohol consumption seen in severe, chronic, relapsing AUDs. Traditionally, the study of AUDs has focused on the direct and indirect effects of alcohol on striatal dopaminergic pathways and their role in the reinforcing effects of alcohol. However, growing evidence also suggests that alcohol directly stimulates the hypothalamic pituitary adrenal (HPA) axis and has effects on glucocorticoid receptors in extrahypothalamic, limbic forebrain, and medial Prefrontal Cortex (PFC) circuits, which contribute to the development of AUDs and their progression in severity, chronicity, and relapse risk. Evidence indicates HPA axis, glucocorticoid, and PFC dysfunction during protracted withdrawal and under high arousal conditions in those with severe AUDs, and novel evidence is also emerging to suggest HPA axis dysfunction with binge/heavy drinking, which is associated with motivation for alcohol in non-dependent individuals. Specifically, alcohol-associated alterations in HPA axis responses to stress and alcohol cues may serve as interoceptive physiological signals and facilitate conditioning mechanisms to influence alcohol motivation. Thus, this dysfunction may serve as a potential biomarker of both risk and of relapse. Based on this emerging data, we conceptualize and present early evidence for treatment targets that may improve PFC function and/or normalize HPA axis functioning and may be beneficial in the treatment and relapse prevention of AUDs. Finally, we suggest that individual differences in alcohol-related pathophysiology in these circuits may modulate treatment and recovery response, thereby supporting the need for building personalized medicine algorithms to understand and treat AUDs. This article is part of the Special Issue entitled "Alcoholism".
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“Chronic activation of the HPA axis causes sustained cortisol to increase and altered stress responses, which is a common occurrence in substance addiction [35].”
From The Impact of Social Media & Technology on Child and Adolescent Mental Health (2025) · cites this paper as [35]
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“Both chronic stress and long-standing alcohol use promote PFC dysfunction [172].”
From Food Addiction and Psychosocial Adversity: Biological Embedding, Contextual Factors, and Public Health Implications (2020) · cites this paper as [172]
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BackgroundPang, T. Y., Hannan, A. J., & Lawrence, A. J. (2018) · Neuropharmacology · doi:10.1016/j.neuropharm.2018.02.021 · Cited by 27
Predisposing factors for increased cortisol levels in oral cancer patients
Figueira, J. A., Sarafim-Silva, B. A. M., Gonçalves, G. M., Aranha, L. N., Lopes, F. L., Corrente, J. E., Biasoli, É. R., Miyahara, G. I., & Bernabé, D. G. (2022) · Comprehensive Psychoneuroendocrinology · doi:10.1016/j.cpnec.2022.100110 · Cited by 27
Wolkowicz, N. R., Peltier, M. R., Wemm, S., & MacLean, R. R. (2022) · Drug and Alcohol Dependence Reports · doi:10.1016/j.dadr.2022.100039 · Cited by 25
Muehlhan, M., Höcker, A., Miller, R. E., Trautmann, S., Wiedemann, K., Lotzin, A., Barnow, S., & Schäfer, I. (2018) · Addiction Biology · doi:10.1111/adb.12681 · Cited by 25
“Chronic heavy alcohol use and alcohol withdrawal can also alter the regulation of the HPA axis.(16,17) Alcohol directly stimulates the secretion of CRH within the paraventricular nuclei of the hypothalami with high doses of alcohol leading to elevated circulating adrenocorticotropic hormone (ACTH) and cortisol levels.”
BackgroundInfluentialVarodayan, F. P., Khom, S., Patel, R. R., Steinman, M. Q., Hedges, D. M., Oleata, C. S., Homanics, G. E., Roberto, M., & Bajo, M. (2017) · Alcohol and Alcoholism · doi:10.1093/alcalc/agx114 · Cited by 24
“, 2010), while stress is a primary trigger for alcohol craving and relapse in alcoholic patients (Blaine and Sinha, 2017).”
BackgroundWemm, S., Tennen, H. A., Sinha, R., & Seo, D. (2022) · Journal of Psychopathology and Clinical Science · doi:10.1037/abn0000771 · Cited by 24
Solomon, M. G., Griffin, W. C., Lopez, M. F., & Becker, H. C. (2019) · Neuroscience · doi:10.1016/j.neuroscience.2019.02.012 · Cited by 23
“Given that stress is known to significantly influence ethanol consumption (Becker, 2017; Becker et al., 2011; Blaine and Sinha, 2017; Sinha, 2012; Spanagel et al., 2014) and that both stress and ethanol exposure alter BDNF activity in brain, it is surprising that very little is known about their combined effects on BD…”
BackgroundKhom, S., Rodriguez, L., Gandhi, P., Kirson, D., Bajo, M., Oleata, C. S., Vendruscolo, L. F., Mason, B. J., & Roberto, M. (2022) · Neurobiology of Disease · doi:10.1016/j.nbd.2022.105610 · Cited by 23
“…cortisol levels in both dependent animals and humans and alcohol withdrawal is associated with increased cortisol levels, which remain elevated even during sustained abstinence compared to healthy subjects, suggesting persistent HPA neuroadaptations (Blaine and Sinha, 2017; Wemm and Sinha, 2019).”
BackgroundSex Differences in Alcohol Use: Is It All About Hormones?
Maddern, X. J., Ursich, L. T., Bailey, G., Pearl, A. J., Anversa, R. G., Lawrence, A. J., & Walker, L. C. (2024) · Endocrinology · doi:10.1210/endocr/bqae088 · Cited by 23
Doremus‐Fitzwater, T. L., Paniccia, J. E., Gano, A., Vore, A. S., & Deak, T. (2018) · Brain Behavior and Immunity · doi:10.1016/j.bbi.2018.02.009 · Cited by 23
“…arthritis; Affleck et al., 1997; Verhoeven et al., 2009), visceral pain disorders (Moloney et al., 2016), anxiety (Faravelli et al., 2012), depression (Hammen, 2005; Mazure et al., 2000), and drug and alcohol dependence (Blaine and Sinha, 2017; Lemieux and al’Absi, 2016; Piazza and Le Moal, 1996).”
BackgroundMakhijani, V. H., Franklin, J. P., Voorhies, K. J. V., Fortino, B., & Besheer, J. (2020) · Psychopharmacology · doi:10.1007/s00213-020-05659-w · Cited by 22
“We examined subregions of the mPFC and amygdala, which are implicated in both PTSD, AUD, and activated by predator odor (Asok et al., 2013, Edwards et al., 2013, Hwa et al., 2019).”
BackgroundInfluentialGoldfarb, E. V., Fogelman, N., & Sinha, R. (2020) · Neuropsychopharmacology · doi:10.1038/s41386-020-0650-y · Cited by 21
“As AUD is associated with elevated basal stress hormones [36] and hippocampal volume changes [37], we hypothesized that chronic alcohol intake in AUD could result in an unusual memory bias: enhanced memory for alcohol-related associations, but not items [12].”
BackgroundThe physiological responses to acute stress in alcohol-dependent patients: A systematic review
Chen, K., Hollunder, B., Garbusow, M., Sebold, M., & Heinz, A. (2020) · European Neuropsychopharmacology · doi:10.1016/j.euroneuro.2020.09.003 · Cited by 21
Mifepristone decreases chronic voluntary ethanol consumption in Rhesus macaques
Jimenez, V. A., Walter, N. A. R., Shnitko, T. A., Newman, N., Diem, K., Vanderhooft, L., Hunt, H., & Grant, K. A. (2020) · The Journal of Pharmacology and Experimental Therapeutics · doi:10.1124/jpet.120.000169 · Cited by 20
“Furthermore, stress is a salient risk factor for relapse (Blaine and Sinha, 2017), suggesting treatments that target the HPA response may be efficacious in treating AUD.”
BackgroundMarcolin, M. L., Hodges, T. E., Baumbach, J. L., & McCormick, C. M. (2018) · Developmental Psychobiology · doi:10.1002/dev.21800 · Cited by 20
Seo, S. Y., Bang, S. K., Kang, S.-Y., Cho, S. J., Choi, K. H., & Ryu, Y. H. (2021) · International Journal of Molecular Sciences · doi:10.3390/ijms22084037 · Cited by 20
“As described in studies of various types of alcoholism, including chronic alcohol administration, withdrawal and binge models, HT7 stimulation alleviates depression and anxiety behaviors and alters the plasma CORT levels [16,34].”
BackgroundCastelli, V., Plescia, F., Maniaci, G., Lavanco, G., Pizzolanti, G., Brancato, A., & Cannizzaro, C. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.996965 · Cited by 20
“Growing evidence suggests that ABD in adolescence correlates with higher tonic levels of heart rate and cortisol, which indicate a hypersensitivity of the brain stress system (68).”
BackgroundCross-talk between the HPA axis and addiction-related regions in stressful situations
Nikbakhtzadeh, M., Ranjbar, H., Moradbeygi, K., Zahedi, E., Bayat, M., Soti, M., & Shabani, M. (2023) · Heliyon · doi:10.1016/j.heliyon.2023.e15525 · Cited by 24
Haass‐Koffler, C. L., Magill, M., Cannella, N., Brown, J. C., Aoun, E. G., Cioe, P. A., Sinha, R., Swift, R. M., Ciccocioppo, R., & Leggio, L. (2023) · Addiction Biology · doi:10.1111/adb.13288 · Cited by 20
“The mechanisms underlying these relationships are complex and include noradrenergic,(9) corticotropin releasing factor (CRF)(10) and glucocorticoid receptor (GR) pathways.(11,12)”
BackgroundAlpers, S. E., Pallesen, S., Vold, J. H., Haug, E., Lunde, L.-H., Skogen, J. C., Mamen, A., Mæland, S., & Fadnes, L. T. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1181046 · Cited by 21
Effects of stress, alcohol prime dose, and sex on ad libitum drinking.
Patock‐Peckham, J. A., Corbin, W. R., Smyth, H. L., Canning, J. R., Ruof, A. K., & Williams, J. G. (2021) · Psychology of Addictive Behaviors · doi:10.1037/adb0000801 · Cited by 19
Brancato, A., Castelli, V., Lavanco, G., D’Amico, C., Feo, S., Pizzolanti, G., Kuchař, M., & Cannizzaro, C. (2022) · Psychological Medicine · doi:10.1017/s0033291722002744 · Cited by 19
Zhou, Y., & Kreek, M. J. (2018) · Journal of Pharmacology and Experimental Therapeutics · doi:10.1124/jpet.117.245621 · Cited by 19
“…stress-responsive systems such as corticotrophin-releasing factor, neuropeptide Y, and glucocorticoid receptor (Koob and Mason, 2016; Mantsch et al., 2016; Blaine and Sinha, 2017; Mason, 2017; Pomrenze et al., 2017; Robinson and Thiele, 2017; Spierling and Zorrilla, 2017; Tunstall et al., 2017).”
BackgroundJohnson, K. A., & Lovinger, D. M. (2020) · Advances in pharmacology · doi:10.1016/bs.apha.2020.02.002 · Cited by 18
Farokhnia, M., Abshire, K. M., Hammer, A., Deschaine, S. L., Saravanakumar, A., Cobbina, E., You, Z., Haass‐Koffler, C. L., Lee, M. R., Akhlaghi, F., et al. (2021) · The International Journal of Neuropsychopharmacology · doi:10.1093/ijnp/pyab004 · Cited by 19
“Moreover, previous studies indicate that alterations in the HPA axis may facilitate the transition from mild-to-moderate alcohol drinking to AUD and may contribute to the risk of relapse (Koob, 2010; Blaine and Sinha, 2017).”
BackgroundHigh-Risk Drinkers Engage Distinct Stress-Predictive Brain Networks
Goldfarb, E. V., Scheinost, D., Fogelman, N., Seo, D., & Sinha, R. (2022) · Biological Psychiatry Cognitive Neuroscience and Neuroimaging · doi:10.1016/j.bpsc.2022.02.010 · Cited by 19
Neira, S., Hassanein, L. A., Stanhope, C. M., Buccini, M. C., D’Ambrosio, S., Flanigan, M. E., Haun, H. L., Boyt, K. M., Bains, J. S., & Kash, T. L. (2022) · Alcoholism Clinical and Experimental Research · doi:10.1111/acer.14901 · Cited by 21
Advancing Pharmacotherapy Development from Preclinical Animal Studies
Egli, M. (2018) · Handbook of experimental pharmacology · doi:10.1007/164_2017_85 · Cited by 19
Sampedro‐Piquero, P., Moreno‐Fernández, R. D., Begega, A., López, M., & Santín, L. J. (2022) · Addiction Biology · doi:10.1111/adb.13158 · Cited by 19
“Besides this, these brain regions regulate the hypothalamic-pituitary-adrenal (HPA) axis activity, which is also a critical mechanism contributing to protracted alcoholism.(15,16) Clinical and experimental studies in both humans and rodents have shown that”
BackgroundHPA axis function in alcohol use disorder: A systematic review and meta-analysis
Dunne, N., & Ivers, J. (2023) · Addiction Neuroscience · doi:10.1016/j.addicn.2023.100114 · Cited by 22
The role of resilience in the relationship between stress and alcohol
Schwandt, M. L., Cullins, E., & Ramchandani, V. A. (2024) · Neurobiology of Stress · doi:10.1016/j.ynstr.2024.100644 · Cited by 20
Hormonal responses in gambling versus alcohol abuse: A review of human studies
Li, Y., Ramoz, N., Derrington, E. A., & Dreher, J. (2020) · Progress in Neuro-Psychopharmacology and Biological Psychiatry · doi:10.1016/j.pnpbp.2020.109880 · Cited by 18
Epigenetic landscape of stress surfeit disorders: Key role for DNA methylation dynamics
Gatta, E., Saudagar, V., Auta, J., Grayson, D. R., & Guidotti, A. (2020) · International review of neurobiology · doi:10.1016/bs.irn.2020.08.002 · Cited by 19
Citrate Synthase and OGDH as Potential Biomarkers of Atherosclerosis under Chronic Stress
Meng, L., Hu, G.-F., Shan, M., Zhang, Y.-M., Yu, Z.-M., Liu, Y.-Q., Xu, H., Wang, L., Gong, T., & Liu, D. (2021) · Oxidative Medicine and Cellular Longevity · doi:10.1155/2021/9957908 · Cited by 16
Finn, D. A. (2023) · Frontiers in Neuroendocrinology · doi:10.1016/j.yfrne.2023.101094 · Cited by 15
Carlson, H. N., & Weiner, J. L. (2020) · International review of neurobiology · doi:10.1016/bs.irn.2020.09.006 · Cited by 16
Bauer, E. E., Shoeman, A., Buhr, T. J., Daniels, K. M., Lyte, M., & Clark, P. (2021) · Alcoholism Clinical and Experimental Research · doi:10.1111/acer.14592 · Cited by 15
“Monoamine activity in other brain regions that comprise parts of the limbic, motor, reward, and stress circuits remains less characterized, despite probable contributions to the motivation to consume alcohol or cognitive dysfunction related to alcohol ingestion (Blaine & Sinha, 2017).”
BackgroundMechanisms of quality-of-life improvement in treatment for alcohol use disorder.
Carlon, H. A., Hurlocker, M. C., & Witkiewitz, K. A. (2022) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000750 · Cited by 15
Szabo, Y. Z., Breeding, T., Hejl, C., Guleria, R. S., Nelson, S. M., & Zambrano‐Vazquez, L. (2020) · Journal of Dual Diagnosis · doi:10.1080/15504263.2020.1771504 · Cited by 15
“Indeed, previous studies have posited that glucocorticoids and the HPA axis may have an important role for the development and chronicity for AUDs due to their connection with limbic and prefrontal cortex circuits (Blaine & Sinha, 2017).”
BackgroundCannady, R., Nguyen, T., Padula, A. E., Rinker, J. A., Lopez, M. F., Becker, H. C., Woodward, J. J., & Mulholland, P. J. (2020) · Neuropharmacology · doi:10.1016/j.neuropharm.2020.108396 · Cited by 16
“, 2012; Becker, 2017), and heavy alcohol drinking causes adaptations in HPA axis function and stress-related brain systems and neurocircuitry (Stephens and Wand, 2012; Lu and Richardson, 2014; Blaine and Sinha, 2017; Weera and Gilpin, 2019).”
BackgroundThe future is now: A 2020 view of alcoholism research
Harris, R. A., & Koob, G. F. (2017) · Neuropharmacology · doi:10.1016/j.neuropharm.2017.06.001 · Cited by 16
“At the clinical level, Blaine and Sinha (2017) review the role of *Corresponding author. harris@austin.utexas.edu (R.A. Harris).”
BackgroundSarkar, S., Tom, A., Das, S., Bharadwaj, B., & Ghosh, A. (2022) · Journal of Mental Health and Human Behaviour · doi:10.4103/jmhhb.jmhhb_191_20 · Cited by 14
Metadata
- Authors
- Blaine, S. K., & Sinha, R.
- Affiliations
- Yale University (US)
- Corresponding author
- Sinha, Rajita
- Venue
- Neuropharmacology
- Publisher
- Elsevier BV
- Published
- 2017-08
- Volume
- 122
- Pages
- 136-147
- ISSN
- 0028-3908 (ISSN-L)
- PMC
- PMC5479733
- OpenAlex
- W2583762848
- Cited by
- 257
- References
- 133
- Citations by year
- 2026: 21 · 2025: 20 · 2024: 25 · 2023: 35 · 2022: 38 · 2021: 30 · 2020: 39 · 2019: 13 · 2018: 29 · 2017: 7
- FWCI
- 3.19
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Neuropharmacology (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Alcoholism (R01-AA13892, R01-AA020504)
- Alcohol Abuse at the National Institutes of Health (R21-AA025277)
- Topics
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Life Sciences › Neuroscience › Behavioral Neuroscience › Stress Responses and Cortisol
- Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › Neurotransmitter Receptor Influence on Behavior
- Keywords
- alcoholism, stress, glucocorticoids, hypothalamic-pituitary-adrenal axis, relapse, drinking motives, binge drinking, prefrontal cortex, alcohol withdrawal, alcohol cue reactivity, interoception, conditioning, biomarkers, personalized medicine, treatment goals
- MeSH terms
- Alcohol Drinking, Alcoholism, Animals, Brain, Glucocorticoids, Humans, Hypothalamo-Hypophyseal System, Pituitary-Adrenal System, Recurrence, Stress, Physiological, Stress, Psychological, Prefrontal Cortex
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