When Kay* had her first sip of alcohol at 13 years old, it felt like she hit the mute button on the negative inner voice that told her she wasn’t enough—not pretty enough, not smart enough, not wealthy enough. From that point on, alcohol became her go-to confidence booster through four years at Northwestern University, a marriage, two kids, a divorce, and a successful career at a global advertising agency. But unlike many of the people around her, Kay’s alcohol use disorder meant she could never stop at just one drink. “My bodily reaction is abnormal when I put alcohol in my system,” she says. “I don’t have an off switch. All I have is a more switch.”

Shortly before her 40th birthday, Kay experienced a rock-bottom moment with alcohol and decided to start attending Alcoholics Anonymous (AA) meetings, inspired by her older sister who had previously done the same. Now 60, Kay has been sober for nearly 21 years, but she realizes things could have easily ended much differently. “Without my kids, I really don’t know that I would have hit bottom enough to change,” she says. And what then? “I’m sure I would be dead by now.”

This isn’t an overstatement. Although Kay entered recovery just in time, many of her friends have succumbed to alcohol-related deaths in the years since she got sober—caused by accidents, suicides, and beyond—reflecting the fact that menopause-age women are being hit particularly hard by alcohol use disorders in America today. A recent study from the National Institutes of Health revealed that while men continue to die at higher overall rates from alcohol, alcohol-related death rates grew by 85 percent for women between 1999 and 2017 (the most recent year data is available), compared to men’s 35 percent increase during that period. When examining the data further, researchers found that alcohol-related death rates in women were highest for those ages 55 to 64, followed closely by those ages 45 to 54.

This isn’t the first time that studies have connected older women with alcohol. From 2006 to 2014, women 45 to 54 also accounted for the highest rate of alcohol-related emergency room visits. And on a broader level, while alcohol use and binge-drinking rates are climbing among women of almost all ages, the increases from 2000 to 2016 were largest for those ages 50 and over.

While this is clearly a crisis, it’s not one that’s talked about very openly—and addiction experts agree that needs to change. “The opioid epidemic makes the papers, but alcohol kills far more people every year [around 88,000] than opioids do [around 48,000],” says psychiatrist and addiction specialist Michael Genovese, MD, chief medical officer of Acadia Healthcare. “It’s so ingrained in our culture that because alcohol is legal, it’s not as big of a problem. But anything in excess becomes a problem—legal doesn’t equal healthy.”

Why are menopause-age women particularly vulnerable to alcohol abuse?

The aforementioned statistics may seem surprising, but for Aaron White, PhD, a senior scientific advisor at the National Institutes of Health and co-author of the latest study, the numbers add up. “Alcohol consumption in the past century peaked in the United States in the mid-1980s, a time when many people currently aged 45-64 were adolescents,” he says. (It’s worth noting that the drinking age in nearly 30 states used to be 18, not 21—until the National Minimum Drinking Age law was passed in 1984.) Back then, 31 percent of 12th grade girls drank five or more drinks in a night at least once every two weeks. Now, however, that number has dropped to 12 percent. Those in the older demographic likely carried their drinking habits with them as they aged, while even more women joined them them later in life.

Experts also believe that the rising alcohol death rates in older women may have to do with the ways in which gender roles have changed over the past 50 years. “If we talk about ages 55 to 64, that’s the baby boomer generation—these are the women who pioneered equality in the workplace,” says Dr. Genovese. “As they were gaining equality in the workplace, they were [possibly] engaging in the same activities as men, which frequently would include more drinking. The same sort of thinking could apply to the 45 to 54 age group.”

At the same time, however, women are still expected to maintain their traditional roles at home, leading to unprecedented levels of pressure and stress. As Dr. White points out, one in five families are now headed by single mothers—double the number in the 1970s—and 70 percent of married mothers work outside the home. (Although we don’t have data yet to show how that last stat is affected by the COVID-19 pandemic, which has put millions of Americans out of work since mid-March.)

“Women often have this need to have it all: Have a successful career, be the perfect mom, be the perfect wife,” says addiction psychiatrist Stacy Cohen, MD, founder of Los Angeles-based mental health practice The Moment. For those who habitually turn to alcohol as a coping mechanism, the problem can sometimes snowball in mid-life, when marriages may start to dissolve, children may start to move out, and careers may start to slow down. “There can be a lot of isolation,” says Kay, who’s now an AA sponsor for several women in this stage of life. “That’s when drinking escalates for a lot of women.”

Hormonal changes during perimenopause and menopause can also lead to depression, which may cause some women to self-soothe with alcohol. “A lot of addiction disorders co-occur with mental illness,” says Dr. Cohen. “Women are twice as likely to experience depression as men, and that number’s growing.” It doesn’t help that alcohol is often marketed to women in the very places they go to nurture their mental and physical health. “Yoga festivals have ‘yoga and wine’ guides, health and lifestyle podcasts are sponsored by vodka brands, and the internet is flooded with recipes for spiked versions of spa water,” says Holly Whitaker, founder and CEO of online recovery community Tempest. “Big Alcohol is capitalizing off the wellness boom, with a specific and targeted hit towards women.”

Why current treatment methods for alcohol use disorder aren’t adequately serving women in mid-life

Despite the fact that so many women over 45 are affected by alcohol use disorders, they’re not often represented or included in societal conversations about alcohol abuse—a reality that could be holding them back from getting the treatment they need. “The women I see in that age range tend to be in a bit of disbelief that they’re even in the room with me talking about this,” says Erica Lubetkin, LMHC, a psychotherapist at the Alma co-practice community in New York City. “Perhaps they grew up in environments where [alcoholism] wasn’t talked about as much as it is now.”

There are also many misconceptions around recovery that still linger from decades past, adds Whitaker. “Traditional recovery programs have made people feel like they need to bottom out or lose everything before re-evaluating their relationship with alcohol, which is a concept we are trying to reframe at Tempest,” she says.

That was certainly the case for Kay, who questioned whether she needed help even after she started going to AA meetings. “It was confusing when I started being with other people in sobriety because they were daily, daytime drinkers, and that’s just not what it looked like for me,” she recalls. “I sat there for a few weeks going, ‘I’ve never been in jail, I’ve never had a DUI… I don’t really know if I’m an alcoholic.'” While the recent sober-curious movement has made it the norm for even casual drinkers to rethink their relationships with alcohol, Whitaker says this messaging may not be reaching the 45-to-64 age group yet.

Even when a woman does make the decision to get help for an alcohol use disorder, the current recovery systems aren’t often built to meet their needs. Lubetkin says that many women are deterred from going to in-patient treatment if they’re still caring for children at home, while Dr. Cohen adds that co-ed facilities can be triggering. “Women tend to do best when they’re in a women-only treatment facility—maybe they want to feel safe because they have a history of trauma, and if there are males they may not feel safe there,” she says. Unfortunately, she says, there are still very few women-only treatment facilities.

Mid-life women who opt to attend a 12-step program may also find that the process doesn’t resonate with them. Take AA, for example, which was founded by two men in the 1930s and hasn’t been updated much since. “The message is often to admit that you’re powerless over alcohol, but a lot of women have had trouble gaining power to begin with and that’s a big part of their issue,” says Dr. Cohen. “I think there needs to be a new approach that’s as accessible as AA, but will have a different message that would speak more to trauma.”

Kay agrees, adding that she had a particularly hard time with the tenth step of the program: taking an inventory of all the times she was resentful, dishonest, or otherwise “wrong” each day. “I found that if I was beating myself up like that daily, it compounded the ‘I’m not enough-ness’ that drove me to drink,” she says. “So I amended that into ‘What did I do well today? Where was I kind? Where was I patient?’ I have to do a lot of translating of the program to make it work for me and the women that I help.”

The shortcomings of existing alcohol use disorder treatment models are what drove Whitaker to create Tempest, an “online sobriety school” that gives women and other marginalized communities the education, tools, and community support needed to stop drinking. “When going through my own recovery, I personally found that other programs were not built—and have not been modernized—for women, and I took issue with the fact that I was disempowered to trust myself and listen to my own voice of reason,” she says.

How do we reverse the trend of alcohol-related deaths for women over 45?

Aside from rethinking the recovery experience for middle-aged women, experts agree that education is the first step to reversing alcohol use disorder. “Primary care doctors need to know either how to treat or where to refer patients for alcohol use disorder,” says Dr. Genovese. He adds that although there are several medications that have proven helpful in treating the disorder, many doctors don’t even know they’re available. “[Alcohol use disorder] has been swept under the rug for such a long time. If we can get people to understand that help is available and treatments are much better than they used to be, that would go a long way to having some sort of impact.”

Dr. White adds that it also needs to be easier for people with alcohol use disorder to access the help they need. To this end, the National Institute on Alcohol Abuse and Alcoholism developed a tool called the Alcohol Treatment Navigator, which lays out the various treatment options and helps people search for quality care near them. The NIAAA also created a digital hub called Rethinking Drinking that helps people determine whether or not their drinking habits may be problematic.

But ultimately, Whitaker believes there needs to be a bigger societal move away from the idea that alcohol is an appropriate way to handle the pressures of life. “Change comes from shifting attitudes toward alcohol consumption—enough of the status quo shifts, and the conversation moves to the center,” she says. “Studies are jarring, but normalizing resistance to alcohol-centric culture through social proof is far more effective.”

For her part, Kay learned that life is indeed much richer without alcohol at the center of it. In the 20 years since she became sober she remarried, adopted a third child, and started her own business. “My life today looks very different on the outside, but the most profound difference is that I am so filled with unconditional love for myself and all of the people around me,” she says. “Is that a function of aging or sobriety? I don’t know, but it feels a lot better.”

*Last name withheld to protect source’s privacy