Alcohol use and disorder across the lifespan

ARTSS9 June 2011

Developmental periods considered

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Lifetime and current drinking and Alcohol use disorder, by age, NESARC

0102030405060708090

100

18-20

21-29

30-39

40-49

50-59

60-69

70+

LT useCurr useCurr AUDPrior AUD

Alcohol Use by Age in the USA, 2009National Household Study on Drug Use and Health

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

Binge, not heavy- 5 or more drinks in a few hours, at least 1 time in the last 30 daysHeavy alcohol use- 5+ drinks, 5+ times in the last 30 days

NIAAA’s Strategic 5-year Plan

“A lifespan perspective will allow researchers to identify how the emergence and progression of drinking behavior is influenced by changes in biology, in psychology, and in exposure to social and environmental inputs over a person’s lifetime, and vice versa.”

“This approach should help researchers discover life stage-appropriate strategies for identifying, treating, and preventing alcohol use disorders.”

Alcohol use: earlychildhood

Drinking among 10, 11 and 12 year olds

0102030405060708090

100

10 11 12

EverLast year

Source: Partnership for a Drug-free America, (Zucker et al, 2009)

on Much is not specific to alcohol, but related to other problems in childhood (e.g. aggression, impulsivity, conduct disorder)

During this age period, expectations about effects of alcohol are learned

Early use this young may affect developing brain structures

Social-environmental factors (family, peers, school, community, culture)

Multilevel dynamic interplay

Points to keep in mind

Some childhood factors that predict future alcohol use and problems

Prenatal exposureFamily historyPoor parenting (maltreatment, neglect, poor monitoring)Trauma – childhood sexual abuseChildhood antisocial behaviorChildhood smoking, other substance useCognitive and learning problemsSelf-regulation problems

Adolescence

Brooke Molina, PhD

University of Pittsburgh

School of Medicine

www.youthandfamilyresearch.com

Monitoring the future 2005

Three out of every four 12th grade students (75%) have at least tried alcohol

Four tenths (41%) of 8th graders have tried alcohol

Been drunk at least once:– 58% of 12th graders– 41% of 10th graders– 20% of 8th graders

Monitoring the Future, 2005

Daily drinking is infrequent – .5 – 3.1% of students

Binge drinking much more common: 5+ drinks in a row in the past 2 weeks– 28% of 12th graders– 21% of 10th graders– 11% of 8th graders

Ethnicity differences in current alcohol use & binge drinking, 12-20 year olds (NSDUH 2009)

0

10

20

30

40

50

60

70

W H As Blk AI/AN Birac

Current useBinge

Gender Differences in levels of Alcohol Use, 12-20 year olds (NSDUH, 2009)

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                

Alcohol Abuse or Dependence, Among 12-17 Year Olds by Race/Ethnicity, 2009

SAMHSA, 2009

Perc

ent

Age First Drink Predicts Adult AUDfrom National Household Study on Drug Use & Health 2009

Adolescent Cognition: Time of Development and Vulnerability

Formal operations not yet in place Brain development continues into the 20s

– Myelination develops prefrontally through the adolescent period

– Enhanced connectivity and organization in specific regions

– Synaptic pruning, especially prefrontally– Pruning + experience adult

efficient/organized/specialized (Luna, Giedd) Ability to assess risk and apply effective decision-

making potentially immature– Estimates of norms for substance use are biased

Deviance Proneness

Problem behavior theory (Jessor et al., 1977)– Problem behaviors co-occur in

adolescence– Risk processes overlap (behavior

problems, school difficulties, family adversities/stresses/ psychopathologies)

– Empirical support plentiful (e.g., Petraitis et al. 1995, for review).

Health Risk Behaviors Among Binge Drinkers (5+ drinks in past 30 days)

0%

10%

20%

30%

40%

50%

60%

SexuallyActive

Cigarettes Marijuana Inhalants CarriedWeapon

Youth Risk Behavior Survey, 2003

Parenting and Socialization

Parental monitoring, effective discipline, relationship warmth/low conflict– Alcohol- and substance-specific parenting

strategies

Peer influence processes (selection and influence)

Broader socialization networks (school and community activities such as after-school sports and religious organizations)

Petraitis, Flay, Miller, 1995, for review; also Chassin et al., 2004

Stress and Affect Regulation

Stress model of drinking – complicated with inconsistent support– Parental alcoholism negative life

events/perceived stress alcohol use• Stress or marker for dysfunction/impairment?• Stress measurement/time lag (Hussong et al 2001)

• Inconsistent support for responsivity to stress and prospective role of mood/anxiety

• More refined measurement of stress, affect, and biological underpinnings (e.g., type and severity of negative affect)

Treatment of adolescents with AUD

No one treatment approach stands out over others

Optimal dosage and length of treatment unclear

Comorbidities not well researchedPharmacotherapy studies small in number

(e.g., a few studies of SSRIs for AUD and depression; stimulants being tested)

Emerging Adulthood

Slides adapted from:

Kristina M. Jackson

Brown University

Emerging Adulthood

Period from the end of secondary school through the attainment of “adult” status (age 18-25)

Bridges adolescence and adulthood Marked by frequent change and

exploration Assumption of adult roles and

responsibilities

Why This New Developmental Stage? Delay in marriage, parenthood

– Increases in education – Changes in women’s roles– Birth control pill, standards of sexual

morality Increased desire for independence,

freedom

Many Developmental Tasks Occur During this Stage Identity exploration & formation Freedom to choose new behaviors &

lifestyles New social networks Separation from families & friends Education, intellectual growth

Drinking Can be Maladaptive

Failure to master tasks frustration and stress alcohol use

Alcohol use failure to master tasks frustration and stress

Long-term effects on physical & psychological well-being; implications for attainment of traditional adult roles

Age trends for past-month drinking (NSDUH 2007)

0

20

40

60

80

16 17 18 19 20 21 22 23 24 25 26-29

30-34

Emerging adulthood

Age trends for past-month binge drinking (NSDUH 2007)

0

10

20

30

40

50

16 17 18 19 20 21 22 23 24 25 26-29

30-34

Emerging adulthood

Prevalence of DSM IV Alcohol Dependence

0%

2%

4%

6%

8%

10%

12%

14%

18-20

21-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70+

National Epidemiologic Survey on Alcohol and Related Conditions (Grant et al., 2004)

Heavy drinking peaks at age 20-21 and then declines

0

10

20

30

40

50

18 19-20

21-22

23-24

25-26

27-28

29-30

35 40 45

He

avy

Use

From 2005 Monitoring the Future data (Johnston et al., 2005)

5+ in a rowEmerging adulthood

Factors that Predict Increase in Normative Drinking

Leaving home– Independence from parental restrictions– New social environment

Attainment of legal drinking age Stage-specific developmental correlates

College Students Show Greater Increase in Drinking

0%

10%

20%

30%

40%

50%

High School Post High School

He

avy

Use

College Non-college

From 1997-1999 Monitoring the Future (O’Malley & Johnston, 2002)

College Students Show Greater Increase in frequency of intoxication

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2

4

6

8

10

High School Post High School

Me

an

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nk in

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st Y

ea

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College Non-college

College Students Don’t Look Like their Non-College Peers Higher rates of heavy use Lower rates of daily drinking Lower prevalence of past-year DSM-IV

alcohol dependence Power of the social environment

Transition to Adult Roles is Associated with the Decline End formal education Employment Marriage Parenthood

Role compatibility theory (Kandel) Role socialization

– Individuals change substance use to be compatible with expectations from the social roles

Role selection – Individuals with pre-existing traits

(including low substance use) select into certain roles

Marriage

New responsibilities Change in social and recreational

activities Increased adult contacts Engagement

Relationship Transitions and Heavy Drinking – Women

Source: Monitoring the Future, (Bachman et al, 1997)

Relationship Transitions and Heavy Drinking – Men

0%

20%

40%

60%

80%

Time j Time j+2

Hea

vy D

rin

kin

g

Single MarriedDivorced Single->MarriedMarried->Divorced

Source: Monitoring the Future study ( Bachman et al 1997)

Parenthood

Pregnancy Impacts social life even more than

marriage– Child care responsibilities – Change in social and recreational activities

Prompts men to reduce drinking

Pregnancy and Heavy Drinking

0%

10%

20%

30%

40%

50%

60%

Time j Time j+2

He

avy

Use

Spouse Pregnant Spouse Non-Pregnant

From Monitoring the Future (Bachman et al., 1997)

0%

10%

20%

30%

40%

50%

60%

Time j Time j+2

He

avy

Use

Pregnant Non-Pregnant

Women Men

Midlife

Adapted from presentation byTheodore Jacob, Ph.D.VA Palo Alto Medical Health Care System

But What Happens After 30 ?

Are these identified patterns (trajectories) stable after young adulthood or does variability and change continue?

Do other drinking pathways emerge at later ages which could not be anticipated from young adult studies?

What historical and dynamic variables allow for prediction of which alcoholics will follow what trajectories for what length of time?

Why So Little Interest in Alcoholism at Midlife?

– Alcoholism was viewed as a unitary disorder– Less “payoff” studying midlife alcoholism– Stage-specific issues (e.g. maturation) are

fewer at midlife making specification of this time period difficult

Class Results

Analyses yielded a 4-class solution: Severe, Chronic Alcoholics (SCAs) Young Adult Alcoholics (YAAs) Late Onset Alcoholics (LOAs) Severe, Nonchronic Alcoholics

(SNCAs)

Results

Four different drinking trajectories were supported

Three trajectories have previous empirical support

1. Most notable was the Severe Chronic Alcoholism type that exhibited early onset, persistent duration, likelihood of comorbid ASP disorder, and paralleled Zucker’s Antisocial Alcoholism

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0.2

0.4

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0.8

1

1.2

< 21 21-23 24-26 27-29 30-32 33-35 36-38 39-41Age

Pro

ba

bili

ty

Class 1: Severe Chronic Alcoholics (24%)Class 2: Severe Non-Chronic Alcoholics (11%)Class 3: Young Adult Alcoholics (37%)Class 4: Late Onset Alcoholics (28%)

Conclusions

Clear support provided for multiple alcoholisms

Empirical verification for differing characteristics into the midlife years

Validation for long-term retrospective methodology

Identification of a newly emerging 4th trajectory

Older Adults and alcohol use

Adapted from presentation by:

Alison A. Moore, MD, MPH

David Geffen School of Medicine at UCLA

Division of Geriatric Medicine

Integrated Substance Abuse Program

Low-Risk Drinking

Under age 65– Men: no more than 2 drinks per day– Women: no more than 1 drink per day

65 and over: – Men and Women: no more than 1 drink

per day

USDHHS, PHS, NIH, NIAAA

Drinking Patterns in Older Persons (not restricted to drinkers)

At-risk drinkers

12%

Low-risk drinkers

25%Abstainers

60%

Abusing or Dependent

3%

Abstainers-60%)

Abuse/Dependent-3%At risk drinkers-12%

Low riskDrinkers-25%

Drinking Patterns in Older Drinkers

Abusing or Dependent

7%

At-risk Drinkers

30%

Low-risk Drinkers

63%

Low riskDrinkers-65%

Abuse/dependent-7%

At riskDrinkers-

30%

Associations with drinking in older adults Younger age Male gender Better socioeconomic status (education,

income) Better health Smoking

Predictors of Late-Life Drinking Problems Male gender Prior and current

alcohol use Smoking Negative life

events* Insomnia** Depression/

Anxiety** Pain*

Avoidance coping Friends’ approval

of drinking No help seeking Use of

psychoactive meds (women)

Moos et al. Addiction 2004

Treatment for Older Adults with Abuse/Dependence Generally older adults do as well or better than

younger adults in treatment. Predictors of better outcomes

– Longer treatment– Greater involvement in after-care programs– Female gender– Social network that does not encourage alcohol use

Oslin et al. Addictive Behaviors 2005Satre et al. Addiction 2004Lemke et al. J Subst Abuse Treatment 2003Blow et al. J Subst Abuse Treatment 2000

Age-Related Factors that Increase Risks from Alcohol Use in Older Persons Physiological factors

ratio body fat to lean muscle mass blood alcohol levels

susceptibility to psychomotor effects (e.g. sedation, confusion, falls)

Other concomitants of aging morbidity medication use

Conditions that may be prevented by moderate alcohol use All-cause mortality Coronary heart disease Congestive heart failure Cerebrovascular disease

– Ischemic stroke Diabetes Cholelithiasis Dementia

Alcohol Use and Risk of CHD:Meta-analysis of 28 cohort studies

Corrao et al. Addiction 2000

Alcohol Consumption and Risk of Incident DementiaCardiovascular Health Study, 1992-1999

0

0.2

0.4

0.6

0.8

1

1.2

1.4

None < 1 1-6 7-13 ≥ 14 FormerDrinker

Quitter

Odds Ratio

Mukamal et al. JAMA 2003

*95% CI excludes 1.0

* *

Average Weekly Number of Drinks Consumed

Drinking Pattern and Risk of MI:Health Professionals Follow-Up Study, 1986-1998

0

0.2

0.4

0.6

0.8

1

<1 1-2 3-4 5-7

Number of Days per Week Alcohol is Consumed

<10.0 gm/drinking day10.0-29.9 gm/drinking day30.0+ gm/drinking day

Rel

ativ

e R

isk

Mukamal et al. NEJM 2003

Moderate Alcohol Use and CHD

Light to moderate (~1 drink) regular (most days) alcohol consumption linked to favorable CHD outcomes.

Moderate alcohol intake linked to increase in HDL and reduced platelet aggregation and increased fibrinolysis.

Conditions for which alcohol use is causative/detrimental

Lip and oropharyngeal cancer

Esophageal varices and cancer

Laryngeal cancer Liver cirrhosis and

cancer Gastro-esophageal

hemorrhage Acute and chronic

pancreatitis

Female breast cancer Epilepsy Hypertension Cardiac arrhythmias Hemorrhagic stroke Psoriasis Depression Alcohol use disorders

Evidence that moderate alcohol use is beneficial among those persons having:– CHD– Stroke– Diabetes – Hypertension

Conclusions

40-60% of older persons drink alcohol In cohort studies alcohol has benefits or

risks in regard to CHD and CHD-related outcomes depending on amount and frequency of alcohol use

Alcohol is a risk for many other disease outcomes

Conclusions (cont)

Most older drinkers are not at-risk because they would meet criteria for alcohol abuse or dependence, but rather because of the amount of alcohol they drink given their other medical conditions

More data needed on the effect of alcohol use and multiple comorbidity on health outcomes

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Alcohol and Society

ARTSS June 2011

0% 2% 4% 6% 8% 10% 12% 14%

Iron deficiency

Unsafe sex

Illicit drugs

Physical inactivity

Low fruit and vegetable intake

Overweight

Cholesterol

Alcohol

Blood pressure

Tobacco

% Total Number of Health Years Lost to Death/Disability

Burden of disease attributable to alcohol among 10 leadingRisk factors in developed countries

Lifetime alcohol consumption, European vs US youth aged 15-16 (EPAD 2000 study)

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5

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15

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50

Au Be Ne De Cz Ge Hu It Fr Ir Sw No UK US

LT use

Consumed alcohol at least 40 times in their lives

Netherlands

US

Monthly use, 2006, European vs US youth aged 15-16 (EPAD 2009 study)

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10

20

30

40

50

60

70

Au Be De Fi Cz Ge Hu Fr Ir Sw UK US

Mnthly use

International comparisons, alcohol use among 15-16 year olds- summary: 1998-2006

-- Boys had higher prevalence of drinking and drunkenness than girls in both years but….

-- Gender gap may be shrinking

-- Regional trends:– Northern European countries show declining alcohol use– Eastern European countries show increase

-- US showed decreasing trend in drunkenness and alcohol use

Percent of fatally injured passenger vehicle drivers with positive BACs by age, 1982-2009

From:McCartt AT, Hellinga LA & Kirley BB, J Safety Res 2010: 173-181

Percent consuming alcohol in past 30 days among ages 18-22, 1975-2008

Percent of fatally injured passenger vehicle drivers ages 16-20 with positive BACs by age,

1982-2008

From:McCartt AT, Hellinga LA & Kirley BB, J Safety Res 2010: 173-181

Summary of MLDA research

-- Deaths go up when MLDA is lowered, go down when it is raised

-- Higher MLDA results in lower alcohol consumption

-- Benefits accrue not only to those directly affected by the law (18-20 year olds) but also to those not directly affected – 16-17 year olds

Comparison of European and American youth (15-16 year olds) (Ahlstrom 2004)

Total Per Capita Consumption in Gallons of Ethanol by State - US, 2006

Source, NIAAA

Cumulative Distribution of Alcohol Consumption in the United States

65% of the population are drinkers*

Males reported drinking 74% and females 26% of all alcohol consumed

73% of the alcohol is consumed by 10% of the population

* Individuals who reported drinking at least one drink in past 12-months

0

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60

80

100

0 10 20 30 40 50 60 70 80 90 100

Percentile Group (High to Low)

Per

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ptio

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NIAAA National Epidemiological Survey on Alcohol and Related Conditions (NESARC) (2001-2002).

Developmental models of drinking in youth

Adapted from presentation by:Robert A. Zucker, Ph.D.

Addiction Research CenterDepartment of Psychiatry

University of Michigan Medical School

Developmental aggregation of the endpoint phenotype (hypothesized)

Family History

Alcoholism Symptoms

Early Childhood undercontrol

Early Childhood negative affectivity

Social Disarray

Adolescent undercontrol

Adolescent negative affectivity

Adolescent alcohol involvement pathway

Developmental mediation and domain aggregation in the final common pathways to the

endpoint phenotype (RESULTS)

Family History

Alcoholism symptoms

Early childhood undercontrol

Early childhood negative affectivity

Social disarray

Adolescent undercontrol

Early adolescent alcohol involvement

xxAlcohol abuse or dependence, current and past, by age, NESARC

0102030405060708090

100

18-20

21-29

30-39

40-49

50-59

60-69

70+

P12 moPP12 mo

Ethnicity differences in current alcohol use & binge drinking, 12-20 year olds (NSDUH 2009)

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               

Past month alcohol use in 12-20 year olds, over time (NSDUH, 2009)

Initial Experience with Alcohol

10% of 9-10 year olds have had alcohol (Donovan, 2004)

1/3 of youth begin drinking before age 13– Normative experimentation vs problem

exposure– Sips vs drinks– Initial sips at young age, occurring in family

context, not associated with risk factors for problem drinking (Donovan & Molina, under review)

Early Initiation into Alcohol

Drinking alcohol (more than a sip or taste) at an early age (~ before age 14) predicts– Heavier drinking and other drug use in

adolescence (Robins & Pryzbeck, 1985; Hawkins et al 1997)

– Adult alcohol dependence (Grant & Dawson, 1998)

– Other adverse outcomes such as vehicular crashes after drinking (Hingson et al., 2002, Accid Anal Prev)