alcohol use and disorder across the lifespan
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Alcohol use and disorder across the lifespan. ARTSS 9 June 2011. Developmental periods considered. ?. ?. -. ?. Lifetime and current drinking and Alcohol use disorder, by age, NESARC. Alcohol Use by Age in the USA, 2009 National Household Study on Drug Use and Health. - PowerPoint PPT PresentationTRANSCRIPT
Alcohol use and disorder across the lifespan
ARTSS9 June 2011
Developmental periods considered
-
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
0
2
4
6
8
10
High School Post High School
Me
an
Nu
mb
er
time
s
Dru
nk in
Pa
st Y
ea
r
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
0
0.2
0.4
0.6
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
-
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)
0
5
10
15
20
25
30
35
40
45
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)
0
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
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
Percentile Group (High to Low)
Per
cen
t of C
on
sum
ptio
n
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)