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.

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Alcohol use and disorder across the lifespan

Alcohol use and disorder across the lifespan

ARTSS

9 June 2011


Developmental periods considered

Developmental periods considered

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Lifetime and current drinking and alcohol use disorder by age nesarc

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

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 days

Heavy alcohol use- 5+ drinks, 5+ times in the last 30 days


Niaaa s strategic 5 year plan

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 early childhood

Alcohol use: earlychildhood


Drinking among 10 11 and 12 year olds

Drinking among 10, 11 and 12 year olds

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


Alcohol use and disorder across the lifespan

Points to keep in mind

onMuch 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


Alcohol use and disorder across the lifespan

Some childhood factors that predict future alcohol use and problems

Prenatal exposure

Family history

Poor parenting (maltreatment, neglect, poor monitoring)

Trauma – childhood sexual abuse

Childhood antisocial behavior

Childhood smoking, other substance use

Cognitive and learning problems

Self-regulation problems


Adolescence

Adolescence

Brooke Molina, PhD

University of Pittsburgh

School of Medicine

www.youthandfamilyresearch.com


Monitoring the future 2005

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 20051

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

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


Gender differences in levels of alcohol use 12 20 year olds nsduh 2009

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

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

Percent

SAMHSA, 2009


Age first drink predicts adult aud from national household study on drug use health 2009

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


Adolescent cognition time of development and vulnerability

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

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

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

Youth Risk Behavior Survey, 2003


Parenting and socialization

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 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

Treatment of adolescents with AUD

No one treatment approach stands out over others

Optimal dosage and length of treatment unclear

Comorbidities not well researched

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


Emerging adulthood

Emerging Adulthood

Slides adapted from:

Kristina M. Jackson

Brown University


Emerging adulthood1

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

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

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

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

Age trends for past-month drinking (NSDUH 2007)

Emerging adulthood


Age trends for past month binge drinking nsduh 2007

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

Emerging adulthood


Prevalence of dsm iv alcohol dependence

Prevalence of DSM IV Alcohol Dependence

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


Heavy drinking peaks at age 20 21 and then declines

Heavy drinking peaks at age 20-21 and then declines

Emerging adulthood

5+ in a row

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


Factors that predict increase in normative drinking

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

College Students Show Greater Increase in Drinking

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


College students show greater increase in frequency of intoxication

College Students Show Greater Increase in frequency of intoxication


College students don t look like their non college peers

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

Transition to Adult Roles is Associated with the Decline

  • End formal education

  • Employment

  • Marriage

  • Parenthood


Role compatibility theory kandel

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

Marriage

  • New responsibilities

  • Change in social and recreational activities

  • Increased adult contacts

  • Engagement


Relationship transitions and heavy drinking women

Relationship Transitions and Heavy Drinking – Women

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


Relationship transitions and heavy drinking men

Relationship Transitions and Heavy Drinking – Men

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


Parenthood

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

Pregnancy and Heavy Drinking

Women

Men

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


Midlife adapted from presentation by theodore jacob ph d va palo alto medical health care system

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


But what happens after 30

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

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

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

Results

Four different drinking trajectories were supported

Three trajectories have previous empirical support

  • 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


Conclusions

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

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

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

Drinking Patterns in Older Persons (not restricted to drinkers)

Abuse/Dependent-3%

At risk drinkers-12%

Abstainers-60%)

Low risk

Drinkers-25%


Drinking patterns in older drinkers

Drinking Patterns in Older Drinkers

Abuse/dependent-7%

Low risk

Drinkers-65%

At risk

Drinkers-30%


Associations with drinking in older adults

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)

Predictors of Late-Life Drinking Problems

Moos et al. Addiction 2004


Treatment for older adults with abuse dependence

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 2005

Satre et al. Addiction 2004

Lemke et al. J Subst Abuse Treatment 2003

Blow et al. J Subst Abuse Treatment 2000


Age related factors that increase risks from alcohol use in older persons

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

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

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

Corrao et al. Addiction 2000


Alcohol consumption and risk of incident dementia cardiovascular health study 1992 1999

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

*95% CI excludes 1.0

*

*

Average Weekly Number of Drinks Consumed

Mukamal et al. JAMA 2003


Drinking pattern and risk of mi health professionals follow up study 1986 1998

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

Mukamal et al. NEJM 2003


Moderate alcohol use and chd

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

Conditions for which alcohol use is causative/detrimental


Alcohol use and disorder across the lifespan

  • Evidence that moderate alcohol use is beneficial among those persons having:

    • CHD

    • Stroke

    • Diabetes

    • Hypertension


Conclusions1

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

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 use and disorder across the lifespan

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