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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 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.”

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)

Points to keep in mind

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

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



Brooke Molina, PhD

University of Pittsburgh

School of Medicine

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)
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


SAMHSA, 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
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 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
  • 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)

  • 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



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

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)

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
  • 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


drinking patterns in older persons not restricted to drinkers
Drinking Patterns in Older Persons (not restricted to drinkers)


At risk drinkers-12%


Low risk


drinking patterns in older drinkers
Drinking Patterns in Older Drinkers


Low risk


At risk


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


Negative life events*




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



Cardiac arrhythmias

Hemorrhagic stroke



Alcohol use disorders

Conditions for which alcohol use is causative/detrimental
Evidence that moderate alcohol use is beneficial among those persons having:
    • CHD
    • Stroke
    • Diabetes
    • Hypertension
  • 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