Alcohol use and disorder across the lifespan

1. Alcohol use and disorder across the lifespan ARTSS 9 June 2011

2. Developmental periods considered ? ? - ?

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

4. 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

5. 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.”

6. Alcohol use: earlychildhood

7. Drinking among 10, 11 and 12 year olds Source: Partnership for a Drug-free America, (Zucker et al, 2009)

8. 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

9. 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

10. Adolescence Brooke Molina, PhD University of Pittsburgh School of Medicine www.youthandfamilyresearch.com

11. 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

12. 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

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

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

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

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

17. 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

18. 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).

19. Health Risk Behaviors Among Binge Drinkers (5+ drinks in past 30 days) Youth Risk Behavior Survey, 2003

20. 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

21. 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)

22. 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)

23. Emerging Adulthood Slides adapted from: Kristina M. Jackson Brown University

24. 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

25. 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

26. 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

27. 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

28. Age trends for past-month drinking (NSDUH 2007) Emerging adulthood

29. Age trends for past-month binge drinking (NSDUH 2007) Emerging adulthood

30. Prevalence of DSM IV Alcohol Dependence National Epidemiologic Survey on Alcohol and Related Conditions (Grant et al., 2004)

31. 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)

32. 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

33. College Students Show Greater Increase in Drinking From 1997-1999 Monitoring the Future (O’Malley & Johnston, 2002)

34. College Students Show Greater Increase in frequency of intoxication

35. 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

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

37. 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

38. Marriage • New responsibilities • Change in social and recreational activities • Increased adult contacts • Engagement

39. Relationship Transitions and Heavy Drinking – Women Source: Monitoring the Future, (Bachman et al, 1997)

40. Relationship Transitions and Heavy Drinking – Men Source: Monitoring the Future study ( Bachman et al 1997)

41. Parenthood • Pregnancy • Impacts social life even more than marriage • Child care responsibilities • Change in social and recreational activities • Prompts men to reduce drinking

42. Pregnancy and Heavy Drinking Women Men From Monitoring the Future (Bachman et al., 1997)

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

44. 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?

45. 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

46. Class Results Analyses yielded a 4-class solution: • Severe, Chronic Alcoholics (SCAs) • Young Adult Alcoholics (YAAs) • Late Onset Alcoholics (LOAs) • Severe, Nonchronic Alcoholics (SNCAs)

47. 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

49. 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

50. 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