Course of Alcohol Use Disorders: Data from a 35 year Follow Up  


Priscila Dib Goncalves, Ph.D.1-2;

 Marc Alan Schuckit, M.D.1;

Tom L. Smith, Ph.D1.  

1University of California San Diego; 2University of Sao Paulo;   


I. Introduction

A. This lecture covers (slide 2)

1. Background on this study

       a. Definitions

       b. AUD clinical course   

2. San Diego Prospective Study results

       B.  Middle age heavy drinking (slide 4) 1

               1. About 25% of middle age men

                      a. Drink daily

                      b. Have 5+ drinks/day in the past month

       2. ↑ Blood Alcohol Concentration (BAC) per drink with age 2-5

               a. Changes in the metabolism as people grow older

                      Slower metabolism: slower oxidation of alcohol  

               b. Higher body fat vs. muscle

                      1’. ↑fat, ↓muscle = less water

                      2’. ↑ blood alcohol concentration per drink

       3. Most of alcohol-related deaths occur at ages 45-60 6

B. Alcohol Use Disorders (AUDs) (slide 5) 7-10

       1. Chronic and severe

       2. AUDs: persistent pattern of problems causing impairment/distress

3. Onset early to mid 20’s

2. AUD prevalence in individual aged 45 to 64

       a. Past year: 10%

       b. Lifetime: 28%

       3. AUDs are related to a decrease lifespan in about 10 years

II. Definitions (slide 6)

A. High risk drinking (slide 7) 11-12

                      a. Men: >14 drinks/ week and > 4 drinks/ occasion

                      b. Women: > 7 drinks/ week and > 3 drinks/ occasion

               c. Standard drink

               .  ~10-12 grams of beverage alcohol [ethanol]

               2’. 12oz can beer / 8oz of malt/ 5oz glass of wine / 1.5oz one shot of liquor

       B. Alcohol Use Disorders (AUDs) (slide 8) 7

1. Diagnosis associated with impairment in functioning

2. DSM-IV criteria

       a. Dependence (3+ criteria)

        1’. Tolerance

        2’. Unsuccessful efforts to cut down

        3’. Taken in ↑ amounts/periods 

        4’. Important activities are reduced or given up

        5’. A lot of time spent: using/recovering

               6’. Continued use despite health problems

        7’. Withdrawal

b. Abuse (1+ criterion)

        1’. Failure to fulfill major roles

        2’. Use in situations that may be physically dangerous

        3’. Legal problems  

        4’. Continued use despite social problems  

              3. AUD remission: abstinence of all symptoms     

       C. Level of Response (LR) to alcohol (slide 9) 13

              1. LR rationale

                      a. Youth drinks for effects

                      b. If need more for effect→ will drink more                       

               2. Instrument: Self-Report of the Effects of Alcohol (SRE)

                      a. Number of drinks required for up to four alcohol effects

                      b. Higher scores indicate more drinks needed for effects = lower LR

               3. Low LR: predicts heavy drinking and AUDs              

III. AUD clinical course (slide 10)

       A. AUD course (slide 11) 8, 14

       1. Onset: early to mid 20’s

       2. Fluctuates with periods of remission and exacerbation of heavy drinking

       B. Remission types and predictors (slide 12) 15-23

       1. Non-abstinence (2 types)

               a. Low risk drinking  

                      1’. Small proportion able to maintain this pattern for long periods

                      2’. Associated with histories of

                             a’. Lower alcohol consumption

                             b’. Fewer alcohol problems

                             c’. Alcohol abuse (versus dependence)

               b. High risk drinking

                      Unknown predictors

       2. Abstinence

              a. More traditional definition of remission

               b. Associated with histories of

                      1’. More frequent and intense alcohol use

                      2’. Great number of alcohol problems  

                      3’. Earlier AUD onset

                      4’. Alcohol dependence (versus abuse)

                      5’. Formal treatment and self help groups    

IV. San Diego Prospective Study (SDPS): 35 year follow up (slide 13)

       A. Longitudinal Studies (slide 14)

               1. Important

                      a. Evaluate the course of alcoholism

                      b. Observe remission predictors

               2. But few studies are 18, 24-26

                      a. > 10 years

                      b. Begin early and continue into age 50+

                      c. Distinguish between drinking outcome types

       B. San Diego Prospective Study (SDPS) (slide 15) 27-33  

              1. University of California, San Diego (UCSD)

              2. 453 participants at study entry    

                      a. 18 to 25 years old  European American / White Hispanic men

                      b. Students and non-academic staff at UCSD                             

                      c. No baseline alcohol dependence

                      d. 50% had a parent with AUD

               3. Assessments (slide 16)  

                      a. Baseline: age 20 34

                             Interview and alcohol challenge  

                      b. Followed at 10 years, then every 5 years

                             Alcohol, drug, psychiatric problems 35-36

                      c. Additional measures at some follow ups

                             1’. Self-Report of the Effects of Alcohol (SRE)

                             2’. Personality questionnaires 37-39

                             3’. “Significant other” report                         

               4. Probands at age 50 (slide 17)

                      a. Original sample: 453

                      b. 11 died

                      c. 442 followed

                      d. 397 in all follow ups through age 50 (90%)

                      e. 165 developed an AUD by age 50

                      f. 156 of AUDs followed at age 55 (94.5%)

               5. Hypotheses (slide 18)

                      a. Most will have low risk/abstinence at age 55

                      b. Remission type predictors 

                                                                           Low risk              High risk        Abstain

                             1’. AUD onset                      Late                      Early              Early     

                             2’. LR                                   High              Low               Low

                             3’. Alcohol consumption     Low               High              High

                             4’ Alcohol problems           Low               High              High

                             5’. Other drug use              Low               High              High

               6. Age 50-55 outcomes (slide 19)

                       a. Probands: divided based on drinking patterns and DSM-IV AUD criteria 

                             Groups (%)                          Abstinent       Risky Drinking      1+DSM

                             1’. Low (14)                         No                 No                         No                       

                             2’. High (20)                       No                 Yes                        No

                              3’. Active AUD (56)            No                 N/A                       Yes

                             4’. Abstain (10)                   Yes                N/A                       N/A                                           

               7. At baseline, groups were similar in (slide 20)

                      a. Demography

                             1’. 23 years old

                             2’. 14% were married

                             3’. 80% had a religion                      

                      b. Drinking patterns

                             1’. 3 drinks/usual

                             2’. 10 days/month

                      c. Positive family history AUDs: 65%                                   

               8. Group characteristics at age 55 (slide 21)

                      a. Similar demographic

                             1’. 17 years of education

                             2’. 92% were ever married

                             3’. 34% were ever divorced

                             4’. 60% had a high status job (physicians, Ph.Ds, lawyers, businesses owners)

                      b. Probands differed in drinking patterns

                                                   Groups:         Low risk                High risk        AUD

                             1’. Frequency, days             12                  17                  21

                             2’. Usual quantity               1.7                 2.4                 3.4

                             3’. Max quantity                 3.2                 6.8                 9.0 

               9. Alcohol/drug use at ages 30-50 (slide 22)

                      a. Similar

                             1’. Drinking patterns

                                    3 drinks/ usual & 15 drinks/max

                             2’. Age of AUD onset: 29 years old

                             3’. Drug use

                                    a’. 63% tobacco

                                    b’. 85% cannabis

                                    c’. 50% stimulants                                                  

                      b. Groups differed (slide 23)

                                                                 Groups:         Low risk           High risk      AUD      Abstain

                             1’. Level of response to alcohol        3.8            4.3                      4.7             5.8      

                             2’. Usual frequency                           12             16                19              18

                             3’. Dependence diagnosis, %            48             53                63              93

                             4’. Treatment/AA, %                         5               15                18              67

                             5’. Cannabis use disorders, %           10             16                28              53

              10. Group membership prediction (slide 24)

                      a. Analysis: logistic regression

                      b. AUD group was used as reference group

                      c. Results showed in odds ratios  

                                                                 Groups:         Low risk           High risk      Abstain

                             1’. Level of response to alcohol        0.48                                     2.03                     

                             2’. Usual frequency                           0.34                                               

                             3’. Treatment/AA                                                                  8.66                 

                             4’. Cannabis use disorders (CUD)                                          4.68          


V. Take home message (slide 25)  

       1. AUDs were persistent in these white collar men (56%)

              These men: ≠ public stereotype of an alcoholic = jobless, unmarried, homeless

       2. Remission types and predictors

               a. Low risk drinking: ↑ LR, ↓ alcohol frequency

               b. High risk drinking: similar to active AUDs

               c. Abstinence: ↓ LR, ↑ treatment, ↑ CUD

       3. Physicians should screen for alcohol use

               a. Also adults at their 50’s and 60’s

               b. All socioeconomic status 


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