Alcohol-Related Problems in Special Populations:


Susan F. Tapert, Ph.D.

University of California, San Diego

VA San Diego Healthcare System

Prepared July 2000 for the Alcohol Medical Scholars Program

I.Introduction {Slide 2}

A.This talk could be adapted for teaching about alcohol-related problems in a variety of subgroups, such as elderly adults, people living with AIDS, another medical subgroup (e.g., those with a Spinal Cord Injury), or a particular ethnic/cultural group.

B.This lecture will cover the following elements of alcohol-related problems in these populations (as shown on Slide 2)

II.Youth (youth = under age 21; adolescence = ages 12 to 18) {Slide 3}

A.Drinking rates

1.It's very common for teens to drink, and it may be a part of normal development [1].

2.Alcohol (and other drug) problems are fairly common types of problems during adolescence [2].

3.There are ethnic differences in the prevalence of alcohol use among youth: Native American and Caucasian youth have the highest rates, then African-American and Hispanic youth (males more than females). Asian youth have the lowest rates [3].

4.Boys are more involved than girls, but the gender difference isn't that great (except in Hispanic youth) [3].

5.Alcohol Abuse and Dependence rates are approximately 6% according to school-based diagnostic interviews (ages 12-18) [4].

6.Many of these youth have other problems as well, such as early sexual experiences, smoking, delinquent behaviors, and other drug use (aside: 56% of U.S. 12th graders have used illicit drugs) [3, 5].

7.BOTTOM LINE: Many teens experiment with drinking, so how do we know if we need to do something about it?

B.Features of drinking during adolescence {Slide 4}

1.Early drinking is associated with an increased risk for additional problems.

a.There is a gateway sequence such that almost all teens who have used drugs drank alcohol before trying other drugs. The most common sequence of substance experimentation is cigarettes, then alcohol, then marijuana, then a variety of other drugs [6].

b.Prognosis - drinking alcohol prior to age 14 is associated with a significantly increased risk of developing alcohol dependence in one's lifetime [7].

2.Teens involved with alcohol and other drugs are likely to have other problems too, and may skip emotional and social milestones (e.g., forming a peer group, developing self-discipline, and dating without the influence of intoxicants) [8].

3.Subtle cognitive deficits may appear for some youth (especially memory and spatial problems) [9].

4.KEY POINT: Early alcohol and drug use might set the stage for more severe problems later in life.

C.Assessment involves looking for signs that may indicate more than just experimentation. {Slide 5}

1.Red flags: injuries or accidents, family problems (e.g., isolation from family), dropping grades (or truancy), mood swings (due to intoxication and/or withdrawal), change in friends (peers have a major influence during adolescence), and blackouts (e.g., forgetting how one got home) [10].

2.Common problems are the "3Ds" -- driving, dating, & drugs (i.e., accidents, early sexual experiences, and early or heavy drug use). Co-occurring problem behaviors and poor judgment are frequently seen as well [11].

3.Health problems and severe withdrawal are uncommon problems (don't wait for these problems because they are very unlikely in youth). Adult criteria for substance abuse and dependence are not ideal for teens due to developmental differences [12].

4.EXAMPLE: A 15-year-old girl living with her mom and 3 older brothers drinks 9-24 beers per occasion 2-4 times a week. After a weekend of heavy drinking, she experienced hand tremor, nausea, headaches, and insomnia for about 2 days following STOPPING drinking, but she did not experience DTs or seizures. Her grades slipped from mostly Bs, and she was losing interest in track. Her mom noticed new friends at the house including some 17-18 year old boys.

5.Screening Tools: {Slide 6}

a. The TWEAK is better than the CAGE for youth. The TWEAK takes about 3 minutes to administer and score [13].

b.Pediatricians can easily use the TWEAK.

c.Tolerance is tricky to assess as youth are in puberty and growing rapidly (e.g., 3 drinks for a 100-lb. boy won't give the same effect once he's 120 lbs. 6 months later).

d.KEY POINT: having any of these 5 TWEAK items is a bad sign in an adolescent.

e.The Personal Experiences Questionnaire (or "PESQ") is a self-report questionnaire that takes about 10-15 minutes to administer, but it provides more a detailed screening on teens [10].

D.Treatment {Slide 7}

1.Most programs are based on adult approaches and don't necessarily address adolescents' needs. Teens with substance use disorders tend to have a broader range of life problems. Treatment may require involvement of multiple life domains, such as school and family [15].

2.Availability: Adolescent-specific treatments are not widely available (especially with managed care).


a.Multi-systemic programs involve the teen, parent, school, and other agencies (like a social worker or pediatrician) working together to monitor the teen's progress and create mutual goals and structure. This modality has the lowest dropout rates and best success of adolescent treatment programs documented so far (although it can be somewhat expensive and time-intensive) [16, 17].

b.Minnesota model (e.g., Hazelden) is an extensive inpatient treatment model that is very expensive and has limited availability.

c.Therapeutic communities involve living in a sober housing environment with other recovering teens for 6 months or longer [18]. They are costly and generally only available in certain areas (e.g., NYC).

d.Cognitive-behavioral therapy can be administered on an inpatient or outpatient basis and in group or individual formats. It involves coping skills training, relapse prevention, goal setting, building healthy rewarding activities into the teen's lifestyle, and enhancing self-esteem by emphasizing the teen's role in treatment. Behavioral coping strategies (e.g., concrete, specific plans for times of craving) are more helpful than cognitive or emotional strategies for youth. Cognitive-behavioral approaches are often integrated into multisystemic therapy [19, 20].

e.Group therapies

i.May have iatrogenic effects if conduct-disordered or delinquent teens are mixed with non-delinquent teens [21].

ii.If carefully arranged, groups can help by providing role models for prosocial behavior.

f.Brief Intervention may be helpful for heavy or problem drinking youth [22].

g.BOTTOM LINE: Involve multiple aspects of teen's life and enlist the teen's active participation in setting goals, but make goals concrete and specific.

4.EXAMPLE: The 15-year-old girl noted earlier benefited most from incorporating HER ideas about her problem and bringing in her brothers, mother, teacher, and best friend to sessions.

5.Pathways to success: There are 3 routes a substance use-disordered teen can take toward achieving a healthy lifestyle [23] {Slide 8}

a.In the Traditional route, teens attend treatment program aftercare meetings and 12-step meetings, and work the 12-step program by getting a sponsor and working the steps. For youth, AA may be preferable to NA since teens are less likely to be exposed to bad influences.

b.Early individuation is especially suitable for older teens from unsupportive families. This entails involvement in school, work (after-school and weekend job) and activities to keep busy, productive, and exposed to positive role models.

c.Family involvement is useful for younger teens with supportive families, and involves spending quality time with parents engaged in mutually-decided upon activities on a regular basis.

6.Treatment Outcome (there is limited data, but existing evidence supports the following): [24]

a.Treatment is better than a wait-list control condition.

b.There is no difference between inpatient and outpatient treatment in terms of relapse rates.

c.Most teens will relapse (66-80% in the first 6 months after treatment), and most relapse situations involve peer pressure (like directly being offered the drink, or just being around other teens who are drinking) [24].

d.KEY POINT: Most teens will use again after treatment, but this is not necessarily considered a "failure" because relapse situations may provide important information on coping skills weaknesses that can then be addressed.

e.IN SUMMARY: Treatment is better than no treatment.

7.Prevention [25]

a.Several school and media-based programs have been attempted to prevent teen smoking, drinking, or other drug use, and have been met with varying degrees of success.

b.Programs are most effective if they are interactive (e.g., role-playing) and if messages come from other teens (peer-based).

c.Scare tactics are generally not effective.

d.Alternative activities that are fun, social, and rewarding should be discussed.

E.Summary {Slide 9}

1.Experimentation with alcohol is common.

2.Heavier drinking can lead to later problems.

3.Change in peers, mild withdrawal, and blackouts are signs of risk.

4.If intervention is needed, treatment is better than no treatment.

5.Optimal intervention involves multiple systems (school, pediatrician, social worker, and family) and collaborating with the adolescent to set concrete goals.

III.Women {Slide 10}


1.Most of what we know about alcohol problems is based on studies of men.

2.Alcohol dependence happens in women too.

3.There are many similarities between male and female alcoholics but also a few differences.

4.EXAMPLE CASE: A 52-year old woman's youngest child moved out. She works part-time for her husband who had a long-standing alcohol problem. She started drinking more when she was out with him, and recently began to drink at home alone in the afternoons.

B.Prevalence {Slide 11}

1.62% of women drink, whereas 83% of men drink. This is a significant difference [26].

2.Women are about half as likely to meet criteria for alcohol abuse or dependence as men are [27].

3.BOTTOM LINE: Alcohol dependence in women is less likely, but still common.

C.Health problems {Slide 12}

1.Alcohol dependent females are at risk for infections, anemia, STDs, hepatitis, UTIs, reproductive organ problems, liver and brain damage [28].

2.They are also at an increased risk for being victims of violence [28].

3.Women experience the same neurocognitive impairments as men despite having drank heavily for fewer years [29].

4.Female alcoholics have increased rates of STDs. STD clinics should assess drinking.

D.Pregnancy {Slide 13}

1.KEY POINT: The effect of alcohol on a developing fetus is a major public health risk for female drinkers.

2.16-35% of pregnant women drink regularly (and 6% used illicit drugs). However, under-reporting of drinking during pregnancy is believed to be common due to stigma [30].

3.4% of pregnant women are frequent drinkers (7 or more drinks per week or 5 or more drinks per occasion) versus 13% of non-pregnant women, suggesting that most frequent-drinking women may cut down during pregnancy (or at least report that they have done so) [31].

4.FAS: occurs in 1.5/1000 births in the U.S. and is diagnosed based on 3 criteria: [32]

a.Facial dysmorphia

b.Growth deficiency

c.CNS deficits, including impulsivity and mental retardation (FAS is the #1 preventable cause of mental retardation)

5.There is no established safe level of drinking during pregnancy, so abstinence is recommended [31]. Heavier drinking has been associated with risk for more severe fetal alcohol effects, and the risk is especially great for women who achieve high blood alcohol concentrations during the first trimester (quantity may be more impactful than frequency).

6.Concurrent additional risks are more likely in pregnant drinkers (e.g., smoking, low-income, or poor prenatal care) [31].

7.A stigma exists such that some women may avoid treatment and prenatal care for fear that their children might be taken away or they will be charged with child abuse.

E.Detection {Slide 14}

1.KEY POINT: Alcohol problems are under-detected in women, especially in pregnant women due to under-reporting.

2.The TWEAK is well-validated on pregnant women [33].

F.Treatment: Despite lower rates of alcohol dependence, women are under-represented in treatment settings {Slide 15}.

1.There are more barriers for women than for men to get to treatment [34, 35].

a.External barriers include lack of resources (e.g., childcare, insurance, or economics), threat of having children taken away, and opposition from the family.

b.Internal barriers include fear of the treatment environment and the stigma.

c.There are low rates of accurate identification of alcohol dependence among women in medical settings, so young women are less likely to be referred to treatment.

d.Minority women are extremely underrepresented in treatment settings.

2. 1.5 million women are estimated to need treatment; 75% of people in treatment programs are male [37].

3.KEY POINT: It is very cost effective to combine obstetrics or prenatal care with drug treatment. Offering frequent visits and a multidisciplinary approach greatly improves healthy birth rates [31].

4.BOTTOM LINE: Overall, it is harder for women to get to treatment than men. Fewer women do get treatment, although they may need it more than men.

5.Brief intervention for heavy or problem drinking may be effective [38].

G.Other issues to discuss with a female alcoholic patient:

1.Possible history of violence or abuse victimization

2.Psychiatric problems

3.If the woman lives with children, she may fear having them taken away.

4.Some studies have suggested better treatment retention in women with more problems (e.g., legal involvement, comorbid psychiatric problems, or childhood sexual abuse) [36].

H.Summary {Slide 16}

1.EXAMPLE - detect & treat

a.In assessing the 52-year old woman noted previously, you find that she is only drinking 5 drinks per day, but she has developed tolerance. Her kids have expressed worries, and she sometimes has vodka with her orange juice in the mornings (she meets 3 TWEAK items).

b.It becomes clear that a major barrier to treatment for her is that she doesn't want anyone to know about her drinking and she is afraid how quitting drinking may change her relationship with her husband who is not interested in quitting. You find the greatest success in working with her OB/GYN to reduce her risk of breast and cervical cancers, and by building her social support network.

2.Alcohol dependence is less common in females than in males, but not altogether uncommon.

3.Women have a greater risk of health problems for the same number years of heavy drinking.

4.There is a risk of continued drinking into pregnancy.

5.Alcohol dependence in women is under-detected and under-treated.

6.Treatment can be effective if barriers are removed and it is combined with healthcare services.


A.If you know something about the population and the things you have learned previously about alcohol dependence, you can apply what you know to this framework. {Slide 17}


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