Course of Alcohol Use Disorders: Data from a 35 Year Follow Up Priscila Dib Gonçalves, Ph.D. Marc A. Schuckit, M.D. Tom L. Smith, Ph.D. University of São Paulo; University of California San Diego

This Lecture Covers Background on this study - Definitions - AUD clinical course San Diego Prospective Study results

This Lecture Covers Background on this study - Definitions - AUD clinical course San Diego Prospective Study results

Middle Age Heavy Drinking Prevalent 25%: men drink daily or have 5+ drinks/day ↑ BAC/drink with age ↑ age → ↓ alcohol oxidation Higher body fat vs. muscle as ↑ age: ↑ BAC/drink Most alcohol-related deaths occur ages 45-60

Alcohol Use Disorders (AUDs) Chronic Persistent pattern of problems Onset early to mid 20s Middle age AUD prevalence 10% past year 28% lifetime AUDs ↓ lifespan ~10 years

This Lecture Covers Background on this study - Definitions - AUD clinical course San Diego Prospective Study results

Standard drink = 10-12 grams of ethanol High Risk Drinking Men Women Drinks/week ≥ 14 7 Drinks/occasion ≥ 4 3 Standard drink = 10-12 grams of ethanol 12oz beer 8oz malt 5oz wine 1.5oz liquor National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2010)

DSM-IV AUD Criteria Remission: abstinence of all symptoms Dependence (3+ criteria) Abuse (1+ criterion) - Tolerance - Unable to stop/cut down - Taken ↑ amounts/periods - Given up activities - A lot of time spent - Use despite health probl. - Withdrawal - Failure major roles - Hazardous use - Legal problems - Use despite social probl. Remission: abstinence of all symptoms

Level of Response (LR) Instrument LR rationale - Youth drinks for effects - If need more for effect→ will drink more Instrument Self-Report of the Effects of Alcohol - Number of drinks required up to 4 effects - ↑ Scores → more drinks for effects = ↓ LR Low LR: predicts heavy drinking and AUDs

This Lecture Covers Background on this study - Definitions - AUD clinical course San Diego Prospective Study results

AUD Course Onset early to mid 20’s Fluctuates - Heavy drinking - Remission Remission types - Non-abstinence (2 types) - Abstinence

Remission Types and Predictors Drinking Abstain Lo risk Hi risk Predictors Drinking intensity Low ? High Drinking frequency Low ? High Alcohol problems Low ? High AUD onset Late ? Early Dependence No ? Yes Treatment/ AA No ? Yes

This Lecture Covers Background on this study - Definitions - AUD clinical course San Diego Prospective Study results

Longitudinal Studies Important to: But few studies are - Evaluate AUD course - Observe remission predictors But few studies are - > 10 years - Begin early and continue to age 50+ - Distinguish between drinking outcome types

San Diego Prospective Study University of California, San Diego (UCSD) 453 participants at study entry 1978-1988 - 18-25 year-old white males - Students/non-academic staff UCSD - No baseline alcohol dependence - 50% had a parent with AUD

Assessments Baseline: Age 20 Interview and alcohol challenge Followed at 10 years; then every 5 years Alcohol, drug, psychiatric problems Additional measures at some follow ups Self-Report of the Effects of Alcohol (SRE) Personality “Significant other” report

Probands at Age 50 156 of AUDs followed at age 55 (94.5%) Original sample: 453 men 11 died 442 followed 397 in all follow ups through age 50 (90%) 165 developed AUD by age 50 156 of AUDs followed at age 55 (94.5%)

Hypotheses 1. Most will have low risk/abstinence at 55 2. Remission outcome characteristics Lo risk Hi risk Abstain AUD onset Late Early Early LR High Low Low Prior drinking Low High High Alcohol problems Low High High Other drug use Low High High LR= level of response

Age 50-55 Outcomes Group (%) Abstinent Risky Drinking 1+ DSM Low (14) No No No High (20) No Yes No AUD (56) No N/A Yes Abstain (10) Yes N/A N/A

Groups = at Baseline (Age 20) Demography 23 years old 14% were married 80% had a religion Drinking patterns 3 drinks/usual 10 days/month + Family History AUD 65%

Groups From 50 to 55 = Demography 17 years of education 92% ever married 34% ever divorced 60% high job status ≠ Drinking patterns Low risk High risk AUD - Frequency 12 17 21 - Usual quantity 1.7 2.4 3.4 - Max quantity 3.2 6.8 9.0

Overall Substance Use 30-50 Drinking patterns 3 drinks/usual 15 drinks/max AUD onset 29 years old Drug use 63% tobacco 85% cannabis 50% stimulants

Groups Differed Ages 30-50 Lo risk Hi risk AUD Abstain Level of response 3.8 4.3 4.7 5.8 Usual frequency 12 16 19 18 Dependence, % 48 53 63 93 Treatment/AA, % 5 15 18 67 CUD, % 10 16 28 53 CUD = cannabis use disorders

Group Membership Predictors Analyses: logistic regression Results showed in odds ratios Lo risk Hi risk Abstain Drinks for effect 0.48 2.03 Usual frequency 0.34 Treatment 8.66 CUD 4.68 CUD = cannabis use disorders

Take Home Message AUDs: persistent in white collar men (56%) Remission types and predictors - Low risk drinking: ↑ LR, ↓ alcohol frequency - High risk drinking: similar to active AUD - Abstinence: ↓ LR, ↑ treatment, ↑ CUD Physicians: screen for alcohol use & problems - 50’s & 60’s - All socioeconomic status