Alcohol-Related Blackouts in College Students Jennifer E. Merrill, Ph.D. Department of Behavioral and Social Sciences Center for Alcohol & Addiction Studies Brown University AMSP 2018

Defining Alcohol-Related Blackout (ARB) Memory loss for all or part of drinking episode Can actively engage in behaviors (e.g., walking) But brain unable to create/retain memories AMSP 2018

ARBs are Prevalent in College ~50% ARB before/during college 30% ARB each year AMSP 2018

Blackouts are not Benign Associated with several negative cons; e.g.: Sexual assault ↑ Risk of injury/emergency department care AMSP 2018

Lecture Covers Types/definitions and mechanisms Prevalence ARB-associated harms Risk factors How to address/avoid ARBs AMSP 2018

Case Example: Jordyn (J) Female, age 19, college sophomore Normal upbringing, light drinker in high school 1st ARB freshmen orientation week Now experiences ARBs ~ once/mo What are causes and consequences of J’s ARBs? AMSP 2018

Lecture Covers Types/definitions and mechanisms Prevalence ARB-associated harms Risk factors How to address/avoid ARBs AMSP 2018

ARBs: Two Types En bloc Fragmentary (“brownout”, “grayout”) Can’t recall large portions of drinking episode Distinct onset Memory not formed; no memory to recall Fragmentary (“brownout”, “grayout”) Partial memory for drinking episode Ability to retrieve partial memory with cues AMSP 2018

Defining ARBs ≠ Passing out Occurrence requires self-report NOT just unwanted sleep, inability to engage Occurrence requires self-report Difficult to detect by outside observer AMSP 2018

Memory Formation & Storage Sensory Mem Short-Term Mem Long-Term Mem Alc interferes here AMSP 2018

How ARBs Work (Theoretically) Alc interferes w/ info transfer from ST to LT storage If modest intoxication can still: Keep new info in ST storage if not distracted Retrieve info placed in LT prior to intoxication ARB=alc impairs storage across longer delays AMSP 2018

Memory Impairment: Dose-related Mild impairment at ↓ doses Greater impairment at ↑ doses But same deficit (no transfer ST  LT) J has en bloc ARB on heaviest drinking nights AMSP 2018

Lecture Covers Types/definitions and mechanisms Prevalence ARB-associated harms Risk factors How to address/avoid ARBs AMSP 2018

Prevalence of ARBs ~ 20% of young adult drinkers ever ARB College students have even ↑ rates ~ 30% ARB each year Among drinkers, 40% past-year ARBs in 4 year college drinkers 2x rate in: 2 year college drinkers Non-college drinking peers AMSP 2018

Gender Differences Males: 35% 1+ ARB over 55 weeks Females: ~50% But no difference in some studies AMSP 2018

ARBs are Recurrent for Some Over 55 weeks 9% have 2 ARB 3% each with 4, 5, or 6 ARB Once every 5 drinking weeks freshmen year AMSP 2018

Lecture Covers Types/definitions and mechanisms Prevalence ARB-associated harms Risk factors How to address/avoid ARBs AMSP 2018

Harms Associated with ARBs ~ 50% with ARB hx have other problems w/ ARB ~30% Insult someone ~30% Spend money unintentionally Compared to drinkers w/out ARB, if 6+ ARB past yr: 70% ↑ Rx in ED next 2 yrs ~3x ↑ Alc-related injury J: Freshman year broke leg while intoxicated More likely OVER 2 years AMSP 2018

Risky Sexual Behavior Compared to men w/out recent ARB, risk for: Men w/ ARB Women w/ ARB 5x ↑ 5x ↑ ~4x ↑ unsafe sex unplanned sex regretted sex ~50% ↑ AMSP 2018

More Harms Associated w/ ARBs Hangovers (8x more likely) Arguing with friends (8x) Doing something regretted (10x) Academic problems Missing class (12x) Getting behind in school work (17x) Doc visit for overdose (can’t arouse) (144x) J (past 6 mo. ARBs) more likely to also report: AMSP 2018

Longer-term Outcomes If frequent ARB 4th year of college, 1 year later: Continued ARBs ↑ Emotional/social alc consequences, e.g.: Regret, anger, worry Felt rejected or hurt reputation ↑ Quantity of alc consumed If J ARB senior yr, expect cont’d problems Continued probs after graduation AMSP 2018

Lecture Covers Types/definitions and mechanisms Prevalence ARB-associated harms Risk factors How to address/avoid ARBs AMSP 2018

Blood Alcohol Concentrations (BAC) ↑ BACARB What determines BAC? Standard (STD) drink = 10 gm ethanol: 12 oz beer, 4 oz wine, 1 oz liquor 1 STD drink → BAC ~ .02 gm/100 ml Person metabolizes ~ 1 STD drink/hour AMSP 2018

High BACARB En bloc: 50% prob at BAC 0.31 gm/100 ml blood 18 STD in 2 hrs  ~ 0.32 Fragmentary: 50% prob at BAC of 0.22 13 STD in 2 hrs  ~ 0.22 But ↑ BACs also a function of: ↓ weight Female gender (↓ alc metabolism) for J (100 lb female), fewer STD may ARB AMSP 2018

Rapid Rate of ↑ in BAC  ARB Rapid rate of ↑ in BAC due to: Gulping Drinking on empty stomach Shots Drinking before social event (i.e., pregaming) Drinking games (e.g., drink for wrong answer) AMSP 2018

Other Drugs + Alc  ARB Depressants, benzos (e.g., diazepam [Valium])  Severe memory impairment at ↑ doses Effects enhanced by alc THC (primary psychoactive compound in marijuana) W/ alc  greater impairment ↓ Awareness of intoxication Stimulants (e.g., coke) ↓ Alc sedation  ↑ drinks J: ↑ ARBs when also uses THC, drinks vodka + w/caffeinated mixer AMSP 2018

Genetic Characteristics ↑ Risk Family hx of alc problems (FH+) ~1/4 more likely Maternal FH+ ↑ risk as much as 2x ~1/2 of variation in ARBs due to genetic variation J’s mom treated for alc AMSP 2018

Low Level of Response to Alc ↑ Risk Low sensitivity per drink of alc Need ↑ alc than most to get desired effect Tend to drink more and more often J describes no “buzz” after first 2-3 drinks AMSP 2018

Other Biological Correlates of ARB After drinking, ARB hx+ ↓ brain activity Race/ethnicity Highest in European American students (like J) Lowest in Asian Intermediate in Hispanic Brain activity on memory task AMSP 2018

Psychological and Social Correlates Sensation seeking Seek stimulating experiences to ↑ arousal Impulsivity Careless, no planning, disregard for cons Earlier age of first drink Generally mirror risk factors for heavy drinking AMSP 2018

Psychological and Social Correlates Perceive peers favor substance use ↑ Estimated % of peers using alc, drugs, tobacco ↑ Perceived peer alc use ↑ Perceived peer approval of alc AMSP 2018

Psychological and Social Correlates Alcohol outcome expectancies (AOEs) = Anticipated outcomes of alcohol use related to: Thoughts, behaviors, moods Negative AOEs (e.g., I would have trouble thinking) Positive AOEs (e.g., I would be friendly) Stronger positive AOEs associated w/ ARBs AMSP 2018

Psychological and Social Correlates Certain reasons for drinking ARBs Drinking to ↑ + mood associated w/: Concurrent ARBs ARBs 1 year later ↑ ARBs over 2 years Drinking to get drunk 7x more likely ARB AMSP 2018

Summary of Correlates Family hx ↑ peer use Low level response European American Sensation seeking Impulsivity Earlier age 1st drink ↑ peer use ↑ peer approval Strong positive AOEs Drinking motives ↑ + mood Get drunk AMSP 2018

What Contributes to Jordyn’s ARBs? Acts without considering cons (impulsive) First drink age 14 Friends drink heavily and approve of ARBs Expects alc makes her feel good Drinks to “get high” AMSP 2018

Lecture Covers Types/definitions and mechanisms Prevalence ARB-associated harms Risk factors How to address/avoid ARBs AMSP 2018

Screen All Patients (Including Teens) Many MDs don’t ask or counsel re: alc harms Ask (for past year): “Forgotten part of evening while drinking?” If yes follow-up questions about ARB frequency Repeated ARBs? (worse outcomes) If yes Refer for further evaluation Treatment worth considering for J AMSP 2018

Teach Anyone with ARBs to ↓ Risk: Avoid liquors (e.g., vodka), especially shots Instead use ↓ % alc (e.g., beer) Space out drinks over time Eat before/during drinking Avoid drinking prior to main social event AMSP 2018

Address Subjective Perceptions of ARBs To what extent perceive ARB negatively? If not bothersome, ↑ perceived risk w/ education: ARB = BACs consistent w/ severe brain impairment This level dysfunction  many neg outcomes Students may not find ARB bothersome. (talk about in context of Jordyn) AMSP 2018

Help Change Attitudes If drinker thinks everyone has ARB… In fact, only 30% of students do Most think ARBs are unacceptable AMSP 2018

Lecture Covered Types/definitions and mechanisms Prevalence ARB-associated harms Risk factors How to address/avoid ARBs AMSP 2018

Takeaway Points: ARBs…. Common among college student drinkers Associated w/ neg outcomes (acute, LT) Risk ↑ with specific styles of drinking, risk factors Avoidable, should be addressed by health providers AMSP 2018