1. 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

2. 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
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3. ARBs are Prevalent in College
~50% ARB before/during college
30% ARB each year
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4. Blackouts are not Benign
Associated with several negative cons; e.g.:
Sexual assault
↑ Risk of injury/emergency department care
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5. Lecture Covers Types/definitions and mechanisms Prevalence
ARB-associated harms
Risk factors
How to address/avoid ARBs
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6. 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

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

8. 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
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9. 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
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10. Memory Formation & Storage
Sensory Mem
Short-Term Mem
Long-Term Mem
Alc interferes here
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11. 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
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12. 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
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13. Lecture Covers Types/definitions and mechanisms Prevalence
ARB-associated harms
Risk factors
How to address/avoid ARBs
AMSP 2018

14. 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
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15. Gender Differences
Males: 35% 1+ ARB over 55 weeks Females: ~50% But no difference in some studies
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16. 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
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17. Lecture Covers Types/definitions and mechanisms Prevalence
ARB-associated harms
Risk factors
How to address/avoid ARBs
AMSP 2018

18. 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

19. 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% ↑
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20. 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:
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21. 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

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

23. 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
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24. 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
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25. 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)
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26. 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
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27. 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
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28. 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
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29. 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
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30. 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
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31. 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
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32. 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
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33. 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
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34. 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
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35. 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”
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36. Lecture Covers Types/definitions and mechanisms Prevalence
ARB-associated harms
Risk factors
How to address/avoid ARBs
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37. 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
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38. 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
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39. 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)
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40. Help Change Attitudes
If drinker thinks everyone has ARB… In fact, only 30% of students do Most think ARBs are unacceptable
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41. Lecture Covered Types/definitions and mechanisms Prevalence
ARB-associated harms
Risk factors
How to address/avoid ARBs
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42. 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