Onset and course of alcoholism over 25 years in middle class men
Introduction
Heavy drinking usually emerges in the late teens, and the alcohol use disorders (AUDs) of abuse or dependence are often apparent by the mid twenties (Johnston et al., 2008, Schuckit et al., 1998). While important variations over time are likely to be seen for a person's drinking patterns and problems, and while many alcoholics have onsets later than the mid twenties (Breslow et al., 2003, Lynskey et al., 2003, Whelan, 1995), at any age an AUD indicates a likelihood of future recurring alcohol problems and an elevated risk for morbidity and early death (Breslow and Graubard, 2008, Schuckit et al., 1998).
One predictable pattern of change over time for both persons with and without AUDs is that the quantities of intake are likely to decrease as individuals enter middle and later life (Bjørk et al., 2008, Breslow and Smothers, 2004, Moos et al., 2004a, Moos et al., 2004b, Moos et al., 2009, Zhang et al., 2008). Thus, it is important to follow groups of drinkers over time. This change can reflect the development of medical problems or the use of medications for which heavier drinking is proscribed, as well as physiological alterations that impact on the effects of alcohol with advancing age. The latter include higher proportions of body fat and associated lower levels of body water, with resulting increased blood alcohol concentrations (BACs) per drink, and enhanced brain reactions to most depressant drugs as people grow older (Kalant, 1998, Lucey et al., 1999). Therefore, with advancing age, even lower daily alcohol intake contributes to increasing risks for falls and hip fractures, cancer, coronary disease and early death (Cumming et al., 1997, Hanson and Li, 2003, Leipzig et al., 1999).
The age-related higher BACs per drink and elevated risks for accidents and medical problems have prompted recommendations that the upper limits of acceptable levels of drinking in older individuals (Grønbæk et al., 1998, Han et al., 2009) should be no more than two to three drinks per day or seven or more standard drinks per week, although some place the upper limit per week at 14 drinks (American Geriatric Society, 2003, Moos et al., 2009). However, half of drinkers age 60 and above exceed the guidelines for “safe” drinking (Kirchner et al., 2007, Merrick et al., 2008), ∼25% of older drinkers consume ≥14 drinks per week (Zhang et al., 2008), and as many as 20% report five or more drinks per occasion five or more times per year (Moos et al., 2009). In the prior year ∼12% of drinking men and women age ≥60 years reported consumption levels that placed them in modest or high risk drinking categories (Sacco et al., 2009), and the prevalence of substance use disorders, including AUDs, in older individuals has been estimated to be between 2% and 5%, with most of these diagnoses missed by clinicians (Lynskey et al., 2003).
Thus, unhealthful drinking and AUDs are important problems in middle-aged and older individuals, and it is clinically useful to understand the predictors and correlates of these conditions. Predictors of AUDs in any group are likely to include a family history (FH) of these disorders (Bennett et al., 1999, Cotton, 1979, Perreira and Sloan, 2001), a vulnerability that reflects a >40% heritability. Relevant genes contribute through intermediate characteristics such as disinhibition or sensation-seeking and a low level of response (LR) to alcohol (McGue, 1999, Schuckit, 2009, Sher, 1991). Regarding LR, the need for higher doses of alcohol to produce desired effects is associated with the subsequent consumption of higher numbers of drinks per occasion, and this phenotype characterizes children of alcoholics, has a >40% heritability, and predicts a higher future risk for AUDs (e.g., Heath et al., 1999, Schuckit and Smith, 2000, Trim et al., 2009, Volavka et al., 1996). Other factors related to a vulnerability toward heavier drinking and alcohol problems include demographic characteristics (e.g., male gender, lower education and a single or divorced marital status), prior smoking and illicit drug use, and previous higher alcohol quantities, frequencies, and alcohol problems (Dawson, 1995; Jacob et al., 2009, Karlamangla et al., 2006, Moos et al., 2004a, Moos et al., 2004b, Perreira and Sloan, 2001, Schutte et al., 2003).
Once an AUD develops, factors similar to those predicting onset, but operating in the opposite direction, might predict remission. The Diagnostic and Statistical Manuals (DSM) of the American Psychiatric Association base the diagnosis of AUDs on repetitive problems, and, therefore, full sustained remission is defined as the absence of any abuse or dependence criteria items for a year or more (APA, 2000). Reflecting data that for most people with alcohol dependence continued remission is likely to require abstinence from drinking, many of those in remission do not drink at all, or if so, consume alcohol rarely and in low amounts (Cox et al., 2004, Maisto et al., 2007, Mann et al., 2005). However, in some studies as many as 30–40% of those who fit DSM remission criteria have consumed at least some alcohol on occasion (Dawson et al., 2005, Vaillant, 2003). Higher probabilities of developing and maintaining remission are seen in the absence of pre-existing disinhibition and related personality disorders, demographic characteristics of higher education and income, evidence of stable relationships (including ongoing marriages and having children in the home), as well as less severe prior patterns of alcohol-related problems and lower levels of alcohol intake (Booth et al., 2004, Dawson et al., 2005, Dawson et al., 2006, Jacob et al., 2009, Moos et al., 2004a, 2005; Schutte et al., 2001, Schutte et al., 2003, Schutte et al., 2006, Weisner et al., 2003). Such longer-term remission from problems associated with AUDs is relatively common, with several studies estimating rates of 40–60%, especially when alcoholics are higher functioning and followed into their 50s and beyond (Grant, 1996, Ojesjo, 1981, Smith et al., 1999, Vaillant, 2003). While only about 25% of alcohol-dependent individuals might ever seek help, professional treatment for alcohol problems, and/or participating in self-help groups such as Alcoholics Anonymous (AA) improves outcome (Humphreys and Moos, 2007, LoCastro et al., 2009, Longabaugh et al., 2005, Moos and Moos, 2005, Moos et al., 2004a).
The variations in alcohol intake and problem patterns throughout the lifespan (Sartor et al., 2003, Schuckit et al., 1997) underscore the need for longitudinal studies that follow populations from early in their drinking careers on to middle age. However, relatively few investigators have used such long-term prospective approaches (Perreira and Sloan, 2001, Schulenberg and Maggs, 2008). While existing studies have added important information to the literature, there is a need for more prospectively gathered detailed data across as many time points and years as possible. Our group recently used Discrete Time Survival Analysis to evaluate a limited number of time invariant (i.e., baseline) predictors of the pattern (or hazard function) of onset of AUDs over 25 years, focusing on that single outcome in a modest sized sample (Trim et al., 2009). The current paper extends the prior results by evaluating 3 types of outcomes using an expanded set of baseline followup variables gathered ∼every 5 years from face-to-face semi-structured interviews. The 3 goals of these analyses were to: (1) identify the characteristics at ∼age 20 that predicted the onset of an AUD; (2) to evaluate baseline variables that predicted earlier versus later onsets of these conditions; and (3) for those men with an AUD onset before age 30, to identify characteristics that predicted remission. Based on a literature review and prior research, we hypothesized that robust predictors of the onset and course of AUDs would include an FH of AUDs, a low LR to alcohol, early life disinhibition (e.g., higher Novelty Seeking), less lifetime stability or achievement (e.g., in education, marital status, etc.), and higher prior intake of alcohol, nicotine, and illicit drugs.
Section snippets
Methods
The data reported here were generated from the San Diego Prospective Study (SDPS), a longitudinal investigation using informed consent procedures as approved by the University of California, San Diego (UCSD) Human Subjects Protections Committee. The subjects, or probands, were originally identified between 1978 and 1988 at baseline (Time 1 or T1) when they were 18- to 25-year-old Caucasian (including White Hispanic) men (Schuckit and Gold, 1988). Subjects with early onset of AUDs (e.g., in the
Results
The 373 subjects included in these analyses were San Diego Prospective Study probands who participated in the ongoing 25-year followup to date and who had complete data for all of the required analyses. They represent an estimated 94% of those who had been scheduled for interview. These men were an average age of 46.5 (3.29) years at their 25-year followup, all were Caucasian (including White Hispanic), and 53.1% had an alcohol-dependent father. Over the 25 years, the rate of AUDs in the FHP
Discussion
This paper describes the predictors of the development of AUDs and aspects of their course over 25 years for 373 men who have been followed through personal interviews about every 5 years since age 20. The SDPS is one of the few prospective evaluations of a non-clinical sample enriched for the alcoholism risk through selection of half of the subjects as FHPs and describing individuals from blue- and white-collar more high functioning families. With a followup rate of >90% across all time
Role of funding source
Funding for this study was provided by NIAAA grant AA005526 and by the State of California for medical research on alcohol and substance abuse through the University of California, San Francisco. The NIAAA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Authors Marc A. Schuckit and Tom L. Smith have materially participated in the research and preparation of the manuscript. Both authors have approved the final manuscript.
Conflict of interest
Marc A. Schuckit and Tom L. Smith have no conflicts of interest.
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