Onset and course of alcoholism over 25 years in middle class men

https://doi.org/10.1016/j.drugalcdep.2010.06.017Get rights and content

Abstract

Background: Patterns of drinking and alcohol problems change with age. However, few studies use multiple data points and detailed history spanning early adulthood to middle age. This study reports such data from 373 men in the San Diego Prospective Study. Methods: Data were generated at baseline (T1) at ∼age 20, and through face-to-face followup interviews ∼every 5 years in >90% of these eligible Caucasian and relatively higher educated men. Subjects were placed into 4 groups regarding their course: 62.5% with no alcohol use disorder (AUD); 17.2% with AUD onset <age 30 and a chronic course; 6.7% with onset ≥age 30 and no recovery; and 13.7% with AUD onset <age 30 and maintained remission for >5 years before the 25-year followup. Results: On a univariate level, low level of response (LR) to alcohol, family history of AUDs, and higher Novelty Seeking at ∼age 20 predicted AUDs with onset before age 30 (mean age  25), but among these only LR predicted later onset (mean age 38) as well. Additional predictors of AUDs included demography (lower education), and greater involvement with alcohol, drugs, and nicotine prior to T1. Sustained remission from AUDs among alcoholics was predicted by lower T1 and T10 drinking frequencies, and being separated or divorced at T10, along with a trend for higher Reward Dependence. Conclusion: These data indicate that information available in ages of the late teens to early twenties can help predict the future onset and course of AUDs, and underscore the importance of longitudinal studies in substance use disorders.

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.

References (77)

  • C. Bjørk et al.

    Time trends in heavy drinking among middle-aged and older adults in Denmark

    Alcohol Clin. Exp. Res.

    (2008)
  • B.M. Booth et al.

    Predictors of short-term course of drinking in untreated rural and urban at-risk drinkers: effects of gender, illegal drug use, and psychiatric comorbidity

    J. Stud. Alcohol

    (2004)
  • G. Borges et al.

    The dimensionality of alcohol use disorders and alcohol consumption in a cross-national perspective

    Addiction

    (2010)
  • R.A. Breslow et al.

    Alcohol consumption by elderly Americans

    J. Stud. Alcohol

    (2003)
  • R.A. Breslow et al.

    Prospective study of alcohol consumption in the United States: quantity, frequency, and cause-specific mortality

    Alcohol Clin. Exp. Res.

    (2008)
  • R.A. Breslow et al.

    Drinking patterns of older Americans: National Health Interview Surveys, 1997–2001

    J. Stud. Alcohol

    (2004)
  • K.K. Bucholz et al.

    A new, semi-structured psychiatric interview for use in genetic linkage studies: a report on the reliability of the SSAGA

    J. Stud. Alcohol

    (1994)
  • C.R. Cloninger

    A systematic method for clinical description and classification of personality variants: a proposal

    Arch. Gen. Psychiatry

    (1987)
  • N.S. Cotton

    The familial incidence of alcoholism: a review

    J. Stud. Alcohol

    (1979)
  • W.M. Cox et al.

    United Kingdom and United States healthcare providers recommendations of abstinence versus controlled drinking

    Alcohol Alcohol.

    (2004)
  • R.G. Cumming et al.

    Epidemiology of hop fractures

    Epidemiol. Rev.

    (1997)
  • D.A. Dawson et al.

    Variation in the association of alcohol consumption with five DSM-IV alcohol problem domains

    Alcohol Clin. Exp. Res.

    (1995)
  • D.A. Dawson et al.

    Maturing out of alcohol dependence: the impact of transitional life events

    J. Stud. Alcohol

    (2006)
  • D.A. Dawson et al.

    Recovery from DSM-IV alcohol dependence: United States, 2001–2002

    Addiction

    (2005)
  • B.F. Grant

    Toward an alcohol treatment model: a comparison of treated and untreated respondents with DSM-IV alcohol use disorders in the general population

    Alcohol Clin. Exp. Res.

    (1996)
  • M. Grønbæk et al.

    Alcohol and mortality: is there a U-shaped relation in elderly people?

    Age Ageing

    (1998)
  • P.J. Gruenewald et al.

    A dose–response perspective on college drinking and related problems

    Addiction

    (2009)
  • B. Han et al.

    Substance user disorder among older adults in the United States in 2020

    Addiction

    (2009)
  • G.R. Hanson et al.

    Public health implications of excessive alcohol consumption

    JAMA

    (2003)
  • A.C. Heath et al.

    Genetic differences in alcohol sensitivity and the inheritance of alcoholism risk

    Psychol. Med.

    (1999)
  • M. Hesselbrock et al.

    A validity study of the SSAGA—a comparison with the SCAN

    Addiction

    (1999)
  • K. Humphreys et al.

    Encouraging post-treatment self-help group involvement to reduce demand for continuing care services: two-year clinical and utilization outcomes

    Alcohol Clin. Exp. Res.

    (2007)
  • T. Jacob et al.

    Drinking trajectories from adolescence to the fifties among alcohol-dependent men

    J. Stud. Alcohol Drugs

    (2009)
  • L.D. Johnston et al.

    Secondary School Students

    (2008)
  • H. Kalant

    Pharmacological interactions of aging and alcohol

  • A. Karlamangla et al.

    Longitudinal trajectories of heavy drinking in adults in the United States of America

    Addiction

    (2006)
  • J. Kirchner et al.

    Alcohol consumption among older adults in primary care

    J. Gen. Intern. Med.

    (2007)
  • R.M. Leipzig et al.

    Drugs and falls in older people: a systematic review and meta-analysis. I. Psychotropic drugs

    J. Am. Geriatr. Soc.

    (1999)
  • Cited by (58)

    • Desformylflustrabromine (dFBr), a positive allosteric modulator of the α<inf>4</inf>β<inf>2</inf> nicotinic receptor modulates the hypnotic response to ethanol

      2021, Alcohol
      Citation Excerpt :

      We employed the LORR assay to study the behavioral response to a sedative-hypnotic dose of ethanol. Studying the acute behavioral response to ethanol is important because studies show that the initial level of response to acute alcohol exposure early in life is predictive of future drinking behavior and alcohol abuse liability (Crabbe, Bell, & Ehlers, 2010; Schuckit & Smith, 2011). Additionally, acute ethanol intoxication is also a leading cause of driving fatalities (National Highway Traffic Safety Administration, 2017).

    • The personality profile of chronic alcohol dependent patients with comorbid gambling disorder symptoms

      2020, Comprehensive Psychiatry
      Citation Excerpt :

      He discriminated three temperament dimensions with neurobiological underpinnings: NS, HA and RD, namely behavioural activation, inhibition and maintenance, which proved to be predictive in the development of AUD [14,15]. Compared to data from general population, several studies established differences in temperament and character: reporting that AUD patients showed higher NS with reduced scores on SD and CO compared to matched control groups [16–18]. In case of GD, literature is scarce, and findings are inconclusive concerning the personality traits described in Cloninger's model.

    • Diagnosis and Treatment Planning in Dentistry

      2017, Diagnosis and Treatment Planning in Dentistry
    View all citing articles on Scopus
    View full text