Deconstructing the age-prevalence curve of alcohol dependence: why "maturing out" is only a small piece of the puzzle

Towards the characterization and validation of alcohol use disorder subtypes: integrating consumption and symptom data

BACKGROUND

There is evidence that measures of alcohol consumption, dependence and abuse are valid indicators of qualitatively different subtypes of alcohol involvement yet also fall along a continuum. The present study attempts to resolve the extent to which variations in alcohol involvement reflect a difference in kind versus a difference in degree.

METHOD

Data were taken from the 2001-2002 National Epidemiologic Survey of Alcohol and Related Conditions. The sample (51% male; 72% white/non-Hispanic) included respondents reporting past 12-month drinking at both waves (wave 1: n = 33644; wave 2: n = 25186). We compared factor mixture models (FMMs), a hybrid of common factor analysis (FA) and latent class analysis (LCA), against FA and LCA models using past 12-month alcohol use disorder (AUD) criteria and five indicators of alcohol consumption reflecting frequency and heaviness of drinking.

RESULTS

Model comparison revealed that the best-fitting model at wave 1 was a one-factor four-class FMM, with classes primarily varying across dependence and consumption indices. The model was replicated using wave 2 data, and validated against AUD and dependence diagnoses. Class stability from waves 1 to 2 was moderate, with greatest agreement for the infrequent drinking class. Within-class associations in the underlying latent factor also revealed modest agreement over time.

CONCLUSIONS

There is evidence that alcohol involvement can be considered both categorical and continuous, with responses reduced to four patterns that quantitatively vary along a single dimension. Nosologists may consider hybrid approaches involving groups that vary in pattern of consumption and dependence symptomatology as well as variation of severity within group.

The impact of lifetime drug use on hepatitis C treatment outcomes in insured members of an integrated health care plan

BACKGROUND

The relation of drug use to HCV treatment outcome in an insured household population has not been previously reported.

METHODS

Lifetime frequencies of marijuana use and non-medical use of stimulants, sedatives, and opioids; hallucinogens; and inhalants were retrospectively assessed in 259 privately insured members of an integrated health care plan treated for chronic hepatitis C virus infection (HCV+) with pegylated interferon alpha and ribavirin and examined with respect to rates of sustained virological response (SVR).

RESULTS

The majority of patients reported chronic use of multiple illegal drugs; 61.6% reported injection drug use (IDU); 79.5% abstained from drug use during the six months prior to HCV treatment. Total frequency of individual drugs, multiple drugs, and length of abstention from drugs prior to HCV treatment were not related to impaired SVR rates. Sustained viral responses were obtained in 80.2% of patients with HCV genotype 2/3 and 45.1% of patients with genotype 1/4/6. Marijuana use during HCV treatment, reported by 8.5% of patients, was associated with higher treatment adherence (95.5% compared with 78.9%, p=0.045), but lower SVR rates (40.9% compared with 62.5%, p=0.041). In addition, drug use during HCV treatment was associated with significantly higher relapse rates, 18.8% compared with 7.7% (p=0.053).

CONCLUSION

A history of chronic illegal drug use should not be considered a deterrent to HCV treatment in members of an integrated health care plan who are motivated to seek treatment and closely monitored, but drug use during HCV treatment, including marijuana use, should be discouraged.

Predicting persistency of DSM-5 alcohol use disorder and examining drinking patterns of recently remitted individuals: a prospective general population study

AIMS

To establish the 3-year persistency rate of alcohol use disorder (AUD) and its predictors, and to examine drinking patterns of recently remitted individuals.

DESIGN AND SETTING

The Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2) surveyed a nationally representative sample of adults (aged 18-64 years) at baseline (response = 65.1%) and 3-year follow-up (response = 80.4%).

PARTICIPANTS

People with AUD at baseline, as defined by DSM-5 (n = 198).

MEASUREMENTS

AUD, drinking patterns and mental disorders were assessed using the Composite International Diagnostic Interview 3.0. Other predictors were assessed with an additional questionnaire. Predictors of persistency were examined with univariable and multivariable logistic regression analyses.

RESULTS

The AUD persistency rate was 29.5% [95% confidence intervals (CI) = 20.0-39.0]. In the multivariable model, the older (25-34 and 35-44) age groups had lower AUD persistency [odds ratio (OR) = 0.05; 95% CI = 0.00-0.49 and OR = 0.14; 95% CI = 0.02-0.79, respectively] than the youngest age group (18-24). A higher number of weekly drinks and a comorbid anxiety disorder predicted AUD persistency (OR = 1.03; 95% CI = 1.00-1.07 and OR = 4.56; 95% CI = 1.04-20.06, respectively). Furthermore, remission was associated with a reduction of six drinks per week between T0 and T1 . It should be noted, however, that 35.8% (95% CI = 22.4-49.2) of people in diagnostic remission still drank more than the recommended maximum (more than seven/14 drinks weekly for women/men).

CONCLUSIONS

Only a minority of people in the Netherlands with alcohol use disorder as defined by DSM-5 still have the disorder 3 years later. Factors that help to identify people at risk of alcohol use disorder persistence are: younger age, a higher number of weekly drinks and a comorbid anxiety disorder. A substantial number of people recently in diagnostic remission still drink above the maximum recommended level.

The developmental psychopathology of alcohol use and alcohol disorders: research achievements and future directions

The last 25 years have seen significant advances in our conceptualization of alcohol use and alcohol use disorders within a developmental framework, along with advances in our empirical understanding that have been potentiated by advances in quantitative methods. These include advances in understanding the heterogeneity of trajectories of alcohol outcomes; new insights about early childhood antecedents, and adolescence and emerging adulthood as important developmental periods for alcohol outcomes; a more nuanced understanding of the influences of developmental transitions, and their timing and contexts; a greater appreciation for the importance of considering multiple levels of analysis (including an increasing number of genetically informative studies); a continuing focus on studying multiple pathways underlying alcohol outcomes; and an increasing focus on studying the effects of alcohol exposure on future development. The current paper reviews these advances and suggests directions for future study.

The developmental psychopathology of alcohol use and alcohol disorders: research achievements and future directions

The last 25 years have seen significant advances in our conceptualization of alcohol use and alcohol use disorders within a developmental framework, along with advances in our empirical understanding that have been potentiated by advances in quantitative methods. These include advances in understanding the heterogeneity of trajectories of alcohol outcomes; new insights about early childhood antecedents, and adolescence and emerging adulthood as important developmental periods for alcohol outcomes; a more nuanced understanding of the influences of developmental transitions, and their timing and contexts; a greater appreciation for the importance of considering multiple levels of analysis (including an increasing number of genetically informative studies); a continuing focus on studying multiple pathways underlying alcohol outcomes; and an increasing focus on studying the effects of alcohol exposure on future development. The current paper reviews these advances and suggests directions for future study.

Substance use disorders and psychiatric comorbidity in mid and later life: a review

BACKGROUND

Globally, adults aged 65 years or older will increase from 516 million in 2009 to an estimated 1.53 billion in 2050. Due to substance use at earlier ages that may continue into later life, and ageing-related changes in medical conditions, older substance users are at risk for substance-related consequences.

METHODS

MEDLINE and PsychInfo databases were searched using keywords: alcohol use disorder, drug use disorder, drug misuse, substance use disorder, prescription drug abuse, and substance abuse. Using the related-articles link, additional articles were screened for inclusion. This review focused on original studies published between 2005 and 2013 to reflect recent trends in substance use disorders. Studies on psychiatric comorbidity were also reviewed to inform treatment needs for older adults with a substance use disorder.

RESULTS

Among community non-institutionalized adults aged 50+ years, about 60% used alcohol, 3% used illicit drugs and 1-2% used nonmedical prescription drugs in the past year. Among adults aged 50+, about 5% of men and 1.4% of women had a past-year alcohol use disorder. Among alcohol users, about one in 14 users aged 50-64 had a past-year alcohol use disorder vs one in 30 elder users aged 65+. Among drug users aged 50+, approximately 10-12% had a drug use disorder. Similar to depressive and anxiety disorders, substance use disorders were among the common psychiatric disorders among older adults. Older drug users in methadone maintenance treatment exhibited multiple psychiatric or medical conditions. There have been increases in treatment admissions for illicit and prescription drug problems in the United States.

CONCLUSIONS

Substance use in late life requires surveillance and research, including tracking substance use in the racial/ethnic populations and developing effective care models to address comorbid medical and mental health problems.

Refining the notion of maturing out: results from the national epidemiologic survey on alcohol and related conditions

OBJECTIVES

Our aim was to determine if the decrease in drug use disorders with age is attributable to changes in persistence, as implied by the notion of maturing out. Also, we examined the association between role transitions and persistence, recurrence, and new onset of drug use disorders.

METHODS

We performed secondary analysis of the 2 waves of the National Epidemiologic Survey on Alcohol and Related Conditions data (baseline assessment 2001-2002, follow-up conducted 2004-2005). We conducted logistic regressions and multinomial logistic regression to determine the effect of age on wave 2 diagnosis status, as well as the interaction between age and role transitions.

RESULTS

Rates of persistence were stable over the life span, whereas rates of new onset and recurrence decreased with age. Changes in parenthood, marital, and employment status were associated with persistence, new onset, and recurrence. We found an interaction between marital status and age.

CONCLUSIONS

Our findings challenge commonly held notions that the age-related decrease in drug use disorders is attributable to an increase in persistence, and that the effects of role transitions are stronger during young, compared with middle and older, adulthood.

Age and the explanation of crime, revisited

Age is one of the most robust correlates of criminal behavior. Yet, explanations for this relationship are varied and conflicting. Developmental theories point to a multitude of sociological, psychological, and biological changes that occur during adolescence and adulthood. One prominent criminological perspective outlined by Gottfredson and Hirschi claims that age has a direct effect on crime, inexplicable from sociological and psychological variables. Despite the attention this claim has received, few direct empirical tests of it have been conducted. We use data from Pathways to Desistance, a longitudinal study of over 1,300 serious youthful offenders (85.8% male, 40.1% African-American, 34.3% Hispanic, 21.0% White), to test this claim. On average, youths were 16.5 years old at the initial interview and were followed for 7 years. We use multilevel longitudinal models to assess the extent to which the direct effects of age are reduced to statistical and substantive non-significance when constructs from a wide range of developmental and criminological theories are controlled. Unlike previous studies, we are able to control for changes across numerous realms emphasized within differing theoretical perspectives including social control (e.g., employment and marriage), procedural justice (e.g., perceptions of the legitimacy and fairness of the legal system), learning (e.g., gang membership and exposure to antisocial peers), strain (e.g., victimization and relationship breakup), psychosocial maturity (e.g., impulse control, self-regulation and moral disengagement), and rational choice (e.g., costs and rewards of crime). Assessed separately, these perspectives explain anywhere from 3% (procedural justice) to 49% (social learning) of the age-crime relationship. Together, changes in these constructs explain 69% of the drop in crime from ages 15 to 25. We conclude that the relationship between age and crime in adolescence and early adulthood is largely explainable, though not entirely, attributable to multiple co-occurring developmental changes.

Early subjective response and acquired tolerance as predictors of alcohol use and related problems in a clinical sample

BACKGROUND

Previous studies have demonstrated that a low subjective response (SR) to alcohol is a risk factor for alcohol use disorders (AUDs), and a recent study suggests that acquired tolerance can be differentiated from initial SR and is also significantly associated with drinking problems. Because the prior study of SR and tolerance focused on a sample of moderate drinkers, the goal of the current study was to examine relations between early SR, acquired tolerance, alcohol use, and alcohol-related problems in a sample of young adults with clinically significant alcohol problems.

METHODS

The current study examined associations between early SR and acquired tolerance and both drinking behavior and alcohol-related problems within a sample of 113 heavy drinking young adults (66.1% male) volunteering for a clinical trial of naltrexone in combination with brief motivational counseling.

RESULTS

Consistent with the 1 prior study examining simultaneous effects of early SR and tolerance, both early SR and acquired tolerance were positively associated with typical drinking behavior, although tolerance was a much stronger predictor within this clinical sample. In contrast to the prior study, early SR was inversely associated with risk for alcohol-related problems, and tolerance was not a significant predictor of problems.

CONCLUSIONS

The results suggested that, controlling for weekly drinking, a low early SR protected against acute negative consequences within a sample of heavy drinkers who had acquired significant tolerance to alcohol effects. It is possible that this protective effect may eventually shift to a risk factor by allowing individuals with a low SR to persist in a pattern of hazardous drinking.

Personality pathology and alcohol dependence at midlife in a community sample

The present study examined the association between personality pathology (PP) and alcohol dependence (AD; both lifetime and in the past 12 months) among middle-aged to older adults incorporating three sources of assessment, specifically, diagnostic interviews as well as self- and informant reports. We collected data from a representative sample of community participants (N = 1,630; ages 54-65 years) and their informants (N = 1,462). Measures employed were the substance use disorder sections of the Mini-International Neuropsychiatric Interview Schedule for Mental Disorders, the Structured Interview for DSM-IV Personality (American Psychiatric Association, 2000, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev.; DSM-IV-TR SIDP) and the NEO-Personality Inventory-Revised (Costa, P. T., & McCrae, R. R., Revised NEO-Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) manual, 1992, Odessa, FL, Psychological Assessment Resources; self-report and informant versions). To complement the diagnostic interview for personality disorders (PDs), we utilized a PD-count technique derived from the five-factor model (FFM), which provided an index of PP liability. Factors representing lifetime and past-12 month AD were regressed on each of the 10 PP factors constructed from the SIDP interview, as well as self-report and informant FFM-count scores. Lifetime diagnosis of AD was positively associated with higher scores on several PP measures, including paranoid, schizotypal, antisocial, borderline, histrionic, and narcissistic PP. There was an inverse relation between lifetime AD and the factor score for obsessive-compulsive PP. With regard to AD in the past 12 months, antisocial, borderline, histrionic, and narcissistic PP factors were significantly associated with increased risk for AD, whereas the obsessive-compulsive and schizoid PP factors were associated with decreased risk for AD. The present data indicate that features of antisocial and borderline PP continue to exhibit a relatively strong association with risk for AD in later middle age.