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Transcript of N ational I nstitute on A lcohol A buse and A lcoholism Preventing Underage Alcohol Use: A...
Nat
ion
al In
stit
ute
on
Alc
oh
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bu
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mN
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l Ab
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Preventing Underage Alcohol Use: A Four-State Meeting
October 2, 2006
Patricia A. Powell, Ph.D., Health Scientist Administrator
Office of Science Policy and CommunicationNational Institute on Alcohol Abuse and Alcoholism
Adolescent Development and Alcohol Use
Nat
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Alcohol: Our Most Primitive Intoxicant
• Egypt (el-Guebaly N, el-Guebaly A (1981). Int J Addict.16:1207-21)– barley beer is probably the oldest drink in the world
with its origin in Egypt prior to 4200 BC
• China (McGovern et al., (2004). Proc Natl Acad Sci USA 101:17593-17598)– 7000 BC - the production of a prehistoric mixed
fermented beverage of rice, honey and fruit (Neolithic village of Jiahu in Henan province)
– 2000 BC- unique cereal beverages (Shang and Western Zhou Dynasties)
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6,139,957546,540354,548
Apparent U.S. Alcohol Consumption, 2000
(in 1000’s of gallons)
Beer
Wine
Spirits
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Alcohol
Alcohol Across the Lifespan
Nat
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lism Moderate Drinking
One Drink = 12 ounces of beer 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits
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Concentration of U.S. Alcohol Consumption
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70
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2.5 5 10 20 30 40 50 60 70 80 90 100
Percentile of Drinkers
Pe
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of
To
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60+
50-59
40-49
30-39
18-29
Highest Volume Lowest Volume
Greenfield TK & Rogers JD. J Stud Alcohol 60:78 (1999)
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Alcohol-related health, personal, and social problems
arise from drinking
too much, too fast, too often
The most harmful pattern is binge drinking: 5 drinks for men, 4 for women, in 2 hours
Nat
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Actual Causes of Death1, United States - 2000
Mokdad AH, Marks JS, Stroup DF, Gerberding JL. JAMA (2004). 29:1238-45; Mokdad AH, Marks JS, Stroup DF, Gerberding JL. (2005). JAMA 19;293:293-4.
0.7%
0.8%
1.2%
1.8%
2.3%
3.1%
3.5%
15.2%
18.1%Tobacco
Alcohol Consumption
Microbial agents
Toxic agents
Motor vehicle
Sexual behavior
Firearms
Illicit drug use
Actual Causes of Death are the major external
(nongenetic) modifiable factors that contribute to
death in the United States
Poor diet and physical inactivity
An estimated 85,000 deaths
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Alcohol is a Leading Risk Factor for Disease In Developed Countries
0% 2% 4% 6% 8% 10% 12% 14%
Iron deficiency
Unsafe sex
Illicit drugs
Physical inactivity
Low fruit and vegetable intake
Overweight
Cholesterol
Alcohol
Blood pressure
Tobacco
% Total Number of Health Years Lost to Death/Disability
Alcohol
The World Health Report 2002: http://www.who.int/whr/2002/en/whr2002_annex14_16.pdf
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U.S. Adult Drinking Patterns and Alcohol Use Disorders (AUD)*
(NESARC 2001-2002)
DRINKING PATTERNBased on the following limits – number of
drinks:
On any DAY—4 (men), 3 (women)
In a typical WEEK—14 (men), 7 (women)
Percent of U.S. adults
aged 18+
An Individual’s Chance of
having an AUD
Never exceeds the weekly or daily screening limits
72%less than
1 in 100
Exceeds only the daily limit 16% 1 in 5
Exceeds both weekly and daily limits 10%almost
1 in 2
*alcohol abuse, alcohol dependence
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Extent of Alcohol Use Problems in the United States
* Alcohol abuse and/or alcohol dependence
• 18 million Americans (8.5% of the population age 18 and older) suffer from alcohol use disorders (AUDs*)
• Over 4 million of our young (18% of the population age 12-17) report drinking monthly with more than half engaging in high-risk drinking patterns
• Alcohol problems cost U.S. society an estimated $185 billion annually
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Adolescent Alcohol Use
What’s the problem?
Why we care
What we know
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Alcohol is the Drug of Choice Among Adolescents
0
5
10
15
20
25
30
35
40
45
50
8th 10th 12thGrade
Pe
rce
nt Alcohol
Cigarettes
Marijuana
Source: Monitoring the Future, 2005
(Past Month Use)
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Begins Early for Many
• Approximately 50% of kids start drinking (have had a full drink) by the 8th grade
• By the time they graduate from high school, the vast majority of young people (about 80%) have experience with alcohol
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5.94.9
7.9
4.2
8.7
2.6
0
2
4
6
8
10
Drinking days/ month Usual # of drinks/occasion
Underage 12-20 Young Adult 21-25 Adult 26 and older
Adolescents Drink Less Frequently than Adults But More Per Occasion
Source: SAMHSA National Survey on Drug Use and Health 2006
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0
10
20
30
40
50
60
70
80
12 13 14 15 16 17 18 19 20 21
Age Category
Pe
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Past Month Use
Past Month Binge
Past Month Heavy
Alcohol Use and Binge Drinking Increase Dramatically During
Adolescence
Source: SAMHSA National Survey on Drug Use and Health 2006
Nat
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High School Seniors, 1975-2004
0102030405060708090
100
Per
cen
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Yearly
Monthly
5+ Drinks
Source: Monitoring the Future, 2004
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15-16 Year Old Students in Countries Throughout Europe Binge Drink
0 10 20 30 40 50 60 70
Denmark
Finland
Norway
Sweden
Romania
Russia
Ukraine
Poland
Turkey
Greece
Italy
Portugal
Germany
Switzerland
Netherlands
Belgium
France
Ireland
UK
USA
1-2
3-5
6-9
10+
Percent
Number of Binge Occasions in thePast Month
The European School Survey Project on Alcohol and Other Drugs, 2000.
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• 5,000 deaths among youth under 21 per year from alcohol related injuries including homicides (1,600) and suicides (300)
• Physical and sexual assaults; unwanted/unintended sexual activity
• Altered academic/vocational trajectories
• Possible adverse effects on developing brain
Direct Consequences of Underage Drinking
Nat
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• Half of all persons who die in traffic crashes involving drinking drivers under age 21 are persons other than the drinking driver
• Among college students under age 21 alone, 50,000 experience alcohol-related date rape, and 430,000 are injured by another student who has been drinking
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Prevalence of Past-year DSM-IV Alcohol Dependence by Age – United States
0%
2%
4%
6%
8%
10%
12%
14%
12-1
7
18-2
0
21-2
4
25-2
9
30-3
4
35-3
9
40-4
4
45-4
9
50-5
4
55-5
9
60-6
4
65-6
9
Age
%
Pre
va
len
ce
18 + yrs. - NIAAA NESARC ( Grant, et al., (2004) Drug and Alcohol Dependence, 74:223-234)12-17 yrs - U.S. Substance Abuse and Mental Health Services Administration 2003 National
Survey on Drug Use and Health (NSDUH)
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Fetus
Child
AdolescentYoung Adult
Middle Age
Senior
Alcohol Across the Lifespan
To understand the trajectory of AUDs we must consider drinking in a developmental context
Nat
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Adolescence and Alcohol Use
Why does alcohol have such a strong appeal to so many youth?
Are young people more vulnerable to alcohol’s effects?
Nat
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• Brain maturation – development of self-regulation
• Endocrine changes
• Shift in reward sensitivity; increased risk taking, sensation seeking, impulsivity
• Sexuality/romantic interest
• Environmental changes – e.g., school transitions, increase social interactions, peer affiliations, driving
• The balance of self to other monitoring shifts
The Multiple, Complex Dynamics of Adolescence
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Structural and Functional Changes in the Brain
Plasticity/ ability to change in response to the environment; creates a period of great learning potential
• Overproduction in number of synapses (till about age 11 in girls, 12 in boys)
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Structural and Functional Changes in the Brain
Increased Efficiency• Decrease in gray matter - dendritic
pruning/ competitive elimination of synapses
• Increase in white matter - increased myelination
Use it or lose it
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Maturation Is Not Uniform Across the Developing Brain
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Frontal Cortex:decision-making, self-control
Limbic System: learning, emotions
The limbic system governing emotions matures relatively early in adolescence and its development may be triggered by pubertal hormones. It may also be responsible for the shift in reward sensitivity that drives adolescents to seek higher levels of novelty and stimulation than they did as children.
The Limbic System
Develops Early in Adolescence
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Frontal Cortex: decision-making, self-control
Limbic System: learning, emotions
Maturation of the prefrontal cortex is more gradual and is linked to age and experience. This region is responsible for integrating input from the senses, memories, values, and aspirations to help us control impulses and make decisions. Reviewed in Steinberg, Lawrence (2004) Ann. N.Y. Acad. Sci. 1021: 77-85.
Maturation of the Prefrontal Cortex
Continues Into the 20’s
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Adolescent Brain Development, Decision-Making, and Risk
• Immaturity of cognitive processing may lead to risky decisions.
• The presence of peers influences decision-making.
• Strong emotions may override rational decision-making.
• Risk-taking may facilitate adolescent transitions.
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Adolescent Brain Development and Alcohol
• The adaptability of the adolescent brain makes it well-suited for the processes of adolescence.
• Do adolescents ‘learn’ addiction more readily?
• Do adolescents respond differently to alcohol compared with adults?
• Are adolescent brains more vulnerable to the effects of alcohol?
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0
10
20
30
40
50
60
<=13 14 15 16 17 18 19 20 >=21
Prevalence of Lifetime Alcohol Dependence by Age of First Alcohol
Use
0
10
20
30
40
50
60
<=13 14 15 16 17 18 19 20 >=21
Family History Positive
Total
Family History Negative
Age at First Alcohol Use Age at First Alcohol Use
% P
reva
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Source: Grant and Dawson. J Subst Abuse. 1998. 10(2):163-73.
Source: 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions
1991-1992 2001-2002
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Extent of Influence
Initiation of Drinking
Social Drinking
Alcoholic Drinking
Environmental (familial and non familial)
Personality/Temperament
Pharmacological effects of ethanol
Drinking Behavior and Alcohol Dependence are Complex Traits Influenced by both
Genes and Environment
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Age of Onset of Psychiatric Disorders
Developed from Time Magazine, January 20, 2003, p.82
Conduct DisorderDepression
Anxiety
Brain Disorders
13
Infancy to 5 Years
Infancy to 5 Years
10 – 13 Years
10 – 13 Years
AutismAttention Deficit Hyperactivity Disorder
Obsessive Compulsive Disorders
Eating Disorders
5 – 10 Years5 – 10 Years
– 20 Years
–13 20 Years
AgeAgeAgeAge
Panic DisorderSocial Phobias
Bipolar Disorder
Conduct DisorderAnti-social Behavior
DepressionAnxiety
Brain Disorders
Brain Disorders
Brain Disorders
13
Infancy to 5 Years
Infancy to 5 Years
Infancy to 5 Years
Infancy to 5 Years
10 – 13 Years
10 – 13 Years
10 – 13 Years
10 – 13 Years
AutismAttention Deficit Hyperactivity Disorder
Eating Disorders
5 – 10 Years5 – 10 Years5 – 10 Years5 – 10 Years
– 20 Years
–– 20 Years
–13 20 Years
13 20 Years
AgeAgeAgeAgeAgeAgeAgeAge
Panic DisorderSocial Phobias
Bipolar Disorder
Developed from Time Magazine, January 20, 2003, p.82
Alcohol and Drug
Use Disorders
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Adolescent Alcohol SensitivityDo Adolescents Respond Differently to Alcohol
From Adults?
Nat
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Biphasic Properties of Alcohol as Intoxicant
GABA
NMDA
DA
Binge DrinkingBinge Drinking
Nat
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less sensitive to some of the aversive effects of acute alcohol intoxication (sedation, hangover, ataxia)
but more sensitive to alcohol’s effects on--
• social facilitation
• disruption of spatial memory
Adolescent Alcohol Sensitivity
Compared with adults, adolescents are:
Reviewed in: Spear, LP and Varlinskaya E(2005). Recent Dev Alcohol. 17:143-59.
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Adolescent Sensitivity to Alcohol
• Adolescents exhibit:– Attenuated sensitivity to alcohol effects that normally
serve as cues to moderate drinking, but
– Greater sensitivity to ethanol-induced social stimulation
– Greater disruption in brain plasticity and memory
Attenuated sensitivity to ethanol effects may permit relatively high levels of alcohol intake in adolescence, potentially leading to adverse consequences during and outlasting adolescence.
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A Low Level of Response to Alcohol Can Predict Future Alcoholism
(Human Studies)
Individuals with a low level of response to alcohol– experience less intense negative effects
of alcohol– require a higher blood alcohol
concentration to feel intoxicatedTherefore, they may drink more heavily and more frequently, and are more likely to develop alcoholism
Source: Schuckit, MA and Smith, TL (2000) J Stud Alcohol 61: 827-835.
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Potential Effects of Adolescent Alcohol Use
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• Binge-like drinking affects memory, alters sensitivity to motor impairment, and damages frontal-anterior cortical regions.
• Prolonged ethanol exposure produces long-lasting neurophysiological changes in cortex and hippocampus.
(Animal Research)
Reviewed in: Monti, PM et al (2005) Alcohol Clin Exp Res. 29(2):207-20. Spear, LP (2002) J Stud Alcohol Suppl 14: 71-81.
Consequences of Adolescent Alcohol Use on the Developing Brain
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Consequences of Adolescent Alcohol Use on the Developing Brain
Adolescents with severe alcohol abuse/ dependence disorders may have:
• neuropsychological impairments
• reduced brain hippocampal volumes
Reviewed in: Monti et al. (2005) Alcohol Clin Exp Res. 29(2):207-20. DeBellis MD et al. (2000) Am J Psychiatry. 2000 May;157(5):737-44.
Questions remain... Are these the result of alcohol abuse
or did they precede it? Do they go away with time?
(Human Studies)
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(Animal Research)
Alcohol and Stress
• Under stress, adolescent monkeys double their alcohol intake
• Excessive alcohol consumption is related to changes in stress hormones and serotonin
Reviewed in Barr, CS et al. (2004) Ann. N.Y. Acad. Sci. 1021: 221-233.
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Potential adverse effects of adolescent alcohol use:
• Impact on functioning during adolescence – Greater sensitivity to alcohol-induced
disruptions in memory and brain plasticity
– Mutual synergism: alcohol risk-taking
– Increased level of stress?
– Circumvention of normal developmental tasks?
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adolescent alcohol use:
• Lasting consequences
– Lasting neurocognitive consequences?
– Increased susceptibility to alcohol use disorders?
Early alcohol use as Marker vs. Causality?
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• Brain maturation – development of self-regulation
• Endocrine changes• Environmental changes – e.g., school
transitions, peers, driving• Sexuality/romantic interest• Increased risk taking, sensation seeking• The balance of self to other monitoring shifts• Pharmacological effects of alcohol
The Multiple, Complex Dynamics of Adolescence
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• What they see and hearMedia including movies,
television programs, music, etc.Advertising/ PromotionsProduct Placements
• Alcoholic beverages with youth appeal
• Price
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Intervening Is Challenging, Because…
• adolescence is complicated
• multiple systems are involved in complex behaviors
• what resonate with children and adolescents change frequently and differ for different individuals
• we want enduring effects
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Scaffolding For Healthy Adolescent Development
Individuals may be protected from extremes in emotion or drive by a context that provides adequate external regulation in the form of support, control, predictability.
Provided by Ron Dahl
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Scaffolding For Healthy Adolescent Development
Thus, while many individuals may experience emotions and drives whose intensity and duration exceeds their regulatory competence, those adolescents who enjoy supportive home, peer, school and neighborhood contexts are buffered from the ill effects …
Provided by Ron Dahl
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Scaffolding For Healthy Adolescent Development
• Presence of a Caring Adult
• Positive Peer Groups• Parental Monitoring• School Connectedness• Alternative Activities
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Part II (coming in 2006)
Alcohol and Development in Youth: Future Research Directions
Fetus
Child
AdolescentYoung Adult
Middle Age
Senior
NIAAA’s Underage Initiative
Part IAlcohol and Development in Youth: A Multidisciplinary Overview
www.niaaa.nih.govPublications