Response to Alcohol Indicative of Future Outcomes in Those with Prior AUDs

Marc Schuckit, MD

Results from a new examination showed that, in individuals with previous alcohol use disorder (AUD), having a lower level of response to alcohol is related to both future problem drinking and abstinence, while a higher level of response per drink was associated with future low-risk drinking as well as high-risk drinking in the absences of multiple alcohol problems.

Recent reports have suggested a higher-than-expected rate of problematic drinking among the elderly, prompting an examination of a number of factors that could be utilized as future predictors of alcohol-related outcomes. Previous research has shown that despite 6% to 36% of older individuals exceeding the defined limits of low-risk, controlled drinking, 16% to 22% of them denied having multiple alcohol problems.

“We have a population, many of whom, I’m imagining, have tried low-risk drinking. Alcoholics can do that, and often do that, for periods of time,” Marc Schuckit, MD, the lead author and distinguished professor of psychiatry at the University of California San Diego, told MD Mag. “Overall, certainly less than 20% and probably more like 10% can do that. Few with alcohol dependence can go back to drinking in a controlled way and stay there.”

The study was a follow-up to the Collaborative Studies of the Genetics of Alcoholism (COGA) and assessed original participants with baseline AUD at an average age of 40 and interviewed them 13 to 26 years later. In total, the authors were able to reach out to 1554 participants and were able to interview 697 (44.9%), though 34 were excluded from analysis.

Participants were evaluated using Chi-square and analysis of variance, and placed into 4 clinically derived categories, based on data from the Self-Report of the Effects of Alcohol (SRE) scores and their level of response (LR) to alcohol:

• Low-Risk: Defined as having consumed alcohol within the year prior but never exceeding 3 standard drinks per day and 13 drinks per week and denied ≥2 alcohol problems in the previous 5 years.
• High-Risk: Defined as having at least 1 occasion in the year prior when they exceeded the low-risk definition but denied ≥2 alcohol problems in the previous 5 years.
• Problem: Defined as having ≥2 alcohol problems in the previous 5 years.
• Abstinent Drinkers: Defined as having consumed no alcohol in the year prior to follow-up and denied having ≥2 alcohol problems in the previous 5 years.

At the follow-up, the 100 (15.1%) individuals identified as part of the Low-Risk group were found to report an average maximum of 2.1 drinks per occasion (standard deviation [SD], 0.76), 2.4 usual drinks per week (SD, 2.01), and 1.7 occasions per week as the usual frequency (SD, 1.46) in the year prior. Comparatively, the 93 (14.0%) members of the High-Risk group reported 6.5 (SD, 3.33) maximum drinks per occasion, 10.7 (SD, 11.44) usual drinks per week, and 3.4 (SD, 2.45) occasions per week, while the Problem (n = 192; 29.0%) group reported 11.3 (SD, 6.85) maximum drinks per occasion, 21.0 (SD, 17.61) usual drinks per week, and 4.1 (SD, 2.51) occasions per week.

The overall average maximum drinks per occasion across all groups was recorded as 7.7 (SD, 6.43), with the usual drinks per week being 13.6 (SD, 15.78) and the usual occasions per week as 3.3 (SD, 2.47). For comparison, at baseline, the overall averages for maximum drinks per occasion, drinks per week, and occasions per week were 24.6 (SD, 10.4), 5.9 (SD, 7.09), and 3.0 (SD, 2.76), respectively.

Schuckit and associates noted that having a high LR was linked to “more benign alcohol outcomes,” suggesting that “more feedback from fewer drinks might make it easier to stop drinking during an evening.” Although, they found that having a lower LR per drink was associated with both problem drinking and abstinence, with the connection of LR to the Abstinent group possibly revealing both that heavy drinking was likely to contribute to the decision to stop consuming alcohol, and that LR is not closely linked to impulsivity, which could have an impact on the probability of returning to heavy drinking patterns.

They also noted that a higher LR per drink might also have contributed to the greater ability of the High-Risk group to avoid multiple alcohol problems in comparison with the Problem group.

Shuckit wrote that "the contributions by LR to predicting outcomes were observed even after considering age, sex, as well as drinking and drug use histories in the same analyses, indicating that LR may have added unique information for predicting later outcomes." Interestingly, he noted, both SRE5, defined as the average drinks needed for the effects of drinking to set in during the approximate first 5 times of drinking, and SRET, the total of the SRE scores, contributed to differentiating between outcome groups. Although, Schuckit wrote that “the fact that these 2 measures were not always concordant is a reminder that they are likely to measure related, but not identical phenomena.”

The average age of onset AUD was 24 (SD, 7.18) years, with 62.6% of the overall group reporting having received treatment for the condition (Low-Risk, 41.0%; High-Risk, 44.1%; Problem, 64.6%; and Abstinent, 75.2%).

Across their lifetimes, the overall group reported a mean of 6.9 (SD, 2.51) alcohol problems (Low-Risk, 5.8 [SD, 2.39]; High-Risk, 5.8 [SD, 2.52]; Problem, 6.8 [SD, 2.54]; Abstinent, 7.6 [SD, 2.27]). At the follow-up point, the number of alcohol problems in the prior 5 years for the Low-Risk, High-Risk, Problem, and Abstinent groups were 0.1 (SD, 0.35), 0.5 (SD, 0.50), 4.4 (SD, 2.04) and 0, respectively, with an overall mean of 2.4 (SD, 2.55) alcohol problems.

“As predicted a lower number of drinks needed for effects (high LR per drink) was related to future Low-Risk Drinking, and to High-Risk Drinking in the absence of multiple alcohol problems,” Schuckit wrote. “Conversely, high SRE scores (low LR per drink) were related to Problem Drinking and Abstinent outcomes.”

Schuckit and colleagues noted that the take-home messages were 3-fold. First, that a year-long period of abstinence is not the only way to characterize positive outcomes in older patients with AUDs. Additionally, that while low-risk drinking occurs in this population, it is not the usual outcome, and those who sustain a pattern of low-risk drinking are often those with modest levels of alcohol and drug problems as well as a higher level of response to alcohol.

“The average alcoholic looks like everybody else, and they don’t usually come into the office totally intoxicated,” Schuckit said. “The incidence of AUDs and alcohol problems look like it’s increased in the last 10 years and that it’s a health problem. If you’ve got someone that meets the criteria for an AUD, the probability that they can go back to controlled drinking is very low.”

The study, "A 22‐Year Follow‐Up (Range 16 to 23) of Original Subjects with Baseline Alcohol Use Disorders from the Collaborative Study on Genetics of Alcoholism," was published in Alcoholism: Clinical and Experimental Research.