Articles of Public Interest

Adults aged 35 to 60 are drinking at unprecedented rates, with those who binge drank in high school reporting more past 30-day high-risk drinking in midlife. And this link may be especially strong for women, according to a study just published in Alcohol: Clinical and Experimental Research Health. These trends are particularly concerning as health conditions, and biological processes common with aging put adults in midlife at greater health risk from alcohol use.

Twenty to 30 percent of all the 35- to 60-year-olds in the study reported binge drinking (four or more drinks for women, five for men), and one out of ten reported high-intensity drinking—having eight to ten drinks in one sitting. Compared to people who did not binge drink in high school, people in the study who binge drank at age 18 had higher rates of alcohol use on a range of alcohol use measures—typical number of drinks, maximum number of drinks, number of binge drinking episodes and number of high-intensity drinking episodes. For example, among those who didn't binge at age 18, only 20% reported binge drinking in midlife compared with 40% among those who did binge at age 18.

Alcohol use is one of the biggest contributors to illness and death for all adults, and alcohol use conveys even more risk for adults in midlife. Decreases in muscle mass and metabolism that are a part of the aging process may inhibit the body's ability to process alcohol. People at this age more commonly have health conditions that are made worse by heavier drinking, such as diabetes, high blood pressure, cardiovascular disease, and osteoporosis.

While men drank more than women on all measures, the association between binge drinking in high school and high-intensity drinking in midlife was stronger for women. Women who reported binge drinking at age 18 were three times more likely to report high-intensity drinking in midlife; men were twice as likely to report high-intensity drinking if they binge drank at age 18. The researchers noted that alcohol use among women in midlife has risen steadily in recent years, while alcohol use among men has not.

Age and race/ethnicity were associated with drinking behaviors. Although alcohol use declined with age, still, one in five 60-year-olds reported binge drinking. And the link between high school binge drinking and maximum drinks was stronger at age 60 than at age 35. White participants reported higher typical and maximum drinks than other racial or ethnic groups. Previous studies have found that non-White drinkers may experience greater adverse outcomes from alcohol use, despite their lower rates of alcohol use frequency, quantity, and alcohol use disorder compared to whites.

For the study, researchers examined data from more than 5000 surveys of adults aged 35, 40, 45, 50, 55, and 60 who have been participating in a national longitudinal study since twelfth grade to understand whether there were long-term connections between binge drinking in adolescence and alcohol use in midlife. Respondents were asked about drinking in the past 30 days, what their typical number and maximum number of drinks they drank on the days they drank.

Links between adolescent binge drinking and midlife alcohol use behaviors by age, sex, and race/ethnicity. M. Patrick, S. Peterson, Y. Pang, Y. Terry-McElrath. (https://doi.org/10.1111/acer.15435).

Young adults think electronic interventions might help to reduce the negative consequences of alcohol use if tailored to their personal needs and goals. In a qualitative study, young adults reported that such real-time interventions should be customizable, easy to use, and provide digestible amounts of non-judgmental information. The authors of the study, just published in Alcohol: Clinical and Experimental Research, highlight the importance of involving users early in the development process to ensure users find harm reduction applications relevant and engaging.

Researchers conducted in-depth interviews with 21 people aged 18 to 24 in the greater Seattle area about whether electronic interventions could help young adults reduce negative consequences of alcohol use. Overall, the young adults felt positive about web-based or mobile interventions, stating that interventions that counted drinks and reported blood alcohol content could increase awareness of alcohol content of drinks and help them pace themselves. Some, however, felt that consequences were unavoidable, as intoxication and social pressure would reduce the ability to engage with real-time interventions.

When asked about features that would make these mobile or web-based interventions most useful, participants emphasized personalization and relevance. For example, the ability to set goals and track drinks as well as mood, behavior, experiences, and where and with whom they are drinking could provide insight into how different factors influence, and are influenced by, how much they drink, they said. Participants noted the importance of a user-friendly design requiring minimal input, particularly during drinking episodes when they may be unfocused due to alcohol use and social demands while allowing users to opt-in to more user-intensive, interactive features.

Certain safety features were suggested, such as alerts that the user's intoxication level is unsafe for driving or shutting down certain apps to prevent texting or spending while intoxicated. Additionally, participants wanted the option to access alcohol-related education and resources, such as information about interactions with medications or mental health conditions, guidance for resisting peer pressure or helping a friend, and local treatment and support resources. Some participants recommended an online community of people who were trying to reduce the negative consequences of drinking, while others felt this could glorify drinking.

The researchers noted that some of the young adults' recommendations have not been effective at reducing negative consequences of drinking. Blood alcohol trackers, which are already widely available, may encourage increased alcohol intake. Some research suggests that mindfulness is effective when focused on a specific behavior, but research is needed to determine its effectiveness with alcohol-related consequences. Research shows mixed results on whether online communities reduce drinking outcomes. However, the study suggests that customizable interventions that emphasize relational factors, are non-judgmental, promote self-awareness, and assess readiness and commitment to change may be appealing to young adults and more effective in reducing negative consequences of drinking.

Discovering what young adults want in electronic interventions aimed at reducing alcohol-related consequences. C. Mackey, G. Sibik, V. Szydlowski, J. Blayney, C. Lee, M. Larimer, B. Hultgren. (https://doi.org/10.1111/acer.15439)

Negative emotions may help explain the link between insomnia and dangerous drinking, according to a small study involving veterans with Alcohol Use Disorder (AUD). The findings provide new insight into why insomnia might be linked AUD. Insomnia symptoms are highly prevalent in people with substance use disorders (SUDs). Among veterans with AUD, for example, almost 2 in 3 experience insomnia. Sleep problems are also linked to negative mood and difficulty regulating emotions, which in turn are associated with risky alcohol use. Previous research has shown that treating insomnia can led to a reduction in alcohol-related problems, though the mechanism for this is not known. For the study in Alcohol: Clinical & Experimental Research, investigators examined negative emotions as a key link between insomnia symptoms and alcohol problems among US military veterans.

Researchers worked with 67 Veterans in treatment for AUD who also met the criteria for Insomnia Disorder (91% male, 84% White, average age 46). The participants were randomized to receive either five sessions of Cognitive Behavioral Treatment–Insomnia, including tracking their adherence to treatment recommendations over five weeks, or a handout on sleep hygiene. They were assessed for insomnia symptoms, alcohol craving and consumption, drinking-related problems (such as feeling unhappy because of alcohol use), symptoms of post-traumatic stress disorder, depression, anxiety, emotional regulation, and current negative affect. These evaluations occurred before treatment, immediately after treatment, and six weeks later. The researchers used statistical analysis to explore associations between sleep, mood, and alcohol-related experiences.

Among both groups—people receiving either CBT-I or the sleep hygiene handout—those who experienced reduced insomnia symptoms also reported decreases in negative emotionality. The benefits included lower PTSD, depression, and anxiety symptoms and improved emotional regulation and affect. These changes, in turn, predicted reductions in alcohol craving and heavy drinking. Increases in negative mood were linked to subsequent increases in alcohol cravings. Changes in insomnia symptoms or negative mood were not associated with changes in alcohol-related problems. Nor did CBT-I offer additional improvements in negative emotionality relative to the sleep hygiene recommendations, perhaps because of participants' weak engagement in the cognitive therapy component or for reasons to do with the study methods. Nevertheless, the study suggests that negative emotionality may help explain links between insomnia symptoms and alcohol-related outcomes.

Improving sleep is a means of easing negative mood, which in turn can provide relief from alcohol craving and heavy drinking. If these study results can be replicated in larger, more diverse samples, they could inform more effective treatments for AUD. CBT-I may be a promising treatment for people who are more open to addressing their insomnia than their, say, PTSD or depression. Although CBT-I may not lead to improved mood for everyone, it can be combined with other interventions that might impact mood, such as mindfulness or emotional regulation skills training. Additional research is needed, including more extensive trials.

Insomnia treatment effects on negative emotionality among veterans in treatment for alcohol use disorder. M. B. Miller, R. Carpenter, M. Nance, L. K. Freeman, J. Metrik, B. Borsari, C. McCrae, J. Merrill, K. Carey, J. McGeary. (https://doi.org/10.1111/acer.15436)

People exposed to alcohol in utero report a greater range and frequency of physical health problems in midlife than those who were not exposed, according to a new study. Prenatal stressors and difficult early life experiences are known to increase the risk of the early onset of disease in adulthood. A theory on the developmental origins of health and disease implies that risky exposures occurring during pregnancy may increase the offspring's vulnerability to the effects of subsequent adverse influences. Prenatal alcohol exposure (PAE) may be one such exposure. Improved understanding of the long-term effects of PAE could lead to improved clinical care for affected people. Identifying areas of concern may also inform early interventions to reduce the long-term impact of PAE. In the study in Alcohol: Clinical & Experimental Research, investigators considered the possible implications of PAE for a wide range of health problems that typically occur as people grow older.

Researchers recruited 357 midlife adults, with and without PAE, from long-term studies in Atlanta and Seattle. The participants had been identified initially via maternal self-reports during pregnancy or were diagnosed with fetal alcohol syndrome (FAS) or fetal alcohol exposure (FAE) in childhood. They were divided into three groups: no PAE, PAE without FAS or the associated facial dysmorphic symptoms, and PAE with FAS or dysmorphia. The participants took a comprehensive health survey that included questions about cancer, problems with vision, hearing, immune function, dentistry, skin, or sleep, and issues affecting cardiovascular, urinary, gastrointestinal, or endocrine function. The investigators compared the reported prevalence of health issues among the three groups while using statistical analyses to account for demographic characteristics and other influences on health, including adverse childhood experiences.

Health problems were reported across all groups; however, people with PAE reported a higher frequency of most health issues. In addition, PAE was linked to an increased risk of hearing, urinary, and gastrointestinal problems, which appear to be directly affected by alcohol exposure after statistical control of other factors. The increased frequency of other health issues suggests that PAE leads to greater vulnerability across many bodily systems, intensifying the negative effects of other social determinants, such as socioeconomic struggles and poor diet. It's also possible that disability associated with PAE renders people less able to maintain healthy behaviors and that the stressors associated with disability further amplify negative health influences. Health status was also related to age, race, gender, and adverse childhood experiences: older white women with more early life adversity reported more health problems. Facial dysmorphia was not associated with a greater risk of physical health problems in midlife.

The findings of this study—one of the first to examine the midlife health of people with PAE—point to a long-term health impact of early alcohol exposure. It is likely that PAE is associated with a complex pattern of risk factors with cumulative health implications. This new insight has the potential to improve the clinical care of—and broader support for—people affected by PAE by promoting comprehensive health evaluations of patients at elevated risk. More research to validate patient self-report through clinical investigation with objective health measures in larger samples is the next step in understanding the impact of early alcohol exposure.

Prenatal alcohol exposure and health at midlife: Self-reported health outcomes in two cohorts. C. Coles, Z. Shapiro, J. Kable, S. Stoner, G. Ritfield, T. Grant. (https://doi.org/10.1111/acer.15441)