Midwest Alcohol Research Center ARTSS ProgramVivia McCutcheon, PhD

Washington University School of MedicineJune 11, 2010

vmccutcheon@wustl.edu

Overview

Historical context

Epidemiology

Physiology

Treatment

William Hogarth, Gin Lane, (engraving) 1751

A Little History

Scientific and Social Context of Women’s Drinking

Studies on Sex Bias in Alcohol Research

• 1984 Marsha Vanicelli et al. studied 259 treatment outcome studies published 1972-1980

– Only 7.8% of subjects were female– Female first authors compared to male first authors were more likely to

• sample women• follow them over time• examine gender differences

• 1995 Pamela Brett et al. studied 1041 articles published in 1990– Still tendency to focus on male subjects, though improved proportion females– Studies using mostly females provided justification for bias– Inadequate justification for using primarily male samples– Misleading interpretation, e.g., generalizing findings from mostly male samples to

females

Why Not Include Women in Alcohol Research?

1798, Cultural Mandate

– “Women, ministers and Jews do not get drunk, as a rule, at least they carefully avoid the appearance of it because their civic position is weak and they need to be reserved. Their outward worth is based merely on the belief of others in their chastity, piousness, and separatistic lore.…[They] are exposed to the attention and criticism of the community, and thus cannot relax in their self-control, for intoxication, which deprives one of cautiousness, would be a scandal for them.”

• Immanuel Kant, 1798, as quoted by EM Jellinek in 1941 Quarterly Journal of Studies on Alcohol

1976, They are Too Hard to Follow

Merton M. Hyman, Center of Alcohol Studies, Rutgers UniversityAlcoholics 15 Years Later , in Work in Progress on AlcoholismAnnals of the New York Academy of Sciences

1919 Study of Women Arrested for Drunkenness • “…drunkenness in women does not present the same

features as in men. Not only is it less common, but addiction to alcohol with them means a further step downward than it does with men. …mental inferiority is more common among women arrested for drunkenness than among men.”

– From Journal of Mental Hygiene, Drunkenness as Seen Among Women in Court, by V.V.Anderson, MD and C.M. Leonard, MD, Medical Director and Assistant Medical Director, Municipal Court of Boston

Personality Characteristics of 100 Women Arrested for Drunkenness, 1919

Mental Defect and Disorder of 100 Women Arrested for Drunkenness, 1919

Female Medicines

Remedies and tonics for “female complaints “ contained as much as 44 percent alcohol

E.g., Lydia Pinkham’s Vegetable Compound, first marketed in 1875

Cure moodiness, dissolve and expel tumors

The advertisements suggested that men loved this compound, because it made women "so much easier to live with." One advertisement exclaimed "Don’t blame her! She cannot help it."

http://www.hagley.lib.de.us/library/exhibits/patentmed/items/lydiapinkhams.html

Lifetime Psychiatric Disorders: DWI-Offenders vs NCS

Women Men

Lapham et al., 2001, Archives General Psychiatry

*

*

*

*

Alcohol Diagnostic Symptoms by DUI Status (COGA)

Alcohol Diagnostic Symptoms by DUI Status (COGA)

2008

DRINK LIKE A LADY!

Drug and Alcohol Service for London, Anti-alcohol campaign targeting binge drinking in young women

CONTEXT!

Context: Timeline of life eventsN=46 women with ≥ 2 DUIs

5 38

Neg

lect

(7)

Phy

sAbu

s (1

6), M

oles

t (18

)

816

1st d

runk

19

Reg

ular

drin

king

20

1st A

D s

x, W

itnes

s (1

8)

22

Mar

riage

(26

), R

ape

(25)

23

Birt

h (3

8), A

ccid

ent (

18),

Dis

aste

r (1

9)

24

Ass

ault

(23)

25

Wea

pon

(15)

27

Last

birt

h (2

7)

28

AD

ons

et

29

1st D

UI,

Alc

tx (

40)

,1st a

bst (

35),

Div

orce

(22

)

301

st in

patie

nt P

sych

/SU

D tx

(32

)

32La

st A

D s

x, 1

st o

ut. T

x (3

5)

36

Last

DU

I

37

Last

inpt

tx

Last

abs

t

40

AD

rec

, las

t out

tx (

18)

AGE

Epidemiology

A Closing Gender Gap ?

12-Month Prevalence AUDS 2001-02

Hasin et al., 2007, Archives General Psychiatry

Lifetime Prevalence AUDS, 2001-02

Hasin et al., 2007, Archives General Psychiatry

Prevalence Lifetime Drinking by Age Cohort

Women Men

Grucza et al., ACER, 2008

1934-43

1944-53

1944-53

1954-1963

*1934-43

1944-53

Prevalence Lifetime AD among drinkers, by Age Cohort

Women Men

*

Grucza et al., ACER, 2008

1944-53

1954-1963

Why the Increase?

Greater gender equity after WWII

More women in work force

Cultural and economic conditions of women closer to those of men

Women’s drinking less stigmatizing

Physiology

Telescoping

Defining At-RiskDrinking

LOW RISK MEN WOMEN

No more than Drinks per day

4 3

AND No more than Drinks per week

14 7

http://rethinkingdrinking.niaaa.nih.gov

TelescopingTime from onset of problem drinking to onset of adverse physical and psychological consequences shorter in women than in men

Medical problems associated with hazardous drinking occur more quickly in women and after smaller amounts of alcohol

Piazza et al., 1989; Project MATCH, 1997; Ashley et al., 1977; Schuckit et al., 1998

Duration hazardous drinking before disease occurrence

0 5 10 15 20 25

Fatty liver

Hypertension

Malnutrition

Gastric Bleeding

Men Women

Ashley et al., 1977, Archives Internal Medicine

Mortality in DUI Offenders, by Gender

Drug Alcohol Depend. 2010 Jul 1;110(1-2):80-4. High mortality among people suspected of drunk-driving. An 18-year register-based follow-up.Impinen A, Mäkelä P, Karjalainen K, Rahkonen O, Lintonen T, Lillsunde P, Ostamo A.

Why Telescoping?

Lower average body water content

Alcohol distributed through body water, less diluted in women

Less alcohol dehydrogenase

Less first-pass metabolism in gastric system so more is absorbed directly into bloodstream as pure ethanol to be metabolized by the liver

Marshall et al., 1983, Hepatology; Frzza et al., 1990, N England J Medicine

No Telescoping of Course in General Population

• Men had higher risk initiating use, alcohol dependence and treatment

• Younger cohorts more likely to drink and to become alcohol dependent– Confirmed closing gender gap in AD: women’s rates

increased more than men’s across cohorts

• Men had shorter time to dependence in every birth cohort

Keyes et al., 2010, American Jrnl. Psychiatry

A little more history…

Treatment

1946: Analysis of Grapevine AA Survey Results

Some Survey Questions

• At what age did you first:– Get drunk?– Experience a blackout?– Begin to lose control of drinking?– Attempt to control your drinking? …– Lose a job as a result of drinking?– Use alcohol to lessen self-consciousness during sex?– Attempt to find comfort in religion?– Start solitary drinking?

So Whose Experiences Inform the Jellinek Curve?

• It’s all in the footnote!– “While 158 members of Alcoholics Anonymous

filled in the forms, only 98 questionnaires of male alcoholics could be used.*”

Current studies remission/relapse lack gender differentiation

• Study of rates and correlates of relapse after remission in 1772 individuals from NESARC includes gender as a covariate only (Dawson et al., 2007, ACER)

• Study of brain reward pathways in alcohol-dependent individuals before treatment included 3 women (out of 51 participants) (Durazzo et al., 2010, JSAD)

Treatment

BarriersRates & Type

Outcome

Barriers to tx for women

• Pregnancy• Childcare responsibilities• Economic• Higher rates co-occurring disorders among

women • Trauma histories• Lack of family or partner support• Greater social stigma and discrimination

Greenfield et al., 2007, Drug and Alcohol Dependence

Rates past-year treatment in adults from population-based sample who met AD criteria in past year

Wu et al., 2004, AJP

Tx use among individuals who initiated contact with tx system, followed for 8 years

Year 1 Years 2-8

*

Gender differences in 1-Year Outcomes

Timko et al., 2002, Addiction

Gender differences in 8-year outcomes

*

**

**

Timko et al., 2002, Addiction

Female Treatment Admissions Reporting Primary Alcohol Abuse, 1992-2007

TEDS Report at http://www.drugabusestatistics.samhsa.gov/2k10/208/208WomenAlc2k10.htm

Secondary Substances of Abuse Among Women Reporting Primary Alcohol Abuse, 1992 and 2007

Take-Home

• Context is important• Increasing rates AUD in younger women• Rapid progression from hazardous drinking to

adverse consequences• Treatment Barriers• Treatment works

The End

Questions?Thanks and enjoy your summer!