Midwest Alcohol Research Center ARTSS ProgramVivia McCutcheon, PhD
Washington University School of MedicineJune 11, 2010
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!
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