Alcohol Use in Midlife Women Connie B. Newman MD, FACP, FAMWA 2018 President, American Medical Women’s Association Adjunct Professor of Medicine Division of Endocrinology, Diabetes and Metabolism New York University School of Medicine [email protected] Disclosures • No disclosures Connie Newman MD Questions • What is known about prevalence of alcohol use, binge drinking, and alcohol use disorder by age and sex? • What is the underlying problem? Why is (alcohol) drinking increasing in middle age women? • How is alcohol metabolized? Is this different in women? • What are health risks? Health benefits? • How can we screen for alcohol problems? • What are treatment options? WHAT CAN CLINICIANS DO TO ADDRESS THIS PROBLEM? Connie Newman MD • Alcohol use disorder (AUD) is not a “moral failing”, but rather a chronic disease with a neurobiological basis • Public and self stigma associated with AUD or excessive drinking is counterproductive • Much of the data available are based on interviews, and therefore may underestimate the magnitude of the disease. Connie Newman MD A Tale of Two Cities Paris 1875-6 London 1751 “Absinthe Drinker” by Edgar Degas “Gin Lane” by William Hogarth Connie Newman MD What is one standard drink? USA: National Institute on Alcohol Abuse and Alcoholism (NIAAA) CANADA: https://www.rethin kyourdrinking.ca/ what-is-a- standard-drink/ Connie Newman MD Low risk drinking, in U.S. https://www.rethinkingdrinking.niaaa.nih.gov/How-much-is-too-much/Is-your- drinking-pattern-risky/whats-Low-Risk-drinking.aspx Connie Newman MD Prevalence Global data 2016 • 32.5% or 2.4 billion people were current drinkers o 25% women o 39% men • Varies by location and by sex • Lowest in low sociodemographic groups • 2.8 million deaths attributed to alcohol o 2.2% of deaths in women o 6.8% of deaths in men GBD 2016 Alcohol Collaborators. Lancet 2018; 392: 1015-35; 195 Countries and Territories Connie Newman MD Average of standard drinks daily by sex: North and South America 2016 Women Men GBD 2016 Alcohol Collaborators. Lancet 2018; 392: 1015-3535; 195 Countries and Territories, 592 prospective and retrospective studies Connie Newman MD Alcohol use in U.S. 2017 age 12 or older Since 2015, binge alcohol use in males is 5 or more drinks, for females 4 or more drinks, on one occasion in the past 30 days Since 2015, heavy alcohol use in males is 5 or more drinks, for females 4 or more drinks, on five or more days in past 30 days SAMHSA 2017 National Survey on Drug Use and Health (NSDUH) Connie Newman MD DSM-V Diagnosis of Alcohol use Disorder (AUD) 11 Questions about activities in previous year; AUD diagnosed when meeting at least 2 criteria • Times when drinking more or longer than intended • More than once tried to cut down on drinking but could not • Spent a lot of time drinking or being sick or getting over aftereffects • Wanted a drink so much that could not think of anything else • Drinking (or being sick from drinking) interefered with caring for home, or family, or caused job problems , or school problems • Continued to drink even though it was causing trouble with your family or friends • Reduced or eliminated participation in other activities because of alcohol use • More than once after drinking became involved in situations that increased your chances of getting hurt (driving, swimming, using machinery, unsafe sex) • Continued drinking even though it caused feelings of anxiety or depression or contributed to another health problem, or after a blackout • Had to drink more than before to get the usual effect or found that usual number of drinks had less effect • Experienced symptoms of withdrawal (shakiness, nausea, sweating, seizure) when cutting back or stopping Connie Newman MD Sex and gender differences in risk factors for alcohol use disorder Women Men • Family hx of AUD • Sexual abuse • Personal hx anxiety • Loss of a parent • Smoking • Relational factors • Personality traits- • Spouse with AUD neuroticism, low self esteem, novelty seeking Genetics Genetics Kendler KS, Edwards AC, Gardner CO. Alcohol Clin Exp Res 2015;39(6):998-1007; Lewis B, Nixon SJ. Alcohol Clin Exp Res 2014;38(1):275-84; Connor JP et al . Lancet 2016; 387:988-998 Connie Newman MD Alcohol use by age group Percentage of adults with at least 1 heavy drinking day in past year, 2018, U.S. NCHS, National Health Interview Survey 2018 50 45 42.9 40 36 35 33 30.4 29.3 30 27.6 28.5 25 22.6 Percent 20 17.1 15 11.8 10 8.2 5.3 5 0 18 - 24 25-44 45-64 65 + Age Group (years) Total Male Female 5 or more drinks in one day for men and 4 or more drinks in one day for women at least once in past year Connie Newman MD Steeper rate of increase in high risk drinking in women from 2001-2* to 2012-3 † National Epidemiological Survey of Alcohol and Related Conditions * n=43,093 † n=36, 309 Percent Change from 2001-2* 18 29.9% 57.9% 15.5% 16 14 12 10 8 6 4 2 0 2001-2 2012-13 Total Women Men * Greatest change in women, age gps 45-64 and 65 and over ≥ 4 drinks in women, ≥ 5 drinks in men (14 g drink) at least weekly Grant BF, Chou P, Saha TD, et al. JAMA Psych. 2017; 74(9): 911-23. Connie Newman MD Higher rate of increase in Alcohol Use Disorder (AUD) in women vs men 2001-2* to 2012-3† National Epidemiological Survey of Alcohol and Related Conditions * n=43,093 † n=36,309 Change from 2001-2 18 Percent 49.4% 83.7% 34.7% 16 14 12 10 8 6 4 2 0 2001-2 2012-13 Total Women Men AUD defined by DSM-IV. Higher increase in women and middle life groups Grant BF, Chou P, Saha TD, et al. JAMA Psych. 2017; 74(9): 911-23. Connie Newman MD Women of middle age had highest increase in frequency of ED visits for acute alcohol consumption All alcohol related ED visits: 2006 3,080,214 / 2014: 4,976,136 9 Acute Women Acute Men 8 7 6 5 4 3 2 1 100,000 population 100,000 Percent change in rates per per in rates change Percent 0 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65+ ******Females and males age 55 to 64: highest increase in frequency of ED visits related to acute alcohol consumption White AM et al. Clin Exp Alc Res 2018; 42(2):352-359 Connie Newman MD Annual % change for ED visits due to chronic alcohol consumption was significantly higher in women ages 25-34 and 55-64 All alcohol related ED visits, US: 2006 3,080,214 / 2014: 4,976,136 12 Chronic Women Chronic Men 10 8 6 Percent 4 2 0 18 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65+ White AM et al. Clin Exp Alc Res 2018; 42(2):352-359 Connie Newman MD WHY? Rationale for increase in alcohol consumption and at risk drinking in women Increase in alcohol use by women across 20th century • Increases in drinking and binge drinking occur in o Women married, never married o Full time employed, part time employed, not employed o Different levels of education, race/ethnicity o Pregnancy • Change in women’s roles o Before prohibition bars were frequented by men, After prohibition bars welcomed men and women o Women entered working force in larger numbers Connie Newman MD Factors influencing frequent drinking of alcohol (≥ 6 d/wk) in women age 45 and older Women Barriers Facilitators Age 45 to 54 Health issues Belief alcohol causes n= 150 relaxation Age 55+ Family commitments Remedy for stressful n=100 Negative short term week side effects (hangover) Supportive friends The belief of “causing ill health in the long term” was not a significant barrier Survey in Australia of 1069 women; older women age 45 + more likely to drink frequently; binge drinking highest in age group 18 to 24 Solutions ▪ Challenge the belief that alcohol is an important means of reducing stress ▪ Highlight healthy alternatives to stress management ▪ Increase awareness of long term health risks Haydon HM et al. BMC Women’s Health 2016; 16:36 Connie Newman MD Pharmacokinetics and pharmacodynamics Alcohol pharmacokinetics and pharmacodynamics differs by sex • Women are more susceptible to effects of alcohol at equivalent consumption • Rationale o Lower body water in women, leads to higher concentration of ethanol o Higher body fat of women o Relatively lower amounts of alcohol dehydrogenase compared to men Connie Newman MD Metabolism of alcohol When metabolism of acetaldehyde is overwhelmed, acetaldehyde accumulates and forms adducts (covalent chemical addition products) with proteins, lipids and DNA, thus impairing their function Loss of function mutations in aldehyde dehydrogenase, such as in Asians, and Ashkenazi Jews, cause accumulation of acetaldehyde, flushing and nausea ADH alcohol dehydrogenase, ALDH acetaldehyde dehydrogenase Setshedi M. et al. Acetaldeyde adducts in chronic liver disease. Oxidative Medicine and Cellular Longevity 2010; 3: 178-85 Metabolism of alcohol When metabolism of acetaldehyde is overwhelmed, acetaldehyde accumulates and forms adducts (covalent chemical addition products) with proteins, lipids and DNA, thus impairing their function Loss of function mutations in aldehyde dehydrogenase, such as in Asians, and Ashkenazi Jews, cause accumulation of acetaldehyde, flushing and nausea ADH alcohol dehydrogenase, ALDH acetaldehyde dehydrogenase Setshedi M. et al. Acetaldeyde adducts in chronic liver disease. Oxidative Medicine and Cellular Longevity 2010; 3: 178-85 Alcohol mediated pathways (liver) leading to hepatocellular cancer HCC hepatocellular carcinoma Cyp 2E1 cytochrome P450 2E1, HSC hepatic stellate cells Setshedi M.