DSM-5 and ICD-11 alcohol use disorder criteria in young adult regular drinkers: Lifetime prevalence and age of onset

How well do DSM-5 criteria measure alcohol use disorder in the general population of older Swedish adolescents? An item response theory analysis

BACKGROUND

This study assesses the psychometric properties of DSM-5 criteria of AUD in older Swedish adolescents using item response theory models, focusing specifically on the precision of the scale at the cut-offs for mild, moderate, and severe AUD.

METHODS

Data from the second wave of Futura01 was used. Futura01 is a nationally representative cohort study of Swedish people born 2001 and data for the second wave was collected when participants were 17/18 years old. This study included only participants who had consumed alcohol during the past 12 months (n = 2648). AUD was measured with 11 binary items. A 2-parameter logistic item response theory model (2PL) estimated the items' difficulty and discrimination parameters.

RESULTS

31.8% of the participants met criteria for AUD. Among these, 75.6% had mild AUD, 18.3% had moderate, and 6.1% had severe AUD. A unidimensional AUD model had a good fit and 2PL models showed that the scale measured AUD over all three cut-offs for AUD severity. Although discrimination parameters ranged from moderate (1.24) to very high (2.38), the more commonly endorsed items discriminated less well than the more difficult items, as also reflected in less precision of the estimates at lower levels of AUD severity. The diagnostic uncertainty was pronounced at the cut-off for mild AUD.

CONCLUSION

DSM-5 criteria measure AUD with better precision at higher levels of AUD severity than at lower levels. As most older adolescents who fulfil an AUD diagnosis are in the mild category, notable uncertainties are involved when an AUD diagnosis is set in this group.

Designing clinical trials to address alcohol use and alcohol-associated liver disease: an expert panel Consensus Statement

Most patients with alcohol-associated liver disease (ALD) engage in heavy drinking defined as 4 or more drinks per day (56 g) or 8 (112 g) or more drinks per week for women and 5 or more drinks per day (70 g) or 15 (210 g) or more drinks per week for men. Although abstinence from alcohol after diagnosis of ALD improves life expectancy and reduces the risk of decompensation of liver disease, few studies have evaluated whether treatment of alcohol use disorders will reduce progression of liver disease and improve liver-related outcomes. In November 2021, the National Institute of Alcohol Abuse and Alcoholism commissioned a task force that included hepatologists, addiction medicine specialists, statisticians, clinical trialists and members of regulatory agencies to develop recommendations for the design and conduct of clinical trials to evaluate the effect of alcohol use, particularly treatment to reduce or eliminate alcohol use in patients with ALD. The task force conducted extensive reviews of relevant literature on alcohol use disorders and ALD. Findings were presented at one in-person meeting and discussed over the next 16 months to develop the final recommendations. As few clinical trials directly address this topic, the 28 recommendations approved by all members of the task force represent a consensus of expert opinions.

Alcohol Use Disorder and Dementia: A Review

PURPOSE

By 2040, 21.6% of Americans will be over age 65, and the population of those older than age 85 is estimated to reach 14.4 million. Although not causative, older age is a risk factor for dementia: every 5 years beyond age 65, the risk doubles; approximately one-third of those older than age 85 are diagnosed with dementia. As current alcohol consumption among older adults is significantly higher compared to previous generations, a pressing question is whether drinking alcohol increases the risk for Alzheimer's disease or other forms of dementia.

SEARCH METHODS

Databases explored included PubMed, Web of Science, and ScienceDirect. To accomplish this narrative review on the effects of alcohol consumption on dementia risk, the literature covered included clinical diagnoses, epidemiology, neuropsychology, postmortem pathology, neuroimaging and other biomarkers, and translational studies. Searches conducted between January 12 and August 1, 2023, included the following terms and combinations: "aging," "alcoholism," "alcohol use disorder (AUD)," "brain," "CNS," "dementia," "Wernicke," "Korsakoff," "Alzheimer," "vascular," "frontotemporal," "Lewy body," "clinical," "diagnosis," "epidemiology," "pathology," "autopsy," "postmortem," "histology," "cognitive," "motor," "neuropsychological," "magnetic resonance," "imaging," "PET," "ligand," "degeneration," "atrophy," "translational," "rodent," "rat," "mouse," "model," "amyloid," "neurofibrillary tangles," "α-synuclein," or "presenilin." When relevant, "species" (i.e., "humans" or "other animals") was selected as an additional filter. Review articles were avoided when possible.

SEARCH RESULTS

The two terms "alcoholism" and "aging" retrieved about 1,350 papers; adding phrases-for example, "postmortem" or "magnetic resonance"-limited the number to fewer than 100 papers. Using the traditional term, "alcoholism" with "dementia" resulted in 876 citations, but using the currently accepted term "alcohol use disorder (AUD)" with "dementia" produced only 87 papers. Similarly, whereas the terms "Alzheimer's" and "alcoholism" yielded 318 results, "Alzheimer's" and "alcohol use disorder (AUD)" returned only 40 citations. As pertinent postmortem pathology papers were published in the 1950s and recent animal models of Alzheimer's disease were created in the early 2000s, articles referenced span the years 1957 to 2024. In total, more than 5,000 articles were considered; about 400 are herein referenced.

DISCUSSION AND CONCLUSIONS

Chronic alcohol misuse accelerates brain aging and contributes to cognitive impairments, including those in the mnemonic domain. The consensus among studies from multiple disciplines, however, is that alcohol misuse can increase the risk for dementia, but not necessarily Alzheimer's disease. Key issues to consider include the reversibility of brain damage following abstinence from chronic alcohol misuse compared to the degenerative and progressive course of Alzheimer's disease, and the characteristic presence of protein inclusions in the brains of people with Alzheimer's disease, which are absent in the brains of those with AUD.

The chronic alcohol consumption influences the gonadal axis in men: Results from a meta-analysis

BACKGROUND

Low testosterone concentrations affect 2-13% of adult males, with a direct association between reduction in testosterone (T) concentrations and cardiovascular events. Lifestyle habits have been linked to visceral fat accumulation and endocrine disorders like secondary hypogonadism. Alcohol intake has also been a topic of debate, with studies showing a detrimental effect on sperm production and underlying mechanisms. This meta-analysis aims to comprehensively evaluate the effect of alcohol consumption on T serum concentrations in adult men.

METHODS

The literature search included only controlled clinical trials comparing men who drink alcohol to men who do not, or who assumed placebo or nonalcoholic beverages. The primary outcome was the comparison of total testosterone serum concentrations between the study and control groups. The publications were examined for publication bias using Egger's test.

RESULTS

Twenty-one studies were included in the analysis for a total of 30 trials that examined the effects of alcohol consumption on testosterone level in 10,199 subjects. The meta-analysis showed that alcohol consumption overall is related to significant reduction in circulating concentrations of total testosterone (mean difference [MD] = -4.02; 95% CI -6.30, -1.73), free T (MD = -0.17; 95% CI -0.23, -0.12), sex hormone binding globulin (SHBG) (MD = -1.94; 95% CI -3.37, -0.48), an increase in estradiol (E2) (MD = 7.65; 95% CI 1.06, 14.23) and neutral effect on luteinizing hormone (LH) (MD = -0.15; 95% CI -0.36, 0.06), independently by age, body mass index (BMI), E2, and LH serum concentrations and alcohol intake. However, these results are evident only in healthy men exposed to chronic alcohol consumption and not in those with a recognized diagnosis of alcohol use disorder or after acute alcohol intake.

CONCLUSION

This study suggests how chronic alcohol consumption may inhibit the gonadal axis in healthy men, although the exact pathophysiological mechanisms connecting alcohol exposure and steroidogenesis are still not completely clarified.

Gender differences in alcohol drinking among adolescents: a school-based survey in China

BACKGROUND

Alcohol drinking among adolescents is associated with their health development. However, the prevalence of alcohol drinking among adolescents in Southwestern China remains largely unexplored. This study aimed to investigate the prevalence of alcohol drinking, with a particular focus on gender differences, among primary and middle school students in Zigong, a city in Southwestern China. Additionally, we examined the association between alcohol consumption and demographic and family factors.

METHODS

A school-based cross-sectional survey was conducted in a city in Southwestern China, encompassing a total of 89 360 students from 132 different ordinary schools, including both primary and middle schools. Participants were recruited through cluster sampling. The Alcohol Use Disorders Identification Test Consumption was employed to assess alcohol consumption. Gender differences in the prevalence of alcohol drinkers across various schools and grades were analysed. Multivariable logistic regression analysis was used to investigate factors associated with hazardous drinking.

RESULTS

Out of the 89 360 participants, 19.0% reported alcohol drinking, with 2.1% classified as hazardous drinkers. There was a higher prevalence of alcohol drinking among boys compared with girls, as well as hazardous drinking. There were significant gender disparities in alcohol drinking observed across various schools and grade levels. A notable divergence between boys and girls was observed starting from grade 10, with a rising prevalence of hazardous drinking among boys and a decline among girls. Additionally, older age, male gender and being left-behind children were identified as risk factors for hazardous drinking, while belonging to a nuclear family and having parents who do not drink were protective factors against hazardous drinking.

CONCLUSIONS

Alcohol consumption is prevalent among Chinese adolescents, with some even classified as hazardous drinkers. These findings may offer valuable insights for policymakers and caregivers, guiding them in formulating appropriate interventions and support strategies.

Alcohol initiation before age 15 predicts earlier hazardous drinking: A survival analysis of a 7-year prospective longitudinal cohort of Australian adolescents

BACKGROUND AND AIMS

Early alcohol use may predict later alcohol problems, but the magnitude of this effect and impact of delayed onset remain uncertain. This study measured age-based differences in progression from first full alcoholic drink to hazardous drinking in one of the largest and most recent prospective cohorts of Australian adolescents.

DESIGN, SETTINGS, PARTICIPANTS AND MEASUREMENT

A 7-year (2012-19) prospective longitudinal cohort of 2082 Australian adolescents was established from the Climate and Preventure (cohort 1) and Climate Schools Combined (cohort 2) studies. Participants completed surveys annually from ages 13 to 20 years. Interval censored survival analyses were conducted with first episode of hazardous drinking [three or more on proxy Alcohol Use Disorders Identification Test (AUDIT-C)] as the survival end-point, controlling for age, sex and mental health symptomatology. Onset of hazardous drinking was expressed as hazard ratios (HRs), and median survival time (years) was used to model first onset of hazardous alcohol use in survival curves.

FINDINGS

Compared with those aged 15 or older, those who had their first full drink at 12 or younger had significantly elevated risk of hazardous drinking onset during the study period [log (HR): 9.3; 95% confidence interval (CI) = 7.0-12.0, P < 0.001]. Compared with those who had their first full drink at ages 13-14, those who delayed until 15 or older had significantly later onset of hazardous drinking; 1.63 years for males (95% CI = 1.31-1.92, P < 0.001) and 1.50 for females (95% CI = 1.15-1.81, P < 0.001), resulting in a median age of onset of hazardous drinking of > 19 for both sexes (male: 19.05 years, 95% CI = 18.74-19.38; female: 19.47 years, 95% CI = 19.19-19.75). First drink at ages 13-14 was associated with the earliest onset of hazardous drinking (males: 17.43 years; females: 17.98 years).

CONCLUSIONS

In Australia, alcohol initiation prior to age 15 appears to be associated with an earlier onset of hazardous drinking than initiation after age 15.

Diagnostic Criteria for Identifying Individuals at High Risk of Progression From Mild or Moderate to Severe Alcohol Use Disorder

Importance

Current Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (DSM-5) diagnoses of substance use disorders rely on criterion count-based approaches, disregarding severity grading indexed by individual criteria.

Objective

To examine correlates of alcohol use disorder (AUD) across count-based severity groups (ie, mild, moderate, mild-to-moderate, severe), identify specific diagnostic criteria indicative of greater severity, and evaluate whether specific criteria within mild-to-moderate AUD differentiate across relevant correlates and manifest in greater hazards of severe AUD development.

Design, Setting, and Participants

This cohort study involved 2 cohorts from the family-based Collaborative Study on the Genetics of Alcoholism (COGA) with 7 sites across the United States: cross-sectional (assessed 1991-2005) and longitudinal (assessed 2004-2019). Statistical analyses were conducted from December 2022 to June 2023.

Main Outcomes and Measures

Sociodemographic, alcohol-related, psychiatric comorbidity, brain electroencephalography (EEG), and AUD polygenic score measures as correlates of DSM-5 AUD levels (ie, mild, moderate, severe) and criterion severity-defined mild-to-moderate AUD diagnostic groups (ie, low-risk vs high-risk mild-to-moderate).

Results

A total of 13 110 individuals from the cross-sectional COGA cohort (mean [SD] age, 37.8 [14.2] years) and 2818 individuals from the longitudinal COGA cohort (mean baseline [SD] age, 16.1 [3.2] years) were included. Associations with alcohol-related, psychiatric, EEG, and AUD polygenic score measures reinforced the role of increasing criterion counts as indexing severity. Yet within mild-to-moderate AUD (2-5 criteria), the presence of specific high-risk criteria (eg, withdrawal) identified a group reporting heavier drinking and greater psychiatric comorbidity even after accounting for criterion count differences. In longitudinal analyses, prior mild-to-moderate AUD characterized by endorsement of at least 1 high-risk criterion was associated with more accelerated progression to severe AUD (adjusted hazard ratio [aHR], 11.62; 95% CI, 7.54-17.92) compared with prior mild-to-moderate AUD without endorsement of high-risk criteria (aHR, 5.64; 95% CI, 3.28-9.70), independent of criterion count.

Conclusions and Relevance

In this cohort study of a combined 15 928 individuals, findings suggested that simple count-based AUD diagnostic approaches to estimating severe AUD vulnerability, which ignore heterogeneity among criteria, may be improved by emphasizing specific high-risk criteria. Such emphasis may allow better focus on individuals at the greatest risk and improve understanding of the development of AUD.

Molecular Toxicology and Pathophysiology of Comorbid Alcohol Use Disorder and Post-Traumatic Stress Disorder Associated with Traumatic Brain Injury

The increasing comorbidity of alcohol use disorder (AUD) and post-traumatic stress disorder (PTSD) associated with traumatic brain injury (TBI) is a serious medical, economic, and social issue. However, the molecular toxicology and pathophysiological mechanisms of comorbid AUD and PTSD are not well understood and the identification of the comorbidity state markers is significantly challenging. This review summarizes the main characteristics of comorbidity between AUD and PTSD (AUD/PTSD) and highlights the significance of a comprehensive understanding of the molecular toxicology and pathophysiological mechanisms of AUD/PTSD, particularly following TBI, with a focus on the role of metabolomics, inflammation, neuroendocrine, signal transduction pathways, and genetic regulation. Instead of a separate disease state, a comprehensive examination of comorbid AUD and PTSD is emphasized by considering additive and synergistic interactions between the two diseases. Finally, we propose several hypotheses of molecular mechanisms for AUD/PTSD and discuss potential future research directions that may provide new insights and translational application opportunities.

An innovative inpatient protocol for alcohol withdrawal prevention in a 16-year-old adolescent: a case report

BACKGROUND

Alcohol cessation in youth with daily drinking poses a risk of severe and life-threatening alcohol withdrawal. If unsupervised, alcohol withdrawal in heavy users can cause severe complications, such as seizures, delirium tremens, and death. We present the case of a teenager admitted at our pediatric center for the prevention of alcohol withdrawal using an innovative protocol, including a fixed-dosage benzodiazepine regimen.

CASE DESCRIPTION

A 16-year-old Caucasian male, known to have anxiety and an attention deficit disorder, was electively admitted for medical stabilization and surveillance of alcohol withdrawal. He had been previously diagnosed with alcohol use disorder and had a past history of withdrawal symptoms. He was prescribed a course of thiamine, folic acid, as well as a fixed-dosage benzodiazepine taper over 5 days. His withdrawal symptoms were evaluated using a standardized Clinical Institute Withdrawal Assessment for Alcohol scale. During his stay, he reported minimal symptoms, as well as a score on the Clinical Institute Withdrawal Assessment for Alcohol scale consistently lower than 5. His mood, motivation, eating habits and sleeping patterns significantly improved during his stay. He developed no medical complications and demonstrated pride in his successes. He was successfully transferred to a long-term rehabilitation center.

CONCLUSIONS

A withdrawal prevention protocol was developed on the basis of existing literature. It included a soothing environment, basic laboratory work evaluating the medical complications of alcohol use, as well as medication aiming to prevent and reduce potential withdrawal symptoms. The patient responded well to the fixed-dosage taper with minimal symptoms and discomfort. Although alcohol use in adolescents is frequent, alcohol withdrawal in this population is rarely seen in a pediatric hospital setting. Nonetheless, given the lack of existing guidelines regarding alcohol withdrawal in adolescents, standardized protocols could be greatly beneficial for the prevention of this condition in this population.

Elevated plasma macrophage migration inhibitor factor is associated with hypertension and hypertensive left ventricular hypertrophy

Previous studies have found that the macrophage migration inhibitor factor is associated with endothelial dysfunction and ventricular remodelling. The aim of this study was to explore the potential relationship between plasma macrophage migration inhibitor factor levels and hypertension and hypertensive left ventricular hypertrophy. A total of 308 participants (including 187 uncomplicated hypertensive patients and 121 healthy controls) were enroled from 2017 to 2019. The association between macrophage migration inhibitor factors and hypertension and hypertensive left ventricular hypertrophy was estimated with univariate and multivariate logistic regression models. Elevated macrophage migration inhibitor factor was associated with the development of hypertension (second tertile: adjusted OR, 2.27, 95% CI, 1.24-4.16, P = 0.008; third tertile: adjusted OR, 5.43, 95% CI, 2.75-10.71, P < 0.001; compared with the first tertile). In addition, we assessed the association between macrophage migration inhibitor factor and left ventricular hypertrophy in hypertensive patients (n = 187). Plasma macrophage migration inhibitor factor was significantly correlated with hypertensive left ventricular mass index (r = 0.580, P < 0.001). In patients with hypertension, an elevated macrophage migration inhibitor factor was significantly associated with hypertensive left ventricular hypertrophy (second tertile: adjusted OR, 3.20, 95% CI, 1.17-8.78, P = 0.024; third tertile: adjusted OR, 24.95, 95% CI, 8.72-71.41, P < 0.001; compared with the first tertile). Receiver operating characteristic analysis indicated that macrophage migration inhibitor factor had reasonable predictive accuracy for the development of hypertensive left ventricular hypertrophy (area under curve 0.84, 95% CI 0.78-0.90, P < 0.001). Our data indicated that elevated macrophage migration inhibitor factor is associated with hypertension and hypertensive left ventricular hypertrophy.

Definition matters: assessment of tolerance to the effects of alcohol in a prospective cohort study of emerging adults

BACKGROUND AND AIMS

Tolerance to the effects of alcohol is an important element in the diagnosis of alcohol use disorders (AUD); however, there is ongoing debate about its utility in the diagnosis AUD in adolescents and young adults. This study aimed to refine the assessment of tolerance in young adults by testing different definitions of tolerance and their associations with longitudinal AUD outcomes.

DESIGN

Prospective cohort study.

SETTINGS

Australia.

PARTICIPANTS

A contemporary cohort of emerging adults across Australia (n = 565, mean age = 18.9, range = 18-21 at baseline).

MEASUREMENTS

Clinician-administered Structured Clinical Interview for DSM-IV Research Version (SCID-IV-RV) assessed for AUD criteria across five interviews, at 6-month intervals over 2.5 years. Tolerance definitions were operationalized using survey-type response (yes/no), clinician judgement (SCID-IV-RV), different initial drinking quantity and percentage increase thresholds and average heavy consumption metrics. AUD persistence was operationalized by the number of times AUD was present across the 2.5-year study period (n = 491), and new-onset AUD was operationalized as any new incidence of AUD during the follow-up period (n = 461).

FINDINGS

The (i) SCID-IV-RV clinician judgement [odds ratio (OR) = 2.50, P = 0.005], (ii) an initial drinking quantity threshold of four to five drinks and 50% minimum increase (OR = 2.48, P = 0.007) and (iii) 50% increase only (OR = 2.40, P = 0.005) were the tolerance definitions more strongly associated with any new onset of AUD throughout the four follow-up time-points than other definitions. However, these definitions were not associated with persistent AUD (Ps > 0.05). Average heavy consumption definitions of tolerance were most strongly associated with persistent AUD (OR = 6.66, P = 0.001; OR = 4.65, P = 0.004) but not associated with new-onset AUD (Ps > 0.05).

CONCLUSIONS

Initial drink and percentage change thresholds appear to improve the efficacy of change-based tolerance as an indicator for new-onset alcohol use disorder diagnosis in self-report surveys of young adults. When predicting persistent alcohol use disorder, average heavy consumption-based indicators appear to be a better way to measure tolerance than self-reported change-based definitions.