Alcohol Research: Current Reviews: V40(2), 2020: Women and Alcohol

2020·8.4 MB·English

THE JOURNAL OF THE NATIONAL INSTITUTE ON ALCOHOL ABUSE AND ALCOHOLISM
W a
omen and lcohol
V 40, n 2, 2020
olume umber
TABLE OF CONTENTS
From the Editors
Mary E. McCaul and Ivana Grakalic
Gender Differences in the Epidemiology of Alcohol Use and
Related Harms in the United States
Aaron M. White
The Endocrine System and Alcohol Drinking in Females
Deborah A. Finn
Alcohol’s Unique Effects on Cognition in Women: A 2020 (Re)view to
Envision Future Research and Treatment
Rosemary Fama, Anne-Pascale Le Berre, and Edith V. Sullivan
Sex Differences in the Neurobiology of Alcohol Use Disorder
Annabelle Flores-Bonilla and Heather N. Richardson
The Role of Stress, Trauma, and Negative Affect in Alcohol Misuse and
Alcohol Use Disorder in Women
Maria Isabel Barros Guinle and Rajita Sinha
Maternal Substance Use: Consequences, Identification, and Interventions
Grace Chang
Alcohol Screening, Brief Intervention, and Referral to Treatment (SBIRT)
for Girls and Women
Kyndal Hammock, Mary M. Velasquez, Hanan Alwan, and Kirk von Sternberg
Treatment Interventions for Women With Alcohol Use Disorder
Barbara S. McCrady, Elizabeth E. Epstein, and Kathryn F. Fokas
Alcohol-Related Disparities Among Women: Evidence and
Potential Explanations
Nina Mulia and Kara M. Bensley
Alcohol and Liver Function in Women
Haripriya Maddur and Vijay H. Shah
Alcohol’s Effects on Breast Cancer in Women
Jo L. Freudenheim
Effects of Alcohol on the Cardiovascular System in Women
Mariann R. Piano, Laurel A. Thur, Chueh-Lung Hwang, and Shane A. Phillips
Sleep and Alcohol Use in Women
Sarah M. Inkelis, Brant P. Hasler, and Fiona C. Baker
Alcohol Research: Current Reviews Vol 40 No 2 | 2020
Alcohol Res. 2020;40(2):14 • https://doi.org/10.35946/arcr.v40.2.14
Published: 5 November 2020
F e
rom the ditors
Mary E. McCaul1 and Ivana Grakalic2
1Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine,
Baltimore, Maryland
2Division of Neuroscience and Behavior, National Institute on Alcohol Abuse and Alcoholism,
National Institutes of Health, Bethesda, Maryland
Recent epidemiological research has identified “Gender Differences in the Epidemiology of
alarming trends in drinking patterns of girls Alcohol Use and Related Harms in the United
and women in the United States. In recent years, States” provides an update on the diminishing sex
the amount and frequency of alcohol use are differences in alcohol consumption, related health
increasing in White and Hispanic girls and young problems, hospitalizations, emergency department
women in contrast to decreasing patterns of heavy visits, and death across the life span.8 Of particular
alcohol use in boys and young men.1,2 Similarly, concern, White highlights the reversal in historical
current and binge alcohol use is rising among alcohol consumption patterns of underage drinkers,
older women,3,4 resulting in increased morbidity such that adolescent girls now report higher rates of
and mortality in this growing segment of the U.S. monthly alcohol use and binge drinking compared
population. For example, emergency room visits with adolescent boys.8 Findings have important
associated with both acute and chronic drinking5 implications for prevention of fetal alcohol
and alcohol-related inpatient diagnoses in U.S. spectrum disorders.
middle-aged adults6 have accelerated more rapidly As illustrated in articles throughout this ARCR
in women than men. Overall, these changes have topic series, many alcohol-related sex differences—
narrowed the long-established gender gap in including development and maintenance of alcohol
alcohol consumption and associated problems, misuse, alcohol-driven cognitive and medical
with women’s drinking patterns across the life problems, and even psychiatric comorbidities—
cycle approaching those of men. derive from key differences in the neurobiology
These epidemiological trends have increased of men and women. In “Sex Differences in the
the urgency of sex-specific, gender-focused Neurobiology of Alcohol Use Disorder,” Flores-
research on alcohol.7 Historically, because they Bonilla and Richardson explore preclinical
were underrepresented among heavy/problem and human research on neural differences
drinkers, women often were omitted from a wide using a three-stage framework of addiction.9
range of alcohol studies, including basic science on Specifically, they examine how neurobiological
alcohol effects in women, alcohol-related medical differences contribute to initial development of
morbidities, social/behavioral consequences of binge/intoxicated drinking, the transition into
drinking, and treatment intervention studies. With withdrawal, negative affect and dysfunctional
this topic series on women and alcohol, Alcohol behaviors associated with continued heavy
Research: Current Reviews (ARCR) seeks to close drinking, and finally development of preoccupation
these knowledge gaps and identify important areas with or craving for alcohol and compulsive
for future research directions. drinking, and relapse.9
Alcohol Research: Current Reviews 1 Vol 40 No 2 | 2020
In “The Endocrine System and Alcohol psychiatric factors that may be contributing to the
Drinking in Females,” Finn extends this accelerating drinking patterns recently observed
neurobiological review by examining the in girls and women.14 Of particular concern is
multidirectional interactions of alcohol, stress, and the growing evidence of a sex-related, chronic
key gonadal sex steroid hormones and stress steroid negative feedback cycle in which childhood
hormones.10 Findings suggest promising directions maltreatment and trauma lead to the development
for development of novel pharmacological of a maladaptive, blunted stress response in girls
treatments for alcohol use disorder (AUD). and women.14 In turn, this blunted neurobiological
In “Alcohol’s Unique Effects on Cognition response escalates alcohol consumption,
in Women: A 2020 (Re)view to Envision Future further blunting neuroendocrine responses, and
Research and Treatment,” Fama, Le Berre, and contributing to the progression from alcohol
Sullivan provide a wide-ranging update on the misuse to AUD.
interrelationships between alcohol and cognition, Given differences between women and
including effects of acute and chronic alcohol men in risk factors, developmental course, and
consumption across the drinking continuum.11 health and psychosocial consequences of alcohol
Although current research indicates many overall misuse and AUD, tailored approaches to alcohol
similarities in structural and functional effects identification, prevention, and intervention for
of alcohol in women and men, the authors bring girls and women may be necessary to maximize
focus to factors that may influence sex-specific treatment outcomes. Indeed, specialized
differences, such as age, drinking patterns, screening instruments that are more sensitive and
abstinence duration, and medical history specific to women are available to improve case
and psychiatric comorbidities.11 One area of identification.15 Although evidence suggests that
particular relevance for women is the effects of women and men have comparable outcomes in
alcohol on social and emotional cognition; this mixed-gender, nonspecialized alcohol treatments,16
relatively young area of cognitive research has women cared for in specialized, women-specific
important implications for both development and programs may experience greater improvements in
consequences of AUD. Overall, it is clear that key areas such as pregnancy outcomes, psychiatric
women who are chronic heavy drinkers experience health, HIV risk reduction, and psychosocial well-
cognitive deficits relative to age-matched women being.17 These areas are reviewed in several key
who are social drinkers or do not drink. These articles in this topic series.
findings should be used to inform development In “Maternal Substance Use: Consequences,
and adaptations of alcohol treatment interventions Identification, and Interventions,” Chang reviews
and recovery programs for women. prevalence and addresses the importance of early
It is well established that women experience identification and intervention for substance use
higher prevalence of mood and anxiety disorders12 among pregnant women, with emphasis on alcohol,
and more frequent interpersonal trauma associated tobacco, cannabis, and opioid exposure.18 She
with higher prevalence of post-traumatic stress reviews strengths and shortcomings of available
disorder13 compared with men, and that these screening tools specific to pregnant women, legal
negative factors have a role in the development and social barriers to implementation of universal
and maintenance of heavy drinking and screening, and available prevention intervention
associated problems in women. In “The Role strategies, particularly for fetal alcohol spectrum
of Stress, Trauma, and Negative Affect in the disorders.18
Development of Alcohol Misuse and Alcohol In “Alcohol Screening, Brief Intervention,
Use Disorder in Women,” Barros Guinle and and Referral to Treatment (SBIRT) for Girls and
Sinha examine the sex-specific neurobiological Women,” Hammock, Velasquez, Alwan, and von
underpinnings of the biological, psychosocial, and Sternberg provide a comprehensive review of
Alcohol Research: Current Reviews 2 Vol 40 No 2 | 2020
the effectiveness of this evidence-based, public socioeconomic groups experience greater harm
health approach to identifying and intervening in despite comparable or lower alcohol consumption.
heavy/harmful alcohol use across the life span, The authors consider possible explanations and
specifically examining SBIRT for girls, women interventions for these disparities.22
of childbearing age, and older women.19 This Finally, we have known for decades that women
clinically relevant, evidence-based article offers are more vulnerable to many of the negative health
information on age-appropriate screening tools consequences of alcohol consumption, in part,
and intervention approaches.19 It also summarizes due to their higher blood alcohol levels achieved
facilitators and barriers to SBIRT implementation at comparable alcohol doses compared with
in social service and health care settings,19 men. Now, research is providing system-specific
including recently identified unanticipated findings of the interplay of alcohol and health
consequences of state-level policies related to in women. Indeed, this topic series addresses
alcohol use during pregnancy.20 sex-specific health effects of alcohol in four key
“Treatment Interventions for Women With areas. In “Alcohol and Liver Function in Women,”
Alcohol Use Disorder” examines women’s barriers Maddur and Shah address the increasing rates of
to treatment seeking and referral, program liver disease in women, the key role that estrogen
services to address these barriers, and efficacy plays in the greater vulnerability and more rapid
of women-specific services relative to traditional progression to alcohol-related liver disease in
mixed-gender care.21 Importantly, McCrady, women compared with men, and sex differences
Epstein, and Fokas address mechanisms of in liver transplant availability and outcomes.24
change, which often are overlooked but highly In “Alcohol’s Effects on Breast Cancer in
relevant to successful development of strategies Women,” Freudenheim highlights the compelling
to tailor treatment to women more effectively.21 evidence that any alcohol use increases breast cancer
Finally, the article considers the effects of women- risk and that risk increases as total consumption
specific substance abuse services on a breadth of increases, emphasizing the importance of targeting
outcomes, ranging from the primary targets of this modifiable risk factor for public education and
alcohol and drug use to secondary outcomes such intervention.25 Current findings suggest that these
as psychosocial well-being, psychiatric health, effects are independent of alcohol beverage type or
pregnancy outcomes, and HIV risk reduction.21 age at alcohol exposure. The author reviews possible
Although much of the research discussed mechanisms for this increased risk including direct
in this topic series addresses sex-specific carcinogenic effects of alcohol and acetaldehyde,
findings, it is critical to bear in mind that this changes in hormones associated with drinking, and
literature often obscures important differences alterations in DNA methylation.25
among women as a group. In “Alcohol-Related Cardiovascular (CV) diseases (e.g.,
Disparities Among Women: Evidence and hypertension, coronary heart disease, stroke)
Potential Explanations,” Mulia and Bensley are the leading cause of death in women.26
address key foci of diversity research, including In “Effects of Alcohol on the Cardiovascular
race, ethnicity, socioeconomic and social status, System in Women,” Piano, Thur, Hwang, and
and sexual orientation.22 Although the research Phillips address the sex-specific findings about
to date is quite limited, these factors have been the contribution of alcohol consumption to CV
shown to influence not only effects of acute morbidity and mortality.27 Unlike the generally
and chronic alcohol consumption, but also linear relationship between drinking and CV
alcohol-related health disparities and access to disease in men, there appears to be a J-shaped
care. The article highlights the “alcohol harm function for women, with no or lower CV risk
paradox”23—that certain racial/ethnic minority at one or two drinks per day and increased risk
groups, particularly African Americans, and lower at and above three or four drinks per day.27 The
Alcohol Research: Current Reviews 3 Vol 40 No 2 | 2020
Publisher’s Note
authors examine the contributions of estrogen to
Opinions expressed in contributed articles do not necessarily
these relationships.27 reflect the views of the National Institute on Alcohol Abuse and
Women are more likely to experience insomnia Alcoholism, National Institutes of Health. The U.S. government
does not endorse or favor any specific commercial product or
and other common forms of sleep dysregulation
commodity. Any trade or proprietary names appearing in Alcohol
compared with men and, in turn, sleep disruption Research: Current Reviews are used only because they are
considered essential in the context of the studies reported herein.
has more severe health consequences for women
Unless otherwise noted in the text, all material appearing in this
compared with men.28 Despite the fact that sleep journal is in the public domain and may be reproduced without
disturbance is one of the most frequent complaints permission. Citation of the source is appreciated.
among persons with AUD,29 sex differences in
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Alcohol Research: Current Reviews 5 Vol 40 No 2 | 2020
Alcohol Res. 2020;40(2):01 • https://doi.org/10.35946/arcr.v40.2.01
Published: 29 October 2020
G d
ender ifferences in the
e A
pidemioloGy of lcohol
U r h
se And elAted Arms
U s
in the nited tAtes
Aaron M. White1
1National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
Over the past century, differences in alcohol use and related harms between males and
females in the United States have diminished considerably. In general, males still consume
more alcohol and experience and cause more alcohol-related injuries and deaths than
females do, but the gaps are narrowing. Among adolescents and emerging adults, gaps in
drinking have narrowed primarily because alcohol use among males has declined more than
alcohol use among females. Among adults, alcohol use is increasing for women but not for
men. Rates of alcohol-related emergency department visits, hospitalizations, and deaths all
have increased among adults during the past two decades. Consistent with the changing
patterns of alcohol use, increases in these outcomes have been larger for women. Recent
studies also suggest that females are more susceptible than males to alcohol-induced liver
inflammation, cardiovascular disease, memory blackouts, hangovers, and certain cancers.
Prevention strategies that address the increases in alcohol consumption and unique health
risks for women are needed.
KEY WORDS: alcohol use disorder, sex, brain, development, stress, mental health, alcohol
INTRODUCTION
alcohol.1 Alcohol caused roughly 3 million deaths
Alcohol consumption has long been a male- (5% of all deaths) that year, including 2.3 million
dominated activity. Globally, men consume more deaths for men (8% of deaths) and 0.7 million
alcohol and account for more alcohol-related harms deaths for women (3% of deaths). Although gender
to self and others than women do. In 2016, 54% gaps in alcohol use seemingly are universal, the
of males (1.46 billion) and 32% of females (0.88 size of the gaps varies between countries and their
billion) age 15 and older worldwide consumed respective cultures, from a male to female ratio for
Alcohol Research: Current Reviews 1 Vol 40 No 2 | 2020
current drinking of 1:1 in New Zealand and Norway narrowing for different reasons among adolescents
to 12.3:1 in India.1-3 Large variations between and emerging adults relative to adults. Specifically,
countries suggest that culturally prescribed alcohol use is declining faster for adolescent and
gender roles, above and beyond physiological sex emerging adult males than for females, whereas gaps
differences, are central in shaping gender-specific are narrowing among adults because of increases in
drinking patterns.4 drinking by women but not by men.15,16
In the United States, more males than females
drink each year (68% males, 64% females). Males
drinkers tend to drink more often and more heavily 100 Past-month alcohol use
than females do,5 consuming nearly three times as Male Female
much pure alcohol per year (19.0 liters for males,
90 Past-year DSM-IV AUD
6.7 liters for females).1,6 Males also are more likely
Male Female
to be arrested for driving under the influence of
alcohol (DUI),7 treated in emergency departments
80
and hospitals for alcohol-related harms,8-10 and to
die from alcohol-related causes.11 In addition, more
males (7%) than females (4%) are diagnosed with )
% 70
an alcohol use disorder (AUD) each year. Among (

r
those with AUD, roughly similar percentages of e
d
males (9%) and females (9%) receive treatment.6 ol 60
Research examining harms experienced due to d
n
another person’s drinking suggests women are more a

likely than men to suffer consequences as a result of 2 50
1

alcohol use by a spouse/partner/ex-partner (4.2% vs. s
e
1.8%) or a family member (5.6% vs. 3.7%).12,13 g
a 40

s
n
NARROWING GENDER GAPS o
s
r
e 30
Although males still outpace females for most P
alcohol-related measures, the gaps are narrowing5,14
(see Figure 1). In the 85 years since the end of
20
Prohibition, drinking habits of males and females
have converged. For cohorts born near 1900, males
outnumbered females roughly 3:1 for measures of 10
alcohol consumption (e.g., prevalence, frequency)
and problematic drinking (e.g., binge drinking,
0
early-onset drinking). Many of these ratios are closer
2 4 6 8 0 2 4 6 8
to 1:1 today, and the differences continue to become 200 200 200 200 201 201 201 201 201
smaller (see the box Summary Statistics on Female
Year
and Male Alcohol Use and Outcomes in the
United States and Figure 1).14 An analysis of six Figure 1 Narrowing gender gaps in the prevalence of
past-month alcohol use and past-year DSM-IV
different national surveys between 2000 and 2016
AUD between females and males age 12 and
suggests that the number of women age 18 and older
older using data from NSDUH 2002–2012.
who drink each year increased by 6% but decreased
Gender gaps narrowed for both measures,
by 0.2% for men, and the number of women who primarily due to increases in alcohol use among
binge drink increased by 14% but by only 0.5% females and smaller declines in AUD among
for men.15 As this article explores, gender gaps are females than males. Source: White et al., 2015.5
Alcohol Research: Current Reviews 2 Vol 40 No 2 | 2020
Summary Statistics on Female and Male Alcohol Use and Outcomes in the United States
Drinking patterns
• Female drinkers consume about one-third as much total pure alcohol per year as male drinkers (6.7 liters for
females, 19.0 liters for males).1
• Alcohol use among people age 12 and older: Lifetime—82% male, 78% female; Past year—68% male, 62%
female; Past month—55% male, 46% female; Binge (4+/5+)* past month—29% male, 20% female28
DSM-IV AUD† (alcohol abuse or dependence) age 12 and older
• Past-year AUD—males, 9.2 million (7%); females, 5.3 million (4%)28
• Percentage who needed and received treatment for DSM-IV alcohol abuse or dependence—males, 9%;
females, 9%28
Overall deaths
• In 2017, 72,558 death certificates listed alcohol as a factor (18,072 females and 54,486 males).64
• Using death certificates and estimates, the Centers for Disease Control and Prevention calculated that 93,296
people died from alcohol-related causes each year between 2011 and 2015 (26,778 females and 66,519 males).11
• The World Health Organization reported that excessive drinking accounted for roughly 3 million deaths (5% of
all deaths) worldwide, including 2.3 million deaths for men (8% of deaths) and 0.7 million deaths for women
(3% of deaths).1
Cirrhosis deaths
• In 2017 there were 44,478 deaths due to cirrhosis and 50% (22,246) were caused by alcohol (15,470 deaths
among males; 6,776 deaths among females).10
• Overall, the rate of death from alcohol-related cirrhosis is more than twice as high for men (9.7 per 100,000)
than for women (4.1 per 100,000).10
Driving under the influence
• More men (10%) than women (5%) reported driving under the influence of alcohol (DUI) in the past year in 2017.19
Gender gaps are narrowing
• Differences are shrinking in drinking patterns, AUD, hospitalizations, emergency department visits, DUI, liver
disease, and deaths.5,14-16,31
*Binge drinking: Defined as four or more drinks on an occasion for females and five or more drinks on an occasion for males
(4+/5+).
†AUD: According to criteria for alcohol abuse and alcohol dependence in the fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV).
ADOLESCENTS
during this period (see Table 1). Among students
Alcohol use, like other drug use, becomes ages 12 to 17, past-month alcohol use is reported
more likely as young people enter and progress by 12% of White students, 9% of Hispanic or
through adolescence, which encompasses the Latino students, 8% of American Indian or
second decade of life or more.17 Data from the Alaska Native students, 6% of Black or African
2018 National Survey on Drug Use and Health American students, 6% of Asian students, and
(NSDUH) suggest that, by age 12, approximately 1 11% of students of two or more races.6 Although
in 100 (1%) adolescents report consuming alcohol more boys (19%) than girls (13%) start drinking
in the previous month.6 The prevalence increases before age 14, girls who begin drinking in early
to nearly 1 in 4 (23%) by age 17. Racial, ethnic, adolescence have a shorter time period between
and gender differences in alcohol use also emerge first drink and first episode of binge drinking.6,18
Alcohol Research: Current Reviews 3 Vol 40 No 2 | 2020