Midwest Alcohol Research Center ARTSS Program
Vivia McCutcheon, PhD
Washington University School of Medicine
June 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 University
Alcoholics 15 Years Later , in Work in Progress on Alcoholism
Annals 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 events
N=46 women with ≥ 2 DUIs
5
16
8
20
19
23
22
25
24
28
27
AGE
29
30
36
32
38
37
40
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
1944-53
*
1934-43
1954-1963
1944-53
1944-53
1934-43
Grucza et al., ACER, 2008
Prevalence Lifetime AD among drinkers,
by Age Cohort
Women
Men
1954-1963
*
1944-53
Grucza et al., ACER, 2008
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
Telescoping
Time 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
Gastric Bleeding
Malnutrition
Hypertension
Fatty liver
0
5
10
Men
Ashley et al., 1977, Archives Internal Medicine
15
Women
20
25
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 alcoholdependent individuals before treatment
included 3 women (out of 51 participants)
(Durazzo et al., 2010, JSAD)
Treatment
Barriers
Rates & 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 populationbased 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!