Exploring the use of alcohol-interactive prescription medication among US drinkers

Approximately 71 percent of American adults drink alcohol. While alcohol interacts negatively with a number of commonly prescribed medications, little is known on a population level about the use of alcohol-interactive (AI) prescription medication among US drinkers. A new study has found that almost 42 percent of drinkers in the US population have used one or more alcohol-interactive prescription medications.

Results will be published in the February 2015 online-only issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"To our knowledge there have been only four previous US population-based studies," said Rosalind A. Breslow, an epidemiologist in the division of epidemiology and prevention research at the National Institute on Alcohol Abuse and Alcoholism as well as corresponding author for the study. "Three, conducted only among elderly people, concluded that substantial numbers of seniors were both drinking and taking alcohol-interactive medications and called for increased awareness about possible harmful consequences. One, conducted among adults of all ages, had a similar conclusion based on assessment of a limited number of prescription medications. Ours is a national-level study that estimates the proportion of adult drinkers who use a wide range of prescription medications that can interact with alcohol to cause numerous harms ranging from nausea, headaches, and loss of coordination to internal bleeding, heart problems, and difficulties in breathing."

Breslow added that her group expected to find greater prevalence among older drinkers. "People develop more chronic diseases as they age," she said, "so older people are more likely to be taking medications, many of which can interact harmfully with alcohol. They also may be taking multiple medications to treat multiple diseases. In addition, older people are at particularly high risk for harmful alcohol-medication interactions. There is some evidence that, as we age, our ability to metabolize alcohol decreases so alcohol might remain in our systems longer to interact with medications. Furthermore, the metabolism of several medications that interact with alcohol slows as we get older, creating a larger window for potential alcohol/medication interactions. For instance, diazepam -- known as Valium -- hangs around in the body about three times longer in a 60-year-old than a 20-year-old, thereby creating a much longer window for potential interactions with alcohol."

Breslow and her co-authors examined data from the 1999-2010 National Health and Nutrition Examination Survey, in which 26,657 adults (13,557 men, 13,100 women) aged ?20 years had provided data on past-year alcohol consumption and past-month prescription medication use. Analyses were adjusted for age, race/ethnicity, education, marital status, and smoking, and were also weighted in order to be nationally representative.

"Almost 42 percent of drinkers in the US population used one or more AI prescription medications," said Breslow. "Among seniors, aged 65 and older, the proportion was even higher, almost 78 percent. Regardless of age, the main therapeutic classes of AI medications used in the population were cardiovascular agents such as blood pressure medications, central nervous system agents such as sleeping pills, pain medications, and muscle relaxers, metabolic agents such as medications for diabetes and cholesterol, and psychotherapeutic agents such as antidepressants and antipsychotics."

Breslow noted that her group had expected a high prevalence rate, however, she emphasized that the data referred to potential, not actual, prevalence. "The data don't tell us exactly how many people in that 41.5 percent actually drink and take their medications within a similar time frame or how often they do so," she said. "However, if someone drinks regularly and takes medications regularly, the likelihood of taking them within a similar time frame is pretty high."

According to co-author Aaron White, a neuroscientist in the division of epidemiology and prevention research at the National Institute on Alcohol Abuse and Alcoholism, the consequences of mixing prescription medications with alcohol can have a variety of effects, some deadly.

"Alcohol can increase blood pressure, which could be counterproductive if one is taking medications to control blood pressure," he explained. "Mixing diuretic medications with alcohol, which is also a diuretic, could contribute to dehydration. Mixing alcohol and other sedatives, like sleeping pills or narcotic pain medications, can cause sleepiness, problems with coordination, and potentially suppress brain stem areas tasked with controlling vital reflexes like breathing, heart rate, and gagging to clear the airway. Alcohol increases insulin levels and lowers blood glucose, so combining alcohol with antidiabetic agents that regulate glucose levels could cause an undesirable drop in blood sugar. And, over time, alcohol can contribute to insulin insensitivity."

"Our findings highlight a major gap in the literature," said Breslow. "We found no US nationally representative data that queried combined use of alcohol with a wide range of prescription medications and yet it appears that a large percentage of people who drink regularly could be at risk of serious alcohol and medication interactions."

Breslow suggested that individuals who drink, particularly the elderly, should be educated about of the risks of combining alcohol with their medications. "We suggest asking one's doctor or pharmacist whether they should avoid alcohol while taking the medications they are prescribed," she said.

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Genes, environment contribute to personal, peer drinking during adolescence and beyond

Alcohol use typically begins during adolescence, within social contexts, and is often correlated with the drinking of one's peers. A new study of how a person's drinking is related to the alcohol use of their peers from early adolescence through to early adulthood has found that both genetic and environmental factors contribute to the correlation between one's own drinking and peer drinking.

Results will be published in the February 2015 online-only issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

"Peers can influence adolescent drinking in different ways," said Alexis C. Edwards, assistant professor in the department of psychiatry at Virginia Commonwealth University as well as corresponding author for the study. "Peer pressure can work in both directions: some kids feel pressured, others are the ones exerting the pressure for whatever reason. Peer pressure doesn't have to be explicit; kids can perceive pressure that's never verbalized. Another way that peers can influence drinking is simply by providing access to alcohol. Furthermore, adolescent drinking behavior often occurs in the context of peer groups rather than in solitary situations. Therefore, it's important not to overlook the role that choice plays in all these scenarios: to varying extents, kids select which peers they hang out with, which in turn has consequences for alcohol use."

"Peer behavior is perhaps the most enduring social correlate of both contemporaneous and subsequent alcohol use, so studies specifically designed to explore the etiology underlying these associations, and particularly those that examine mechanistic processes, are tremendously important to the field," added Shawn J. Latendresse, assistant professor in the department of psychology & neuroscience at Baylor University.

"We have access to a rich twin dataset that uniquely allows us to tease apart the complicated relationships of peer selection and peer influence, all in the context of genetic and environmental influences underlying behavior," said Edwards. "We examined men simply because we only had the necessary data for men. It would be very interesting to see if the same patterns hold among women, because there are some differences in drinking behaviors across the sexes."

Edwards and her colleagues used data collected in Wave Three of the Virginia Adult Twin Study of Psychiatric and Substance Use Disorders. From that larger study of adult Caucasian twins, study authors analyzed data from a sample of 1,790 men, provided through structured clinical interviews that included retrospective reports of their own drinking as well as their peers' alcohol-related behaviors from adolescence into young adulthood, ages 12 to 25 years. The influence of three plausible models of genetic and environmental influences on the relationship between phenotypes was examined over time.

"There seem to be two take-home messages," said Edwards. "First, genetic and environmental factors contribute to the correlation between one's own drinking and their peers' drinking. Second, apart from these shared genetic and environmental liabilities, there are causal processes at play: your own drinking phenotype causes you to select peers based on their drinking, and your peers' drinking influences your own drinking."

"Most notable, from the perspective of developmental science, is the fact that this study provides initial evidence of bidirectional influences among the drinking behaviors of individuals and their peers," added Latendresse. "Yet, despite increasing additive genetic influences across adolescence, the majority of the variance in alcohol consumption continues to be attributable to environmental factors. This is particularly encouraging, as there remains great potential within the research community to identify modifiable aspects of the environment that can then serve as the focus of applied prevention/intervention efforts."

Both Edwards and Latendresse commented on the finding of a clear increase in the influence of genetic factors as the adolescents moved into adulthood, and a corresponding decrease in the influence of shared environmental factors.

"The increase in the relevance of genetic factors is pretty typical," said Edwards. "As we age and gain more autonomy, our behavior is driven more by our own genetic liabilities and we are less influenced by the familial environment."

"In general, as twins mature and become more independent of one another -- for example, attend different schools, live in separate homes -- they tend to share fewer of the influences within their physical and social environments, while their genetic similarities remain constant," added Latendresse. "Of course, unique aspects of the twins' environments are just as influential as their shared biology, and often more so, when it comes to their own alcohol consumption and the perceived consumption of their peers."

"I hope that our study helps clarify the relationship observed between self and peer drinking behaviors across adolescence into adulthood," said Edwards. "But there's no way around the fact that this relationship is complicated. Our contribution is to provide evidence that shared genetic/environmental liabilities and causal processes are at play simultaneously: the association isn't an either/or situation."

Latendresse agreed. "It is also important to note that the increasing role of genes across development that is evidenced in this, and many other studies, might not be as straight forward as it appears. For example, because one's genes generally aren't subject to change, any change in the influence or expression of one's genes is likely 'triggered' by other biological and/or environmental processes. However, within the types of statistical models employed in this study, all of these conditional effects would necessarily be partitioned in with the additive genetic variance. In this way, environmental influence has the potential to be misallocated."

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