Substance-Related and Addictive Disorders

The Importance of Identifying Characteristics Underlying the Vulnerability to Develop Alcohol Use Disorder Ismene L. Petrakis, M.D.

The article by Gowin et al. (1), in this issue of the Journal, describes a study evaluating characteristics that represent risk factors for the development of alcohol use disorder. The authors carefully examined a large sample of healthy social drinkersusingan innovative laboratoryparadigmandfoundthat family history of alcoholism, male sex, and impulsivity—when combined—were associated with high rates of binge drinking during the laboratory paradigm.This study documents different patterns of alcohol exposure within individual drinking ses- sions. The findings suggest that those with characteristics as- sociatedwith a higher risk of developing alcohol use disorder experiencedhigheralcoholexposurewithinsessions.Theau- thors conclude that young social drinkers at risk for alcohol usedisorderhavemarkedly different patternsof drinking and encourage the evaluation of bingedrinking in clinical settings as a potential indicator of vulnerability to alcohol use disorder.

This study is quite timely, and its publication for a wide psychiatric audience is important given the recently docu- mentedincrease intheprevalenceofalcoholusedisorder.Over the past decade, there has been a dramatic increase in rates of alcohol use, high-riskdrinking, and alcohol-related conditions (2).Thisdespite scientificadvances intheunderstandingof the underlying neurobiology (3), genetics (4), and treatment of alcohol use disorder (5). The high rates of consumption with the resultant medical consequences and socioeconomic cost re- present a public health crisis. Thefinding that high-risk drinking is on the rise suggests that understanding factors that influence problematic drinking patterns and targeting high-risk groups should be a priority for health care professionals.

The present study does exactly that. It extends the exist- ing literature about risk factors associated with vulnerability for alcohol use disorder. The risks of developing alcohol use disorder include a strong family history of alcoholism (6), sex (6), and impulsivity (7). Research on understanding the mechanisms of these underlying risks has focused on altered subjective response to alcohol in the laboratory, for example, basedon familyhistory (8), impulsivity (9), andgenotype (10). Nevertheless, conflicting results have been reported (11), and discrepant hypotheses on the relationship of subjective re- sponse to family history have been proposed (8). In addition, it is hard to control for other factors, and some studies have suggested that drinking history, rather than family history, is the important factor determining alcohol response and subsequent risk (12). Furthermore, subjective response may

or may not lead to differences in drinking patterns outside of laboratory settings.

This study extends previous findings in two important ways. First of all, the authors have simultaneously evaluated several different previously identified factors. Results from this study suggest that the risk factors are additive, which is both intuitive and important when considering a complex disorder such as alcohol use disorder. More importantly, however, the authors have evaluated these risk factors per- taining to actual patterns of drinkingor alcohol exposurewithin a controlled laboratory setting. These data would be hard to collect outside a laboratory setting, given the limitations of self- report of alcohol use and the introduction of other factors that might complicate results. Given the recent epidemiologic findings, results suggest- ing that family history is related to alcohol exposure and binge drinking, rather than subjective response, indicate that binging may be a more meaningful clin- ical phenomenon.

The methodology of this study deserves to be highlighted. There aremany paradigms used in research that provide a platform for understanding factors thought to be important to vulnerability and relapse; these include sub- jective effects of alcohol, alcohol consumption patterns, and related phenomenon such as craving. Paradigms using oral alcohol administration, including self-administration, while ecologically valid cannot control for factors such as variable absorption and metabolism (13). The novel paradigm used in this study is a self-administration intravenous paradigm, whichcontrols for interindividualdifferences, andeliminates cues (which may be both a strength and a weakness) and is thought to reflect pure pharmacologic effects. This paradigm has been used to test bothmedication and genetic effects (14, 15). It has the potential to be an important tool in medication development, as a way to test novel compounds before con- ducting larger clinical trials.

There are several limitations of this study that should be acknowledged.Theeliminationof factors that influencedrinking are also a weakness, since expectancy, taste, and environmental cues influence drinking in a “real-world” environment. As such,

The high rates of consumption with the resultant medical consequences and socioeconomic cost represent a public health crisis.

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EDITORIALS

this paradigm loses someecological validity. As the authorspoint out, the cross-sectional design is a limitation, and they suggest that longitudinal work would be an important next step when evaluatingwhether thedrinkingpatternsnoted in the laboratory are associated with long-term risk of the development of alco- hol use disorder.

Despite these limitations, the undertaking of well-designed, laboratorystudies identifyingriskfactorsforthedevelopmentof alcoholusedisorder issorelyneeded.Despitedecadesofworkin the alcohol-related field, findings have not influenced actual behavior asmeasured by the prevalence of alcohol use disorder or of alcohol-related medical consequences. As the treatments developed have modest efficacy and poor uptake (16), efforts toward preventing the development of alcohol use disorder could have important benefits. The authors make the clinical point that binge drinking may be an indicator of vulnerability and should be assessed. This perhaps should be taken a step further, since evidence is mounting that there are clinical characteristics that influence risk. There is sufficient evidence to support a good clinical evaluation that includes the assess- ment of other factors such as family history and impulsivity as possible risk factors, which may lead to binge drinking and increase the risk. It is important for the scientific community to developassessmentsandinterventionsthatcanbedisseminated widely to evaluate and address alcohol use-related disorders.

AUTHOR AND ARTICLE INFORMATION

From the VAConnecticut Healthcare System,WestHaven, Conn., and the DepartmentofPsychiatry, YaleUniversity School ofMedicine,NewHaven, Conn.

Address correspondence to Dr. Petrakis ([email protected]).

Dr. Petrakis has servedasaconsultant toAlkermes.Dr. Freedmanhas reviewed this editorial and found no evidence of influence from this relationship.

Accepted August 2017.

AmJPsychiatry2017;174:1034–1035;doi: 10.1176/appi.ajp.2017.17080915

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