1. Motivations for Alcohol Use Evan Goulding, MD, PhD Department of Psychiatry and Behavioral Sciences Feinberg School of Medicine Northwestern University

2. © Alcohol Medical Scholars Program 2 Alcohol Related Problems  Costly: $185 billion  Lethal: 3 rd leading modifiable cause death

3. © Alcohol Medical Scholars Program 3  Alcohol use common –Drink during lifetime= 90%  BUT only some develop problems –Disorder during lifetime = 15%  Problems take time to develop  Gives clinicians time to intervene  NEED TO KNOW WHO IS AT RISK Identify Risk Factors

4. © Alcohol Medical Scholars Program 4 Reasons As Risks  Certain reasons → ↑ risk  Knowing reasons (motivations) –Identifies risk –Can guide intervention –Assist ↓ use and harm

5. © Alcohol Medical Scholars Program 5 Three Cases  Common characteristics – 18 yr old males, starting college – Say drinking makes going out more fun  Tom: –likes the high, it’s exciting, pleasant  Rich: –helps enjoy party, celebrate, fit in, be liked, sociable  Harry: –likes feeling, ↑ confidence, helps upset, cheers up

6. © Alcohol Medical Scholars Program 6 Lecture Covers  Alcohol use and problems  Risk factors for problems  Types of motivations for use  Personality, motivations, problems  How motivations guide treatment

7. © Alcohol Medical Scholars Program 7 Key Points  Different motivations for use: – Exist – Predict different levels of risk  Asking about motivations: – Can guide clinical care

8. © Alcohol Medical Scholars Program 8 Lecture Topic  Alcohol use and problems  Risk factors for problems  Types of motivations for use  Personality, motivations, problems  How motivations guide treatment

9. © Alcohol Medical Scholars Program 9 Alcohol Use Disorder (AUD) –Tolerance –Withdrawal –↑ Amount/time use –Desire/inability to ↓ use –↑ Time obtain/use/recover –↓ Other due to use –Use despite problems –↓ Role obligations –Hazardous use –Interpersonal problems –Craving  Use → impairment   ≥ 2, 12-mo period

10. © Alcohol Medical Scholars Program 10 Safe Drinking Limits  For women: –Drinks per occasion≤ 3 –Drinks per week≤ 7  For men: –Drinks per occasion≤ 4 –Drinks per week≤ 14

11. © Alcohol Medical Scholars Program 11 At-Risk Drinking  Above limits = at-risk drinking  ↑ Probability –Liver disease –Financial and marital problems –Serious injuries –Problematic use

12. © Alcohol Medical Scholars Program 12 Alcohol Use Patterns  Abstain (0 drinks last mo, < 12/yr): 49%  Low-risk drinking:22%  At-risk drinking w/out AUD:21%  AUD: 8%

13. © Alcohol Medical Scholars Program 13 Use Problems  By age 18: –75% tried alcohol –60% intoxicated ≥ 1x  Quantities peak early 20s –Then quantities ↓  Ongoing ↑ quantities → problems  Onset use to dependence ~ 15yrs

14. © Alcohol Medical Scholars Program 14 Identifying Risk Important  Only some develop problems  Problems develop over time  Opportunity to intervene  NEED TO KNOW WHO IS AT RISK

15. © Alcohol Medical Scholars Program 15 Lecture Topic  Alcohol use and problems  Risk factors for problems  Types of motivations for use  Personality, motivations, problems  How motivations guide treatment

16. © Alcohol Medical Scholars Program 16 Genes Contribute  Explain ~ 50% risk for problems  Operate via 4 characteristics 1. Impaired breakdown of alcohol: ↓ risk 2. Low level sensitivity to alcohol: ↑ risk 3. Some psychiatric disorders: ↑ risk 4. Some personality traits: ↑ risk

17. © Alcohol Medical Scholars Program 17 Role of Personality Traits  Personality = stable pattern of – Thinking – Feeling – Behaving In relation to oneself and others  Traits genetically influenced

18. © Alcohol Medical Scholars Program 18 Traits That Risk  ↑ Sensation seeking  ↓ Conscientiousness  ↑ Impulsivity  ↑ Negative mood  ↑ Mood lability

19. © Alcohol Medical Scholars Program 19 Environment Contributes  Family –Lower levels support → ↑ risk  Peers –Heavy drinking → ↑ risk  Social/cultural –Belief most people drink heavily → ↑ risk  Current status –Lack rewards/stress → ↑ risk  Current situation –Easy get alcohol (cheap, close) → ↑ risk

20. © Alcohol Medical Scholars Program 20 Motives As Link  Genetic/environmental → motives  Motives → use/problems Different outcomes Different motivations Different traits  Motives identify risk pathways

21. © Alcohol Medical Scholars Program 21 Lecture Topic  Alcohol use and problems  Risk factors for problems  Types of motivations for use  Personality, motivations, problems  How motivations guide treatment

22. © Alcohol Medical Scholars Program 22 Motivational Model of Use  Alcohol use –Goal directed behavior –Goal: desire to achieve some outcome –Make decisions to drink/how much based goal  Different goals have different –Preceding risk factors (personality traits) –Subsequent outcomes (low-risk, at-risk use)

23. © Alcohol Medical Scholars Program 23 Motivations: 2 Dimensions  Valence: direction of mood change –↑ Positive mood –↓ Negative mood  Source: change mood by altering an –Internal state –External situation

24. 4 Types of Motivations External Internal Positive Negative SOURCE VALENCE Social -Good time w/ friends -Be sociable (↑ + mood, external source ) Conformity -Be liked, fit in -Friends pressure (↓ - mood, external source ) Enhancement -Get high -Fun, exciting (↑ + mood, internal source ) Coping -Forget problems -Help when depressed -Feel more confident (↓ - mood, internal source )

25. © Alcohol Medical Scholars Program 25 Common Motives  Good time with friends~72% (social)  Get high ~48% (enhancement)  Relax~41% (coping)  Boredom~23% (coping)  Get away problems~21% (coping)  Due frustration/anger~17% (coping)  Fit in~10% (conformity) Terry-McElrath, YM et al, J Drug Issues 39, 677-714 (2009)

26. © Alcohol Medical Scholars Program 26 Types of Young Drinkers  Social ~50% –Endorse social motives  Enhancement/social ~30% –Endorse enhancement and social motives  Coping/enhancement/social ~10% –Strongly endorse coping motives –Also enhancement and social motives

27. © Alcohol Medical Scholars Program 27 Lecture Topic  Alcohol use and problems  Risk factors for problems  Types of motivations for use  Personality, motivations, problems  How motivations guide treatment

28. © Alcohol Medical Scholars Program 28 Motives - Drinking Outcomes  Social motives (be sociable, enjoy party) -Low-risk drinking -Drink at mixed sex parties/bars, w/ families  Enhancement motives (get high, fun) –At-risk drinking, ↑ risk AUD ~1.3 fold –Drink at bars w/ same sex friends  Coping motives (forget problems, cheer up) –At-risk drinking, ↑ risk AUD ~1.5 fold –Drink at home alone

29. © Alcohol Medical Scholars Program 29 Motives - Personality Traits  Enhancement motives –↑ sensation seeking –↓ conscientiousness –↑ impulsivity  Coping motives –↑ negative mood –↑ mood lability –↑ impulsivity

30. © Alcohol Medical Scholars Program 30 Motives As Link ↑ Impulsivity ↑ Sensation seek ↓ Conscientious ↑ Alcohol use ↑ Alcohol problems ↑ Negative mood ↑ Mood lability Coping Enhancement Personality Motives Outcomes

31. © Alcohol Medical Scholars Program 31 Changes With Age (18 to 35)  Personality –Impulsivity ↓ –Negative mood/mood lability ↓  Motivations –Enhancement ↓ (get high47 → 32%) –Coping ↓ (boredom 23 → 6%)  Drinking patterns –Use ↓ after ~22yo –Alcohol related problems ↓

32. © Alcohol Medical Scholars Program 32 Coping Links Change  Coping links change personality/problems  Continued coping → ↑ risk use/problems ↓ Use ↓ Problems ↓ Coping ↑ Mood stability ↑ Self- control

33. © Alcohol Medical Scholars Program 33 Clinical Implications  Match Rx to personality traits  Rx target improved coping skills  Recognize coping motives to: –Identify risk –Provide feedback

34. © Alcohol Medical Scholars Program 34 Lecture Topic  Alcohol use and problems  Risk factors for problems  Types of motivations for use  Personality, motivations, problems  How motivations guide treatment

35. © Alcohol Medical Scholars Program 35 Prevention in High School  Limited ↓ drinking generic programs  Improve by target personality traits  Educate target students about –Coping/enhancement → ↑ drinking/problems –Alternative coping skills  These steps ↓ –Drinking/problems –Coping motives

36. © Alcohol Medical Scholars Program 36 Prevention in College  Similar approach might help  Important – peak alcohol use early 20s – onset AUD in some  Brief intervention student health – ↓ alcohol use if at-risk use

37. © Alcohol Medical Scholars Program 37 Brief Intervention  Ask – if drink, frequency, quantity  Advise – state concern, recommend change  Assess – willingness change  Assist – if ready help change  Arrange – reinforce change w/ follow up

38. © Alcohol Medical Scholars Program 38 Asking Why Drink Helps  Identify individuals at risk –Coping → ↑ heavy use, ↑ problems (directly) –Enhancement → ↑ heavy use → ↑ problems  Guide intervention –Feedback about risk of different motives –Coping → alternatives to ↓ negative mood –Enhancement → alternatives to ↑ positive mood

39. © Alcohol Medical Scholars Program 39 Case #1  Type: social/ enhancement  Risk: intermediate  Traits: ↑ sensation, ↓ conscientious, ↑ impulsivity  Discuss: risks enhancement motives  Suggest: alternatives to ↑ positive mood Tom- likes feeling, getting high, exciting, pleasant

40. © Alcohol Medical Scholars Program 40 Case #2  Type: social/ conformity  Risk: lower  Traits: none  Discuss: use within safe drinking limits Rich- helps enjoy party, celebrate, fit in, be liked, sociable

41. © Alcohol Medical Scholars Program 41 Case #3  Type: social/ enhancement/coping  Risk: higher  Traits: ↑ negative/labile mood, ↑ impulsivity  Discuss: risks coping motives  Suggest: alternatives to ↓ negative mood  Consider: referral for alcohol, mood problems Harry- likes feeling, ↑ confident, helps upset, cheer up

42. © Alcohol Medical Scholars Program 42Summary  Traits → motivations → outcomes  Coping –Risk: ↑ heavy alcohol use, ↑ problems –Traits: ↑ negative mood, ↑ mood lability, ↑ impulsivity –Provide: alternatives to ↓ negative mood  Enhancement -Risk: ↑ heavy alcohol use → ↑ problems -Traits: ↑ sensation seeking, ↓ conscientious, ↑ impulsivity -Provide: alternatives to ↑ positive mood  Ask motives → ↑ clinical care, ↓ progress AUD