These results indicate that clinicians and researchers should give adequate consideration to which AUD criteria might be most salient in identifying older versus younger drinkers with persistent problems who might benefit from interventions and treatment. The need to consider changes in endorsement patterns of specific items in different age groups could also be important for future iterations of the DSM. The specific criterion items that change with time might be different in different populations, a question that requires further research. However, the current prospective findings across 2 generations of the SDPS using the same diagnostic instrument and led by the same research team indicate that the changes observed here are not likely to be an artifact of the measures used and support for Hypothesis 1 is likely to be observed in other populations as well. As predicted in Hypothesis 2, the prospective SDPS data revealed a decreased prevalence of endorsement of tolerance over time among probands with persistent AUDs. AUD offspring demon strated a non-significant overall pattern for decreased endorsement of this criterion over time. The pattern of decreases in tolerance over time among individuals with AUDs is consistent with several cross-sectional and retrospective investigations in the literature . One possible explanation for this decreased endorsement with increasing age might reflect how tolerance is likely to be defined in research and clinical situations where the emphasis is usually on a recent time frame.Tolerance might have occurred earlier in the drinking career and been relatively constant throughout the heavy drinking years with the result that an individual with an AUD might indicate that tolerance, while technically present, was not newly observed in the more recent past.
Another potential contributor to decreased acknowledgment of D1 over time is the fact that at older ages,cannabis grow equipment drinkers are likely to actually increase their intensity of reaction to alcohol because they experience higher blood alcohol levels per drink as a consequence of: slower oxidation of ethanol in the liver; lower body water with age related to decreased water-rich body muscle; and age-related increased GABA sensitivity However, Hypothesis 3 regarding a potential increase with age in endorsement of the criterion of withdrawal was not supported in these analyses where probands with persistent AUDs demonstrated a significant decrease, rather than an increase, in self-reported symptoms of withdrawal between ages 31 and 43.Hypothesis 3 might be more relevant to individuals with AUDs in their 50s and/or those with more medical problems compared to SDPS participants . However, the current results were similar to those of the cross-sectional general population survey by Harford et al that suggested that rates of self-reported withdrawal phenomena did not change dramatically during midlife. Hypothesis 4 predicted age-related decreasing rates of endorsement of criterion A2 that related to using alcohol in hazardous situations. Consistent with this projection, our prospective data for probands with persistent AUDs documented significant decreases in endorsement rates of A2 over time, perhaps as a consequence of decreases in most risky behaviors with increasing age . The SDPS offspring with persistent AUDs demon strated non-significant decreases in endorsement of A2 over time. Hypothesis 4 is consistent with the potentially normal distribution of the age of endorsement of this item in the general population cross-sectional study, although the adolescent data indicated no change in endorsement of hazardous use . Except for the specific criterion items described immediately above, our group did not believe there was sufficient evidence in the prior literature to support specific hypotheses for changes in rates of endorsement of the remaining AUD criterion items in individuals with persistent AUDs.
However, the current data indicated that endorsement of spending a great deal of time involved with alcohol increased significantly over time in both generations of SDPS participants with persistent AUDs. Two additional DSM criteria demonstrated significant increases of endorsements for probands with a similar direction of change in offspring. These included drinking alcohol in higher amounts or for longer periods than intended and continued drinking despite social or interpersonal problems . The non-significant results in offspring might reflect the limitation of analyses to 2 time points and the smaller sample in the younger generation. The final significant change in endorsements over time for pro bands involved decreases in A1 regarding failure to fulfill obligations because of alcohol, but no change in rates of reports of this item was noted for offspring. The decreased rate over time for probands had not been originally hypothesized, and the result might be spurious. However, one might speculate that the decreasing endorsement of A1 for AUD probands might reflect the combination of higher levels of maturity between the early 30s and mid-40s along with decreasing pressures with age of raising young children and potentially diminished worrying about seeking success in one’s vocation . Similarly, while another change was not hypothesized and any conclusions should be drawn with caution, the only criterion for which the change over time was significant for offspring but not probands was an increase in the rate of endorsement of giving up important activities due to alcohol . This result in the younger generation might reflect the mirror image of some of the same changes over time noted in pro bands where the lower level of maturity and higher levels of impulsivity in the 20s contributed to the younger participants being more likely to take time to drink rather than attend to other activities.
The current analyses focused on DSM-IV criteria, but the results might be relevant to DSM-IIIR as well. As to DSM-5, 10 of the 11 diagnostic criteria are the same across the 3 systems, and the only change in criteria occurred when DSM-5 deleted legal problems and added a new criterion involving craving . Although in prior item response theory analyses,vertical grow system legal problems and craving were both found to add relatively little information to the latent concept of the DSM diagnosis or to not fit into a continuum with the other criteria , those were largely based on cross-sectional analyses, and it is not clear whether the results of the current analyses would be similar if data on craving had been available. Another difference between the 3 DSM approaches to an AUD diagnosis is that DSM-5 required endorsement of at least 2 criteria for a diagnosis, while DSM-IIIR and DSM-IV abuse required only a single item. In light of this difference, it is noteworthy that the re-analyses of the data from Tables 2 and 3 after limiting the sample to subjects who endorsed at least 2 criteria did not produce major changes in the current results. However, direct testing of the applicability of our findings to other diagnostic systems will be important.Data from both proband and offspring samples supported Hypothesis 1, and both subgroups demonstrated increases over time in the proportions endorsing criterion D5, spending a great deal of time involved with alcohol. However, although some findings in probands were similar in offspring, patterns for other criteria followed a different course regarding significant changes in the 2 generations. Such differences across older and younger individuals with persistent AUDs are not surprising in light of prior studies that documented differences in the typical ages of onset of some alcohol problems over time . In summary, the current analyses support 2 major conclusions. First, the salience of many DSM AUD criterion items among individuals with persistent AUDs changed significantly with age in both SDPS generations. This finding occurred despite the use of the same interview instrument and the same principal investigators who pro spectively evaluated the same individuals in both generations at all relevant follow-ups. These consistencies are important because differences in each of these items can affect the pattern of diagnostic item performance . The second overarching conclusion is the relative paucity of data on the question of whether the psychopathological process involved in AUDs manifests in different ways across development in the same individuals with persistent AUDs, a question that requires more study. In the current analyses, both generations demonstrated decreases in endorsement of tolerance and an increasing prevalence of experiencing a great deal of time to obtain, use, or recover from the effects of alcohol.
There was more modest consistency across generations for endorsement of the use of alcohol in hazardous situations, but additional studies are needed to evaluate whether the specific items that change with age during persistent AUDs might differ in different populations. The relatively unique nature of the data presented here regarding changes in endorsement of specific DSM AUD items across multiple evaluations of individuals with persistent AUDs contributes to the need to emphasize some important caveats. First, the data regarding the offspring across 2 time points are especially tentative because of their relatively short follow-up. Second, it is important to remember that 2 different groups of subjects provided the data for the changes in endorsements for samples aged 21 to 27 and 31 to 43 years. Third, the samples for both AUD probands and offspring are somewhat small. Fourth, the current population is almost exclusively European American and relatively well educated, and thus, the generalizability to other ethnic and education groups is not clear. Similarly, our requirement that an AUD had to be present at multiple time points excluded subjects with less persistent AUDs and those with no alcohol diagnoses and it is possible that the current results do not rep resent a more general pattern of AUD item endorsement over time . Fifth, The SDPS selected male but not female pro bands, and no data are available on females in their fourth and fifth decades. Also, in light of the variability in the course of AUDs over time , as clinical researchers and clinicians we believe that there are assets for understanding the picture of both recent histories and vulnerabilities toward future alcohol problems from focusing on a 5-year course of alcohol problems rather than limiting our analyses to the prior 12 months as might be considered as a current condition. It is possible that a different pattern of results might have been seen with a 12-month window of alcohol problems. Next, the data collection and subsequent analyses did not include the item of craving, and thus, the applicability of the current data to DSM-5 is not clear. Finally, the data relate only to alcohol and additional studies are needed to determine the age-related patterns of changes in endorsement that are likely to be seen in individuals with other sub stance use disorders.The discovery of the cannabinoid receptors and endocannabinoid ligands has generated a great deal of interest in identifying opportunities for the development of novel cannabinergic therapeutic drugs. Such an effort was first undertaken three decades ago by a number of pharmaceutical industries, but was rewarded with only modest success. However, the newly acquired knowledge on the physiological roles of the endocannabinoid system has significantly enhanced these prospects. At the June 27, 2004 workshop”Future Directions in Cannabinoid Therapeutics II: From the Bench to the Clinic”, sponsored by the University of California Center for Medicinal Cannabis Research, we on the Scientific Planning Committee were asked to identify the areas of research with the most immediate promise for the development of novel therapeutic agents. The Committee identified four broad areas involving modulation of the endocannabinoid system as particularly promising in this regard: agonists for central CB1 cannabinoid receptors and peripheral CB2 receptors, antagonists of CB1 receptors, inhibitors of endocannabinoid deactivation, and endocannabinoid-like compounds that act through mechanisms distinct from CB1 and CB2 receptors activation. Below, we summarize the data presented at the Workshop and the consensus of its participants on the most exciting opportunities for drug discovery.BAY-387271 , a centrally acting cannabinoid agonist in Phase II clinical studies for the treatment of stroke. The interest of the pharmaceutical industry in the application of cannabinoid agonists to the treatment of pain conditions is not recent. Indeed, most of the compounds now in experimental use derive from such an interest. Historically however cannabinoid agonist development has not proved clinically fruitful, largely because of the profound psychotropic side effects of centrally active cannabinoid agonists, hence the attention given to peripherally acting cannabinoids, which exhibit significant analgesic efficacy and low central activity in animal models. Neuroprotection is a relatively new area for cannabinoid agonists, but one that appears to be already well advanced.