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CME / ABIM MOC / CE

Can Energy Drinks Lead to Future Substance Abuse?

  • Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 9/15/2017
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 9/15/2018
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Target Audience and Goal Statement

This article is intended for primary care physicians, addiction medicine specialists, nurses, and other clinicians whose patients may consume energy drinks.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Assess the association between consumption of energy drinks and drunk driving among young people
  • Analyze the relationship between energy drink consumption and substance use in the current study


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Author

  • Pauline Anderson

    Freelance writer, Medscape

    Disclosures

    Disclosure: Pauline Anderson has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor, UC Irvine Department of Family Medicine; Associate Dean for Diversity and Inclusion, UC Irvine School of Medicine, Irvine, California

    Disclosures

    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: McNeil Consumer Healthcare
    Served as a speaker or a member of a speakers bureau for: Shire Pharmaceuticals

Editor/CME Reviewer

  • Robert Morris, PharmD

    Associate CME Clinical Director, Medscape, LLC

    Disclosures

    Disclosure: Robert Morris, PharmD, has disclosed no relevant financial relationships.

Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC

    Lead Nurse Planner, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Can Energy Drinks Lead to Future Substance Abuse?

Authors: News Author: Pauline Anderson; CME Author: Charles P. Vega, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 9/15/2017

Valid for credit through: 9/15/2018

processing....

Clinical Context

Energy drinks have exploded in popularity during the past decade, particularly among young people. The authors of the current study estimate that 1 in 3 adolescents and young adults in the United States consume energy drinks. Many of these individuals combine energy drinks with alcohol. The authors of the current research previously evaluated the relationship between energy drink consumption and the risk of drunk driving. Their results were published in the November 2016 issue of Alcoholism, Clinical and Experimental Research.[1]

An estimated 57% of young people in the study cohort reported consuming energy drinks in the past year, and 71% mixed alcohol with energy drinks. Researchers found a direct correlation between any energy drink consumption and a higher risk of drunk driving. In addition, participants who consumed energy drinks plus alcohol consumed more alcohol overall, and they had a higher risk of drunk driving.

The current study by Arria and colleagues monitors this same cohort to evaluate the trajectory of energy drink use across time, as well as whether energy drinks are associated with substance use during early adulthood.

Study Synopsis and Perspective

Persistent consumption of energy drinks may predispose young adults to substance use, new research suggests.

Investigators, led by Amelia M. Arria, PhD, School of Public Health, University of Maryland, College Park, found that college students who regularly drink highly caffeinated energy drinks were at increased risk for later use of alcohol, cocaine, or prescription stimulants.

The consumption of energy drinks by young people is "a red flag" for use of other substances, Dr Arria told Medscape Medical News.

"Physicians who manage the care of people in recovery who are in this age group should certainly take a look at energy drink consumption as a possible contributor to relapse," she added.

The study was published online August 8 in Drug and Alcohol Dependence.[2]

Sensation Seeking

The research included students enrolled in an ongoing longitudinal study that began in 2004 at a large public university.

The analysis included 1099 participants (54% women; 72% non-Hispanic white) who completed at least 1 annual assessment in which patterns of energy drink consumption were assessed.

In interviews, participants were asked which energy drinks they had consumed, and how often, in the past year. They were categorized into 3 patterns of use:

  • Frequent (≥52 days)
  • Occasional (12-51 days)
  • Infrequent (1-11 days)

Participants were asked in year 4 to estimate the frequency and quantity of caffeinated beverages other than energy drinks they had consumed during a typical week in the past year.

In years 4 and 8, the researchers assessed past-year frequency of alcohol use and assessed for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for alcohol use disorder (AUD).

For the same years, researchers also collected information on the use of cigarettes, marijuana, cocaine, nonmedical prescription stimulants (NPS), and nonmedical prescription analgesics.

The investigators used the 7-item impulsive sensation-seeking subscale of the Zuckerman-Kuhlman Personality Questionnaire, which study participants self-administered at baseline.

At baseline, participants also completed the Dysregulation Inventory, and the investigators administered an adapted version of the conduct disorder screener that captures conduct problems in childhood.

Statistical analyses created 4 "trajectory" groups on the basis of probability of energy drink consumption:

  • Desisting (steadily declining probability)
  • Nonuse (probability consistently at or near zero)
  • Persistent (high probability in every year)
  • Intermediate (probability ranging from 33%-53%)

The persistent group made up approximately half the sample (51.4%); the nonuse group represented 20.6%; the intermediate group, 17.4%; and the desisting group, 10.6%.

From ages 21 to 25 years, energy drink consumption declined in annual prevalence, from a weighted 62.5% to 49.1%.

"So the probability of being an energy drink user decreased over time as subjects got older," said Dr Arria.

However, in the persistent group, the probability of consuming energy drinks was consistently high (≥87% during all 4 years). In the nonuse group, the probability of past-year energy drink consumption never exceeded 2%.

Those with infrequent and occasional patterns of energy drink consumption composed the vast majority of energy drink consumers in 3 of the 4 trajectory groups. The nonuse group consistently refrained from any energy drink consumption.

The investigators found that sensation seeking, conduct problems, and behavioral dysregulation were all positively associated with a higher probability of energy drink consumption, with the nonuse group having the lowest and the persistent group the highest risk scores (P <.001 for all).

The nonuse group generally exhibited the lowest level of substance use with the exception of other caffeine products and alcohol, which were lowest in the intermediate group.

The persistent group exhibited the highest mean probability of AUD risk, and for tobacco, marijuana, and cocaine use.

Logistical regression analyses showed that compared with the nonuse group, those in the persistent group were at significantly higher risks for AUD, NPS, and cocaine use (for all, P <.05). Those in the intermediate group were also at increased risk of using NPS and cocaine relative to the nonuse group.

That consumption of energy drinks is a potential trigger for substance use is suggested by the fact that for those in the desisting group, who were energy drink users at age 21 years but who then stopped, the risks for cocaine use, use of NPS, and AUD declined, said Dr Arria.

"That makes us somewhat confident that this is looking at the contributing influence of energy drink use."

Unique Contributor

The relationship with substance use outcomes appeared to be specific to energy drink consumption and not the use of other forms of caffeine, such as coffee. This higher risk might be linked with the relatively high caffeine concentration of these beverages, said Dr Arria.

"[Energy drink] consumption might have a unique contributory role for the development and escalation of NPS and cocaine use among young adults," the authors write.

It has been suggested that the effect of caffeine on dopamine receptors may potentiate the use of other psychostimulants, they note.

Because the investigators adjusted for sensation seeking, the relationship between energy drinks and subsequent substance use cannot be entirely accounted for by a propensity for risk taking, said Dr Arria.

The study findings suggest that use of energy drinks be investigated as a possible contributing influence or a "novel catalyst" for substance use, she said.

This is especially true for young people, she added. "We are calling for more studies of the use of energy drinks among adolescents."

She noted that teens are already undergoing "very significant neurodevelopmental changes" that might predispose them to drug use in general.

"The study highlights the need for a more intensified research agenda around energy drinks, given that they are consumed by a significant proportion of both adolescents and young adults, and we know very little about the long-term risk of regular consumption," said Dr Arria.

Young people who drink energy drinks often mix them with alcohol. Dr Arria stressed the need to examine whether this might "represent an added risk on top of alcohol use."

She and her colleagues previously found that energy drink consumption is related to the risk for alcohol dependence.

The US Food and Drug Administration (FDA) mandates that soda drinks cannot contain more than 72 mg of caffeine per 12 ounces. There are no FDA regulations related to maximal caffeine content of energy drinks. Some companies voluntarily list the caffeine content on labels.

Consumption of energy drinks has been associated with other negative health outcomes in addition to possibly leading to later substance use. These outcomes include serious cardiac events, such as cardiac arrest in patients with congenital long QT syndrome.

No Surprise

Commenting on the findings for Medscape Medical News, Lynn Webster, MD, vice president of scientific affairs, PRA Health Sciences, Salt Lake City, Utah, who is board certified in pain and addiction medicine, said the findings are not surprising.

"We know that most substance use disorder begins in youth," said Dr Webster. "Energy drinks are just one substance that is easily, and legally, obtained" by young people.

Dr Webster stressed that "biology" makes energy drinks attractive to some people. "Our risk of a substance use disorder is resident in our biology, not a drug."

Biology, he added, is a product of genetics and environment. The more stress in that environment, the greater the risk for a substance use disorder.

Although those who find energy drinks rewarding "are naturally at a higher risk of seeking rewards from other stimulants," that does not mean that all young people who consume energy drinks will develop a stimulant use disorder or AUD, said Dr Webster.

He agreed that the new study should have policy implications.

"It's important to understand that most of those with an opioid use disorder began in their youth using or abusing other substances. If we are to solve the current opioid crisis -- or any substance use disorder -- we must focus on the policies that will prevent the development of the disease early in life."

The National Institute on Drug Abuse funded this research. Dr Arria has disclosed no relevant financial relationships. Dr Webster consults with several pharmaceutical companies that develop drugs for the treatment of pain and addiction.

Drug Alcohol Depend. Published online August 8, 2017.

Study Highlights

  • Study participants were originally recruited in 2004 when they enrolled at a large US public university. All participants were between 17 and 19 years old at study entry.
  • Participants continued to be observed after graduation. The current study focuses on data collected during study years 4 to 8.
  • Energy drink consumption was measured annually, and participants recorded consumption of other caffeinated beverages in study year 4. Substance use was evaluated in years 4 and 8.
  • Researchers also evaluated impulsiveness and behavioral dysregulation using validated instruments.
  • The main study outcome was the association between energy drink consumption and substance use, which was adjusted to account for personality characteristics. Researchers also evaluated trends in the consumption of energy drinks across time.
  • The average prevalence of energy drink consumption declined from 62.5% at age 21 years to 49.1% at age 25 years.
  • The percentage of participants reporting rare consumption of energy drinks (1 day to 11 days of consumption annually) remained stable during the study period. The percentage of individuals who consumed energy drinks on at least 52 days of the year declined from 11.7% at the outset of the study to 5.9% in 2008.
  • Researchers divided the study cohort into persistent, desisting, intermediate, and nonuse categories based on their trends in energy drink consumption during the 4-year period. Men and non-Hispanic whites were overrepresented in the persistent group.
  • Sensation seeking, conduct problems, and behavioral dysregulation were all associated with increased energy drink consumption.
  • Compared with participants in the nonuse category, participants in the persistent category had higher risks for substance use. Specifically, they were more likely to misuse or abuse alcohol, prescription stimulants, and cocaine.
  • However, energy drink consumption was not associated with marijuana use, tobacco use, or the nonmedical use of prescription analgesics.
  • The desisting group had similar rates of substance use compared with the nonuse group.
  • The consumption of other caffeinated beverages was not associated with a higher risk for any form of substance use.

Clinical Implications

  • Higher levels of energy drink consumption among young adults was previously linked with a higher risk of drunk driving. Consuming energy drinks and alcohol concomitantly also indirectly raised the risk of drunk driving.
  • In the current study by Arria and colleagues, persistent use of energy drinks was associated with higher risks for misuse or abuse of alcohol, prescription stimulants, and cocaine. However, energy drink consumption was not associated with marijuana use, tobacco use, or the nonmedical use of prescription analgesics.
  • Implications for the Healthcare Team: The current study suggests that desisting from energy drink consumption during young adulthood can reduce the risk for substance misuse compared with persistent consumption of energy drinks.

CME Test