Energy Drinks May Trigger Future Substance Use

Pauline Anderson

August 14, 2017

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.

Dr Amelia Arria

"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.

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 one 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 three patterns of use:

  • Frequent (52 or more 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 DSM-IV criteria for alcohol use disorder (AUD).

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

The investigators used the seven-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 four "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% to 53%).

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

From age 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 energy drink consumption patterns composed the vast majority of energy drink consumers in three of the four 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 to the nonuse group, those in the persistent group were at significantly higher risk 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 risk 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 to 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 energy drink use should 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 risk for alcohol dependence.

The US Food and Drug Adminstration (FDA) mandates that soda drinks cannot contain more than 72 mg of caffeine per 12 oz. There are no FDA regulations related to maximum 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 an SUD.

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 alcohol use disorder, 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 research was funded by the National Institute on Drug Abuse. 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. Abstract


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