Drs. Jennifer Merrill and Mary Beth Miller - Alcohol-induced Blackouts

I'm Dr. Noah Emory, I'm Dr. Sam Acuff, and this is the Addiction Psychologist Podcast. On this episode of the Addiction Psychologist Podcast, we're going to be talking with Dr. Jim Merrill and Mary Beth Miller. Dr. Merrill is a professor in the Center for Alcohol and Addiction Studies in the Department of Behavioral and Social Sciences, the School of Public Health at Brown University. Dr. Mary Beth Miller is the Millsap Distinguished Associate Professor in the Department of Psychiatry and Psychological Sciences at the University of Missouri. They're going to be talking with us about alcohol-induced blackouts. Welcome to the show, we're really excited to have you. Thanks for having us. Thanks so much, it's an honor. Well, we're huge fans of your work, and so we're really excited to have you on to talk about some of your newest stuff coming out. But before we begin, at the beginning of every episode, we'd like to have some of our guests tell a little bit about their training history and their background, and so maybe Mary Beth, you could get us started. Yeah, thank you guys for having us. I never miss an episode, love the show. I will be brief though because you already had me on for the sleep episode, but I went to a small liberal arts college. I started out as a Spanish and music major actually, but ended up taking a psychology class, a couple of psychology classes and then fell in love with research in those. At the end of undergrad, I took a year off trying to get more research experience so I could get into grad school, ended up working for that year as a case manager more or less at an adolescent substance treatment center, which was absolutely critical to my career trajectory. I learned a lot about motivational interviewing there and working with patients that year and then ended up at the clinical psychology program at Oklahoma State and then did two, I did internship in two years of postdoc at Brown, which is where my good friend and grad school labmate, Casey Clayworn introduced me to Jen. So I'll tell a much longer story about my path. I was always a good student, but kind of toward the end of high school, I honestly wasn't even sure I wanted to go to college, but I did. It was the late '90s, which I've heard that kids these days are calling the late 1900s, which makes me feel really old. I ended up at a small liberal arts college, State University of New York or SUNY, Brockport, which was close to my home in Rochester, New York, and I was a first generation college student. Without disclosing too much about what things were like for me in college, I'll say that probably like a lot of college kids. I was in a friend group and an environment that was conducive to heavy drinking. We had few bars within walking distance from the dorms, and in my social circle, it was uncommon to go out to bars or parties multiple nights a week. One thing that sticks out to me and I actually confirmed this with my college girlfriends this morning that I was remembering very correctly, but one of the bars had $1.50 pictures. It was 25 years ago, but I think today that that would still be the equivalent of under $3. A picture, mind you, has five standard size beers in it, which is concerningly cheap. I'd say my college experience kind of set the stage for my later research interests in some non-academic ways. It was definitely there that I started to wonder a lot about why some people hardly drink at all. Others are drinking to the point of lacking out, and maybe even doing so repeatedly. I didn't know what I wanted to major in. As I entered my junior year, they forced me to pick something. I had enjoyed my enter to site class like Mary Beth, so I settled on that. Then as undergrad was coming to an end, I decided, "Okay, maybe this school thing is okay," and started to think I wanted to take it farther and pursue grad school. I didn't really know what all the possible career paths in psychology were, and I definitely wasn't yet a competitive applicant for PhD programs. So I took a two-year gap to build my resume. I took some graduate level classes, studied for the GREs, and probably most importantly, since I had decided I wanted to go to clinical psych PhD, I need to get more research experience. There weren't a lot of local opportunities related to my interests in alcohol use, but I found Dr. Jen Reed on the internet. I found her alcohol research lab in Buffalo only about an hour drive from where I was living, reached out to see if she would take a volunteer. I am forever grateful to Jen Reed for taking a chance on me. I was driven, but also a little rough round the edges, I'd say. So, Jen, if you're listening, thank you again for giving me that opportunity. Through volunteering in the lab in my gap years, I just got a lot more exposure to what research actually is and how much I liked it. I loved that research gave you the opportunity to really think about like any question about human behavior. Why do people act in a certain way? Think in certain ways. How does the environment influence that? And then you get to think about how can I go about answering that question in a systematic scientific creative way, which for me was really exciting. So, next I actually ended up staying in Jen Reed's lab for my PhD, although only after having been rejected from Baster's programs the year before that, which I think goes to show how much of a difference a single year of extra experience can make. My dissertation focused on how college students think about or subjectively evaluate the negative consequences of their drinking. So, these things that people experience like hangovers, blackouts, researchers, and clinicians tend to think they're very negative, but do the people who are having those experiences feel that way, and how do those evaluations lead to change in drinking or not changing drinking? Next, clinical internship at the Charleston Consortium or the Medical University of South Carolina, MUSC, where I got more training in clinical work with people with substance use disorders. And by the way, in another moment of rejection, I didn't even get an interview for Brown's internship. But after that, I finally did get to come to Brown in 2012 for my postdoc at the Center for Alcohol and Addiction Studies cast with the amazing Dr. Kate Carey. I had idolized a lot of her work through grad school and never would have dreamed that by 2026, I'd be playing pickle ball with Kate Carey on a weekly basis, which is really fun. But on postdoc, I got marks exposure to mechanisms of behavior change and I'll call intervention research. I started collecting more mentors, people like Nancy Barnett and Christy Jackson, and got some really excellent grant rating training, wrote a KO one mentor training award to extend my dissertation work on how people think about the consequences of their drinking, and to get more training in a few key areas. So, I wanted to learn more about qualitative research, ecological momentary assessment, or EMA, longitudinal data analysis, and intervention development. And was really fortunate to have that K funded to stay at CAS, where I've been ever since. So I transitioned to faculty there in 2014, and I think it was the year after I started my faculty position that Mary Beth rotated in as a postdoc to benefit from Dr. Carey's mentorship. And that's when the two of us started sharing our love of research on black outs and started collaborating in that space. Very cool, yeah. Thank you for that overview. And if anyone wants to hear more about Mary Beth's training, go listen to that episode, the sleep episode, and then also just stay for the rest of the episode. It's really great stuff. But yeah, we were talking about this before, Jen, so not to embarrass you, but you, I think even amongst your peers, but definitely for someone who is a few years behind, you were probably the first couple of years in grad school, especially where like my most cited person. So we've been dying to have you come on the show for a really, really long time. And so we're just really glad you're here. And the work you've been doing from the beginning, you know, I think with the help of incredible team of mentors, but the work you've been doing from the beginning is just really quite impressive, so excited to talk about it today. Oh, yeah, I agree. Yeah, we talked offline a little bit for those listening, but in the lab, I trained in, we used the term legend status to describe Dr. Merrill's work during that time, which for me was like 2012 era for us was like, absolute legend status, super central to a bunch of work that I've did. So really been wanting to have you on the show for a long time and grateful that you'd be able to make some time for us. I tell the listeners how rad I look right now. Totally appropriate to me. Well, we're super excited. We're super excited to have you both on because you all are doing some incredible work and, you know, we can have you both talk about a bunch of different things, but you're doing some really cool work on alcohol induced lackouts. So I think this was sort of burned by a fairly recent paper that you all published that just got us excited it got us thinking about. it. And so, you know, happy to have you sort of give a broad overview, but also to hear a little bit about this specific paper. So let's just get started off with some background on blackout drinking. What exactly is an alcohol-induced blackout? So, blackouts are periods of alcohol-induced anterior grade amnesia, anterior grade meaning you remember things that happened before you started drinking, but then lose memories of things that happened while you're drinking. And in the most severe form of blackout, you can't remember anything after a certain point of time. And I wanted to share a story here to make this really concrete. Also, I can't share stories in publications, so I get to share it here. But when I was working as a post-back, I worked with this girl who blacked out almost every time she drank. And her stories have had just a huge impact on my work in this space. And one of the stories she told me was about a time she went out with friends. And it's a normal night. They're having fun. They're out drinking with other people. And then the next thing she knows, she's riding in a car. It's like she woke up. It's clearly much later now, but she doesn't know what time it is. And she's in a car with about six other people. And she doesn't know a single person in the car. She was with like six of her good friends. And now she's in a car riding with six people she doesn't know. And then she realizes they're all dudes. She's driving in a car with six random dudes. She doesn't know. And she doesn't know how she got there in her phone's dead, of course. And if this was the first time she'd ever blacked out, she'd be terrified. But this isn't the first time she blacked out. She knows she's blacked out. And everyone's laughing and smiling and like being cool, singing along to the radio. So she assumes that she's safe and she plays it cool and has to act like she knows what she's doing and what's happening and who those people are. So she can try to piece together like who they are and how she got there. So that's a pretty extreme example of blackout. And this is something that happened. This was like one of dozens of stories that she had like this. So this is pretty extreme. But you can imagine as like a new person in this space, why stories like this had a huge impact on me and have really like instilled passion in me to prevent these experiences for other people. A more common example of blackout might be just like not remembering the midnight trip to Kudoba with all your friends and not even realizing you don't remember it until your friends tell you about it the next day. That's a much more common blackout experience. So first of all, shout out to Kudoba. Love Kudoba. Second of all. So it's sort of like, you know, just specifically a memory relate like, you know, you continue to operate as a human. Things continue to move along. But it's the memory kind of. It's just a gap. Yeah. Totally. Yeah. And there's basically like two different types that we look at in the research. So on block blackouts and fragmentary blackouts. I think the story that Mary Beth described is really more of that on block type. So that's the type where there's a definitive onset and then some complete memory loss for some period of time after that. Regardless of how much people try to remind you of what happened during that period, you're not going to remember it. So on block is actually a French phrase. It means as a whole or in a single block. And that's how you can remember it. And this type of blackout, there's a block of time that's missing. And of course, there's variability and kind of how long that block of time might be. It might, in many cases, I think, you know, someone can't remember a stretch of time leading up to going to bed. And Mary Beth already mentioned, those are the less common of the two types. So I think data indicate that among people who regularly drink somewhere between 20 to 25 percent will endorse that kind of experience. But then the second type, the fragmentary blackout, sometimes people call them brownouts or grayouts. And this involves a more partial memory loss. So someone might not lose that whole block of time, but their memories might be fuzzier or more minor details might not be recalled or you don't remember something until you're cute in a certain way. So maybe when someone first wakes up, they don't remember that they dance on the tables the night before or that they got into this very deep conversation with a friend, but later that morning when they're at brunch with the friends that they've been out with, the friends remind them of something that they said or did and they do recall it. And so that type is quite a bit more common about half of people who drink say that they have that experience. And when we're looking at heavy drinking samples, more like 20 to 80 percent report having experienced fragmentary blackouts. Judd and I are also working on a couple of different measurement papers in this space. And so I think it's also important to acknowledge like neuroscientists also think that these two different types of blackout have different brain mechanisms as well. So a lot of this comes from basic neuroscience and animal models. A lot of cool work done by Erin White who unfortunately passed away last year. But then Kim Frommey's group, including Brian Hartzler and Regan Weatherill have also explored these pathways in humans. And so for on block, what we think happens is that alcohol interrupts long-term pretentiation in the limbic areas of the brain, specifically the hippocampus. And that happens in such a way that prevents consolidation of memory. So it's not that you're forgetting something here, you truly never formed a memory. And because they were never consolidated, they can't be retrieved no matter how hard you try. Whereas in the case of fragmentary blackouts, they think that those memories are formed in the hippocampus. But alcohols affects on the frontal lobes makes it hard to retrieve them. So you need cues to remember. I kind of want to add that, you know, while we know these are two different experiences from the neuroscientific research that Mary Beth is mentioning and also from qualitative studies where people describe the two types of experiences we do also see a lot of overlap. So, you know, people who report one type also often report the other type. And we even see overlap in the two types on the same night. So in one of my studies, we recruited a little over 200 young adults who engage in high intensity drinking. So for females, that's eight or more drinks at a time, and for males, ten or more drinks. And the participants complete ecological momentary assessments, including next day questions about both types of blackouts. And to start with just straight frequency of each type, the fragmentary blackouts were occurring on 13% of their drinking events and block much less frequent, 2% of their drinking events. But among the nights where either or occurred, both types actually occurred about 10% of the time. And there's also interesting data that we have on the order of that. So on the nights when they had both, we asked which happened first. And it was really rare for the on block blackout, the complete blackout to occur first. So it was half the time that it was fragmentary blackout and then end block. And the other half of the time, it was like fragmentary on block and then back to fragmentary. So while there are distinct types in some ways, there can definitely be overlap within people and even within a single drinking occasion. I'm actually so mad about this because Angela de Bello is one of our close collaborators, kept telling me that we would see this day level overlap. And I thought for sure he was wrong. Like I thought the on block experience would supersede the fragmentary experience. So you'd get people reporting one or the other at the day level, but he was right. And we see this, can we see the same kind of overlap in my ongoing study, which is with people who meet for alcohol use disorder as well. So Angela was right. I guess. Yeah, you shouldn't have said it on like a recording space, you know, necessarily, but that's fair. That's fair. Now everybody's going to know. He's been waiting for this. Yeah, that's right. Shout out, Angela. Yeah, agreed. That's the beautiful part about collaboration, frankly, right? And is that, you know, people have all kinds of different perspectives that bring important details to bear in these types of ways that we wouldn't have think about it, clinical experiences you've had, collaborators experiences. And one of these things like this, where I think it's pretty understudy, even though I think everybody out there, if I just grabbed a person on the street, they've heard of blackouts. But the science of blackouts, I think, is much more mysterious to maybe community members and things like this. And so we really got a pull from all kinds of different directions, I think to really advance the work, which is why I think some of the work that you're doing here is just so important. And so, so it sounds like there's, you know, there's different kinds and they happen maybe at different rates and there's different neurological processes happening that kind of undergird them a little bit. Do we know like what causes this kind of impairment and how alcohol is kind of like mixed up in the system here? Yeah. So Aaron White wrote a really great review of the neuroscience behind blackouts in 2003, which I highly recommend if you want to do work in the space. I'm not going to pretend to do that because I'm not actually an artist. But behaviorally, researchers have been saying since the 60s and 70s that heavy drinking alone is insufficient to produce a blackout. So Donald Goodwin's team at WashU did a lot of this work in the 60s exclusively among men. And they found that blackouts occur on days that participants reported drinking fast or drinking on an empty stomach. So they hypothesized that blackouts occur due to rapid increases in BAC or blood alcohol concentration, which means that anything that leads to rapid increase in BAC might also be linked to blackout. So you've, there's been data on like pre-gaming and drinking games all being linked to blackout, but we would really expect the increase in BAC to be the mechanism leaking those two behaviors. Yeah. And we see that in our EMA data too. So in one paper that I published with Ryan Carpenter, we use my K data. This was a sample of about 100 college students who reported heavy episodic drinking. So for females, four or more drinks, males, five or more drinks. And in that study, they completed EMAs hourly during their drinking events. And Ryan calculated change in their estimated BAC from one hourly report to the next hourly report. And we found that both the peak level of blood alcohol concentration that they reached, but also getting there more quickly, a faster increase in BAC from hour to hour, both were associated with a higher likelihood of blacking out. And then in my study of the young adults who drink to high intensity levels, one of our primary aims is to look at whether blackouts are predicted by different features of a drinking event when measured with alcohol biosensors. So we have these risk-worn backtrack skin bracelets that detect alcohol transdermally or through the skin. And they're so cool because they're measuring levels of alcohol in the body continuously. So we get readings every 20 seconds about how much alcohol is in someone's body. And we can really visualize the alcohol curve and extract different metrics to characterize what does the ascending limb, the peak, the descending limb look like. And Rob Tracy's group kind of beat me to the punch here in a paper led by Veronica Richards. They found that three different transdermal alcohol concentration or attack measures all predicted blackouts when they were tested individually. So getting to that higher peak transdermal alcohol concentration level, getting there more quickly, and a longer duration over which someone's tack was rising, all three of those things were significant predictors or blackouts. Although there was some nuance depending on what was in the model. So when they put either peak TAC or the duration over which the TAC was rising or both in the same model as the rise rate, the rise rate kind of got kicked out. It was no longer significant. And the duration over which tack was rising was kind of the only independent predictor blackouts, which is super interesting. And one way I hope that I can extend what's already been published is by looking separately at how those features look on block versus fragmentary blackout days. So we're still formally analyzing the data working with my postdoc Molly Maloney and a PhD student Nathan Didier, who's at the cutting edge of like figuring out how we actually process all of these TAC data, but our descriptive analyses do suggest there's differences across these three types of days. So days with no memory loss versus fragmentary versus on block. The on block blackout days have the highest peaks, fastest increases, longest durations. And that's followed by the fragmentary blackouts, which then also have higher peaks, faster increases, and longer durations than the days without any memory loss. So I'm really excited to prepare that for publication. Yeah, absolutely. That's really interesting. I mean, going back to the point that Angela developed made about the fragmentary often preceding or can on some of these nights, I suspect during those times people are still drinking. So maybe it kind of is like when you start to lose signal on a phone call, you can kind of still hear, and then eventually the call drops. And so I imagine that's because alcohol consumption is still increasing. Well, it sounds like the duration and the speed at which you reach a high BAC matters a lot. But it also sounds like you still got to get to maybe a certain level or on average. So I'm wondering a little bit about what we know about at what level of alcohol and toxication might you expect to have a blackout experience? Yeah. Brian Hartzler and Ken Frommi published a really interesting study comparing estimated BACs for different kinds of blackouts. And they found that fragmentary blackouts tend to occur as low as like a.07 BAC, which I'm going to guess. Maybe people know this, but.08 is the legal driving limit in a lot of states. And then the likelihood of on-block increases dramatically after.25. But both of them actually occurred at a wide range of BACs. Yeah. And again, I'll talk about my EMA data with the young adults drinking to these high intensity levels. That sample is really allowing us to observe a lot of blackouts. So the average estimated BAC on days with a fragmentary blackout was.17. And then the average estimated BAC on the days with an on-block blackout was a little bit higher at.2. But we also definitely observed quite a range again. So the fragmentary blackouts we observed at estimated BACs as low as.04 and the on-block as low as.07. So again, there's definitely more to blacking out than just how intoxicated someone gets. There's other data out there on the number of drinks that are likely to lead to memory loss, which, of course, is not as precise as estimated blood alcohol concentration. But I do think that it's a little bit more digestible for the average person to think about and to potentially be able to monitor or control. So a study that Florian Labhart and Switzerland led, they were looking at what's the optimal threshold for the number of drinks that's likely to predict blackouts and other consequences. And in their adult sample, it was five or six drinks for females and at least seven for males. And then I recruited him to help replicate his analyses and my data with college students. And we found that seven drinks was the optimal threshold for predicting blackouts in both females and males. - So you drink seven and you've got a shot at having a blackout experience. But.04, I mean, that's a really low. I mean, some people presumably could reach that in a handful of drinks. - Or less even. - Yeah. - And I worry about making too much of the.04 because it is across the entire drinking episode. How long did they drink and how many drinks did they have? It is possible that they reached a higher point early in the drinking event or drink very quickly at the beginning. But then started spacing out their drinks and ended up with the calculation for estimated BAC that was pretty low. But. - But I mean, but it's still plausible, I think. And this is where the tactile will be so helpful. But like if you don't eat or you're sick or based on our study, you're not sleeping well. For example, like I think there are lots of things that could contribute to reaching a higher BAC with a very small number of drinks, which if you're estimating BAC based on self reported drinks would look very low. - Right. And yeah, there's just a ton of individual difference. And of course, certain people are more susceptible than others. - Yeah, well, that was going to be my next question. Is, you know, presumably there are individual differences. So what do we know about that? - Yeah, it definitely seems like yes for on block especially. So Crystal Davis has a really cool paper where they use twin data to look at genetic risk for BAC out and they found that about 16% of variance in BAC out is attributable genetics after accounting for the genetic risk for heavy drinking more broadly, which was especially interesting. I had to go reread the paper for this podcast actually because they found something totally different for passing out, which is super interesting to me. But then Reagan, whether I also has a study demonstrating that add a lesson to our substance naive who later experienced BAC outs show increased neural effort during inhibitory processing, which they interpret or tell me means there is a neurobiological vulnerability to BAC out. And then other studies have found rules for like prenatal alcohol exposure and then earlier onset of alcohol use. But without genetic or neuro testing, early onset isn't only one of those that you would actually know that you have. - A recent paper that Mary Beth and I published together again using data from the study of young adults engaging in high intensity drinking, we looked at a bunch of baseline correlates of whether or not our participants reported a blackout during the 28 days of EMA. And some of the variables we hypothesize would be related based on prior literature weren't. So specifically, the literature is pretty mixed, but it does lean towards suggesting that blackouts are more common in females. And our study, we didn't find that. So among a sample of males and females, both of whom are drinking to high intensity levels, the likelihood of blackouts was the same. We also thought that people who endorsed having a higher tolerance to alcohol might be more likely to blackout, but we didn't find support for that. Although this might have been due to the fact that we use this single self-report item of tolerance, and we were controlling for how intoxicated they got each night. So maybe one of the mechanisms by which tolerance would influence blackouts were taking out of the model. Some of our other hypotheses were supported. So we're controlling for how intoxicated they got that night and how intoxicated people got on average over the course of the study. But even after controlling for those two things, both types of blackouts were more likely among participants with a high. level of subjective response to alcohol. And I know you had a whole episode on subjective response with Andrea King. It's a complicated construct. But the way we measured it in this study was how many drinks did it take you? Specifically the first several times that you drank to feel the effects of alcohol and to experiencing like feeling dizzy or sumbling. And the participants who said it took them fewer drinks to experience those effects, meaning they had a higher subjective response were the ones that were more likely to report blackouts in that study. So sort of a potential greater susceptibility or sensitivity? Yes, exactly. I think yeah, I think it makes a lot of sense that people are more sensitive to the intoxicating effects might be more likely to blackout. Yeah, that makes a lot of sense that there would be both contextual factors around influencing the likelihood or experience of blacking out like not eating or sleeping or things like this that might make, you know, me more susceptible on one day given another, but also a bunch of individual difference characteristics that makes me more likely to experience them overall compared to somebody else. I think that makes a lot of sense. And you know, that's the beauty of science is that it's usually pretty nuanced and complicated. But at least this I think makes a bunch of intuitive sense. You know, I think if we asked some people on the side of the road, you know, they thought that there was factors like that. They probably would say yes. I think I would submit they probably would say a bunch of other stuff too that want to ask you about. Are there any like myths about blackouts that like we just don't line up with what we know about it scientifically or clinically in the space? So I don't know if this is a myth necessarily, but people get really confused about the difference between blacking out and passing out the like in reviewers. I always have to be very clear. And I always have to explain what passing out means in your blackout papers, because otherwise they'll think they're the same. But in a blackout, you know, I think Sam alluded to this earlier, you're walking, you're talking. You can drive. You can have sex. You can do all of these things. You are conscious. You just don't remember it later. If you're passed out, you're asleep. You're unconscious. That's like totally different. Yeah. Yeah. Another one I think has to do with kind of norm. So in the same way that people and young adults in particular tend to really overestimate how normal drinking is and how normal heavy drinking is, we know that some young adults believe that everybody blacks out. But that's certainly not the case. We talked about estimates earlier, only about half of young adults who drink have the fragmentary type of blackout. And of course, there's this larger subset who don't drink at all and don't have blackouts related to this idea of what's normative. A lot of young adults think blacking out is just no big deal. So some of our data shows that blackouts are among the least negatively evaluated consequences. And we found that with both survey data and qualitative interviews with my colleagues Rosemary Ward and Ben Reward. And we analyzed massive amounts of Twitter data to see how people talk about blackouts online. And we saw a lot of evidence that they're downplaying the severity, making light of this experience. So you know, overall these things should suggest that people who have the experience don't think it's a bad thing. But I think Mary Beth and I both would want to emphasize that they're certainly not just no big deal. And perhaps especially while the brain is still developing. Well, if you don't mind asking like, why do you think people don't see them as such such a big deal? Yeah, I have often wondered if in some ways it's protective to not remember something that, you know, you may have really embarrassed yourself or or done something that you otherwise would have regretted. But if you don't remember it, then how can you feel super bad about it? I think again, norms really play a role into it. If you think all of your friends are doing it. And when you have these conversations the next day, it's a funny thing to talk about, you know, the whole movie, the hangover, they're recreating what happened in a blackout, which is made to be very humorous and and to seem like a normal experience. I feel like I have to jump in here though, because I do think I don't know if this is kind of what you meant Angelo, the Angelo in my head is saying it's a lot of cognitive dissonance though, right? It's like I have to justify this crazy thing that happened to me. I have to downplay it at least now. It's funny. But then the other thing I was going to say, Jen, that I think came up in our qualitative data with one of the first projects we did on blackouts. We did qualitative interviews or focus groups with college students. And I think they said there and I I wonder about this with the Twitter data too that part of it is like a language issue where I'm using the term blackout drinking and I'm saying I want to get blackout drunk. But if you ask them like, okay, so tonight when you go out, you want to make sure you don't remember it. Tomorrow like they would be like, well, no, I'm using the term blackout drinking to be like, I want to have a really heavy fun drinking episode is what they mean. It's kind of quantity or intoxication. Yeah. Yeah. Yeah. We definitely saw that slang for it. So to speak. Yeah. Definitely. I also wonder if it's like a badge of honor a little bit culturally, you know, given like college student drinking movies and things like the hangover. Yeah. It's like not just simply that's humorous to tell now, but it represents like a status almost in a culture of drinking. If that makes you a fitting in normal. Yeah. Yeah. For people talk about it like that that's connected to norms, right? That like I think a lot of people are having this and so having it this way kind of takes me up to another level in a meaningful way, both in terms of how I'm drinking, but also how I'm perceived by my by my peers in a meaningful way. I've always wondered that a little bit about some of the consequences here are like, you know, not every but we we researchers think of them as like, oh, that's like a bad thing. And then like we talked to people who like actually know, I actually thought that was a good thing or right and and the dissonance of it in the retrospect. I think does cloud it a bit where, you know, luckily you have some EMA data here that gets pretty close and so you can get close proximity in time where they, you know, experienced it recently at least. Yeah. And I mean, they are happening in the context of other positive effects of drinking, right? So like, even if someone doesn't like blacking out, they might be willing to have that experience. If it means they're also going to have a ton of fun that they don't remember. Yeah, or they are they're fitting in or some other kind of socially reinforced or, you know, positive emotion-based experience that would coincide with that that the when we put the two parts together, the net of that is positive. Yeah, right? Especially when you don't have like something super regrettable that took place in the blackout that you're able to get told back to later. Yeah. It's like, oh, that thing like blackout crashed the car, right? Like probably nobody's like, oh, that was super fun, right? But the one where you blacked out and you know, did something that wasn't maybe mildly embarrassing, but everybody laughed, you know, gets you a little bit different place. Yeah, we did ask like, we did ask in one study about how worth it the drinking event was and they did, you know, nights with blackouts were perceived to be less worth it than nights without blackouts. So sometimes some people are recognizing and maybe that's because of some of the other negative things that might be happening alongside the blackout. Yeah, this I think brings up an important nuance that's probably pretty different from maybe how scientists or clinicians would think about blackouts and how maybe our participants or people out in the community. And so maybe we could just talk a little bit about like why are blackouts considered such an important marker of alcohol related harms? Like, why do we think of them as bad things? Yeah. Yeah, so a lot of the work has been cross-sectional with some exceptions. And one cross-sectional study that I think about often Ralph Hingson and his colleagues have a 2016 paper they tested whether people who endorse young adults who endorse blackout in the past six months, do they also endorse other negative consequences in that same time period? And they're controlling for drinking levels, but they definitely found association. So as just a few examples, the young adults who had blacked out were also almost 10 times more likely to report hangovers, 10 times more likely to do something they regretted, and over 100 times more likely to have an alcohol overdose. So, but of course, the work doesn't really clarify whether blackout drinking per se is associated with or is causing elevated risks for those other consequences. And then in longitudinal work, there's some work linking blackouts to harm in terms of learning and brain changes. There was also a study done in Switzerland on whether blackouts are related to alcohol use disorder over time, though only among males who were age 20 at baseline, but they found these findings really interesting. So among those men that were blacking out at age 20 and were not yet dependent on alcohol, there was an increased odds that they would be dependent by age 25. And then for the guys who were blacking out at age 20 and already were dependent, they were more likely to still be dependent at age 25 and to increase their dependent severity. And then finally, I'll just mention a bit about what we know at the event level. It's our group and others have used daily data to get at the potential link between blackouts and other consequences on the same night. And we've also found other consequences to be more likely on days that involve blackouts than drinking days that don't, specifically things like embarrassing yourself or having a hangover. Even after controlling for how much someone drank, [BLANK_AUDIO] more likely to also endorse those things. But still, none of this really suggests causality necessarily. So even though these other consequences occurred as a result of the same drinking event, we can't confirm with these data that blackout caused to the other consequences. And we can't even be sure that some of the other outcomes occurred after the blackout started. Although I'm going to go on record saying, I think the blackout comes first and like, is linked very much to other consequences. On the record now, you all have it. I can go grind myself later when someone proves it wrong. Ruby Beth loves going on record. Yeah, we just, yeah, we just need to pull it back. We've got receipts if it comes through in the data, right? And we're like, yeah, we just have to find a way to test it. Yes, yes, that's that's the probably the real challenge, right? Is that the nature of the condition probably has some meaningful effects on the ways we can collect data, which is why some of these biosensor and other types of advanced techniques that you two have been kind of getting into here seem like they have such great promise. Yeah, I do, I do want to say though, that regardless, even if they don't come first, I feel like blackouts and their link to harm are really important because they also seem to increase openness to intervention. And so in, in prospective studies, blackouts aren't consistently linked to changes in drinking, but like drinking patterns specifically less than like alcohol use disorder symptoms, but they, they have been linked multiple times to increase motivation to change. And like Jen said, like decreased perception that the drinking event was worth it. And then in Sam, Sam's 2019 paper, it was only the more intensive of our existing interventions are linked to changes in blackout. So the, the, like brief interventions we already have, maybe those don't necessarily decrease blackout on their own in a general population sample, but we have at least two samples now where we found that if you give those brief interventions to people who had a blackout in the past month, they are more effective in reducing drinking among. So basically, the blackout may have primed them to be more open to the intervention that they've then received, even though it's a lower level intervention. And I think that's, that's really important kind of on its own. Yeah, I agree. I mean, when something like that's pretty low threshold can make a difference, especially given some of the longitudinal data you all just mentioned, you know, that, that's really important. And I remember, I think I was in at RSA when Ralph Hankson gave the talk about that paper. And I remember this was one of the early times where I was like shocked by a finding, because I think there's like 144 times more than 144. Yeah, 140. This is, see, we were just talking about, uh, funny, this whole thing's about memory, I guess my memory is terrible. Very met a moment. But I, I know, I'm, but I remember, yeah, 144 times more likely to have an emergency room visit. I think if you have, have blacked out and I mean, it's just, that is a, that is a shocking risk. And of course, you're right, association, not causation, but you got to think there's something important about that with an odds. I've never seen an odds ratio like that. So, but no, you just alluded to this, this idea of like the difficulty in sort of, you know, capturing some of this because the experience itself, Loon's to difficulty in like, you know, measuring the experience, the phenomenon. And so, but you, you two, this is published or the study that we alluded to, I think at the beginning, you know, you are trying to figure out how we can potentially detect blackouts as they're happening. So I wonder if you would be willing to just sort of walk us a little bit through, you know, the rationale what you found with this study. Yeah, I wish I could take credit for this research idea. I actually stole this idea from my best friend, Jenna, who doesn't care that I steal her ideas because she's a nurse. So, but I was explaining to her what blackouts are and why they happen. And as soon as I explained it, like without even missing a beat, she was like, oh, OK, so if I wanted to know if someone's blacking out, I can just tell them something and then 15 minutes later, just ask them if they remember. And it was one of those jaw-dropping ones, like if you've seen pursuit of happiness, the dude spends like hours trying to figure out the Rubik's cube and then Will Smith does it in like two minutes, that's what this moment was for me like actually. Yeah, I think that's very good work. So that was like early in my grad school training. And as it turns out, Donald Goodwin's group at Washoe had already done this. So in the late 60s, they recruited just 10 men from an unemployment office in St. Louis, brought them into the lab, administered crazy high doses of alcohol, like I think the equivalent drink equivalent was like 10 drinks, then tested their memory for neutral and salient cues. And none of the participants while they were drinking had impairment in like long-term memory or facts, and they could all perform calculations while they were intoxicated. But five of them were unable to recall the cues that they'd seen just 30 minutes ago, and they still couldn't remember them the next day. And all five of those people also reported like a history of blackout. So that was like the when we applied for the pilot funding, that was the story, I told not the not the Jenna story. But then so for our trial, what we did, we recruited 63 young adults with a history of blackout. And the actual memory test was integrated into our ecological momentary assessment or EMA Tiger Wear platform. So participants just downloaded the Tiger Wear app like they would for any other EMA study in the memory task is just like one of the possible questions you can put in your survey basically. And so if they as they're doing the prompts throughout the day while they're drinking, if they reported drinking that end of at the end of each drink report, at the end of the first drink report, they get a message indicating they were about to begin a memory test, and they needed to remember the image. And so then once they clicked a button confirming they were ready, then an image or the stimulus would be displayed for five seconds. And then after five seconds and open text question would pop up asking them what they saw. And that's actually a really important part of the design, because you want to one make sure that they perceived the image and actually saw it. And then also we wanted to record how they were going to describe it because the images are kind of vague rate. And then 15 minutes after that, they'd get two additional prompts first a free recall like open text box question asking we showed you an image what did you see. And then right after that a recognition item asking which of these three images did you see in one of them was the correct image. So theoretically, if they couldn't recall the image, but they could recognize it, that would indicate a fragmentary blackout is what we were thinking. And then if they don't recall or recognize that would indicate on block block out. And so we did that. Yeah, we did that. It was just like a memory test every hour that they're drinking. Yeah, I just have to say this is very upsetting to me. Why? I'll clever this. It's like one of those ones where it's just like, oh, yeah, I feel like I feel like the reason I like like social psychology or some basic sciences because it's always it's always such an interesting design, but you know less applicable to real life. And this is like one of those moments. I think where you all really managed to marry these, you know, clinical applicability to this really elegant basic sort of design. Yeah, that I think is really useful. So yeah, anyway, sorry. Yeah, and that's where Jen's EMA expertise was critical here too, because I had never this was my first EMA study. Well, okay, so then what we found well, and we used a visual memory specifically, it shouldn't actually matter. I think this was mostly a logistical decision because Jen had recommended using the international effective picture system, the IEPs images, because they include neutral positive negative. We don't actually have a big enough sample to to know if that matters, but that's one of the things they did in the done good win study. And so we wanted to have all different types of images theoretically, it shouldn't matter. But now we have the data to kind of explore it. I haven't explored it though. So don't ask. But in terms of what we found. Okay, so first we kind of saw this coming on block blackouts were pretty rare. It's a 30 day protocol. We only had 10 participants and we did recruit for people with a history of blackout who have pretty heavy drinkers, but we only had 10 participants report 19 on block blackouts total throughout the trial. We had 34 participants report 85 fragmentary blackouts. So we ended up just combining those for the analysis and the outcome so the outcome is just any form of blackout whatsoever and we can't differentiate fragmentary from the on block in this data. But altogether we had 38 participants then who had any form of blackout. The other non-exciting but important outcome was that basically no one failed the recognition task. So analysis also focused only on free recall because everybody got the recognition task right. Okay, so the most exciting findings relate to the diagnostic accuracy of the test right. So basically if you fail the test is that a good indicator of blackout. And here the results were half disappointing and half super progressing as all research I feel like. So participants failed at least one recall task so blackouts are day level we gave the memory task multiple times in the night but since blackouts happen at the day level we had to aggregate the memory task data somehow. So we looked at did you fail at least one recall. task. They failed a recall task on 105 days. So for the test, that's indicating they had a blackout on 105 days. But they only actually reported a blackout the next day for 41 of those days. So that's a 39% positive predictive value, which is not nearly as high as I would like it to be. But they correctly recalled all the images in the night on 339 days. So 339 days, the test is telling us they didn't have a blackout, and they denied a blackout the next day on 312 of those days. So the negative predictive value was 92%, which is really good. And the negative predictive value for on-block specifically was 99%. So if you correctly recall all the images, you are almost certainly not having on-block blackout. In diagnostic testing, sensitivity and specificity are also important. So I'll just go through that really quickly. They failed one or more recall test on 41 of the 68 days that they subsequently reported a blackout. So that's 60% overall sensitivity. It was 82% for on-block specifically, which is good. And then in terms of specificity, they correctly recalled all the tests on 316 of 380 days that they did not then have a blackout. So 83% specificity. Which is actually, these aren't that far off from some of the other like fields of priority testing things that are available in the literature. But all together, this means that failing the test doesn't necessarily mean you're having a blackout. They were out drinking and we weren't standing there watching them. So we don't know how much effort they were putting in necessarily to remember the images. But if you pass the memory test, you're highly unlikely to be experiencing a blackout, particularly on-block blackout. That's very interesting. Yeah, I guess it depends on what you want to do with it, right? If you're trying to, you know, like if we were thinking about how it might apply to some kind of clinical setting, for instance, avoiding doing stuff while you're experiencing a blackout would probably be a pretty good space to be in. And that sounds like the data there are pretty supportive of opportunities to figure out whether or not that's going on. But there's probably a lot of stuff that still needs to be done here, although shout out to like very clever set of methods as well as just, you know, really strong application here to trying to really kind of separate noise from signal here, which I think is really challenging to do in a space like this, especially given the nature of the construct, let alone the data analysis and all the complications there. Yeah, I actually, I should give, I should give Ed Merkle a shout out here because I, he actually randomly, this is off, off topic kind of, but he asked me to present my data randomly at a quant seminar and I was like, what am I going to present at a quant seminar? But I presented these data just to be like, here's some cool data that are like messy and he was like, I could help you with those. And then he did and I'm so glad because I would not, Jen and I would not have done these analyses like this. He's like Bayesian modeling and so. Yeah, yeah, science is truly a team sport in this regard. Yes, yes. Nobody can know everything, but everybody knows something. And so, you know, that's why going to conferences or presenting your data, even if you feel, you know, uncertain about them can be such a useful place because it gives you future directions to really take this. And so maybe you could tell us a little bit about what you think needs to be done still in the space. I'm sure there's a lot more that could be done and maybe you have some thoughts about it. Yeah, so many things. What I really wish we could do is get people blacked out in the lab to study them, but I don't see that in the 60s. Yeah, yeah, free bell mom report, I guess, free bell mom, yeah, Stanford prison study, you know, yes, but I am an ethical person. And yes, yes, you know, I think the work that I think just make sure is cited. Yes, I think, you know, the work that Mary Beth is doing and that she just described being able to detect blackouts in real time would open up a lot of possible research directions and help us better confirm what kinds of event level things are predicting a blackout or the consequence of a blackout. We still need more work to understand why certain person level characteristics or event level things relate to blacking out. So as one example, we recently showed that blacking out was more likely following nights of poor sleep, but we don't know why. So it could be that poor sleep is altering the way people subjectively experience alcohol or maybe it's a difference in how the body can process alcohol after a night of poor sleep. So that's another area that Mary Beth and I are hoping to pursue in a place where the field would really benefit from more animal models and neuroscience. And then of course, we need to do more work related to prevention and intervention. Can we learn more about the people that don't seem to blackout? What's protecting them? Can we change blackout norms? How common and normal people think they are or can we increase people's knowledge about the ways that different features of a drinking event like how quickly they drink might increase their risk? So yeah, if any students out there need dissertation ideas, feel free to tackle some of these. We can't do it all. Yes, yes. I reach out for collaboration. Yeah, yeah. For folks. Yeah, there's always more ideas. There's always room. This isn't a zero sum field, full findings, create more ideas. So yeah, I love that. Well, thank you all. I mean, this has been an incredible episode and we're really just pleased with this conversation. And I've learned so much. So we really appreciate it. I'm wondering if you all are ready to transition to the take homes. Yeah, let's do it. Sure. Great. Okay. So what do you think the take home message are for people who are in recovery or who might be interested in making a change to their alcohol use? Yeah, we couldn't decide which of these was most important. So you got too hate take homes for people. So first, drinking outcomes depend more on how you drink than what you drink. For example, if you're drinking in part to build social connections, blackout styles of drinking actually rob you of that. They rob you of the memories of those connections you were trying to build. So imagine like having a heart to heart with someone while you're drunk, but you're blacked out. And the next day, you don't even remember that is like the exact opposite of what you're trying to go for there. So if you want to maximize the benefits of drinking, it's really in your best interest to slow down. I think the young adults that I talk to you are usually surprised here that at its healthiest your body can only process about one drink an hour. So something you consider the second take home there was that there are really ways to prevent blackout related harm in particular in the moment. So if you're worried about a friend who blacks out, you can just give them a memory test. Like we have to use the app because participants don't really want to, well, they would drink differently if we were like standing next to them, seeing their memory. But like you don't have to use an app. You can just show them an image, tell them a word. It is important to make sure that have them repeat it back to you first because they're drinking. And so you want to make sure they know what they saw. But then wait 15 minutes asking what it was. And I think one thing we learned from our studies, like probably don't freak out if they don't remember it at first. But if you try it more than once and they can't pass a memory test, I personally, I wouldn't leave that person alone. That's a really important, I think a really important take home here. A couple of them actually. And then you know, all the stuff that you've been talking about here has reminded me of my clinical work that I've done with, you know, with young adults who drink heavily. And so I wonder what the take home is for practitioners you might have. Yeah. So, I mean, probably another myth is that blackouts are equivalent to alcohol dependence. And while that's not true, they are likely a good screening tool for people who might benefit from brief intervention or more intensive intervention. And as we've discussed, if someone's black and out, they're probably experiencing other negative consequences and most people don't want to blackout. So if they're willing to tell a practitioner that this happened to them, it might serve as an in-road to offer advice on reducing drinking. Yeah, really, really good point. What take homes for policy makers? Yeah, this is a tough one. We don't really talk much about it today, but a couple thoughts. One, I think a lot of states have implemented policies banning things like drink specials. So things like those $1.50 pictures that I was able to purchase as a 21-year-old. Those specials are likely to target young people who, when given the opportunity to drink a lot for very little money, are going to do that. And while there's no data on that, I suspect that policies like that are helpful for reducing blackouts, so continue to push for those. I'd also say, again, most of the time when people blackout, it's not intentional. So anything we can do to raise awareness of how much and how quickly their drinking could help. We see a lot of these very strong single container drinks now, right? Like there's hard sellers that are double the percentage, but appear to be a single drink. And I've noticed that in some countries like Australia and New Zealand, the drink containers are labeled with the number of standard drinks that they contain. So I've really been thinking about that a lot and thinking that it'd be great if US policymakers would adopt requirements on containers related to number of servings and perhaps information on safe drinking guidelines, things that can make it easier for people to know and understand what they're consuming so that they can alter the amount or at at least the the pace at which they're drinking. So I'm excited to be moving into that space a little bit too. - That's so cool. Well yeah, that is, I think really, you know, that's just like a easy solution, right? Like right on the thing, you have it in your hand, tells you how many drinks and also here are the guidelines on drinking, right? - Yes. - That's one of those ones where it's just like super, whenever you have super clever, policy is obviously a very complicated space as you mentioned. - Yeah. But I think things like simple solutions for complicated problems are really the path forward. And so that's such a great take home. What would you say the take home is maybe for underserved populations? - Well, we've come a long way in terms of including women in blackouts for search, so that's good. - Great point. - Great point. - But with few notable exceptions, most participants in these studies are between 18 and 30 and identify as cisgender and white. A lot of them are current college students. In those samples, you usually see highest rates of blackout among white participants and then Hispanic and black and then Asian participants. But in our, I've done a couple of veteran studies. In those studies, we actually found pretty similar rates of blackout across race ethnicity and in our ongoing study of adults with alcohol use disorder, we actually have 100% rates of blackout among the Hispanic and the white participants in that study. And then I mean, high rates across the board 'cause everyone has to meet for alcohol use disorder. But I thought it was interesting that it's 100% for some races and ethnicities. We've also found some evidence of sex differences and predicators of blackout among black, Hispanic and Asian samples. And so we'd really love to see increased representation of people from more diverse backgrounds and people who haven't been studied as much, including like young adults who aren't in college and then also just like a very limited research among midlife or older adults. But I think with or without data, blackouts almost certainly put some populations at more risk than others. And so this is a really important area. - Yeah, absolutely. We did an episode with those are all important areas to continue to grow in Alexis Curbis. I think Dr. Alexis Curbis about older adults. And so it actually got me thinking about like changes in metabolism and stuff that happened sort of around 50 year old, you know, and that start to happen. And yeah, I just wonder how that affects so. Anyway, random little thought there. But we really appreciate your take homes, but really just this episode in general, incredibly informative. And I think we've communicated this to both of you, but we really appreciate you and your work. And you both have also been incredibly successful and have multiple lines of really impactful research. So we're wondering if you could tell us a little bit about, give us a little bit of advice, what would you recommend that we and trainees do to be as successful as you? - Yeah, I say first do what excites you. Sometimes there's a balance between and a finding ideas that you're excited about, but also knowing that there are certain things that might be important right now or are very fundable. And I really think, you know, finding the questions that you're genuinely excited about is the best way to stay motivated. I also think it's important to just prioritize doing good science over trying to reach certain levels of productivity. A lot of emphasis is placed on how many papers we publish, sometimes as a trainee or even now I've felt like almost defined by how many papers I have. And I recall I'm more than one occasion expressing my mentors like I'm disappointed I don't have as many papers as so and so. And they really reminded me that the number isn't the most important thing and that people in the field are paying attention to quality as much as quantity. And you don't want to be known as someone who just has a lot of papers. It's most important to be putting rigorous and meaningful work out there. Third, I'll say, don't wait to celebrate your accomplishments once the paper is accepted or grants funded. I think submitting the paper or the grant is what we should celebrate as that's really the point after which you've put in all this work. And that's the part that's really under your control. So personally I like to treat myself to the spa after I submit a grant and then finally, you know, think about how to make yourself a marketable collaborator. I've learned that every time I have a chance to work with somebody new, it's my opportunity to sell myself. If I do a good job on that collaboration, I'm likely going to be asked to work with that person on another paper, as well as grants, which is very important for many of us to sustain our careers. And kind of related to that, I think it's in your best interest as young investigators to find something that you can excel in and ideally something that's perhaps somewhat unique. So whether it's being an expert in a certain topic area, some type of method, clinical skills, statistical skill, having something that's kind of unique will increase the chances that you'll be sought out for team science, which, as we already mentioned, is the best science to do. - Yeah, the only thing I wanted to add to what Jen just said is that I think sometimes younger early career people misinterpret, like, find what you excel in as meaning that you need to be like the best or the smartest at something. And I just wanna emphasize, you don't have to be the smartest person in the room. I'm like the fourth of five kids. I've literally never in my life and the smartest person in the room. But it's not really about who's the smartest. It's like, research is about figuring things out and solving problems and that requires listening for one and intuition and collaboration and ability to mobilize teams. And so I just encourage you not to worry about being the smartest. Just focus on doing good science and building good teams like Jen already said. - Yeah, well, yeah. - Finding good people. - Which you two, I think are a great exemplars of that. And so quality folk, yeah. We really appreciate this. Thank you so much. - That's fun, thank you. - Really wanted to have you on the show for a long time. And so thank you both for both listening to the show, which is still surprising to you that anybody does that. And also making some time to just share your experience and your research with our audience. - It was fun. - Thank you. Yeah, thank you. (upbeat music) (upbeat music)