Science and Law
6th March 2013

The Science of Defending Energy Drink and Alcohol Combinations

In this post you will learn why the safety of alcohol-mixed energy drinks (AMED) have become a hot controversy. Litigation is heating up in this area, and now, more than ever, there is a significant need for a clear understanding of the science – a core service we have been providing our attorney clients for over a decade.

The Science of Defending Energy Drink and Alcohol Combinations

In this post you will learn why the safety of alcohol-mixed energy drinks (AMED) have become a hot controversy. Litigation is heating up in this area, and now, more than ever, there is a significant need for a clear understanding of the science – a core service we have been providing our attorney clients for over a decade.

First off, what is an AMED? AMEDs include pre-mixed caffeinated alcoholic beverages, bar cocktails (like the popular Red Bull/Vodka), self-mixed cocktails, as well as energy drinks and alcohol consumed separately but within a short period of time (Howland). To state the obvious, the common thread among these scenarios is ingesting energy drinks (which contain caffeine and other ingredients) plus alcohol.

                            (Image courtesy of Ambro / FreeDigitalPhotos.net)

POPULARITY OF AMED

Amazingly, AMEDs have dramatically increased in popularity amongst teens and young adults in the past few years. For example, in a study published in Nutrition Journal, the authors report that 51% of college students reported consuming greater than one energy drink each month for the current semester, and 54% of these consumed energy drinks to have with alcohol while partying. Another study reported that almost 25% of college students that are current alcohol drinkers consumed AMED.

An additional testament to the popularity of AMED is the volume of pre-mixed caffeinated alcoholic beverages (CABs) being produced. According to a study cited in a CDC report on CABs, “two leading brands of CABs together experienced a 67-fold increase in sales, from 337,500 gallons in 2002 (the first year of significant CAB production) to 22,905,000 gallons in 2008.”

Clearly, with such explosive growth, it is important for stakeholders to understand the risks of AMED through a balanced and critical assessment of the science.

PURPORTED RISKS OF AMED

From a review of the literature, there appear to be three types of risk purportedly related to AMED consumption (For Examples See Howland, de Haan):

1) Energy drinks offset the sedating effects of alcohol (relevant ingredient being caffeine)

2) Energy drinks reduce sensation of intoxication, therefore impairing judgment relative to risky behavior

3) Energy drinks drive greater alcohol consumption from the reduced feeling of intoxication

MECHANISMS OF ACTION OF ALCOHOL AND CAFFEINE

Overall, the opposing effects of alcohol (a depressant) and caffeine (a stimulant) are thought to converge and result in the outcomes described above. Let’s take a look at the mechanism of action of alcohol and caffeine.

One mechanism through which alcohol (i.e. ethanol) exerts its mechanism of action is by its direct influence on specific neurotransmitters. For example, it is thought that short-term alcohol consumption can increase the effect of various “sedation” receptors in the central nervous system (e.g. gamma-aminobutyric acid (GABA) receptor, and glycine receptor). Another mechanism includes increasing the activity of inhibitory neuromodulators such as adenosine, which may also lead to sedation. The resultant effect is that a sedative state is provoked, while triggering a “feel-good” sensation by the release of serotonin and dopamine (See Valenzuela for a review on this topic).

Caffeine is a well-studied central nervous system stimulant that can have effects on the heart, and other muscles by modulating the activity of three molecules: adenosine, adrenaline, and dopamine.  For adenosine, which normally slows down nerve cell activity (causing tiredness), caffeine competes with adenosine receptors and actually leads to increased excitability of neurons.  Ingestion of caffeine also leads to enhanced adrenaline, which can influence the heart beat, muscle tightening, and alertness. Lastly, caffeine can delay the rate of dopamine re-uptake, leading to more pleasurable feelings (See Winston and Fredholm reviews for comprehensive coverage on this topic).

AMED STUDIES

With respect to studies on outcomes related to individuals ingesting the combination of alcohol and caffeine-containing products (i.e,. AMED), the results have been extraordinarily inconsistent. Further, many of these studies tend to be observational in nature, and as discussed in a previous ISS blog post (Epidemiology Methods in Litigation), it is difficult to pin-down cause and effect using such observational study designs.

Below is a sampling of studies (among the many others) that have been published, demonstrating the inconsistency in the data:

In a 2012 survey of Dutch college students, investigators examined the differences in alcohol consumption and its consequences when consumed alone and when mixed with energy drinks.  The authors reported that students who mix alcohol with energy drinks actually consumed less alcohol when they consumed AMED, compared with occasions on which they consumed alcohol only, and “AMED did not increase the likelihood of potentially dangerous activities or serious negative consequences, such as driving while intoxicated, being injured, or getting involved in a fight, unplanned sexual activity, or taking foolish risks” (de Haan 2012).

According to another study, college students who consumed AMED were found to be “at increased risk for alcohol-related consequences, even after adjusting for the amount of alcohol consumed.”  Further, a study by Thombs et al. reported that “[bar] patrons who had consumed alcohol mixed with energy drinks were at a 3-fold increased risk of leaving a bar highly intoxicated … as well as a 4-fold increased risk of intending to drive upon leaving the bar district, compared to other drinking patrons who did not consume alcoholic beverages mixed with energy drinks.”

However, there have been strong criticisms of certain study designs used to study the effects of AMED, and indeed, when potential confounding is controlled for, the studies generally report no positive association between AMED use and demonstration of risky behaviors. An example is the Peacock et al. study, where the authors found that “the odds of engaging in risk-taking were less during AmED sessions relative to alcohol sessions.”  The problem of confounding is laid out nicely by Howland in his JAMA article: “It is possible that personality traits such as impulsivity and sensation seeking cause AMED consumption, rather than AMED causing risky behaviors.”

As always, a balanced and critical analysis of the scientific literature is required to fully understand the potential risks of AMED. The science on AMED continues to emerge, and the “true” effect of AMED on the three risk areas outlined above remain largely unknown.

Check out our previous blogs on The Science of Caffeine Toxicity and The Regulatory Status of Caffeine for more on caffeine and energy drinks.

About Innovative Science Solutions

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