EXPERT REACTION: Teenage girl dies after alcohol-energy drink mix

This tragic case reminds us that alcohol use can be lethal. ‘Binge’ drinking is common in teenage girls in Australia and has many other risks including acute accident or injury, intoxication and aspiration and unwanted sexual encounters, sometimes resulting in unplanned pregnancy. Also, inadvertent exposure of the unborn child to the harms of alcohol may occur when women drink before they realise they are pregnant. Alcohol can injure the developing brain of the unborn child, with lifelong consequences including fetal alcohol spectrum disorder.

Death and other harms can occur with intoxication even when alcohol is not combined with other drugs. Young women must be made aware of the potential harms of alcohol to themselves and others, including the unborn child, and assisted to refrain from drinking to excess or mixing alcohol with other drugs.

The information from reports in the media remains scant, and await forensic confirmation, but at the time of writing, there is speculation that there has been another tragic loss of a young Australian life associated with recreational drug consumption- in this case, an attempt to create a cocktail of alcohol, an energy drink - and incidentally flavoured with lollies.

If this indeed proves to be the case, it will sadly not be the first such case described. The commonest active ingredient in most energy drinks is caffeine, followed by compounds such as guarana, taurine & ginseng, all of which can act as stimulants in some people. Both caffeine and alcohol are ‘recreational drugs’, in that they are consumed in 21st century Australia for purposes other than therapeutic effect. Their legality, particularly in the case of alcohol, should not be misconstrued as a reflection of safety. It shouldn’t come as any surprise then that it is possible to overdose on either.

Caffeine poisoning is rare, and deaths even rarer. Alcohol intoxication is an all-too-common cause of harm and death in Australia, in what is a largely unfettered, lobby-influenced market. But the combination of alcohol and caffeine, particularly in uninitiated drinkers, can be significantly more dangerous than the sum of the hazards of each. Several studies have demonstrated that caffeine can mask the effects of fatigue, which is a natural effect of isolated alcohol consumption. As a consequence, those consuming caffeine can drink more alcohol, for longer, at ever increasing rates of disinhibition, and risk of poisoning from the alcohol moiety. In addition, research conducted at the ANU by Dr Rebecca McKetin showed that caffeinated alcoholic beverages appear to increase the desire to drink more alcohol, often described as ‘the priming effect’.

While bad news for unsuspecting young Australians, increased alcohol consumption within this demographic is not an unpalatable prospect for retailers. In the USA, as rates of emergency presentations related to premixed / ready-to-drink (RTD) caffeinated alcoholic beverages soared, they came to the attention of the FDA & were banned in 2010. Australia has some of the strictest laws regarding energy drinks in the world, but the simple addition of alcohol seems to have rendered them largely invisible to scrutiny.

Are these sorts of deaths preventable? Certainly, better information about the general potential harms from alcohol (despite it being a legal drug), including the exacerbated harms from the combination with energy drinks, might help. If we know anything about this space, it’s that the alcohol industry cannot be trusted to provide appropriately robust messaging regarding a product from which it profits.

And what should we tell young people? Probably the same message applies for any recreational drug consumption -  “Don’t mix your drugs - and go low, and slow.”

Prohibition didn’t work in the 1920s and 30s in reducing the harms from alcohol, and it still doesn’t - either for alcohol, or any other recreational drug.

Alcohol is the drug most commonly associated with a drug-related death in Australia. Although fewer adolescents are drinking alcohol than in previous years, when they do drink, they are likely to choose a caffeinated alcoholic beverage. Espresso martinis, rum and cokes, vodka Red Bulls®, and Jägerbombs are examples.

Caffeine does nothing to reduce the effects of alcohol, but it does increase alertness and offset fatigue. People are notoriously poor at judging their intoxication levels. Drinking a lot of caffeine may make it even harder for people to know when to say no to alcohol. Experimental studies have demonstrated that caffeine increases people's desire to drink in a dose-dependent manner, such that drinking greater amounts of caffeine may lead to more alcohol consumption.

Combining caffeine and alcohol is not a great mix for anyone at any age. My heart breaks for these parents.

There are a number of Australian studies which point to a relatively common practice for young adults consuming a mixture of alcohol and amphetamines (in particular). They do this because alcohol has sedative qualities while amphetamines are stimulants. As a consequence the person consuming alcohol is able to stay awake for a much longer period of sustained drinking. In the case of the teenage girl reported in the media today, the energy drinks she reportedly consumed could have had a similar effect as they contain stimulants such as caffeine and guarana.

There are obvious dangers for the young adult involved, but the evidence is that death is an unusual outcome. This behaviour needs to be explicitly addressed as an emerging health issue.