1 Diagnosis and Treatment of Alcohol Dependence Lon R. Hays, MD, MBA Professor and Chairman an Department of Psychiatry University of Kentucky Medical Center
2 Defining the Standard Drink A standard drink = 14 g ethanol 12 oz of regular beer or cooler (5% alcohol) 5 oz of table wine (12% alcohol) 1.5 oz of hard liquor (40% alcohol, l 80 proof) The average person metabolizes about 1 standard drink per hour 12 oz 8-9 oz 5 oz 3-4 oz 2-3 oz 1.5 oz 1.5 oz beer or malt liquor table wine fortified wine cordial, brandy spirits cooler 8.5 oz shown in a (such as sherry liqueur, (a single jigger) 12 oz glass that, or port) or aperitif of 80 if full, would hold about 1.5 standard drinks of malt liquor 3.5 oz shown 2.5 oz shown (a single jigger of 80-proof gin, vodka, whiskey, etc.) shown straight and in a highball glass with ice to show level before adding mixer 12 oz 8.5 oz 5 oz 3.5 oz 2.5 oz 1.5 oz 1.5 oz Source: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; NIH Publication No
3 Addiction has so many dimensions and disrupts so many aspects of an individual s life, treatment for this illness is never simple. Alan Leshner, MD
4 Why Should We Be Concerned?
5 Medical Complications of Alcohol Abuse/Dependence
6 Comorbidity Substance Use Disorders are particularly prevalent among individuals id with psychiatric i disorders
7 National Comorbidity Survey Half of female alcoholics have a history of major depression One-quarter of male alcoholics have a depression history
8 Medical Complications of CNS Alcohol Use Cardiovascular Gastrointestinal Endocrine
9 CNS Manifestations Withdrawal/DT s Alcoholic Dementia Hepatic Encephalopathy 40 Wernicke s 10 0 Encephalopathy Korsakoff s s Psychosis East 40 West st Qtr 2nd Qtr 3rd Qtr 4th Qtr North
10 Cardiovascular Cardiomyopathy Arrhythmias h h i Hypertension Myocardial y Depression
11 Effects of Chronic Alcohol Use on Body Systems Cognitive deficits psychosis Oral/esophageal cancer Cirrhosis Pancreatitis Cardiomyopathy arrhythmias hypertension stroke Stomach ulcers, gastritis Duodenal ulcers Sources: Schuckit MA. In: Harrison s Principles of Internal Medicine. New York: McGraw-Hill; 2001: American Psychiatric Association. DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.
12 Diseases Associated with Chronic Alcohol Use Primary Pi Diseases Secondary Diseases Alcohol poisoning Alcoholic heart disease (cardiomyopathy) Alcoholic gastritis Alcoholic li liver cirrhosis i Alcoholic nerve disease (polyneuropathy) Alcoholic psychoses Cancer (lip, mouth, pharynx, esophagus, larynx, liver, stomach) Diabetes Gastrointestinal disease Heart disease (hypertension, stroke) Liver disease Pancreatitis (acute, chronic) Pneumonia/influenza Tuberculosis Sources: Schuckit MA. In: Harrison s Principles of Internal Medicine. New York: McGraw-Hill; 2001: American Psychiatric Association. DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.
13 Gastrointestinal Fatty Liver Alcoholic h li Hepatitis Alcoholic Cirrhosis Pancreatitis Gastritis
14 Endocrine Hypogonadism Feminization
15 Assessment to Determine Level of Care Acute Intoxication and/or Withdrawal Potential Biomedical Conditions and Complications Emotional and Behavioral Conditions Treatment Acceptance or Resistance Relapse Rl Potential il Recovery Environment
16 Continuum of Care Medically Managed Inpatient Residential Treatment Partial Hospitalization Intensive Outpatient Treatment Psychotherapy/Counseling Alcoholic s Anonymous
17 Methods of Detoxification Benzodiazepines Barbiturates t Valproic Acid Carbamazepine p
18 Factors Associated With Alcohol Dependence Alcohol dependence is a complex disorder in which many factors act together to produce the illness Approximately 50% of the risk is attributed to genetics Genetic factors can act in combination with other biological or environmental factors May arise in individuals without any apparent family history of alcohol dependence as a result of environmental and/or interpersonal factors Source: American Psychiatric Association. DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.
19 Brain Reward Pathways The VTA-nucleus accumbens pathway is activated by all drugs of dependence including alcohol This pathway is important not only in drug dependence but also in essential Nucleus physiological behaviors accumbens such as eating, drinking, sleeping and sex Ventral tegmental t area (VTA) Source: Messing RO. In: Harrison s Principles of Internal Medicine. 2001:
20 Effects of Acute Alcohol on Reward Circuits Dopamine and Opioid Systems Indirectly increases dopamine levels in the mesocorticolimbic system Associated with positively reinforcing/rewarding effects of alcohol Indirect interaction with opioid receptors results in activation of opioid system Associated with reinforcing effects via µ-receptors cp Sources: Koob GF, et al. Neuron. 1998;21: Messing RO. In: Harrisions Principles of Internal Medicine, 15 th ed. 2001:
21 Effects of Acute Alcohol on Other Neural Circuits GABA and Glutamate Systems Increases the effects of GABA, the major inhibitory neurotransmitter in the brain Inhibits the effects of glutamate, the major excitatory neurotransmitter in the brain Contributes to decreased anxiety and increased sedation during acute alcohol intake GABA = gamma-aminobutyric acid. Source: Littleton J. Alcohol Health Res World. 1998;22:13-24.
22 Pharmacotherapy in the Treatment of Alcohol Dependence
23 Naltrexone Approved by the FDA in 1996 Blocks rewarding effects through its effect on endogenous opioid systems
24 Acamprosate (Calcium Acetyl Homotaurinate) Approved by the FDA in 2004 Chemically related to glutamate (brain s chief excitatory neurotransmitter)
25 Disulfiram (Antabuse Antabuse ) Prevents drinking by preventing liver from fully metabolizing alcohol Inhibits aldehyde dehydrogenase Reaction: nausea, flushing, high blood pressure, chest pain
26 Vivitrol Monthly Injection of Naltrexone 360 mg
27 Treatment of Comorbid Conditions Depression Panic i Disorder Generalized Anxiety Disorder Social Anxiety Disorder