DSM-IV Alcohol Dependence Alcohol and Drug Abuse David Gilder, MD Division of Mental Health Scripps Clinic Alcohol Research Center The Scripps Research Institute 1.5.11 Three or more criteria, same 12 months Tolerance Withdrawal Larger amounts Can t control Time spent Activities given up Continued use despite persisting physical or psychological problems Black=More, Yellow=Mid, Green=Less on Severity Continuum DSM-IV Alcohol Abuse Maladaptive pattern of use, same 12 months, need one: Role failure Hazardous Use Legal Problems Social/Interpersonal Problems Not Alcohol Dependence Black=More, Yellow=Mid, Green=Less on Severity Continuum Screening for Alcohol Risk Quantity/Frequency 5 drinks per day, once per week (men) 4 drinks per day, once per week (women) 14 per week (men), 7 per week (women) If exceed both, 50% have alcohol abuse or dependence CAGE: 2 out of 4 questions = alcohol problem AUDIT Prevalence of Alcohol-Impaired Driving by Drinking Style (past 30 days drinkers) Age Binge Heavy Neither 18-24 43% 0% 2% 25-39 37% 4% 1% 40-54 29% 3% 1% 55+ 19% 2% 1% Total 34% 3% 1% Flowers et al., 2008ACER Percent of Youth Developing Alcohol Dependence Based on the Age of First Drinking Under 13 41% 3.2X 13-14 44% 3.5X 15-16 35% 2.8X 17-18 21% 1.7X 19-20 14% 1.1X 21+ ~10% ~0.8X All ages 13% 1.0X Grant and Dawson, 1997JSA
Percent of Youth Developing Alcohol Dependence Based on the Age of First Drinking Grant BF & Dawson DA (1997) JSA. 9: 103-10. Alcohol Metabolizing Enzymes 50 3.2X 3.5X Alcohol Acetaldehyde Acetate ADH ALDH % Developing Alc Dep 40 30 20 10 0 2.8X 1.7X 1.1X < 13 13-14 15-16 17-18 19-20 21+ 0.8X All ages ADH2*1 (Wild Type) High Activity Alleles: ADH2*2 (Asians, Jews) ADH2*3 (Af Am-30%; Am In-5%) Low Activity Alleles: ALDH2*1 (Wild Type) ALDH1A1*2(Am In, Other) ALDH2*2 (Asians-40%) Age First Drinking Increase in Drinking and Psychiatric Illness in Second Generation Mexican Americans Disorder Born Mexico Born USA Alcohol 6% 15% Drug 0.4% 4% Depression 8% 15% Anxiety 9% 16% Grant et al., 2004AGP Converging Acute Actions of Drugs of Abuse on the Ventral Tegmental Area and Nucleus Accumbens Effect of a CRF Antagonist on Responding for Ethanol in Dependent and Non-Dependent Rats From: Nestler EJ, Nat Neurosci, 2005, 8:1445-1449. From: Funk C and Koob GF, unpublished results.
Competitive CRF Antagonist Blocks the Anxiogenic Effects of Alcohol Withdrawal Reward Transmitters Implicated in the Motivational Effects of Alcohol and Drugs Positive Hedonic Effects (Intoxication) Increased Dopamine, Opioid Peptides, Serotonin, GABA Feeling good, euphoric, calm, happy, not in pain Negative Hedonic Effects (Withdrawal) Decreased Dopamine, Opioid Peptides, Serotonin, GABA Feeling bad, dysphoric, anxious, depressed, in pain From: Rassnick S, Heinrichs SC, Britton K and Koob GF, Brain Res, 1993, 605:25-32. Co-morbidity of Alcohol Dependence and Psychiatric Disorders: COGA (Rates, Men) Con- Alcohol Dependent (n=2713) Psych Disorder trols Ind Sub Total (n=919) Panic 0.7 2.8b 1.1 3.9a Agoraphobia 0.4 1.1 1.3 2.4b Social Phobia 0.7 2.4c 0.6 3.0b OCD 1.0 1.0 1.5 2.5c Major Dep 9.3 8.3 30.1 38.4a Bipolar 0.7 1.5 1.2 2.7b Comparison vs. Controls sig at (a) p<0.001, (b) p<0.01, (c) p<0.05 Schuckit et al., 1997Add Rates of Anxiety and Depression Disorders in Individuals with Alcohol and Drug Use Disorders Alcohol Dx Drug Dx Anxiety Dx 48% (3X) 30% (2X) Depression 41% (2X) 41% (2X) Dx Kessler et al., 1997AGP; Hasin et al., 2007AGP; Conway et al., 2006JCP Medications for Alcohol Use Disorders disulfiram (Anatabuse) Poisons ALDH; compliance poor naltrexone (Revia) Opiate receptor blocker; effective in large US study acamprasate (Campril) Glutamate receptor blocker; effective in European studies, not in large US study
Acamprosate (Campral) Promotes abstinence in detoxified alcoholics 20 randomized, placebo controlled studies Complete abstinence at 6 months: Acamprosate: 36% Placebo: 23% Acamprosate also decreases the quantity and frequency of drinking in non-abstinent (relapsing) alcoholics Pervasive Use H.S. Seniors: 46% College Students: 51% Young Adults: 57% In 2002, 1 million people (0.4% of population) received treatment for cannabis dependence or abuse Lifetime prevalence disorder: 8.5% First use mid-teens to early twenties Risks Medical: similar to tobacco Poor school, job performance Amotivational syndrome (depression)?gateway drug Co-morbidity with other drug dependence and psychiatric disorders THC is stored in body s fat toxicology tests can remain positive for more than 1 month THC may mobilize with weight loss Mass spectrometry vs. standard urine toxicology testing: THC increase of more than 1.5 times in a mass spectroscopy test suggests continued use Cannabinoid (CB1) receptor blocker rimonabant pulled for multiple side effects Opioids Common forms: heroin methadone prescription medicines: morphine, Vicodin, Percodan, Oxycontin Oral, snorting, smoking, iv use Diversion, street availability, unintentional OD Reported rates of iatrogenic addiction to prescription opioids: 3 21% Opioids Use is common H.S. Seniors 2% have used heroin 14% have used any opiate for a high Young Adults: 2% have used heroin 17% have used any opiate for a high Urine toxicology screen usually negative within 3-7 hours; metabolites sometimes longer
Opioid Addiction: Treatment Detox: clonidine, benzodiazepines Maintenance methadone buprenorphine Buprenex Suboxone (buprenorphine/naloxone:4/1) Best if combined with psychotherapy, support group Strategies for Cutting Down: Harm Avoidance Keeping track Counting and measuring Setting goals Avoiding triggers Planning to handle urges Knowing your no Treatment Screening and Diagnosis Advise and Assist (Brief Intervention) Use meds in conjunction with detox, psychotherapy, AA or other support group Consultation and Referral Community Resources NIAAA Clinician s guide with info on screening, brief intervention, meds for alcohol Impaired Professional US Physicians: same rates of alcohol and drug use disorders as general population Use patterns may vary by specialty Access an important issue, e.g., opioids Warning Signs Treatment issues: Intervention Obstacles: identification by treatment provider, medical knowledge of patient Institutional guidelines Employee Assistance Program Medical Board, Board of Registered Nursing Follow-up post treatment