Alcohol use disorders, health and treatment interventions J. Rehm Social and Epidemiological Research (SER) Department, Centre for Addiction and Mental Health, Toronto, Canada Dalla Lana School of Public Health, University of Toronto (UofT), Canada Dept. of Psychiatry, Faculty of Medicine, UofT, Canada PAHO/WHO Collaborating Centre for Mental Health & Addiction Epidemiological Research Unit, Technische Universität Dresden, Klinische Psychologie & Psychotherapie, Dresden, Germany
Prevalence of substance use disorders PREVALENCE
Alcohol use disorders 2012 (WHO Global status report 2014)
Distribution of AUD around the world (GSRAH) 0.0% 2.0% 4.6% 7.4% 11.4% 18.9% 30.1% 0.003 0.02 0.05 0.07 0.1 0.2 0.3
Burden of AUD as disease and risk factor BURDEN
Alcohol use disorders DALYs per 100,000 people, Age standardized, Both sexes, 2010 <71.4 71.4 93.8 93.8 118.6 118.6 184.4 184.4 239.2 239.2 290.9 290.9 339 339 389.8 389.8 525.6 >525.6 ATG VCT BRB COM W Africa DMA Caribbean LCA GRD TTO MDV TLS MUS SYC MHL KIR SLB FSM VUT WSM FJI TON E Med. MLT Persian Gulf SGP Balkan Peninsula
Global burden of disease in DALYs 2013 by level 2 risk factors
Burden is relatively stable since 1990 For alcohol use disorders (defined as alcohol dependence in GBD), the trend from 1990 to 2010 has been stable.
Percentage of deaths How many deaths are attributable to alcohol dependence? 25 20 15 10 5 0 Alcohol-attributable Alcohol-attributable (net) Heavy drinking Alcohol dependence Men 16,1% 13,9% 11,1% 10,7% Women 8,5% 7,7% 5,3% 3,7% Total 13,6% 11,8% Men Women Total 9,2% 8,4% Rehm et al Eur Neuropsychopharm 2013
While burden is high, treatment rates are low TREATMENT
Treatment of mental disorders globally Kohn et al., 2004
Treatment in Europe ESEMED study Alonso et al., 2004
Newer data Europe: 22.3% of people with alcohol dependence are treated Rehm et al., 2015, BMC Family Practice
And what would happen if we started to treat..
Simulations: what burden could be prevented by increasing treatment rates in the EU? Most conservative estimate: mortality burden! Approach bottom up: estimates for each country and then aggregated Approach was selected as current treatment rates are lowest for all mental disorders: under 10% in the EU! Effectiveness of treatment was based on Cochrane reviews Five scenarios selected Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease
Number of deaths avoided over one year in men by treatment for AD in the EU in 2004 by five different treatment modalities (up to 13% of all alcohol-attributable deaths) Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease
Number of deaths avoided over one year in women by treatment for AD in the EU in 2004 by five different treatment modalities (up to 9% of all alcohol-attributable deaths) Rehm et al., 2012 Alcohol consumption, alcohol dependence, and attributable burden of disease
The link to heavy drinking Rehm et al., 2014 Alc Alc (rejoinder)
Another model But does it reflect reality? Roerecke et al., 2013, J. Clin. Psychiatry
Relative risk for mortality Relative risk for mortality How could alcohol dependence treatment be successful? It reduces level of consumption either to abstinence or by sizable reduction of heavy drinking Typical risk curve for alcohol (e.g., liver cirrhosis mortality) Relative gain in risk for mortality of reducing by three drinks/day for different levels of drinking Drinks per day Roerecke & Rehm, 2013 Alc.Alc Drinks per day
Reduced drinking including abstinence to continued heavy drinking (RR: 0.41 after 8.8 years on average) Risk of heavy drinkers in red
Other results of the meta-analyses Reduction of drinking without abstinence was also significantly better than continued heavy drinking Abstinence was associated with the lowest mortality rate Conclusion: reducing drinking helps in any case, the more you reduce, the better
How could treatment be increased? Primary health care is key! Primary care physicians identify people with AUD, but make no interventions. Why? Lack of education, lack of financial incentives, fear to loose patients, not within leading paradigm Currently, primary health care is limited to SBIRT (screening, brief intervention, referral to specialized treatment) -> no treatment! If treatment is brought back to primary health care physicians, low coverage and stigmatization my change!
Stigmatization and thresholds continuous concepts may reduce stigmatization The problem of groups (Nominal Group Theory Tajfel) It is harder to stigmatize against a continuum where we are all part of The key is to stress the continuum and de-emphasize the thresholds!
AUD are prevalent, cause a lot of burden which could be reduced, if treatment is initiated which reduces consumption CONCLUSION