Alcoholism and Substance Abuse

Focus Alcoholism

Phenomenology Definitions Intoxication Addiction Tolerance Physical Dependence Withdrawal Substance Dependence Substance Abuse

Intoxication Reversible, Substance-specific physiological and behavioral changes due to recent exposure to a psychoactive substance.

Tolerance The decline in potency continued use higher doses are needed for same effect. Receptor mediated Common

Physical Dependence The development of withdrawal symptoms once a drug is stopped.

Withdrawal A physiological state Cessation/reduction in amount of drug Generally opposite of drug’s normal effects.

Addiction Compulsion Psychic, rather than therapeutic, effects

Other Terms Alcoholism DSM-related terms Substance dependence Substance Abuse

Epidemiology

Substance Use

Alcohol Dependence Very common ECA: ~14% > 10 million Americans Another 8 million “problem drinkers” Only 3% “skid row”

Epidemiology: Illicit Abuse (%)

Alcohol Dependence Gender % >> & Probably 2 types

Alcohol Dependence: Age More common in adults, but... Teenage also common 15% HS 5+ drinks/occasion/week 31% HS intoxicated 6+/year Under-Dx in elderly ♂: alcohol ♀: look for prescription drugs

Alcohol Dependence: Social Factors More common Rural Undereducated Low socioeconomic Less likely to drink More likely to abuse

Alcohol Dependence: Socioeconomics Associated with Unstable marriages Increase risk divorce 3X Unstable work

Alcohol Dependence: Medical Ramifications 20-50% hospital admissions May be unrecognized ~20% ER visits 80% of cirrhosis 33% of suicides

Pathology

Pathology of Acute Physiological Tolerance Withdrawal Addiction

Etiology

Etiology of Substance Abuse: Genetics 1 parent: 20% 2 parents 20-50% sons of father 50% if severe alcoholic and criminal: 90% risk in son.

Genetics Twins fraternal:28% identical: 54% Adopted Danish Adoption Study (1974) adopted sons of alcoholics raised by non- alcoholic foster parents still had increased risk of alcoholism.

Social Influences

Diagnosis

Diagnosis Substance Dependence Maladaptive pattern of substance use $ 3 or more (1 year): Tolerance Withdrawal larger amounts Desire/Cut down Time spent Activities Continued use

Diagnosis Substance Abuse Maladaptive pattern $ 1 (1 year) recurrent use 6failed obligations hazardous use Legal problems Continued use despite causing interpersonal or social problems. R/O: Substance dependence

Other Diagnoses Substance Intoxication Substance Withdrawal

Diagnoses: Other substances Alcohol Amphetamines and related Caffeine Cannabis Cocaine Hallucinogens Inhalants Nicotine Opioids Phencyclidine and related Sedatives Polysubstance Abuse ($ 3) Other

Diagnosis Other Schemas for Alcohol Greek letters Typologies

Diagnosis CAGE Questionnaire Have you ever felt the need to Cut down on drinking Have you ever felt Annoyed by criticisms of drinking Have you ever had Guilty feelings about drinking Have you ever taken a morning Eye opener

Diagnosis Clues History Physical Labs

Differential Normal use What’s normal?

Comorbid Disorders and Complications Alcohol Withdrawal Uncomplicated Seizures Hallucinosis DT’s

Comorbid Disorders and Complications Fetal Alcohol Syndrome Comorbid Medical Disorders Comorbid Psychiatric Illnesses

Course Relapses and remission Predictors Gender Age of onset Family history

Treatment

General Principles Alcohol Acute treatment: Manage withdrawal Long term treatment: Abstinence Question of Controlled Use

Detox

Long Term Treatment

Modalities Groups Family therapy Medications

Medication Treatment Disulfiram Naltrexone Other Contraindicated

Treatment: General Rules Supportive care Sobriety is goal Work (don’t compete) with AA Identify triggers of relapse Anticipate relapses, encourage return Reasonable goals

Treatment Efficacy NIAAA data 70% recovery after 18 months 50% needed only minimal intervention abstinence related to intensity (not length) of tx.

Alcoholics Anonymous 40% retention in 12 months