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PHP 1540: Alcohol Use and Misuse Sept. 12, 2012
Dr. Kate Carey Department of Behavioral & Social Sciences Center for Alcohol & Addiction Studies 121 South Main Street Room 531
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Continuum of Symptom Severity yellow = abuse symptoms; orange = dependence symptoms
Adapted from Li et al. (2007) Symptom severity estimated based on frequency of endorsement across a range of drinkers; Association with drinking patterns based on groupings of current drinkers who endorsed each symptom at 30% or higher. No clear progression from abuse to dependence symptoms
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Diagnostic and Statistical Manual of Mental Disorders (DSM)
DSM-IV specified 2 disorders: Alcohol Abuse Alcohol Dependence DSM-5 revisions published in May 2013 proposed a single Alcohol Use Disorder Why? No logical sequence of sx from abuse to dependence Reliability of DSM-IV Alcohol Abuse was not good Psychometric studies revealed a unidimensional structure, with items that could be ordered along a severity dimension
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Copyright © American Psychiatric Association. All rights reserved.
From: DSM-5 Criteria for Substance Use Disorders: Recommendations and Rationale Am J Psychiatry. 2013;170(8): doi: /appi.ajp Craving = a strong desire or urge to use a substance Figure Legend: DSM-IV and DSM-5 Criteria for Substance Use Disorders c Two or more substance use disorder criteria within a 12-month period. Date of download: 9/4/2013 Copyright © American Psychiatric Association. All rights reserved.
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DSM-V revisions to diagnostic criteria
Alcohol Use Disorder requires at least 2 (of 11) criteria occurring within 12 months Severity specifier 2-3 criteria = mild disorder 4-5 moderate disorder 6+ = severe disorder So the new diagnostic system retains the ability to distinguish more severe from mild alcohol problems BUT based on number and not type.
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Common correlates of alcohol dependence
Mood changes: depression, anxiety, guilt Medical problems: accidents Social problems: under- employment, financial problems, family conflict, interpersonal/social, legal, generalized stress malnutrition, GI disturbance cognitive impairment cancers muscle wasting cardiac problems peripheral neuropathy liver dysfunction
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Course of drinking Onset in teens/20’s
Over time quantity down, frequency up Variable: no standard progression “maturing out” with onset of adult roles Drinking patterns/problems changeable usually onset is in teens or twenties (M AOO for AA & AD = 22; Hasin et al., 2007); use of drugs peaks in range; after age 25, lifestyle transitions such as taking on family/work roles predicts lower drug use; alcohol consumption also tends to decrease with age: frequency up, quantity down; course is variable: may take years to develop impairment; no standard progression of symptoms and negative consequences (family hx -> quicker development of problems) drinking patterns among both nonproblem and problem drinkers tend to change over time; heavy drinking may alternate with nondrinking; different types of problems may be seen over the course of time M age of first tx = 30; hence, about an 8 year lag between onset and tx (Hasin et al., 2007) with increasing age,"maturing out" of problem drinking; SR rate goes up after age 50 however, alcoholism that is seen in treatment settings tends to be a chronically relapsing disorder, i.e., frequent relapses and remissions heavy drinking over a period of 10 years can result in severe physical consequences; severe psychosocial consequences can occur at any time
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Course of AUDs Chronic drinking -> physical consequences; psychosocial consequences at any time Subset w/ chronically relapsing disorder Change/recovery may be treatment-facilitated change or self-initiated Resolutions: Death Continuous AUDs Abstinence Controlled, nonproblem drinking M age of first tx = 30; hence, about an 8 year lag between onset and tx (Hasin et al., 2007) with increasing age,"maturing out" of problem drinking; SR rate goes up after age 50 however, alcoholism that is seen in treatment settings tends to be a chronically relapsing disorder, i.e., frequent relapses and remissions heavy drinking over a period of 10 years can result in severe physical consequences; severe psychosocial consequences can occur at any time
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Drinking Patterns in the US
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Spectrum of drinkers and consequences
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Defining harmful drinking
High volumes: drinking too much too fast “binge” = a pattern of drinking alcohol that brings BAC to .08 g% or above Over 2 hours: Males: 5 or more SDs Females: 4 or more SDs “Heavy drinking” = 5/4+ on one occasion used in surveys to determine risky drinking “At risk” drinking: >14 drinks/wk for men >7 drinks/wk for women NIAAA binge definition: A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gram percent or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours.
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What is “Low-Risk” Drinking?
no more than 7 drinks/week for most women No more than 3 drinks/day no more than 14 drinks/week for most men No more than 4 drinks/day Who should NOT drink this much? Women who are pregnant or trying to conceive People taking medication or with medical conditions People planning to drive Recovering alcoholics Children and adolescents Dufour (1999)
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Epidemiology: the systematic study of the rates, distribution, causes, and consequences of physical disease and mental disorders in a population.
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Epidemiology terms to know. . .
Incidence Prevalence point prevalence lifetime prevalence Focusing on occurrence rates, 2 methods are used, each conveying different information: Incidence refers to the number of new cases of dysfunction occurring in a specified population (population at risk) during a discrete period. Prevalence refers to the number of people who have a disorder at a given point in time. Prevalence rates can be determined for any "temporal window of assessment." point prevalence reveals the % of people experiencing the disorder at the time of assessment (e.g. last month, last 12M) lifetime prevalence measures the % of people who have ever experienced the disorder, even if they are no longer experiencing it. Comparing point prevalence to lifetime prevalence provides information about the remission rate of the disorder Both incidence and prevalence rates convey useful and unique information: - Incidence rates are used to examine causal theories and the value of prevention programs. - If the number of people developing a given condition is increasing or decreasing, incidence estimates can serve as outcome data regarding the efficacy of prevention programs. [e.g., HIV infection] Current prevalence rates are more likely to be used when planning health services and the need for practitioners -- to determine the amount of clinical resources necessary to alleviate a given condition. [e.g., alcohol abuse] Cohort: group of people who share a common feature, often demographic, like age range or grade in school Odds Ratio: A relative measure of risk. The ratio of the likelihood of an event occurring in one group, relative to another. The odds of an event happening is the probability that the event will happen divided by the probability that the event will not happen. The odds ratio compares the odds for two groups, one serving as the reference (denominator) An odds ratio of 1 implies that the event is equally likely in both groups
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Some reasons why is it useful to know about incidence & prevalence
Allocation of $ resources Cross cultural comparisons Determination of the need for research Evaluation of the effects of public health/policy measures
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U.S. Drinking Rate Edges Up Slightly to 25-Year High
July 30, 2010 U.S. Drinking Rate Edges Up Slightly to 25-Year High Beer remains beverage of choice for drinkers by Frank Newport Results for this Gallup poll are based on telephone interviews conducted July 8-11, 2010, with a random sample of 1,020 adults, aged 18 and older, living in the continental U.S., selected using random-digit-dial sampling. For results based on the total sample of national adults, one can say with 95% confidence that the maximum margin of sampling error is ±4 percentage points. Identification as a drinker less among Adults 55 and older (59% vs 72% 18-54) Those with HS education or less (58% vs college graduates 79%) Those who attend church weekly (54% vs 75% attending seldom/never) Those making less than $30K/yr (48% vs. 81% making > $75K) Protestants (61% vs 78% Catholics)
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Epidemiological data on drinking:
National Survey on Drug Use and Health (NSDUH) annual, random sample of ~70,000 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) 2 waves (02-03, 04-05), >43,000 RM.htm NSDUH: sponsored by Substance Abuse and Mental Health Services Administration (SAMHSA) NESARC: sponsored by NIAAA; 2 waves thus far
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More sources for epi data on drinking:
Monitoring the Future Survey annual sample of 8th, 10th, 12th graders; college students Behavioral Risk Factor Surveillance System (BRFSS): Annual, by state MTF: sponsored by NIDA, focuses on youth and trends over time BRFSS: sponsored by the CDC and state health departments; used to identify emerging health problems; establish and track health objectives; develop, implement, and evaluate a broad array of disease prevention activities; and support health-related legislative efforts.
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Figure 3.1 Current, Binge, and Heavy Alcohol Use among Persons Aged 12 or Older, by Age: 2010 NSDUH
Use in the last month is represented by the total height of bars Grey = Binge = 5+ at least once in last month Dark Blue = Heavy = 5+ binges in last month
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Figure 3.2 Current, Binge, and Heavy Alcohol Use among Persons Aged 12 or Older, by Race/Ethnicity: 2010 NSDUH The highest prevalence of alcohol use is found among: Among users, the greatest proportion of binge users is found among: The absolute rate of binge alcohol use was lowest among:
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Prevalence of Binge Drinking in US by Age, 2010
17% overall prevalence Definition: 5+/4+ in last month OVERALL PREVALENCE = 17%, M = 4x/month, M = 8 drinks/occasion MEN = 23%, M = 5x/month, M = 9 drinks/occasion WOMEN = 11%, M = 3x/month, M = 6 drinks/occasion (MMWR, Vol. 61, January 10, 2012)
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Prevalence of Alcohol Use Disorders: 1-year and lifetime prevalence
Any AUD 8.5% 30.0% alcohol abuse 4.7% 17.8% alcohol dependence 3.8% 12.5% Among those who started drinking before age 14, 45% developed AD Among those who started drinking at age 21 or older, 10% developed AD Grant, B.F.; and Dawson, D.A. Age at onset of alcohol use and its association with DSM–IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse 9:103–110, PMID: Hasin et al. (2007) According to Hasin et al. (2007), the prevalence of AUDs varies significantly by . . .
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Towards understanding the etiology of alcohol problems. . .
Etiology = the study of the cause or origins Anticipating next class: What did your culture/ethnic origins teach YOU about drinking ? What was acceptable? What was not? For whom?
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