1. An Introduction to Diagnosis and Treatment of Alcoholism Marc A. Schuckit, M.D. Copyright Alcohol Medical Scholars Program1

2. 2 Alcohol Prevalence 490% Ever drank 460% Current drinkers 4>40% Temporary problems 410-20% Abuse 43-10% Dependence

3. YEARLY COSTS IN US $300 Billion Overall $71 Billion Direct Costs 22,000 Deaths + 2,000,000 Injuries 4,600,000 Damaged Vehicles 15% - 25% Healthcare Budget 90% of Liver Disease 72% of Pancreatitis 41% of Seizure Disorders 13% Breast Cancers Copyright Alcohol Medical Scholars Program3

4. DSM-IV Dependence 1. Tolerance* 2. Withdrawal* 3. Larger amounts/longer period than intended 4. Inability to, or persistent desire to, cut down or control 5. A great deal of time spent obtaining, using, or recovering 6. Important activities given up or reduced 7. Use despite problems caused or exacerbated by use *Dx: “with Physiological Dependence ” Copyright Alcohol Medical Scholars Program4

5. DSM-IV Abuse 1. Failure to fulfill major role obligations 2. Use in hazardous situations 3. Legal Problems 4. Use despite problems Copyright Alcohol Medical Scholars Program5

6. 6 Alcoholism Natural History Event Age 1st drink 13 1st drunk 15 1st problem 18 1st dependence25-40 Death 60

7. Copyright Alcohol Medical Scholars Program7 Alcoholism Course Fluctuating: écontrolled use éproblems éabstinence 20% spontaneous remission

8. Copyright Alcohol Medical Scholars Program8 Dual Diagnosis 2/3 Have Psych. Dx 1/3 Axis I Most are Substance Induced Disorders Schiz., MDD, ASPD  Risk Use a Timeline

9. Copyright Alcohol Medical Scholars Program9 TIMELINE B40  Age Onset Dependence ‚ Ages 3+ mo. Abstinence  Ages of Major Disorder

10. Copyright Alcohol Medical Scholars Program10 Ask All Patients About Problems In: Relationships School or job Accidents Arrests Health THEN tie in substances

11. Copyright Alcohol Medical Scholars Program11 State Markers GGT > 30 MCV > 91 CDT < 20 +UA; Lipids; etc. Questionnaires: MAST CAGE

12. POSSIBLE BRIEF SELF-ADMINISTERED QUESTIONNAIRES FOR SCREENING ALCOHOL PROBLEMS 1. 4 Item CAGE 2. 5 Item TWEAK 3. 25 Item Michigan Alcohol Screening Test (MAST) 4. 10 Item Alcohol Use Disorders Identification Test (AUDIT) Copyright Alcohol Medical Scholars Program12

13. Stages of Treatment F Identification F Detoxification 4 Physical exam and history 4 Vitamins 4 Reassurance 4 + Benzodiazepines F Rehabilitation 4 Enhance motivation 4 Help readjust to life 4 Relapse Prevention 4 + Medications F Aftercare Copyright Alcohol Medical Scholars Program13

14. Copyright Alcohol Medical Scholars Program14 Withdrawal Autonomic dysfunction - Insomnia - Anxiety * Begin 8+ hours * Peak at day 2 * Diminish at day 5 * Disappear 3 - 6 months

15. Copyright Alcohol Medical Scholars Program15 Treatment of Withdrawal 4Physical examination 4Supports 4Vitamins 4CNS depressants

16. Copyright Alcohol Medical Scholars Program16 Rehabilitation Increase motivation Help rebuild life  Relapse Prevention +/- medications

17. Copyright Alcohol Medical Scholars Program17 Alcohol Rehab ? Naltrexone ? Acamprosate ? Disulfiram ? SSRI ? Buspirone Not: LI, Anti-depressants, Other

18. Copyright Alcohol Medical Scholars Program18 GENETICS Familial MZ > DZ 4x  Risk, Even if Adopted LR Predicts Risk