1. Alcoholism and Substance Abuse

2. Focus Alcoholism

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

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

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

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

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

8. Addiction Compulsion Psychic, rather than therapeutic, effects

10. Other Terms Alcoholism DSM-related terms Substance dependence Substance Abuse

11. Epidemiology

12. Substance Use

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

14. Epidemiology: Illicit Abuse (%)

15. Alcohol Dependence Gender % >> & Probably 2 types

16. 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

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

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

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

20. Pathology

21. Pathology of Acute Physiological Tolerance Withdrawal Addiction

22. Etiology

23. 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.

24. 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.

25. Social Influences

26. Diagnosis

27. 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

28. 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

29. Other Diagnoses Substance Intoxication Substance Withdrawal

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

31. Diagnosis Other Schemas for Alcohol Greek letters Typologies

32. 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

33. Diagnosis Clues History Physical Labs

34. Differential Normal use What’s normal?

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

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

37. Course Relapses and remission Predictors Gender Age of onset Family history

39. Treatment

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

41. Detox

42. Long Term Treatment

43. Modalities Groups Family therapy Medications

45. Medication Treatment Disulfiram Naltrexone Other Contraindicated

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

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

48. Alcoholics Anonymous 40% retention in 12 months