1. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-1 Ting-Kai Li, M.D. Director National Institute on Alcohol Abuse and Alcoholism National Institutes of Health Department of Health and Human Services Complexities of Co-occurring Disorders Harnessing Services Research to Improve Care for Mental, Substance Use, and Medical/Physical Disorders June 24, 2004 Alcohol Use Disorders and Co- occurring Conditions

2. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-2 !Extent of the Problem !Alcohol and Co-occurring Conditions !Onset of Alcohol Use and Alcohol Use Disorders !Screening and Brief Intervention !Conclusion Presentation Overview

3. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-3 In the United States:  18 million Americans suffer from alcohol abuse or dependence – 100,000 die annually  One in four children under age 18 is exposed to family alcohol problems  Between 20%-40% of hospital admissions are alcohol-related  Alcohol problems cost U.S. society an estimated $185 billion annually Extent of the Problem

4. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-4 Disease Burden by Illness - DALY United States, Canada and Western Europe, 2000 15 - 44 year olds

5. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-5 Cumulative Distribution of Alcohol Consumption in the United States

6. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-6  Reinforcing Effects Positive Negative  Aversive Effects  Peer/Cultural Influences Why Some People Drink/Do Not Drink

7. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-7 tension reduction stress dampening The Self-Medication Hypothesis Drinking to obtain relief from: stress anxiety depression dysphoria Negative Reinforcement

8. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-8 Pharmacodynamic Effects on Central Nervous System

9. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-9 DisorderAlcohol Dependence Nicotine dependence6.4 x Any drug dependence36.9 x Co-Occurrence of Current (12-month) Alcohol Dependence and Nicotine and Any Drug Dependence

10. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-10 DisorderAlcohol Dependence Major depression3.7 x Dysthymia2.8 x Manic disorder5.7 x Hypomania5.2 x Panic (with agoraphobia)3.6 x Panic (without agoraphobia)3.4 x Social phobia2.5 x Specific phobia2.2 x Generalized anxiety3.1 x NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003. Co-Occurrence of Current (12-month) DSM-IV Alcohol Dependence and Mood and Anxiety Disorders

11. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-11 NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003. DisorderAlcohol Dependence Antisocial7.1 x Avoidant3.8 x Dependent6.1 x Histrionic7.5 x Obsessive-compulsive2.2 x Paranoid4.6 x Schizoid2.9 x Co-occurrence of Current (12-month) DSM-IV Alcohol Dependence and Personality Disorders

12. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-12 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 5101520253035404550 Age Percentage in each age group who begin using alcohol Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003 Age at Onset: DSM-IV Age of First Use of Alcohol

13. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-13 Grant and Dawson. J Subst Abuse. 1998;10(2):163-73. Prevalence of Lifetime Alcohol Dependence by Age of First Alcohol Use and Family History of Alcoholism

14. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-14 Age of Onset: Alcohol Dependence Age at Onset of DSM-IV Alcohol Dependence

15. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-15 Grant, B.F. et al., Drug and Alcohol Dependence, in press 2004. Prevalence of past-year DSM-IV alcohol dependence: United States, 2001-2002:

16. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-16 Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003 Percentage in each age group who develop a first-time cannabis use disorder Age at Onset of DSM-IV Cannabis Use Disorders

17. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-17 Age at Onset: DSM-IV Tobacco Dependence

18. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-18 Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003 Age at Onset of DSM-IV Major Depression

19. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-19 Age of Onset of Brain Disorders

20. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-20 !The striking similarity in the age of onset of diagnosable cases of alcohol dependence, cannabis use disorder, tobacco dependence, and major depression is a critical window of opportunity for preventing alcohol abuse and dependence !Understanding the relationship of alcohol use to environmental influences (e.g., stress) and co- occurring conditions (e.g., depression) requires longitudinal studies of: - the relatives of singly and dually affected subjects (high- risk subjects design), and - the developmental trajectory of these disorders and drug use disorders in children and adolescents (general population design) Conclusion

21. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-21. U.S. Preventive Services Task Force (USPSTF) Recommendations on Screening and Behavioral Counseling Interventions in Primary Care To Reduce Alcohol Misuse The USPSTF: !recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings (B recommendation) !concludes that there is insufficient evidence to recommend interventions to prevent or reduce alcohol misuse by adolescents in primary care settings (I recommendation) U.S. Preventive Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care To Reduce Alcohol Misuse: Recommendation Statement. Annals of Internal Medicine 2004;140:554-556

22. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-22 New Proposed Science-Based Screening Guidelines

23. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-23 !Uses the first three AUDIT questions: 1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 5 (U.S.) or more drinks on an occasion? !The third question alone is: - sensitive for heavy drinking (79%) and alcohol abuse/ dependence (81%) - specific (83%) for heavy drinking, abuse and dependence AUDIT-C 1 1 Bush et al, Arch Intern Med. 1998;158:1789-1795

24. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-24 A Simple, Effective Screening Protocol (Proposed)

25. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-25 A Simple, Effective Screening Protocol (Proposed)

26. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-26 Conclusion Study interventions to prevent or reduce alcohol misuse by adolescents in primary care and other settings

27. 6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-27 Acknowledgements Bridget F. Grant Ph.D., Ph.D. Charlene Le Fauve, Ph.D. Brenda G. Hewitt