alcohol use disorders and co-occurring conditions
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Alcohol Use Disorders and Co-occurring Conditions. 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 - PowerPoint PPT PresentationTRANSCRIPT
6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-1NIAAA
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Ting-Kai Li, M.D.Director
National Institute on Alcohol Abuse and Alcoholism
National Institutes of HealthDepartment of Health and Human Services
Complexities of Co-occurring DisordersHarnessing Services Research to Improve Care for
Mental, Substance Use, and Medical/Physical DisordersJune 24, 2004
Alcohol Use Disorders and Co-occurring Conditions
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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
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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
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Source: WHO – Burden of Disease Statistics, 2001
Unipolar depressive disorders
Alcohol use disorders
Road traffic accidents
Drug use disorders
Self inflicted injuries
Bipolar disorder
Schizophrenia
HIV/AIDS
0 2 4 6 8 10 12 14 16 18
Percent of Total
Source: WHO – Burden of Disease Statistics, 2001
Unipolar depressive disorders
Alcohol use disorders
Road traffic accidents
Drug use disorders
Self inflicted injuries
Bipolar disorder
Schizophrenia
HIV/AIDS
0 2 4 6 8 10 12 14 16 18
Percent of Total
Unipolar depressive disorders
Alcohol use disorders
Road traffic accidents
Drug use disorders
Self inflicted injuries
Bipolar disorder
Schizophrenia
HIV/AIDS
0 2 4 6 8 10 12 14 16 180 2 4 6 8 10 12 14 16 180 2 4 6 8 10 12 14 16 180 2 4 6 8 10 12 14 16 18
Percent of Total
Disease Burden by Illness - DALY United States, Canada and Western Europe, 2000
15 - 44 year olds
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0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
Percentile Group
Pe
rcen
t o
f C
on
su
mp
tio
n
Source: Greenfield and Rogers; J. Stud. Alcohol 60:; 79-89, 1999
0
20
40
60
80
100
0 10 20 30 40 50 60 70 80 90 100
Percentile Group
Pe
rcen
t o
f C
on
su
mp
tio
n
Source: Greenfield and Rogers; J. Stud. Alcohol 60:; 79-89, 1999
Cumulative Distribution of Alcohol Consumption in the United States
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6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-6
Reinforcing Effects
PositiveNegative
Aversive Effects
Peer/Cultural Influences
Why Some People Drink/Do Not Drink
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6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-7
tension reduction
stress dampening
The Self-Medication HypothesisDrinking to obtain relief from:
stress
anxiety
depression
dysphoria
Negative Reinforcement
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Pharmacodynamic Effects on Central Nervous System
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6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-9
Disorder Alcohol Dependence
Nicotine dependence 6.4 x
Any drug dependence 36.9 x
Co-Occurrence of Current (12-month) Alcohol Dependence and Nicotine and Any
Drug Dependence
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6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-10
Disorder Alcohol Dependence
Major depression 3.7 x
Dysthymia 2.8 x
Manic disorder 5.7 x
Hypomania 5.2 x
Panic (with agoraphobia) 3.6 x
Panic (without agoraphobia) 3.4 x
Social phobia 2.5 x
Specific phobia 2.2 x
Generalized anxiety 3.1 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
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6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-11
NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
Disorder Alcohol Dependence
Antisocial 7.1 x
Avoidant 3.8 x
Dependent 6.1 x
Histrionic 7.5 x
Obsessive-compulsive 2.2 x
Paranoid 4.6 x
Schizoid 2.9 x
Co-occurrence of Current (12-month) DSM-IV Alcohol Dependence and Personality
Disorders
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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%
5 10 15 20 25 30 35 40 45 50
Age
Pe
rce
nta
ge
in
ea
ch
ag
e g
rou
p w
ho
be
gin
u
sin
g a
lco
ho
l
Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
Age at Onset: DSM-IV Age of First Use of Alcohol
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Grant and Dawson. J Subst Abuse. 1998;10(2):163-73.
0
10
20
30
40
50
60
13 14 15 16 17 18 19 20 21
Age at First Alcohol Use
% P
reva
lenc
e
FHPTotalFHN
Prevalence of Lifetime Alcohol Dependence by Age of First Alcohol Use and Family
History of Alcoholism
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6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-14Age of Onset: Alcohol Dependence
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
5 10 15 20 25 30 35 40 45 50
Age
Per
cen
tag
e in
eac
h a
ge
gro
up
wh
o d
eve
lop
fi
rst-
tim
e a
lco
ho
l de
pen
den
ce
Li TK, Hewitt B, Grant BF. Biological Psychiatry (2004). In press Li TK, Hewitt B, Grant BF. Biological Psychiatry (2004). In press
Age at Onset of DSM-IV Alcohol Dependence
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0%
2%
4%
6%
8%
10%
12%
14%
Grant, B.F. et al., Drug and Alcohol Dependence, in press 2004.
Prevalence of past-year DSM-IV alcohol dependence:
United States, 2001-2002:
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Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
Per
cen
tag
e in
eac
h a
ge
gro
up
wh
o d
evel
op
a
firs
t-ti
me
can
nab
is u
se d
iso
rder
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
5 10 15 18 25 30 35 40 45 50 55 60 65 70
Age
Cannabis Use Disorders
Alcohol Dependence
Age at Onset of DSM-IV Cannabis Use Disorders
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0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
5 10 15 20 25 30 35 40 45 50 55 60 65 70
Age
Tobacco Dependence
Alcohol Dependence
Per
cen
tag
e in
eac
h a
ge
gro
up
wh
o d
eve
lop
fi
rst-
tim
e to
bac
co d
epen
den
ce
Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
Age at Onset: DSM-IV Tobacco Dependence
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Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
5 10 15 20 25 30 35 40 45 50 55 60 65 70
Age
Major Depression
Alcohol Dependence
Per
cen
tag
e in
eac
h a
ge
gro
up
wh
o d
eve
lop
fi
rst-
tim
e M
ajo
r D
epre
ssio
n
0.0%
0.2%
0.4%
0.6%
0.8%
1.0%
1.2%
1.4%
1.6%
1.8%
5 10 15 20 25 30 35 40 45 50 55 60 65 70
Age
Major Depression
Alcohol Dependence
Per
cen
tag
e in
eac
h a
ge
gro
up
wh
o d
eve
lop
fi
rst-
tim
e M
ajo
r D
epre
ssio
nAge at Onset of DSM-IV Major
Depression
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6/22/2004 Complexities Co-occurring Disorders-Li-6-23-04-final-19
Conduct Disorder-Anti-social Behavior-
DepressionAnxiety
Brain Disorders
13
Infancy to 5 Years
Infancy to 5 Years
10 – 13 Years
10 – 13 Years
AutismAttention Deficit Hyperactivity Disorder
Obsessive Compulsive Disorders
Eating Disorders
----5 – 10 Years5 – 10 Years
– 20 Years
–13 20 Years
AgeAgeAgeAge
Panic DisorderSocial Phobias
Bipolar Disorder
Alcohol and Drug Use Disorders
Alcohol and Drug Use Disorders
Developed from Time Magazine, January 20, 2003, p.82
Conduct Disorder-Anti-social Behavior-
DepressionAnxiety
Brain Disorders
Brain Disorders
Brain Disorders
13
Infancy to 5 Years
Infancy to 5 Years
Infancy to 5 Years
Infancy to 5 Years
10 – 13 Years
10 – 13 Years
10 – 13 Years
10 – 13 Years
AutismAttention Deficit Hyperactivity Disorder
Obsessive Compulsive Disorders
Eating Disorders
----5 – 10 Years5 – 10 Years5 – 10 Years5 – 10 Years
– 20 Years
–– 20 Years
–13 20 Years
13 20 Years
AgeAgeAgeAgeAgeAgeAgeAge
Panic DisorderSocial Phobias
Bipolar Disorder
Alcohol and Drug Use Disorders
Alcohol and Drug Use Disorders
Developed from Time Magazine, January 20, 2003, p.82
Age of Onset of Brain Disorders
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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
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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
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New Proposed Science-Based Screening Guidelines
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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-C1
1Bush et al, Arch Intern Med. 1998;158:1789-1795
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1. high-risk drinking (personal harm)
2. DSM-IV abuse
3. DSM-IV dependence
Score:
Action(s)Step
Assess:
No further actiona. less than 4
b.4 plus
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?
Ask AUDIT- C (Three questions)
1. high-risk drinking (personal harm)
2. DSM-IV abuse
3. DSM-IV dependence
Score:
Action(s)Step
Assess:
No further actiona. less than 4
b.4 plus
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?
Ask AUDIT- C (Three questions)
A Simple, Effective Screening Protocol (Proposed)
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Action(s)Step
Determine Action:
Refer to alcoholism treatment and
treat/refer for collateral physical/psychological problems
DSM-IV alcohol dependence
brief intervention or
treat/refer for collateral physical/psychological problems
DSM-IV alcohol abuse
minimal/brief intervention or
treat/refer for collateral physical/psychological problems
If:
high-risk drinking
Action(s)Step
Determine Action:
Refer to alcoholism treatment and
treat/refer for collateral physical/psychological problems
DSM-IV alcohol dependence
brief intervention or
treat/refer for collateral physical/psychological problems
DSM-IV alcohol abuse
minimal/brief intervention or
treat/refer for collateral physical/psychological problems
If:
high-risk drinking
A Simple, Effective Screening Protocol (Proposed)
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Conclusion
Study interventions to prevent or reduce alcohol misuse by adolescents in primary care and other settings
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Acknowledgements
Bridget F. Grant Ph.D., Ph.D.
Charlene Le Fauve, Ph.D.
Brenda G. Hewitt