an introduction to diagnosis and treatment of alcoholism marc a. schuckit, m.d. copyright alcohol...
TRANSCRIPT
An Introduction to Diagnosis and Treatment of Alcoholism
Marc A. Schuckit, M.D.
Copyright Alcohol Medical Scholars Program 1
Copyright Alcohol Medical Scholars Program 2
Alcohol PrevalenceAlcohol Prevalence
90% Ever drank60% Current drinkers>40% Temporary problems10-20% Abuse3-10% Dependence
3Copyright Alcohol Medical Scholars Program
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 Budget90% of Liver Disease
72% of Pancreatitis
41% of Seizure Disorders
13% Breast CancersCopyright Alcohol Medical Scholars Program 3
4Copyright Alcohol Medical Scholars Program
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 Program 4
5Copyright Alcohol Medical Scholars Program
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 Program 5
Copyright Alcohol Medical Scholars Program 6
Alcoholism Natural HistoryAlcoholism Natural HistoryEvent Age1st drink 131st drunk 151st problem 181st dependence 25-40Death 60
Copyright Alcohol Medical Scholars Program 7
Alcoholism CourseAlcoholism Course
•Fluctuating:controlled useproblemsabstinence
•20% spontaneous remission
8Copyright Alcohol Medical Scholars Program
Dual Diagnosis
2/3 Have Psych. Dx
1/3 Axis I
Most are Substance Induced Disorders
Schiz., MDD, ASPD Risk
Use a Timeline
9Copyright Alcohol Medical Scholars Program
TIMELINE
B 40
Age Onset Dependence
Ages 3+ mo. Abstinence
Ages of Major Disorder
Copyright Alcohol Medical Scholars Program 10
Ask All Patients About Problems In:
•Relationships•School or job•Accidents•Arrests•Health
THEN tie in substances
Copyright Alcohol Medical Scholars Program 11
State MarkersState Markers•GGT > 30
•MCV > 91
•CDT < 20
•+UA; Lipids; etc.
•Questionnaires:
MAST
CAGE
12Copyright Alcohol Medical Scholars Program
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 Program 12
13Copyright Alcohol Medical Scholars Program
Stages of Treatment Identification
Detoxification
Physical exam and history
Vitamins
Reassurance
+ Benzodiazepines
Rehabilitation
Enhance motivation
Help readjust to life
Relapse Prevention
+ Medications
Aftercare
Copyright Alcohol Medical Scholars Program 13
Copyright Alcohol Medical Scholars Program 14
WithdrawalWithdrawal
Autonomic dysfunction - Insomnia - Anxiety
Autonomic dysfunction - Insomnia - Anxiety
* Begin 8+ hours
* Peak at day 2
* Diminish at day 5
* Disappear 3 - 6 months
Copyright Alcohol Medical Scholars Program 15
Treatment of WithdrawalTreatment of Withdrawal
Physical examination
Supports
Vitamins
CNS depressants
Copyright Alcohol Medical Scholars Program 16
RehabilitationRehabilitation
Increase motivation
Help rebuild life
Relapse Prevention
+/- medications
17Copyright Alcohol Medical Scholars Program
Alcohol Rehab
? Naltrexone
? Acamprosate
? Disulfiram
? SSRI
? Buspirone
Not:
LI, Anti-depressants, Other
18Copyright Alcohol Medical Scholars Program
GENETICS
Familial
MZ > DZ
4x Risk, Even if Adopted
LR Predicts Risk