Transcript Opioid Dependence During Pregnancy

Acute Alcohol Use
and Suicide Attempts
Courtney L. Bagge, PhD
University of Mississippi Medical Center
© AMSP 2012
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Rates
 Suicidal
>
36,000 die by suicide
 10th

behavior is common
cause of death in US
5 attempts per suicide
© AMSP 2012
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Rates

Alcohol use/misuse is common
 Use
 Lifetime: 90%
 Past year: 53%
 Misuse
(lifetime)
 Abuse/problems:
15%
 Dependence/alcoholism: 10%
© AMSP 2012
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Use & AUD Overlap
Acutely Used Alcohol
AUD
~30%
No
AUD
~70%
Have AUD
No
Acute
Use
~30%
Acute
Use
~70%
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Clinical Case

Primary care check-up
 30
yr old female
 Drinks
1-2 drinks every 2 mo.
 No
suicidal thoughts
 No
history of depression
 Mentions
relationship prob.
© AMSP 2012
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Lecture will Cover
 Definitions
 Relations
 Reasons
for drinking
 Prevention/Treatment
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Definitions
 Suicidal

thoughts (ideation)
Thoughts of killing oneself
 Suicidal
behavior
 Self-inflicted
act (intent to die)
 Suicide:
Fatal outcome
 Attempt:
Non-fatal outcome
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Alcohol: Standard Drink
 ~10
gm pure alcohol
Beer:
12 oz.
Wine:
4 oz.
Spirits:
1.5 oz.
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Alcohol: Drinking Patterns
 Quantity
frequency
 Heavy episodic
drinks/occasion ♂
 4+ drinks/occasion ♀
 5+
 Binge

Intox. > 2 days
 Give up usual activities for intox.
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Alcohol Use Disorders
Abuse
Dependence
1+ in same 12 mos:
3+ in same 12 mos:
1.
↓ role obligations
1.
Tolerance
2.
Hazardous use
2.
Withdrawal
3.
Use more or longer
4.
Desire/inability to ↓
5.
Other activities given up
6.
↑ obtain, use, recover
7.
Use despite problems
3.
4.
Legal problems
Interpersonal problems
 dependence
© AMSP 2012
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Acute Alcohol Use
 Any
context
 Acute
 When
 Acute
alcohol: 1 drinking instance
discussing attempts
alcohol: 1 specific instance
 Drinking
prior to attempt (3-6 hrs)
 Drinking
any alcohol
 Drinking
to intoxication
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Lecture will Cover
 Definitions
✔
 Relations
 Reasons
for drinking
 Prevention/Treatment
© AMSP 2012
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Descriptive Statistics

Drinking on day of attempt: 40%
 Subgroups differ

Men (53%) > Women (40%)
 < age 50
 ↑ AUD

Design limitations

Rates only descriptive
 Association not tested
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Case-Control Research

Who is likely to attempt suicide?
 Compare 2 groups on alcohol use
Exposed
(Drink)
Not
Exposed
Exposed
(Drink)
Attempt
“CASES”
Not
Exposed
No Attempt
© AMSP 2012
“CONTROLS”
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Key Findings

Acute use (> 100 g): 60X risk
 Chronic use (>100 g/day): 3X risk
 Modeled together:

Acute use > effect (6X risk)
 Chronic use no longer ↑ risk

Design limitations

No best control group
 Many case-control differences
© AMSP 2012
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Case-Crossover Research

When is someone likely to attempt?
 1 person: Compare use in 2 periods
Control Period
Case Period
Day didn’t attempt
Day attempted
Drink?
Drink?
Suicide Attempt
© AMSP 2012
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Key Findings

↑ risk of suicide attempt while drinking



Regardless of sex, age, marital
Infrequent drinkers (< 1 mo)

Acute drinking ↑ risk than others

Clinical importance
3rd variable

Event
Time of day

Place

Situation
Drink
© AMSP 2012
Attempt
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Lecture will Cover
 Definitions
 Relations
 Reasons
✔
✔
for drinking
 Prevention/Treatment
© AMSP 2012
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Reasons for Drinking: Day of Attempt

Non-Suicide Related Reasons



Social, Enhancement, & Coping
Prevalence: 67%

60% no influence

40% impaired judgment
How increase risk?

↑ neg. mood, aggressiveness, impulsivity

All or nothing thinking

Alcohol myopia- attentional shortsight
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Reasons for Drinking: Day of Attempt
 Suicide Related Reasons
 To
facilitate attempt (33%)
 As suicide method (26%)

How increase risk?
 ↑ courage
 Anesthetize pain of dying
 Alcohol poisoning
 Interaction with other substances
© AMSP 2012
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Lecture will Cover
 Definitions
 Relations
 Reasons
✔
✔
for drinking
✔
 Prevention/Treatment
© AMSP 2012
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Doc Visit: Unique Opportunity!

Docs likely contacted 1 mo prior
 Primary
 Mental

care doctor (45%)
health provider (20%)
Primary care: Many seek help
© AMSP 2012
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Doc Visit: Unique Opportunity!

Evaluate both

Screen
 Monitor
 Prevent
 Treatment

Ask all drinkers about suicide

Regardless of chief complaint
 Don’t be afraid to ask
 Not cause suicide, but ↓ risk
© AMSP 2012
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Stepwise Progression: Ask all ?
Ever thought about:
1)



Death/dying?
Life not worth living?
Ending life?
Ever attempted suicide?
3) Current thoughts?
 If ideation +
2)


Ask frequency, duration, intensity
Plan and intent
© AMSP 2012
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Docs: Ask all about alcohol patterns

Alcohol Use Identification Test-C
Q1) Frequency of any use
0
(Never) to 4 (4 or more X/week)
Q2) # drinks/typical drinking day
0
(None) to 4 (10 or more)
Q3) Frequency of heavy episodic use
0

(Never) to 4 (almost daily or daily)
Scoring 0-12 (screen ≠ diagnosis)
 AUD
→ Men > 4; Women > 3
 Sensitivity: 80-90%; specificity: 60-70%
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Docs: Ask why patient drinks

Enhancement, social, to cope
 If cope: ↑ risk for suicidal thoughts
 Help find other coping strategies

How coped in past w/out alcohol?
 Talk
to someone/Call friend
 Leave situation/Walk in park
 Distract self/Watch comedy

Docs remember: Don’t ignore

Infrequent drinkers or not AUD
© AMSP 2012
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Clinical Case

Primary care check-up
 30
yr old female
 No suicidal thoughts
 No history of depression
 Drinks 1-2 drinks every 2 mo.
 No evidence of AUD
 Mentions relationship prob.
 What else should we ask?
© AMSP 2012
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What happened to the patient?
 Relationship
 Attempted
 Brought
 Used
break up
suicide
to ER-said
alcohol for coping
 Suicidal
 Drinking
thoughts shortly before act
connected to attempt?
© AMSP 2012
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Behavior Chain Analysis
 Prevent
future alc/suicide acts
 Discuss recent alc/suicide episode
1) Identify when problem started
2) Identify how vulnerable to problem





Physical illness
Not taking medications
Eating/sleeping too much
Drug use
Alcohol use © AMSP 2012
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VULNERABILITIES:
up late,
no lunch
Identify Linksstaying
in the
Chain
for
Solutions
TARGET
VULNERABILITIES:
Event:
OrderEvent:
1st beer
Order staying
2nd beerup late, no lunch
Prompting
Event:
Relationship break-up
Suicide Attempt
Event: Order 4th beer
Think: Think:
never find
I amThink:
goingI to
forget
feel
better. Don’t need
anyoneabout
else him
him!
After Attempt
Mood: Mood:
9
7 Mood: 5 Think: I can’t live w/out him
Angry:Angry:
7
7 Angry: 5 Mood: 9
Do: Drive
to
a bar
Angry: 7
Do:TARGET
Drink
Do: Order another beer
Do: Go to bathroom; take 100
Tylenol
Dialectical Behavior Therapy
 Skills
to ↓ both behaviors
 4 skill types: To ↑ ability to
 Focus
on here-and-now
 Have + relationships
 Regulate emotions
 Tolerate – situations/emotions
© AMSP 2012
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This Lecture Covered
 Definitions
 Relations
 Reasons
✔
✔
for drinking
 Prevention/Treatment
© AMSP 2012
✔
✔
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Key Messages

40% drink prior to attempt
 Acute/Chronic use


Reasons


↑ risk while drinking
Non-suicide reasons (common)
Assessment:

Assess ALL systematically
 Ongoing assessment of both
 Explore alcohol-suicide connection
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