Transcript Alc. Subst. abuse 01 - University of Illinois Archives

BEHAVIORAL SCIENCE UNIT:
SUBSTANCE ABUSE
Part A: Alcoholism as a detailed example
Part B: Other Categories of Drug Abuse
Prepared with the Assistance of:
James E. Black, MD PhD
Department of Psychiatry
Wasatch Canyons Center
Salt Lake City, UT 84123
BIO-PSYCHO-SOCIAL PERSPECTIVE ON SUBSTANCE
ABUSE:
BIO: some people are genetically vulnerable, drugs vary
in their addictive potential, and health risks to users vary
substantially.
PSYCHO: comorbid psychiatric disorders, elevated stress,
or impaired cognition are all risk factors for addiction.
SOCIAL: all drug abuse is socially defined, such that a
“bad” drug may be a “good” drug in another culture or
time.
(Cocaine was once a component of a popular soft drink)
Casual or “Recreational” Substance Use
This pattern of use typically does not cause major problems.
However, naïve users may unwittingly overdose or get into
legal problems.
“Gateway” drugs also may introduce drugs to individuals that
are at genetic risk of addiction. Similarly, recreational use can
lower cultural barriers to substance abuse or addiction (e.g.,
seeing parents drink beer makes it easier for teenagers to try it
themselves).
On the other hand, cultures that endorse “responsible” drinking
and stigmatize drunkenness (e.g., Italian or French drinking of
wine with dinner) can model low-risk behaviors for young
people, perhaps lowering the incidence of addiction.
DSM-IV Definition of Substance Abuse
"A maladaptive pattern of substance use leading to ... distress,
as manifested by one (or more) of the following, occurring
within a 12-month period:
(1) recurrent substance use resulting in a failure to fulfill
major role obligations at work, school, or home...
(2) recurrent substance use in situations in which it is
physically hazardous
(3) recurrent substance-related legal problems...
(4) continued substance use despite having persistent or
recurrent social or interpersonal problems caused or
exacerbated by the ... substance..."
Substance Dependence
A maladaptive pattern of substance use manifested by three or more of the
following:
1) tolerance – a need for increasing amounts of drug to get the desired effects;
2) withdrawal – either the characteristic withdrawal syndrome for a substance, or
using a substance to avoid withdrawal symptoms (e.g., “hair of the dog…”)
3) increased use - the substance is progressively taken in larger amounts or for
longer periods than intended (e.g., a coke run that is only stopped when the
money runs out).
4) loss of control - There is a persistent desire or unsuccessful attempts to cut
back or control drug use (the addiction has become painful, but the patient is now
stuck)
5) obsessing about using - A great deal of time is spent on planning how to obtain
the substance (e.g., finding the money, planning the buy), using the substance
(e.g., drinking round the clock through a weekend), or on recovering from the
hangover (e.g., calling in sick on Monday).
6) other parts of life become unimportant - The patient sacrifices important
activities in order to keep using (e.g., not going to your kid’s baseball games;
breaking dates; not completing work assignments).
7) using becomes irrational - The patient keeps using with the full knowledge
that this will result in physical, psychological, or legal problems (e.g., continued
drinking after a diagnosis of liver cirrhosis). This is the “insanity” of addiction.
Alcohol and Substance Use
* Up to 90% of adult Americans use at least some alcohol
* Caffeine - 80%; Tobacco - 25%
* Illicit drugs - 37% of population over age 12
* Issues from a medical (and societal) perspective are use to
excess, lack of control, situations not socially approved,
deleterious effects on health
* Comorbidity of substance abuse and Psychiatric disturbance
is common
COSTS OF DRUG ABUSE TO SOCIETY
Impairment costs:
lost productivity (e.g., calling in sick, hangovers, intoxication
at work)
actual damages (e.g., DUI damages, crime to feed a habit),
medical costs (e.g., deaths to cirrhosis, spread of HIV,
emphysema)
indirect costs (e.g., stress on family, shame)
social costs (e.g., cost of law enforcement, prisons, money
laundering)
COSTS OF DRUG ABUSE TO SOCIETY
alcohol $ 99 billion, 1/3 lost productivity
illegal drugs $ 67 billion, 3/4 social costs
smoking $ 91 billion, 1/2 early death, much of remainder is
medical
Note that smoking involves little crime or lost productivity, so
most of the cost is health related. Note that illegal drugs often
involve crime to pay for drugs or involve law enforcement to
punish users, thus very high social costs.
Recognition and Treatment of Alcohol or Substance Abuse
by the Physician
* Knowledge of characteristics of alcohol or substance abuse,
pharmacology of substances
* Recognize substance abuse/dependency in patient, despite
efforts to conceal or deny
* Knowledge of acute management procedures
* Knowledge of long-term treatment/rehabilitation options
*Awareness of own biases
ALCOHOL IN THE USA
alcoholism is one of the most common psychiatric disorders, with
life-time prevalence of about 13% (NIMH ECA study)
other psychiatric disorders increase the risk of alcoholism (e.g., by
self-medicating depression or anxiety).
mean consumption is 3 gallons of pure ethanol a year
70% of adults drink just occasionally, 12% drink heavily (i.e.,
drinking daily or getting drunk more than 3 times a month)
the 30% heaviest drinkers consume 4/5 of all alcohol in USA
the10% heaviest drinkers consume half of all alcohol in USA
(clearly alcoholism)
GENETICS OF ALCOHOLISM
*1960 Swedish study found concordances of 71% for identical twins, 32%
fraternal twins; many other studies have confirmed high heritability. This
is clinically useful when the family history is postive for alcoholism; the
patient should be educated about their vulnerability.
*the specifics of heritability have been difficult to find. Claims that it
caused by dopamine receptor mutations or by “personality” features have
been debunked.
*distinguishing two patterns of alcoholism may be clinically useful:
Type 1: late onset of drinking (sometimes as late as retirement,
these patients feel guilty about drinking, often related depression or
anxiety symptoms (i.e., self-medicating), generally do not break the law.
The daughters of Type 1 patients are at risk of depression, suggesting a
link between substance abuse and mood disorders.
Type 2: early onset of drinking (often before puberty), show an
addictive pattern with high tolerance, often show disregard for
consequences, engage in criminal behavior. Less motivated to seek
treatment, but court-ordered rehab can be helpful.
ALCOHOL PHARMACOLOGY
*is a CNS depressant, but suppresses anxiety (e.g., shyness) and social norms (e.g.,
date rape) before motor impairment and stupor
*legal intoxication in Illinois is 80 mg/dl (.08%), but cognitive and motor
impairments occur below that
*coma can occur at 300 mg/dl, but with tolerance alcoholics can be awake at up to
600 mg/dl. Inexperienced drinkers can drink fatal overdoses of alcohol on a dare or
for a party trick.
*synergism with other CNS depressants, resulting in many accidental or intentional
overdoses (especially common factor in suicides)
*causes release of endorphins, resulting in euphoria and later craving
*withdrawal includes autonomic hyperactivity: tachycardia, sweating, hypertension
*CNS withdrawal is manifested by irritability, tremor, and seizures. The seizures
can occur days after the last drink. Delerium tremens is extreme cardiovascular
instability, can be fatal, needs hospital admission.
WERNICKE’S ENCEPHALOPATHY:
easily preventable cause of brain damage
*primarily caused by thiamine deficiency, not direct alcohol
damage to brain
*manifests with nystagmus, diplopia, truncal ataxia, apathy,
confusion, memory impairment
*if untreated, can cause disability or death
*doctors easily confuse it with intoxication or head injury
*be conservative: give thiamine injections early and often in
ER. It’s cheap and safe.
ALCOHOLISM IN THE ELDERLY:
a hidden epidemic
*as many as 3 million older Americans are affected by
problem drinking (about 8% in community, 20% in hospital)
*elderly are hospitalized as often for alcohol complications as
for heart attacks
*elderly are more vulnerable to complications (depression,
suicide, falls, malnutrition, heart disease, medication
interactions)
*typical doctors only recognize 1 in 3 elderly with alcohol
problems
SUBSTANCE ABUSE AMONG CHILDREN:
another hidden epidemic
(1995 high school seniors)
% smoking cigarettes daily: 21.6%
% using cocaine daily over last year: 4.0%
% using crack daily over last year: 2.1%
% using marijuana daily over last year: 34.7%
% having 5 or more drinks at one time in last 2 weeks: 29.8%
(from the American Health Foundation, 1996)
ALCOHOLISM: making a diagnosis
* patients are often in denial or ashamed, so you need to be
open and supportive
** take a good history:
* think about what might explain family or job problems,
vagueness, odd injuries
** physical exam:
* poor hygiene, spider angiomas, flushed nose/palms, tremor
or stagger
ALCOHOLISM: making a diagnosis
CAGE QUESTIONAIRE: a quick and easy probe
Have you ever...
1. thought about CUTTING down?
2. felt ANNOYED when others criticize your drinking?
3. felt GUILTY about drinking?
4. used alcohol as an EYE-OPENER?
TREATMENT OF ALCOHOLISM:
most effective approach is integrated, multimodal, and longterm
bio: Antabuse, Revia, SSRIs, but avoid cross-addiction
psycho: confront denial, address psychiatric comorbidity,
relapse prevention, support MD-pt alliance
social: AA (forgiveness, modeling, peer support) and family,
community support for rehab efforts, laws directed at
supporting recovery
MEDICATIONS FOR ALCOHOLISM
disulfiram (Antabuse) simply punishes the drinker, requires
cooperation, and can be dangerous
naltrexone (Revia), an opiate antagonist, decreases craving
and blocks “rush”
comorbid disorders can be relapse triggers, so prescribe for
issues of depression, anxiety, pain, ADHD
“helping” can cause relapse, so be careful with prescribing
benzos or narcotics
there is no magic bullet: meds can only help within a full
program
PSYCHOLOGICAL ISSUES
psychotherapy can address issues of childhood trauma,
interpersonal problems, or personality
family members are central: source of enabling, aggravation
of guilt or stress, possible victims, potentially invaluable
support
group therapy is uniquely valuable for resolving guilt,
modeling success, managing relapse, and providing social
support
ALCOHOLICS ANONYMOUS:
a valuable ally for health professionals
the first “12 step” program, old and very popular
independence makes it more trusted and basically free group
therapy
repeatedly confronts denial and reinforces accepting help from
others
models successful ways to stay sober & its rewards
offers relief from guilt, finding meaning in life
“serenity prayer” fosters acceptance, problem solves, helps
manage stress
SUBSTANCE ABUSE CATEGORIES OTHER THAN
ALCOHOL
* stimulants (e.g., cocaine, amphetamines, Ritalin)
* sedative-hypnotics (e.g., barbiturates, benzos)
* narcotics (e.g., heroin, opium, prescription narcotics)
* hallucinogens (e.g., marijuana, LSD, peyote)
* nicotine (now in DSM-IV)
* inhalants (gasoline, paint, etc. mostly young people:
brain damaging)
* anabolic steroids & growth hormone (?addictive, but
dangerous)
THE DOCTOR’S ROLE IN TREATING ADDICTION
Be knowledgeable about
addiction and its treatment
community resources and allies
For the patient, provide:
basic information
medical authority
alliance with the support system or family
monitor and follow-up
cultivate doctor-patient relationship