Your Federal Quarterly Tax Payments are due April 15th Get Help Now >>

Archives by jennyyingdi

VIEWS: 3 PAGES: 27

									NIAAA   6/22/2004                         Complexities Co-occurring Disorders-Li-6-23-04-final-1




                    Alcohol Use Disorders and Co-
NIAAA




                        occurring Conditions
NIAAA




                                Ting-Kai Li, M.D.
                                     Director
NIAAA




                    National Institute on Alcohol Abuse and
                                   Alcoholism
NIAAA




                           National Institutes of Health
                     Department of Health and Human Services
NIAAA




                    Complexities of Co-occurring Disorders
              Harnessing Services Research to Improve Care for
NIAAA




            Mental, Substance Use, and Medical/Physical Disorders
                                   June 24, 2004
NIAAA
NIAAA   6/22/2004                  Complexities Co-occurring Disorders-Li-6-23-04-final-2




                    Presentation Overview
NIAAA
NIAAA




                 Extent of the Problem
                 Alcohol and Co-occurring
NIAAA




                  Conditions
NIAAA




                 Onset of Alcohol Use and Alcohol
                  Use Disorders
NIAAA




                 Screening and Brief Intervention
NIAAA




                 Conclusion
NIAAA
NIAAA   6/22/2004                          Complexities Co-occurring Disorders-Li-6-23-04-final-3



                             Extent of the Problem
NIAAA




               In the United States:
NIAAA




                     18 million Americans suffer from alcohol
                      abuse or dependence – 100,000 die
NIAAA




                      annually
                     One in four children under age 18 is exposed
NIAAA




                      to family alcohol problems
NIAAA




                     Between 20%-40% of hospital admissions
                      are alcohol-related
NIAAA




                     Alcohol problems cost U.S. society an
                      estimated $185 billion annually
NIAAA
NIAAA   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
NIAAA




                                  15 - 44 year olds
                                 Unipolar
NIAAA




                     depressive disorders
                    Alcohol use disorders
NIAAA




                    Road traffic accidents

                       Drug use disorders
NIAAA




                     Self inflicted injuries

                          Bipolar disorder
NIAAA




                            Schizophrenia
NIAAA




                                  HIV/AIDS
                                               0   2     4     6       8    10     12     14    16     18

                                                                   Percent of Total
NIAAA




                    Source: WHO – Burden of Disease Statistics, 2001
NIAAA   6/22/2004                                                          Complexities Co-occurring Disorders-Li-6-23-04-final-5



                                             Cumulative Distribution of Alcohol
NIAAA




                                             Consumption in the United States
NIAAA




                                             100
                    Percent of Consumption




                                             80
NIAAA




                                             60
NIAAA




                                             40

                                             20
NIAAA




                                               0
NIAAA




                                                   0   10   20   30   40   50    60     70     80     90 100
                                                                  Percentile Group
NIAAA




                                         Source: Greenfield and Rogers; J. Stud. Alcohol 60:; 79-89, 1999
NIAAA   6/22/2004                   Complexities Co-occurring Disorders-Li-6-23-04-final-6



                    Why Some People Drink/Do Not
NIAAA




                              Drink
NIAAA




                      Reinforcing Effects
NIAAA




                         Positive
NIAAA




                         Negative
                      Aversive Effects
NIAAA




                      Peer/Cultural Influences
NIAAA
NIAAA
NIAAA   6/22/2004                   Complexities Co-occurring Disorders-Li-6-23-04-final-7



                    Negative Reinforcement
NIAAA




                           tension reduction
NIAAA




                           stress dampening
NIAAA




            The Self-Medication Hypothesis
                    Drinking to obtain relief from:
NIAAA




                                stress
NIAAA




                                anxiety
NIAAA




                              depression
                              dysphoria
NIAAA
NIAAA   6/22/2004               Complexities Co-occurring Disorders-Li-6-23-04-final-8

                    Pharmacodynamic Effects on
                      Central Nervous System
NIAAA
NIAAA
NIAAA
NIAAA
NIAAA
NIAAA
NIAAA
NIAAA   6/22/2004                         Complexities Co-occurring Disorders-Li-6-23-04-final-9


                   Co-Occurrence of Current (12-month)
                Alcohol Dependence and Nicotine and Any
NIAAA




                           Drug Dependence
NIAAA




                    Disorder               Alcohol Dependence
NIAAA
NIAAA




                    Nicotine dependence                   6.4 x
NIAAA




                    Any drug dependence                 36.9 x
NIAAA
NIAAA
NIAAA   6/22/2004                                       Complexities Co-occurring Disorders-Li-6-23-04-final-10

                          Co-Occurrence of Current (12-month)
                    DSM-IV Alcohol Dependence and Mood and Anxiety
NIAAA




                                      Disorders

                             Disorder                            Alcohol Dependence
NIAAA




              Major depression                                                  3.7 x
NIAAA




              Dysthymia                                                         2.8 x
              Manic disorder                                                    5.7 x
NIAAA




              Hypomania                                                         5.2 x
              Panic (with agoraphobia)                                          3.6 x
NIAAA




              Panic (without agoraphobia)                                       3.4 x
              Social phobia                                                     2.5 x
NIAAA




              Specific phobia                                                   2.2 x
              Generalized anxiety                                               3.1 x
NIAAA




          NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
NIAAA   6/22/2004                                       Complexities Co-occurring Disorders-Li-6-23-04-final-11

                        Co-occurrence of Current (12-month)
                      DSM-IV Alcohol Dependence and Personality
NIAAA




                                      Disorders
NIAAA




                            Disorder                           Alcohol Dependence
                    Antisocial                                               7.1 x
NIAAA




                    Avoidant                                                 3.8 x
                    Dependent                                                6.1 x
NIAAA




                    Histrionic                                               7.5 x
NIAAA




                    Obsessive-compulsive                                     2.2 x
                    Paranoid                                                 4.6 x
NIAAA




                    Schizoid                                                 2.9 x
NIAAA




          NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003.
NIAAA   6/22/2004                                                                 Complexities Co-occurring Disorders-Li-6-23-04-final-12


                                                Age at Onset: DSM-IV Age of First
                                                         Use of Alcohol
NIAAA




                                                      35.0%
             Percentage in each age group who begin
NIAAA




                                                      30.0%

                                                      25.0%
NIAAA



                          using alcohol




                                                      20.0%
NIAAA




                                                      15.0%

                                                      10.0%
NIAAA




                                                      5.0%

                                                      0.0%
NIAAA




                                                              5   10   15   20    25     30      35      40      45      50
                                                                                 Age
NIAAA




                                    Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
NIAAA   6/22/2004                                              Complexities Co-occurring Disorders-Li-6-23-04-final-13
                    Prevalence of Lifetime Alcohol Dependence
                      by Age of First Alcohol Use and Family
NIAAA




                              History of Alcoholism
NIAAA




                                     60

                                     50
                      % Prevalence




                                                                                            FHP
NIAAA




                                     40                                                     Total
                                                                                            FHN
                                     30
NIAAA




                                     20
NIAAA




                                     10

                                     0
NIAAA




                                          13   14   15   16    17    18      19     20     21
                                                    Age at First Alcohol Use
NIAAA




         Grant and Dawson. J Subst Abuse. 1998;10(2):163-73.
NIAAA   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
NIAAA



               Percentage in each age group who develop


                                                          1.8%
NIAAA




                     first-time alcohol dependence



                                                          1.6%

                                                          1.4%
NIAAA




                                                          1.2%

                                                          1.0%

                                                          0.8%
NIAAA




                                                          0.6%

                                                          0.4%
NIAAA




                                                          0.2%

                                                          0.0%
NIAAA




                                                                 5   10   15   20    25       30       35       40      45       50

                                                                                        Age
NIAAA




                               Li TK, Hewitt B, Grant BF. Biological Psychiatry (2004). In press
NIAAA   6/22/2004                                                         Complexities Co-occurring Disorders-Li-6-23-04-final-15

                             Prevalence of past-year DSM-IV alcohol
                                          dependence:
NIAAA




                                    United States, 2001-2002:
            14%
NIAAA




            12%

            10%
NIAAA




              8%
NIAAA




              6%

              4%
NIAAA




              2%

              0%
NIAAA




                        20       24       29       34       39       44       49       54       59       64       69        +
                      8-       1-       5-       0-       5-       0-       5-       0-       5-       0-       5-     70
                    1        2        2        3        3        4        4        5        5        6        6
NIAAA




          Grant, B.F. et al., Drug and Alcohol Dependence, in press 2004.
NIAAA   6/22/2004                                                                       Complexities Co-occurring Disorders-Li-6-23-04-final-16

                                                      Age at Onset of DSM-IV Cannabis
                                                               Use Disorders
NIAAA

           Percentage in each age group who develop


                                                      1.8%
               a first-time cannabis use disorder



                                                      1.6%                                     Cannabis Use Disorders
NIAAA




                                                      1.4%                                     Alcohol Dependence
                                                      1.2%
NIAAA




                                                      1.0%
NIAAA




                                                      0.8%

                                                      0.6%
NIAAA




                                                      0.4%

                                                      0.2%
NIAAA




                                                      0.0%
                                                             5   10   15 18   25   30   35     40    45    50     55    60    65    70
                                                                                          Age
NIAAA




          Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions,
          2003
NIAAA   6/22/2004                                                              Complexities Co-occurring Disorders-Li-6-23-04-final-17

                                                      Age at Onset: DSM-IV Tobacco
                                                              Dependence
NIAAA


           Percentage in each age group who develop


                                                      1.8%
                first-time tobacco dependence



                                                      1.6%
NIAAA




                                                                                            Tobacco Dependence
                                                      1.4%
                                                                                            Alcohol Dependence
                                                      1.2%
NIAAA




                                                      1.0%
                                                      0.8%
NIAAA




                                                      0.6%
                                                      0.4%
NIAAA




                                                      0.2%
                                                      0.0%
NIAAA




                                                             5   10 15 20 25 30 35 40 45 50 55 60 65 70
                                                                                 Age
NIAAA




          Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions,
          2003
NIAAA   6/22/2004                                                                              Complexities Co-occurring Disorders-Li-6-23-04-final-18

                                                         Age at Onset of DSM-IV Major
                                                                 Depression
NIAAA


           Percentage in each age group who develop



                                                      1.8%
NIAAA




                                                      1.6%                                            Major Depression
                  first-time Major Depression




                                                      1.4%                                            Alcohol Dependence
NIAAA




                                                      1.2%

                                                      1.0%
NIAAA




                                                      0.8%

                                                      0.6%
NIAAA




                                                      0.4%

                                                      0.2%
NIAAA




                                                      0.0%
                                                             5   10   15   20   25   30   35     40    45   50    55    60   65    70
                                                                                                Age
NIAAA




                           Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003
NIAAA   6/22/2004                                       Complexities Co-occurring Disorders-Li-6-23-04-final-19



                    Age of Onset of Brain Disorders
NIAAA




                                             13 – 20      Social Phobias               Alcohol and
                                                                                       Alcohol and
NIAAA




                                              Years     Panic Disorder                  Drug Use
                                                                                        Drug Use
                                                       Bipolar Disorder                 Disorders
                                                                                        Disorders
                    Age
NIAAA




                                   10 – 13          Eating Disorders
                                    Years         Obsessive Compulsive Disorders
NIAAA




                                                   -
                                            Anti-social Behavior
                          5 – 10
                          Years           Conduct Disorder                                Brain
                                        Depression
NIAAA




                                                                                        Disorders
                                      Anxiety
NIAAA




           Infancy to          Attention Deficit Hyperactivity Disorder
            5 Years           Autism
NIAAA




             Developed from Time Magazine, January 20, 2003, p.82
NIAAA   6/22/2004                               Complexities Co-occurring Disorders-Li-6-23-04-final-20


                                     Conclusion
NIAAA




               The striking similarity in the age of onset of
                diagnosable cases of alcohol dependence,
                cannabis use disorder, tobacco dependence, and
NIAAA




                major depression is a critical window of
                opportunity for preventing alcohol abuse and
NIAAA




                dependence
               Understanding the relationship of alcohol use to
NIAAA




                environmental influences (e.g., stress) and co-
                occurring conditions (e.g., depression) requires
NIAAA




                longitudinal studies of:
                    - the relatives of singly and dually affected subjects (high-
NIAAA




                      risk subjects design), and
                    - the developmental trajectory of these disorders and drug
NIAAA




                      use disorders in children and adolescents (general
                      population design)
NIAAA   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
NIAAA




               Counseling Interventions in Primary Care To Reduce
                                 Alcohol Misuse
NIAAA




               The USPSTF:
                 recommends screening and behavioral counseling
NIAAA




                  interventions to reduce alcohol misuse by adults,
                  including pregnant women, in primary care settings (B
NIAAA




                  recommendation)
                 concludes that there is insufficient evidence to
NIAAA




                  recommend interventions to prevent or reduce alcohol
                  misuse by adolescents in primary care settings (I
NIAAA




                  recommendation)

               U.S. Preventive Services Task Force. Screening and Behavioral Counseling Interventions
NIAAA




           .   in Primary Care To Reduce Alcohol Misuse: Recommendation Statement. Annals of
               Internal Medicine 2004;140:554-556
NIAAA   6/22/2004               Complexities Co-occurring Disorders-Li-6-23-04-final-22

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

                                          AUDIT-C1
NIAAA




            Uses the first three AUDIT questions:
NIAAA




                    1. How often do you have a drink containing alcohol?

                    2. How many drinks containing alcohol do you have on a
NIAAA




                       typical day when you are drinking?

                    3. How often do you have 5 (U.S.) or more drinks on an
NIAAA




                       occasion?

            The third question alone is:
NIAAA




                    -   sensitive for heavy drinking (79%) and alcohol abuse/
                        dependence (81%)
NIAAA




                    -   specific (83%) for heavy drinking, abuse and dependence
NIAAA




         1Bush      et al, Arch Intern Med. 1998;158:1789-1795
NIAAA   6/22/2004                          Complexities Co-occurring Disorders-Li-6-23-04-final-24

                    A Simple, Effective Screening Protocol
                                   (Proposed)
NIAAA




          Step                 Action(s)
NIAAA




          Ask AUDIT- C          1. How often do you have a drink
          (Three questions)        containing alcohol?
NIAAA




                                2. How many drinks containing alcohol do
                                   you have on a typical day when you are
                                   drinking?
NIAAA




                                3. How often do you have 5 (U.S.) or more
                                   drinks on an occasion?
NIAAA




          Score:
           a. less than 4      No further action
NIAAA




           b.4 plus            Assess:
                                1. high-risk drinking (personal harm)
                                2. DSM-IV abuse
NIAAA




                                3. DSM-IV dependence
NIAAA   6/22/2004                           Complexities Co-occurring Disorders-Li-6-23-04-final-25


                    A Simple, Effective Screening Protocol
                                     (Proposed)
NIAAA




          Step                          Action(s)
NIAAA




          Determine Action:
NIAAA




          If:                      minimal/brief intervention or
              high-risk drinking   treat/refer for collateral
NIAAA




                                    physical/psychological problems
                DSM-IV alcohol     brief intervention or
NIAAA




                abuse
                                   treat/refer for collateral
                                    physical/psychological problems
NIAAA




                DSM-IV alcohol     Refer to alcoholism treatment and
                dependence
                                   treat/refer for collateral
NIAAA




                                    physical/psychological problems
NIAAA
NIAAA   6/22/2004                   Complexities Co-occurring Disorders-Li-6-23-04-final-26




                            Conclusion
NIAAA




               Study interventions to prevent or reduce
NIAAA




               alcohol misuse by adolescents in primary
               care and other settings
NIAAA
NIAAA
NIAAA
NIAAA
NIAAA
NIAAA   6/22/2004                 Complexities Co-occurring Disorders-Li-6-23-04-final-27




                      Acknowledgements
NIAAA
NIAAA




                    Bridget F. Grant Ph.D., Ph.D.
                     Charlene Le Fauve, Ph.D.
NIAAA




                         Brenda G. Hewitt
NIAAA
NIAAA
NIAAA

								
To top