AMSP Junior Scholar Outline
Alisa B. Busch, M.D., MS.
September 17, 2005
Alcohol and Drug Dependence: Comparisons to Other Chronic Medical Disorders
[SLIDE 1]
I. Introduction
A. What constitutes a medical disease or illness? [SLIDE 2]
1. Characteristics(1)
a) Clinical signs/symptoms
b) Pathologic Process
c) Etiology
i. Influenced by family history
ii. Influenced by environmental exposure
2. Will demonstrate in this lecture how all apply to dependence as well and that dependence is chronic medical illness.
B. Common misconceptions why alcohol/drug dependence are not chronic, medical conditions. [SLIDE 3]
1. Dependence is a behavior, not an illness.
a) It is volitional, not involuntary.
b) No one is forced to drink/use drugs; can stop if they want to.
2. While dependence has volitional component, so do other chronic medical conditions. Also, like other chronic medical conditions, dependence has
a) genetic component
b) defined pathophysiology in brain
c) is affected (both onset and prognosis) by personal choice and culture.
C. This lecture reviews [SLIDE 4]
1. Importance of identifying and treating alcohol/drug dependence.
2. Definition.
3. Barriers to identification and treatment of substance use disorders (SUD).
4. Comparisons of dependence vs. other chronic medical disorders
a) Heritability
b) Pathophysiology
c) Individual behaviors/cultural influences
d) Treatment goals/strategies
e) Treatment adherence
f) Outcomes
5. Implications of treating dependence as a chronic medical condition.
II. Importance of identifying and treating alcohol/drug dependence.
A. Epidemiology [SLIDE 5]
1. Abuse/Dependence
a) 2003 national survey(2): 21.6 million persons current SUD in U.S.
i. Alcohol 15 million
ii. Illicit drugs 4 million
iii. Both 3 million
b) 90% in need did not receive treatment(2)
2. Other chronic medical conditions
a) Diabetes: 18.2 million people (2002 national survey)(3)
b) HIV/AIDS: 950,000 people(year 2000 national estimate) (4)
3. 2004 U.S. Census: 293,655,404(5)
B. Annual U.S. treatment costs $155 billion. [SLIDE 6]
C. Examples of medical sequelae(6-8) [SLIDE 7]
1. Cardiovascular
a) Alcohol: hypertension, cardiomyopathy, MI.
b) Cocaine: MI, cardiac arrthymias.
c) Methamphetamine: hypertension, arrhythmia or heart failure.
d) IV use: endocarditis.
2. Gastrointestinal system
a) Alcohol: Mallory Weiss tear, gastric bleeding, fatty liver, cirrhosis.
b) IVDU: Hepatitis B and C.
3. Neurological
a) Alcohol--Korsakoff’s and Wernicke’s syndrome (opthalmoplegia, ataxia, and encephalopathy), peripheral neuropathy, cerebellar degeneration, cognitive deficits.
b) Opioids—peripheral neuropathy.
c) Cocaine—seizures, hemorrhagic stroke, subarachnoid hemorrhage.
d) Amphetamine—stroke, subarachnoid hemorrhage.
4. Reproductive function
a) Alcohol—low sperm count, testicular atrophy; amenorrhea, infertility, spontaneous abortion, fetal alcohol syndrome.
b) Cocaine—impotence: amenorrhea, fetal congenital malformations.
D. Lost productivity, unemployment, lost/cut back work days. [SLIDE 8]
1. Heavy drinking → ↑ unemployment; ↑ lateness; ↑injury; ↓ weeks of employment; and ↓ performance.(9, 10)
2. Problem drinking à ↓ probability of working.(11)
3. Heroin use à ↓ productivity by $12 million in 1996.(12)
E. Family impacts
5. Premature death.
6. ↓ Earnings.
7. Emotional stressors.
III. Diagnosis [SLIDE 9]
A. Clinical interview key in making diagnosis.
B. Definitions of dependence across diagnostic systems (i.e., ICD-10 and DSM-IV) reliable.(13)
C. No laboratory tests available but (like diabetes) such tests supplement information from interviews.
1.
Alcohol: liver
function tests (AST/ALT, GGT), ↑ MCV, ↑CDT
2. Intravenous Drug Use (IVDU): Hepatitis B and C.
D. Definitions(14) [SLIDE10]
1. Abuse [SLIDE 11]
a) Maladaptive pattern of use
b) Causing impairment
c) ≥ 1 within 12 month period
i. Inability to fulfill major roles.
ii. Use in physically hazardous situations
iii. Legal problems
iv. Continued use despite social/interpersonal problems
d) Dependence never met
2. Dependence [SLIDE 12]
a) Maladaptive pattern of use
b) Causing impairment
c) ≥ 3 within 12 months
i. Tolerance
a. Need more for same effect
b. Decreased effect with same amount used
ii. Withdrawal
a. Withdrawal syndrome
b. Take substance to relieve/avoid withdrawal
iii. Larger amounts/longer period than intended
iv. Persistent desire/unsuccessful efforts to cut down
v. Much time spent getting/using/recovering
vi. Give up/reduce important social/occupational/ recreational activities
vii. Continued use despite physical/ psychological problems
IV. Barriers to identification and
treatment
A. Patients [SLIDE 13]
1. 2003 national survey: 95% with abuse/dependence don’t feel need treatment.(2)
2. Stigma(15)
a) Concern will be judged.
b) Prior negative experiences with doctors.
B. Providers: [SLIDE 14]
1. Biases based on personal experiences(15)
a) Negative attitudes towards intoxication/drug use.
b) Attitudes if clinician relative has SUD: approximately 1/3 of med students.(16)
c) Personal experiences: 3.5%-9% med students have substance dependence(17)
2. Educational barriers
a) Medical schools/residencies inadequately educate (18)
i. 1998 survey of preclinical medical students(19)
a. 20% “no SUD training”
b. 56% “small amount”
ii. 2000 study of residencies (ER, psychiatry, primary care, and Ob-Gyn)(20)
a. 44% without required SUD training
b. 56% required only 4-15 hours of training; median of 7 hours.
b) Clinicians don’t understand:
i. effectiveness of identification methods and treatment(21)
ii. what to do with the information.
3. Clinician biases/negative attitudes; inadequate education; and stigma → reluctance to screen(22, 23)
V. Is drug/alcohol dependence different from other chronic medical disorders?
[SLIDE 15]
A. Comparison with diabetes,
hypertension and asthma
1. Well studied conditions
2. Effective treatments
3. Not “curable”
B. Heritability estimates from twin studies. [SLIDE 16]
1. Hypertension 25%-50%(24, 25)
2. Diabetes(26-29)
a) Type I 30%-55%
b) Type II 80%
3. Asthma 36%-70%(30, 31)
4. SUD(32-35)
a) Heroin 34%
b) Alcohol 55%
c) Marijuana 52%
C. Like other medical conditions, dependence has a distinct pathophysiology.
1. Effects on brain
circuitry [SLIDE
17]
a) Alcohol/drugs either directly or indirectly acutely activate mesolimbic dopamine rich reward system(36-39)
i. Center of motivation/emotion/memory
ii Extends from ventral tegmentum to nucleus accumbens
iii. Projects to limbic system and orbitofrontal cortex
b) Opioids/ alcohol also affect opioid and GABA receptors (36-39)
c) Prolonged use →changes in brain function. (36, 37, 40-42)
i. Brain metabolic activity
ii. Receptor availability
iii. Gene expression
iv. Responsiveness to environmental cues
d) Unclear if changes return to normal with abstinence(43)
2. Changes in brain circuitry à ↑ difficulty changing alcohol/drug behavior
a) Pairing of person/places/things/specific emotions → rapid and entrenched learning/conditioning.
b) May elicit cravings. Even after long abstinence(44)
D. Risk factors for many diseases reflect familial/genetic factors and
personal choice.(45, 46)
1. Familial/genetic influences [SLIDE 18]
a) Alcohol metabolizing enzymes impact risk of heavy drinking.(47-50)
b) Eating habits impact risk of diabetes (e.g., Native Americans).
c) Salt sensitivity can predispose to hypertension. (46)
2. Personal choices [SLIDE 19]
a) Exercise influences diabetes and hypertension.
b) Foods influence both disorders.
c) Smoking impacts on diabetes, hypertension, and asthma.
d) Compliance a major problem in all conditions.
E. Similarities in treatment.
1. Treatment goals(51-53) [SLIDE 20]
a) Chronic medical conditions
i. Minimize symptoms/exacerbations.
ii. Maximize function (physical, social and role function).
iii. Treatment requires chronic care and monitoring.
b) Alcohol/drug dependence
i. Minimize symptoms/exacerbations.
ii. Maximize function (physical, social and role function).
iii. Treatment requires chronic care and monitoring. But, insurance restrictions often à
1) Limits on covered services
2) Emphasis on acute care, rather than ongoing treatment.
2. Treatment strategies