Margaret
Rukstalis, M.D.
University of
Pennsylvania
Prepared for
the Alcohol Medical Scholars Program
April 25, 2002
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2
A. Material is relevant to a wide span of health
care professionals
1. Medical Students
2. Nurses
3. Staff working in substance use disorders
programs
B. Goal: To place
alcohol use disorders and nicotine use disorders into clinical perspective
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C. This lecture will cover:
1. Brief introduction to substance use disorders
2. The application of this information to
alcohol use disorders
3. The relevance to nicotine use disorders
4. A review of the relationships among the two
substance use disorders
A. Diagnoses are established to indicate
problems.
1. Greater than occasional
2. Greater than trivial
3. Past behavior is the best predictor of future
behavior
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B. Criteria for dependence [1]
1. Must be pattern of 3+ repetitive problems
occurring together as a syndrome.
2. International classification of diseases
(ICD) and American Psychiatric Classification (DSM) are similar.
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3. The criteria include:
a. Tolerance = need for more drug to maintain
effect or reduced effect with same amount
b. Withdrawal (usually the opposite of the acute
effects).
c. Taking more than intended or more often than
planned.
d. Persistent desire to cut back.
e. Spending large amounts of time using or
recovering
f. Decreased social/occupational/recreational
functioning.
g. Continued use despite physical/psychological
problems, e.g.:
1. Lung disease
2. Liver disease
3. Cancer
4. Depression
4. If tolerance or withdrawal
present=physiological component, indicates more severe past and more severe
future problems.
5. Optimal clinical usefulness, same overall
criteria used for all dugs.
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6
C. Criteria for abuse [1]
1. Only diagnose if history of dependence is not
present.
2. Applies to most drugs- not nicotine (as
discussed below).
3. Criteria:
repetitive problems in any one of four possible areas.
a.
Failure to fulfill major role obligations
b.
Use in hazardous situations
c.
Legal problems
d.
Use despite problems
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D. The clinical
course of dependence is predictable
1. Age of onset similar to general population.
2. Early problems similar to general population.
3. In late teens (for nicotine) or 20’s (for
alcohol), repetitive problems become apparent while others are learning to
decrease use and avoid problems.
4. Dependence, and abuse, increase risk for
serious future problems.
5. Alcohol and nicotine cause early death.
6. Course usually involves fluctuations between
problems; abstinence in response to problems; efforts at controlled use
(sometimes lasting for months); resumption of problems, and so on.
7. High rate of
spontaneous remission (extended periods of abstinence without treatment) for
all substance use disorders. Estimate for alcohol dependence, 20-30%.
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E. Most drug
dependencies are genetically influenced. [2]
1. Run in families
2. Higher similarity in identical then
fraternal twins
3. Adopted away offspring have high risks
4. Genetic influences explain 50%+ risk of
alcohol use disorders; similar amount for nicotine dependence; crossover will
be discussed in the final section of lecture.
III. Overview of Alcohol Use Disorders
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A. Acute effects of alcohol associated with
alcohol use disorders
Repetitive
intoxication involves decreased cognition while drunk; hangovers next morning;
problems thinking clearly; etc. ( Keep these in mind as you think about acute
effects of nicotine).
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B. Alcohol use disorders are common
1. Lifetime risk for dependence: 15% in males; 8% in females
2. Lifetime risk for abuse, an additional 5-10%
3. 80+% alcohol dependent, also nicotine
dependent [2-4]
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C. Life span cut by 15 years [5,
6]. Leading causes of death include:
1. Heart disease: High blood pressure, high
blood fats, cardiomyopathy
2. All cancers (including lung). Note these two causes are important for nicotine
as well.
3. Accidents
4. Suicide (Note, tie between nicotine
dependence and depressive symptoms will be covered later).
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D. 60% of risk for alcohol dependence is
genetic [2]
1. Fourfold increased risk among relatives. Risk varies with number of alcohol-dependent
relatives and closeness of genetic relationship.
2. Risk for alcohol dependence in identical
twins of alcoholics is twice as high as in fraternal twins.
3. Fourfold increase risk in children of
alcoholics also seen if adopted out at birth and raised by non-alcoholics.
4. Alcohol dependence is typical, complex
genetically-influenced disorder.
a. Both genes and environment
b. Multiple characteristics inherited in
different families
i. Alcohol-metabolizing enzymes
ii. High levels of impulsivity
iii. An early need for high doses of alcohol to
produce effect
IV. Nicotine Dependence.
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A. Criteria for Nicotine Dependence [1]
1. All seven dependence criteria are relevant
2. Must be pattern of 3+ repetitive problems
occurring as a syndrome.
a. Tolerance = need for more drug to maintain
effect or reduced effect with same amount
b. Withdrawal (usually the opposite of the acute
effects).
c. Taking more than intended or more often than
planned.
d. Persistent desire to cut back.
e. Spending large amounts of time using NOT
recovering
f. Decreased social/occupational/recreational
functioning.
g. Continued use despite physical/psychological
problems, e.g.:
1. Lung disease
2. Liver disease
3. Cancer
4. Depression
3. DSM IV does
not list abuse. Briefly speculate on
possible reasons. May be reconsidered
for DSM-V.
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B. Acute
nicotine intoxication includes [7, 8]:
1. Feeling energized.
2. Enhanced ability to focus attention.
3.
Decreased tension
4.
Speculate on how some of effects might decrease alcohol
intoxication
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C. Epidemiology: many people try nicotine (usually by smoking cigarettes); rate of
dependence relatively high [9]
1. 72% men, 61% women ever smoked
2. 33% men, 6% women ever used chewing tobacco
3. 26% men, 23% women in NCS (N=4414) with
nicotine dependence [10]
5.
Majority of nicotine dependent (90%) also drink alcohol
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D. The clinical course of nicotine dependence [6]
1. Smoking usually begins in early adolescence,
age 12-13
2. Increase in risk for use and dependence once
a person has smoked four
or more cigarettes [11]
3. Tolerance develops to adverse effects.
4. Repeated heavy use of nicotine produces DSM
IV criteria for nicotine dependence.
Usually 1+ year
behind daily smoking, risk continues into 40’s
5. Age of onset for dependence: ~ 25
6. If a person is NOT a regular smoker by age
25, not likely to do so
7. Increased prevalence of smoking in people
with depression.
Abstinence
associated with worsening of clinical depressions [12-16]
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E. Genetics: 60-70% of risk for nicotine
dependence is genetic [15, 16]
1.
Risk higher in identical twins compared to fraternal twins.
2.
Children and siblings of smokers have a 2-4X increased risk
for smoking
3.
Similar smoking histories in identical>fraternal twins
4.
Nicotine dependence is typical of complex
genetically-influenced disorder
a. Both genes and
environment
b. Multiple characteristics inherited in
different families
V. The Relationship Between Alcohol Use
Disorders and Nicotine Dependence
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A. Intoxication with nicotine and alcohol
1. Enhanced energized effect of each
2. Enhanced physiologic responses: e.g. increased heart rate, BP
3.
Reduced sedative and less performance impairment of alcohol
seen with nicotine compared with sedation and decreased performance with
alcohol alone [15-18]
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B.
Epidemiology [4, 19, 20]
1.
Non-alcoholic persons who drink alcohol are 2X more likely
to smoke than abstainers
2.
80%+ with
alcohol dependence also smoke cigarettes
3.
Alcohol
dependent smokers report smoking more cigarettes/day than non-dependent smokers
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C. Natural
History
1.
Similar to either alcohol or nicotine dependence
2.
Continued combined use might develop because of positive or
reinforcing effects
3.
One drug may increase the desire to use the other
4.
Co-use of nicotine and alcohol might progress as people try
to avoid discomfort or withdrawal
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C.
Genetic Crossover [16, 21]
1. In female
twins
a.
Overlapping liability for alcohol-nicotine use is modest,
20-30% of variance
b.
Use of tobacco and alcohol is strongly genetically mediated
c.
Environmental factors play minor role in use vs. abstinence
2. Heritability
in male twins:
a.
55% for alcohol dependence
b.
60% for nicotine dependence
c.
Substantial genetic correlation between both disorders
VI. Treatment Issues: What the Material Presented Thus Far Means to the Clinician.
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A. Treatment Issues.
1. General approach to treatment of chronic
relapsing disorders (e.g. diabetes, hypertension, substance use disorders)
2. Includes cognitive behavioral approach