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AMSP Outline- Alcohol and Intimate Partner Violence (IPV) - Anika Alvanzo

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I.       Introduction

A.               Alcohol Use Disorders (AUD): significant public health problem

1.      ~16% are heavy drinkers1; 18 million have AUD2

2.      Prevalence of at-risk drinking in primary care = 15%3-5

3.     Economic costs of abuse/dependence = $185 billion in 19986

4.     3rd leading cause of death (following tobacco and obesity) 7

B.               Intimate Partner Violence (IPV) also significant problem

1.      In U.S., 1/4 women and 1/12 men experience physical or sexual IPV

2.     Translates to > 22 million women and about 7 million men 8

3.     Primary care: = 40% lifetime; 10%current 9, 10

4.      IPV costs >$5.8 billion /yr; $4.1 billion from direct medical and mental health services 11  

5.     Accounts for ~30% of homicides of women12

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C.               This lecture covers

1.     Alcohol/IPV

a)      Definition and epidemiology

b)     Health consequences

c)      Identification and Treatment

d)     Relationship between Alcohol and IPV

e)     Treatment for concurrent AUD and IPV

 

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II.    Alcohol Use Disorders

A.               Definitions

1.     Current guidelines exist for alcohol consumption

a)      A standard drink =

(1)  12 oz of beer
(2)  5 oz of table wine
(3)  3-4 oz of fortified wine
(4)  1.5 oz of liquor (a “shot”) 13

b)     1 drink/day for women and up to 2 drinks/day for men14

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2.     “At-risk” drinking

a)      Definitions vary

(1)   Men ≥ 5 drinks/day or ≥ 15 drinks/week
(2)    Women ≥ 4 drinks/day and ≥ 8 drinks/week13
(3)   Risk for alcohol-related problems ↑ when limits exceeded

3.      “Binge” drinking

a)      Historically, used for 2+ days drunk

b)     Expanded to include: pattern of consumption that brings blood alcohol concentration (BAC) level to ≥0.08%

c)      According to 1 source:  corresponds to ≥ 5 drinks for men or ≥ 4 drinks for women, within 2 hours15

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4.     Alcohol dependence- ≥ 3 of the following within a 12-month period:

a)      Tolerance

(1)   ↑ use for same effect
(2)   ↓ effect with same amount used

b)     Withdrawal

(1)   Characteristic withdrawal syndrome
(2)   Use of same or related substance to relieve withdrawal symptoms

c)      Use of larger amounts over longer periods than intended

d)     Desire or unsuccessful efforts to cut down

e)     ↑ time spent in activities to obtain or recover from alcohol

f)       Give up important social/occupational/recreational activities

g)     Continued use despite persistent physical or psychological problems16

5.     Alcohol abuse- not dependence but repeated problems ≥ 1 area:

a)      Inability to fulfill role obligations (i.e. missing work/school)

b)     Recurrent use in physically hazardous situations

c)      Legal problems (i.e. drunk driving, public intoxication)

d)     Social or interpersonal problems (i.e. marital problems) 16

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B.               Epidemiology of Use and AUDs

1.     Sex differences1, 17, 18,

a)      More men drink than women

(1)   current drinkers: 72% men, 60% women 1
(2)   “binge” drinking last 30 days: 31% men, 15% women 17
(3)   heavy drinkers: 17% men, 13% women 1
(4)   current abuse: 7% men, 3% women 18
(5)   current dependence: 5% men, 2% women 18

b)     However, no gender differences age 12-17

2.      Age 1, 17

a)      Highest rates of alcohol misuse seen in young adults (18-24)

(1)   heavy drinkers: 20%
(2)   binge drinkers: 41%, peak of 48% at 21
(3)   current abuse: 9%
(4)   current dependence: 13%

b)     Prevalence decreases with increasing age

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3.      Race/Ethnicity 1, 17, 18

a)      Whites

(1)   current drinking: 70%
(2)   heavy drinking: 16%
(3)   current abuse/dependence: 9%

b)     Black/African Americans

(1)   current drinking: 53%
(2)   heavy drinking: 16%
(3)  current abuse/dependence: 7%

c)      Asians/Pacific Islander

(1)   current drinking: 48%
(2)   heavy drinking: 10%
(3)  current abuse/dependence: 4%

d)     American Indians/Alaska Natives

(1)   current drinking: 58%
(2)   heavy drinking: 22%
(3)   current abuse/ dependence: 12%

e)     Hispanics

(1)   current drinking: 60%
(2)   heavy drinking: 22%
(3)   current abuse/ dependence: 8%

 

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4.      Associated Health Consequences20, 21

a)      GI

(1)   Pancreatitis-
(a)   10% alcoholics acute pancreatitis
(b)   Alcohol thought to stimulate production of digestive enzymes
(2)   Liver- Threshold: 80 grams of ethanol/day x 10-20 years
(a)   Corresponds to ~ 1L wine, 8 standard beers, or 1/2 pint of hard liquor/day
(b)   Fatty liver- 80%; hepatitis 35%; cirrhosis < 20% w/alcoholism

b)     Neuro

(1)   Neuropathy- seen in 5-15%
(2)   Cerebellar dysfunction- seen in <1%

c)      CV- associated with 20% increased mortality

(1)   #1 cause of non-ischemic dilated cardiomyopathy
(2)  Arrhythmias in up to 60% of binge drinkers, “holiday heart”

d)     Hematologic-

(1)   90% w/alcoholism have macrocytosis
(2)   toxic effect on bone marrow- affects all blood cell types

e)     Mental Health

(1)   insomnia and blackouts
(2)   depression - up to 40% co-occurrence
(3)   Many more substance induced problems not covered here

 

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C.               Identification/Assessment of Drinking

1.     Clinical indicators for screening13

a)      New patient visit

b)     Annual exam

c)      Urgent care/Emergency visit

d)     Pregnancy

e)     Need for medicine that interacts with alcohol

f)       Clinical suspicion (e.g. alcohol on breath, family member statements)

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2.      Screening

a)      NIAAA Clinician’s Guide 13

(1)   Determine # of heavy drinking days in past year:
(2)   Determining the Weekly Average intake
(a)    # of drinking days in average wk x # of drinks on avg drinking day
(b)   Remember problematic use: men ≥15 drinks/wk; women ≥8 drinks/wk

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b)     Alcohol Used Disorders Identification Test (AUDIT) 22

(1)   10-item questionnaire
(2)   max score of 40
(3)   + if ≥8 for men; ≥ 4 for women

c)      Prime MD- Patient Health Questionnaire (Prime MD- PHQ) 23

(1)   Assesses 8 diagnoses, including alcohol abuse or dependence
(2)   Does not meet diagnostic criteria, but good screening tool
(3)   5 items
(4)   + if ≥ 1 answered affirmatively

 

 

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D.               Treatment for Alcohol Use Disorders

1.     Behavioral

a)      Brief interventions (e.g. motivational interviewing)

(1)   drinking discussed in context of health
(2)   objective: build motivation to initiate or continue change
(3)   if not dependent goal often = moderation

b)     Cognitive behavioral therapy

(1)   integrates principles of behavioral and cognitive social learning theories
(2)   Goal:  learn and practice behavioral coping strategies
(3)   Objective: change both thought processes and actions

c)      12-Step Programs (e.g. Alcoholics Anonymous)- often have a spiritual component

2.     Pharmacologic13, 20

a)      Acamprosate (Campral)

(1)   Mechanism: ↑ GABA activity, ↓ N-methyl-d-aspartate activity
(2)   Response: ↓ protracted withdrawal symptoms
(3)   Dosing: 2g/day; 666mg tid

b)     Disulfuram (Antabuse)

(1)   Mechanism: Inhibition of alcohol dehydrogenase
(2)   Results: nausea/vomiting, flushing, headache, tachycardia, hypotension when one drinks
(3)   Dosing: average 250mg daily

c)      Naltrexone (ReVia)

(1)   Mechanism: opioid antagonist
(2)   Reaction: ↓ alcohol effect, ↓ positive reinforcement
(3)   Dosing: 50 – 100 mg daily

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III.  Intimate Partner Violence (IPV)

A.               Definition includes: 24

1.      Pattern of assaultive and coercive behaviors

a)      Perpetrator is/was/wishes to be an intimate partner

b)     Goal: to exert control over partner

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2.     IPV includes many types of behaviors

a)      Physical (e.g. pushing, slapping, kicking, choking)

b)     Sexual (e.g. unwanted touching, coerced sex, rape)

c)      Emotional (e.g. ridiculing, criticizing, withholding affection)

d)     Stalking

e)     Threats

f)       Property destruction

g)     Neglect (e.g. failing to care for disabled partner)

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B.               Epidemiology of IPV

1.     Sex differences: Women > men are victims

a)      Lifetime prevalence from National Violence Against Women Survey (NVWS): 8

(1)   Men: 8%
(2)   Women: 25%

b)     Of those assaulted, assault occurred after age 18: 8

(1)   Men: 18%
(2)   Women: 76%

c)      National Crime Victimization Survey (NCVS):  women were 85% of IPV victims in 199912

 

 

2.     Risk varies by age: 12, 25

a)      16-19:  17.4 victimizations/1,000; 22% of all female homicide victims

b)     20-24: 21.3 victimizations/1,000; 32% of female homicide victims

c)      35-49: 8.1 victimizations/1,000; 38% of female homicide victims

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3.     Racial/Ethnic differences

a)       African Americans report higher rates of IPV

(1)   NCVS: 35% higher than whites and 2 1/2x that of women of other races12
(2)   NVWS: OR 1.35 8
(3)   9th National Alcohol Survey (NAS)
(a)   ↑both male-to-female and female-to-male IPV26
(b)   differences in male-to-female violence not significant if consider SES
(4)   Some studies suggest that ↑ rates due to AA women more likely to report

b)     Intimate partner homicide: ↓ over years (except White females)

(1)    1976 - 2004, IPV homicides for all other race/genders ↓ 
(2)   Rates ↓> 55% except, White females steady at 5%25, 27, 28

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4.     Associated Health Consequences of IPV

a)      Associated with multiple health consequences: 29-34 (Slide 18)

(1)   Increased healthcare utilization and expenditures (> $1,000/yr)
(2)   GI complaints
(a)   Digestive problems, such as irritable bowel disease (35% vs. 19%)
(b)   Chronic abdominal pain (22% vs. 11%)
 
 
 
 
(3)   GU complaints
(a)   Pelvic pain (17% vs. 9%)
(b)   Sexually transmitted infections (STI) (30% vs. 10%)
(c)   Urinary tract infections (29% vs. 17%)
(d)   Unwanted pregnancy (39% vs. 8%)
(4)   Mental Health (OR 3.3)
(a)   Substance misuse (OR 2.6)
(b)   Depression (OR 2.1)
(c)   PTSD (OR 3.7)
(d)   Suicidal ideation

 

 

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b)     IPV is associated with 8 / 10 of the leading health indicators for Healthy People 201029

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C.               Identification/Assessment of IPV

1.     Clinical indicators for screening

a)      New patient visit

b)     Annual exam

c)      Urgent care/emergency visit

d)     Pregnancy

e)     Clinical suspicion

(1)   multiple somatic complaints
(2)   delay between injury and presentation

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2.     Keys from the history29

a)      Delay between injury and presentation

b)     Frequent missed appointments, noncompliance

c)      Mechanism of injury inconsistent with history

d)     Multiple somatic complaints

e)     Mental Illness

f)       Recurrent STIs

g)     Substance misuse

3.     Keys from the physical exam29

a)      Central pattern of injury

(1)   Breasts
(2)    Abdomen
(3)    Genitalia

b)     Defensive wounds (i.e. ulnar aspect)

c)      Multiple injuries/bruises in different stages of healing

d)     Physical injury during pregnancy

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4.      Questions/Tools29

a)      Framing Statements

(1)   Goal is to set the stage for questioning
(2)   “Because violence is so common in our society, I have begun asking all my patients about it….”

b)     Indirect Questions: open-ended questions with multiple responses

(1)    “What happens when you and your partner argue?”
(2)   “How do you and your partner handle disagreements?”

 

 

 

c)      Direct questions: only one answer possible

(1)   “Are you in a relationship with someone who hurts or threatens you?”
(2)   “Have you ever been in a relationship in which you feared for your safety?”
(3)   “Have you ever been in a relationship where you were forced or coerced to participate in sexual activities against your will?”

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d)     Abuse Assessment Screen

(1)   5-item screen asks about physical/sexual IPV and fear of partner
(2)   includes a body map to document sites of injury

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e)     Danger Assessment Tool 35, 36

(1)   Designed to assess for risk of lethality
(2)   Includes calendar to document dates of assaults

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D.               Response to IPV

1.      Interventions for victims

a)      Validate patient’s disclosure (e.g. show empathy)

b)     Respond to safety issues

c)      Provide resource information- know your local resource contact info

(1)   Crisis Hotlines- National Hotline 1-800-799-SAFE
(2)   Support Group numbers
(3)   Shelter numbers

2.      Interventions for perpetrators- usually from by local community services board

a)      Batterer intervention programs- distinct from anger management

b)     Individual counseling

 

 

 

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IV.Alcohol and IPV

A.               Alcohol and IPV Victimization

1.     Victims of IPV- ↑ likely to report alcohol problem

a)      IPV victims 3 x more likely to report heavy alcohol use8

b)    prevalence of alcohol-related problems based on degree of IPV37

(1)   5% in women with no past-year violence
(2)   16% in women reporting moderate IPV
(3)   24% in women reporting severe IPV
(4)  men:  13% vs. 34% vs. 48%

c)      Another study: past year IPV = 59% vs. 13% for those with and without drinking problem 38

2.     Women in alcohol treatment report higher rates of IPV39-43

a)      87% reported moderate IPV, 40% severe IPV

b)     Compared to 28% and 8%, in the community

3.     Directional relationship: IPV →later problem drinking

a)      One Study: women reporting IPV at 23 ↑ alcohol misuse at 2944

b)     Another study: new physical or sexual assault = ↑ alcohol use over time45

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B.               Alcohol and IPV Perpetration

1.     Associations between partner with alcohol problem and IPV46-48

a)      ↑alcohol problems in men in IPV49

(1)   One study: prevalence of alcohol-related diagnoses = 50%
(2)   Male-to-female violence ~ 10x ↑ on days when male partner drinking
(3)   ~20x ↑on heavy drinking day

b)     ↑IPV perpetration in men in alcohol treatment50-53

(1)   male-to-female IPV ~50%
(2)   IPV associated with ↑ alcohol problem severity

2.     Appears to be more of a threshold effect than a linear effect: violence risk ↑ once a certain number of drinks consumed vs. ↑ risk with ↑ # drinks consumed54

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C.               Treatment for co-occurring AUD and IPV

1.     Victimization: Trauma-informed therapies, which address both history of trauma and substance misuse, show promise

a)      Seeking Safety55

(1)   Developed for co-occurring PTSD and addiction
(2)   + effect on trauma-related symptoms and substance use

b)     Trauma Recovery Empowerment Model (TREM) 56

(1)   Developed for co-occurring trauma and mental illness
(2)    ↓trauma symptoms and alcohol and drug scores

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2.     Perpetration

a)      Little to no data on combination therapy

b)     Data suggest some ↓ violence after treatment for alcohol dependence57

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V.   Summary

A.               Alcohol misuse and IPV are significant public health problems

B.               Alcohol misuse and IPV commonly co-occur

C.               Should routinely inquire about both

1.     Ask about both alcohol use and IPV in the clinical encounter

2.     Screen for IPV in addiction treatment settings

3.     Screen for alcohol misuse in settings serving victims of IPV

D.               More research is needed on integrated treatment

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Questions