AMSP Junior Scholar Outline

Alisa B. Busch, M.D., MS.

September 17, 2005


Alcohol and Drug Dependence: Comparisons to Other Chronic Medical Disorders



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                              [SLIDE 21]

a) Chronic medical conditions: screening, assessment and ongoing monitoring.

b) Alcohol/drug dependence: screening, assessment and ongoing monitoring.

3. Treatment components                              [SLIDE 22]

a) Chronic medical conditions: educating patients and family members re how to control exacerbations.                                                           

i. Motivating lifestyle and behavior modification.

1) Asthma: smoking cessation, remove allergens from home (e.g., furry pets).

2) Diabetes and hypertension: smoking cessation, diet, exercise.

ii. Treating co-occurring conditions to prevent complications

1) Asthma: allergic rhinitis, GE reflux

2) Diabetes: cardiovascular and renal disease, retinopathy

3) Hypertension: cardiovascular disease, CVA.

iii. Pharmacotherapy individualized to patient needs.

1) Asthma: inhaled corticosteroids, beta-agonists

2) Diabetes: insulin preparations, oral hypoglycemic medications

3) Hypertension: ACE inhibitors, beta-blockers

b) Alcohol/drug dependence: educating patients and family members re how to control exacerbations                                                           

i.         Motivation of lifestyle and behavioral modification (e.g., discontinue use, staying away from triggers [people, places and things].

ii.       Treating co-occurring conditions/complications to prevent complications

1) Treating co-occurring psychiatric disorders

2) Treating/preventing medical sequelae.

iii.      Pharmacotherapy individualized to treatment needs.

1)      Acute detoxification

a. Alcohol: chlordiazepoxide, diazepam

b. Opioids: methadone, buprenorphine

2)      Chronic, continuing treatment

a.       Alcohol: naltrexone, acamprosate, disulfiram, topiramate (preliminary evidence)

b.      Opioids: naltrexone, methadone/buprenorphine (maintenance treatment)

c.       Cocaine: disulfiram (preliminary evidence).

iv. Core of treatments (as in asthma, diabetes, and hypertension treatment) are behavioral therapies.(54)

1) Motivational Interviewing: often brief and aimed at getting patient to accept continued treatment.

2) Relapse Prevention Therapy: focuses on process of relapse in order to prevent.


VI.  Does treatment work?: Comparisons between asthma/diabetes/hypertension and alcohol/drug dependence.                                

A.    What does “work” mean?                                                            [SLIDE  23]

1. Cure?—No Cure

2. Patients compliant with treatment?

3. Symptom reduction/improved functional outcomes?

B. Compliance                            [SLIDE 24]

1. Chronic Medical Conditions

a). Medications

i. Asthma 30%(55)

ii. Diabetes

a. < 60% Type I(56)

b. 36%-93% Type II.(57)

iii. Hypertension 50%-70%(58, 59)

b) Behavioral and diet modification compliance < 30%.(55, 56, 60, 61)

2. Dependence: Treatment compliance with medications and continued treatment  33-53%.(62-64)

C. Symptom reduction/functional outcomes                          [SLIDE 25]

            1. Chronic Medical Condtions

a) Type II diabetes: at 3 years follow-up inadequate glycemic control 50% with medication; 75% with diet alone.(65)

b) Asthma: adults at 1 year follow-up 10% hospitalized, 35% used ER, 35% reduced activity prior month.(66)

c) Hypertension: at 1 year follow-up > 50% inadequate blood pressure control.(67)

2.  Alcohol/drug dependence                             

a. Community treatment seeking populations: Drug Abuse Treatment Outcomes Study (DATOS)(68)                                    [SLIDE 26]           

1) 10,000 patients interviewed during treatment, 3,000 re-interviewed 1 year later; 96 programs; 11 cities across U.S.

i. Significant ↓alcohol/drug use persons in treatment < 3months

a) Heroin: long term residential (LTR)/outpatient treatment ↓ 55%

b) Cocaine: LTR/outpatient ↓ 55%

c) Marijuana: LTR ↓ 55%, outpatient ↓ 75%

d) Alcohol: LTR ↓ 35%, outpatient ↓ 65%

ii. Significant further ↓ use if in treatment ≥6 months

a) Heroin: LTR/outpatient ↓ 80%-85%

b) Cocaine: LTR/outpatient ↓ 80%-85%

c) Marijuana: LTR/outpatient ↓ 75% -80%

d) Alcohol: LTR/outpatient ↓ 75% -80%

2) Individual treatment outcomes vary depending on:

      i. severity of illness and other problems

ii. treatment appropriateness

iii. patient motivation/active engagement in treatment.

b. Non-Treatment seeking populations can also be helped.                                                                                                           

1)  4,000 persons with IVDU seeking HIV testing(69)      [SLIDE 27]

i. Randomly assigned testing alone or testing + 3 motivational interviewing sessions

ii. Intervention group improved over testing alone group at 6 months

a)  ½ rate drug injection (20% vs. 45%)

b)  4x more likely abstinent

c)  Lower arrest rates (14% vs. 24%)

2) SUD treatment in pregnant women seeking prenatal care(70)                                                 [SLIDE 28]     

i.  Case-control comparison; intervention = 1 week residential care followed by twice-weekly SUD treatment during scheduled prenatal visits

ii. Intervention group improved compared to controls at delivery

a)  Cocaine positive urines (37% vs. 63%)

b)  Higher infant birth weight

c)  Longer gestational periods

d)  Fewer infants requiring NICU admissions

e)  Shorter duration NICU admissions

f) Lower treatment costs ($14.5K vs. $46.7K)

D. Predictors of poor response/compliance                   [SLIDE 29]

1. Chronic medical conditions(55, 56, 60, 61, 71)

a) Low socioeconomic status

b) Co-occurring psychiatric conditions

c) Lack of family/social supports

2. Alcohol/Drug Dependence(54, 72, 73)

a) Low socioeconomic status

b) Co-occurring psychiatric conditions

c) Lack of family/social supports


VIII. Summary and implications                             

A. Drug and alcohol dependence are chronic medical conditions      [SLIDE 30]

                        1. Genetic susceptibility.

                        2. Chronic pathophysiologic and functional changes.

                        3. Risk factors influenced by familial, cultural and personal choice.

                        4. Similar rates of treatment compliance/symptom exacerbation.

                        5. Require ongoing monitoring and treatment

6. Treatment shares similar goals of improving function, decreasing exacerbations/complications.

B. Adapt strategies used in treatment of other chronic medical conditions for treatment of alcohol and drug dependence.(43)  Importance of:      [SLIDE 31]

               1. Incorporating into routine clinical care

                        a) SUD screening

                        b) Brief interventions

                        c) Patient/family education

                        d) Medical management

                        e) Referral criteria

2. Changing medical education: ↑ amount/quality of med student/resident education.                                          [SLIDE 32]

3. Changing health insurance policy: implement similar insurance coverage (parity) for SUD compared to other chronic medical conditions.

a) Enable patients to remain in continuing care/monitoring.

b) Remove limits/restrictions on number of days/visits allowed.




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