Epidemiology, Natural History, and Treatment of Alcohol Problems in Clinical Settings

1
Epidemiology, Natural History, and Treatment of
Alcohol Problems in Clinical Settings
2
Objectives

• Participants will be able to
• describe the definitions, prevalence, and
  treatment effects of alcohol problems
• identify the natural history of problem drinking
  in the context of a chronic illness paradigm
• discuss ways to contribute to a reduction in the
  morbidity and mortality of alcohol and drug
  disorders

3
Why is this Important?

• Alcohol problems are common
• Alcohol is implicated in many health
  problems
• Interaction with medication
• Patient expectations
• Because intervention WORKS!

4
We have created a huge pool of people at-risk
for alcohol-related problems...
20-30 million people are at-risk
5
Treatment Works

• Brief intervention techniques
• At-risk and problem drinkers
• 10-30 reduction at 12 months

• Specialized treatment approaches
• Alcohol dependence
• 5-year abstinence varies

6
Current Cigarette Smokers Who Have Received
Advice to Quit From a Health Care Professional
Current Smokers
Female
Male
United States, Ages 21 1964 -1991
7
Role of the Primary Clinician

• Identify
• Assess
• Brief intervention
• Refer
• Pharmacotherapy
• Follow-up

8
Health Risks

• Cancer
• Liver Disease
• Fetal alcohol syndrome
• Hypertension
• Stroke

9
12-Month Prevalence (Primary Care)
1-9
At-risk Drinkers 9
Problem Drinkers 8
Alcohol Dependent 5
Low-risk Drinkers 38
Abstainers 40
Manwell, et al, 1997
10
Relationship Between Alcohol Use and Alcohol
Problems...
Alcohol Use
None
Light
Moderate
Heavy
At Risk
Dependent
Problem
Low Risk
Severe
Moderate
Small
None
Alcohol Problems
11
What is a Standard Drink?
a small glass of sherry 4 oz.
1 can of ordinary beer or ale 12 oz.
a single shot of spirits whiskey, gin, vodka,
etc. 1.5 oz.
a glass of wine 5 oz.
a small glass of liqueur or aperitif 4 oz.
12
Alcohol Use Disorders

• Low-risk use
• At-risk use
• Problem use
• Dependent use

13
Low-Risk Use

• Alcohol use at low or moderate levels
• No more than 1-2 drinks/day
• No more than 3-4 drinks/occasion
• No use in risky situations

14
At-Risk Use

• Drinking above established cut-off limits
• No current problems
• or
• Alcohol use in risky situations

15
Problem Use

Alcohol consumption with adverse effects

• behavioral
• family
• medical

• mental health
• employment
• social

16
Dependent Use

• Impaired control
• Preoccupation with use
• Consequences of use
• Physiological withdrawal

17
Factors Associated with Improved Prognosis

• Stable employment
• Supportive family
• Absence of major medical problems
• cognitive function intact
• Patient motivation
• Minimal denial
• Personal crisis

18
Factors Associated with Improved Prognosis
(continued)

• Therapeutic coercion
• Continued threat of loss
• Clear contract
• Multidimensional treatment module
• Attention to relapse
• Clinician factors
• Motivation
• Caring, nonjudgmental

19
Chronic Illness Paradigm

• Elevated cholesterol
• High blood pressure
• Diabetes
• Arthritis
• Alcohol problems

20
Liver Cirrhosis Incidence/Death Data for Men
1-20
Relative risk
20 15 10 5 0
Coates et al
Kagan et al
Kono et al
Pequinot et al
Tuyns et al
Bofetta et al
0 10 20 30 40 50 60 70 80
Data truncated at 70g/day Grams of alcohol/day
21
Estimated Pooled Risk Function Curves Alcohol
and Cancer Risk (Source Duffy Sharples,
1992)
1-21
2.6 2.4 2.2 2 1.8 1.6 1.4 1.2 1
Stomach
Colorectal
Esophagus
Relative risk
Breast
Liver
Oral
Pharynx
Larynx
0 20 40 60 80 100
Grams of alcohol/day
22
Strokes Data from 7 Studies of Men
1-22
3 2.5 2 1.5 1 0.5 0
Donahue et al
Includes incidence and death
Gill et al
Kono et al
Semenciw et al
Shaper et al
Ben-Shlomo et al
Relative risk
Boffeta et al
0 10 20 30 40 50 60 70 80
Grams of alcohol/day
23
1-23
Total Cardiovascular Mortality
2.5 2 1.5 1 0.5 0
Dyer et al
Kono et al
Marmot et al
Klatsky et al (men women)
Shaper et al
Relative risk
Semenciw et al
0 20 40 60 80 100
Grams of alcohol/day
24
All Cause Mortality in Men Eight Studies
with Significant Association
1-24
3 2.5 2 1.5 1 0.5 0
Dyer et al
Shaper et al
Kagan et al
Kittner et al
Klatsky et al
Kono et al
Relative risk
Marmot et al
Boffeta et al
0 10 20 30 40 50 60 70 80 90
Grams of alcohol/day
25
Alcohol and Mortality Among Young Men Source
Andreasson et al (1988)
1-25
Relative risk
35 30 25 20 15 10 5 0
6 5 4 3 2 1 0
Violent death
Other causes
Total mortality
Mortality per 1000


Grams/day
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
26
Characteristics of Chronic Illness

• Late onset of clinical symptoms
• Unpredictable course
• Complex etiology
• Behavioral treatment

27
Late Onset of Clinical Symptoms

• Cholesterol - Strokes, MI
• Hypertension - Kidney Disease
• Alcohol - Cirrhosis, motor vehicle accidents

28
Unpredictable Course

• It is difficult to predict the clinical course of
  an individual patient with an elevated
  cholesterol or blood pressure.
• Only 10-20 of persons with alcohol problems
  develop significant health effects.

29
Etiology

• Genetics (two- to three-fold increased risk of
  cholesterol, blood pressure, and alcohol
  problems)
• Environment (significant increased risk in the
  presence of personal, family, community problems)
• Complex genetic and environmental interactions

30
Treatment

• Behavior changes
• Pharmacotherapy
• Compliance
• Role of contracts

31
Readiness to Change Scale
resistance
ambivalence
X
X
X
Taking action
Not considering change
Thinking about change
Ready to change
Maintaining change
32
Summary
1. Alcohol and drug disorders are common and
affect patients, families, and society 2.
Primary care physicians are uniquely positioned
to recognize alcohol and drug problems and
initiate treatment
33
Summary (continued)
3. Attitudes often hinder physicians when
diagnosing and treating substance abuse Alcohol
problems are nobodys fault Physicians should
recognize maladaptive attitudes and their
sources, especially moralism and pessimism
34
Summary (continued)
4. Alcohol and drug problems are diagnosable and
treatable disorders 5. Knowledge and skills for
recognition and treatment can be learned
35
Per Capital Alcohol Consumption(Liters of
ethanol)
1970 1980 1990 Australia 8.1 9.6 8.4 Aust
ria 10.5 11.0 10.4 Belgium 8.9 10.8 9.9 Cana
da 6.1 8.6 7.5 Denmark 6.8 9.1 9.9 Finland
4.4 6.4 7.7 France 16.2 14.9 12.7 Germany 10
.3 11.4 10.6 Great Britain 5.3 7.3 7.6 Iceland
3.2 3.9 3.9 Ireland 5.9 7.3 7.2 Italy 13.
7 13.0 8.7
1970 1980 1990 Japan 4.6 5.4 6.5 Luxembou
rg 10.0 10.9 12.2 Netherlands 5.6 8.8 8.2 New
Zealand 7.6 9.6 7.8 Norway 3.6 4.6 4.1 Portug
al 9.9 11.0 9.8 Spain 11.6 13.6 10.8 Sweden
5.8 5.7 5.5 Switzerland 10.7 10.8 10.8 Turkey
0.5 0.7 0.6 United States 6.7 8.2 7.5
Edwards et al. Alcohol Policy and the Public
Good. Oxford University Press, 1994.
36
Alcohol-Related and Other Traffic Crash
Fatalities, United States
60 50 40 30 20 10 0
Other fatalities
Fatalities (in thousands)
Alcohol-related fatalities
1977 1979 1981 1983 1985 1987 1989 1991 1993 Y
ear Source Campbell et al, 1995
37
Deaths in Europe from Cirrhosis per 1,000 Living
Country Total Males Females Bulgaria 15
.0 22.0 07.8 Poland 13.9 19.1 09.2 Belgiu
m 11.9 14.4 09.5 Finland 10.7 15.3 0
4.2 Switzerland 09.5 12.9 06.1 Malta 09
.0 14.0 03.9 Greece 08.9 12.1 05.8 Israel
08.7 10.3 07.0 Sweden 06.8 08.8 04
.7 United Kingdom 06.1 06.9 05.3 Netherlands
05.1 06.3 03.9 Norway 04.4 05.4 03.3 Ire
land 02.9 03.1 02.7
Country Total M ales Females Hungary 54.
8 79.7 32.6 Romania 38.1 47.5 28.8 German
y, 33.7 47.9 19.4 Dem Rep Austria
28.2 41.2 16.4 Portugal 26.9 39.3 15.
1 Italy 26.8 31.7 18.0 Czechoslovakia 25
.1 38.1 13.4 Germany, 22.2 30.4 14.6 Fed
Rep Spain 21.0 30.0 12.9 Luxembourg
18.7 21.9 15.4 Former Yugoslavia 18.4 27.7 10.
2 France 17.0 23.3 10.6
Edwards et al. Alcohol Policy and the Public
Good. Oxford University Press, 1994.
38
Deaths in the Americas and the Caribbean from
Cirrhosis per 1,000 Living
Country Total M ales Females Mexico
48.6 72.5 21.8 Chile 46.2 67.5
26.5 Puerto Rico 29.7 47.2 13.5 Ecuador
21.7 28.7 14.1 Costa Rica 20.4 2
6.7 13.1 Venezuela 19.4 28.6 09.6 Arge
ntina 13.3 20.1 06.4 Trinidad
Tobago 13.2 19.6 06.7 Cuba 12.4 13
.3 11.3 Panama 11.6 14.2 07.7 United
States 11.6 15.2 08.0 Uruguay 11.5
17.5 06.8 Canada 09.3 12.7 05.8
Statistics supplied by WHO, Geneva. Source
Edwards et al. Alcohol Policy and the Public
Good. Oxford University Press, 1994.