alcohol: what’s the problem?...–foetal alcohol effects –psychoactive effects: alcohol...
TRANSCRIPT
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Alcohol:
What’s the problem?
Professor Colin Drummond
Institute of Psychiatry,
Kings College London
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Topics
• What causes alcohol problems?
• Alcohol dependence
• Conclusions
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Alcohol is a toxic and dependence
producing DRUG • Acute effects
– Highly variable
– Pleasure, relaxation
– Impaired judgement, coordination, balance
– Mood effects
– Argumentativeness and aggression
– Drowsiness
– Impaired consciousness
– Coma, respiratory depression and death.
• Chronic effects
– Toxic effects on organs
– Over 60 diseases
– Psychiatric disorders
– Foetal alcohol effects
– Psychoactive effects: alcohol dependence
– 3rd leading cause of disability after tobacco and hypertension
– No universally “safe” level
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What causes alcohol
problems?
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What is a “unit” of alcohol?
• 8g ethanol
• 1/2 pint beer (3%)
• 1 measure spirits (25ml)
• 1/4 pint strong lager (6%)
• 1 litre of spirits = 40 units
• 1 bottle of wine = 9 units
• 1 can of very strong lager (9%) = 4 units
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“Safe” and “harmful” levels
• “Safe”
- men < 21 units per week
- women < 14 units per week
• “Harmful”
- men > 50 units per week
- women > 35 units per week
Royal College of Psychiatrists, 1986
• Daily limits 4/3 units
Department of Health, 1995
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What causes problems? Acute
effects
• Impaired judgement
• Disinhibition
• Aggressiveness
• Loss of coordination
• Drowsiness
• Coma
• Alcohol poisoning
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BLOOD ALCOHOL CONCENTRATION AND EFFECTS
AMOUNT BLOOD ALCOHOL EFFECT
(mg/100ml)
1 PINT BEER 30 INCREASED
DOUBLE WHISKY ACCIDENT RISK
1.5 PINTS 50 CHEERFULNESS
3 WHISKIES IMPAIRED JUDGEMENT, DISINHIBITION
2.5 PINTS 80 LOSS OF DRIVING LICENSE
5 WHISKIES (IF CAUGHT)
5 PINTS 150 LOSS OF SELF CONTROL
10 WHISKIES QUARRELSOMENESS, SLURRED SPEECH
6 PINTS 200 STAGGER, DOUBLE VISION
1/2 BOTTLE WHISKY BLACKOUTS
9 PINTS 400 OBLIVION, DROWSINESS,
3/4 BOTTLE WHISKY COMA
12 PINTS 500 DEATH POSSIBLE
1BOTTLE WHISKY DEATH LIKELY AT 600+
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What causes problems?
Chronic effects
• Tissue damage
• Chronic effects on the brain
• Psychiatric comorbidity
• Relationships (inc. marital and parenting)
• Loss of employment
• Financial problems
• Alcohol dependence
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South West London comorbidity
study McCloud, Drummond, Barnaby, Omu, Burns, 2004
• 200 consecutive admissions to 2 psychiatric hospitals
• Screened with AUDIT
• 49% AUDIT 8+, 53% of males, 44% of females
– Psychosis OR 0.2
– Mood disorder OR 2.1
– Non-SMI OR 6.5
• Suicidal presentation:
– AUDIT 8+ OR 3.0
– AUDIT 15+ OR 7.8
• Full alcohol history 0.5%, partial history 27%
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The Alcohol Dependence Syndrome
Edwards & Gross, 1976
• Narrowing of drinking repertoire
• Salience of drink seeking behaviour
• Increased tolerance
• Repeated withdrawal symptoms
• Relief or avoidance of withdrawal
• Subjective awareness of compulsion to drink
• Reinstatement after a period of abstinence
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Dependence syndrome Edwards & Gross, 1976
• Special kind of problem related to drinking
• Conceptually distinct from other problems
related to drinking
• Dimensional rather than categorical
• Clustering of symptoms not all of which
are invariably present
• Has at its basis an altered drive state
• Underlying processes
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Aetiology of alcohol dependence
• Genetics
• Social learning
• Expectancy
• Stress
• Exposure: peer group, occupational, availability, price
• Conditioning: classical, reinforcement
• Neurobiology: dopamine, opioid, HPA
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Falling blood
alcohol level
(US)
Withdrawal
symptoms
(including craving)
(UR)
Alcohol cues
(e.g. sight and
smell of favourite
drink)
(CS)
Conditioned
withdrawal
(including craving)
(CR)
Conditioning model of alcohol cue reactivity
Drummond, Cooper & Glautier, 1990
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Drug-paired
stimuli
Positive
affect
Negative
affect
Urges
Positive
outcome
expectancies
Physiological
activation
Self
efficacy
Drug
use
Coping
Attributions
+
+
+
+
+
+
+
- -
-
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Dynamic regulatory model of craving and relapse
Niaura, 2000
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Prevalence of Past-year DSM-IV Alcohol
Dependence by Age – United States
0%
2%
4%
6%
8%
10%
12%
14%
12-17
18-20
21-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
Age
%
Pre
va
len
ce
18 + yrs. - NIAAA NESARC ( Grant, et al., (2004) Drug and Alcohol Dependence, 74:223-234)
12-17 yrs - U.S. Substance Abuse and Mental Health Services Administration 2003 National
Survey on Drug Use and Health (NSDUH)
Prevalence of Past-year DSM-IV Alcohol Dependence
by Age in the United States
Source: NIAAA 2001-2002 NESARC data (18-60+ years of age)
and SAMHSA 2003 NSDUH (12-17 years of age)
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Prevalence of Lifetime Alcohol Dependence by Age of First Alcohol Use and Family History of Alcoholism
2001-2002
0
10
20
30
40
50
60
=21
1991-1992
0
10
20
30
40
50
60
13 14 15 16 17 18 19 20 21
Parental History Positive
Total
Parental History Negative
% P
revale
nce
Age at First Use of Alcohol
Prevalence of Lifetime Alcohol Dependence by Age of
First Alcohol Use and Parental History of Alcoholism
Source: NIAAA 1991-1992 NLAES data (left panel) and
NIAAA 2001-2002 NESARC data (right panel)
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What is the outcome?
• In the young and minimally dependent: up to
80% improvement
• In dependent drinkers
- Short term (1 year): relapse common, up to 90% any drinking, 70% reinstatement
- Long term (20 years): 40% dead (3.6 fold increase, most
in 45-55 year age group), 30% continuing problems,
30% abstinent or problem free
- Most deaths due to chest & heart disease, excess of
injury and poisoning
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Conclusions
• Alcohol is a toxic and dependence producing drug
• It has individually variable effects
• There is no universally “safe” level
• Major and growing public health problem
• Considerable health, criminal justice, and other costs
• Need for effective strategies, including better early intervention