will my child become an alcoholic...7/1/14 1 the science of biological prevention: will my child...

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The Science of Biological Prevention: Will My Child Become an Alcoholic or Drug Addict?

Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D Clinical Associate Professor University of Georgia College of Pharmacy Athens, Georgia 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 1

The Science of Biological Prevention is translated into the

Epidemiology of Addictive Diseases

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What is Epidemiology?

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A Modern Definition

Study of the occurrence and distribution of health-related diseases or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problem

(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)

Basic Triad of Descriptive Epidemiology

THE THREE ESSENTIAL CHARACTERISTICS OF DISEASE WE LOOK FOR IN DESCRIPTIVE EPIDEMIOLOGY ARE:

! PERSON

! PLACE

! TIME

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Personal Characteristics (whom)

! Age

! Gender

! Socio-economic status (education, occupation, income)

! Marital status

! Ethnicity/race/genetic profile

! Behavior / habits

Place (where ?)

! Geographically restricted or widespread (outbreak, epidemic, pandemic)? Off-shore (tsunami…)

! Climate effects (temperature, humidity, combined effects..)

! Urban / sub-urban-squatter / rural ! Relation to environmental exposure (water, food supply, etc) ! Multiple clusters or one?

Time (when ?)

! Changing or stable?

! Clustered (epidemic) or evenly distributed (endemic)?

! Time-trends: Point source, propagated, seasonal, secular, combinations

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Basic triad of analytical epidemiology THE THREE PHENOMENA ASSESSED IN

ANALYTIC EPIDEMIOLOGY ARE:

HOST

ENVIRONMENT AGENT

Progression of Drug Dependence

From: Heilig M and Koob GF, Trends Neurosci, 2007, 30:399-406.

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Neurocircuitry of Addiction

Derived from: Koob G, Everitt, B and Robbins T, Reward, motivation, and addiction. In: Squire LR, Berg D, Bloom FE, du Lac S, Ghosh A, Spitzer NC (Eds.), Fundamental Neuroscience, 3rd edition, Academic Press, Amsterdam, 2008, pp. 987-1016.

Binge/Intoxication Stage

Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238

Withdrawal/Negative Affect Stage


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Reward Transmitters Implicated in the Motivational Effects of Drugs of Abuse

Dopamine … “dysphoria”

Opioid peptides ... pain

Serotonin … “dysphoria”

GABA … anxiety, panic attacks

Dopamine

Opioid peptides

Serotonin

GABA

Positive Hedonic Effects Negative Hedonic Effects of Withdrawal

Preoccupation/Anticipation “Craving” Stage


Brain Arousal-Stress System Modulation in the Extended Amygdala

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Pain, Emotions, and the Amygdala

From: Neugebauer V, Li W, Gird GC and Han JS, The Neuroscientist, 2004, 10:221-234.

Binge/Intoxication Stage


Withdrawal/Negative Affect Stage


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Preoccupation/Anticipation “Craving” Stage


Epidemiology of Use and Abstention

01020304050607080

18-24 25-44 45-64 > 64

Drank past yearLifetime abstainer

P

erce

nt

Agents

! Biological (micro-organisms)

! Physical (temperature, radiation, trauma, others)

! Chemical (acids, alkalis, poisons, tobacco, others)

! Environmental (nutrients in diet, allergens, others)

! Psychological experiences

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What outcomes ?

Mortality: all cause / cause-specific

Morbidity Disease-specific indicators / General indicators: clinic use, hospitalization, medication use

Quality of life General / Disease-specific

Costs

CLASSIC EPIDEMIOLOGIC RESEARCH INTO ETIOLOGY

Environmental factor(s)

Outcome

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CLASSIC EPIDEMIOLOGIC RESEARCH INTO ETIOLOGY

Environmental Factor(s) Outcome

Other factors including health care

Probability of Transitioning from Alcohol Use to Dependence MERRILL NORTON, PharmD, DPh, ICCDP-D Clinical Associate Professor College of Pharmacy The University of Georgia


� Small proportion of population affected

� Large contribution to societal burden •  Physical disorders •  Absenteeism (work,

school) •  Failure to fulfill one’s

social roles •  Interpersonal &

functional problems

•  Global Status Report on Alcohol and Health. http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf (Accessed October 8, 2012) •  http://alcoholabuseandrehab.blogspot.com/2012/08/what-is-alcohol-abuse.html 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D

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� Nationally representative face-to-face survey of 43,093 respondents, 18 years and older.

� Conducted by NIAAA in 2001-2002 � Civilian, non-institutionalized population in

United States in housing, including group quarters. •  Includes Alaska and Hawaii •  Hospitals, jails and prisons not among the group

quarters sampled � Oversampling of:

•  Blacks •  Hispanics •  Young Adults aged 18-24


15.2 Million 15.4

Million

Co-Occurring Disorders

Substance Use

Disorder Only

SMI Only

4.2 Million


� Mood and anxiety disorders are more common among persons who have substance abuse disorders than among those who do not. This increase appears to be independent of the substance of abuse

� Consistent with NSDUH, only a minority of people with substance use disorders seek treatment---5.81% alcohol use disorder, 13.1% drug use disorder •  However, of those who do seek treatment �  Of those with alcohol use disorder, 40.69% have a mood

disorder and 33.38% have an anxiety disorder �  Of those with a drug use disorder, 60.31% have a mood

disorder and 42.63 % have an anxiety disorder


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� Of particularly note for SAMHSA is that while only 25.81% of those with a mood disorder seek treatment, those who also have a substance abuse disorder are even less likely to seek treatment: •  20.78% for any substance use disorder •  17.45% for any alcohol use disorder •  7.96% for any drug use disorder

•  In other words, the presence of a co-occurring substance use disorder militates against treatment seeking behavior among persons with mood disorders, and the service systems are not adequately responsive to persons with co-occurring mood and substance use disorders.


� Only 5.81% of those with an alcohol use and 13.10% of those with drug use disorders seek treatment.

� Those who seek treatment with substance use disorders increase when there is a co-occurring mood or anxiety disorder.


Key Policy Questions

How treatment seeking behavior can be increased among those with substance use disorders?

What can be done to accommodate greater systems strain from increased demand?

While 13.1% of those with drug use disorders seek treatment,

86.9% do not


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2% users transition to dependence after first year of use 11% after decade of first use

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3069146/pdf/nihms-258354.pdf (Accessed October 8, 2012) 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 37

� No evidence regarding transition from alcohol use to dependence in pharmacy students

GOAL: Estimate the probability of student pharmacists transitioning from alcohol use

to dependence


The Student Pharmacists Chemical Health Scale Research Study

!   The initial study to evaluate at high risk factor development in student pharmacists; (Pre-Disease Cohort)

!   The study will be expanded to study practicing pharmacists graduated the last 20 years; (Disease Development Cohort);

!   The study will require a comprehensive look at recovering pharmacists to match potential risk factors with Pre-Disease cohort; ( Disease Cohort);

!   Primary purpose of study is to evaluate disease development during school and professional transitions

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The Study Design !   The reason for this study is to identify potential addiction predictability risk factors in student-

pharmacists to create an assessment instrument in pharmacy for determining addiction risk factors in future pharmacists.

!   These risk factors are:

!   1.) Age of First use;

!   2.) Family History of Addiction/Mental Illness;

!   3.) Current Alcohol Use;

!   4.) Trauma History;

!   5.) Impulsivity;

!   6.) Negative Proscriptions;

!   7.)Protective Factors;

!   8.) Genetic Use Patterns.

!   The intent of gathering this information is in effort to develop a model for an effective Alcohol and Drug Education and Intervention Program that may be replicated nationally.

7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D

The Study Population

!   N=394

!   P-1 First Year Student Pharmacists

!   P-2 Second Year Student Pharmacists

!   P-3 Third Year Student Pharmacists

!   Collected data using Qualtrics statistical software in Clinical Skills Laboratory

!   This is an UGA IRB approved 85 question voluntary anonymous survey


The Study Population 2013

!   N= 365

!   P-1s

!   P-2s

!   P-3s

!   P-4s ( to be collected )

!   Residents( PGY-1 and PGY-2)

!   SPCHS II 2013 130 Questions UGA IRB approved Qualtrics Survey


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2. What is your gender? # Answer Response %

1 Male 133 34%

2 Female 262 66%

Total 395 100%


4. What is your current year in Pharmacy School?

# Answer Response %

1 First Year 138 35%

2 Second Year 145 37%

3 Third Year 106 27%

4 Fourth Year 4 1%

5 Residency 1 0%

Total 394 100%


6. What is your ethnic background?

# Answer Response %

1 American Indian or Alaskan Native

0 0%

2 Asian or Pacific Islander 94 24%

3 African American 23 6%

4 Hispanic 3 1%

5 White 261 66%

6 Other 13 3%

Total 394 100%


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Gene0cs

•  When scien0sts look for "addic0on genes," what they are really looking for are biological differences that may make someone more or less vulnerable to addic0on.

•  Scien0sts will never find just one single addic0on gene. Suscep0bility to addic0on is the result of many interac0ng genes.

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18. FAMILY HISTORY OF ALCOHOLISM/SUBSTANCE ABUSE

# Question Problem, but no treatment

Problem treated

No problem

Unknown Responses Mean

1 Grandparents 64 24 252 49 389 2.74

2 Mother 15 5 359 7 386 2.93

3 Father 36 27 313 13 389 2.78

4 Brother/Sister 28 10 328 18 384 2.88

5 Children 1 0 260 97 358 3.27

6 Current Spouse 8 1 267 83 359 3.18

7 Other 28 12 208 91 339 3.07


19. FAMILY HISTORY OF PSYCHIATRIC ILLNESS

# Question Problem, but no treatment

Problem treated

No problem

Unknown Responses Mean

1 Grandparents 30 25 277 57 389 2.93

2 Mother 23 32 319 13 387 2.83

3 Father 25 19 325 15 384 2.86

4 Brother/Sister 27 30 315 14 386 2.82

5 Children 0 0 268 83 351 3.24

6 Current Spouse 0 5 275 74 354 3.19

7 Other 12 11 227 84 334 3.15


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22. CURRENT ALCOHOL USE How often do you drink alcohol? # Answer Response %

1 Never 67 17%

2 Less than Once a Month 65 16%

3 Once a Month 31 8%

4 2-3 Times a Month 100 25%

5 Once a Week 72 18%

6 2-3 Times a Week 56 14%

7 Daily 4 1%

Total 395 100%


23. How many drinks containing alcohol do you have on a typical day when you are drinking?

# Answer Response %

1 1 to 2 140 43%

2 2 to 4 125 38%

3 5 to 6 44 13%

4 7 to 9 14 4%

5 10 or more 3 1%

Total 326 100%


28. How often in the last year have you had a feeling of guilt or remorse after drinking.

# Answer Response %

1 Never 217 66%

2 Less than once a month 92 28%

3 Monthly 16 5%

4 Weekly 3 1%

5 Daily or almost daily 0 0%

Total 328 100%


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Trauma History/Stressful Life Events

•  A systema0c review of the literature indicates that trauma and stressful life events (death, losses of property, etc.) has a strong influence on a person developing an addic0on;

•  Student Pharmacists report at least 4.5 stress life events/traumas prior to entering pharmacy school


32. TRAUMA HISTORY Have you ever experienced a significant traumatic experience in your lifetime?

# Answer Response %

1 Yes 113 29%

2 No 282 71%

Total 395 100%


Nega0ve Proscrip0ons

•  Preven&on Message; •  Social Support; Who Would Talk to About Serious Problem;

•  Ac&vi&es : Athle&cs, Extracurricular, Religious Beliefs and Prac&ces;

•  Community Domain; •  Family Domain; •  Drug availability. 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-‐D 54

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37. NEGATIVE PROSCRIPTIONS Indicate whether you agree or disagree with the following: Prescription dru...

# Answer Response %

1 Strongly agree 279 71%

2 Agree 92 23%

3 Neutral 10 3%

4 Disagree 9 2%

5 Strongly Disagree 5 1%

Total 395 100%


Protec0ve factors

•  Preven&on Message; •  Social Support; Who Would Talk to About Serious Problem;

•  Ac&vi&es : Athle&cs, Extracurricular, Religious Beliefs and Prac&ces;

•  Community Domain; •  Family Domain; •  Drug availability. 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-‐D 56

44. PROTECTIVE FACTORS Indicate the level at which the following applies to you: I talk to my parents/sp...

# Answer Response %

1 Always applies 145 37%

2 Mostly applies 137 35%

3 Applies 42 11%

4 Somewhat applies 55 14%

5 Does not apply 15 4%

Total 394 100%


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The Gene&c Component-‐The Kreek-‐McHugh-‐Schluger-‐Kellogg Scale: a new, rapid method

for quan&fying substance abuse and its possible applica&ons.

•  designed to quan&fy self-‐exposure to opiates, cocaine, alcohol, and/or tobacco;

•  assesses the frequency, amount, and dura&on of use of a par&cular substance during the individual's period of greatest consump&on;

•  assesses the mode of use, whether the substance use is current or past, and whether each substance is the substance of choice;

•  preliminary results show that the KMSK scale may have both construct validity similar to that of other established self-‐report measures and the poten&al to be an effec&ve screening instrument for the assessment of a life&me diagnosis of alcohol, opiate, or cocaine dependence.


58. Are you using currently? # Answer Response %

1 Yes 91 29%

2 No 221 71%

Total 312 100%


59. How long did this pattern of drinking last?

# Answer Response %

1 More than a year 48 16%

2 Six months to one year 69 22%

3 Less than six months 192 62%

Total 309 100%


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The probability of transitioning from alcohol use to dependence is greatest three years after the first use of alcohol

0

0.01

0.02

0.03

0.04

0.05

0.06

0 1 2 3 4 5 6 7 8 9 > 10

Proportion of At-Risk Respondents Who Transition To Alcohol Dependence

18 19 20 21 22 23 24 25 26 27 28+ 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 61

Overall P3 P2 P1

Mean 23.787 24.99 23.91 22.73

Median 22 24 22 22

Mode 22 22 22 21

Total No. of Respondents *

393 105 145 137

* Total number includes P4 respondents (not listed) 62

Overall P3 P2 P1

Mean 17.38 17.2 17.58 17.37

Median 18 17 18 18

Mode 18 21 18 18

Total No. of Respondents *

349 99 124 121

* Total number includes P4 respondents (not listed) 63

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FAMILY HISTORY OF ALCOHOLISM/SUBSTANCE ABUSE

Overall P3 P2 P1

No. with Family HX 169 50 62 54

Total No. 395 106 145 138

Percent with Family HX 42.78 47.17 42.76 39.13

Total No. of 1st Degree Relatives with Alcohol/S.A. Problems

259 80 86 86

No. of Relatives with Alcohol/S.A. Problem per Respondent with Family HX

1.53 1.6 1.39 1.59

No. Fathers 63 22 23 17

No. Mothers 20 6 6 7

No. Grandparents 88 27 24 35

No. Siblings 38 10 15 12

No. Children 1 0 0 1

No. Spouses 9 5 1 2

No. Other 40 10 17 12 64

Overall P3 P2 P1

Greater than 15 (%)

7 (1.9) 3 (3.23) 3 (2.59) 1 (0.9)

8 to 15 (%) 50 (13.6) 11 (11.83) 20 (17.2) 19 (16.52)

0 to 7 (%) 267 (88.3) 79 (84.95) 93 (80.2) 95 (82.61)

§  Scores (General Interpretation) §  > 15: high level of alcohol problems §  8 to 15: medium level of alcohol problems §  0 to 7: low level of alcohol problems

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FAMILY HISTORY OF PSYCHIATRIC DISORDER

Overall P3 P2 P1

No. with Family HX 139 22 56 48

Total No. 395 106 145 138

Percent with Family HX 35.19 30.19 38.62 33.8

Total No. of 1st Degree Relatives with Alcohol/S.A. Problems

239 58 95 82

No. of Relatives with Alcohol/S.A. Problem per Respondent with Family HX

1.72 1.8 1.7 1.71

No. Fathers 44 10 21 13

No. Mothers 55 12 21 21

No. Grandparents 55 11 20 23

No. Siblings 57 16 18 20

No. Children 0 0 0 0

No. Spouses 5 1 4 0

No. Other 23 8 11 5 66

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FAMILY HX OF ALCOHOLISM/S.A.

Overall P3 P2 P1

Mean 16.6 16.67 16.9 16.82

Median 16 17 16 16

Mode 16 18 16 16

FAMILY HX PSYCHIATRIC DISORDER

67

Overall P3 P2 P1

Mean 16.7 17.1 16.53 16.8

Median 17 17 16 17

Mode 16 21 15 18

AUDIT SCORE > 16

Overall P3 P2 P1

Mean 16.28 16.67 18 14

Median 17 17 18 14

Mode 18 17 18 14

AUDIT SCORE 8 TO 15

68

Overall P3 P2 P1

Mean 16.1 16.2 16.5 15.94

Median 16 16 16 16

Mode 16 16 16 16

Overall P3 P2 P1

Mean 17.6 17.33 17.8 17.67

Median 18 18 18 18

Mode 18 21 18 18

AUDIT SCORES 0 to 8 69

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Overall P3 P2 P1

Experienced Traumatic Event in Lifetime

102 35 40 25

Received Counseling for Traumatic Event

31 10 12 8

Alcohol or Drugs Led to Traumatic Event

14 3 5 6

Turning to Alcohol or Drugs Helps to Cope

15 5 5 5

Alcohol or Drugs Relieves Pain from Trauma

10 3 2 5

Quit Smoking But Wanted to Restart After Traumatic Event

11 7 2 2

70

The probability of transitioning from alcohol use to dependence is greatest three years after the first use of alcohol

0

0.01

0.02

0.03

0.04

0.05

0.06

0 1 2 3 4 5 6 7 8 9 > 10

Proportion of At-Risk Respondents Who Transition To Alcohol Dependence

18 19 20 21 22 23 24 25 26 27 28+ 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 71


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will my child become an alcoholic...7/1/14 1 the science of biological prevention: will my child...

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