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Alcohol Use, Abuse, and Dependence. Ting-Kai Li, M.D. Director National Institute on Alcohol Abuse and Alcoholism National Institutes of Health U.S. Department of Health and Human Services. Ting-Kai Li, M.D. Director National Institute on Alcohol Abuse and Alcoholism .

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Alcohol use abuse and dependence l.jpg

Alcohol Use, Abuse, and Dependence

Ting-Kai Li, M.D.

Director

National Institute on Alcohol Abuse and Alcoholism

National Institutes of Health

U.S. Department of Health and Human Services


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Ting-Kai Li, M.D.

Director

National Institute on Alcohol Abuse

and Alcoholism

http://www.niaaa.nih.gov/AboutNIAAA/DirectorsCorner/default.htm




Alcohol our most primitive intoxicant l.jpg
Alcohol: Our Most Primitive Intoxicant

  • Egypt (el-Guebaly N, el-Guebaly A, 1981, Int J Addict., 16:1207-21)

    • barley beer is probably the oldest drink in the world with its origin in Egypt prior to 4200 BC

  • China(McGovern et al., 2004, PNAS, 101:17593-17598)

    • 7000 BC - the production of a prehistoric mixed fermented beverage of rice, honey and fruit (neolithic village of Jiahu in Henan province)

    • 2000 BC- unique cereal beverages (Shang and Western Zhou Dynasties)


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Ancient Warnings About Alcohol and Harmful Use Through the Ages

  • 1600-1050 BC - Downfall of Egyptian and Chinese Empires and Dynasties attributed to excessive alcohol use

  • 460-320 BC-Grecian Scholars issued advisories on drunkenness and moderate drinking

    • Plato – No use under age 18, between 18-30 use in moderation, no restrictions for use by those older than 40

    • Aristotle and Hippocrates were both critical of drunkenness

  • 11th Century AD - Simeon Seth, a physician in the Byzantine Court, wrote that drinking wine to excess caused inflammation of the liver, a condition he treated with pomegranate syrup



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NIAAA National Epidemiological Survey on Alcohol and Related Conditions (NESARC) (2001-2002).

Cumulative Distribution of Alcohol Consumption in the United States


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Most people abstain or drink moderately placing them at low risk for alcohol use disorders. In general, Moderate Drinking is up to 2 drinks/day for men; up to 1 drink/day for women

(USDA/HHS Dietary Guidelines, 2005)

One drink: one

12

-

ounce

can or bottle

of

beer

or

wine

cooler

, one

5

-

ounce

glass of

wine

, or

1.5 ounces

of 80

-

proof distilled

spirits

.

Drinking Patterns: Rates and RisksModerate Drinking


Drinking patterns rates and risks high risk drinking l.jpg

1 risk for alcohol use disorders. In general, Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

Drinking Patterns: Rates and RisksHigh-Risk Drinking

  • Nearly 3in10U.S. adultsengageinthese high-risk drinking patterns1

  • Men: more than 14 drinks in a typical week

    • more than4 drinks on any day

    • Women: more than 7 drinksin a typical week

    • more than 3 drinks on any day


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Drinking Patterns: Rates and Risks risk for alcohol use disorders. In general, Binge Drinking

The National Advisory Council on Alcohol Abuse and Alcoholism has recommended the following definition of Binge Drinking

  • A “binge” is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gm% or above. For the typical adult, this pattern corresponds to consuming 5or more drinks (male) or 4 or more drinks (female) in about 2 hours. Binge drinking is clearly dangerous for the drinker and for society


U s adult drinking patterns and risks 2001 2002 odds ratios l.jpg
U.S. Adult Drinking Patterns and Risks risk for alcohol use disorders. In general, 2001-2002: Odds Ratios

NIAAA National Survey on Alcohol and Related Conditions, (2001-2002)


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U.S. Substance Abuse and Mental Health Services Administration, 2003 National Survey on Drug Use and Health (NSDUH)

Harmful Drinking Pattern Across the Lifespan Number of Days in Past 30 Drank 5 or More Drinks


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Relative Risk of an Alcohol-Related Health Condition as a Function of Daily Alcohol Intake

Adapted from Corrao et al. (2004), Preventive Medicine, 38:613–619


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NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2004.

Odds of Co-Occurrence of Current (12-month)DSM-IV Alcohol Dependence and Selected Psychiatric Conditions


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N Conditions, 2004.ational Institute on Alcohol Abuse and Alcoholism

Burden of Disease Attributable to Alcohol Among the 10 Leading Risk Factors for Disease In Developed Countries

The World Health Report 2002: http://www.who.int/whr/2002/en/whr2002_annex14_16.pdf


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Alcohol Abuse Conditions, 2004.


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Definition and Diagnostic Criteria for Alcohol Abuse/ Conditions, 2004.Harmful Use of Alcohol

*Ninety percent of those diagnosed as having Alcohol Abuse endorse this criterion. Others are 20% or less (Dawson, DA. Unpublished NESARC Analysis, 2006)


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Do Alcohol Use Disorders Fall Along a Continuum of Severity? Conditions, 2004.

  • Data from NIAAA’s two general population sampleepidemiological studies* and others (e.g., Langenbucher et al., 2004; Krueger et al., 2004; Kahler and Strong, 2006; Saha et al., 2006; Proudfoot et al., 2006) agree that:

    • Alcohol Use Disorders are not bi-axial (abuse and dependence), but fall along a continuum of severity

    • Current criteria for alcohol abuse are not associated only with a milder form of alcohol use disorder; most tap into the more severe end of an alcohol use continuum

    • Current criteria for abuse and dependence contain redundancies

* NESARC and the 1991-1992 NIAAA National Longitudinal Alcohol Epidemiological Survey (NLAES)


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Alcohol Dependence Conditions, 2004.(Alcoholism)


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Elements of Alcohol Dependence: DSM-IV and ICD-10 Conditions, 2004.(3 of 7 during one year required for diagnosis)

* elements of addiction


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18 + yrs. - NIAAA NESARC ( Grant et al. (2004) Conditions, 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 United States, 2001-2002

Prevalence of DSM-IV Alcohol Dependence in 2001-2002 was 3.8%



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Alcohol Conditions, 2004.use, abuse, and dependence are complex behavioral traits influenced by many factors:

  • genetic and biological responses

  • environmental influences

  • stages of development, from childhood to early adulthood



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Developmental Trajectory of AUD Conditions, 2004.Initiation and Continuation of Drinking

Initiation of Drinking

Progression

Alcoholic Drinking

Extent of Influence

Environmental (familial and non familial)

Personality/Temperament (Endophenotype)

Pharmacological effects of ethanol (Intermediate Phenotypes)



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Between Individual Variations in Responses to Alcohol Conditions, 2004.(Why drink; Drink more; Drink despite)

  • Pharmacokinetics: absorption, distribution, and metabolism of alcohol

    3-4 fold

  • Pharmacodynamics: subjective and objective responses to alcohol

  • 2-3 fold

About one-half of these differences is genetic



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Source: NIAAA National Epidemiologic Survey on Alcohol and Related Conditions, 2003

Age at Onset: DSM-IV Age of First Use of Alcohol, Nicotine, and Cannabis


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Parental History Positive Related Conditions, 2003

Total

Parental History Negative

Prevalence of Lifetime Alcohol Dependence by Age of First Alcohol Use and Family History of Alcoholism


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Ethanol Related Conditions, 2003

( ml/day) g/kg/day

*p=<0.05

Water

(ml/day)

2

5

10

15

20

25

30

40

% ethanol

Daily Consumption by P and NP Rats Responding on a Two-Bar Operant Task for Water and Different Concentrations of Ethanol

Murphy JM, Gatto GJ, McBride WJ, Lumeng L, Li TK ((1989). Alcohol. 6(2):127-31.


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Treatment of Alcohol Use Disorders Related Conditions, 2003



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Heterogeneity of Treatment Populations: Related Conditions, 2003Severity


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Clinical Trials in the Last Fifteen Years Have Shown: Related Conditions, 2003

  • Different kinds of behavioral therapies work equally well (e.g., motivational enhancement, cognitive behavioral, 12-steps)

  • Naltrexone with Disease Management works and potentially can be used in primary care settings


Behavioral therapies l.jpg

Selected References: Moyer et al. (2002) Related Conditions, 2003Addiction, 97: 279-292; Miller et al. (2002) Addiction, 97: 265-277; O’Farrell et al. (2000) J. Sub.Abuse Treat., 18: 51-54

Behavioral Therapies


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FDA Related Conditions, 2003Approved Medications for Treating Alcohol Dependence


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Medications for Treating Alcohol Dependence – Related Conditions, 2003Under Investigation


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Examples of NIAAA-Supported Clinical Pharmacotherapy Trials for AUDs and Co-morbid Psychiatric Conditions


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NIAAA Clinician’s Guide for AUDs and Co-morbid Psychiatric ConditionsHelping Patients Who Drink Too Much


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Conclusion: Alcohol Research Strengths and Opportunities for AUDs and Co-morbid Psychiatric Conditions

  • Alcohol pharmacogenetics

    • human and animal models

  • Animal models

    • genes, pathways and networks, and GxE interactions

  • Epidemiology

    • longitudinal general population and high-risk studies

  • Treatment

    • behavioral

    • pharmacological


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