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Alcohol and Intimate Partner Violence Anika A. H. Alvanzo, MD, MS Virginia Commonwealth University Medical Center Introduction Alcohol Misuse/Alcohol Use Disorders (AUD) ~16% at risk drinkers; ~ 9% AUD Cost ~ $185 billion 3rd leading cause of death Intimate Partner Violence (IPV)

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alcohol and intimate partner violence

Alcohol and Intimate Partner Violence

Anika A. H. Alvanzo, MD, MS

Virginia Commonwealth University Medical Center

introduction
Introduction
  • Alcohol Misuse/Alcohol Use Disorders (AUD)
    • ~16% at risk drinkers; ~ 9% AUD
    • Cost ~ $185 billion
    • 3rd leading cause of death
  • Intimate Partner Violence (IPV)
    • 1/4 women and 1/12 men
    • Cost ~ $6 billion/yr
    • ~ 1/3 of homicides of women
this lecture will cover
This Lecture Will Cover:
  • Alcohol/IPV
    • Definition and Epidemiology
    • Health Consequences
    • Identification
    • Treatment
    • Association between alcohol and IPV
    • Treatment for co-occurrence
alcohol use guidelines
Alcohol Use Guidelines
  • Standard drink
    • 12 oz. beer
    • 5 oz. of wine
    • 1.5 oz. of spirits (hard liquor)
  • ≤ 2 drinks/day for men
  • ≤ 1 drink/day for women
definitions of alcohol use
Definitions of Alcohol Use
  • Heavy/“At-risk” drinking
    • Men: ≥ 5 drinks/day or ≥15 drinks/week
    • Women: ≥4 drinks/day or ≥8 drinks/week
  • Binge drinking
    • Historically: used for 2+ days drunk
    • More recently: pattern with BAC ≥ 0.08%
definition of aud
Alcohol dependence ≥ 3

Withdrawal

Tolerance

Exceed limits

Not able to stop/cut down

Much time drinking

Give up other activities

Use despite problems

Alcohol abuse ≥ 1

Role failure

Risk of bodily harm

Legal problems

Relationships

Definition of AUD
epidemiology of use and aud
Epidemiology of Use and AUD

Sex/Age differences:

Men Women

Heavy drinking: 17% 13%

Current abuse: 7% 3%

Current dependence: 5% 2%

18-24 yo

20%

9%

13%

epidemiology
Epidemiology

Racial/Ethnic Differences:

Native Am

Whites

Hispanics

Blacks

Asians

Current

Heavy

Abuse/ Dependence

58%

70%

60%

53%

48%

22%

16%

12%

16%

10%

12%

9%

8%

7%

4%

health consequences of aud
Health Consequences of AUD
  • GI
    • Pancreatitis- 10%
    • Liver diseases
      • 80% fatty liver
      • 35% hepatitis
  • Neuro
    • Neuropathy- 10%
    • CBL dysfx- <1%
  • CV- 20% ↑ mortality
  • Blood- toxic for blood
  • Mental Health
    • Depression
      • 40% co-occurrence
identification of drinking
Identification of Drinking
  • Clinical indicators for screening
    • New patient
    • Annual exam
    • ER visit
    • Pregnancy
    • Rx medicine that interacts with alcohol
    • Clinical suspicion
      • Alcohol on breath
      • Family member statements
screening
Screening
  • NIAAA Clinician’s Guide
    • # of heavy drinking days in past year
      • Men: ≥ 5 drinks; women: ≥ 4 drinks
    • Weekly drinking average
      • # of drinking days in average week

X

      • # of drinks on average drinking day

5

4

20

Weekly average =

screening13
Screening
  • Alcohol Use Disorders Identification Test (AUDIT)
    • 10 items
    • + if ≥ 8 for men and ≥ 4 for women
  • PRIME MD- Patient Health Questionnaire
    • 5 items
    • + if ≥ 1
treatment for aud
Treatment for AUD
  • Behavioral
    • Brief Interventions
    • Cognitive Behavioral Therapy
    • 12-step programs
  • Pharmacologic
    • Acamprosate (Campral)
      • Dose: 2g/day; 666mg tid
    • Disulfiram (Antabuse)
      • Dose: 250mg/day
    • Naltrexone (ReVia)
      • Dose: 50-100mg/day
definition of ipv
Definition of IPV
  • A pattern of intentionally coercive and assaultive behaviors
    • Perpetrator is/was/wishes to be an intimate partner
    • Goal of behavior is to exert control
definition of ipv17
Definition of IPV
  • IPV includes many types of behavior
    • Physical
    • Sexual
    • Psychological/emotional
    • Stalking
    • Threats
    • Property destruction
    • Neglect
epidemiology of ipv
Epidemiology of IPV
  • Sex differences:
    • Women ↑ victims; men ↑perpetrators
      • Lifetime prevalence: men 8%, women 25%
      • Women comprised 85% of IPV victims in 1999
  • Age differences:
    • Victimizations: highest prevalence age 20-24
    • Homicides: highest prevalence age 35-49
epidemiology of ipv19
Epidemiology of IPV
  • Racial and ethnic differences
    • African Americans ↑ IPV
    • Hispanics ↓ IPV non-Hispanics
    • White women smallest ↓ in IPV homicide
ipv associated health effects
IPV: Associated Health Effects
  • ↑ healthcare expenditures
  • GI
    • Chronic abdominal pain
    • Digestive problems
  • GU
    • Pelvic pain
    • Sexually transmitted infections (STI)
  • Mental Health
    • Substance misuse
    • Depression, anxiety, PTSD
healthy people 2010 ipv
Access to care

Environ quality

Immunizations

Injury and violence

Mental health

Overweight/Obesity

Physical activity

Sexual behavior

Substance abuse

Tobacco use

Healthy People 2010: IPV

Leading Health Indicators

identification of ipv
Identification of IPV
  • Clinical indicators for screening
    • New patient
    • Annual exam
    • Urgent/emergent visit
    • Pregnancy
    • Clinical suspicion
red flags for ipv
Historyclues

↑ somatic complaints

Injury ≠ exam

Mental illness

Recurrent STIs

Substance misuse

Physical exam clues

Central injuries

Defensive wounds

Multiple stages of healing

Injury in pregnancy

Red Flags for IPV
identification
Identification
  • Framing statements
    • “Because violence is so common in our society, I have begun asking all of my patients about it.”
  • Indirect questions
    • “How do you and your partner handle disagreements?”
  • Direct questions
    • “Are you in a relationship with someone who hurts or threatens you?”
abuse assessment screen
Abuse Assessment Screen
  • 5-item questionnaire
  • Asks about:
    • Lifetime physical abuse
    • Past year physical abuse
    • Sexual abuse
    • Abuse during pregnancy
  • Includes body map
abuse assessment screen26
1 = Threats of abuse including use of a weapon

2 = Slapping, pushing; no injuries and/or continuing pain

3 = Punching, kicking, bruises, cuts and/ or continuing pain

4 = Beating up, severe contusions, burns, broken bones

5 = Head injury, internal injury, permanent injury

6 = Use of weapon; wound from weapon

Abuse Assessment Screen

Mark The Area Of Injury On The Body Map Using the Following Scale:

danger assessment tool
Danger Assessment Tool
  • 20-item questionnaire
  • Assesses risk for lethality
  • Factors linked to severe or lethal IPV
  • Calendar to document assaults
interventions
Interventions
  • Victims:
    • Validate disclosure (e.g. show empathy)
    • Respond to safety concerns
    • Provide resources
      • National Hotline 1-800-799-SAFE
  • Perpetrators:
    • Batterer intervention programs
    • Individual counseling
alcohol and ipv victimization
Alcohol and IPV Victimization
  • IPV victims ↑ problems with alcohol
    • 3x more heavy use
    • 5% → 16% → 24% with ↑ violence
  • Women in alcohol treatment ↑ IPV
    • 87% moderate IPV vs. 28% in community
    • 40% severe IPV vs. 8% in community
  • IPV problem drinking
alcohol and ipv perpetration
Alcohol and IPV Perpetration
  • Men in batterer intervention = ↑ alcohol
    • Up to 50% have alcohol problem
    • ↑ violence on heavy drinking days
  • Men in alcohol treatment = ↑ IPV
    • Prevalence ~ 50%
trauma sud interventions
Trauma/SUD Interventions
  • Seeking Safety
    • Group behavioral intervention
    • PTSD and SUD
    • ↓ PTSD symptoms and substance use
  • Trauma Recovery Empowerment Model
    • Group behavioral intervention
    • Hx trauma and mental illness
    • ↓ trauma symptoms and substance use
treatment of aud and ipv
Treatment of AUD and IPV
  • Perpetration
    • Few studies ↓ IPV after alcohol Rx
    • Only 1 study of integrated therapy
      • + effect on alcohol & IPV post-treatment
      • No difference at 6 month f/u
summary
Summary
  • Alcohol misuse + IPV = major public health problems
  • Alcohol misuse + IPV commonly co-occur
  • Should routinely ask about both
    • Ask about both in routine clinical encounter
    • Screen for IPV in addiction treatment settings
    • Screen for alcohol misuse in settings serving victims of IPV
  • More research is needed