Basics on Alcohol

1. Basics on Alcohol Steven D. LaRowe, Ph.D. Center for Drug and Alcohol Program Medical University of South Carolina Substance Abuse Treatment Center Ralph H. Johnson VAMC

2. Alcohol is “tricky” • Many people drink, but only a few qualify has having a diagnosis of abuse or dependence • Most “budding” alcoholics want to continue to drink, or control drinking • AA disease model = you’ll never drink again • Some patients will resist that and will turn away from treatment • Hard to know who is the person who will drink responsibly in the future, or who will never be able to again • Need to “roll with this resistance”

3. What is moderate drinking? • Men: no more than 4 drinks per day • Men: no more than 14 drinks per week • Women: no more than 3 drinks per day • Women: no more than 7 drinks per week

4. How many people drink? • 18 and over, between 40 and 70% drink • Heavy drinkers: between 5 and 20% • Rates of Dependence: 7% young adults (18-25), 3% for those over 26

5. Basic Wiring of the Brain

6. DSM-IV: Alcohol Abuse 1 or more within a 12-month period: • Drinking results in failure to fulfill major role obligations at work, school, or home • Drinking in situations in which it is physically hazardous • Recurrent alcohol-related legal problems • Drinking despite social/interpersonal problems • These symptoms must never have met the criteria for alcohol dependence.

7. DSM-IV: Alcohol Dependence 3 or more in the same 12-month period: • Tolerance: • Either need more to effect OR experience markedly diminished effects • Withdrawal: • Either withdrawal syndrome for alcohol or drink to avoid the syndrome • Drinking more over a longer period than was intended. • Desire/unsuccessful efforts to cut down/control use. • Excessive time is spent in obtaining, using or recovering from alcohol • Reduced social, occupational, or recreational activities b/c drinking • Continue to use it even though it causes physical or psychological problems

8. Recall: Learning occurs quickly when using alcohol/drugs – change in gene expression is involved. Genes determine protein structure, structure of protein determines function, etc. Abuse Dependence Time to develop ETOH dependence 5 to 10 year progression The 3-stage progression of addiction Source: Kalivas & Volkow, 2005)

9. Biological Action of Alcohol • GABA – neurotransmitter involved in inhibition – is increases by alcohol • Glutamate – neurotransmitter involved in excitation, memory (NMDA is a type of glutamate receptor) – is inhibited by alcohol • Alcohol indirectly causes release of dopamine, presumably through effects on GABA, which regulates dopamine release

10. Alcohol going in and out • “Biphasic” meaning “two phases” • As alcohol levels increase, dopamine is released, people feel good (a.k.a. the “ascending limb” • Peaks about an hour after last drink on empty stomach, longer if you’ve eaten (2 hours) • (Warning: people doing shots can do a bunch in a few minutes, and feel “OK” and leave, but the real intoxication is yet to come) • After alcohol levels peak, they start to decrease and sedative effects are most notable (a.k.a. the “descending limb”

11. Source: King et al. 2002

12. Drinks, BAL, and effects Source: http://www.alcohol.vt.edu/Students/alcoholEffects/estimatingBAC/index.htm

13. Drinks, BAL, and effects Source: http://www.alcohol.vt.edu/Students/alcoholEffects/estimatingBAC/index.htm

14. When the party’s over • “Rebound” occurs when alcohol clears • Now, glutamate makes a comeback • In persons not tolerant to alcohol it can disturb sleep • Chronic exposure to alcohol leads to changes in GABA. Body makes less of it, so when its gone, Glutamate rules the day • Lots of Glutamate activity  CNS activation  withdrawal symptoms = shakes, anxiety, and extreme cases, seizures and Delerium Tremens

15. Tolerance • Functional: you function even when others would be severely impaired if they drank the same amount • Tolerance does not develop equally across all domains (e.g. OK mental functions, but still impaired coordination) • Environment dependent tolerance – tolerance in one place but not another • Liver can speed up, but this can cause it to process other things (like other meds) too quickly (Source: NIAAA Alcohol Alert 28)

16. Special Concern: Alcohol Withdrawal • Can have severe, even deadly, result, if untreated • Therefore, you need to have some idea whether you client is at risk • Can begin within a few hours of cessation of drinking • Can last up to 72 hours • “Kindling” theory – the more withdrawals you have, the more risk of seizures • Seizures can be damaging, and if you have one, you are more at risk for another

17. DSM-IV: Alcohol Withdrawal 2 (or more) of the following, developing within several hours to a few days after alcohol cessation/reduction:  • autonomic hyperactivity (e.g., sweating or pulse rate  greater than 100) • increased hand tremor • insomnia • nausea or vomiting • transient visual, tactile, or auditory hallucinations or illusions • psychomotor agitation • anxiety • grand mal seizures   

18. Screening for Alcohol problems • CAGE: Two "yes" responses indicate that the respondent should be investigated further. The questionnaire asks the following questions: • Have you ever felt you needed to Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt Guilty about drinking? • Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

19. Know what “Standard Drink” Is • People will count a 24 oz. “tall boy” beer as 1 beer – it’s more like 2 • People will make a drink with several shots (“double, triple”, and count it as 1 drink • One client told me she had “3 drinks” last night, but I found out later that each was a mixed drink with 5 shots of vodka each! Source: A Pocket Guide for Alcohol Screening and Brief Intervention, NIAAA

20. Quick Alcohol Withdrawal Questions Questions to ask: • Ask if they’ve ever been “detoxed” for alcohol • Ask about withdrawal symptoms (shakes, sweats) • Ask about number of previous withdrawals they’ve gone through • If in private practice, cultivate a relationship with a psychiatrist or other medical practitioner

21. CIWA • Clinical Institute Withdrawal Assessment • At the VA, we have a “CIWA protocol” • Essentially, the medical people assess withdrawal over time • Treatment for withdrawal has traditionally been benzodiazepines (e.g. Valium, Ativan) • We are trying to use anti-seizure medications (e.g. Gabapentin, Carbemazepine), because they are not cross-tolerant to alcohol (and less addictive) Click here for a copy of the CIWA

22. Among people over 21, those who with dependence are more likely to have started drinking before the age of 14 (8%) than age 21 (1%). Alcohol dependence develops over 5-10 years, so if drinking has occurred longer than that, dependence more likely People who exceed both daily/weekly limits have a 50% chance of abuse/being dependent Can they stop? If no, possibly they have become compulsive drinkers. More treatment attempts = more likely they have serious dependence (compulsive) problem Objective evidence of problems What I look for when assessing a drinker • When did drinking begin? • How many years of heavy drinking? • How many standard drinks per day? • Do you ever have just one or 2 drinks? • How many times in treatment? • # of Charges for DUI’s, drunk and disorderly (CHARGES not convictions, in case they took a plea)

23. More things I look for • As part of your standard intake, you’ll have gotten family, work, medical histories. • Keep these in mind, as problems in these areas are often alcohol-related but not seen as such by the drinker! • You might be able to make that link in sessions to help increase your motivation. • However, it is important to ask the patient what she/he sees as being problems cause by alcohol

24. Using your BAL monitor • We typically have used BAL monitor for individual therapy in research • We have them on hand at VA • They are always useful, but a patient might not show up if he/she thinks she might come up positive • Things to watch for when patients come up positive…(e.g. they will come up positive and still deny using) • Some cough syrups make people come up positive – not an excuse though!

25. Biological indicators of drinking

26. Clinical issues • Is this a person who can never, ever drink again or might this be someone who can moderate? • There are a number of people who “spontaneously” remit, and stop drinking on their own (as high as 30%) • On the other hand, if they could have remitted, would they be here for treatment? (Maybe, maybe not)

27. Abstinence versus Moderation • The more evidence for dependence (e.g. older age, longer drinking time, more failed treatments), elevated liver leves, the more I might guide client towards goal of complete abstinence • Younger age, less time drinking, controlled drinking might be more acceptable goal • In general, however, even if patient wants controlled drinking, I will suggest that it works better after an extended period of abstinence (based on clinical experience, no empirical evidence in my possession so far)

28. Abstinence vs. Moderation • Many times, I will think the patient in no way can handle drinking, yet patient insists on trying controlled drinking • I will negotiate with them a weekly and daily limit (start low, below recommended levels, the patient argues us) • I will then have patient track drinking (educate about standard drinks), and see if they can keep limits • If patient can’t keep limits, then we revisit abstinence

29. Activity • Create a client, complete with drinking history. Decide the extent to which client is aware of their problem. • Recognize that some people will report problems but not see them related to drinking • Recognize that many people are in treatment at someone else’s behest • Recognize the tendency to minimize and underreport problems