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Copyright Alcohol Medical Scholars Program 1 Alcohol and Drug Dependence: Comparisons to Other Chronic Medical Disorders Alisa B. Busch, M.D., M.S. Alcohol.

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Presentation on theme: "Copyright Alcohol Medical Scholars Program 1 Alcohol and Drug Dependence: Comparisons to Other Chronic Medical Disorders Alisa B. Busch, M.D., M.S. Alcohol."— Presentation transcript:

1 Copyright Alcohol Medical Scholars Program 1 Alcohol and Drug Dependence: Comparisons to Other Chronic Medical Disorders Alisa B. Busch, M.D., M.S. Alcohol and Drug Abuse Treatment Program, McLean Hospital Department of Psychiatry, Harvard Medical School

2 Copyright Alcohol Medical Scholars Program2 Characteristics of Medical Illnesses  Clinical signs and symptoms  Pathologic process  Etiology Genetics Genetics Environment Environment  Alcohol/drug dependence = chronic medical illness

3 Copyright Alcohol Medical Scholars Program3 Alcohol/Drug Dependence Misconceptions  Behavior, not an illness  People can stop if they want to  BUT chronic medical illnesses have volitional components as well.

4 Copyright Alcohol Medical Scholars Program4 Overview of Lecture  Why is this important?  Dependence vs. other chronic illnesses Heritability Heritability Pathophysiology Pathophysiology Individual behaviors/cultural influences Individual behaviors/cultural influences Tx Tx Goals/strategiesGoals/strategies Adherence & outcomesAdherence & outcomes  Tx and policy implications

5 Copyright Alcohol Medical Scholars Program5 Scope of the Problem (SAMHSA, 2003; CDC, 2003; Am Diabetes Assoc, 2002)

6 Copyright Alcohol Medical Scholars Program6 Under-Treated Population Persons needing treatment 2003 (SAMHSA, 2003)

7 Copyright Alcohol Medical Scholars Program7 Other Clinical Considerations  Medical complications CardiovascularCardiovascular GIGI NeurologicalNeurological Reproductive functionReproductive function

8 Copyright Alcohol Medical Scholars Program8 Quality of Life Impact  Function/employment ↑ Unemployment, job loss & injury ↑ Unemployment, job loss & injury ↓ Job performance ↓ Job performance ↓ Productivity ↓ Productivity  Family Premature death Premature death ↓ Earnings ↓ Earnings ↑ Emotional stress ↑ Emotional stress

9 Copyright Alcohol Medical Scholars Program9 Dependence: Making the Diagnosis  Clinical interview is key  Definitions reliable  Lab tests supplement EtOH: ↑LFTs; ↑MCV; ↑ CDT EtOH: ↑LFTs; ↑MCV; ↑ CDT IVDU: Hepatitis B/C, HIV IVDU: Hepatitis B/C, HIV

10 Copyright Alcohol Medical Scholars Program10 Definitions  Abuse  Dependence

11 Copyright Alcohol Medical Scholars Program11 Abuse  Maladaptive use → impairment  ≥ 1 within 12 months: Impaired roles Impaired roles Use in hazardous situations Use in hazardous situations Legal problems Legal problems Continued use despite problems Continued use despite problems  Dependence criteria not met (DSM-IV-TR, 2004)

12 Copyright Alcohol Medical Scholars Program12 Dependence  Maladaptive use → impairment  ≥ 3 within a year: Tolerance Tolerance Withdrawal Withdrawal Larger amounts or period than intended Larger amounts or period than intended Unable to ↓ use Unable to ↓ use Excessive time spent Excessive time spent ↓ Important activities ↓ Important activities Use despite problems Use despite problems (DSM-IV-TR, 1994)

13 Copyright Alcohol Medical Scholars Program13 Patient Barriers  Lack of insight 95% with SUD don’t feel need tx 95% with SUD don’t feel need tx  Stigma Concerns will be judged Concerns will be judged Neg. experiences with MDs Neg. experiences with MDs (SAMHSA, 2003)

14 Copyright Alcohol Medical Scholars Program14 Clinician Barriers  Personal experiences → biases Negative attitudes Negative attitudes SUD in SUD in 33% of clinician relatives33% of clinician relatives ~5% med students~5% med students  Inadequate education Biases + inadequate education → reluctance to screen

15 Copyright Alcohol Medical Scholars Program15 Is Alcohol / Drug Dependence Different from Other Chronic Illnesses?  Comparison with DM, HTN, and asthma Well studied medical conditions Well studied medical conditions Effective treatments available Effective treatments available None “curable” None “curable”

16 Copyright Alcohol Medical Scholars Program16 Heritability Estimates  Chronic Medical Illnesses HTN: ~35% HTN: ~35% DM: Type I ~40%; Type II 80% DM: Type I ~40%; Type II 80% Asthma: ~55% Asthma: ~55%  SUD Heroin: 35% Alcohol: 55% Marijuana: 50%

17 Copyright Alcohol Medical Scholars Program17 Dependence Pathophysiology  Acute All drugs/EtOH All drugs/EtOH DA reward systemDA reward system Opioids/EtOH Opioids/EtOH Opioid & GABA receptorsOpioid & GABA receptors  Chronic MetabolismMetabolism Gene expressionGene expression  ? Abstinence → return to normal

18 Copyright Alcohol Medical Scholars Program18 Family/Genetics Influences Susceptibility DMHTN EtOH Dep Eating habits Salt Sensitivity EtOH metab enzymes (Braxton et al, Circulation 1996; Svetkey et al, Htn 1996; Schuckit, Am J Pyschtr 1994)

19 Copyright Alcohol Medical Scholars Program19 Personal Choice Influences Susceptibility DMHTNAsthma EtOH Dep Exercise/Lifestyle Diet & Smoking Tx Compliance

20 Copyright Alcohol Medical Scholars Program20 Overall Treatment Goals CMI = Chronic medical illness Dep = Alcohol/drug dependence CMIDep Chronic care needed Minimize symptoms/exacerbations Maximize function (physical, social and role function)

21 Copyright Alcohol Medical Scholars Program21 Treatment Strategies: Assessment & Treatment CMIDep Screening Assessment Ongoing monitoring

22 Copyright Alcohol Medical Scholars Program22 Treatment Strategies: Educating Patient/Family CMIDep Motivate lifestyle/behavior changes Prevent complications Individualize pharmacotherapy

23 Copyright Alcohol Medical Scholars Program23 Does Treatment Work? Cure? Compliance with treatment? Symptom reduction or improved function?

24 Copyright Alcohol Medical Scholars Program24 Does Treatment Work?: Compliance  Chronic medical conditions Medication 30% - ~60% Medication 30% - ~60% Behavioral/diet recommendations < 30% Behavioral/diet recommendations < 30% (Cramer, Diabetes Care 2004; Borhani et al, JAMA 1995)  Alcohol/drug dependence Medication & continued treatment ~40% Medication & continued treatment ~40% (Bouza et al, Addiction 2004; Chick et al, Br J Psychtr 1992)

25 Copyright Alcohol Medical Scholars Program25 Treating Chronic Medical Illness: Clinical Outcomes DM-II25-50% Meds &/or behav changes behav changesHospitalizedER ↓ Activity prior month HTN50% Asthma10%35%35% (Turner et al, JAMA 1999; Yurk et al, Am J Man Care 2004; Godley et al, Am J Hlth Syst Pharm 2001)

26 Copyright Alcohol Medical Scholars Program26 Treating Dependence: Clinical Outcomes  ↓ Heroin  ↓ Cocaine  ↓ EtOH Tx < 3 mo 55%55%~50% Tx ≥ 6mo ~85%~85%~80% (Hubbard et al, Psychol of Addiction 1997)

27 Copyright Alcohol Medical Scholars Program27 Treating Dependence: Non-Treatment Seeking Populations I  IVDU seeking HIV testing Testing vs. +3 motiv. interview sessions Testing vs. +3 motiv. interview sessions Intervention group Intervention group ½ Drug injection rate½ Drug injection rate 4x > Likelihood abstinence4x > Likelihood abstinence ↓ Arrest rates↓ Arrest rates (Booth et al, Drug & Alc Dep 1996)

28 Copyright Alcohol Medical Scholars Program28 Treating Dependence: Non-Treatment Seeking Populations II  Pregnant women seeking prenatal care Intervention: residential tx & SUD counseling Intervention: residential tx & SUD counseling ↓ Cocaine + urines↓ Cocaine + urines > Gestational periods> Gestational periods ↑ Infant birth wt↑ Infant birth wt ↓ Infant ICU admissions & length of stay↓ Infant ICU admissions & length of stay ↓ Tx costs↓ Tx costs (Svikis et a, Drug & Alc Dep 1997)

29 Copyright Alcohol Medical Scholars Program29 Predictors of Poor Compliance/Treatment Response CMIDep Low socioeconomic conditions Co-occurring psychiatric conditions Lack of family/social supports

30 Copyright Alcohol Medical Scholars Program30 Alcohol/Drug Dependence = Chronic Medical Conditions  Genetic susceptibility  Chronic pathophysiologic/functional changes  Risk factors influenced by choices  Similar treatment goals & strategies  Similar clinical outcomes

31 Copyright Alcohol Medical Scholars Program31 Treatment Implications  Adapt strategies similar to other common chronic medical illnesses Screening Screening Brief interventions Brief interventions Medical management Medical management Patient/family education Patient/family education Referral criteria Referral criteria

32 Copyright Alcohol Medical Scholars Program32 Implications  Medical education Amount Amount Quality Quality  Policy - Parity Continuing care Continuing care Days/visits Days/visits


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