Alcohol The Way You Define the Problem Influences Your Solution Daniel W. Hungerford, DrPH Webinar National SBIRT ATTC March 9, 2016

What is framing?

Agent Environment Host Epidemiologic Triad

alcohol laws, culture drinkers Epidemiologic Triad

1870 to 1920

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1920 to 1935

1935 to 2016

1948 Science Enters the Picture

1948 First published randomized clinical trial ~ 1964Early indications that BIs may work ~ 1965First population studies (a.k.a. Epidemiology) 1970NIAAA established 1977First true brief intervention studies

IOM Report 1990

1. community-based interventions ► public health screening ► multiple settings ► brief interventions ► referral to specialized treatment 2. specialty treatment ► severe problems ► prior history of dependence, ► comorbidity (liver damage, mental illness) Two-part IOM Treatment System

lifetime abstinence current abstinence low risk drinking excessive drinking harmful drinking dependence symptoms addiction Spectrum of Use and Misuse intoxication

The Drinker’s Pyramid

Types of Drinkers Addicted Low- Risk Risky/Harmful 4% 25% 71%

Alcoholism isn’t what you think it is. 70% with a dependence diagnosis have one episode of less than 4 years. Not chronic for them. About 75% of them recover fully. And about half of that group still drinks at low-risk levels 75% of those who recover do so without any kind of help Only 13% ever receive any specialty treatment

Epi Summary 1 Results Alcohol dependence: 4% of population Most recover without help, do not relapse, and many continue to drink, symptom free at low-risk levels. Implications Specialty treatment: unnecessary and inappropriate for most?

Epi Summary 2 Results 25% of population: drinking too much, not alcoholic. 6 nonalcoholic heavy drinkers per alcoholic Implications Focusing on alcoholics can solve just a small part of the problem.

My Forehead-smack Reframe lifetime abstinence current abstinence low risk drinking excessive drinking harmful drinking dependence symptoms addiction intoxication Addicted Low- Risk Risky/Harmful 4% 25% 71%

drinking too much too much in a single day too much in a week Drinking Too Much: 2 Types intoxication repeated toxic exposure to cells/tissues

too much in a single day acute effects intoxication cognitive function coordination risk taking too much in a week chronic effects repeated toxic exposure cell and tissue damage 2 Types with Different Outcomes

too much in a single day acute effects intoxication cognitive function coordination risk taking too much in a week chronic effects repeated toxic exposure cell and tissue damage 2 Types with Different Outcomes

too much in a single day acute effects intoxication cognitive function coordination risk taking too much in a week chronic effects repeated toxic exposure cell and tissue damage 2 Types with Different Outcomes

chronic effects acute effects fetal alcohol spectrum disorders medication interactions burns falls drowning motor vehicle crashes pedestrian injuries loss of consciousness alcohol poisoning assaults intimate partner violence child abuse property crimes suicide homicide risky sex cancer cirrhosis liver failure pancreatitis gastritis addiction hypertension cardiovascular disease neurologic damage weight gain

acute effects burns falls drowning motor vehicle crashes pedestrian injuries loss of consciousness alcohol poisoning assaults intimate partner violence child abuse property crimes suicide homicide risky sex

chronic effects cancer cirrhosis liver failure pancreatitis gastritis addiction hypertension cardiovascular disease neurologic damage weight gain

chronic effects acute effects fetal alcohol spectrum disorders medication interactions

† Adapted by D Hungerford from: Cole S, Bogenschutz M, Hungerford D (2011). Motivational interviewing and psychiatry: use in addiction treatment, risky drinking and routine practice. FOCUS, 9: †People regularly drinking over the daily limit may experience both acute and chronic effects. †† Alcohol is toxic to human cells at relatively low levels. drinking too much too much in a single day too much in a week chronic effects acute effects burns falls drowning motor vehicle crashes pedestrian injuries loss of consciousness alcohol poisoning assaults intimate partner violence child abuse property crimes suicide homicide risky sex cancer cirrhosis liver failure pancreatitis gastritis addiction hypertension cardiovascular disease neurologic damage weight gain intoxication repeated toxic exposure †† cognitive function coordination risk taking cell and tissue damage fetal alcohol spectrum disorders medication interactions Drinking Too Much: Acute and Chronic Health Effects

What is the fundamental problem with alcohol? Prevailing View: Alcoholics are the problem. Reframe: Drinking too much is the problem.

My years with the Prevailing Paradigm Just get them into treatment. Just lower the bar for treatment. “He works with alcoholics.” This will never work with alcoholics. We don’t have anybody to refer to. This isn’t medicine; it’s mental health or SA treatment. I didn’t know CDC worked on alcohol.

People need to know how much is too much. The Next Step And believe it. Health professionals should lead the way.