An Introduction to Diagnosis and Treatment of Alcoholism

Marc A. Schuckit, M.D.

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Alcohol PrevalenceAlcohol Prevalence

90% Ever drank60% Current drinkers>40% Temporary problems10-20% Abuse3-10% Dependence

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YEARLY COSTS IN US$300 Billion Overall

$71 Billion Direct Costs

22,000 Deaths + 2,000,000 Injuries

4,600,000 Damaged Vehicles

15% - 25% Healthcare Budget90% of Liver Disease

72% of Pancreatitis

41% of Seizure Disorders

13% Breast CancersCopyright Alcohol Medical Scholars Program 3

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DSM-IV Dependence

1. Tolerance*

2. Withdrawal*

3. Larger amounts/longer period than intended

4. Inability to, or persistent desire to, cut down or control

5. A great deal of time spent obtaining, using, or recovering

6. Important activities given up or reduced

7. Use despite problems caused or exacerbated by use

*Dx: “with Physiological Dependence”Copyright Alcohol Medical Scholars Program 4

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DSM-IV Abuse

1. Failure to fulfill major role obligations

2. Use in hazardous situations

3. Legal Problems

4. Use despite problems

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Alcoholism Natural HistoryAlcoholism Natural HistoryEvent Age1st drink 131st drunk 151st problem 181st dependence 25-40Death 60

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Alcoholism CourseAlcoholism Course

•Fluctuating:controlled useproblemsabstinence

•20% spontaneous remission

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Dual Diagnosis

2/3 Have Psych. Dx

1/3 Axis I

Most are Substance Induced Disorders

Schiz., MDD, ASPD Risk

Use a Timeline

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TIMELINE

B 40

Age Onset Dependence

Ages 3+ mo. Abstinence

Ages of Major Disorder

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Ask All Patients About Problems In:

•Relationships•School or job•Accidents•Arrests•Health

THEN tie in substances

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State MarkersState Markers•GGT > 30

•MCV > 91

•CDT < 20

•+UA; Lipids; etc.

•Questionnaires:

MAST

CAGE

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POSSIBLE BRIEF SELF-ADMINISTERED QUESTIONNAIRES FOR SCREENING

ALCOHOL PROBLEMS

1. 4 Item CAGE

2. 5 Item TWEAK

3. 25 Item Michigan Alcohol Screening Test (MAST)

4. 10 Item Alcohol Use Disorders Identification Test (AUDIT)

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Stages of Treatment Identification

Detoxification

Physical exam and history

Vitamins

Reassurance

+ Benzodiazepines

Rehabilitation

Enhance motivation

Help readjust to life

Relapse Prevention

+ Medications

Aftercare

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WithdrawalWithdrawal

Autonomic dysfunction - Insomnia - Anxiety

Autonomic dysfunction - Insomnia - Anxiety

* Begin 8+ hours

* Peak at day 2

* Diminish at day 5

* Disappear 3 - 6 months

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Treatment of WithdrawalTreatment of Withdrawal

Physical examination

Supports

Vitamins

CNS depressants

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RehabilitationRehabilitation

Increase motivation

Help rebuild life

Relapse Prevention

+/- medications

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Alcohol Rehab

? Naltrexone

? Acamprosate

? Disulfiram

? SSRI

? Buspirone

Not:

LI, Anti-depressants, Other

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GENETICS

Familial

MZ > DZ

4x Risk, Even if Adopted

LR Predicts Risk