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Chapter 15: Alcohol Use Disorders Lara A. Ray Kelly E. Courtney Guadalupe A. Bacio Prevalence of Alcohol Use Alcohol is third largest risk factor for disability and disease 90% of U.S. adults report consuming alcohol Alcohol abuse: 4%-5% prevalence Alcohol dependence: 3.8% point prevalence; 12.5%-14% lifetime 8.5% of U.S. adults (17.6 million) suffer from AUDs in given year Higher prevalence of dependence among males Highest prevalence of abuse and dependence in 18-29 age group Highest risk for lifetime alcohol abuse in older cohorts (30-65) In past decade, 12 month prevalence of dependence has declined and prevalence of abuse has increased Economic cost of abuse and dependence in 1998 = $184.6 billion History Perspectives on Alcohol Use Mid-1930s: Alcohol legalized in U.S. Societal and political views on alcohol consumption have varied considerably since then: 1960s and early 1970s: Drug-friendly culture End of 20th century: Increased public concerns about heavy alcohol and drug use, underage drinking, deaths from drunk driving, alcoholrelated deaths on college campuses Two approaches to deal with alcohol use: 1. Conservative with focus on punishment 2. Liberal with focus on reducing harm Treatment modalities have also shifted over the years Self-Help Approaches Alcoholics Anonymous (1935): First community-based approach offering free peer-delivered group treatment First to combine religion, medicine, help of sponsors Criticisms: Spiritual, powerlessness, abstinence, discourages use of meds Now: 100,000 groups; 150 countries; 2 million members Research evidence from RCTs More rational, humanistic approaches developed, focusing on cognitive-behavioral principles and self-empowerment Rational Recovery (RR), Moderation Management (MM), Self- Management and Recovery Training (SMART) More limited research Due to low cost and accessibility, self-help approaches likely to remain core part of treatment, but more research needed Treatment Approaches Throughout past 20 years, treatments evolved primarily from two major approaches: 1. Rehabilitation (e.g., employee assistance programs, education classes) • Belief that treatment better alternative to punishment and will increase chances of returning to baseline of productive functioning 2. Harm-reduction • Belief that human beings will continue to engage in behaviors that are potentially dangerous • Goal to reduce intake and minimize harm by providing individuals with safer ways to engage in such risky behaviors (e.g., designated drivers) • Widely debated, but research support for use in treatment and prevention Treatment Goals Continuing debate between abstinence and moderation as treatment goals 1. Abstinence: Standard clinical practice in U.S. 2. Moderation/controlled drinking: Alternative to abstinence May be more appropriate for certain cases (e.g., less severe, younger, no family history, less impaired control over drinking) Some evidence for better outcomes when clients choose their treatment goals One study found abstinence goal > conditional abstinence > controlled drinking But, treatment x drinking goal interaction History of Diagnosis of AUDs Personality disorder in DSM-I (“addictive personality”) (1952) Then (1976), shift to focusing on impact of substances on person’s life and functioning DSM-III (1980) First time specific diagnostic criteria Added abuse vs. dependence distinction DSM-III-R (1987) and DSM-IV (1994) More concrete operational criteria, increased reliability of diagnosis Changes to withdrawal and tolerance criterion (DSM-III required one) DSM-IV tolerance and withdrawal as sufficient but not necessary Substance-Related and Addictive Disorders Uses Alcohol Use Disorder (AUD) for prior abuse and dependence diagnoses Adds Gambling Disorder, Cannabis Withdrawal and Caffeine Withdrawal Eliminates polysubstance dependence and physiological subtype New specifiers indicate if: in a controlled environment or on maintenance therapy Early remission is 3 to 12 months; Sustained remission is more than 12 months ( both without meeting full criteria but not counting the craving symptom) DSM-5 Criteria for Alcohol Use Disorder (AUD) Mild = 2 to 3 symptoms; Moderate = 4 to 5 symptoms; Severe= 6 to 11 symptoms (within a 12 month period) Includes DSM-IV criteria for alcohol abuse Recurrent alcohol use resulting in a failure to fulfill major role obligations Recurrent alcohol use in situations in which it is physically hazardous. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. DSM-IV criteria for alcohol dependence Tolerance Withdrawal Alcohol is often taken in larger amounts and/or over longer periods of time Persistent desire or unsuccessful efforts to stop or cut down alcohol use. Increased amount of time is spent consuming, obtaining, or recovering Important occupational, social, or recreational activities are given up/reduced Alcohol consumption continues despite the knowledge of having persistent or recurrent physiological and psychological problems AUDs Cross-Culturally Patterns of alcohol use and misuse vary cross-culturally U.S. high-risk subgroups: Whites, Native Americans, males Lower risk for immigrants (“immigrant paradox”) Observed cross-cultural differences in drinking patterns may be due to cultural factors (e.g., attitudes toward drinking, role of family, gender roles, alcohol expectancies) Typologies for cultural views towards drinking: “Wet” vs. “dry” cultures 2 axes: (1) engagement with alcohol; (2) serious drinking Temperance vs. nontemperance cultures Recent directions: Mediators and moderators of relationship between culture and alcohol use; cultural influence on cognitive factors (e.g., expectancies); other cultural factors (e.g., role of family) Developmental Considerations Alcohol use typically starts in early adolescence Starting to drink before age 15 increases risk for later dependence Escalates during late adolescence (ages 16-20) Period of highest risk for developing AUDs By 12th grade, 72% of adolescents report ever drinking; 55% getting drunk; 25% binge drinking in past 2 weeks College students: 44% binge drinking; 25% AUD in past 12 months Gender differences emerge in late adolescence/early adulthood Risk factors for drinking in adolescence: Peer (e.g., substance- using peers) and family contexts (e.g., decrease in parental monitoring) Need to develop prevention programs to delay drinking initiation Theory Biopsychosocial Model Psychosocial and biological factors interplay in the development of the complex, heterogeneous phenomenon known as AUDs (Psychosocial: Personality, environmental variables) (Biological: Genetics, neurobiology) Diverse pathways to diagnosis Phenotypic complexity of alcoholism = diverse symptom presentations Psychosocial Factors Expectancy theory: Information reflecting alcohol’s reinforcement value stored as memory templates when templates activated affective experience triggered can influence behavior Widely studied and empirically supported theory of alcohol misuse Tension-reduction theory: Individuals drink alcohol because of its ability to reduce tension Stress-response dampening (SRD) effects of alcohol Certain contextual differences moderate effects of alcohol on tension (e.g., hostility, anxiety sensitivity, heightened stress reactivity) Psychosocial Factors Personality theory: Personality traits account for some of variance in vulnerability to AUDs, but no support for “alcoholic personality” Proposed clinical subtypes (sets of personality characteristics): • Type 1 and Type 2 alcoholics • Type A and Type B alcoholics Also, specific personality traits relevant to risk for alcoholism Impulsivity/disinhibition (particularly impulsive decision making) Starting to integrate this research with behavioral genetics, cognitive neuroscience, stress and coping, physiological responses to alcohol, and developmental theories Psychosocial Factors Social learning theory (SLT) focuses on three aspects of behavior: 1. 2. Social-environmental: Situational factors paired with drinking (triggers) Coping skills: Ability to cope with stressful events without drinking • CBT skills building: Refusal skills, coping with urges and negative feelings 3. Cognitive factors: Self-efficacy and alcohol expectations SLT applied to relapse process: Lapses from poor coping skills in high-risk situations low self-efficacy regarding ability to cope expectancies that drinking is an effective coping strategy in future situations Dynamic interplay between distal and proximal risk factors in determining relapse (Marlatt-Witkiewitz model) • Distal: Less active coping efforts, lower self-efficacy, higher craving, less self-help group and treatment participation • Proximal: Personal characteristics and experiences Biological Factors Multiple neurotransmitter systems underlying pharmacological and behavioral effects of alcohol Mesolimbic dopamine activation: Alcohol consumption and cue exposure increase dopamine activity in the nucleus accumbens Psychostimulant theory of addiction: Stimulant effects of addictive substances produce positive reinforcement Individuals who experience greater rewards from alcohol more likely to develop problems Shift to models focusing on incentive salience (i.e., craving) Acquisition and sensitization of craving for alcohol produced by repeated ingestion and associated dopamine release After pathways sensitized, craving can be activated by the dopamine release initiated in response to alcohol cues or priming doses Biological Factors Allostatic model of dependence: Integrates neurobiology of rewarding effects of alcohol with mechanisms related to negative reinforcement (e.g., alcohol withdrawal, influence of stress) Reward and stress circuits become dysregulated with repeated alcohol exposure Clinical neuroscience of addiction: Insights from neuroscience are being incorporated into clinical research and practice Still need more research to effectively translate these findings to patients suffering from alcoholism Behavior genetics: 50% to 60% heritability (twin and adoption studies) Some phenotypes heritable (e.g., alcohol sensitivity, metabolism) Recent interest in identifying endophenotypes No single gene likely to fully explain genetic liability Treatment Treatment: Overview 700,000 alcoholics receive treatment every day Residential/inpatient intensive outpatient programs 85% of individuals who meet lifetime criteria for AUD never receive formal treatment or participate in self-help groups Most common modalities: Detoxification, behavioral treatments (e.g., AA), pharmacotherapy, brief primary care interventions Psychosocial intervention more common than pharmacotherapy Most approaches highly eclectic, have not been evaluated for efficacy Many with empirical support, but none highly successful Attempts to identify specific patient characteristics that might predict response to a particular treatment Project MATCH: Only 4/21 variables found to improve outcome (e.g., anger, social networks) Psychosocial Treatments Psychosocial Treatments Pharmacological Treatments Often used to manage withdrawal symptoms Few community programs combine meds and psychosocial treatment Few effective medication options FDA-approved for alcohol dependence: Disulfiran (Antabuse), acamprosate, vivitrol Naltrexone: Most studied; some evidence reduces drinking days and lower rates of relapse, but inconsistent Ondansetron: 5-HT3 antagonist; reduction of drinking among early-onset alcoholics; mechanism unknown Topiramate: Anticonvulsant; reduced drinking and craving; mechanism unclear Quetiapine and olanzapine: Reduce craving by targeting mesolimbic DA Pharmacological Treatments: Future Directions Identify psychosocial predictors of medication compliance and efficacy Expand knowledge of dosing issues Improve the dissemination of research findings to practicing clinicians Examine the combined effects of psychosocial and pharmacotherapy treatments Investigate the role of genetic factors in predicting treatment response to pharmacotherapies as one way to potentially match patients to treatments COMBINE Project Looked at different combinations of meds and psychotherapies Naltrexone, acamprosate, placebo Combined behavioral intervention (CBI) or medication management (MM) MM with naltrexone, CBI, or both most effective Investigated whether Asn40Asp SNP in the mu opioid receptor gene predicted clinical response to naltrexone (an opioid antagonist) Better response to MM and naltrexone for Asp40 than Asn40/Asn40 carriers Consistent with other findings: Stronger hedonic response to alcohol in Asp40 carriers Naltrexone attenuates rewarding effects of alcohol more strongly among Asp40 carriers Example of pharmacogenetics allowing for more personalized medicine Summary and Future Directions Summary AUDs are multifaceted in their etiology, maintenance, and relapse processes Biopsychosocial model: Alcohol pathology results from interplay between biological and psychosocial variables Increased understanding of biological and psychological factors used to inform DSM-5 and guide treatment development Individuals develop AUDs through multiple pathways, and different factors may maintain the disorder or lead to relapse Various historical, cultural, developmental, diagnostic, theoretical, and treatment considerations Current recovery rates modest Future Directions Future progress hinges on ability to capture the complexity of AUDs (e.g., multiple pathways) Research and clinical work needed to integrate various aspects of the biopsychosocial model to capture this complexity Role of clinical neuroscience and translational science Role of clinical scientists and practitioners in advancing understanding of mechanisms of alcoholism and other addictive/complex behaviors Merge understanding of phenomenology of addiction and psychopathology with neural findings