Download Dependence

Heavy Drinking & Alcohol
Dependence:
Remission & Recovery
Mark L. Willenbring, MD
Director, Division of Treatment & Recovery Research
National Institute on Alcohol Abuse and Alcoholism
National Institutes of Health
Bethesda, MD, USA
[email protected]
NIAAA
Definitions

Disease, illness or disorder: a condition
characterized by failure of selfregulation of an organ or organ system,
causing clinically significant impairment
or distress, or an increased risk for
development of same.
Definitions

Remission: disappearance of the signs
and symptoms of a disease.


Partial remission: some but not all signs
and symptoms are no longer present
Full remission: all signs and symptoms of a
disease are no longer present
Definitions


Response: significant reduction in
impairment or distress in the absence of
full remission.
Non-response: no change or worsening
of impairment or distress following
treatment.
Definitions

Well-being is a measurable state
characterized by dominance of positive
over negative affect, effective coping,
social support and productive activity.
Thesis


Recovery is a condition characterized by
full remission and a state of well-being
following an episode of illness
The primary roles of the health care
system are risk reduction and treatment
of disorder with the goal of achieving
remission
Questions




Recovery from what?
Are remission and recovery different,
and if so, how?
How do we measure remission and
recovery?
What is treatment?
Questions



What are the goals of health care
services?
What is the best way to achieve these
goals?
What is the role of other institutions and
activities in society vis a vis recovery?
Recovery from what?
“Sorry,
no water. We’re just a support group.”
Do we mean…

Alcoholism: a primary, progressive,
incurable disease characterized by
craving and loss of control over
drinking, which, if not arrested, leads
inevitably to physical, psychological,
social and spiritual ruin and, ultimately,
death?
Or do we mean…

Alcohol Dependence: a disorder
characterized by impaired control over
drinking, spending increasing amounts of
time on it, use despite physical or
psychological symptoms caused or
exacerbated by it, tolerance and
withdrawal (3/7 DSM-IV criteria within a
one-year period)?
Or do we mean…

Chronic excessive alcohol use, which
increases risk for acute problems, such
as physically hazardous use and trauma,
and for end-organ damage, primarily of
the liver (fibrosis) and brain
(dysregulation of the systems regulating
pleasure, reward, motivation and
incentive salience)?
Recovery from What?
Diagnosis
Definitions

Standard drink: typical US drink containing
about 14 grams of absolute alcohol



12 oz. beer
5 oz. wine (5 drinks per bottle)
1.5 oz. shot of 80 proof spirits (11 drinks per pint
Definitions

Heavy drinking: exceeding NIAAA
recommended maximum daily limits




Men: 5+ drinks in a day
Women: 4+ drinks in a day
Regular heavy drinking: monthly or greater
Alcohol use disorder: regular heavy drinking
causing symptoms &/or dysfunction
Heterogeneity of Alcohol Use: Diagnosis
DSM-IV Abuse/Dependence
None
70%
Mild
Moderate
Severe
Chronic
(“At-risk”) (Harmful use) (Dependence) dependence
~21%
~5%
~3%
~1%
Never exceeds • Exceeds
daily limits
daily limits
• No current
sequelae
• Exceeds
daily limits
• Current
sequelae
• Daily or near
daily heavy
drinking
• Current
sequelae
• Withdrawal
• Daily or near
daily heavy
drinking
• Current
sequelae
• Withdrawal
• Chronic or
relapsing
Risk model of episodic heavy drinking
and adverse outcomes
Episodic heavy drinking
Minimum 1x/month
Usual 5-12x/month
Social dysfunction
(“abuse”)
Trauma
Acute illnesses
Risk model of regular heavy drinking
and adverse outcomes
Regular heavy drinking
Minimum 1x/week
Usual 4-7x/week
Brain disease
(addiction)
Liver disease
(fibrosis, cirrhosis)
Other adverse
outcomes –
Health & social
Prevalence of disorder (%)
Alcohol Disorders in Heavy Drinkers
Exceeds limits
weekly
Dependence with Abuse
40
35
30
Abuse Only
25
20
15
10
5
Dependence
without Abuse
0
0
50
100
150
200
250
300
350
400
Days per year exceeds daily limits
Johnson et al., The Lancet 361:1677-1685, 2003
Prevalence of disorder (%)
Alcohol Disorders in Heavy Drinkers
40
35%
35
30
25
= 57%
20
15
14%
8%
10
5
0
0
50
100
150
200
250
300
350
400
Days per year exceeds daily limits
Johnson et al., The Lancet 361:1677-1685, 2003
Prevalence of disorder (%)
Alcohol Disorders in Heavy Drinkers
40
35%
43% of daily heavy drinkers do not
35
30
meet criteria for any alcohol disorder
25
= 57%
20
15
14%
8%
10
5
0
0
50
100
150
200
250
300
350
400
Days per year exceeds daily limits
Johnson et al., The Lancet 361:1677-1685, 2003
Alcohol Dependence Syndrome
Edwards and Gross (1976). British J. of Addictions 1:1058-1061







Narrowing of the drinking repertoire
Salience of drink-seeking behavior
Increased tolerance to alcohol
Repeated withdrawal symptoms
Relief or avoidance of withdrawal symptoms by
further drinking
Subjective awareness of compulsion to drink
Reinstatement after abstinence
DSM-IV Diagnostic Criteria for
Alcohol Use Disorders (AUD)
Alcohol Abuse
1 of 4 required for a diagnosis
Alcohol Dependence
3 of 7 required for a diagnosis
 Failure to fulfill major role
 Tolerance
obligations
 Drinking in physically
hazardous situations*
 Withdrawal
 Legal problems
 Social or interpersonal
problems
 Quit control
 Larger/longer
 Neglect of activities
 Time spent to obtain, use, or
recover from alcohol use
 Continued use despite
physical/psychological problems
Does not meet the diagnostic
criteria for alcohol dependence
*Ninety percent of those diagnosed as having Alcohol Abuse endorse this criterion. Others are
20% or less (Dawson, DA. Unpublished NESARC Analysis, 2006)
An Alcohol Use Disorder Continuum Using
Item Response Theory
Quit/control
Hazardous Use
Tolerance
Withdrawal
Time spent
Social/interpersonal
Neglect roles
Activities given up
Legal problems
Saha TD, Chou SP, Grant BF (2006). Psychological Med., 36: 931-941
How Hazardous Drinking Relates to DSM-IV Alcohol
Abuse and Alcohol Dependence – A Model*
# times consuming 5+/4+ drinks per day in a week
Legal Problems
Activities Given Up
Neglect Roles
ho
D
se
U
l
e rs
d
r
iso
Time Spent Obtaining/Recovering
co
Al
Use Despite Physical/Psychological Problems
e
Withdrawal
um
ev
daily
-IV
M
S
fD
o
y
ri t
Tolerance
Inability to Quit or
Control Drinking
Larger amts./
Longer periods
u
tin
n
Co
S
of
3-4x/wk
Social/Interpersonal Problems
2x/wk
Hazardous Use
1x/wk
Graphic representation of severity of symptoms and relationship to consumption based on Saha et al., 2007. Drug
and Alcohol Dependence, doi:10.1016/j.drugalcdep.2006.12.003
Dependence
Abuse
*Based on 30% endorsement of severity criteria by current drinkers (individuals who have consumed any alcohol in a month)
Dimensional Diagnosis of AUD?
Alcohol Use Disorder
Risk Drinking
Mild
• Exceeds
daily limits
Exceeds
50+ times/yr
daily limits
<50 times/yr • No current
sequelae
Moderate
• Exceeds
daily limits
50+ times/yr
• Current
sequelae
Severe
• Daily or near
daily heavy
drinking
• Current
sequelae
• Withdrawal
Unremitting
• Daily or near
daily heavy
drinking
• Current
sequelae
• Withdrawal
• Chronic or
relapsing
Natural History, Recovery
and Relapse
Hazardous drinking peaks
between 19-25 years of age
4.5
Males
4
Females
3.5
3
Days
2.5
2
1.5
1
0.5
0
12
13
14
15
16
17
18
19
20
21
22-23 24-25 26-29 30-34 35-49 50-64
65+
Age
U.S. Substance Abuse and Mental Health Services Administration 2003 National Survey on Drug Use
and Health (NSDUH)
Prevalence of Alcohol
Dependence Peaks Early
Past-Year DSM-IV
Alcohol Dependence
14%
Onset age 21
12%
10%
8%
6%
4%
2%
0%
0
-2
8
1
4
-2
1
2
9
-2
5
2
4
-3
0
3
9
-3
5
3
4
-4
0
4
9
-4
5
4
4
-5
0
5
9
-5
5
5
Age
Grant, B.F. et al., Drug and Alcohol Dependence, 2004.
4
-6
0
6
9
-6
5
6
70
+
1st Treatment in US is 8-10 years later
Past-Year DSM-IV
Alcohol Dependence
14%
1st treatment
age 31
12%
10%
8%
6%
4%
2%
0%
0
-2
8
1
4
-2
1
2
9
-2
5
2
4
-3
0
3
9
-3
5
3
4
-4
0
4
9
-4
5
4
4
-5
0
5
9
-5
5
5
Age
Grant, B.F. et al., Drug and Alcohol Dependence, 2004.
4
-6
0
6
9
-6
5
6
70
+
Age in clinical trials is around 40
Past-Year DSM-IV
Alcohol Dependence
14%
12%
Average trial
participant
10%
8%
6%
4%
2%
0%
0
-2
8
1
4
-2
1
2
9
-2
5
2
4
-3
0
3
9
-3
5
3
4
-4
0
4
9
-4
5
4
4
-5
0
5
9
-5
5
5
Age
Grant, B.F. et al., Drug and Alcohol Dependence, 2004.
4
-6
0
6
9
-6
5
6
70
+
Heterogeneity of Course
Early onset
& recovery
Chronic &
severe
Typical
treatment
case
High
Severity
Chronic but
moderate
Low
12
18
25
32
Age
40
50
60
Subtypes of alcohol dependence





Cluster 1: Young adult
Cluster 2: Functional
Cluster 3: Intermediate familial
Cluster 4: Young antisocial
Cluster 5: Chronic severe
Moss H et al., Drug Alc Depen 2007
Subtypes of alcohol dependence
Cluster
Age DSM-IV Max # Sought
Onset Criteria drinks help (%)
1. Young adult 31.5 19.6
3.9
13.8
18.7
2. Functional
%
19.4 37.0
3.6
10.0
17.0
3. Intermediate 18.8 32.0
familial
4. Young
21.2 15.5
antisocial
5. Chronic
9.2 15.9
severe
3.7
9.8
26.9
4.7
17.1
34.4
5.4
15.4
66.0
(Moss et al., Drug Alc Depen 2007)
Subtypes of alcohol dependence
Cluster
Age DSM-IV Max # Sought
Onset Criteria drinks help (%)
1. Young adult 31.5 19.6
3.9
13.8
18.7
2. Functional
%
19.4 37.0
3.6
10.0
17.0
1/3
have
mild
self18.8 32.0
3.7
9.8
26.9
limiting course in youth
3. Intermediate
familial
4. Young
21.2 15.5
antisocial
5. Chronic
9.2 15.9
severe
4.7
17.1
34.4
5.4
15.4
66.0
(Moss et al., Drug Alc Depen 2007)
Subtypes of alcohol dependence
Cluster
Age DSM-IV Max # Sought
Onset Criteria drinks help (%)
1. Young adult 31.5 19.6
3.9
13.8
18.7
2. Functional
%
19.4 37.0
3.6
10.0
17.0
3. Intermediate 18.8 32.0
3.7
9.8
26.9
familial
4. Young
21.2 15.5
4.7
17.1
34.4
40% have later-onset,
antisocial
moderate
with 66.0
5. Chronic
9.2 15.9
5.4 form15.4
severe
psychopathology
(Moss et al., Drug Alc Depen 2007)
Subtypes of alcohol dependence
Cluster
Age DSM-IV Max # Sought
Onset Criteria drinks help (%)
1. Young adult 31.5 19.6
3.9
13.8
18.7
2. Functional
%
19.4 37.0
3. Intermediate 18.8 32.0
familial
4. Young
21.2 15.5
antisocial
5. Chronic
9.2 15.9
severe
3.6
10.0
1/3 have early
17.0
onset,
severe9.8
chronic
3.7
26.9
dependence
4.7
17.1
34.4
5.4
15.4
66.0
(Moss et al., Drug Alc Depen 2007)
Severity predicts disability
DSM-IV Diagnosis
Mean SF-12 score
Abuse
49.8
Dependence diagnosis
3 criteria +
4 criteria +
47.3
5 criteria +
47.4
6 criteria +
43.3
7 criteria +
42.3
Hasin et al., Arch Gen Psychiatry 2007
49.3
Co-morbidity clusters in subgroup
Other disorder
Other drug
dependence
Any Mood
Controlled for
+ Controlled for
sociodemographics psychopathology
18.7*
7.5
3.2
1.7
Any Anxiety
2.7
1.5
Any Personality
3.2
1.8
Hasin et al., Arch Gen Psychiatry 2007 *Odds ratios
Berkson’s Fallacy
Berkson’s Fallacy (Berkson, 1946, 1955) occurs
whenever the association between the
independent variable and the dependent variable
differs between the population from which the
sample derives and the general population.
Also known as the Clinician’s Illusion
Berkson’s Fallacy - Example


At autopsy, lower prevalence of cancer in
people with TB  led to recommendation to
infect cancer patients with TB
In fact, TB was more common in cancer cases
that went to autopsy than those that did not!
Pearl, 1929
Berkson’s Fallacy - Example



In a community sample of 2784, 257 people
were hospitalized in a 6 month period
Large positive correlation between respiratory
and locomotor diseases – connected?
They were independent – but people with both
were much more likely to be hospitalized


7-10% of people with one disorder hospitalized
29% of people with both hospitalized
Fleiss, 1981
Episodic nature of alcohol use
disorders (AUD)




>70% have one episode only
Average episode lasts 4 years or less
Those who have >1 average 5 episodes
Episodes are of decreasing length
Hasin et al., Arch Gen Psychiatry 2007
Current Status of Adults with
Prior to Past Year Dependence
Still
Dependent
25%
Dependent
25.0%
Abstainer
18.2%
Full
Remission
36%
Low risk
drinker
17.7%
Partial
remission
27.3%
Asx risk
drinker
11.8%
Partial Remission 39%
Source: NIAAA
“Natural recovery”
“Boy, I’m going to pay for
this tomorrow at yoga class”
Most change occurs “naturally”



About one-quarter of people with AUD who
recover ever receive any professional
treatment or AA exposure
13% have entered a treatment program
“All recovery is natural recovery”
– Griffth Edwards 2005
Most change occurs “naturally”

Valliant (1995) found no temporal relationship
between recovery and treatment
 Pathways to recovery included new love
relationship, substitute dependency,
coercion, & religious/spiritual involvement
 70% of those achieving abstinence did so
outside of treatment context
Natural Recovery

Treatment-seekers differ from
“natural” recoverers
 Less severe dependence; lower peak BAL
 Less co-morbidity
 Better social function and resources
(social capital)
Dawson 2005, Bischof et al. 2001, Fein & Landman 2005
Fein and Landman, 2005
Many people with SUDs remit spontaneously
70%
60%
50%
Still dependent
Partial remission
Asymptomatic drinker
Abstainer
40%
30%
20%
10%
0%
<5
5 to 9
10 to 19
20+
Interval since onset of dependence (yrs)
Dawson et al., 2004
Recurrence of any symptoms after 3
years, by length of initial remission
35
30
Percentage
25
0-4 years
5-9 years
10-14 years
15-19 years
20+ years
20
15
10
5
0
Recurrent symptoms
Dawson et al., ACER, 2007
Recurrence of dependence after 3
years, by length of initial remission
35
30
Percentage
25
0-4 years
5-9 years
10-14 years
15-19 years
20+ years
20
15
10
5
0
Dependent
Dawson et al., ACER, 2007
Recurrence of dependence after 3
years, by length of initial remission
9
8
Percentage
7
6
0-4 years
5-9 years
10-14 years
15-19 years
20+ years
5
4
3
2
1
0
Dependent
Dawson et al., ACER, 2007
Implications



Considerable heterogeneity of drinking
patterns, associated symptoms and
disability
Most heavy drinkers do not have
addiction
Most alcohol dependence is not chronic
or recurrent
Implications



We don’t understand the mechanisms of
change in drinking behavior
Most change does not include either
professional treatment or mutual help groups
Current treatment programs are not
appropriate for most people who drink too
much (and they are neither attractive nor
accessible)
Patient Preference





Most people do not like
what we offer
Information and
services need to be:
Accessible
Affordable
Attractive
What is treatment?
A highly specific, magical
transformative process than
can only occur with my help and
in my program.
treatment

A set of professional services provided for a
fee which are designed to assist individuals
with a specific disorder or risk of disorder.
Dimensional Diagnosis of AUD?
Alcohol Use Disorder
Risk Drinking
Mild
• Exceeds
daily limits
Exceeds
50+ times/yr
daily limits
<50 times/yr • No current
sequelae
Moderate
• Exceeds
daily limits
50+ times/yr
• Current
sequelae
Severe
• Daily or near
daily heavy
drinking
• Current
sequelae
• Withdrawal
Unremitting
• Daily or near
daily heavy
drinking
• Current
sequelae
• Withdrawal
• Chronic or
relapsing
Implications for a Continuum of Care
•Facilitated
Treatment Self-Change
•Brief Motivational Counseling
•Widespread availability
• Internet
Selective
Prevention
Risk Drinking
Mild
• Toll-free telephones
• Bookstores
• Schools & workplaces
Moderate
Severe
Unremitting
• Churches
• Criminal justice system
Next step
• Primary care for a Continuum of Care
Implications
• General mental health care
• Bulk of people needing treatment are here
• Pharmacotherapy Treatment
Selective
• Outpatient behavioral treatment
Prevention
• Remission oriented rehabilitation programs
Risk Drinking
Mild
Moderate
Severe
Unremitting
Implications for a Continuum of Care
Addiction SpecialtyTreatment
sector
Selective
• Fully integrated with medical
Prevention
and psychiatric care systems
• Able to manage severe
co-morbidities
• Disease management for
Risk Drinking
chronic Mild
or relapsing
disorders
Moderate
Severe
Unremitting
Community recovery support

Peer-oriented, primarily volunteer
organizations which provide a recovery
context for individuals seeking support to
initiate or sustain recovery from a disorder.
Implications for a Continuum of Care
Addiction SpecialtyTreatment
sector
Selective
• Fully integrated with medical
Prevention
and psychiatric care systems
• Able to manage severe
co-morbidities
• Disease management for
Risk Drinking
chronic Mild
or relapsing
disorders
Moderate
• Coordination with community
recovery support
organizations
Severe
Unremitting
NIAAA Clinicians Guide-2005 Edition
Updated in 2007
NIAAA Clinician’s Guide





Screening, diagnosis
Brief motivational counseling
Encourages treatment of dependence in nonaddiction program settings
Supports pharmacotherapy of alcohol
dependence
Chronic care management
The 2006 Edition of the Guide
2007 Update to the Guide
Medication management
support tools
For non-specialist
health professionals
Provides behavioral
platform for patients
receiving medications
Based on COMBINE
trial
2007 Update to the Guide
Additional online support
Dedicated web page
Patient education materials
Pre-formatted progress notes
Animated slide show for training
Interactive web training
www.niaaa.nih.gov/guide
NIAAA Research Related to Recovery



Mechanisms of Behavior Change Initiative
Research on long-term course and
identification of factors determining changes
in trajectory
Research on social context and the role of
recovery contexts
NIAAA Research Related to Recovery




Use of pharmacotherapy over longer periods
Research on chronic care management models
Research on adaptive treatment models
Research on innovative models of service
delivery
Summary




Alcohol use disorders (AUD) are common and most
typically start in adolescence and early adulthood
(although mid-life onset is not rare)
Drinking and drinking-related problems and disorders
exist on a continuum
There multiple subtypes of alcohol dependence, ranging
in age of onset, severity, co-morbidity and course
AUD are episodic illnesses; about ¾ of people with
AUD recover after one episode
Summary


Most recovery occurs without treatment or AA
For people in remission from dependence, 3year recurrence rates are lower than for treated
persons



25% have recurrence of any symptoms
5% have recurrence of dependence
Abstinence and low-risk drinking remissions
have similar rates of relapse after 3 years in
people younger than 35 years