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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