Download Family Factors that Contribute to Alcohol Use - NOFAS

Models of Addiction
Competency #3
Midwest Regional Fetal Alcohol
Syndrome Training Center
MRFASTC
Competency 3: Models of
Addiction
• This competency applies concepts
and models of addiction to women of
childbearing age, including those
who are pregnant, to provide
appropriate prevention services,
referral, and case management.
MRFASTC
Learning Goals
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Explain past and current theories of alcohol use.
Describe the categories of alcohol use in women.
Describe stages of alcohol use/dependence/addiction
and individual interventions.
Explain the “stages of change” model in alcohol use
treatment.
Address psychiatric co-morbidities related to alcohol
use.
Recognize characteristics of alcohol dependent
families.
MRFASTC
Past and Current Models
of Alcohol Use
• Moral Model
• Sociocultural Models
• Psychological Models
• Addictive Disease Model
• Biomedical Model
MRFASTC
Past and Current Models of
Alcohol Use: Moral
• Personal choice whether to drink or
abstain.
• Individual doesn’t have the moral
strength to resist alcohol’s
temptation.
• Punishment of behavior is important.
• Blame is placed on the alcoholdependent individual.
MRFASTC
Past and Current Models of
Alcohol Use: Sociocultural
• Abuse is facilitated by society.
• Problem due to lack of economic
opportunity and positive role models.
• Treatment involves education,
economic opportunity and
reintegration back into society.
MRFASTC
Past and Current Models of
Alcohol Use: Psychological
• Heavy drinking is promoted by observing others
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and is used to numb pain or achieve pleasure.
Problem due to lack of other coping skills to
deal with stress.
Treatment involves learning positive coping
skills, reducing stressors, and resolving
emotional problems.
Conditioning model is sometimes used
(drinking is punished and abstaining is
rewarded).
MRFASTC
Past and Current Models
of Alcohol Use: Addictive
• Sometimes confused with biomedical
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model.
Promotes idea that addiction is a disease
that is progressive and curable.
Loss of control over drinking and denial of
problem are indicators of disease.
Abstinence is first step to treatment. Other
options include AA, outpatient and
residential detoxification.
MRFASTC
Past and Current Models
of Alcohol Use: Biomedical
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Most widely supported in scientific literature
Alcohol dependence is a brain disorder
Genetic and environmental basis for
dependency
Abstinence advisable but not seen as necessary
for all people with dependency
Favors harm-reduction approach, drug
substitution, craving reduction medication and
brief psychotherapy
MRFASTC
Alcoholism-Definition
• Alcoholism is a primary, chronic disease
with genetic, psychosocial, and
environmental factors influencing its
development and manifestations. The
disease is often progressive and fatal. It is
characterized by continuous or periodic
impaired control over drinking,
preoccupation with the drug alcohol, use of
alcohol despite adverse consequences, and
distortions in thinking, most notably denial.
MRFASTC
Alcoholism-Characteristics
• Alcoholism is an addictive disease
process characterized by:
 Craving
and compulsions
 Loss of control
 Continued use despite adverse
consequences
MRFASTC
Alcohol Abuse
DSM IV Criteria
• One of more of the following occurring in the past
twelve months:
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Role failure (interference with homework or school
obligations).
Risk of bodily injury.
Drinking while driving (operating machinery or
swimming).
“Run-ins” with the law (arrests or near arrests).
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Relationship trouble (with friends and family).
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• If yes to one or more, your patient abuses alcohol.
MRFASTC
Alcohol Dependency
DSM IV Criteria
Three or more of the following occurring in
the past twelve months:
• Tolerance
• Withdrawal
• Impaired control
• Drank more or
longer than intended
• Spent a lot of time
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drinking
Neglect of activities
Kept drinking
despite problems
If yes to three or more, your patient has alcohol dependency.
MRFASTC
Categories of Alcohol Use
in Women
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Statistics show that
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Over 50% of women report alcohol use
One in eight women report binge drinking
10% of pregnant women report any alcohol use; 2-4%
of them report binge drinking
Standard drink: contains about 14 grams of pure
alcohol which is equivalent to:
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One 12-ounce beer or wine cooler
One 5-ounce glass of wine
1.5 ounces of 80-proof distilled spirits
MRFASTC
Drinking Patterns and Risk
of Alcohol Dependence
1: Abstainers (0%)
2: Low-risk drinking (<1 in 100)
3: At-risk drinking (1 in 5)
4: Problem drinking (1 in 2)
5: Alcohol dependent drinking (100%)
MRFASTC
The Case
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Loretta comes to your office today to determine if she is
pregnant. She is a 28 y.o. single mom with a 6 y.o. child. She
uses alcohol, smokes, and sporadically uses marijuana.
Drinking Amount: 2-3 standard drinks (beer) per night, up
to 6 on a Saturday night.
Problems : Becomes nervous if stops drinking for more than
a day and has insomnia. Has difficulty raising her child who
has ADHD and holding down a job. No trouble with the law.
Tolerance: Takes 3 drinks to feel high, no control issues.
What is Loretta’s drinking pattern?
MRFASTC
Stages of Alcohol
Use/Dependence/Addiction
• Stage 1: Tolerance – ability to drink
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without becoming intoxicated
Stage 2: Physical dependency –
motivates the large bulk of alcoholic
drinking; drinks to alleviate symptoms
Stage 3: Major organ change – alcohol
has done measurable damage to the body
MRFASTC
Stage One: Tolerance
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Occasional use
One drug/two gateway
drugs (nicotine or
marijuana)
Tolerance
Occasional hangover
Anxiousness
Disruptive sleep
patterns
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Mild depression
Frequent
colds/infections
Reduced sexual
inhibitions
Mild tremors/shakes
Vivid dreams
Pleasant memories of
use
Occasional blackouts
MRFASTC
Stage One Tolerance:
Outside influences
• Family problems
• In trouble with the law (close calls)
MRFASTC
Stage Two: Physical
Dependency
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Daily, usually a.m. use
Variety of drugs
Increase tolerance
Withdrawal symptoms:
headache/nausea
Irritability/mood
swings/paranoia
Sleeplessness
Sexual problems
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Depression and other
psychiatric diagnoses
Intention tremor
Nightmares
Preoccupation/cravings
Development of blackout
patterns
Disease pathology
developing in major organs
MRFASTC
Stage Two Physical
Dependency: Outside
influences
•School/work problems
•DWI/DUI/unlawful possession
MRFASTC
Stage Three: Major Organ
Changes
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Maintenance use
Multiple drug
addiction
Change in tolerance
Migraines/vomiting
Mood disorders/
paranoia
Insomnia
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Suicidal ideation/attempts
Impotence
Delirium tremens
Night sweats
Compulsion/use despite
consequences
Longer more frequent
duration of memory loss
Major organ damage
MRFASTC
Stage Three Major Organ
Changes: Outside influences
 Loss
of job/family/school
 Incarceration
MRFASTC
The Case
• What stage of addiction
characterizes Loretta?
MRFASTC
Interventions: Advise and
Assist
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State your conclusions and recommendations clearly:
“I believe you have an alcohol use disorder and I strongly
recommend you quit drinking.”
Relate alcohol use to the patients concerns and medical
findings if present.
Negotiate a drinking reduction goal.
Abstinence is the safest course for patients with alcohol
abuse/dependence and pregnancy/breast feeding.
Patients who have at-risk, problem drinking or milder forms
of abuse or dependency and are unwilling to abstain may be
successful in cutting down, use a brief intervention.
MRFASTC
Interventions: Advise
and Assist
• Consider referral for additional evaluation by an
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addiction specialist, especially if the patient is
dependent.
Consider referring to a mutual help group.
For patients who are dependent, consider:
 medically managed withdrawal (detoxification)
 prescribing a medication for alcohol dependent
individuals who endorse abstinence as a goal
Arrange follow up appointments.
MRFASTC
Medications for Alcohol Use
Disorders
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Disulfiram 250-500mg po qd– Produces an unpleasant
flushing reaction when patients drink alcohol.
• Naltrexone 50mg po qd – Blocks opioid receptors that are
involved in the rewarding effects of drinking alcohol and the
craving for alcohol after establishing abstinence.
• Acamprosate 666mg po tid, 333mg po tid if renal
impairment - Probably works by reducing symptoms of
protracted abstinence such as insomnia, anxiety and
restlessness.
(Greater effectiveness is achieved if use of these agents are
combined with AA or counseling).
MRFASTC
The Case
• What treatment would you recommend
for Loretta?
MRFASTC
Stages of Change
• Stages of change model arose out of smoking
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cessation research.
Behavioral change is not a single discrete event,
but involves phases which are clearly
identifiable.
Characteristic clinician actions during each stage
can move the patient forward in the process.
Relapses are inevitable, normal and are a part
of the process.
MRFASTC
Stages of Change and
Clinician Actions
Stage-Definition
Characteristic Clinician Actions
Pre-contemplation:
not considering change
Motivate through emotional appeal to a better if change
occurs.
Contemplation:
thinking about change
Help the patient assess risks and benefits for change
and not changing in their lives.
Preparation:
planning to change
Help the patient prepare a specific behavioral plan.
Action:
actively changing
Provide support and encouragement. Help in judging
effectiveness of plan. Modify plan if not working.
Maintenance/Relapse:
trying to maintain change
Normalize relapse, assess upsetting emotional events or
mental illness, such as depression, and treat it promptly
as these emotional events are a big cause of relapse.
MRFASTC
The Case
After giving Loretta advice and assistance,
Loretta consented to a brief intervention but
found it difficult to set a drinking reduction
goal or form a plan. While she was convinced
she needed to make a change, she didn’t
know how she was going to do it given her
lifestyle. In what stage of change is Loretta
and what should the clinician do?
MRFASTC
Psychiatric Co-morbidities
• Definition: Refers to the co-occurrence of two
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disorders. Co-morbidity is often marked by
greater functional impairment and self
destruction and chronic treatment is often more
difficult.
Alcoholism is one of the most common
psychiatric disorders, with a prevalence of 8 to
14%. The most common co-morbidities among
women are anxiety and mood disorders.
MRFASTC
Psychiatric Co-morbidities
• Dis-inhibitions and feeling of sadness/irritability
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contribute to suicide attempts and completed
suicides.
Anti-social personality disorder may be
associated with alcohol-related disorders. The
presence of this diagnosis will increase the
likelihood of criminal behavior.
For adolescents, one might find conduct
disorders and repeated antisocial behavior as
well as depression and suicide, eating disorders
and hormonal imbalances.
MRFASTC
The Case
• In assessing co-morbidities the
clinician discovered symptoms of
depression in Loretta. After 3 months
of treatment with a selective serotonin
reuptake inhibitor, Loretta seemed to
put more energy into changing her
alcohol use, including joining an
Alcoholics Anonymous group.
MRFASTC
Characteristics of the
Alcohol Dependent Families
• Genetics
• Environmental family factors
MRFASTC
Role of Genetics
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Whether women drink in the first place is more
determined by environmental factors; however, genetic
factors play a larger role in determining whether alcohol
use will develop into abuse or dependency.
Genes determine how quickly alcohol metabolizes,
tolerance to alcohol, and craving for alcohol all of which
are linked to the chance of developing alcohol addiction.
An estimated 5 to 10% of female relatives and 25% of
male relatives of alcoholics will themselves develop
alcohol dependency suggesting that alcoholism can be
transmitted from generation to generation.
MRFASTC
Family Factors that
Contribute to Alcohol Use
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Stress, isolation and low self esteem in the household. One study
determined that the death of a spouse, divorce, or either a member
of the family moving in or out were three of many stressful
experiences that alcoholics have linked to need for consumption.
High levels of emotional abuse, parental alcoholism, constant
parental conflict, feeling unwanted or unloved.
A parent/caregiver’s lack of involvement or negative involvement in
the lives of their children in the formative years.
A parent’s consumption of alcohol is thought to be associated with
their child’s initiation and continuation of alcohol consumption.
MRFASTC
Characteristics of Chemically
Dependent Families
• Family members have low self esteem.
• Family rules are rigid or nonexistent.
• Blaming and defensiveness.
• Isolated family members.
• Feelings are not expressed openly or
appropriately.
MRFASTC
Characteristics of Chemically
Dependent Families
• Roles may be confused with children acting
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as parents and parents acting as dependent
children.
Stress related illness is common
Denial is present at every level.
Compulsive behaviors appear in an effort to
defend against stress or chemical
dependency.
MRFASTC
Intervention: Family Factors
• Family therapy to uncover and
change dysfunctional dynamics.
• Al – Anon for family members.
MRFASTC
The Case
The clinician uncovered Loretta’s
unhappiness with her relationship with her
boyfriend. She felt her boyfriend was not
supportive of her desire to gain control over
her addiction, as he was a very heavy drinker
also. He often bought alcohol for Loretta and
encouraged her to drink. What intervention is
indicated?
MRFASTC
Conclusion
• Alcoholism, dependency or abuse, is a chronic
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illness requiring follow up, multiple modalities of
treatment and consideration for the person’s
stage of change, co-morbidities, and family
factors.
Alcoholism, dependency or abuse, are treatable
disorders, the earlier the better.
The case: Loretta was successful in treating her
addiction, (unfortunately she had to find a new
boyfriend).
MRFASTC