Alcohol:

What’s the problem?

Professor Colin Drummond

Institute of Psychiatry,

Kings College London

Topics

• What causes alcohol problems?

• Alcohol dependence

• Conclusions

Alcohol is a toxic and dependence

producing DRUG • Acute effects

– Highly variable

– Pleasure, relaxation

– Impaired judgement, coordination, balance

– Mood effects

– Argumentativeness and aggression

– Drowsiness

– Impaired consciousness

– Coma, respiratory depression and death.

• Chronic effects

– Toxic effects on organs

– Over 60 diseases

– Psychiatric disorders

– Foetal alcohol effects

– Psychoactive effects: alcohol dependence

– 3rd leading cause of disability after tobacco and hypertension

– No universally “safe” level

What causes alcohol

problems?

What is a “unit” of alcohol?

• 8g ethanol

• 1/2 pint beer (3%)

• 1 measure spirits (25ml)

• 1/4 pint strong lager (6%)

• 1 litre of spirits = 40 units

• 1 bottle of wine = 9 units

• 1 can of very strong lager (9%) = 4 units

“Safe” and “harmful” levels

• “Safe”

- men < 21 units per week

- women < 14 units per week

• “Harmful”

- men > 50 units per week

- women > 35 units per week

Royal College of Psychiatrists, 1986

• Daily limits 4/3 units

Department of Health, 1995

What causes problems? Acute

effects

• Impaired judgement

• Disinhibition

• Aggressiveness

• Loss of coordination

• Drowsiness

• Coma

• Alcohol poisoning

BLOOD ALCOHOL CONCENTRATION AND EFFECTS

AMOUNT BLOOD ALCOHOL EFFECT

(mg/100ml)

1 PINT BEER 30 INCREASED

DOUBLE WHISKY ACCIDENT RISK

1.5 PINTS 50 CHEERFULNESS

3 WHISKIES IMPAIRED JUDGEMENT, DISINHIBITION

2.5 PINTS 80 LOSS OF DRIVING LICENSE

5 WHISKIES (IF CAUGHT)

5 PINTS 150 LOSS OF SELF CONTROL

10 WHISKIES QUARRELSOMENESS, SLURRED SPEECH

6 PINTS 200 STAGGER, DOUBLE VISION

1/2 BOTTLE WHISKY BLACKOUTS

9 PINTS 400 OBLIVION, DROWSINESS,

3/4 BOTTLE WHISKY COMA

12 PINTS 500 DEATH POSSIBLE

1BOTTLE WHISKY DEATH LIKELY AT 600+

What causes problems?

Chronic effects

• Tissue damage

• Chronic effects on the brain

• Psychiatric comorbidity

• Relationships (inc. marital and parenting)

• Loss of employment

• Financial problems

• Alcohol dependence

South West London comorbidity

study McCloud, Drummond, Barnaby, Omu, Burns, 2004

• 200 consecutive admissions to 2 psychiatric hospitals

• Screened with AUDIT

• 49% AUDIT 8+, 53% of males, 44% of females

– Psychosis OR 0.2

– Mood disorder OR 2.1

– Non-SMI OR 6.5

• Suicidal presentation:

– AUDIT 8+ OR 3.0

– AUDIT 15+ OR 7.8

• Full alcohol history 0.5%, partial history 27%

The Alcohol Dependence Syndrome

Edwards & Gross, 1976

• Narrowing of drinking repertoire

• Salience of drink seeking behaviour

• Increased tolerance

• Repeated withdrawal symptoms

• Relief or avoidance of withdrawal

• Subjective awareness of compulsion to drink

• Reinstatement after a period of abstinence

Dependence syndrome Edwards & Gross, 1976

• Special kind of problem related to drinking

• Conceptually distinct from other problems

related to drinking

• Dimensional rather than categorical

• Clustering of symptoms not all of which

are invariably present

• Has at its basis an altered drive state

• Underlying processes

Aetiology of alcohol dependence

• Genetics

• Social learning

• Expectancy

• Stress

• Exposure: peer group, occupational, availability, price

• Conditioning: classical, reinforcement

• Neurobiology: dopamine, opioid, HPA

Falling blood

alcohol level

(US)

Withdrawal

symptoms

(including craving)

(UR)

Alcohol cues

(e.g. sight and

smell of favourite

drink)

(CS)

Conditioned

withdrawal

(including craving)

(CR)

Conditioning model of alcohol cue reactivity

Drummond, Cooper & Glautier, 1990

Drug-paired

stimuli

Positive

affect

Negative

affect

Urges

Positive

outcome

expectancies

Physiological

activation

Self

efficacy

Drug

use

Coping

Attributions

+

+

+

+

+

+

+

- -

-

-

Dynamic regulatory model of craving and relapse

Niaura, 2000

Prevalence of Past-year DSM-IV Alcohol

Dependence by Age – United States

0%

2%

4%

6%

8%

10%

12%

14%

12-17

18-20

21-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

Age

%

Pre

va

len

ce

18 + yrs. - NIAAA NESARC ( Grant, et al., (2004) Drug and Alcohol Dependence, 74:223-234)

12-17 yrs - U.S. Substance Abuse and Mental Health Services Administration 2003 National

Survey on Drug Use and Health (NSDUH)

Prevalence of Past-year DSM-IV Alcohol Dependence

by Age in the United States

Source: NIAAA 2001-2002 NESARC data (18-60+ years of age)

and SAMHSA 2003 NSDUH (12-17 years of age)

Prevalence of Lifetime Alcohol Dependence by Age of First Alcohol Use and Family History of Alcoholism

2001-2002

0

10

20

30

40

50

60

=21

1991-1992

0

10

20

30

40

50

60

13 14 15 16 17 18 19 20 21

Parental History Positive

Total

Parental History Negative

% P

revale

nce

Age at First Use of Alcohol

Prevalence of Lifetime Alcohol Dependence by Age of

First Alcohol Use and Parental History of Alcoholism

Source: NIAAA 1991-1992 NLAES data (left panel) and

NIAAA 2001-2002 NESARC data (right panel)

What is the outcome?

• In the young and minimally dependent: up to

80% improvement

• In dependent drinkers

- Short term (1 year): relapse common, up to 90% any drinking, 70% reinstatement

- Long term (20 years): 40% dead (3.6 fold increase, most

in 45-55 year age group), 30% continuing problems,

30% abstinent or problem free

- Most deaths due to chest & heart disease, excess of

injury and poisoning

Conclusions

• Alcohol is a toxic and dependence producing drug

• It has individually variable effects

• There is no universally “safe” level

• Major and growing public health problem

• Considerable health, criminal justice, and other costs

• Need for effective strategies, including better early intervention