The Nature of AddictionThe Nature of Addiction

… … and the power of interventionand the power of intervention

September 1st, 2005September 1st, 2005Barry M. Rosen, M.D.Barry M. Rosen, M.D.

The Sequoia CenterThe Sequoia Center

Nature of Addiction

Loss of controlLoss of control Harmful ConsequencesHarmful Consequences Continued Use Despite ConsequencesContinued Use Despite Consequences DenialDenial

Use – Abuse - Addiction

Spectrum of disordersSpectrum of disorders Predictable with genetic predispositionPredictable with genetic predisposition Otherwise emerges like the rest of life Otherwise emerges like the rest of life

. . . in the rear view mirror. . . in the rear view mirror Petroleum dependence is good analogy for Petroleum dependence is good analogy for

developmental process of addictiondevelopmental process of addiction

Understanding the disease

BPSS: BPSS: Bio-Psycho-Social-Spiritual ModelBio-Psycho-Social-Spiritual Model

Bio-Psycho-Social-Spiritual Model

Four Unique Dimensions of LifeFour Unique Dimensions of Life Each with defining hungerEach with defining hunger Each restructured by addictionEach restructured by addiction Each with a scientific applicationEach with a scientific application Each with a mystery beyond knowledgeEach with a mystery beyond knowledge Each with info about loss of controlEach with info about loss of control

Why do people continue to drink Why do people continue to drink and use despite profound and use despite profound consequences?consequences?

Why the loss of control?Why the loss of control?

The Main Inquiry…

Biological Lens … hunger for food & sex

Genetic predispositionGenetic predisposition

• Animal Breeding StudiesAnimal Breeding Studies

• Adoption and Twin StudiesAdoption and Twin Studies

• Family Tree StudiesFamily Tree Studies

Biologic Lens continued

Neurotransmitters shiftsNeurotransmitters shifts

• Dopamine & Reward PathwaysDopamine & Reward Pathways

• Serotonin & Appetitive BehaviorsSerotonin & Appetitive Behaviors

• Opiates & Mood RegulationOpiates & Mood Regulation

• GABA, Glutamate (NMDA), other GABA, Glutamate (NMDA), other neuropeptides & kinasesneuropeptides & kinases

CRFCRF

Homeostasis Homeostasis & &

AllostasisAllostasis

Case Presentation

64 y.o. eastern European woman with no 64 y.o. eastern European woman with no family hx of etoh, using alcohol to manage family hx of etoh, using alcohol to manage benign essential tremors, sent for benign essential tremors, sent for consultation she went into DT’s post-op. consultation she went into DT’s post-op. Family brought her in for treatment.Family brought her in for treatment.

Biological Lens

Take home points-Take home points- Pre-addicts are different biologicallyPre-addicts are different biologically Addicts are “normal” under the influenceAddicts are “normal” under the influence Using gets hooked to primal needsUsing gets hooked to primal needs

Psychological Lens… hunger for love

Complex Denial systemComplex Denial system

Shame, Guilt, Self-Hatred, Acting-OutShame, Guilt, Self-Hatred, Acting-Out

Personality ChangesPersonality Changes

The Question of “Underlying Disorders”The Question of “Underlying Disorders”

Subtle Denial Stunts

““I’m a functioning alcoholic …”I’m a functioning alcoholic …”

Q: “Is your dad an addict?”Q: “Is your dad an addict?”

A: “He’s a functioning addict.”A: “He’s a functioning addict.”

Co-morbidity

Psychiatric DisturbancesPsychiatric Disturbances(esp. Axis II character disorders)(esp. Axis II character disorders)

Concurrent Pain Disorders/HIVConcurrent Pain Disorders/HIV

Co-Morbid EnvironmentCo-Morbid Environment

Psychological Lens

Denial Denial An essential coping strategyAn essential coping strategy

Protects one from the painful core of Protects one from the painful core of shameshame

Protects one from the Protects one from the workwork of recovery of recovery

Case

46 y.o. man with 10 yrs off alcohol, drinks 46 y.o. man with 10 yrs off alcohol, drinks glass of champagne with new girlfriend @ glass of champagne with new girlfriend @ brother’s 50brother’s 50thth birthday party. Over 2 months birthday party. Over 2 months drinking increases as he tells himself he’ll drinking increases as he tells himself he’ll stop as soon as he has any problems. stop as soon as he has any problems. Drinking 1 qt daily for 12 months and Drinking 1 qt daily for 12 months and presents with hemorrhagic pancreatitis.presents with hemorrhagic pancreatitis.

Take home points

Addicts are structurally different Addicts are structurally different psychologicallypsychologically

BPSS modelBPSS model

Social Lens … hunger for family, clan, culture

Cultural Pressure to useCultural Pressure to use

Family systems dynamicsFamily systems dynamics

Co-AddictionCo-Addiction

Systemic Denial Systemic Denial

Case Presentation

31 y.o. man with abdominal pain, elev. 31 y.o. man with abdominal pain, elev. LFT’s, triglycerides of 27,000, diagnosed LFT’s, triglycerides of 27,000, diagnosed with hyperlipidemic induced pancreatitis with hyperlipidemic induced pancreatitis who came to tx after continuing his 1 qt. who came to tx after continuing his 1 qt. Daily intake of vodka.Daily intake of vodka.

Take home points

Using behavior is socially normativeUsing behavior is socially normative

Family and friend system unconsciously Family and friend system unconsciously accommodates to the dysfunctionaccommodates to the dysfunction

There are social levels of resistance to There are social levels of resistance to change (which has been labeled co-change (which has been labeled co-addiction or co-dependency)addiction or co-dependency)

Spiritual Lens… hunger for meaning and purpose

SpiritualitySpirituality Hunger for meaning, purpose and Hunger for meaning, purpose and

possibilitypossibility Distinct from religionDistinct from religion The organizing principle of lifeThe organizing principle of life

Spirituality’s impact on treatment

The treatment process offers:The treatment process offers: New hope and possibilityNew hope and possibility

Experiencing of caring and loveExperiencing of caring and love

Life beyond the senses Life beyond the senses

Oriah Mountain Dreamer, an Indian Elder

It doesn't interest me what you do for a It doesn't interest me what you do for a living. I want to know what you ache for, living. I want to know what you ache for, and if you dare to dream of meeting your and if you dare to dream of meeting your heart's longing. heart's longing.

It doesn't interest me how old you are. I want It doesn't interest me how old you are. I want to know if you will risk looking a fool for to know if you will risk looking a fool for love, for your dream, for the adventure of love, for your dream, for the adventure of being alive. being alive.

It doesn't interest me what planets are It doesn't interest me what planets are squaring your moon. I want to know if you squaring your moon. I want to know if you have touched the center of your own have touched the center of your own sorrow, if you have been opened by life's sorrow, if you have been opened by life's betrayals or have become shriveled and betrayals or have become shriveled and closed from fear of further pain. I want to closed from fear of further pain. I want to know if you can sit with pain, mine or your know if you can sit with pain, mine or your own, without moving to hide it or fade it or own, without moving to hide it or fade it or fix it. fix it.

I want to know if you can be with joy, mine or I want to know if you can be with joy, mine or your own, if you can dance with wildness your own, if you can dance with wildness and let the ecstasy fill you to the tips of and let the ecstasy fill you to the tips of your fingers and toes without cautioning us your fingers and toes without cautioning us to be careful, to be realistic, to remember to be careful, to be realistic, to remember the limitations of being human. the limitations of being human.

It doesn't interest me if the story you are It doesn't interest me if the story you are telling me is true. I want to know if you can telling me is true. I want to know if you can disappoint another to be true to yourself; if disappoint another to be true to yourself; if you can bear the accusation of betrayal and you can bear the accusation of betrayal and not betray your own soul, if you can be not betray your own soul, if you can be faithfull and therefore be trustworthy. faithfull and therefore be trustworthy.

  

I want to know if you can see beauty, even when it's I want to know if you can see beauty, even when it's not pretty, every day, and if you can source your not pretty, every day, and if you can source your own life from its presence. I want to know if you own life from its presence. I want to know if you can live with failure, yours and mine, and still can live with failure, yours and mine, and still stand on the edge of a lake and shout to the silver stand on the edge of a lake and shout to the silver of the full moon, "Yes!" of the full moon, "Yes!"

  

It doesn't interest me to know where you It doesn't interest me to know where you live or how much money you have. I live or how much money you have. I want to know if you can get up, after want to know if you can get up, after the night of grief and despair, weary the night of grief and despair, weary and bruised to the bone, and do what and bruised to the bone, and do what needs to be done to feed the children. needs to be done to feed the children.

It doesn't interest me who you know or how you It doesn't interest me who you know or how you came to be here. I want to know if you will stand came to be here. I want to know if you will stand in the center of the fire with me and not shrink in the center of the fire with me and not shrink back. back.

  It doesn't interest me where or what or with whom It doesn't interest me where or what or with whom you have studied. I want to know what sustains you have studied. I want to know what sustains you, from the inside, when all else falls away.you, from the inside, when all else falls away.

I want to know if you can be I want to know if you can be alone with yourself and if you alone with yourself and if you truly like the company you keep truly like the company you keep in the empty moments. in the empty moments.

Questions about Questions about

Bio-Psycho-Social-SpiritualBio-Psycho-Social-Spiritual Model? Model?

Brief Intervention Brief Intervention What does it entail?What does it entail?Does it work?Does it work?

Brief Intervention

Brief intervention strategies have been Brief intervention strategies have been studiedstudied

They workThey work They are more effective than doing nothingThey are more effective than doing nothing They are at times as effective as more They are at times as effective as more

extensive treatmentextensive treatment

Really Brief TherapyIn the Age of Managed Care

Kristenson et. Al. 1983, Sweden. N of 585Kristenson et. Al. 1983, Sweden. N of 585 Intervention group was counseled by an MD to Intervention group was counseled by an MD to

moderate their drinking, saw a nurse monthly moderate their drinking, saw a nurse monthly and MD quarterly.and MD quarterly.

The controls received a letter about LFT The controls received a letter about LFT elevation and followed every other year.elevation and followed every other year.

The Brief Intervention group had greater GGT The Brief Intervention group had greater GGT reductions, fewer sick days & hospitalizations reductions, fewer sick days & hospitalizations and had 50% of the mortality over 6 year and had 50% of the mortality over 6 year follow.follow.

Brief Intervention

WHO Study – WHO Study – Babor & Grant, 1992Babor & Grant, 1992

Screened over 32,000 pts in healthcare settings in Screened over 32,000 pts in healthcare settings in 10 nations10 nations (Australia, Bulgaria, Costa Rica, Kenya, Mexico, (Australia, Bulgaria, Costa Rica, Kenya, Mexico,

Norway, USSR, USA, Wales & Zimbabwe)Norway, USSR, USA, Wales & Zimbabwe)

At 9 months, all interventions showed a 1/3At 9 months, all interventions showed a 1/3rdrd reduction in alcohol consumptionreduction in alcohol consumption

Brief Intervention

FRAMESFRAMES F- Feedback to the patientF- Feedback to the patient R- Responsibility of the patient to changeR- Responsibility of the patient to change A- Advice to reduce or stop drinkingA- Advice to reduce or stop drinking M- Menu of choices for actionM- Menu of choices for action E- Empathy is central to the interventionE- Empathy is central to the intervention S- Self-efficacy of the patient to changeS- Self-efficacy of the patient to change

Brief Intervention

On going follow up is helpfulOn going follow up is helpful Helping facilitate the referrals for the ptHelping facilitate the referrals for the pt Follow up phone callsFollow up phone calls More severe (gamma) alcoholics may be More severe (gamma) alcoholics may be

less responsive to this than the less less responsive to this than the less dependent (alpha) alcoholicsdependent (alpha) alcoholics

Conclusions

Brief intervention is better than no Brief intervention is better than no treatmenttreatment

Brief intervention is often comparable to Brief intervention is often comparable to more extensive treatmentmore extensive treatment

Problem drinkers most frequently see care Problem drinkers most frequently see care givers who are not addiction experts but givers who are not addiction experts but who can be very impactful and helpfulwho can be very impactful and helpful

Questions about Questions about

Brief Intervention?Brief Intervention?

Why is this important?

Alcoholism Facts

Cost of alcoholism and alcohol abuse to the Cost of alcoholism and alcohol abuse to the nation was $157 billion in 1999nation was $157 billion in 1999 Additional $110 billion for other drugsAdditional $110 billion for other drugs

Approximately 70% of this total is due to Approximately 70% of this total is due to losses in earning and productivity due to losses in earning and productivity due to alcohol related illness and early deathalcohol related illness and early death

Haight-Ashbury Free ClinicHaight-Ashbury Free Clinic

Alcoholism Facts

Patients with untreated alcohol dependence Patients with untreated alcohol dependence incur general health care costs at least 100% incur general health care costs at least 100% higher than those without alcoholismhigher than those without alcoholism

Every dollar invested in treatment for Every dollar invested in treatment for alcohol and other drug problems potentially alcohol and other drug problems potentially saves $7 in future costssaves $7 in future costs

Actual Causes of Death in the United States in 1990

Cause __ Estimated No. % of Total DeathsCause __ Estimated No. % of Total Deaths

TobaccoTobacco 400,000400,000 1919 Diet/ActivityDiet/Activity 300,000300,000 1414 AlcoholAlcohol 100,000100,000 5 5 Microbial AgentsMicrobial Agents 90,000 90,000 4 4 Toxic AgentsToxic Agents 60,000 60,000 3 3 FirearmsFirearms 35,000 35,000 2 2 Sexual BehaviorSexual Behavior 30,000 30,000 1 1 Motor VehiclesMotor Vehicles 25,000 25,000 1 1 Illicit use of drugsIllicit use of drugs 20,000 20,000 <1 <1 TotalTotal 1,060,000 1,060,000 50 50

Source: McGinnis JM, Foege WH (1993), Actual Causes of Death in the United States JAMA (270) 18, 2207-2212Source: McGinnis JM, Foege WH (1993), Actual Causes of Death in the United States JAMA (270) 18, 2207-2212

Selected Conditions Attributable to Substance Abuse

Disease CategoryDisease Category SubstanceSubstance Attributable Risk Attributable Risk AIDS - adultAIDS - adult I.V. Drug UseI.V. Drug Use 32%32% AsthmaAsthma Passive smoking/smoking 27% Passive smoking/smoking 27% Bladder Cancer - malesBladder Cancer - males SmokingSmoking 53%53% Breast CancerBreast Cancer AlcoholAlcohol 13%13% Cheek and Gum CancerCheek and Gum Cancer Smokeless TobaccoSmokeless Tobacco 87%87% EndocarditisEndocarditis I.V. Drug UseI.V. Drug Use 75%75% Esophogeal CancerEsophogeal Cancer Alcohol/SmokingAlcohol/Smoking 80%80% Low Birth WeightLow Birth Weight SmokingSmoking 42%42% Chronic PancreatitisChronic Pancreatitis AlcoholAlcohol 72%72% Pregnancy - Placenta PreviaPregnancy - Placenta Previa SmokingSmoking 43%43% SeizuresSeizures AlcoholAlcohol 41%41% StrokeStroke Smoking & CocaineSmoking & Cocaine 65%65% TraumaTrauma Alcohol & DrugsAlcohol & Drugs 40%40%

Source: Jeffry Merrill, CASA Substance Abuse Epidemiologic Database 1993Source: Jeffry Merrill, CASA Substance Abuse Epidemiologic Database 1993

Minnesota Consolidated Fund Annual Cost OffsetsExpenditures averaged $50 million annually for 1991 and 1992. Almost 80% of the costs for treating chemical dependency clients are offset in the first year alone.

Cost Area 6 months before tx 6 months after tx. cost per unit savings forCost Area 6 months before tx 6 months after tx. cost per unit savings for 18,400 pt/yr18,400 pt/yr

____________________________________________________________________________________________________________________________________________ Medical hospital days 1220 680 $400 $7.9 millMedical hospital days 1220 680 $400 $7.9 mill Psych hospital daysPsych hospital days 1760 780 $300 $10.9 1760 780 $300 $10.9

millmill Detox admissionsDetox admissions 460 150 $285 $3.3 460 150 $285 $3.3

millmill DWI arrestsDWI arrests 280 30 $1000 $9.2 mill 280 30 $1000 $9.2 mill Other arrestsOther arrests 380 90 $750 380 90 $750 $8.0 $8.0

millmill

$39.2 mill$39.2 mill

Source: Cynthia Turmire, Minnesota Department of Human ServicesSource: Cynthia Turmire, Minnesota Department of Human Services

Number of Participants in California Diversion Program June 2000

Active Instate participants:Active Instate participants: 256256

Active Out of State participants:Active Out of State participants: 17 17

Applicants in Evaluation process: Applicants in Evaluation process: 4848

Total Number being MonitoredTotal Number being Monitored:: 321321

June 2000

PARTICIPANT SPECIALTIES

Family PracticeFamily Practice 4444

AnesthesiologyAnesthesiology 3838

Internal MedicineInternal Medicine 3434

Emergency Medicine Emergency Medicine 1818

PsychiatryPsychiatry 18 18

Obstetrics/GynecologyObstetrics/Gynecology 1111

SurgerySurgery 1010

OrthopedicsOrthopedics 9 9

PediatricsPediatrics 8 8

OphthalmologyOphthalmology 7 7

General PracticeGeneral Practice 6 6

RadiologyRadiology 4 4DermatologyDermatology 3 3UrologyUrology 2 2PathologyPathology 2 2Ear, Nose and ThroatEar, Nose and Throat 2 2CardiologyCardiology 2 2Plastic SurgeryPlastic Surgery 2 2NeurologyNeurology 1 1Administrative MedicineAdministrative Medicine 0 0Thoracic SurgeryThoracic Surgery 0 0OtherOther 2929

March 2000March 2000

SPECIALTIES AT RISK % of CALIFORNIA % of DIVERSION% of CALIFORNIA % of DIVERSION LICENSED PHYSICIANS*LICENSED PHYSICIANS* PARTICIPANTS+ PARTICIPANTS+

AnesthesiologyAnesthesiology 55 1515Emergency MedicineEmergency Medicine 33 8 8Plastic SurgeryPlastic Surgery 11 2 2Obstetrics/GynecologyObstetrics/Gynecology 66 8 8Family PracticeFamily Practice 88 1212RadiologyRadiology 22 3 3Internal MedicineInternal Medicine 1515 1515PsychiatryPsychiatry 77 7 7UrologyUrology 22 2 2NeurologyNeurology 22 2 2PediatricsPediatrics 77 6 6General PracticeGeneral Practice 6 6 5 5OphthalmologyOphthalmology 3 3 2 2OrthopedicsOrthopedics 44 2 2CardiologyCardiology 33 1 1OtolaryngologyOtolaryngology 2 2 0.50.5DermatologyDermatology 22 0.50.5General SurgeryGeneral Surgery 5 5 1 1OtherOther 17 17 6 6

*California licensed physicians by primary specialty as of 9/7/94, California Medical Association *California licensed physicians by primary specialty as of 9/7/94, California Medical Association +As of 1/1/95+As of 1/1/95

Primary Drugs of Abuse by Diversion Participants

Vicodin12%

Cocaine7%

Alcohol44%

Demerol8%

Other Drugs7%

Marijuana1%

Amphetamines4%

Fentanyl6%

Other Narcotics11%

March 2000

The CASA National Survey of Primary Care Physicians and Patients on Substance Abuse

Conducted by the Survey Research Conducted by the Survey Research laboratory, University of Illinois at Chicago laboratory, University of Illinois at Chicago Spring and Summer of 1999Spring and Summer of 1999

Reported April 2000Reported April 2000

Funded by Josiah Macy, Jr. foundationFunded by Josiah Macy, Jr. foundation

National Survey

94% of primary care physicians (except 94% of primary care physicians (except pediatricians) failed to include substance pediatricians) failed to include substance abuse among the five diagnoses they abuse among the five diagnoses they offered when presented with early offered when presented with early symptoms of alcohol abuse in an adult symptoms of alcohol abuse in an adult patientpatient

CASA National Survey of Primary Care Physicians & Patients on Substance Abuse

648 primary care physicians sampled648 primary care physicians sampled

510 adult patients currently in treatment for 510 adult patients currently in treatment for substance abuse in 10 facilities in substance abuse in 10 facilities in California, Illinois, New York & MinnesotaCalifornia, Illinois, New York & Minnesota

59.2 % of pediatricians mentioned 59.2 % of pediatricians mentioned substance abuse as a potential diagnosessubstance abuse as a potential diagnoses

40.8 % would not have been diagnosed by 40.8 % would not have been diagnosed by their pediatrician their pediatrician

Why Physicians don’t discuss Alcohol or Drug Abuse with Patients 57.7% Patients often lie57.7% Patients often lie 35.1 % Time constraints35.1 % Time constraints 29.5% May question patients’ integrity29.5% May question patients’ integrity 25% Don’t want to frighten/anger patient25% Don’t want to frighten/anger patient 15.7% Uncertainty about treatments15.7% Uncertainty about treatments 12.6% Personally uncomfortable with subject12.6% Personally uncomfortable with subject 11% May encourage patient to see other MD11% May encourage patient to see other MD 10.6% Insurance doesn’t reimburse MD time10.6% Insurance doesn’t reimburse MD time

Sir Wm. Osler on Sir Wm Halstadfrom “Inner History of Johns Hopkins Hospital

““The proneness to seclusion, the slight peculiarities The proneness to seclusion, the slight peculiarities amounting to eccentricities at times (which to his old amounting to eccentricities at times (which to his old friends in New York seemed more strange than to us) were friends in New York seemed more strange than to us) were the only outward traces of the daily battle through which the only outward traces of the daily battle through which this brave fellow lived for years. When we recommended this brave fellow lived for years. When we recommended him as full surgeon to the hospital in 1890, I believed, and him as full surgeon to the hospital in 1890, I believed, and Welch did too, that he was no longer addicted to morphia. Welch did too, that he was no longer addicted to morphia. He had worked so well and so energetically that it did not He had worked so well and so energetically that it did not seem possible that he could take the drug and done so seem possible that he could take the drug and done so much.much.

““About six months after the full position had been About six months after the full position had been given, I saw him in severe chills and this was the given, I saw him in severe chills and this was the first information I had that he was still taking first information I had that he was still taking morphia. Subsequently, I had many talks about it morphia. Subsequently, I had many talks about it and gained his full confidence. He had never been and gained his full confidence. He had never been able to reduce the amount to less than three grains able to reduce the amount to less than three grains daily; on this, he could do his work comfortably daily; on this, he could do his work comfortably and maintain his excellent physical vigor for he and maintain his excellent physical vigor for he was a very muscular fellow). I do not think anyone was a very muscular fellow). I do not think anyone suspected him, not even Welch.”suspected him, not even Welch.”

Take Homes

Addiction is a disease & there is treatmentAddiction is a disease & there is treatment It is not being routinely identified by MD’sIt is not being routinely identified by MD’s Pt. behavior is not representative of the Pt. behavior is not representative of the

person & at times is appalling & evocativeperson & at times is appalling & evocative Screening is easily done and sensitiveScreening is easily done and sensitive Brief intervention worksBrief intervention works You can make an enormous differenceYou can make an enormous difference

Screening for alcoholism

Screening principlesScreening principles

Screening toolsScreening tools

Screening vs. AssessmentScreening vs. Assessment

Population issuesPopulation issues

Alcoholism: A Definition ““Alcoholism is a primary, chronic disease with genetic, psychosocial, and Alcoholism is a primary, chronic disease with genetic, psychosocial, and

environmental factors influencing its development and manifestation. The environmental factors influencing its development and manifestation. The disease is often progressive and fatal. It is characterized by impaired disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodicdenial. Each of these symptoms may be continuous or periodic.”.”

American Society of Addiction Medicine 1992American Society of Addiction Medicine 1992

ASAM DefinitionASAM Definition

History and Physical as Screening Develop a routine for CD concernsDevelop a routine for CD concerns

First line screening questionsFirst line screening questions

Second line screening questionsSecond line screening questions This is similar to the search for CADThis is similar to the search for CAD

The Interviewer …

Needs to be tactfulNeeds to be tactful

Non-judgmentalNon-judgmental

High clinical suspicion & low High clinical suspicion & low suspiciousnesssuspiciousness

Quality of Screening Tools

Sensitivity & SpecificitySensitivity & Specificity

Sensitivity is the accuracy with which a Sensitivity is the accuracy with which a positive response predicts presence of positive response predicts presence of alcoholismalcoholism

Specificity is the ability of a negative Specificity is the ability of a negative response to rule out alcoholismresponse to rule out alcoholism

Qualities of Screening Tools

- brief is better for compliance- brief is better for compliance

- quantification is helpful- quantification is helpful

- sensitivity more important than specificity- sensitivity more important than specificity

Screening vs. Assessment

All healthcare workers can do assessmentsAll healthcare workers can do assessments All therapists can do assessmentsAll therapists can do assessments All hospitalized patients can be assessedAll hospitalized patients can be assessed All ambulatory patients can be assessedAll ambulatory patients can be assessed All office questionnaires can include toolsAll office questionnaires can include tools Offices, clinics, ER’s, pre-ops etc. are Offices, clinics, ER’s, pre-ops etc. are

missing alcoholics & addicts without toolsmissing alcoholics & addicts without tools

Screening Instruments

MAST-Michigan Alcohol Screening … #25MAST-Michigan Alcohol Screening … #25 SMAST- Short Michigan … #13 SMAST- Short Michigan … #13 BMAST - Brief Michigan … #10BMAST - Brief Michigan … #10 CAGE - #4CAGE - #4 FOY - #3FOY - #3 Trauma Scale - #5Trauma Scale - #5

Other …

AUDIT - AUDIT - Alcohol Use Disorders Identification testAlcohol Use Disorders Identification test

– 10 questions developed by the WHO in 6 countries10 questions developed by the WHO in 6 countries 3 questions on use, 4 on dependence, 3 on 3 questions on use, 4 on dependence, 3 on

problemsproblems– Developed to identify at risk & problem drinkersDeveloped to identify at risk & problem drinkers– Sensitivity in the 90% and specificity in the 60%Sensitivity in the 90% and specificity in the 60%

SAAST - SAAST - Self administered Alcohol Screening TestSelf administered Alcohol Screening Test

– 35 questions, 5-10 minutes (Sensitivity 35 questions, 5-10 minutes (Sensitivity 91%/Specificity 93%91%/Specificity 93%

ADI - ADI - Adolescent Drinking Inventory - 24 questionsAdolescent Drinking Inventory - 24 questions– 88% Sensitivity/82% specificity88% Sensitivity/82% specificity

ADI Adolescent Drinking Inventory ADI - 25 question inventory focusing on drinking-related ADI - 25 question inventory focusing on drinking-related

loss of control as well as social, psychological and loss of control as well as social, psychological and physical symptoms of alcohol related problems.physical symptoms of alcohol related problems.

Allen and colleagues reported correct identification in 88% Allen and colleagues reported correct identification in 88% of adolescents with alcohol problems and 82% of those of adolescents with alcohol problems and 82% of those without alcohol problems.without alcohol problems.

Allen, J.P.; Eckardt, M.J.; and Wallen, J. Screening for alcoholism: Techniques and issues.Allen, J.P.; Eckardt, M.J.; and Wallen, J. Screening for alcoholism: Techniques and issues.

CAGE Questionnaire

C - C - Cut DownCut Down - Have you ever felt you should - Have you ever felt you should CCut down on your ut down on your drinking? drinking?

A - A - Annoyed -Annoyed - Have people Have people AAnnoyed you by criticizing your nnoyed you by criticizing your drinking? drinking?

G - G - GuiltyGuilty - - Have you ever felt Have you ever felt GGuilty about your drinking?uilty about your drinking?

E - E - Eye openerEye opener - - Have you ever had a drink first thing in the Have you ever had a drink first thing in the morning to steady your nerves or get morning to steady your nerves or get

rid of a rid of a hangover? hangover?

Cage - continued

Takes 1 minute to completeTakes 1 minute to complete At a cut-off score of 2 in one study:At a cut-off score of 2 in one study:

Correctly identified 75% of alcoholics Correctly identified 75% of alcoholics (sensitivity)(sensitivity)

And 96% of non-alcoholics (specificity)And 96% of non-alcoholics (specificity)

Bush, B.; Shaw, S.; Cleary, P., Delbanco, T.L.; and Aronson, M.D. Screening for alcohol abuse Bush, B.; Shaw, S.; Cleary, P., Delbanco, T.L.; and Aronson, M.D. Screening for alcohol abuse using the CAGE questionnaire. American Journal of Medicine 82-231-235, 1987using the CAGE questionnaire. American Journal of Medicine 82-231-235, 1987

T - ACE Questionnaire T-ACE - The “G” item in CAGE is replaced with T for toleranceT-ACE - The “G” item in CAGE is replaced with T for tolerance

- Was developed to identify pregnant women whose drinking - Was developed to identify pregnant women whose drinking threatens the threatens the baby (defined in one study as intake of one baby (defined in one study as intake of one ounce of absolute alcohol or ounce of absolute alcohol or greater).greater).

- CAGE has been criticized for missing earlier stage disease.- CAGE has been criticized for missing earlier stage disease. - Women are more susceptible to alcohol damage because of - Women are more susceptible to alcohol damage because of

absence absence of gastric ADH and lessor amounts of of gastric ADH and lessor amounts of total body fat, therefore water.total body fat, therefore water.

- Questions about tolerance are less likely to trigger psychological - Questions about tolerance are less likely to trigger psychological denial denial as many people do not understand its implications.as many people do not understand its implications.

Sokol, R.J.; Martier. S.S.; and Ager, J.W. The T-ACE questions: Practical prenatal detection of Sokol, R.J.; Martier. S.S.; and Ager, J.W. The T-ACE questions: Practical prenatal detection of risk-drinking. American Journal of Obstetrics and Gynecology 160(4):863-870, 1989risk-drinking. American Journal of Obstetrics and Gynecology 160(4):863-870, 1989

Biochemical Screens

MCVMCV AST/SGOTAST/SGOT GGT - gamma glutamyl transpeptidaseGGT - gamma glutamyl transpeptidase CDT - carbohydrate-deficient transferrinCDT - carbohydrate-deficient transferrin

Carbohydrate content of transferrin, including Carbohydrate content of transferrin, including sialic acid, galactose, and N-acetylglucosamine sialic acid, galactose, and N-acetylglucosamine tend to be lower in actively drinking alcoholicstend to be lower in actively drinking alcoholics

Not readily available or used clinicallyNot readily available or used clinically

Trauma Scale Questions

Have you had any fractures or dislocations to your Have you had any fractures or dislocations to your bones or joints?bones or joints?

Have you been injured in a road traffic accident?Have you been injured in a road traffic accident?

Have you injured your head?Have you injured your head?

Have you been injured in an assault or fight (not Have you been injured in an assault or fight (not including sports)?including sports)?

Have you been injured after drinking?Have you been injured after drinking?

Table 2. Diagnostic Power of Individual Tests for Detecting Alcohol Abuse

Trauma Scale GGT MCV HDLTrauma Scale GGT MCV HDL QuestionnaireQuestionnaire

Differentiating social drinkers from outpatients abusing alcohol Differentiating social drinkers from outpatients abusing alcohol Sensitivity (alcohol abuse outpatients with abnormal test) 68 39 49 26Sensitivity (alcohol abuse outpatients with abnormal test) 68 39 49 26 Specificity (social drinkers with normal test) 81 94 99 88Specificity (social drinkers with normal test) 81 94 99 88 Positive predictive value 78 86 96 68 Positive predictive value 78 86 96 68

(abnormal test-takers who are alcohol abuse outpatients.)(abnormal test-takers who are alcohol abuse outpatients.) Overall accuracy 74 67 77 57 Overall accuracy 74 67 77 57

(alcohol abuse outpatients and social drinkers correctly classified)(alcohol abuse outpatients and social drinkers correctly classified)

Detecting excessive drinking among family practice patientsDetecting excessive drinking among family practice patients Sensitivity (excessive drinkers with abnormal test) 67 33 25 0Sensitivity (excessive drinkers with abnormal test) 67 33 25 0 Specificity (normal drinkers with normal test) 70 89 94 87Specificity (normal drinkers with normal test) 70 89 94 87 Positive predictive value 29 37 40 0Positive predictive value 29 37 40 0

(abnormal. test-takers who are excessive drinkers)(abnormal. test-takers who are excessive drinkers) Overall accuracy 70 80 84 75 Overall accuracy 70 80 84 75

(normal drinkers and excessive drinkers correctly classified).(normal drinkers and excessive drinkers correctly classified).

Question about screening?

Screening is effectiveScreening is effective

And treatment works!And treatment works!