will my child become an alcoholic...7/1/14 1 the science of biological prevention: will my child...
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The Science of Biological Prevention: Will My Child Become an Alcoholic or Drug Addict?
Dr. Merrill Norton Pharm.D.,D.Ph.,ICCDP-D Clinical Associate Professor University of Georgia College of Pharmacy Athens, Georgia 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 1
The Science of Biological Prevention is translated into the
Epidemiology of Addictive Diseases
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What is Epidemiology?
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A Modern Definition
Study of the occurrence and distribution of health-related diseases or events in specified populations, including the study of the determinants influencing such states, and the application of this knowledge to control the health problem
(Porta M, Last J, Greenland S. A Dictionary of Epidemiology, 2008)
Basic Triad of Descriptive Epidemiology
THE THREE ESSENTIAL CHARACTERISTICS OF DISEASE WE LOOK FOR IN DESCRIPTIVE EPIDEMIOLOGY ARE:
! PERSON
! PLACE
! TIME
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Personal Characteristics (whom)
! Age
! Gender
! Socio-economic status (education, occupation, income)
! Marital status
! Ethnicity/race/genetic profile
! Behavior / habits
Place (where ?)
! Geographically restricted or widespread (outbreak, epidemic, pandemic)? Off-shore (tsunami…)
! Climate effects (temperature, humidity, combined effects..)
! Urban / sub-urban-squatter / rural ! Relation to environmental exposure (water, food supply, etc) ! Multiple clusters or one?
Time (when ?)
! Changing or stable?
! Clustered (epidemic) or evenly distributed (endemic)?
! Time-trends: Point source, propagated, seasonal, secular, combinations
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Basic triad of analytical epidemiology THE THREE PHENOMENA ASSESSED IN
ANALYTIC EPIDEMIOLOGY ARE:
HOST
ENVIRONMENT AGENT
Progression of Drug Dependence
From: Heilig M and Koob GF, Trends Neurosci, 2007, 30:399-406.
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Neurocircuitry of Addiction
Derived from: Koob G, Everitt, B and Robbins T, Reward, motivation, and addiction. In: Squire LR, Berg D, Bloom FE, du Lac S, Ghosh A, Spitzer NC (Eds.), Fundamental Neuroscience, 3rd edition, Academic Press, Amsterdam, 2008, pp. 987-1016.
Binge/Intoxication Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238
Withdrawal/Negative Affect Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238
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Reward Transmitters Implicated in the Motivational Effects of Drugs of Abuse
Dopamine … “dysphoria”
Opioid peptides ... pain
Serotonin … “dysphoria”
GABA … anxiety, panic attacks
Dopamine
Opioid peptides
Serotonin
GABA
Positive Hedonic Effects Negative Hedonic Effects of Withdrawal
Preoccupation/Anticipation “Craving” Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238
Brain Arousal-Stress System Modulation in the Extended Amygdala
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Pain, Emotions, and the Amygdala
From: Neugebauer V, Li W, Gird GC and Han JS, The Neuroscientist, 2004, 10:221-234.
Binge/Intoxication Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238
Withdrawal/Negative Affect Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238
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Preoccupation/Anticipation “Craving” Stage
Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) 217-238
Epidemiology of Use and Abstention
01020304050607080
18-24 25-44 45-64 > 64
Drank past yearLifetime abstainer
P
erce
nt
Agents
! Biological (micro-organisms)
! Physical (temperature, radiation, trauma, others)
! Chemical (acids, alkalis, poisons, tobacco, others)
! Environmental (nutrients in diet, allergens, others)
! Psychological experiences
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What outcomes ?
Mortality: all cause / cause-specific
Morbidity Disease-specific indicators / General indicators: clinic use, hospitalization, medication use
Quality of life General / Disease-specific
Costs
CLASSIC EPIDEMIOLOGIC RESEARCH INTO ETIOLOGY
Environmental factor(s)
Outcome
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CLASSIC EPIDEMIOLOGIC RESEARCH INTO ETIOLOGY
Environmental Factor(s) Outcome
Other factors including health care
Probability of Transitioning from Alcohol Use to Dependence MERRILL NORTON, PharmD, DPh, ICCDP-D Clinical Associate Professor College of Pharmacy The University of Georgia
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� Small proportion of population affected
� Large contribution to societal burden • Physical disorders • Absenteeism (work,
school) • Failure to fulfill one’s
social roles • Interpersonal &
functional problems
• Global Status Report on Alcohol and Health. http://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsruprofiles.pdf (Accessed October 8, 2012) • http://alcoholabuseandrehab.blogspot.com/2012/08/what-is-alcohol-abuse.html 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D
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� Nationally representative face-to-face survey of 43,093 respondents, 18 years and older.
� Conducted by NIAAA in 2001-2002 � Civilian, non-institutionalized population in
United States in housing, including group quarters. • Includes Alaska and Hawaii • Hospitals, jails and prisons not among the group
quarters sampled � Oversampling of:
• Blacks • Hispanics • Young Adults aged 18-24
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15.2 Million 15.4
Million
Co-Occurring Disorders
Substance Use
Disorder Only
SMI Only
4.2 Million
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� Mood and anxiety disorders are more common among persons who have substance abuse disorders than among those who do not. This increase appears to be independent of the substance of abuse
� Consistent with NSDUH, only a minority of people with substance use disorders seek treatment---5.81% alcohol use disorder, 13.1% drug use disorder • However, of those who do seek treatment � Of those with alcohol use disorder, 40.69% have a mood
disorder and 33.38% have an anxiety disorder � Of those with a drug use disorder, 60.31% have a mood
disorder and 42.63 % have an anxiety disorder
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� Of particularly note for SAMHSA is that while only 25.81% of those with a mood disorder seek treatment, those who also have a substance abuse disorder are even less likely to seek treatment: • 20.78% for any substance use disorder • 17.45% for any alcohol use disorder • 7.96% for any drug use disorder
• In other words, the presence of a co-occurring substance use disorder militates against treatment seeking behavior among persons with mood disorders, and the service systems are not adequately responsive to persons with co-occurring mood and substance use disorders.
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� Only 5.81% of those with an alcohol use and 13.10% of those with drug use disorders seek treatment.
� Those who seek treatment with substance use disorders increase when there is a co-occurring mood or anxiety disorder.
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Key Policy Questions
How treatment seeking behavior can be increased among those with substance use disorders?
What can be done to accommodate greater systems strain from increased demand?
While 13.1% of those with drug use disorders seek treatment,
86.9% do not
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2% users transition to dependence after first year of use 11% after decade of first use
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3069146/pdf/nihms-258354.pdf (Accessed October 8, 2012) 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 37
� No evidence regarding transition from alcohol use to dependence in pharmacy students
GOAL: Estimate the probability of student pharmacists transitioning from alcohol use
to dependence
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The Student Pharmacists Chemical Health Scale Research Study
! The initial study to evaluate at high risk factor development in student pharmacists; (Pre-Disease Cohort)
! The study will be expanded to study practicing pharmacists graduated the last 20 years; (Disease Development Cohort);
! The study will require a comprehensive look at recovering pharmacists to match potential risk factors with Pre-Disease cohort; ( Disease Cohort);
! Primary purpose of study is to evaluate disease development during school and professional transitions
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The Study Design ! The reason for this study is to identify potential addiction predictability risk factors in student-
pharmacists to create an assessment instrument in pharmacy for determining addiction risk factors in future pharmacists.
! These risk factors are:
! 1.) Age of First use;
! 2.) Family History of Addiction/Mental Illness;
! 3.) Current Alcohol Use;
! 4.) Trauma History;
! 5.) Impulsivity;
! 6.) Negative Proscriptions;
! 7.)Protective Factors;
! 8.) Genetic Use Patterns.
! The intent of gathering this information is in effort to develop a model for an effective Alcohol and Drug Education and Intervention Program that may be replicated nationally.
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The Study Population
! N=394
! P-1 First Year Student Pharmacists
! P-2 Second Year Student Pharmacists
! P-3 Third Year Student Pharmacists
! Collected data using Qualtrics statistical software in Clinical Skills Laboratory
! This is an UGA IRB approved 85 question voluntary anonymous survey
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The Study Population 2013
! N= 365
! P-1s
! P-2s
! P-3s
! P-4s ( to be collected )
! Residents( PGY-1 and PGY-2)
! SPCHS II 2013 130 Questions UGA IRB approved Qualtrics Survey
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2. What is your gender? # Answer Response %
1 Male 133 34%
2 Female 262 66%
Total 395 100%
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4. What is your current year in Pharmacy School?
# Answer Response %
1 First Year 138 35%
2 Second Year 145 37%
3 Third Year 106 27%
4 Fourth Year 4 1%
5 Residency 1 0%
Total 394 100%
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6. What is your ethnic background?
# Answer Response %
1 American Indian or Alaskan Native
0 0%
2 Asian or Pacific Islander 94 24%
3 African American 23 6%
4 Hispanic 3 1%
5 White 261 66%
6 Other 13 3%
Total 394 100%
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Gene0cs
• When scien0sts look for "addic0on genes," what they are really looking for are biological differences that may make someone more or less vulnerable to addic0on.
• Scien0sts will never find just one single addic0on gene. Suscep0bility to addic0on is the result of many interac0ng genes.
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18. FAMILY HISTORY OF ALCOHOLISM/SUBSTANCE ABUSE
# Question Problem, but no treatment
Problem treated
No problem
Unknown Responses Mean
1 Grandparents 64 24 252 49 389 2.74
2 Mother 15 5 359 7 386 2.93
3 Father 36 27 313 13 389 2.78
4 Brother/Sister 28 10 328 18 384 2.88
5 Children 1 0 260 97 358 3.27
6 Current Spouse 8 1 267 83 359 3.18
7 Other 28 12 208 91 339 3.07
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19. FAMILY HISTORY OF PSYCHIATRIC ILLNESS
# Question Problem, but no treatment
Problem treated
No problem
Unknown Responses Mean
1 Grandparents 30 25 277 57 389 2.93
2 Mother 23 32 319 13 387 2.83
3 Father 25 19 325 15 384 2.86
4 Brother/Sister 27 30 315 14 386 2.82
5 Children 0 0 268 83 351 3.24
6 Current Spouse 0 5 275 74 354 3.19
7 Other 12 11 227 84 334 3.15
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22. CURRENT ALCOHOL USE How often do you drink alcohol? # Answer Response %
1 Never 67 17%
2 Less than Once a Month 65 16%
3 Once a Month 31 8%
4 2-3 Times a Month 100 25%
5 Once a Week 72 18%
6 2-3 Times a Week 56 14%
7 Daily 4 1%
Total 395 100%
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23. How many drinks containing alcohol do you have on a typical day when you are drinking?
# Answer Response %
1 1 to 2 140 43%
2 2 to 4 125 38%
3 5 to 6 44 13%
4 7 to 9 14 4%
5 10 or more 3 1%
Total 326 100%
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28. How often in the last year have you had a feeling of guilt or remorse after drinking.
# Answer Response %
1 Never 217 66%
2 Less than once a month 92 28%
3 Monthly 16 5%
4 Weekly 3 1%
5 Daily or almost daily 0 0%
Total 328 100%
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Trauma History/Stressful Life Events
• A systema0c review of the literature indicates that trauma and stressful life events (death, losses of property, etc.) has a strong influence on a person developing an addic0on;
• Student Pharmacists report at least 4.5 stress life events/traumas prior to entering pharmacy school
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32. TRAUMA HISTORY Have you ever experienced a significant traumatic experience in your lifetime?
# Answer Response %
1 Yes 113 29%
2 No 282 71%
Total 395 100%
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Nega0ve Proscrip0ons
• Preven&on Message; • Social Support; Who Would Talk to About Serious Problem;
• Ac&vi&es : Athle&cs, Extracurricular, Religious Beliefs and Prac&ces;
• Community Domain; • Family Domain; • Drug availability. 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-‐D 54
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37. NEGATIVE PROSCRIPTIONS Indicate whether you agree or disagree with the following: Prescription dru...
# Answer Response %
1 Strongly agree 279 71%
2 Agree 92 23%
3 Neutral 10 3%
4 Disagree 9 2%
5 Strongly Disagree 5 1%
Total 395 100%
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Protec0ve factors
• Preven&on Message; • Social Support; Who Would Talk to About Serious Problem;
• Ac&vi&es : Athle&cs, Extracurricular, Religious Beliefs and Prac&ces;
• Community Domain; • Family Domain; • Drug availability. 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-‐D 56
44. PROTECTIVE FACTORS Indicate the level at which the following applies to you: I talk to my parents/sp...
# Answer Response %
1 Always applies 145 37%
2 Mostly applies 137 35%
3 Applies 42 11%
4 Somewhat applies 55 14%
5 Does not apply 15 4%
Total 394 100%
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The Gene&c Component-‐The Kreek-‐McHugh-‐Schluger-‐Kellogg Scale: a new, rapid method
for quan&fying substance abuse and its possible applica&ons.
• designed to quan&fy self-‐exposure to opiates, cocaine, alcohol, and/or tobacco;
• assesses the frequency, amount, and dura&on of use of a par&cular substance during the individual's period of greatest consump&on;
• assesses the mode of use, whether the substance use is current or past, and whether each substance is the substance of choice;
• preliminary results show that the KMSK scale may have both construct validity similar to that of other established self-‐report measures and the poten&al to be an effec&ve screening instrument for the assessment of a life&me diagnosis of alcohol, opiate, or cocaine dependence.
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58. Are you using currently? # Answer Response %
1 Yes 91 29%
2 No 221 71%
Total 312 100%
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59. How long did this pattern of drinking last?
# Answer Response %
1 More than a year 48 16%
2 Six months to one year 69 22%
3 Less than six months 192 62%
Total 309 100%
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The probability of transitioning from alcohol use to dependence is greatest three years after the first use of alcohol
0
0.01
0.02
0.03
0.04
0.05
0.06
0 1 2 3 4 5 6 7 8 9 > 10
Proportion of At-Risk Respondents Who Transition To Alcohol Dependence
18 19 20 21 22 23 24 25 26 27 28+ 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 61
Overall P3 P2 P1
Mean 23.787 24.99 23.91 22.73
Median 22 24 22 22
Mode 22 22 22 21
Total No. of Respondents *
393 105 145 137
* Total number includes P4 respondents (not listed) 62
Overall P3 P2 P1
Mean 17.38 17.2 17.58 17.37
Median 18 17 18 18
Mode 18 21 18 18
Total No. of Respondents *
349 99 124 121
* Total number includes P4 respondents (not listed) 63
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FAMILY HISTORY OF ALCOHOLISM/SUBSTANCE ABUSE
Overall P3 P2 P1
No. with Family HX 169 50 62 54
Total No. 395 106 145 138
Percent with Family HX 42.78 47.17 42.76 39.13
Total No. of 1st Degree Relatives with Alcohol/S.A. Problems
259 80 86 86
No. of Relatives with Alcohol/S.A. Problem per Respondent with Family HX
1.53 1.6 1.39 1.59
No. Fathers 63 22 23 17
No. Mothers 20 6 6 7
No. Grandparents 88 27 24 35
No. Siblings 38 10 15 12
No. Children 1 0 0 1
No. Spouses 9 5 1 2
No. Other 40 10 17 12 64
Overall P3 P2 P1
Greater than 15 (%)
7 (1.9) 3 (3.23) 3 (2.59) 1 (0.9)
8 to 15 (%) 50 (13.6) 11 (11.83) 20 (17.2) 19 (16.52)
0 to 7 (%) 267 (88.3) 79 (84.95) 93 (80.2) 95 (82.61)
§ Scores (General Interpretation) § > 15: high level of alcohol problems § 8 to 15: medium level of alcohol problems § 0 to 7: low level of alcohol problems
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FAMILY HISTORY OF PSYCHIATRIC DISORDER
Overall P3 P2 P1
No. with Family HX 139 22 56 48
Total No. 395 106 145 138
Percent with Family HX 35.19 30.19 38.62 33.8
Total No. of 1st Degree Relatives with Alcohol/S.A. Problems
239 58 95 82
No. of Relatives with Alcohol/S.A. Problem per Respondent with Family HX
1.72 1.8 1.7 1.71
No. Fathers 44 10 21 13
No. Mothers 55 12 21 21
No. Grandparents 55 11 20 23
No. Siblings 57 16 18 20
No. Children 0 0 0 0
No. Spouses 5 1 4 0
No. Other 23 8 11 5 66
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FAMILY HX OF ALCOHOLISM/S.A.
Overall P3 P2 P1
Mean 16.6 16.67 16.9 16.82
Median 16 17 16 16
Mode 16 18 16 16
FAMILY HX PSYCHIATRIC DISORDER
67
Overall P3 P2 P1
Mean 16.7 17.1 16.53 16.8
Median 17 17 16 17
Mode 16 21 15 18
AUDIT SCORE > 16
Overall P3 P2 P1
Mean 16.28 16.67 18 14
Median 17 17 18 14
Mode 18 17 18 14
AUDIT SCORE 8 TO 15
68
Overall P3 P2 P1
Mean 16.1 16.2 16.5 15.94
Median 16 16 16 16
Mode 16 16 16 16
Overall P3 P2 P1
Mean 17.6 17.33 17.8 17.67
Median 18 18 18 18
Mode 18 21 18 18
AUDIT SCORES 0 to 8 69
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Overall P3 P2 P1
Experienced Traumatic Event in Lifetime
102 35 40 25
Received Counseling for Traumatic Event
31 10 12 8
Alcohol or Drugs Led to Traumatic Event
14 3 5 6
Turning to Alcohol or Drugs Helps to Cope
15 5 5 5
Alcohol or Drugs Relieves Pain from Trauma
10 3 2 5
Quit Smoking But Wanted to Restart After Traumatic Event
11 7 2 2
70
The probability of transitioning from alcohol use to dependence is greatest three years after the first use of alcohol
0
0.01
0.02
0.03
0.04
0.05
0.06
0 1 2 3 4 5 6 7 8 9 > 10
Proportion of At-Risk Respondents Who Transition To Alcohol Dependence
18 19 20 21 22 23 24 25 26 27 28+ 7/1/14 Merrill Norton Pharm.D.,D.Ph.,ICCDP-D 71
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