Basics on AlcoholBasics on Alcohol

Steven D. LaRowe, Ph.D.Steven D. LaRowe, Ph.D.

Center for Drug and Alcohol ProgramCenter for Drug and Alcohol ProgramMedical University of South CarolinaMedical University of South Carolina

Substance Abuse Treatment CenterSubstance Abuse Treatment CenterRalph H. Johnson VAMCRalph H. Johnson VAMC

Alcohol is “tricky”Alcohol is “tricky” Many people drink, but only a few qualify has Many people drink, but only a few qualify has

having a diagnosis of abuse or dependencehaving a diagnosis of abuse or dependence Most “budding” alcoholics want to continue to Most “budding” alcoholics want to continue to

drink, or control drinkingdrink, or control drinking AA disease model = you’ll never drink againAA disease model = you’ll never drink again Some patients will resist that and will turn away Some patients will resist that and will turn away

from treatmentfrom treatment Hard to know who is the person who will drink Hard to know who is the person who will drink

responsibly in the future, or who will never be responsibly in the future, or who will never be able to againable to again

Need to “roll with this resistance”Need to “roll with this resistance”

What is moderate drinking?What is moderate drinking?

Men: no more than 4 drinks per dayMen: no more than 4 drinks per dayMen: no more than 14 drinks per weekMen: no more than 14 drinks per weekWomen: no more than 3 drinks per dayWomen: no more than 3 drinks per dayWomen: no more than 7 drinks per weekWomen: no more than 7 drinks per week

How many people drink?How many people drink?

18 and over, between 40 and 18 and over, between 40 and 70% drink70% drink

Heavy drinkers: between 5 Heavy drinkers: between 5 and 20%and 20%

Rates of Dependence: 7% Rates of Dependence: 7% young adults (18-25), 3% for young adults (18-25), 3% for those over 26those over 26

Basic Wiring of the BrainBasic Wiring of the Brain

DSM-IV: Alcohol AbuseDSM-IV: Alcohol Abuse

1 or more within a 12-month period: 1 or more within a 12-month period: Drinking results in failure to fulfill major role Drinking results in failure to fulfill major role

obligations at work, school, or home obligations at work, school, or home Drinking in situations in which it is physically Drinking in situations in which it is physically

hazardous hazardous Recurrent alcohol-related legal problemsRecurrent alcohol-related legal problems Drinking despite social/interpersonal Drinking despite social/interpersonal

problemsproblems These symptoms must never have met the These symptoms must never have met the

criteria for alcohol dependence.criteria for alcohol dependence.

DSM-IV: Alcohol DependenceDSM-IV: Alcohol Dependence3 or more in the same 12-month period: 3 or more in the same 12-month period: Tolerance:Tolerance:

Either need more to effect OR experience markedly diminished Either need more to effect OR experience markedly diminished effects effects

Withdrawal:Withdrawal: Either withdrawal syndrome for alcohol or drink to avoid the Either withdrawal syndrome for alcohol or drink to avoid the

syndrome syndrome Drinking more over a longer period than was intended. Drinking more over a longer period than was intended. Desire/unsuccessful efforts to cut down/control use. Desire/unsuccessful efforts to cut down/control use. Excessive time is spent in obtaining, using or recovering Excessive time is spent in obtaining, using or recovering

from alcoholfrom alcohol Reduced social, occupational, or recreational activities b/c Reduced social, occupational, or recreational activities b/c

drinkingdrinking Continue to use it even though it causes physical or Continue to use it even though it causes physical or

psychological problemspsychological problems

The 3-stage progression of addictionThe 3-stage progression of addiction

DependenceAbuse

Recall: Learning occurs quickly when using alcohol/drugs – change in gene expression is involved. Genes determine protein structure, structure of protein determines function, etc.

5 to 10 year progressionTime to develop ETOH dependence

Source: Kalivas & Volkow, 2005)

Biological Action of AlcoholBiological Action of Alcohol

GABA – neurotransmitter involved in GABA – neurotransmitter involved in inhibition – is increases by alcoholinhibition – is increases by alcohol

Glutamate – neurotransmitter involved in Glutamate – neurotransmitter involved in excitation, memory (NMDA is a type of excitation, memory (NMDA is a type of glutamate receptor) – is inhibited by glutamate receptor) – is inhibited by alcoholalcohol

Alcohol indirectly causes release of Alcohol indirectly causes release of dopamine, presumably through effects on dopamine, presumably through effects on GABA, which regulates dopamine GABA, which regulates dopamine releaserelease

Alcohol going in and outAlcohol going in and out ““Biphasic” meaning “two phases”Biphasic” meaning “two phases” As alcohol levels increase, dopamine is As alcohol levels increase, dopamine is

released, people feel good (a.k.a. the released, people feel good (a.k.a. the “ascending limb”“ascending limb”

Peaks about an hour after last drink on empty Peaks about an hour after last drink on empty stomach, longer if you’ve eaten (2 hours)stomach, longer if you’ve eaten (2 hours)

(Warning: people doing shots can do a bunch in (Warning: people doing shots can do a bunch in a few minutes, and feel “OK” and leave, but the a few minutes, and feel “OK” and leave, but the real intoxication is yet to come)real intoxication is yet to come)

After alcohol levels peak, they start to decrease After alcohol levels peak, they start to decrease and sedative effects are most notable (a.k.a. the and sedative effects are most notable (a.k.a. the “descending limb”“descending limb”

Source: King et al. 2002

Drinks, BAL, and effectsDrinks, BAL, and effectsBAC Table for Men

Body Weight in Pounds

Drinks 100 120 140 160 180 200 220 240

Condition

0 .00 .00 .00 .00 .00 .00 .00 .00 Only Safe Driving Limit

1 .04 .03 .03 .02 .02 .02 .02 .02

2 .08 .06 .05 .05 .04 .04 .03 .03

3 .11 .09 .08 .07 .06 .06 .05 .05

4 .15 .12 .11 .09 .08 .08 .07 .06

5 .19 .16 .13 .12 .11 .09 .09 .08

Driving Skills

Significantly Affected

Possible Criminal Penalties

6 .23 .19 .16 .14 .13 .11 .10 .09

7 .26 .22 .19 .16 .15 .13 .12 .11

8 .30 .25 .21 .19 .17 .15 .14 .13

9 .34 .28 .24 .21 .19 .17 .15 .14

Legally I ntoxicated

Criminal Penalties

10 .38 .31 .27 .23 .21 .19 .17 .16 Death

Possible

Subtract .01% for each 40 minutes of drinking. 1 drink = 1.25 oz. 80 proof liquor, 12 oz. beer, or 5 oz. wine

Source: http://www.alcohol.vt.edu/Students/alcoholEffects/estimatingBAC/index.htm

Drinks, BAL, and effectsDrinks, BAL, and effects

BAC Table for Women

Body Weight in Pounds

Drinks 90 100 120 140 160 180 200 220 240 Condition

0 .00 .00 .00 .00 .00 .00 .00 .00 .00 Only Safe Driving Limit

1 .05 .05 .04 .03 .03 .03 .02 .02 .02

2 .10 .09 .08 .07 .06 .05 .05 .04 .04

3 .15 .14 .11 .10 .09 .08 .07 .06 .06

4 .20 .18 .15 .13 .11 .10 .09 .08 .08

5 .25 .23 .19 .16 .14 .13 .11 .10 .09

Driving Skills

Significantly Affected

Possible Criminal Penalties

6 .30 .27 .23 .19 .17 .15 .14 .12 .11

7 .35 .32 .27 .23 .20 .18 .16 .14 .13

8 .40 .36 .30 .26 .23 .20 .18 .17 .15

9 .45 .41 .34 .29 .26 .23 .20 .19 .17

Legally I ntoxicated

Criminal Penalties

10 .51 .45 .38 .32 .28 .25 .23 .21 .19 Death

Possible

Subtract .01% for each 40 minutes of drinking. 1 drink = 1.25 oz. 80 proof liquor, 12 oz. beer, or 5 oz. wine.

Source: http://www.alcohol.vt.edu/Students/alcoholEffects/estimatingBAC/index.htm

When the party’s overWhen the party’s over

““Rebound” occurs when alcohol clearsRebound” occurs when alcohol clears Now, glutamate makes a comebackNow, glutamate makes a comeback In persons not tolerant to alcohol it can disturb In persons not tolerant to alcohol it can disturb

sleepsleep Chronic exposure to alcohol leads to changes in Chronic exposure to alcohol leads to changes in

GABA. Body makes less of it, so when its gone, GABA. Body makes less of it, so when its gone, Glutamate rules the dayGlutamate rules the day

Lots of Glutamate activity Lots of Glutamate activity CNS activation CNS activation withdrawal symptoms = shakes, anxiety, and withdrawal symptoms = shakes, anxiety, and extreme cases, seizures and Delerium Tremensextreme cases, seizures and Delerium Tremens

ToleranceTolerance Functional: you function even when others would Functional: you function even when others would

be severely impaired if they drank the same be severely impaired if they drank the same amountamount

Tolerance does not develop equally across all Tolerance does not develop equally across all domains (e.g. OK mental functions, but still domains (e.g. OK mental functions, but still impaired coordination)impaired coordination)

Environment dependent tolerance – tolerance in Environment dependent tolerance – tolerance in one place but not anotherone place but not another

Liver can speed up, but this can cause it to Liver can speed up, but this can cause it to process other things (like other meds) too process other things (like other meds) too quicklyquickly

(Source: NIAAA Alcohol Alert 28)(Source: NIAAA Alcohol Alert 28)

Special Concern: Alcohol Special Concern: Alcohol WithdrawalWithdrawal

Can have severe, even deadly, result, if Can have severe, even deadly, result, if untreateduntreated

Therefore, you need to have some idea whether Therefore, you need to have some idea whether you client is at riskyou client is at risk

Can begin within a few hours of cessation of Can begin within a few hours of cessation of drinkingdrinking

Can last up to 72 hoursCan last up to 72 hours ““Kindling” theory – the more withdrawals you Kindling” theory – the more withdrawals you

have, the more risk of seizureshave, the more risk of seizures Seizures can be damaging, and if you have one, Seizures can be damaging, and if you have one,

you are more at risk for anotheryou are more at risk for another

DSM-IV: Alcohol WithdrawalDSM-IV: Alcohol Withdrawal

2 (or more) of the following, developing within several hours to a few days after alcohol cessation/reduction: 

autonomic hyperactivity (e.g., sweating or pulse rate  greater than 100)

increased hand tremor insomnia nausea or vomiting transient visual, tactile, or auditory hallucinations or

illusions psychomotor agitation anxiety grand mal seizures     

Screening for Alcohol problemsScreening for Alcohol problems CAGE: Two "yes" responses indicate that the CAGE: Two "yes" responses indicate that the

respondent should be investigated further. The respondent should be investigated further. The questionnaire asks the following questions:questionnaire asks the following questions:

1.1. Have you ever felt you needed to Have you ever felt you needed to CCut down on ut down on your drinking? your drinking?

2.2. Have people Have people AAnnoyed you by criticizing your nnoyed you by criticizing your drinking? drinking?

3.3. Have you ever felt Have you ever felt GGuilty about drinking? uilty about drinking? 4.4. Have you ever felt you needed a drink first Have you ever felt you needed a drink first

thing in the morning (thing in the morning (EEye-opener) to steady ye-opener) to steady your nerves or to get rid of a hangover? your nerves or to get rid of a hangover?

Know what “Standard Drink” IsKnow what “Standard Drink” Is12 oz. of beer or cooler

8-9 oz. of malt

liquor8.5 oz. shown in a 12-oz.

glass that, if full, would hold about 1.5 standard drinks of

malt liquor

5 oz. of

table wine

3-4 oz. of

fortified wine

(such as sherry or port) 3.5 oz. shown

2-3 oz. of

cordial, liqueur

or aperitif

2.5 oz. shown

1.5 oz. of

brandy(a single jigger)

1.5 oz. of spirits

(a single jigger of 80-proof gin, vodka, whiskey, etc.) Shown

straight and in a highball glass with ice to show level before

adding mixer*

               

12 oz.

               

   

8.5 oz

          

     

5 oz.

             

3.5 oz.

           

   

2.5 oz.

              

1.5 oz.

                   

  

1.5 oz.•People will count a 24 oz. “tall boy” beer as 1 beer – it’s more like 2•People will make a drink with several shots (“double, triple”, and count it as 1 drink•One client told me she had “3 drinks” last night, but I found out later that each was a mixed drink with 5 shots of vodka each!

Source: A Pocket Guide for Alcohol Screening and Brief Intervention, NIAAA

Quick Alcohol Withdrawal Quick Alcohol Withdrawal QuestionsQuestions

Questions to ask:Questions to ask: Ask if they’ve ever been “detoxed” for alcoholAsk if they’ve ever been “detoxed” for alcohol Ask about withdrawal symptoms (shakes, Ask about withdrawal symptoms (shakes,

sweats)sweats) Ask about number of previous withdrawals Ask about number of previous withdrawals

they’ve gone throughthey’ve gone through If in private practice, cultivate a relationship with If in private practice, cultivate a relationship with

a psychiatrist or other medical practitionera psychiatrist or other medical practitioner

CIWACIWA Clinical Institute Withdrawal AssessmentClinical Institute Withdrawal Assessment At the VA, we have a “CIWA protocol”At the VA, we have a “CIWA protocol” Essentially, the medical people assess Essentially, the medical people assess

withdrawal over timewithdrawal over time Treatment for withdrawal has traditionally been Treatment for withdrawal has traditionally been

benzodiazepines (e.g. Valium, Ativan)benzodiazepines (e.g. Valium, Ativan) We are trying to use anti-seizure medications We are trying to use anti-seizure medications

(e.g. Gabapentin, Carbemazepine), because (e.g. Gabapentin, Carbemazepine), because they are not cross-tolerant to alcohol (and less they are not cross-tolerant to alcohol (and less addictive)addictive)

Click here for a copy of the CIWAClick here for a copy of the CIWA

What I look for when assessing a What I look for when assessing a drinkerdrinker

When did drinking When did drinking begin?begin?

How many years of How many years of heavy drinking?heavy drinking?

How many How many standardstandard drinks per day?drinks per day?

Do you ever have just Do you ever have just one or 2 drinks?one or 2 drinks?

How many times in How many times in treatment?treatment?

# of Charges for DUI’s, # of Charges for DUI’s, drunk and disorderly drunk and disorderly (CHARGES not (CHARGES not convictions, in case convictions, in case they took a plea)they took a plea)

Among people over 21, those who with dependence are more likely to have started drinking before the age of 14 (8%) than age 21 (1%). Alcohol dependence develops over 5-10 years, so if drinking has occurred longer than that, dependence more likely

People who exceed both daily/weekly limits have a 50% chance of abuse/being dependent

Can they stop? If no, possibly they have become compulsive drinkers. More treatment attempts = more likely they have serious dependence (compulsive) problem

Objective evidence of problems

More things I look forMore things I look for

As part of your standard intake, you’ll have As part of your standard intake, you’ll have gotten family, work, medical histories.gotten family, work, medical histories.Keep these in mind, as problems in these Keep these in mind, as problems in these

areas are often alcohol-related but not seen areas are often alcohol-related but not seen as such by the drinker!as such by the drinker!

You might be able to make that link in You might be able to make that link in sessions to help increase your motivation.sessions to help increase your motivation.

However, it is important to ask the patient However, it is important to ask the patient what she/he sees as being problems cause what she/he sees as being problems cause by alcoholby alcohol

Using your BAL monitorUsing your BAL monitor We typically have used BAL monitor for We typically have used BAL monitor for

individual therapy in researchindividual therapy in research We have them on hand at VAWe have them on hand at VA They are always useful, but a patient might not They are always useful, but a patient might not

show up if he/she thinks she might come up show up if he/she thinks she might come up positivepositive

Things to watch for when patients come up Things to watch for when patients come up positive…(e.g. they will come up positive and positive…(e.g. they will come up positive and still deny using)still deny using)

Some cough syrups make people come up Some cough syrups make people come up positive – not an excuse though!positive – not an excuse though!

Biological indicators of drinkingBiological indicators of drinking

Clinical issuesClinical issues

Is this a person who can never, ever drink Is this a person who can never, ever drink again or might this be someone who can again or might this be someone who can moderate?moderate?

There are a number of people who There are a number of people who “spontaneously” remit, and stop drinking “spontaneously” remit, and stop drinking on their own (as high as 30%)on their own (as high as 30%)

On the other hand, if they could have On the other hand, if they could have remitted, would they be here for remitted, would they be here for treatment? (Maybe, maybe not)treatment? (Maybe, maybe not)

Abstinence versus ModerationAbstinence versus Moderation The more evidence for dependence (e.g. older The more evidence for dependence (e.g. older

age, longer drinking time, more failed age, longer drinking time, more failed treatments), elevated liver leves, the more I treatments), elevated liver leves, the more I might guide client towards goal of complete might guide client towards goal of complete abstinenceabstinence

Younger age, less time drinking, controlled Younger age, less time drinking, controlled drinking might be more acceptable goaldrinking might be more acceptable goal

In general, however, even if patient wants In general, however, even if patient wants controlled drinking, I will suggest that it works controlled drinking, I will suggest that it works better after an extended period of abstinence better after an extended period of abstinence (based on clinical experience, no empirical (based on clinical experience, no empirical evidence in my possession so far) evidence in my possession so far)

Abstinence vs. ModerationAbstinence vs. Moderation Many times, I will think the patient in no way can Many times, I will think the patient in no way can

handle drinking, yet patient insists on trying handle drinking, yet patient insists on trying controlled drinking controlled drinking

I will negotiate with them a weekly and daily limit I will negotiate with them a weekly and daily limit (start low, below recommended levels, the (start low, below recommended levels, the patient argues us)patient argues us)

I will then have patient track drinking (educate I will then have patient track drinking (educate about standard drinks), and see if they can keep about standard drinks), and see if they can keep limitslimits

If patient can’t keep limits, then we revisit If patient can’t keep limits, then we revisit abstinenceabstinence

ActivityActivity

Create a client, complete with drinking history. Create a client, complete with drinking history. Decide the extent to which client is aware of Decide the extent to which client is aware of their problem.their problem.

Recognize that some people will report problems Recognize that some people will report problems but not see them related to drinkingbut not see them related to drinking

Recognize that many people are in treatment at Recognize that many people are in treatment at someone else’s behestsomeone else’s behest

Recognize the tendency to minimize and Recognize the tendency to minimize and underreport problemsunderreport problems