Alcoholism: new conception, old challenges

Transcription

1 Alcoholism: new conception, old challenges Australian Doctors in Recovery Inaugural NZ Doctors in Recovery 18 March 2018 Doug Sellman Professor of Psychiatry & Addiction Medicine National Addiction Centre University of Otago, Christchurch

2 Four questions 1. What is the new unitary diagnosis of alcoholism 2. Is alcoholism a brain disease or a learned habit? 3. What is the best treatment advice to give a person with alcoholism? 4. How to reduce the incidence of alcoholism in New Zealand?

3 Trunk and disorderly! Tipsy elephants staggering around South African Kruger National Park intoxicated after eating huge quantities of fermented marula fruit

4 High-volume alcohol-preferring rat

5 Inhabitants of forests in south-eastern Guinea, enjoy rich, alcoholic brew fermented from sugary sap Chimpanzees observed engaging in habitual drinking (Guardian 2015, quoting Royal Society Open Science)

6 Life can t be enjoyed without alcohol

7 Social events aren t proper events without alcohol

8 To be in the in-crowd means drinking with the in-crowd

9 The New Zealand Way of Life 25% of NZ drinkers are heavy drinkers (AUDIT) Half of serious violent crimes relate to alcohol An extraordinary proportion of presentations at Emergency Departments on Friday and Saturday nights are alcohol-related Up to 3000 children born with FASD every year 70,000 alcohol-related physical and sexual assaults each year A third of alcohol-related deaths are cancer

10 Jordan is 39 years old, married with two sons aged 12 and 10 and works night-shifts as a nurse. He also owns and partruns a restaurant, as well as renovating a house he and his wife recently bought. He is currently taking a break from his marriage following a late night drunken altercation when out of frustration he pushed his wife Sally, who fell, badly twisting her ankle. When Sally threatened to call the Police, Jordan went and stayed with a close friend/colleague for the night. Sally took out a non-molestation order out on him the next day. Jordan subsequently went and lived in their half-renovated house.

11 Jordan first got drunk at age 10 and began drinking regularly on Friday and Saturday nights at age 15, when he and friends normally each drank six 750ml bottles (18 standard drinks) each night. He got into several fights, had one or two blackouts, but mainly recalls having a great time. His heaviest period of drinking was when he was in Australia in his early 30s about 10 sds, five days a week. During that time he showed evidence of hazardous use, tolerance, use despite interpersonal conflict and a lot of time taken up with drinking. He is currently three months abstinent, aiming to prove to his wife he isn t an alcoholic.

12 Other Addiction History: nil of note Other Psychiatric History: currently low in mood, but still working hard despite lowered motivation, decreased enjoyment of life and not feeling as sharp as usual Family History: heavy drinking family, but no one diagnosed as alcoholic Personal History: warm family upbringing, felt loved, did well at school, optimistic personality, good marriage overall but two strong personalities who often argue about trivialities even when neither been drinking MSE: low mood evident, but could raise a smile, just; no evidence of cognitive impairment or any other psychiatric phenomenology

13 What is Jordan s alcohol diagnosis? What is the best advice to give Jordan regarding his drinking?

14 Shifts in the diagnosis of alcoholism over the past 50 years DSM1 (1952) DSM2 / ICD 8 (1968) (1969) ICD9 / DSM3 / DSM3-R / ICD10 / DSMIV (1977) (1980) (1987) (1992) (1994) Alcohol Abuse Alcoholism Alcoholism Alcohol Dependence Sociopathic Personality Disturbance Antisocial Personality Antisocial Personality Disorder

15 Drug Use Continuum Abstinence Low risk Hazardous Problem Mild Moderate/severe use use use dependence dependence ADDICTION Focussed behavioural change Fundamental lifestyle change

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17 Shifts in the diagnosis of alcoholism over the past 60 years DSM-I (1952) DSM-II / ICD8 (1968) (1969) ICD9 / DSM-III / DSM-IIIR / ICD10 / DSM-IV (1977) (1980) (1987) (1991) (1994) DSM5 (2013) Alcohol Abuse Alcoholism Alcoholism Alcohol Use Disorder Sociopathic Personality Disturbance Alcohol Dependence Antisocial Personality Antisocial Personality Disorder Antisocial Personality Disorder

18 Drinking Continuum No Low risk Hazardous Mild alcohol use Moderate Severe drinking drinking drinking disorder (AUD) AUD AUD ADDICTION

19 Proposed grouping of DSM-5 criteria for alcohol use disorder based on severity weightings (Saha et al., 2006) Dyscontrol Use is often longer than intended Unsuccessful attempts to cut down/stop Use when physically hazardous Physiological changes Withdrawal evidence Acquired tolerance Compulsion to use Craving Use despite physical/psychological problems Social and interpersonal problems Salience A lot of time spent Neglect of roles Activities given up

20 What is Jordan s alcohol diagnosis? At his heaviest period of use, evidence of: dyscontrol (hazardous use) physiological features (tolerance) compulsion to use (use despite interpersonal conflict) salience (a lot of time taken up with drinking) Diagnosis: moderate alcohol use disorder

21 What is the best advice to give Jordan regarding his drinking?

22 Mark and Linda Sobell (1995) Controlled drinking after 25 years: How important was the great debate? Sanchez-Craig et al (1984) Mildly dependent drinkers Randomly assigned to abstinence or controlled drinking No difference in outcome at two years Majority of successful outcomes involved moderation Foy et al (1984) Severely dependent drinkers Randomly assigned to abstinence or controlled drinking No difference in outcome at five years Majority of successful outcomes involved abstinence

23 Suggested abstinence advice in relation to severity of alcohol use disorder (DSM-5) Sellman et al. Aust N Z J Psychiatry 2014;48: Copyright by The Royal Australian and New Zealand College of Psychiatrists

24 What is the best advice to give Jordan regarding his drinking? The best strategy is not to give (unsolicited) advice but rather, facilitate discovery.

25 Alcoholism: Brain disease or learned habit?

26 Alcoholism: Disease or Habit?

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28 Brain Disease (Volkov) Caricature Person can t help it Person needs medical treatment In practice Progressive brain changes underlying disordered behaviour Medications and therapy can assist a persons recovery Learned Habit (Lewis) Person simply chose it Person can simply choose not to be addicted Normal learning processes lead to changes in neural pathways Self-empowerment is critical to a re-learning process of moving on

29 Behind every addiction is an industry pushing a moreish engineered product

30 Behind every addiction there is an industry scheming to make you and your children one of their favourite customers for life

31 Alcohol: No Ordinary Commodity (2010)

32 5+ Solution MPAAD+ Marketing Pricing Accessibility Age of purchase Drink-driving PLUS: Increase treatment opportunities for heavy drinkers

33 Five main reforms 1. End alcohol advertising and sponsorship 2. End ultra cheap alcohol 3. End anytime-anywhere alcohol 4. End teenage purchase of alcohol 5. End legal drunk driving

34 Combination of effectiveness and public support of these reforms Effectiveness Public Support (0, +, ++, +++) % 1. Dismantle marketing +/ Raise the price Reduce trading hours Raise purchase age Lower drink driving limit

35 The Alcohol NON-Reform Bill 1. Marketing - some limited restriction of TINKERING advertising to minors only 2. Pricing NOTHING 3. Accessibility no alcohol from convenience stores & voluntary local alcohol policies?? COULD YIELD SOMETHING 4. Age of purchase maintain 18 years for both on-licence NOTHING and for off-licence 5. Drink driving limits NOTHING

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37 British American Tobacco NZ

38 Alcoholism: New conception, old challenges 1. The new unitary diagnosis of alcoholism is a return to the 1960s 2. Addiction interruption, using abstinence for a variable amount of time depending on the severity of alcoholism, is compatible with both alcoholism conceived as a brain disease and as a learned habit 3. The old challenge remains - working alongside a person with alcoholism and conducting individualised therapeutic experiments together 4. The old challenge remains - advocating for effective alcohol reform to reduce alcohol-related harm including the incidence of alcoholism, when governments tend to place higher value on Big Business than Public Health