The Science of Biological Prevention is translated into the Epidemiology of Addictive Diseases

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1 The Science of Biological Prevention: Will My Child Become an Alcoholic or Drug Addict? Dr. Clinical Associate Professor University of Georgia College of Pharmacy Athens, Georgia 1 The Science of Biological Prevention is translated into the Epidemiology of Addictive Diseases 2 What is Epidemiology? 1

2 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 2

3 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 3

4 Basic triad of analytical epidemiology THE THREE PHENOMENA ASSESSED IN ANALYTIC EPIDEMIOLOGY ARE: HOST AGENT ENVIRONMENT Progression of Drug Dependence From: Heilig M and Koob GF, Trends Neurosci, 2007, 30:

5 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 Binge/Intoxication Stage Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) Withdrawal/Negative Affect Stage Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010)

6 Reward Transmitters Implicated in the Motivational Effects of Drugs of Abuse Positive Hedonic Effects Dopamine Opioid peptides Serotonin GABA Negative Hedonic Effects of Withdrawal Dopamine dysphoria Opioid peptides... pain Serotonin dysphoria GABA anxiety, panic attacks Preoccupation/Anticipation Craving Stage Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) Brain Arousal-Stress System Modulation in the Extended Amygdala 6

7 Pain, Emotions, and the Amygdala From: Neugebauer V, Li W, Gird GC and Han JS, The Neuroscientist, 2004, 10: Binge/Intoxication Stage Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) Withdrawal/Negative Affect Stage Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010)

8 Preoccupation/Anticipation Craving Stage Koob, G. F. and Volkow. N. D. Neurocircuitry of Addiction, Neuropsychopharmacology reviews 35 (2010) Epidemiology of Use and Abstention Percent Drank past year Lifetime abstainer > 64 Agents! Biological (micro-organisms)! Physical (temperature, radiation, trauma, others)! Chemical (acids, alkalis, poisons, tobacco, others)! Environmental (nutrients in diet, allergens, others)! Psychological experiences 8

9 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 9

10 CLASSIC EPIDEMIOLOGIC RESEARCH INTO ETIOLOGY Other factors including health care Environmental Factor(s) Outcome Probability of Transitioning from Alcohol Use to Dependence MERRILL NORTON, PharmD, DPh, ICCDP-D Clinical Associate Professor College of Pharmacy The University of Georgia 29 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. (Accessed October 8, 2012)

11 Nationally representative face-to-face survey of 43,093 respondents, 18 years and older. Conducted by NIAAA in 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 Million Substance Use Disorder Only 4.2 Million 15.4 Million SMI Only Co-Occurring Disorders 32 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 % 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 % have an anxiety disorder 33 11

12 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. 34 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 cooccurring mood or anxiety disorder. 35 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 36 12

13 2% users transition to dependence after first year of use 11% after decade of first use (Accessed October 8, 2012) 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 38 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 13

14 The Study Design! The reason for this study is to identify potential addiction predictability risk factors in studentpharmacists 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. 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 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 Questions UGA IRB approved Qualtrics Survey 14

15 2. What is your gender? # Answer Response % 1 Male % 2 Female % Total % 4. What is your current year in Pharmacy School? # Answer Response % 1 First Year % 2 Second Year % 3 Third Year % 4 Fourth Year 4 1% 5 Residency 1 0% Total % 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 % 6 Other 13 3% Total % 15

16 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. Merrill Norton Pharm.D.,D.Ph.,ICCDP- D FAMILY HISTORY OF ALCOHOLISM/SUBSTANCE ABUSE # Question Problem, but no treatment Problem treated No problem Unknown Responses Mean 1 Grandparents Mother Father Brother/Sister Children Current Spouse Other FAMILY HISTORY OF PSYCHIATRIC ILLNESS # Question Problem, but no treatment Problem treated No problem Unknown Responses Mean 1 Grandparents Mother Father Brother/Sister Children Current Spouse Other

17 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% Times a Month % 5 Once a Week 72 18% Times a Week 56 14% 7 Daily 4 1% Total % 23. How many drinks containing alcohol do you have on a typical day when you are drinking? # Answer Response % 1 1 to % 2 2 to % 3 5 to % 4 7 to % 5 10 or more 3 1% Total % 28. How often in the last year have you had a feeling of guilt or remorse after drinking. # Answer Response % 1 Never % 2 Less than once a month 92 28% 3 Monthly 16 5% 4 Weekly 3 1% 5 Daily or almost daily 0 0% Total % 17

18 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 Merrill Norton Pharm.D.,D.Ph.,ICCDP- D TRAUMA HISTORY Have you ever experienced a significant traumatic experience in your lifetime? # Answer Response % 1 Yes % 2 No % Total % 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. Merrill Norton Pharm.D.,D.Ph.,ICCDP- D 54 18

19 37. NEGATIVE PROSCRIPTIONS Indicate whether you agree or disagree with the following: Prescription dru... # Answer Response % 1 Strongly agree % 2 Agree 92 23% 3 Neutral 10 3% 4 Disagree 9 2% 5 Strongly Disagree 5 1% Total % 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. Merrill Norton Pharm.D.,D.Ph.,ICCDP- D PROTECTIVE FACTORS Indicate the level at which the following applies to you: I talk to my parents/sp... # Answer Response % 1 Always applies % 2 Mostly applies % 3 Applies 42 11% 4 Somewhat applies 55 14% 5 Does not apply 15 4% Total % 19

20 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. Merrill Norton Pharm.D.,D.Ph.,ICCDP- D Are you using currently? # Answer Response % 1 Yes 91 29% 2 No % Total % 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 % Total % 20

21 The probability of transitioning from alcohol use to dependence is greatest three years after the first use of alcohol 0.06 Proportion of At-Risk Respondents Who Transition To Alcohol Dependence > Overall P3 P2 P1 Mean Median Mode Total No. of Respondents * * Total number includes P4 respondents (not listed) 62 Overall P3 P2 P1 Mean Median Mode Total No. of Respondents * * Total number includes P4 respondents (not listed) 63 21

22 FAMILY HISTORY OF ALCOHOLISM/SUBSTANCE ABUSE Overall P3 P2 P1 No. with Family HX Total No Percent with Family HX Total No. of 1 st Degree Relatives with Alcohol/S.A. Problems No. of Relatives with Alcohol/S.A. Problem per Respondent with Family HX No. Fathers No. Mothers No. Grandparents No. Siblings No. Children No. Spouses No. Other Greater than 15 (%) Overall P3 P2 P1 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 65 FAMILY HISTORY OF PSYCHIATRIC DISORDER Overall P3 P2 P1 No. with Family HX Total No Percent with Family HX Total No. of 1 st Degree Relatives with Alcohol/S.A. Problems No. of Relatives with Alcohol/S.A. Problem per Respondent with Family HX No. Fathers No. Mothers No. Grandparents No. Siblings No. Children No. Spouses No. Other

23 Overall P3 P2 P1 Overall P3 P2 P1 Mean Mean Median Median Mode Mode FAMILY HX OF ALCOHOLISM/S.A. FAMILY HX PSYCHIATRIC DISORDER 67 Overall P3 P2 P1 Overall P3 P2 P1 Mean Mean Median Median Mode Mode AUDIT SCORE > 16 AUDIT SCORE 8 TO Overall P3 P2 P1 Mean Median Mode AUDIT SCORES 0 to

24 Overall P3 P2 P1 Experienced Traumatic Event in Lifetime Received Counseling for Traumatic Event Alcohol or Drugs Led to Traumatic Event Turning to Alcohol or Drugs Helps to Cope Alcohol or Drugs Relieves Pain from Trauma Quit Smoking But Wanted to Restart After Traumatic Event The probability of transitioning from alcohol use to dependence is greatest three years after the first use of alcohol 0.06 Proportion of At-Risk Respondents Who Transition To Alcohol Dependence >

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