Alcohol:
What’s the problem?
Professor Colin Drummond
Institute of Psychiatry,
Kings College London
Topics
• What causes alcohol problems?
• Alcohol dependence
• Conclusions
Alcohol is a toxic and dependence
producing DRUG
• Acute effects
– Highly variable
– Pleasure, relaxation
– Impaired judgement,
coordination, balance
– Mood effects
– Argumentativeness
and aggression
– Drowsiness
– Impaired
consciousness
– Coma, respiratory
depression and death.
• Chronic effects
– Toxic effects on
organs
– Over 60 diseases
– Psychiatric disorders
– Foetal alcohol effects
– Psychoactive effects:
alcohol dependence
– 3rd leading cause of
disability after tobacco
and hypertension
– No universally “safe”
level
What causes alcohol
problems?
What is a “unit” of alcohol?
•
•
•
•
8g ethanol
1/2 pint beer (3%)
1 measure spirits (25ml)
1/4 pint strong lager (6%)
• 1 litre of spirits = 40 units
• 1 bottle of wine = 9 units
• 1 can of very strong lager (9%) = 4 units
“Safe” and “harmful” levels
• “Safe”
- men < 21 units per week
- women < 14 units per week
• “Harmful”
- men > 50 units per week
- women > 35 units per week
Royal College of Psychiatrists, 1986
• Daily limits 4/3 units
Department of Health, 1995
What causes problems? Acute
effects
•
•
•
•
•
•
•
Impaired judgement
Disinhibition
Aggressiveness
Loss of coordination
Drowsiness
Coma
Alcohol poisoning
BLOOD ALCOHOL CONCENTRATION AND EFFECTS
AMOUNT
1 PINT BEER
DOUBLE WHISKY
1.5 PINTS
3 WHISKIES
BLOOD ALCOHOL
(mg/100ml)
30
50
2.5 PINTS
5 WHISKIES
5 PINTS
10 WHISKIES
80
6 PINTS
1/2 BOTTLE WHISKY
9 PINTS
3/4 BOTTLE WHISKY
12 PINTS
1BOTTLE WHISKY
200
150
400
500
EFFECT
INCREASED
ACCIDENT RISK
CHEERFULNESS
IMPAIRED
JUDGEMENT, DISINHIBITION
LOSS OF DRIVING LICENSE
(IF CAUGHT)
LOSS OF SELF CONTROL
QUARRELSOMENESS,
SLURRED SPEECH
STAGGER, DOUBLE VISION
BLACKOUTS
OBLIVION, DROWSINESS,
COMA
DEATH POSSIBLE
DEATH LIKELY AT 600+
What causes problems?
Chronic effects
•
•
•
•
•
•
•
Tissue damage
Chronic effects on the brain
Psychiatric comorbidity
Relationships (inc. marital and parenting)
Loss of employment
Financial problems
Alcohol dependence
South West London comorbidity
study
McCloud, Drummond, Barnaby, Omu, Burns, 2004
• 200 consecutive admissions to 2 psychiatric hospitals
• Screened with AUDIT
• 49% AUDIT 8+, 53% of males, 44% of females
– Psychosis
– Mood disorder
– Non-SMI
OR 0.2
OR 2.1
OR 6.5
• Suicidal presentation:
– AUDIT 8+
– AUDIT 15+
OR 3.0
OR 7.8
• Full alcohol history 0.5%, partial history 27%
The Alcohol Dependence Syndrome
Edwards & Gross, 1976
•
•
•
•
•
•
•
Narrowing of drinking repertoire
Salience of drink seeking behaviour
Increased tolerance
Repeated withdrawal symptoms
Relief or avoidance of withdrawal
Subjective awareness of compulsion to drink
Reinstatement after a period of abstinence
Dependence syndrome
Edwards & Gross, 1976
• Special kind of problem related to drinking
• Conceptually distinct from other problems
related to drinking
• Dimensional rather than categorical
• Clustering of symptoms not all of which
are invariably present
• Has at its basis an altered drive state
• Underlying processes
Aetiology of alcohol dependence
•
•
•
•
•
Genetics
Social learning
Expectancy
Stress
Exposure: peer group, occupational, availability,
price
• Conditioning: classical, reinforcement
• Neurobiology: dopamine, opioid, HPA
Conditioning model of alcohol cue reactivity
Falling blood
alcohol level
(US)
Alcohol cues
(e.g. sight and
smell of favourite
drink)
(CS)
Withdrawal
symptoms
(including craving)
(UR)
Conditioned
withdrawal
(including craving)
(CR)
Drummond, Cooper & Glautier, 1990
Dynamic regulatory model of craving and relapse
Drug-paired +
stimuli
+
+
Positive
affect
+
Negative
affect
+
Urges
Positive
outcome
expectancies
Self
efficacy
Physiological
activation
-
+
-
+
Coping
Attributions
-
Niaura, 2000
-
Drug
use
Prevalence of Past-year DSM-IV Alcohol Dependence
by Age in the United States
Prevalence of Past-year DSM-IV Alcohol
Dependence by Age – United States
14%
% Prevalence
12%
10%
8%
6%
4%
2%
65
-69
60
-64
55
-59
50
-54
45
-49
40
-44
35
-39
30
-34
25
-29
21
-24
18
-20
12
-17
0%
Age
18 + yrs. - NIAAA NES ARC ( Grant, et al., (2004) Drug and Alcohol Dependence, 74:223-234)
12-17 yrs - U.S. Substance Abuse and Mental Health Services Administration 2003 National
Survey on Drug Use and Health (NSDUH)
Source: NIAAA 2001-2002 NESARC data (18-60+ years of age)
and SAMHSA 2003 NSDUH (12-17 years of age)
Prevalence of Lifetime Alcohol Dependence by Age of
Prevalence
of Lifetime
Alcohol
Dependence
by Age of First
First Alcohol
Use and
Parental
History of Alcoholism
Alcohol Use and Family History of Alcoholism
2001-2002
1991-1992
60
% Prevalence
60
Parental History Positive
Total
Parental History Negative
50
50
40
40
30
30
20
20
10
10
0
0
13
14
15
16
17
18
19
20
21
<=13
14
15
16
17
18
Age at First Use of Alcohol
Source: NIAAA 1991-1992 NLAES data (left panel) and
NIAAA 2001-2002 NESARC data (right panel)
19
20
>=21
What is the outcome?
• In the young and minimally dependent: up to
80% improvement
• In dependent drinkers
- Short term (1 year): relapse common, up to 90% any
drinking, 70% reinstatement
- Long term (20 years): 40% dead (3.6 fold increase, most
in 45-55 year age group), 30% continuing problems,
30% abstinent or problem free
- Most deaths due to chest & heart disease, excess of
injury and poisoning
Conclusions
• Alcohol is a toxic and dependence
producing drug
• It has individually variable effects
• There is no universally “safe” level
• Major and growing public health problem
• Considerable health, criminal justice, and
other costs
• Need for effective strategies, including
better early intervention