Substance Use Disorders
Chapter G.1

ALCOHOL MISUSE

Joseph M Rey
DEPRESSION IN CHILDREN AND
ADOLESCENTS

Adapted by Thomas Campbell
and Julie Chilton

The “IACAPAP Textbook of Child and Adolescent Mental Health” is available at theIACAPAP website http://iacapap.org/iacapap-textbook-of-child-and-adolescentmental-health
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Alcohol Use DisorderOutline•
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BurdenEpidemiology
Pathophysiology
Etiology
Clinical Assessment
Diagnosis
Treatment
Prevention
References
The Triumph of Bacchus or The Drunks (c.1629).
Diego Velázquez, Museo del Prado, Madrid

Alcohol Use Disorder

Background

Ethanol (ethyl alcohol--EtOH)
Fermentation of carbohydrates
Began nearly 9000 years ago
Not available in some countries
Classification:• Fermented• Distilled• Measured in ml of alcohol/100 ml of beverage• Alcohol by volume (ABV)• 6% Beer = 6 ml of EtOH/100ml•••••

Alcohol Use Disorder

Per Head Consumption• Worldwide consumption= 6L/person (2005)• 29% not purchased legally• Eastern Europe: highest drinking rates• 1/5 deaths from harmful drinking inCommonwealth of Independent States• Western Europe: lowest rates of intoxication• High abstention: Muslim, female populations
WHO’s Global Status Report on Alcohol and Health 2011https://www.who.int/substance_abuse/publications/global_alcohol_report/msbgsr
uprofiles.pdf

Alcohol Use Disorder

Burden Of Alcohol Use• Risk factor for incident disability-adjusted life-years(DALYs)• 7% of all DALYs in 10–24 year-olds• 4% of deaths worldwide• Higher rate of fatal injuries in the young• Greater burden: males, poorer people, lower incomecountries• Significant economic burden– >1%GDP– High income (USA: 2.7% )– Middle income (S Korea: 3.3%)

Alcohol Use DisorderCausal/Component Factor of Disease and Injury• Reduced school and work performance• Accidents and injuries• Family disharmony and violence• Suicide, homicide, crime• Teratogenicity• Neurotoxicity• Acquired brain damage in later years• Cancer• Cirrhosis of the liver(WHO, 2011)

Alcohol Use Disorder

Alcohol and Suicide

https://www.youtube.com/watch?v=UgK5QtV6QUc&feature=relmfu

WetWetanddrypatternand Dry Pattern
Alcohol Use Disorder• Wet: small amounts frequently– Meals and family celebrations– Southern Europe• Dry: irregular heavy drinking– Less family oriented occasions– Northern Europe

Alcohol Use Disorder

Epidemiology• Varies between different countries and cultures– Rite of passage– Teen risk taking• Worldwide increase in recent decades:– Industrialization of the developing world– Globalization– Growing wealth– Increased availability of high-alcohol pre-prepareddrinks– Lower relative price of alcoholic beverages– Increased publicity and marketing

Alcohol Use Disorder

Monitoring the Future and ESPAD• Monitoring the future (USA)– Survey 50,000 students/year– Substance use behavior and attitudes
http://monitoringthefuture.org/• ESPAD– European School Survey Project on Alcohol andOther Drugs– 35 European countries– 100,000 age 16 students
http://www.espad.org/

Alcohol Use Disorder

Pathophysiology of Alcohol Use• Rapid absorption and distribution• Disinhibition, impaired memory and decision
making, incoordination• Nausea, vomiting, hangover, blackouts, andacute gastritis• Stupor, coma, and death from respiratory
depression

“I drank an ‘Irish car bomb’ and a beer and two shotsof Smirnoff vodka. I was perfectly fine. Then it hit me
all at once (I think I drank too fast). I was told thefollowing day that I tried to kiss people at the party
including a girl, her sister and another boy (I'm a girlby the way). I woke to thorns in my feet, dirt in myshoes, my cell phone was in the woods, my keys inanother person's custody, and my car rearranged. I
woke not having to pee, so I hope I didn't just decideto pee in front of everybody. Oh god, I think I would
die of shame!” (Anonymous).

Alcohol Use Disorder

Pathophysiology of Alcohol Use
BAC range* (g/100 mL of blood) and[alcohol consumed − approximate
standard drinks**]

Observable effects

0.01-0.05 [1-3]Normal behavior, subjective feelings ofrelaxation, talkative, more confident

0.05-0.08 [3-5]Euphoria: increased self-confidence,talkativeness, disinhibition, loss ofconcentration, impaired coordination.

0.09-0.15 [5-9]

Excitement: Slurring speech, unsteadybalance, emotional instability, loss ofjudgement.

0.16-0.25 [9-16]

Confusion: disorientation, nausea,
vomiting, memory impairment, staggering
gait, apathy, incoordination

Above 0.25 [>16]

Stupor, coma:

Alcohol Use Disorder

Metabolism• BAC increases 10-20 mg/100 ml per 10g EtOH
• EtOH breakdown at 7-10g/ hour
• Metabolized by liver– Alcohol dehydrogenase– Aldehyde dehydrogenase• Onset before age 14 high risk for AUD• Teratogenic

Alcohol Use Disorder

Alcohol and the Developing Brain:
Use During Pregnancy
Fetal Alcohol Syndrome (FAS):– Teratogenic effects of alcohol on the fetus– 1% of all births in western countries have somedeficits– Full syndrome occurs with binge or repeated use– Facial features from exposure during week 3Alcohol Use Disorder

Alcohol and the Developing Brain:
Use During Adolescence• Earlier onset– especially before 14– increased likelihood of adverse outcomes: AUD, morerapid progression, longer duration, greater difficultywith abstinence• Different effects on adolescent vs adult brain– more resistant to:• intoxicating effects• aversive effects– more sensitive to social facilitation effects

Alcohol Use Disorder

Alcohol and the Developing Brain:
Risk Factors for Early Onset Drinking• Conduct disorder• Anxiety• Shyness• Depression• ADHD• Being abused• Family conflict• Poor parenting• Inadequate monitoring• Poverty• Parental modelingof drinking• Peer influences

Gary Reinbach, a 22 year old Englishman from
Dagenham, Essex, died in hospital after he wasrefused a liver transplant because he could notprove he had not drank alcohol for at least six
months — one of the requirements for livertransplant in the UK. Mr Reinbach had been
admitted to hospital 10 weeks earlier withcirrhosis of the liver. His family said he had
started drinking at 11 years of age and drankheavily after the age of 13 (Rouse, 2009).

https://www.youtube.com/watch?v=zXjANz9r5F0&feature=related

Alcohol Use Disorder

Factors that Increase Risk of AUDs
• Genetic– Adoption, twin, family studies• Individual– ADHD, conduct disorder, anxiety• Family– Parent or sibling drinking habits– Permissive parenting– Poor supervision• Social– Friends– Culture– Easy availability– Being an indigenous minority

Alcohol Use Disorder

Pathophysiology of Alcohol Use

Alcohol Use Disorder

Pathophysiology of Alcohol Use

Alcohol Use DisorderPathophysiology of Alcohol Use

Alcohol Use Disorder

Clinical Assessment• Building rapport:– Non-judgmental– Motivational interviewing• Confidentiality:– Discuss scope and limits– Improves disclosure• Screening:– All adolescents– If positive -> gather details– From general to specific questions

Alcohol Use Disorder

Assessment Interview• Adjust to developmental age and stage• Screen psychiatric co-morbidities• Information gathered about:– Predisposing factors– Triggers– Perpetuating factors– Family/friends use– Protective factors

Alcohol Use DisorderClinical Assessment: Important Questions
Age at initiation

The age at which more than a sip of alcohol wasconsumed

Frequency of consumption• Daily, weekly, or irregularly?

Amount and type

• Describe last drinking occasion• Number of each type of drink consumed?

Pattern• Describe recent drinking• Describe heaviest drinking periodContext••••

Triggers for use: boredom or anxiety
Drinking alone, with friends or both?
What benefits do you get out of drinking?
How do you pay for it?

Alcohol Use Disorder

Clinical Assessment: Clarify Consequences
Intoxication• Have you ever been drunk?
• How many times?
• Ever had blackouts?

Hangover• Ever had a hangover?
• Does it often when you drink?

Accidents• Involved in a car accident afterdrinking?

Risk Taking• Unprotected sex after drinking?
• Driven a car while intoxicated?

Impairment• Alcohol caused impairment in otherareas of functioning?

Alcohol Use Disorder

Alcohol Use Disorders Identification Test (AUDIT)
AUDIT Score: Risk Stratification• < 8: Low risk drinking or abstinence• 8-15: Alcohol use > low-riskrecommendations• 16-19: Harmful or hazardousdrinking• > 19: High risk or dependence
https://www.who.int/substance_abuse/publications/audit/en/

Alcohol Use Disorder

Two-Question Screen• In the past year, have you sometimes been
under the influence of alcohol in situations
where you could have caused an accident orgotten hurt?
• Have there often been times when you had a
lot more to drink than you intended to have?
1 Yes = 8 x risk of AUD(Newton and colleagues, 2011)

Alcohol Use DisorderBiomarkers• Acute:– Blood alcohol Content (BAC)• Chronic:– Aspartate aminotransferace (AST)– Alanine aminotransferace (ALT)– Mean corpuscular volume (MCV)– Gamma glutamyltransferase (GGT)Alcohol Use Disorder

Diagnosis
Diagnosis:
Intoxication
Intoxication:– Most common EtOH issue in adolescents– Severe = EtOH poisoning– 1st, exclude other causes– 2nd, impaired functioning?
– 3rd, at least one of:slurred speech, incoordination, unsteady gait, nystagmus,attention or memory impairment, stupor, coma

Alcohol Use Disorder

Diagnosing AUD and Withdrawal

Diagnosis = two or more presentA 17-year-old German man was taken to emergency
because of vomiting and dizziness after having run
two 100 m races at school. He was hyperventilating,slightly tachycardic and tired but could be awaken. He
subsequently revealed having drunk 3 L of an energy
drink and 1 L of vodka (equivalent to 4600 mg oftaurine, 780 mg of caffeine and 380 g of alcohol).
Combining energy drinks with alcohol is becoming
increasingly popular among youth. The combination,
particularly in large amounts, poses considerable risk.
(Schöffl et al, 2011).

Alcohol Use Disorder

Treatment

Source: National Institute on Alcohol Abuse and Alcoholism (NIAAA)

Treatment
Treatment: Intoxication
Alcohol Use Disorder• Common in adolescents• Severe intoxication= alcohol poisoning– Requires immediate attention– Hypothermia, arrhythmias, compromised heart
function and breathing– No gag or cough reflexà acute respiratory
obstruction with vomit– Aggressive respiratory and cardiovascular supportive
care– Exclude traumatic injuries and comorbid ingestions– Follow up with intervention or treatment

Treatment
Treatment: Withdrawal
Alcohol Use Disorder

Withdrawal:– Majority treated as outpatient– Try to involve family– Reassurance, encouragement without criticism– Fluids, nutrition, thiamine, multivitamins– Severe cases: benzodiazepines to reduce seizure risk
• Fixed schedule• Symptom-triggered regime– Severe agitation or hallucinations: add haloperidol

Alcohol Use Disorder

General Treatment• Often mandated (by parents, school or court)• Build rapport• Gain insight• Motivation for change: MotivationalInterviewing• At home breathalysers• Abstinence vs. harm reduction– Specific needs, personality, and beliefs

Alcohol Use DisorderStages of Change• Pre-contemplation• Contemplation• Preparation/determination• Action• Maintenance• Relapse

Alcohol Use DisorderTreatment• Psychosocial Treatments:– Brief interventions, popular– Opportunistic interventions– Individualized feedback from e-treatments– Contingency management therapy– Alcoholics Anonymous• Pharmacologic Treatments:– Disulfram, naltrexone, and acomprosate.
– Medications + psychosocial treatments = better
outcomes• Breathalyzers

Alcohol Use Disorder

Psychosocial Treatments• Motivational enhancement therapy• Brief interventions• Internet & cellular phone based interventions• Family therapy• Multi-systemic therapy• Contingency management therapy• Cognitive behavior therapy (CBT)• Alcoholics Anonymous (AA)• Multi-modal treatments

Alcohol Use Disorder

Youth and AA

https://aa.org.au/

Alcohol Use Disorder

Contingency Management• Assessment of problem• Formal agreement• Schedule of rewards• Breathalyzer test 2/week• Example: 1st negative test: $2; 2nd negative
test: $4; 3rd negative test: $6; 4th test
positive: $0, reward schedule is reset
Stanger et al (2009)

Alcohol Use Disorder

Pharmacology and AUD
Medications (Dose*)

CommentsDisulfiram(Start 125mg/day -> 500mg/day)-Alcohol sensitizing-Unpleasant reaction

Naltrexone(Start 25mg/day -> 50mg/day)-Helps prevent relapse-Long-acting available-Monitor LFTs

Acamprosate(666 mg TID)

-Improve abstinence-Side effects: nausea, insomnia, diarrhea

Other-Baclofen, SSRIs, Ondansetron, andTopiramate*These are the recommended doses for adults

Alcohol Use Disorder

Is Naltrexone Effective for Alcoholism?

https://www.youtube.com/watch?v=vQ8SVFjm05w

Alcohol Use Disorder

Resources:

National Institute on Alcohol Abuse and Alcoholism
Helping Patients Who Drink Too Much: A Clinician's Guide and RelatedProfessional Support Resources

https://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

Alcohol Use Disorder

Prevention

A car crash on Jagtvej in Copenhagen, Denmark. Source: Wikimedia Commons

Prevention
Prevention
Alcohol Use Disorder• Universal vs. targeted interventions• Legislative Measures:– Regulating minimum drinking age– Drinking and driving laws
– Advertising– Minimum pricing– Availability

Alcohol Use Disorder

Prevention• Prevention Programs:– Increase knowledge about harm
– Explore attitudes and perceptions– Develop decision making, assertiveness, and coping
skills– Increase awareness of influences on alcohol use– Personalized feedback• Longer term benefits with psychosocial
approaches– Unplugged program and Good Behaviour Game
http://www.state.ky.us/agencies/behave/misc/DBWHandouts/BI12/Di
ana%20Session%201%20Ho%20-%20Good%20Behavior%20Game.pdf