mini med delightful poison pub

ALCOHOL

A Delightful Poison?

Director, TEACH Project, Centre for Addiction and Mental HealthDirector, Collaborative Program in Addiction Studies, University of Toronto

Assistant Professor (Status Only) Factor‐Inwentash Faculty of Social Work, U of T

Marilyn Herie PhD, RSW

“Alcohol may be man’s worst enemy, but the bible says love your enemy.”

- Frank Sinatra

"He was a wise man who invented beer." -Plato

1. A feature that resonated for me

2. A question I want to think through

3. A seed I could plant now

Learning Objectives

At the end of this session, you will be able to:1.

Identify the physical effects of alcohol

2.

Define low‐risk drinking and reflect on where your  own and others’

drinking fits into Canadian drinking 

norms3.

Explain why women and older adults are at higher 

risk for alcohol‐related problems4.

Use simple screening tools to detect who might be 

at risk for alcohol problems5.

Access credible and evidence‐based online 

resources, self‐help and treatment programs.

Addiction: A binary construct?

Addiction: A continuum of severity

No Alcohol Problems

Severe Alcohol Problems

Psychoactive Drug Classes

1) Depressants

2) Opiates/Opioids

3) Stimulants

4) Hallucinogens

5) Psychiatric Medications

Depressants

Opiates/Opioids

methamphetimine.co.uk

Stimulants

Hallucinogens

psychology.wikia.com

Psychiatric Medications

www.camh.ca

What is standard?

http://www2.ku.edu

= 14 grams or .6 oz of pure alcohol

http://wcu.edu

http://www.camh.ca

Women:10 drinks per week

2 drinks per day

Men:15 drinks per week

3 drinks per day

How much do Canadians drink?How much do Canadians drink?

Canadian Men = 

________ standard drinks

Canadian women = 

________ standard drinks

Turn to the person next  to you and tell them 

your guess of the  percentage of Canadian 

men

and Canadian  women

who drink more 

than 14 standard drinks  in a typical week.

Jolinda almost never drinks at home with her family, but occasionally on week ends she gets together with a group of female friends for dinner and conversation. On the rare occasions when she has more than one or two drinks she says that she feels drunk and dizzy. Jolinda is known among her social group as the one who “can’t hold her liquor,” and is sometimes the subject of friendly teasing among the group.

Alex loves to entertain and socialize with friends and family. His dinner parties are legendary for their fine food and wine, and creating new recipes and shopping for hard-to-find ingredients is one of his favourite hobbies. If he were asked to quantify his drinking, Alex wouldn’t know where to start – alcohol is very much a part of his life, yet he has a successful career and a close relationship with his adult children, although his wife sometimes “nags” him about his drinking. Although he drinks a lot on many occasions, his friends have only rarely ever seen him “drunk”.

•Tolerance•Cross‐tolerance•Potentiation

XPOTENTIATION

Absorption and Metabolism

mucous membranes (mouth)

large intestine

esophagus

stomach (up to 20%)

small intestine (up to 80%)

Alcohol is metabolized in the body mainly by the liver. The brain, pancreas, and stomach also metabolize alcohol.

pancreasliver

stomach

esophagus

brain

http://pubs.niaaa.nih.gov/publications/AA72/AA72.htm

http://pubs.niaaa.nih.gov/publications/AA72/AA72.htm

Further broken down to carbon dioxide and water

Other enzymes:cytochrome P450 2E1 (CYP2E1)

catalase

Chemical name for alcohol

Enzyme in the liver transforms ethanol into a toxic compound

A known carcinogen, quickly broken down…

…by another enzyme into…

http://caaneo.ca/about/blog/?page_id=30

.0554

http://caaneo.ca/about/blog/?page_id=30

.0875

Physical Effects of Alcohol

http://www.drugabuse.gov/publications/teaching-packets/brain-actions-cocaine- opiates-marijuana/section-ii-introduction-to-reward-system/2-reward-pathw

Effects on the Brain

• Limbic system:

complex monitoring system  including memory and emotion

• Cerebellum:

motor coordination, also  emotion and memory

• Cerebral Cortex:

think, plan, behave  intelligently and social interaction –

damage 

can impair problem‐solving, memory and  learning

Sullivan et al., Neuropsychology

CONTROL ALCOHOL

Effects on the Cerebellum

Reduction in size of brain cells and brain mass shrinks

What are the  heart risks of  chronic 

heavy or  binge 

drinking?

• Alcoholic  cardiomyopathy

• Arrhythmias• Strokes• Hypertension

NIAAA, 2011

Binge drinkers are 40% more likely to suffer any kind of stroke

“There is now little doubt that  moderate alcohol consumption is 

associated with reduced coronary  heart disease risk in both men and  women.”

Herie and Skinner, 2010

Moderate drinking can…

• Reduce/inhibit build up of fat in arteries and  raise HDL (“good”) cholesterol

• Prevent clotting – guards against stroke and  heart attack

• Keep blood pressure in check

Potentially reduced risk of heart disease

Potentially increased risk

of cancer

Smoking + Drinking POTENTIATES cancer- causing properties of each substance

http://www.drugabuse.gov/publications/teaching-packets/brain-actions-cocaine- opiates-marijuana/section-ii-introduction-to-reward-system/2-reward-pathw

11% of all breast cancers

ACETALDEHYDE damages genetic material in cells, and causes cells to grow too quickly

http://www.drugabuse.gov/publications/teaching-packets/brain-actions-cocaine- opiates-marijuana/section-ii-introduction-to-reward-system/2-reward-pathw

What are the  risks to the 

liver of  chronic  alcohol use?

http://www.drugabuse.gov/publications/teaching-packets/brain-actions-cocaine- opiates-marijuana/section-ii-introduction-to-reward-system/2-reward-pathw

• Steatosis

(fatty  liver)

• Alcoholic  hepatitis

• Fibrosis (scar  tissue)

• Cirrhosis– Jaundice, Type 

2 diabetes, Liver  cancer

NIAAA, 2011

90% of heavy drinkers will develop fatty liver

1 in 5 will develop alcoholic hepatitis

1 in 4 will develop cirrhosis

What are the  pancreatic 

risks of  chronic  heavy or 

binge  drinking?

http://www.drugabuse.gov/publications/teaching-packets/brain-actions-cocaine- opiates-marijuana/section-ii-introduction-to-reward-system/2-reward-pathw

• Acute  pancreatitis

• Chronic  pancreatitis

–Pancreatic  cancer

– Type 2 diabetes

NIAAA, 2011

Approx 5% of heavy drinkers will develop pancreatitis

Alcohol’s Effects on the Immune  System

Alcohol suppresses the immune system

Chronic use impairs white blood cell functioning

Impairment up to 24 hours after binge drinking

How can I tell who is at risk?

DSM 5: Proposed Revisions

“Given the empirical evidence, the DSM‐5  Substance Use Disorders

Workgroup  

recommends combining abuse and  dependence into a single disorder of graded 

clinical severity, with two criteria required to  make a diagnosis.”

www.dsm5.org

A maladaptive pattern of substance use leading to clinically  significant impairment or distress, as manifested by 2 or more of 

the following within a 12 month period:

1.

Failure to fulfill major  obligations at school, work 

or home2.

Recurrent use in physically 

hazardous situations3.

Persistent 

social/interpersonal  problems

4.

Tolerance5.

Withdrawal

6.

Larger amounts or for  longer period than 

intended

7.

Persistent desire or  unsuccessful efforts to cut 

down/control8.

Time spent in obtaining, 

using or recovering9.

Important activities given 

up or reduced10.

Continued use despite 

knowing that physical or  psychological problems will 

become worse or were  caused

11.

Craving, strong desire or  urge

www.dsm5.org

X?

X

X

X

X

?

?

?

X

Three Suggested Screening Tools

1.

Quantity/Frequency2.

CAGE

3.

Single Item

1. Quantity/Frequency Questions

• How many days per week did you drink over  the last month? 

• On a day when you drink, how many drinks  do you have? 

• How many times during the last month did  you drink more than 5 drinks? (binge  

drinking)

Cooney, Zweben & Fleming, 1995

30

4-5

6-7

2. CAGE QUESTIONS1.

Have you ever felt the need to Cut down 

on your drinking?

2. Have you ever been Annoyed at criticism 

of your drinking?

3. Have you ever felt Guilty about your 

drinking?

4. Have you ever had a morning Eye 

opener?2 or more “yes” answers is clinically significant.

Mayfield et al., 1974

NO

YES

NO

NO

3. Single Item• A one‐item questionnaire developed for 

brief screening in primary care settings.  • Ask client:How many times in the past year have you had ___ or more drinks in a day?__ = 5 for men__ = 4 for women

Scoring:

an answer of more than 1 identifies  unhealthy alcohol use

National Institute on Alcohol Abuse and Alcoholism (NIAAA): Helping Patients Who Drink Too Much: A Clinician's Guide 2007

6 x 12 = 72

Psychosocial Treatment Resources

ContinuumofPsychosocial TreatmentServices

Pre

vent

ion

Custodial C

are

Levels of Treatment IntensityMinimallyIntensive

HighlyIntensive

Mild toModerate

SubstantialTo Severe

FacilitateRecoverywithout

Treatment

Brief Community

Interventions (e.g.., self-help manuals,physician’s advice)

Short-termOutpatient

Self-ChangeOriented

InterventionsShort-termOutpatientTherapist-Directed

Interventions

ResidentialHospital-Based

Day Treatment

ResidentialSocialModel

ExtendedOutpatient

Interventions

Long-termResidential

Severity of ProblemsCAMH

Client‐Treatment Matching• Lack of strong evidence by which to match clients to specific 

treatments• Does not mean that clients all require the same types of services• A variety of flexible and individualized services are required• Guidelines for selecting services are needed

Lo Lo Hi

Lo-Hi Lo-Hi Mod-Hi

Mod-Hi Mod-Hi Mod

Mod-Hi LoMod-Hi

Brief Outpatient

ProblemMultiplicity

Social Support& Stability

Drug UseSeverity

Outpatient

Day Treatment

Residential

Skinner & Martin, 1995

www.connexontario.ca

www.camh.ca

McLaughlin Information Centre

CAMH now has 'centralized access' with one doorway  (a front door) to ALL services

1‐800‐463‐6273

or 416‐595‐6111

Call if you would like:• General addiction and mental illness information • Information on how to obtain assessments for 

mental health and addictions

What if the person refuses to seek help?

www.alcoholhelpcenter.net

Case Example

• Alex, 52 years old• Drinks 7 days per week• Approximately 40 drinks per week

www.alcoholhelpcenter.net

How does your drinking compare with  other Canadian men in your age group?

Within the last twelve (12) months: • You reported drinking on approximately 

100.0% of days

in the last year. 

• You reported that you drank a total of 

? #  of drinks

in the last year. 

www.alcoholhelpcenter.net

Within the last twelve (12) months: • You reported drinking on approximately 

100.0% of days

in the last year. 

• You reported that you drank a total of 2080  drinks

in the last year. 

www.alcoholhelpcenter.net

This also means that: 

• You spent approximately 

? $  in the last  year, depending on where you drank (at 

home, in a bar, etc.). 

www.alcoholhelpcenter.net

This also means that: • You spent approximately $10,400

in the last 

year, depending on where you drank (at  home, in a bar, etc.). 

www.alcoholhelpcenter.net

• You consumed (on average) 500 calories

from  alcohol on days that you drink. Based on the 

total amount of drinking you had enough  alcohol to add roughly 59 pounds

or 27 

kilograms to your weight in the last year.  Note:

One drink has about 100 calories and 

3,500 calories roughly equals 1 extra pound of  weight. 

• You also reported that within the past year,  the greatest number of drinks you had on one 

occasion was 12 drinks. www.alcoholhelpcenter.net

www.alcoholhelpcenter.net

www.alcoholhelpcenter.net

You reported that you weigh 160 lbs. This  means that: 

• If your liver is healthy, burning one drink takes you 2  hours. Burning four drinks takes you about 8 hours. 

If you had ten drinks, it will take about 19

hours until there is no alcohol in your system. 

www.alcoholhelpcenter.net

• In the last year you spent about 

? hours under the  influence of alcohol

(based on your typical drinking 

during one week).

www.alcoholhelpcenter.net

• In the last year you spent about 4,004

hours  under the influence of alcohol

(based on your 

typical drinking during one week).

www.alcoholhelpcenter.net

Hmm…

1. A feature that resonated for me

2. A question I want to think through

3. A seed I could plant now

Playlist

• La Traviata, Giusseppe

Verdi: The "Drinking Song”• Eric Burdon and War – Spill the Wine• UB 40 – Red Red

Wine 

• Frank Sinatra – The Lady is a Tramp• Jimmy Buffett –

Margaritaville

• Garth Brooks – Friends in Low Places • Amy Winehouse

–

Rehab

• Frank Sinatra – One for My Baby (One for The  Road)