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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)