Showing posts with label alcohol use disorders. Show all posts
Showing posts with label alcohol use disorders. Show all posts

Sunday, February 11, 2018

The Problem of the Drinking Spouse




Any physician treating alcoholism knows this scenario very well.  You have finally convinced a person that they have a problem with alcohol.  They have been in treatment and either using or not using MAT (medication assisted treatment - naltrexone or acamprosate).  They are at the point where they are abstinent many more days than they are drinking.  This is a critical point for many people who are daily drinkers.  As you work with them in trying to define critical factors for continued use they identify: "My husband/wife refuses to stop drinking.  They say it is my problem.  They like drinking and they refuse to stop.  They have alcohol at the house."

There are many variations on that theme.  Some spouses will keep all of the alcohol locked up and imbibe only when the sober spouse is sleeping.  Some will not have any alcohol at all, but continue to drink in social situations accompanied or unaccompanied by the sober spouse.  Some will just resent the sober spouse and the sudden restriction in the couple's social life.  Many couples start drinking to increase their social activity and expand their social contacts.  In many businesses, this level of socialization and the associated drinking is expected.  The associated level of emotionality in the marriage can increase precipitously based on the new expectations of the sober spouse about how things should be to support their sobriety.  The combination of the environmental cues from alcohol and increased emotionality greatly increase the risk for continued alcohol use and make all of these patterns untenable.  Convincing the drinking spouse that their behavior does not facilitate sobriety in the marriage is a difficult task - if it is attempted at all.

Are there any large scale studies that back up those clinical observations?  A certain portion of drinking spouses may respond to clear scientific evidence if they cannot respond to the advice of a counselor or physician.  It turns out that there are and a lot of that work has been done by Kendler and co-authors. 

The most recent paper in JAMA Psychiatry (1) looks at the issue of spousal resemblance for alcohol use disorder.  In the study, subjects were obtained from a generational sample of all people born between 1960 and 1990 in Sweden who were married before December 31, 2013.  They were identified as having alcohol use disorders (AUD) through several databases that looked at medical diagnoses, medication assisted treatment prescriptions (disulfiram, naltrexone, acamprosate) and convictions or suspicions of at least two alcohol related crimes.  That resulted in marital pairs - 5883 where the husband first developed an AUD and 2679 where the wife first developed an AUD.  They note that in marital pairs, first onset AUD was much greater in pairs where a spouse had an AUD than when they did not.

They analyzed the data by two methods.  First, they looked at hazard ratios of developing an AUD relative to a control group matched by sex, birth year, year or marriage, family history of AUD, and parental educational level.  Second, they looked at intraindividual hazard ratios across subsequent marriages and divorces.

In the first analysis, the hazard ratio of AUD in the wife after the husband had an initial AUD was 13.82 dropping to 2.75 over the first two years.  In the case of  husbands after a wife's first registration of AUD the hazard ratio was 9.21 falling more slowly to 3.09 after 3 years.

In the intraindividual comparisons - for husbands moving from a spouse with no AUD to one with an AUD resulted in a HR of 7.02.  Moving from a spouse with an AUD to one without and AUD decreased the risk to a HR of 0.50 for AUD.  The protective effects persisted in the same direction in second and third marriages.  They produced a comprehensive tables of 20 possible combinations of spouses +/- AUDs and list the protective and predisposing combinations.  In each case, whether or not the prospective spouse has an AUD predicts the the probands status.

The authors conclude that this is tentative evidence that a spouses alcohol use status has a causal effect on their spouses drinking.  They suggest the likely processes and suggest that assortative mating is a factor in the large increase in drinking that can occur when a man or woman without an AUD marries a man or woman with an AUD.  Assortative mating has been previously studied by Kendler (4) and is defined as mate selection that depends on similarity across traits - in this case drinking patterns and risk factors for AUD.  It is an interesting concept because it suggests at least part of the mechanism of greatly increased risk in the spouses of drinkers.  A non-drinking spouse with those characteristics may have more credibility as a protective effect, but those specifics are not clear at this time. 

The limitations are discussed in the original paper and I won't belabor them here.  Clearly the study design is an issue.  It is likely that cases were missed.  I have not seen it studied, by my experience with diagnoses and the American insurance system suggests that many people will do what they can to stay off of a database.  I can't imagine that is not also true in Sweden.  They did a comparison of the AUD prevalence of their data to Norway and found the prevalence was lower.  This methdology also focuses on more severe AUD.  I based that on the fact that the DSM-5 committee eliminated legal problems as a diagnostic criteria for AUD based on it not adding much to the criteria because it was associated with most of the other criteria.              

An observation about the study.  It could not have occurred in the United States - at least not on the same scale.  In the US, treatment for alcohol or substance use problems comes under the the auspices of §CFR 42, limiting access to information for research purposes.  Advocates for these restrictions will of course say they are necessary and that people can still release information like they can for any other medical condition - but like most of these regulations there is general confusion and intimidation of clinicians to the point that the extra hurdles necessary to do research are seldom breached.  In the US, in the case of non-public programs like Medicare or Medicaid, all of the data is aggregated by health care system.  In Scandinavian countries all patients are on a single national database.  In the Swedish study, the researchers assigned unique serial numbers to all of the subjects and the ethics committee approval waived consent because of this procedure.

This study gets back to a philosophy of life and the issue of sobriety or at least self-correcting abstinence.  Couples do have conversations about drinking.  They do make conscious decisions about drinking and substance use.  They observe one another when they have become too intoxicated and had significant embarrassment or hangover effects.  If there are no baseline agreements about the use of intoxicants early in the marriage there should be a discussion about self correcting abstinence.  When do we agree to stop whatever we are doing as a couple and reassess our use of intoxicants.  Things do not have to get to the level of an actual alcohol or substance use disorder.

Finally, what about the approach to the couple when there is a clearly defined alcohol or substance use problem?  The couple's dynamic does need to be identified and addressed.  For any physician or counselor approaching the problem is fraught with difficulty.  Spouses tend to be defensive, resentful, and in some cases openly hostile to the idea that they need to stop drinking.  The drinking spouse may see the physician or counselor as affiliated with the nondrinking spouse and that can amplify the resentment and negative emotion.  There are programs with a more neutral response that treats the drinking spouse in an entirely different context and provides the necessary education.  Al-Anon is the prototypical self help program for spouses that attempts to address anger, resentment, and provide a focus on positive strategies.  I am still waiting to see an explicit manual, pamphlet, or book that is focused on why the drinking spouse needs to stop drinking.  If I missed that please send me a link to that resource.   

Before you send a comment on the couple where one person is sober and the other person drinks, I can assure you that I am aware that the situation exists.  I typically see it where the spouses are independent and often have separate social and recreational outlets.  In many cases, one of the spouses works excessively and alcohol use is incorporated into work activities or becomes a ritual on the way home.  The situation I hope to address here is one where both spouses are drinking - usually too much and one of them wants to quit.

I have not seen a lot written about the problem or the solution.


George Dawson, MD, DFAPA


References:

1: Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. The Origin of Spousal Resemblance for Alcohol Use Disorder. JAMA Psychiatry. 2018 Feb 7. doi: 10.1001/jamapsychiatry.2017.4457. [Epub ahead of print] PubMed PMID: 29417130

Full text available on line.  Please read it.

2: Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. Effect of Marriageon Risk for Onset of Alcohol Use Disorder: A Longitudinal and Co-Relative Analysis in a Swedish National Sample. Am J Psychiatry. 2016 Sep 1;173(9):911-8. doi: 10.1176/appi.ajp.2016.15111373. Epub 2016 May 16. PubMed PMID: 27180900.    

3: Kendler KS, Lönn SL, Salvatore J, Sundquist J, Sundquist K. Divorce and theOnset of Alcohol Use Disorder: A Swedish Population-Based Longitudinal Cohort and Co-Relative Study. Am J Psychiatry. 2017 May 1;174(5):451-458. doi: 10.1176/appi.ajp.2016.16050589. Epub 2017 Jan 20. PubMed PMID: 28103713; PubMed Central PMCID: PMC5411284.

4: Maes HH, Neale MC, Kendler KS, Hewitt JK, Silberg JL, Foley DL, Meyer JM,Rutter M, Simonoff E, Pickles A, Eaves LJ. Assortative mating for major psychiatric diagnoses in two population-based samples. Psychol Med. 1998 Nov;28(6):1389-401. PubMed PMID: 9854280.


Graphics Credit:

Photo at the top is from Shutterstock per their licensing agreement.

Wednesday, August 30, 2017

Dementia Prevention And Substance Use Disorders

Dementia from Addictive Compounds



As a geriatric psychiatrist and an addiction psychiatrist, what I see happening in both professional literature and lay literature is mind boggling.  There is a clear bias advocating for the benign and even therapeutic effects of alcohol and addicting drugs.  What most articles omit is that the health effects of alcohol are limited to no more than two standard drinks per day for men and one drink per day for women.  The drinks cannot be all taken on the same day.  The limits are per day not per week.  Most of the evidence also suggests that the alcoholic beverage should be wine rather than beer or distilled spirits.  Recent studies suggest that of the 70% of Americans who drink - about 1/3 of them are probably drinking in excess of those amounts.  Doing the arithmetic that amounts to about 56 million people.  Even a low percentage of brain injury will result in a significant number of cases od dementia. Moderate to heavy drinking (3-12+ drinks/day) carries the associated risks of high carbohydrate intake and sedentary life style.  It is very common to find that moderate to heavy drinkers stop their usual outdoor activities and exercise and spend a lot of time watching television.  This can lead to obesity, glucose intolerance and dyslipidemia and in the worst case scenario metabolic syndrome.  All of those consequences lead to increased risk of cardiovascular and cerebrovascular disease.  

There are addiction risks with alcohol consumption apart from atherosclerotic heart disease. Alcohol is proarrhythmic and doubles the risk for arrhythmia.  In one large Danish study (11) they noted that alcohol intake and a history of atrial fibrillation was a risk factor for ventricular fibrillation.  Some authors view alcohol use a risk factor in preventable atrial fibrillation.  In clinical practice it is very common to interview patients with atrial fibrillation who notice that during times of heavy alcohol use they can sense that they are in atrial fibrillation and they spontaneously convert to sinus rhythm as their blood alcohol levels drop.  Atrial fibrillation is a causative mechanism for embolic stroke and associated cognitive disorders.

The direct toxic effect of alcohol on the brain has been debated for years. Amnesia from Wernicke-Korsakoff syndrome is a known diagnostic entity related to thiamine deficiency associated with excessive alcohol use.  It is probably underdiagnosed in most populations compared with postmortem diagnoses of the specific lesions consistent with Wernicke-Korsakoff syndrome (WKS).  A large number of people with alcohol use problems have demonstrable cognitive effects on testing as well as structural and functional brain imaging brain imaging studies suggest some effect on brain structure.  The lack of a pathological lesion has led some to suggest that this is a non-specific effect, but it is very likely that there are several variants of cognitive dysfunction related to alcohol use that are not associated with WKS (12).  On a clinical basis it is very common to see patients with subjective cognitive impairment that typically involves working memory, declarative memory, and executive function.  In treatment setting where abstinence from alcohol is assured many of these problems seem to clear up after about 60 days of abstinence.  But there are also populations of people with varying degrees of anterograde and retrograde amnesia that is not as dense as expected with full WKS.  Many of these patients are seen in treatment settings and never referred for comprehensive assessments of their cognitive disorder.  To my knowledge there have been no studies looking at the issue of whether or not partial amnestic states correlate with WKS lesions at autopsy.        

The problems with recognizing and treating cognitive disorders associated with substance use problems are exemplified in the first few paragraphs about alcohol.  They are no less important for other commonly abused substances.  In the case of stimulants, amphetamine analogues are known neurotoxins.  Studies by Volkow and others have shown persistent changes in dopaminergic neurons up to 15 months after the last use.  This may correlate with a persistent attentional deficit that leads patients to conclude that they now have attention deficit disorder.  Additional brain insults from hemorrhagic strokes and cardiovascular problems associated with long term stimulant use are common.  Stimulants are well known precipitants of acute myocardial ischemia and brain complications from hypoperfusion and emboli.  Acute hypertension and tachycardia are part of the acute intoxication syndrome that can lead to hypertension and hemorrhagic stroke.  This recurrent cycle leads to commonly observed complications of cardiomyopathy in the 4th and 5th decades of life and heightened risk of ventricular arrhythmias and cardiac arrest.

The graphic at that top of this post is not exhaustive - but point out some significant acute and chronic complications of drug use that can lead to permanent brain injury.  These mechanisms cannot be overlooked as avoidable causes of dementia.  I will be trying to elaborate on this graphic in the future to look at developing a review in this area.  Any acute acre and addiction psychiatrist is probably more aware of these syndromes and complications because they are encountered in clinical practice.  I have not seen any formal estimates of the fraction of dementia cases are preventable by avoiding these compounds.  The largest fraction of dementia cases would likely be attributable to the most commonly used drugs - tobacco and alcohol.  Drugs that kill more people acutely on a proportional basis like stimulants and opioids probably leave fewer survivors with dementia as a complication.  

Contrary to the conventional wisdom these days - avoiding dementia is another strong argument for a sober life style.


George Dawson, MD, DFAPA


References:

1: de Gaetano G, Costanzo S, Di Castelnuovo A, Badimon L, Bejko D, Alkerwi A,Chiva-Blanch G, Estruch R, La Vecchia C, Panico S, Pounis G, Sofi F, Stranges S, Trevisan M, Ursini F, Cerletti C, Donati MB, Iacoviello L. Effects of moderate beer consumption on health and disease: A consensus document. Nutr Metab Cardiovasc Dis. 2016 Jun;26(6):443-67. doi: 10.1016/j.numecd.2016.03.007. Epub 2016 Mar 31. Review. PubMed PMID: 27118108.

Moderate consumption is defined as 1 drink per day in women and 2 drinks per day  for men in a non-binge drinking pattern. J-shaped dose-response curve

2: Fernández-Solà J. Cardiovascular risks and benefits of moderate and heavy alcohol consumption. Nat Rev Cardiol. 2015 Oct;12(10):576-87. doi: 10.1038/nrcardio.2015.91. Epub 2015 Jun 23. Review. PubMed PMID: 26099843.

U-Shaped dose-response curve

3: Matsumoto C, Miedema MD, Ofman P, Gaziano JM, Sesso HD. An expanding knowledge of the mechanisms and effects of alcohol consumption on cardiovascular disease. J Cardiopulm Rehabil Prev. 2014 May-Jun;34(3):159-71. doi: 10.1097/HCR.0000000000000042. Review. PubMed PMID: 24667667.

4: Graff-Iversen S, Jansen MD, Hoff DA, Høiseth G, Knudsen GP, Magnus P, Mørland J, Normann PT, Næss OE, Tambs K. Divergent associations of drinking frequency and binge consumption of alcohol with mortality within the same cohort. J Epidemiol Community Health. 2013 Apr;67(4):350-7. doi: 10.1136/jech-2012-201564. Epub 2012 Dec 12. PubMed PMID: 23235547.

5: Weyerer S, Schäufele M, Wiese B, Maier W, Tebarth F, van den Bussche H,Pentzek M, Bickel H, Luppa M, Riedel-Heller SG; German AgeCoDe Study group (German Study on Ageing, Cognition and Dementia in Primary Care Patients). Current alcohol consumption and its relationship to incident dementia: results from a 3-year follow-up study among primary care attenders aged 75 years and older. Age Ageing. 2011 Jul;40(4):456-63. doi: 10.1093/ageing/afr007. Epub 2011 Mar 2. PubMed PMID: 21367764.

6: Bathla M, Singh M, Anjum S, Kulhara P, Jangli S IIIrd. Metabolic syndrome indrug naïve patients with substance use disorder. Diabetes Metab Syndr. 2016 Sep 3. pii: S1871-4021(16)30183-7. doi: 10.1016/j.dsx.2016.08.022. [Epub ahead of print] PubMed PMID: 27618517

Alcohol was the main substance used by patients meeting WHO criteria for Metabolic Syndrome.

7: Vancampfort D, Hallgren M, Mugisha J, De Hert M, Probst M, Monsieur D, Stubbs B. The Prevalence of Metabolic Syndrome in Alcohol Use Disorders: A Systematic Review and Meta-analysis. Alcohol Alcohol. 2016 Sep;51(5):515-21. doi: 10.1093/alcalc/agw040. Epub 2016 Jun 23. Review. PubMed PMID: 27337988. 

1 person in 5 with alcohol use disorder has metabolic syndrome.

8: Wakabayashi I. Frequency of heavy alcohol drinking and risk of metabolicsyndrome in middle-aged men. Alcohol Clin Exp Res. 2014 Jun;38(6):1689-96. doi: 10.1111/acer.12425. Epub 2014 May 12. PubMed PMID: 24818654.

Positive correlation between heavy drinking and metabolic syndrome.

9: Yousefzadeh G, Shokoohi M, Najafipour H, Eslami M, Salehi F. Association between opium use and metabolic syndrome among an urban population in Southern Iran: Results of the Kerman Coronary Artery Disease Risk Factor Study (KERCADRS). ARYA Atheroscler. 2015 Jan;11(1):14-20. PubMed PMID: 26089926; PubMed Central PMCID: PMC4460348.

Current opioid users had the highest prevalence of metabolic syndrome (39.6%) but the study was confounded by a high baseline rate in the controls (37.2%).

10:   Brunner S, Herbel R, Drobesch C, Peters A, Massberg S, Kääb S, Sinner MF.Alcohol consumption, sinus tachycardia, and cardiac arrhythmias at the Munich Octoberfest: results from the Munich Beer Related Electrocardiogram Workup Study (MunichBREW). Eur Heart J. 2017 Apr 25. doi: 10.1093/eurheartj/ehx156. [Epub ahead of print] PubMed PMID: 28449090.

11: Jabbari R. Ventricular fibrillation and sudden cardiac death during myocardialinfarction. Dan Med J. 2016 May;63(5). pii: B5246. Review. PubMed PMID: 2712702.

12: Ridley NJ, Draper B, Withall A. Alcohol-related dementia: an update of the evidence. Alzheimers Res Ther. 2013 Jan 25;5(1):3. doi: 10.1186/alzrt157. eCollection 2013. Review. PubMed PMID: 23347747.


Supplementary:

The calculation for the following observation:

Recent studies suggest that of the 70% of Americans who drink - about 1/3 of them are probably drinking in excess of those amounts.  Doing the arithmetic that amounts to about 56 million people.

321M(current US population) - 80M (population less than drinking age) x 0.7 (percentage of population that drinks) x 0.3 percentage of excess drinkers = 56 million people.
 


Wednesday, December 28, 2016

The Moral Dilemma Of Alcohol Exposure







Before anyone schools me about Prohibition - I give lectures on Prohibition. I know it doesn't work and I know the reasons why. I also know that talking about restricting intoxicants in any way is counter to the current zeitgeist of liberalizing their availability.

I also treat alcoholics and I know how that works. When I see Minnesota's largest and most famous retailer opening up large and attractive liquor stores where there used to be not so attractive foods courts and positioning it right across from the cash registers - I know that will be a problem for a lot of people trying to stay sober. I know that for many people in recovery - an attractive liquor store in their favorite retail store or grocery store creates a very high probability of relapse - even if they know that relapse may result in death or severe disability. In Minnesota liquor stores hours is another issue. In states where liquor sales are prohibited like Minnesota, it is incentive to drive across the border into bordering states in order to buy alcohol. A modification is the availability of low alcohol content beer from grocery stores and gas stations.

Another proxy measure for relapse risk would be the total number of bars in each state.  That data is harder to get.  I have information from a tavern owner that the business organization representing them sets the maximum number at 1 tavern or bar per 500 people, but the actual limits are subject to local jurisdiction.  In reality the maximum tavern/bar concentrations occur in North Dakota, Montana, Wisconsin, and South Dakota ranging from 1621 - 2268 people per tavern/bar.  At the lower end Virginia ranks 50th at 64,773 people per tavern/bar. (US Census Bureau Data per The Forum).

Are retailers that desperate that they all need to compete in this low margin business? Why are governments in this business at all? I know that there are vocal people everywhere who argue for their unalienable right to intoxicants. One of the main arguments has always been that the vast majority of people can drink and not incur any problems from it. What about the people who cannot? Binge drinking, alcohol poisoning, and excessive alcohol use are all major public health problems according to the CDC. The direct and indirect cost of excessive drinking in the US is about $249 billion in direct and indirect costs.

One of the main arguments of cannabis advocates is how dangerous alcohol is. Alcohol costs $1.90 per drink according to the CDC in complications from drinking. That cost is probably artificially low because treatment and detoxification from alcohol is rationed and most people don't get anywhere near the level of treatment they need. In Twin Cities metro hospitals - drug and alcohol use can account for up to 60% of admissions. Potential consumer advocates in this case belong to an organization that values anonymity and as far as I know has not been very politically active.

The CDC (Community Preventive Services Task Force) suggests that alcohol excise taxes need to be increased, alcohol outlet density needs to be decreased, hours of sales need to be decreased rather than increased, and retailers need to be held liable for damages caused by underage or intoxicated drinkers. The tax suggestion reminds me of the general theory of sin taxes and why they really don't work from a governing standpoint. It basically generates money for politicians to spend and is typically diverted away from any stated use that involves treating complications of the activity.

To me the alcohol issue is much bigger than who sells it, but governments have a big problem at the moral and public health levels. Just carrying forward the CDC recommendations invites rhetorical response about prohibition or temperance. I have found myself in illogical arguments with both individuals and families about the right to drink oneself to death. Make no mistake about it, the issue was not suicide - just continuing to drink with advanced liver disease and repeated hospitalizations for bleeding problems and encephalopathy due to advancing liver disease and the associated anatomical and physiological changes.

At its base, the alcohol problems and tolerating excessive alcohol use is a cultural problem. In the Midwest where binge drinking is most prominent, teenagers start drinking in middle school. In many areas it is a rite of passage. Even though the majority of people don't drink. It is very difficult to find social settings that are alcohol free. Alcohol use in most settings is promoted as the social norm with the exception of a few subcultures. Barring a widespread cultural movement that promotes moderation or abstinence, it appears that the usual educational measures about the dangers of alcohol use will be the primary intervention point. Secondary and tertiary prevention depends on a robust system of care for alcohol use and that currently does not exist. In some cases close monitoring by the correctional system for people with DWI infractions can be effective, but that does not address either the group of people who do not come to legal attention or those for which legal intervention is not a deterrent.  It also does not provide long term solutions to the problem of continued alcohol use.

Despite all of the current hype about how some intoxicants are wonder drugs and the ongoing arguments about legalization of all or most intoxicants - I can't help but see this as another moral dilemma. The will of the many basically writing off the serious problems of the few. This often plays out in families where one member clearly has a severe drinking problem and the others (usually a spouse) refuses to not drink in front of them or not have alcohol available in the home.  It all comes down to the rationalization that everyone can control their drinking or that drinking can be seen as bad behavior and that is obviously not true.

The moral dilemma of increasing alcohol availability or the government sanctioned availability of any intoxicant is the same.  It is based on the theory that people in general can use these intoxicants without damaging other members of society or themselves to the point that they do not become a cost to the rest of society.  That essentially writes off the group of people with uncontrolled use who cannot do that.  American society traditionally handles that problem by punishment and rationing availability of treatment and detox services.  Functional detox services staffed by physicians are practically unheard of.  Contrary to that guy in your freshman philosophy course who doubted the meaning of everything - moral philosophers can also add a perspective here.  Consider this quote from Blackburn about the nature of moral knowledge:

"There are countless small unpretentious things that we know with perfect certainty.  Happiness is preferable to misery, and dignity is better than humiliation.  It is bad that people suffer and worse if a culture turns a blind eye to their suffering.  Death is worse than life; the attempt to find a common point of view is better than a manipulative contempt for it." (1).

The availability and treatment of alcohol related problems in American society on one hand and the motivation to profit from it on the other hand seems to stand Blackburn's quote on its ear.  In the US there is a clear blind eye approach to alcoholism.

It may be time to come up with a better plan for living.


George Dawson, MD, DFAPA


References:

1:  Simon Blackburn.  Being Good - A Short Introduction To Ethics.  Oxford University Press. Oxford, UK. p. 134.


Graphic:

Liquor store density is from Health Indicators Warehouse at www.healthindicators.gov and is in the public domain.  This graphic was generated on that site. (click to enlarge)