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Alcohol and Intimate Partner Violence Anika A. H. Alvanzo, MD, MS Virginia Commonwealth University Medical Center Introduction • Alcohol Misuse/Alcohol Use Disorders (AUD) – ~16% at risk drinkers; ~ 9% AUD – Cost ~ $185 billion – 3rd leading cause of death • Intimate Partner Violence (IPV) – 1/4 women and 1/12 men – Cost ~ $6 billion/yr – ~ 1/3 of homicides of women Alcohol Medical Scholars Program, 2007 This Lecture Will Cover: • Alcohol/IPV – Definition and Epidemiology – Health Consequences – Identification – Treatment – Association between alcohol and IPV – Treatment for co-occurrence Alcohol Medical Scholars Program, 2007 Alcohol misuse and AUDs Alcohol Medical Scholars Program, 2007 Alcohol Use Guidelines • Standard drink – 12 oz. beer – 5 oz. of wine – 1.5 oz. of spirits (hard liquor) • ≤ 2 drinks/day for men • ≤ 1 drink/day for women Alcohol Medical Scholars Program, 2007 Definitions of Alcohol Use • Heavy/“At-risk” drinking – Men: ≥ 5 drinks/day or ≥15 drinks/week – Women: ≥4 drinks/day or ≥8 drinks/week • Binge drinking – Historically: used for 2+ days drunk – More recently: pattern with BAC ≥ 0.08% Alcohol Medical Scholars Program, 2007 Definition of AUD Alcohol dependence ≥ 3 Alcohol abuse ≥ 1 • • • • • • • • Role failure Withdrawal Tolerance Exceed limits Not able to stop/cut down Much time drinking Give up other activities Use despite problems • Risk of bodily harm • Legal problems • Relationships Alcohol Medical Scholars Program, 2007 Epidemiology of Use and AUD Sex/Age differences: Men Women 18-24 yo 20% Heavy drinking: 17% 13% 7% 3% 9% Current dependence: 5% 2% 13% Current abuse: Alcohol Medical Scholars Program, 2007 Epidemiology Racial/Ethnic Differences: Current Heavy Native Am Whites Hispanics Blacks Asians 58% 70% 60% 53% 48% 22% 16% 12% 16% 10% Abuse/ Dependence 12% 9% 8% 7% 4% Alcohol Medical Scholars Program, 2007 Health Consequences of AUD • GI – Pancreatitis- 10% – Liver diseases • 80% fatty liver • 35% hepatitis • Neuro – Neuropathy- 10% – CBL dysfx- <1% • CV- 20% ↑ mortality • Blood- toxic for blood • Mental Health – Depression • 40% co-occurrence Alcohol Medical Scholars Program, 2007 Identification of Drinking • Clinical indicators for screening – New patient – Annual exam – ER visit – Pregnancy – Rx medicine that interacts with alcohol – Clinical suspicion • Alcohol on breath • Family member statements Alcohol Medical Scholars Program, 2007 Screening • NIAAA Clinician’s Guide – # of heavy drinking days in past year • Men: ≥ 5 drinks; women: ≥ 4 drinks – Weekly drinking average • # of drinking days in average week 5 X • # of drinks on average drinking day Weekly average = 4 20 Alcohol Medical Scholars Program, 2007 Screening • Alcohol Use Disorders Identification Test (AUDIT) – 10 items – + if ≥ 8 for men and ≥ 4 for women • PRIME MD- Patient Health Questionnaire – 5 items – + if ≥ 1 Alcohol Medical Scholars Program, 2007 Treatment for AUD • Behavioral – Brief Interventions • Pharmacologic – Acamprosate (Campral) • Dose: 2g/day; 666mg tid – Cognitive Behavioral Therapy – Disulfiram (Antabuse) • Dose: 250mg/day – 12-step programs – Naltrexone (ReVia) • Dose: 50-100mg/day Alcohol Medical Scholars Program, 2007 Intimate Partner Violence Alcohol Medical Scholars Program, 2007 Definition of IPV • A pattern of intentionally coercive and assaultive behaviors – Perpetrator is/was/wishes to be an intimate partner – Goal of behavior is to exert control Alcohol Medical Scholars Program, 2007 Definition of IPV • IPV includes many types of behavior – Physical – Sexual – Psychological/emotional – Stalking – Threats – Property destruction – Neglect Alcohol Medical Scholars Program, 2007 Epidemiology of IPV • Sex differences: – Women ↑ victims; men ↑perpetrators • Lifetime prevalence: men 8%, women 25% • Women comprised 85% of IPV victims in 1999 • Age differences: – Victimizations: highest prevalence age 20-24 – Homicides: highest prevalence age 35-49 Alcohol Medical Scholars Program, 2007 Epidemiology of IPV • Racial and ethnic differences – African Americans ↑ IPV – Hispanics ↓ IPV non-Hispanics – White women smallest ↓ in IPV homicide Alcohol Medical Scholars Program, 2007 IPV: Associated Health Effects • ↑ healthcare expenditures • GI – Chronic abdominal pain – Digestive problems • GU – Pelvic pain – Sexually transmitted infections (STI) • Mental Health – Substance misuse – Depression, anxiety, PTSD Alcohol Medical Scholars Program, 2007 Healthy People 2010: IPV Leading Health Indicators • Access to care • Overweight/Obesity • Environ quality • Physical activity • Immunizations • Sexual behavior • Injury and violence • Substance abuse • Mental health • Tobacco use Alcohol Medical Scholars Program, 2007 Identification of IPV • Clinical indicators for screening – New patient – Annual exam – Urgent/emergent visit – Pregnancy – Clinical suspicion Alcohol Medical Scholars Program, 2007 Red Flags for IPV • History clues • Physical exam clues – ↑ somatic complaints – Central injuries – Injury ≠ exam – Defensive wounds – Mental illness – Multiple stages of – Recurrent STIs – Substance misuse healing – Injury in pregnancy Alcohol Medical Scholars Program, 2007 Identification • Framing statements – “Because violence is so common in our society, I have begun asking all of my patients about it.” • Indirect questions – “How do you and your partner handle disagreements?” • Direct questions – “Are you in a relationship with someone who hurts or threatens you?” Alcohol Medical Scholars Program, 2007 Abuse Assessment Screen • 5-item questionnaire • Asks about: – Lifetime physical abuse – Past year physical abuse – Sexual abuse – Abuse during pregnancy • Includes body map Alcohol Medical Scholars Program, 2007 Abuse Assessment Screen Mark The Area Of Injury On The Body Map Using the Following Scale: 1 = Threats of abuse including use of a weapon 2 = Slapping, pushing; no injuries and/or continuing pain 3 = Punching, kicking, bruises, cuts and/ or continuing pain 4 = Beating up, severe contusions, burns, broken bones 5 = Head injury, internal injury, permanent injury 6 = Use of weapon; wound from weapon Alcohol Medical Scholars Program, 2007 Danger Assessment Tool • 20-item questionnaire • Assesses risk for lethality • Factors linked to severe or lethal IPV • Calendar to document assaults Alcohol Medical Scholars Program, 2007 Interventions • Victims: – Validate disclosure (e.g. show empathy) – Respond to safety concerns – Provide resources • National Hotline 1-800-799-SAFE • Perpetrators: – Batterer intervention programs – Individual counseling Alcohol Medical Scholars Program, 2007 Alcohol and IPV Victimization • IPV victims ↑ problems with alcohol – 3x more heavy use – 5% → 16% → 24% with ↑ violence • Women in alcohol treatment ↑ IPV – 87% moderate IPV vs. 28% in community – 40% severe IPV vs. 8% in community • IPV problem drinking Alcohol Medical Scholars Program, 2007 Alcohol and IPV Perpetration • Men in batterer intervention = ↑ alcohol – Up to 50% have alcohol problem – ↑ violence on heavy drinking days • Men in alcohol treatment = ↑ IPV – Prevalence ~ 50% Alcohol Medical Scholars Program, 2007 Trauma/SUD Interventions • Seeking Safety – Group behavioral intervention – PTSD and SUD – ↓ PTSD symptoms and substance use • Trauma Recovery Empowerment Model – Group behavioral intervention – Hx trauma and mental illness – ↓ trauma symptoms and substance use Alcohol Medical Scholars Program, 2007 Treatment of AUD and IPV • Perpetration – Few studies ↓ IPV after alcohol Rx – Only 1 study of integrated therapy • + effect on alcohol & IPV post-treatment • No difference at 6 month f/u Alcohol Medical Scholars Program, 2007 Summary • Alcohol misuse + IPV = major public health problems • Alcohol misuse + IPV commonly co-occur • Should routinely ask about both – Ask about both in routine clinical encounter – Screen for IPV in addiction treatment settings – Screen for alcohol misuse in settings serving victims of IPV • More research is needed Alcohol Medical Scholars Program, 2007 Questions Alcohol Medical Scholars Program, 2007