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Alcohol and Intimate Partner Violence

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)

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Alcohol and Intimate Partner Violence

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  1. Alcohol and Intimate Partner Violence Anika A. H. Alvanzo, MD, MS Virginia Commonwealth University Medical Center

  2. 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

  3. This Lecture Will Cover: • Alcohol/IPV • Definition and Epidemiology • Health Consequences • Identification • Treatment • Association between alcohol and IPV • Treatment for co-occurrence

  4. Alcohol misuse and AUDs

  5. 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

  6. 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%

  7. Alcohol dependence ≥ 3 Withdrawal Tolerance Exceed limits Not able to stop/cut down Much time drinking Give up other activities Use despite problems Alcohol abuse ≥ 1 Role failure Risk of bodily harm Legal problems Relationships Definition of AUD

  8. Epidemiology of Use and AUD Sex/Age differences: Men Women Heavy drinking: 17% 13% Current abuse: 7% 3% Current dependence: 5% 2% 18-24 yo 20% 9% 13%

  9. Epidemiology Racial/Ethnic Differences: Native Am Whites Hispanics Blacks Asians Current Heavy Abuse/ Dependence 58% 70% 60% 53% 48% 22% 16% 12% 16% 10% 12% 9% 8% 7% 4%

  10. 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

  11. 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

  12. 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 X • # of drinks on average drinking day 5 4 20 Weekly average =

  13. 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

  14. Treatment for AUD • Behavioral • Brief Interventions • Cognitive Behavioral Therapy • 12-step programs • Pharmacologic • Acamprosate (Campral) • Dose: 2g/day; 666mg tid • Disulfiram (Antabuse) • Dose: 250mg/day • Naltrexone (ReVia) • Dose: 50-100mg/day

  15. Intimate Partner Violence

  16. 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

  17. Definition of IPV • IPV includes many types of behavior • Physical • Sexual • Psychological/emotional • Stalking • Threats • Property destruction • Neglect

  18. 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

  19. Epidemiology of IPV • Racial and ethnic differences • African Americans ↑ IPV • Hispanics ↓ IPV non-Hispanics • White women smallest ↓ in IPV homicide

  20. 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

  21. Access to care Environ quality Immunizations Injury and violence Mental health Overweight/Obesity Physical activity Sexual behavior Substance abuse Tobacco use Healthy People 2010: IPV Leading Health Indicators

  22. Identification of IPV • Clinical indicators for screening • New patient • Annual exam • Urgent/emergent visit • Pregnancy • Clinical suspicion

  23. Historyclues ↑ somatic complaints Injury ≠ exam Mental illness Recurrent STIs Substance misuse Physical exam clues Central injuries Defensive wounds Multiple stages of healing Injury in pregnancy Red Flags for IPV

  24. 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?”

  25. Abuse Assessment Screen • 5-item questionnaire • Asks about: • Lifetime physical abuse • Past year physical abuse • Sexual abuse • Abuse during pregnancy • Includes body map

  26. 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 Abuse Assessment Screen Mark The Area Of Injury On The Body Map Using the Following Scale:

  27. Danger Assessment Tool • 20-item questionnaire • Assesses risk for lethality • Factors linked to severe or lethal IPV • Calendar to document assaults

  28. 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

  29. 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

  30. 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%

  31. 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

  32. 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

  33. 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

  34. Questions

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