When is a drinking problem actually addiction? What are the physical and psychological symptoms of alcohol dependence? Can genetics or family history predispose a person to alcohol addiction? Listen in as psychiatrist Stephen Delisi, MD, talks with host William C. Moyers about the warning signs of alcohol use disorder (the term doctors now use for alcoholism), including physical and mental health symptoms, the process of withdrawal and effective treatment options.
0:00:16:00 William Moyers
Hello and welcome to Let's Talk, a series of podcasts produced by the Hazelden Betty Ford Foundation on the issues that matter to us, the issues that we know matter to you as well. Substance use prevention, research, treatment for addiction, recovery management, advocacy and education. I'm your host, William Moyers and today I'm joined by Dr. Stephen Delisi the Medical Director for Professional Education Solutions at Hazelden. Dr. Delisi, thanks for joining us.
0:00:45 Dr. Stephen Delisi
Thank you for having me, William.
0:00:46 William Moyers
What does it mean to be the Medical Director of Professional Education Solutions at Hazelden?
0:00:50 Dr. Stephen Delisi
That's an excellent question. The Professional Education Solutions division of Hazelden Betty Ford is a newer division with our organization. We are responsible for our external training and consultative services as well as prevention services out to state and local agencies as well as federally qualified health centers and community mental health. This came out of the real need to address the opioid crisis in our nation and integrating medical services, behavioral health services and addiction services. And the team that I'm the Medical Director of we go around the country implementing those integrative, whole-person solutions.
0:01:35 William Moyers
Of course you have a lot of experience at Hazelden Betty Ford not just in this area but also down in the trenches of treating patients. Could you share a little bit about that?
0:01:42 Dr. Stephen Delisi
I sure can. I've been with Hazelden Betty Ford now for 14 years. The first decade of that I was in the trenches. Very busy addiction medicine and addiction psychiatry practitioner. Seeing patients throughout the day, five, six days a week. I then became the regional Medical Director here in the Midwest. At the time that we rolled out our Comprehensive Opioid Response with the Twelve Steps, our COR-12 program, to really address the opioid crisis as it hit close to home. And I've been the Assistant Dean of our Graduate School, and now the Medical Director of this training and consultative services.
0:02:16 William Moyers
0:02:21 William Moyers
Of course today, or along that that journey, of training patients at Hazelden Betty Ford, you have seen a lot of patients with alcoholism.
0:02:30 Dr. Stephen Delisi
0:02:31 William Moyers
And—and our topic for today is really to talk about the impact that alcohol has on people and specifically, how we have evolved in terms of our perception on what it means to be an alcoholic and—and what it means to have an alcohol use disorder.
0:02:44 Dr. Stephen Delisi
0:02:45 William Moyers
Talk to us a little bit about the transition between categorizing everybody as an alcoholic and the fact that we use the term alcohol use disorder today.
0:02:55 Dr. Stephen Delisi
Yes. So alcoholism is more of a—a lay general term. And a large basket. Indicating that the individual is really struggling to control one's use of alcohol. When we talk about a specific alcohol use disorder, we're making a medical diagnosis. And that is based upon different criteria that we look for. And then we can also use those criteria to determine whether the person has a mild alcohol use disorder, moderate alcohol use disorder or severe. Similar to other chronic illnesses that we want to determine to the severity.
0:03:31 William Moyers
Why does that matter to be able to gauge the severity? They always talked about when, at least when I went through treatment, that you know you're an alcoholic, period.
0:03:39 Dr. Stephen Delisi
0:03:39 William Moyers
Or you're a drug addict, period. But there's a difference now.
0:03:42 Dr. Stephen Delisi
There really is. Because we really are now focused on a person-centered approach to treatment. We wanna be matching the appropriate evidence-based treatment modalities with the level of severity of one's illness.
0:03:56 William Moyers
So how does somebody know when they might be suffering from an alcohol use disorder or more significantly how does a family member or an employee know when somebody has that?
0:04:05 Dr. Stephen Delisi
Well there's no one yes or no the answer to that.
0:04:07 William Moyers
Aha. [nods, smiles]
0:04:09 Dr. Stephen Delisi
We don't, unfortunately, have yet a test that you can draw blood for. We look for different criteria, again. We look for the person losing control of the amount or the frequency that they're drinking. So, they're themselves or loved ones are noticing that they're drinking more than was intended. Or more than they used to doing that.
0:04:29 William Moyers
0:04:30 Dr. Stephen Delisi
We also look for are they starting to pull away from the family? Are they not as engaged in things that they used to really enjoy? Is their level of functioning at school or at work or in the home diminished? Are they starting to use alcohol in ways that are risky? Like drinking and driving. Do they need to drink more to get the same effect? That's what we call tolerance. And then further, do they have cravings and withdrawal symptoms when they stop using?
0:05:03 William Moyers
How do you apply those red flags or those factors across socioeconomic or age differences?
0:05:13 Dr. Stephen Delisi
0:05:13 William Moyers
Because certainly alcohol use disorder would affect a young person differently than it would an elderly person.
0:05:19 Dr. Stephen Delisi
That is very, very true. But the way that we do that in terms of different ages is that we look at those different criteria based upon what you would expect the person to be doing if they're a high school student versus if they are in their fifties or sixties. So for a—a high school student, we'd be looking at are they drinking at school? Are they drinking with friends? Are they being late for school or not going to school? Whereas someone who is—is older, we'd be looking at are they reduced in their productivity at work? Are they not doing the family obligations? So we—that's how we address that. We also in terms of gender differences, there—there are specific differences. And when we talk about kind of thresholds of how much someone is drinking, those are somewhat different between men and women. For a man at-risk drinking, is drinking five drinks in a day or fifteen or more drinks per week. But for a woman, that level is four drinks or more per day, eight or more in a week.
0:06:29 William Moyers
What about the genetics of—
0:06:32 Dr. Stephen Delisi
Very important. Very important.
0:06:32 William Moyers
Since you certainly came into the field we've—science has made tremendous strides around the genetics that are involved in the dynamics of an alcohol use disorder, or a drug addiction.
0:06:41 Dr. Stephen Delisi
0:06:42 William Moyers
Talk to us about what we are learning in that regard.
0:06:44 Dr. Stephen Delisi
Genetics, family history, inheritability, is one of the top risk factors for alcohol use disorder and other substance use disorders. Having a parent with an alcohol use disorder increases a child's risk of developing an alcohol use disorder four times.
0:07:02 William Moyers
0:07:03 Dr. Stephen Delisi
Four times. About fifty percent of the risk of developing an alcohol use disorder is determined by our genetics. Now having said that, that does not mean that if your parent has an alcohol use disorder, you are going to have one. But your risk is four times higher than if your parent had not had that risk.
0:07:21 William Moyers
And so what's your counsel to a parent, a mom or a dad, who might be recovering from an alcohol use disorder or a dependency on drugs? What's your counsel to the parents on how to talk to a child about their history?
0:07:35 Dr. Stephen Delisi
Yeah. First and foremost, be—be honest. When the child is at an age especially as they enter into early junior high age, it's important for that child to know that increased risk and that family history. But at the same time, you want to be very cautious as a parent in sharing any stories that would glamorize the—the use of alcohol or drugs. So I recommend that people talk about it similar to any other family history of a disease. In the same way that you would share with the family that there's a history of heart disease and we need to be more cautious about what we're eating and the exercise that we're getting. Similar with an alcohol use disorder. This is the family history. And really we need to be cautious and avoid early use of alcohol. That's another real high risk factor, William.
0:08:31 William Moyers
Tell us more.
0:08:32 Dr. Stephen Delisi
Yeah. Addiction is a neurodevelopmental disorder. For most people it starts in adolescence and where it can really start is by initial use prior to the age of say 16 years old.
0:08:44 William Moyers
0:08:46 Dr. Stephen Delisi
That is significantly more risky than starting after the age of say 21 or 24.
0:08:53 William Moyers
0:08:54 Dr. Stephen Delisi
Changes in the brain.
0:08:56 William Moyers
0:08:57 Dr. Stephen Delisi
We now know, from a neurobiological perspective, that the early use and continued use of alcohol and other drugs changes key areas of the brain.
0:09:08 William Moyers
Can they be changed back?
0:09:11 Dr. Stephen Delisi
You know, we—we absolutely see that. There can always be continued risk. Once those changes have occurred, there is risk for recurrence of this chronic illness. But at the same time, by following evidence-based practices—
0:09:26 William Moyers
0:09:27 Dr. Stephen Delisi
—We can strengthen some of the resiliency within the person's brain.
0:09:32 William Moyers
0:09:33 Dr. Stephen Delisi
And engage other areas of the brain like the frontal cortex. The front part of our brain that really helps to control some of the areas of the brain that under gird our addictions and our emotions.
0:09:47 William Moyers
Mmm. Let's talk a little bit about the treatment. We only have a couple of minutes.
0:09:50 Dr. Stephen Delisi
0:09:50 William Moyers
But when—when somebody is diagnosed with an alcohol use disorder, to your point, not all—one size shoe doesn't fit all.
0:09:59 Dr. Stephen Delisi
It doesn't. That's right.
0:09:59 William Moyers
There's no diagnosis that everybody is gonna have. So, how do you go about applying what you know in that regard to the treatment of an alcohol use disorder?
0:10:09 Dr. Stephen Delisi
Sure. First and foremost, the message that I would like to start with is early screening, early assessment and recognition, so that we can engage with treatment at a mild alcohol use disorder.
0:10:25 William Moyers
So—so just to that point before our interview—
0:10:27 Dr. Stephen Delisi
0:10:28 William Moyers
So a mild alcohol use disorder should be treated?
0:10:32 Dr. Stephen Delisi
Yes. But many times, that can be treated through education and support of that individual in an outpatient environment.
0:10:39 William Moyers
0:10:40 Dr. Stephen Delisi
And that's what we really want to be doing. That's again the team that I'm the Medical Director of. One of the things that we're implementing in primary care offices is screening at every visit for an alcohol use disorder. Similar to screening for diabetes and heart disease and hypertension. Getting those recognition's early so that interventions can be done before it gets severe. Once this person has a severe alcohol use disorder, that is something would—that they need to seek medical attention. Abruptly stopping drinking after a long period of drinking can be life-threatening. There can be seizures and there can be death. So, that's something that we recommend seeking the care of a medical professional and having formal medical-guided detoxification.
0:11:37 William Moyers
And of course the—that really matters too when people are using their private health insurance to access care because the insurance company which will be covering the cost of a lot of this—
0:11:47 Dr. Stephen Delisi
0:11:47 William Moyers
Needs to be part of the process as it relates to where a person might fall on that spectrum.
0:11:53 Dr. Stephen Delisi
Very true. And that's again why we wanna be doing the assessment to determine whether it's mild, moderate, or severe, and then placing the person at the level of care that's most appropriate. And insurance companies, that's what they are also looking for. They wanna make sure that the individuals that they're insuring are getting the appropriate care at the appropriate level and the appropriate time.
0:12:17 William Moyers
I'm struck by what you said regarding the fact that doctors in a primary care setting can—can recognize or diagnose an alcohol use disorder. But that requires that the doctor know about that.
0:12:31 Dr. Stephen Delisi
0:12:30 William Moyers
So how—and we know that medical schools often times are not exactly on the forefront of educating their students around alcohol and other drug use—
0:12:39 Dr. Stephen Delisi
That is very true.
0:12:40 William Moyers
So what would be your recommendation to medical schools for example in terms of educating doctors?
0:12:45 Dr. Stephen Delisi
Yes. So, a case in point—when I was in medical school I got one or two hours of training in addiction. When I was a psychiatry resident at a very good residency program, I received two hours of lecture on addiction. It was really under the guidance of an influential addiction psychiatrist who was my mentor that I got the training that I needed. Again, our training in consultation service, that's—that's what we do is—is we bring that information. Medical schools are improving. With our nation's opioid crisis and with the chronic crisis of alcohol use disorder, medical schools are starting to respond. And we are seeing medical students and residents that come and train with us. We are seeing that they are getting more education. We just need to continue to call for more and better education.
0:13:50 William Moyers
Dr. Delisi, we know that they're gonna—a lot of professionals watch these podcasts or listen to them, but we know at the end of the day that it's families that are desperately searching for information.
0:13:58 Dr. Stephen Delisi
0:13:59 William Moyers
What are some of those warning signs that they might need to seek to connect those dots towards getting help?
0:14:04 Dr. Stephen Delisi
Yes. Seeing their loved one staying out later. Coming home actually smelling of alcohol. Drinking alcohol first thing in the morning. Follow—falling away from the family. Not going to work. Or when at work or school, seeing the functioning just decreased. Or, when not drinking, you actually can see the person start to shake.
0:14:29 William Moyers
0:14:30 Dr. Stephen Delisi
It's like withdrawal symptoms. Exactly.
0:14:31 William Moyers
Mmm-hmm. And then of course if they connect those dots and they realize that that loved one needs to get help, what's your counsel to families or to professionals?
0:14:39 Dr. Stephen Delisi
Yeah. My—to—to both of them, this is a medical illness. This needs to be addressed like a medical illness. So, seek your primary care provider. A trusted mental health professional. Or reach out to a facility that treats and knows about addiction. Absolutely, we have people at Hazelden Betty Ford answering the phones around the clock. To answer questions, to guide individuals and to point people in the direction of the most appropriate care. The—the good news is that treatment works and there is considerable hope. Please reach out for that hope.
0:15:19 William Moyers
Thanks for leaving us with that message today. Dr. Stephen Delisi, Medical Director at Hazelden Betty Ford. Psychiatrist, somebody who cares passionately for people who struggle—
0:15:28 Dr. Stephen Delisi
0:15:29 William Moyers
—And their families. Thank you for joining us today.
0:15:32 Dr. Stephen Delisi
Thanks for having me. It's been a pleasure.
0:15:33 William Moyers
And on behalf of our Executive Producer Lisa Stangl, I'm your host, William Moyers, thank you for joining us for another edition of Let's Talk. We'll see you next time.