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Mixin' It up - Alcohol and
Legal Drugs
Peter A. Kreckel, RPh.
Assistant Professor of
Pharmacology
St. Francis University
Physician Assistant Sciences
• Tim Mizak
• Nick Wytiaz
Student Pharmacists
University of Pittsburgh
School of Pharmacy
What is Alcohol?
• Alcohol (ethyl alcohol or ethanol) is a
central nervous system depressant
– Rapidly absorbed from the stomach & small
intestine into the bloodstream
– Metabolized in the liver by enzymes
– Intensity of effect on the body is directly
related to the amount consumed
Centers for Disease Control & Prevention: Summary Health Statistics for U.S. Adults: National Health
Interview Survey, 2008. \http://www.cdc.gov/alcohol/faqs.htm#1
Alcohol Use in the U.S.
• 50% of adults are
regular drinkers (at
least 12 drinks in the
past year)
- Incidence in the
Northeast: 54%
• 14% of adults are
infrequent drinkers
(1-11 drinks in the
past year)
Centers for Disease Control & Prevention: Summary Health Statistics for U.S. Adults: National Health
Interview Survey, 2008. http://www.cdc.gov/fastats/alcohol.htm
What is a Standard Drink?
• Equal to 13.7 grams of pure alcohol
http://myhealth.ucsd.edu/library/healthguide/en-us/images/media/medical/hw/alcohol.jpg
Levels and Patterns of Drinking
• Heavy drinking
– For women, more than 1 drink per day on average.
– For men, more than 2 drinks per day on average.
• Binge drinking
– For women, 4 or more drinks during a single
occasion.
– For men, 5 or more drinks during a single occasion.
• Excessive drinking includes heavy
drinking, binge drinking or both.
Under Age Drinking
• The 2007 Youth Risk Behavior Survey
found that among high school
students, during the past 30 days:
– 45% drank some amount of alcohol
– 26% binge drank
– 11% drove after drinking alcohol
– 29% rode with a driver who had been
drinking alcohol
Alcohol and Sex
“Tequila Makes Her Clothes Fall Off” by Joe Nichols
• 60% of college women who are infected with
STDs, including genital herpes and AIDS, report
being under the influence of alcohol at the time they
had intercourse with the infected person.
• As many as 70% of college students admit to
having engaged in sexual activity primarily as a
result of being under the influence of alcohol, or to
having sex they wouldn't have had if they had been
sober.
• 90% of all campus rapes occur when alcohol
has been used by either the assailant or the victim.
Recommended Consumption
• The National Institute on Alcohol Abuse
and Alcoholism recommends:
– Men <65: no more than 14 drinks per
week, no more than 4 drinks per sitting
– Women<65: no more than 7 drinks per
week
– Women & men > 65: no more than 7
drinks per week, no more than 3 drinks
per sitting
University of Michigan Comprehensive Cancer Center website: http://www.cancer.med.umich.edu
Just a reminder…
PURCHASE, CONSUMPTION, POSSESSION OR
TRANSPORTATION OF LIQUOR OR MALT OR
BREWED BEVERAGES BY A MINOR
Section 6308 of the Pennsylvania Crimes Code
(Title 18)
• A person commits a summary offense if he/she,
being less than 21 years of age, attempts to
purchase, purchases, consumes, possesses or
knowingly and intentionally transports any liquor
or malt or brewed beverages
And if you get caught….
Penalty
1 st Offense
2 nd Offense
Subsequent
Offenses
Fine
0-$300
0-$500
0-$500
Jail
0-90 days
0-90 days
0-90 days
License
Suspension
90 days
1 year
2 years
Why Do People React Differently to
Alcohol?
• Reactions to alcohol are dependent on
numerous factors, including:
–
–
–
–
–
–
–
Age
Gender
Race or ethnicity
Physical condition (weight, fitness level, etc)
Amount of food consumed before drinking
How quickly the alcohol was consumed
Family history of alcohol problems
– Use of drugs or prescription medications
Centers for Disease Control & Prevention: Summary Health Statistics for U.S. Adults: National Health
Interview Survey, 2008. \http://www.cdc.gov/alcohol/faqs.htm#1
Alcohol-Related Drug Interactions
• 2 Types:
– Pharmacokinetic- alcohol alters the metabolism or
excretion of the drug or vice versa
– Pharmacodynamic- additive effects of alcohol and
drugs
• Alcohol is metabolized in the liver by aldehyde
dehydrogenase and cytochrome P450 2E1 (CYP2E1)
– Infrequent drinkers: CYP2E1 metabolizes a small
fraction
– Chronic drinkers: have increased CYP2E1 activity
(up to 10x)
• Important to take into account an individual’s alcohol use
patterns when looking at drug interactions
Analgesics:
Aspirin, NSAIDS (Advil®, Aleve®, etc.)
•  risk of GI hemorrhage: both aspirin and
alcohol damage GI lining
• Avoid alcohol/NSAIDS within 8-10 hours of
heavy drinking.
• Acetaminophen (Tylenol®)
• Alcohol causes  in Tylenol’s toxic
metabolites. See liver failure.
Opioids: Morphine, Methadone, Percocet®,
Oxycontin®, Vicodin®, Lortab®
• Both narcotics and alcohol are CNS
depressants
• Will see excessive CNS depression (additive
effect)
• Alcohol can cause  dissolution of some
tablets/capsules and cause  absorption
leading to fatal doses
Sedatives/Hypnotics:
• Barbiturates: see  CNS depression
• may  absorption, AND block metabolism of
barbiturates
• Benzodiazepines (Valium®, Ativan®, Xanax®):
alcohol may  aggression
• may  absorption, AND block metabolism of
benzodiazepines
• Ambien®:  depressant effects
• may see  risk of sleep driving
Others:
• Antihistamines (Chlor-Trimeton®,
Benadryl®):  drowsiness
• Claritin® is ok
• Antibiotics- Keflex®, Bactrim-DS®, Flagyl®
and Tindamax®: may cause Disulfram
reaction
• Antipsychotics (Seroquel®, Abilify®,
Geodon®): Impaired psychomotor
performance
• Avoid alcohol use beyond 1 or 2 drinks
Treatment of AlcoholismAntabuse®
• Mechanism: blocks acetaldehyde
dehydrogenase
– Acetaldehyde increases up to 10-fold causing:
flushing, throbbing headache, respiratory difficulty,
nausea, copious vomiting, sweating, thirst, chest
pains, palpitations, hypotension, tachycardia, syncope
• Avoid alcohol in all forms
• Clinically, it reduces drinking days, but does not enhance
abstinence
• Compliance is THE major factor determining efficacy of
disulfiram
• BEST CHOICE: for a person who needs emergency
help to stop drinking NOW.
Treatment of Alcohol AbuseRevia®
• Naltrexone (Revia®)
• Mechanism: Blocks opioid receptors to reduce
the pleasurable effects from alcohol. Increases
abstinence days, reduces heavy drinking days
and improves overall outcome.
• BEST CHOICE: Abstinence from alcohol is NOT
required for therapy. Helps for patients with high
levels of cravings, especially in risky drinking
situations.
Treatment of AlcoholismCampral®
•
•
Acamprosate (Campral®)
Mechanism: reduces the anxiety & other
unpleasant effects of alcohol withdrawal,
balances the GABA and Glutamate
neurotransmitters in the brain.
•
BEST CHOICE: for patients with significant
liver pathology. Patients with SEVERE alcohol
withdrawal symptoms. Patients able to initiate
abstinence, but have difficulty in maintaining
newly regained abstinence.
The 12 Steps of AA: 1-4
1. We admitted we were powerless over
alcohol-that our lives had become
unmanageable.
2. Came to believe that a Power greater than
ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives
over to the care of God as we understood
Him.
4. Made a searching and fearless moral
inventory of ourselves.
A.A. World Services, Inc.
The 12 Steps of AA: 5-8
5. Admitted to God, to ourselves, and to
another human being the exact nature of our
wrongs.
6. Were entirely ready to have God remove all
these defects of character.
7. Humbly asked Him to remove our
shortcomings.
8. Made a list of all persons we had harmed,
and became willing to make amends to them.
A.A. World Services, Inc.
The 12 Steps of AA: 9-12
9. Made direct amends to such people wherever
possible, except when to do so would injure them or
others.
10. Continued to take personal inventory and when we
were wrong promptly admitted it.
11. Sought through prayer and meditation to improve
our conscious contact with God, as we understood
Him, praying only for knowledge of His will for us
and the power to carry that out.
12. Having had a spiritual awakening as the result of
these Steps, we tried to carry this message to
alcoholics, and to practice these principles in all our
affairs.
A.A. World Services, Inc.
Dextromethorphan ABUSE
• Dextromethorphan, the d-isomer of the opiate agonist
levorphanol, is metabolized by the cytochrome P450
2D6 enzyme system in the liver. This metabolite,
dextrorphan, has a high affinity for the excitatory amino
acid receptor, the N-methyl-D-aspartate (NMDA)
receptor, producing a “high.”
• Symptoms following ingestion of high doses (five to ten
times the normal therapeutic dose) include euphoria, an
altered sense of time, paranoia, and disorientation. In
addition, tactile, visual, and auditory hallucinations may
occur.
• The effects seen with dextromethorphan abuse are
similar to those seen after phencyclidine (PCP) use,
another agent which blocks NMDA receptors.
EFFECTS of DXM abuse
•
•
•
•
•
•
•
•
•
Increased perceptual awareness
Altered time perception
Feelings of “floating” or dissociation of the body
Visual disturbances
Tactile, auditory, visual hallucinations
Paranoia
Disorientation and lack of coordination
Slurred speech
Impaired judgment and mental performance
Sources for Dextromethorphan
• Robitussin DM 10mg DXM + 100mg
guaifenesin/ 5cc (“Roboshake”)
• Delsym 30mg 30mg DXM/ 5cc
(“Agent orange) (check out Urban Dictionary)
• Coricidin HBP Cough and Cold: 30mg
DXM + chlorpheniramine 4mg (Skittles)
Dosage of DXM for ABUSE
Plateau Dose
(mg)
Behavior
effects
Robitussin Delsym Coricidin
DM
HBP
1st
100200
200400
300600
Mild
stimulation
50100ml
100200ml
150300ml
1734ml
3468ml
50100
3-7
tabs
7-14
5001500
Dissociative
sedation
250750ml
83250
17-50
2nd
3rd
4th
Euphoria
hallucinations
Distorted visual
perception.
Loss of
coordination
10-20
DXM OVERDOSE
• If ingested over 7.5mg DXM/kg should be
referred to Emergency Dept
• Can also overdose on antihistamines,
decongestants if included in products
• Serotonin syndrome if also taking: SSRI,
Zyvox, tramadol:
– Hyperthermia
– Muscle rigidity
– Myoclonus (clonic muscle twitching)
– Changes in mental status and vital signs
Blizzard
• Concentrated Bath salts (Ivory Snow Salts)
• Produces a “meth like high” when ingestedeither by eating, smoking or injecting
• Causes anxiety, hallucinations & paranoia
• Doesn’t show up (for now) on drug tests
• Preliminary testing indicates that the active
ingredients in many brands contain MDPV (3,4methylenedioxypyrovalerone) and/or
mephedrone.
Blizzard- MDPV
source: drugs-forum.com
• MDPV, 3,4-methylenedioxypyrovalerone, is an
alkaloid in the pyrrolidine and ketone chemical
classes.
• Pharmacologically, it functions as a dopaminenorepinephrine reuptake inhibitor (NDRI) with
stimulatory effects on the central nervous system
and cardiovascular system.
• It was first synthesized by Boehringer Ingelheim and
patented in 1969, but was never marketed. MDPV
appeared as a recreational drug in 2005.
• Can blunt effect of increased heart rate with
Propranolol
• Dosage: MDPV can be taken orally, sublingually,
rectally, intravenously, intramuscularly, insufflated,
and inhaled. Oral doses for most users start at
about 3-5 mg