Download Alcohol and Cocaine - Alcohol Medical Scholars Program

Alcohol and
Cocaine
Katie McQueen, M.D.
Baylor College of Medicine
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Developed for the Alcohol Medical
Scholars Program
Introduction
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Goal - Review important issues in the
concomitant use of alcohol and cocaine
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Definitions and rationale
Historical trends and epidemiology
Biochemical effects
Medical consequences
Overview of treatment
Developed for the Alcohol Medical
Scholars Program
Rationale
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Alcohol and cocaine are frequently used
together
Harm is greater
 Treatment outcomes are different
 Identification is important
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Developed for the Alcohol Medical
Scholars Program
Spectrum of Alcohol Use
A
B
S
T
I
N
E
NONPROB
USE
ATRISK ABUSE DEP
USE
N
C
E
Use
Consequences Repetition
+
-
+
-/+
-
+
+
+
+
++
+
Loss of control, preoccupation, compulsivity, physical dependence +
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Scholars Program
Problematic Use of Alcohol
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National Institute of Alcohol Abuse and
Alcoholism recommends no more than:
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Women - 3/occasion or 7/week
Men - 4/occasion or 14/week
Elderly - 1/occasion or 7/week
Problematic – harm, but does not meet
criteria for ABUSE
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Scholars Program
Substance Abuse - DSM IV
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Maladaptive pattern with repetitive
impairment in at least one:
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Failure to fulfill role obligations
Recurrent use in hazardous situations
Persistent or recurrent social or interpersonal
problems
Does not meet criteria for DEPENDENCE
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Scholars Program
Substance Dependence - DSM IV
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Maladaptive pattern with three or more:
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Tolerance
Withdrawal
Using more and/or using for longer times
A desire or repeated attempts to cut down
Lots of time using or recovering
Reduced activities: social, work, recreation
Recurrent use despite physical and psychological
problems
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Scholars Program
Historical Trends
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Alcohol
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Cocaine
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Egyptians made wine 3500 BC
Distilled spirits made over 1000 years ago
Prohibition 1919-1933
Alkaloid extracted from coca plant
100 years of use - tonic, anesthetic
Peak use in 1980’s
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Scholars Program
Epidemiology - Alcohol
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Alcohol National Household Survey - 2001
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48%
21%
6%
6%
drink
>5 per occasion
regularly drink >5
abuse or dependence
11.0 million alcohol alone
 2.4 million alcohol and an illicit substance
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Scholars Program
Epidemiology - Cocaine
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Cocaine National Household Survey–
2001
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2% (4 million) tried cocaine in the last year
0.7% met criteria abuse or dependence
 In 2000 - 0.5%
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Concomitant Use
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75% of cocaine users also use alcohol
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Drug Abuse Warning Network - ER visits
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Cocaine most common illicit - 29%
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Cocaine and alcohol most common
combination - 13%
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Scholars Program
Factors - Concomitant Use
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Genetic - vulnerability to substance
dependence
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Biologic - blunt or increase effects
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Psychosocial - conduct disorder/antisocial
personality, availability, social pressure,
cultural factors
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Scholars Program
Biochemical Effects
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Alcohol
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Sedative-hypnotic
Increase in dopamine and GABA, inhibit
NMDA
Metabolized in liver by alcohol
dehydrogenase
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Scholars Program
Biochemical Effects
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Cocaine
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Many forms: hydrochloride salt and crack
Highly reinforcing
Strong CNS stimulant
Increase in dopamine and norepinephrine
Metabolized in liver by cholinesterase
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Scholars Program
Biochemical Effects - Combined
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Alcohol leads to a 30% increase in blood
levels of cocaine
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Combination produces cocaethylene
increases dopamine release
 enhances risk for cardiac death
 enhances length of high
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Chronic alcohol leads to increase brain-toplasma cocaine ratio
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Dangers of Intoxication
Alcohol
Cocaine
Arrhythmias
Arrhythmias
Respiratory depression
Heart attack
Accidents
Stroke
Psychosis
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Scholars Program
Dangers of Long-term Use
Alcohol
Cocaine
heart attack
arrhythmias
stroke
spontaneous abortion
birth defects
psychiatric problems
heart attack
arrhythmias
stroke
spontaneous abortion
birth defects
psychiatric problems
liver disease
pancreatitis
crack lung
intravenous drug use
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Scholars Program
Psychiatric Effects - Combined
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More euphorigenic and rewarding
Attenuation of alcohol’s cognitive
impairment
Violence
Sexual risk-related behaviors
Impulsive decision making, impaired
learning and memory
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Scholars Program
Phases of Treatment
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Screening and intervention
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Recognition and treatment of withdrawal
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Rehabilitation
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Counseling
Medication
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Scholars Program
Screening
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Quantity and frequency
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Consequences
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Standardized screening:
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AUDIT
 alcoholscreening.org
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CAGE-AID
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Scholars Program
Intervention
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Demonstrate empathy
Feedback about consequences
Identify willingness to change
Recommendations and options
Discuss patient’s response
Arrange referral and follow-up
Developed for the Alcohol Medical
Scholars Program
Withdrawal - Alcohol
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Symptoms: anxiety, HTN, tachycardia, nausea,
tremor, disorientation
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Severe - seizures, delirium tremens 5%
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Benzodiazepines – moderate to severe
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Admission: severe medical, psychiatric or social
problems, or a history of severe withdrawal
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Developed for the Alcohol Medical
Scholars Program
Withdrawal - Cocaine
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Few physical signs
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Agitation, drug-seeking behavior,
depression
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may lead to drinking
Treatment supportive and symptomatic
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Scholars Program
Overview of Rehabilitation
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Principles
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Increase motivation for abstinence
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Help people rebuild their lives
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Relapse prevention and aftercare
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Scholars Program
Counseling Techniques
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Cognitive Behavioral Therapy
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Relapse Prevention
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Small groups and individual
Past problems and future goals
Relationships, jobs, housing
Triggers – identify and avoid
Rehearse plans in case of relapse
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Scholars Program
Counseling Techniques, Cont.
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12 Step Facilitation
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Motivational Enhancement Therapy
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Resolve ambivalence, non-confrontational
Contingency Management
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Abstinence, self-motivation, and peer support
Rewards in exchange for meeting goals
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Scholars Program
Medications – Combined Dependence
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Naltrexone (Trexan or Revia)
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opiate antagonist
longer time to first drink and first relapse
Disulfiram (Antabuse)
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aversive agent, aldehyde dehydrogenase
many side effects limit usefulness
May reduce use combined with therapy
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Scholars Program
Treatment - Combined
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Patient characteristics
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Research
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longer history of substance use
financial and family disruption
poorer outcomes
fewer studies on combined disorders
poorer outcomes suggest need for more intensive
and flexible methods
early abstinence important
Developed for the Alcohol Medical
Scholars Program
Summary
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Alcohol and cocaine use significant public health
issue
When used simultaneously form cocaethylene may increase toxicity
Deleterious effects are more than additive
cardiovascular
 psychiatric
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Identification, detoxification, rehabilitation
important - few data on combined disorders
Developed for the Alcohol Medical
Scholars Program