Alcohol and Cocaine
Katie McQueen, M.D.
Prepared for the Alcohol Medical
Scholars Program {Slide 1}
I.
Introduction
{Slide 2}
A. The goal of this lecture:
1. Designed for medical and other health professional
students
2. Emphasis is on the concomitant use of alcohol and
cocaine.
B. To accomplish this, the lecture will cover:
1. Epidemiology of alcohol, cocaine and combined use in
the U.S.
2. Biochemical effects of alcohol and cocaine when used
in combination
3. Medical consequences of short term and long term use
of alcohol and cocaine
4. The principles of treatment for alcohol and cocaine
abuse and/or dependence with a focus on treatment of patients who use both
alcohol and cocaine
C. The topic is important because: {Slide 3}
1. Alcohol and cocaine are frequently used together
2. Harm from the combination greater than isolated use
of either substance
3. Treatment outcomes are different for simultaneous use
4. Therefore, identification of simultaneously use is
important
D. The lecture will present data on use, abuse, and
dependence.
1. Use of psychoactive substances occurs on a spectrum
from abstinence to dependence {Slide 4}
2. Problematic use of alcohol [1] {Slide 5}
a. NIAAA recommendations for moderate drinking:
i. Women 3/occ. and 7/week, Men 4/occ and 14/week,
Elderly 1/occ and 7/week
b. Harm without meeting criteria of abuse
3. Abuse - Maladaptive pattern with repetitive
impairment in at least one area [2]: {Slide 6}
a. failure to fulfill role obligations
b. recurrent use in hazardous situations
c. recurrent substance-related legal problems
d. persistent or recurrent social or interpersonal
problems
4. Dependence Maladaptive pattern with three or more
[2]: {Slide 7}
a. tolerance
b. withdrawal
c. substance taken in larger amounts/longer times
d. desire/attempts cut down
e. great deal of time spent obtaining, using, or
recovering from substance use
f. reduced social, occupational, or recreational
activities
g. recurrent use despite physical and psychological
problems
A. Historical perspective and trends {Slide 8}
1. Alcohol
a. Egyptians made wine 3500 BC
b. Distilled spirits over 1000 years ago
c. Prohibition 1919-1933
2. Cocaine [3, 4]
a. Alkaloid extracted from coca plant
b. >100 years of use, historically as tonic/elixir
and anesthetic, peak use in 1980ıs
B. Epidemiology {Slide 9}
1. Alcohol 2001 National Household Data [5]
a. 48% US population drinks
b. 21% (46 million) >5/occasion in the last month
c. 6% (13 million) heavy (>5/occasion on 5+days/mo)
d. 6% (11million abuse/dependence alcohol alone, 2.4
abuse/dependence on alcohol and illicit)
2. Cocaine [3, 5]
a. 2% (4million) tried cocaine
b. 0.7% abuse or dependent up from 0.5% in 2000
c. Data is based on self report. Previous studies have demonstrated that
prevalence of illicit drug use is underestimated when self report is relied
upon.
C. Combined use {Slide 11}
1. Estimated that 75% of cocaine use alcohol both
independently and while using cocaine. [6]
2. Drug Abuse Warning Network measures drug related
episodes in selected large Emergency Departments [7]
a. cocaine is most common illicit (29% of drug related
ED visits)
b. cocaine and alcohol most common combination (13% of
drug related ED visits)
3. Factors leading to high prevalence of combined use
[6] {Slide 12}
a. Genetic vulnerability to substance dependence 4
fold increase in alcohol dependence and increase in stimulant abuse and
dependence when parent has alcohol dependence
b. Biologic simultaneous use to blunt or increase
effects
c. Psychosocial increased risk in conduct
disorder/antisocial personality disorder
d. Availability, social pressure, cultural factors
A. Important to understand the biochemical effects of
alcohol and cocaine to appropriately identify, treat, and prevent further harm
B. Alcohol [8] {Slide 13}
1. Sedative-hypnotic or CNS depressant
2. Increase in dopamine and GABA, inhibit NMDA
3. Metabolized by liver by alcohol dehydrogenase
C. Cocaine {Slide 14}
1. Used in two forms hydrochloride salt (nasal and IV)
and ³freebase² or crack (smoked) [4]
2. Highly reinforcing especially with inhalation [8]
3. Strong CNS stimulant interferes with reabsorption of
dopamine and norepinephrine [8]
4. Metabolized in liver by cholinesterase serum half
life 45 to 90 minutes
D. Combined {Slide 15}
1. Alcohol leads to 30% increase in blood levels of
cocaine if given at same time or preceeding [9]
2. Liver combines to produce cocaethylene increased
dopamine release, possible increase risk sudden cardiac death [4, 9]
3. Humans cannot distinguish between cocaine and
cocaethylene [9]
4. Chronic alcohol leads to increase brain-to-plasma
cocaine ratio [10]
A. Intoxication {Slide 16}
1. Alcohol Intoxication - Short term risk of arrhythmias, respiratory depression, motor vehicle and boating
accidents, increase homicide and suicide [11]
2. Cocaine Intoxication - Short term risk of arrhythmias,
heart attack (increase factor of 24 in 60 minutes post ingestion),
stroke, psychosis [4, 6, 12]
B. Long-term Effects many are similar [4,6,8,9,12]
{Slide 17}
1. Alcohol [11]
a. CV most important with combined cocaine use (heart
attack, atrial arrhythmias, dilated cardiomyopathy, hypertension)
b. Neurologic (stroke, cerebellar, polyneuropathy, dementia, impaired
cognitive testing) GI symptoms (hepatitis, cirrhosis, gastritis, ulcers, pancreatitis)
c. GYN/Endocrine (spontaneous abortion, dysfunctional uterine bleeding, fetal alcohol
syndrome, electrolyte and acid/base disorders)
d. Psychiatric (depression, anxiety)
2. Cocaine [11]
a. Cardiovascular (dilated cardiomyopathy,
hypertension, arrhythmias)
i. increased cardiotoxicity with combined use
ii. increased heart rate and oxygen demand
b. Neurologic (stroke, headache, vasculitis, impaired cognitive testing)
c. GYN (spontaneous abortion, placental abruption, fetal defects)
i. combination more than additive risk birth defects
d. Psychiatric (anxiety, depression, psychosis)
e. Pulmonary (crack lung)
f. Risks intravenous drug use (human immunodeficeincy
virus, Hepatitis C Virus, endocarditis, skin infections)
C. Combined Psychiatric Effects [9, 14, 15] {Slide 18}
1. More euphorigenic and rewarding increased high
2. Attenuation of alcoholıs cognitive impairment
decreased alcohol sedation
3. Increased interpersonal and physical violence
4. Increased sexual risk-related behaviors
5. Impulsive decision making, decrease learning/memory
A. Overview of Treatment [8] {Slide 19}
1. Screening and Intervention
2. Recognition and Treatment of Withdrawal
3. Rehabilitation
a. Counseling cornerstone
b. Medications - limited role
B. Screening identification of disorder [1] {Slide 20}
1. Quantity and frequency identifies problematic
alcohol use and warrants further screening
2. Consequences identifies abuse and/or dependence and
warrants further screening
3. Standardized Screens
a. AUDIT 10 questions good at identifying problematic
use, abuse, and dependence alcohol only [16]
i. Available online alcoholscreening.org
b. CAGE-AID 4 questions adapted from CAGE good at
identifying abuse and dependence alcohol and drugs [17]
i. Have you ever tried to Cut-down on your drinking or drug use?
ii. Do you get Annoyed when people talk about your drinking or drug use?
iii. Do you feel Guilty about your drinking or drug use?
iv. Have you ever had an Eye-Opener? (drinking or using drugs first thing in
the morning)
4. Intervention engaging in treatment, making the
referral [1] {Slide 21}
a. Demonstrate empathy
b. Feedback about potential and current consequences
c. Identify willingness to change
d. Provide recommendations and options
e. Discuss patient reactions and responses
f. Arrange follow-up and referral
C. Withdrawal Alcohol [6, 8, 18] {Slide 22}
1. Symptoms maybe mild, moderate, or severe and include
anxiety, autonomic disturbances (tachycardia, sweating, fever, labile blood
pressure) can be rated using Clinical Institute Withdrawal Assessment of
Alcohol Scale, Revised (CIWA-Ar) [19]
a. Severe: seizures and/or delirium tremens 5%
2. Management includes thorough history and physical,
thiamine, folate, magnesium, and benzodiazepines
a. Many different regimens available
3. Initial treatment can be inpatient or intensive
outpatient
a. Inpatient preferred for severe medical illness,
unstable living conditions, poor psychosocial support, history of severe
withdrawal, and patients with multiple previous treatment episodes
b. Outpatient appropriate for patients with good social
support and less co-morbidity
D. Withdrawal Cocaine [6, 8] {Slide 23}
1. Few physical signs
2. Initially profound agitation, depression, and drug
seeking
3. Subsequently depression, anxiety, anhedonia
4. Alcohol may be used by patients to alleviate symptoms
5. Treatment is supportive, aimed at symptoms
E. Rehabilitation [8, 20] {Slide 24}
1. Principles:
a. Increase motivation for abstinence
b. Help people rebuild their lives
c. Relapse prevention, treatment retention, and
aftercare improve long-term abstinence
2. Counseling techniques {Slide 25}
a. Most are based on Cognitive Behavioral Therapy
i. Small groups and individual counseling
ii. Focus on past problems and future goals
iii. Important to address relationship, housing, and
employment issues
b. Relapse Prevention
i. Identify triggers for drug use and develop strategies
for avoidance
ii. Rehearse plans to regain abstinence in case of
relapse
3. Counseling techniques [6,8, 21-23] {Slide 26}
a. 12-step facilitation abstinence through
self-motivation and peer support
b. Motivational Enhancement resolve ambivalence,
non-confrontational, develop discrepancy between current actions and future
goals
c. Contingency Management rewards in exchange for
goals
d. These techniques have been utilized in many clinical
trials including Project Match and the NIDA Collaborative Cocaine Treatment
Trial [21-23]
4. Pharmacotherapy some studies promising and ongoing
but not recommended for general use [6, 8, 24, 25] {Slide 27}
a. Naltrexone (Trexan or Revia) [26, 27]
i. Long-acting opiate antagonist
ii. FDA approved 1994
iii. May decrease craving conflicting results
b. Disulfram (Antabuse) {Slide 28}
i. Aversive agent
ii. Inhibits aldehyde dehydrogenase
iii. Many side effects limit usefulness
c. Both medications studied in cocaine-alcohol users
may reduce use when combined with behavioral therapy [28]
F. Treatment Combined {Slide 29}
1. Characteristics: longer history of drug and alcohol
use, increased financial difficulties, family disruption, poorer outcomes [29]
2. Most studies recruit subjects with single drug
history
3. Principles
a. Abstinence of both emphasized
b. Poorer outcomes à more intensive and flexible methods
A. Epidemiology - Alcohol and cocaine use disorders
remain significant public health issues
B. Biochemical effects Alcohol and cocaine used
simultaneously form cocaethylene
C. Medical effects
1. Deleterious consequences - more than additive.
c. cardiovascular
d. psychiatric
2. Simultaneous intoxication and withdrawal complicate
diagnosis
D. Identification, detoxification, rehabilitation and
aftercare important for treatment, but little data exists on treatment and
outcomes for combined disorders
E. More research is needed
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