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

 

II.              Epidemiology and Historical Perspective

 

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

 

III.            Biochemical effects

 

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]

 

 

 

 

IV.           Medical Effects and Consequences

 

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

 

V.             Treatment

 

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

 

VII.          Summary {Slide 30}

 

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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