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Alcohol and Cocaine

Katie McQueen, M.D.

Baylor College of Medicine

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Introduction

Goal - Review important issues in the concomitant use of alcohol and cocaine

Definitions and rationale Historical trends and epidemiology Biochemical effects Medical consequences Overview of treatment

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Rationale

Alcohol and cocaine are frequently used together

Harm is greater Treatment outcomes are different Identification is important

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NON-NON-PROBPROBUSEUSE

AT-AT-RISKRISKUSEUSE

ABUSEABUSE DEPDEP

UseConsequencesRepetitionLoss of control, preoccupation, compulsivity, physical

dependence

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AA

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SS

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II

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EE

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CC

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Spectrum of Alcohol Use

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Problematic Use of Alcohol

National Institute of Alcohol Abuse and Alcoholism recommends no more than: 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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Substance Abuse - DSM IV

Maladaptive pattern with repetitive impairment in at least one: 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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Substance Dependence - DSM IV

Maladaptive pattern with three or more: 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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Historical Trends

Alcohol Egyptians made wine 3500 BC Distilled spirits made over 1000 years ago Prohibition 1919-1933

Cocaine Alkaloid extracted from coca plant 100 years of use - tonic, anesthetic Peak use in 1980’s

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Epidemiology - Alcohol

Alcohol National Household Survey - 2001 48% drink 21% >5 per occasion 6% regularly drink >5 6% abuse or dependence

11.0 million alcohol alone 2.4 million alcohol and an illicit substance

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Epidemiology - Cocaine

Cocaine National Household Survey– 2001

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

75% of cocaine users also use alcohol

Drug Abuse Warning Network - ER visits

Cocaine most common illicit - 29%

Cocaine and alcohol most common combination - 13%

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Factors - Concomitant Use

Genetic - vulnerability to substance dependence

Biologic - blunt or increase effects

Psychosocial - conduct disorder/antisocial personality, availability, social pressure, cultural factors

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Biochemical Effects

Alcohol Sedative-hypnotic Increase in dopamine and GABA, inhibit

NMDA Metabolized in liver by alcohol

dehydrogenase

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Biochemical Effects

Cocaine 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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Biochemical Effects - Combined

Alcohol leads to a 30% increase in blood levels of cocaine

Combination produces cocaethylene increases dopamine release enhances risk for cardiac death enhances length of high

Chronic alcohol leads to increase brain-to-plasma cocaine ratio

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Dangers of Intoxication

AlcoholArrhythmias

Respiratory depression

Accidents

CocaineArrhythmias

Heart attack

Stroke

Psychosis

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Dangers of Long-term UseCocaine

heart attack

arrhythmias

stroke

spontaneous abortion

birth defects

psychiatric problemscrack lungintravenous drug use

Alcoholheart attack

arrhythmias

stroke

spontaneous abortion

birth defects

psychiatric problemsliver diseasepancreatitis

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Psychiatric Effects - Combined

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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Phases of Treatment

Screening and intervention

Recognition and treatment of withdrawal

Rehabilitation Counseling Medication

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Screening

Quantity and frequency

Consequences

Standardized screening: AUDIT

alcoholscreening.org CAGE-AID

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Intervention

Demonstrate empathy Feedback about consequences Identify willingness to change Recommendations and options Discuss patient’s response Arrange referral and follow-up

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Withdrawal - Alcohol

Symptoms: anxiety, HTN, tachycardia, nausea, tremor, disorientation Severe - seizures, delirium tremens 5%

Benzodiazepines – moderate to severe

Admission: severe medical, psychiatric or social problems, or a history of severe withdrawal

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Withdrawal - Cocaine

Few physical signs

Agitation, drug-seeking behavior, depression

may lead to drinking

Treatment supportive and symptomatic

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Overview of Rehabilitation

Principles

Increase motivation for abstinence

Help people rebuild their lives

Relapse prevention and aftercare

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Counseling Techniques

Cognitive Behavioral Therapy Small groups and individual Past problems and future goals Relationships, jobs, housing

Relapse Prevention Triggers – identify and avoid Rehearse plans in case of relapse

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Counseling Techniques, Cont.

12 Step Facilitation Abstinence, self-motivation, and peer support

Motivational Enhancement Therapy Resolve ambivalence, non-confrontational

Contingency Management Rewards in exchange for meeting goals

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Medications – Combined Dependence

Naltrexone (Trexan or Revia) opiate antagonist longer time to first drink and first relapse

Disulfiram (Antabuse) aversive agent, aldehyde dehydrogenase many side effects limit usefulness

May reduce use combined with therapy

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Treatment - Combined

Patient characteristics longer history of substance use financial and family disruption poorer outcomes

Research fewer studies on combined disorders poorer outcomes suggest need for more intensive

and flexible methods early abstinence important

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Summary Alcohol and cocaine use significant public health

issue When used simultaneously form cocaethylene -

may increase toxicity Deleterious effects are more than additive

cardiovascular psychiatric

Identification, detoxification, rehabilitation important - few data on combined disorders