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Transcript of Developed for the Alcohol Medical Scholars Program 1 Alcohol and Cocaine Katie McQueen, M.D. Baylor...
Developed for the Alcohol Medical Scholars Program
1
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
BB
SS
TT
II
NN
EE
NN
CC
EE
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