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									Alcohol and Cocaine

                            Katie McQueen, M.D.

     Prepared for the Alcohol MedicalScholars Program {Slide 1}

   Introduction{Slide 2}

               The goal of this lecture:

                        Designed for medical and other health

                        Emphasis is on the concomitant use of alcohol

               To accomplish this, the lecture will cover:

                        Epidemiology of alcohol, cocaine and combined use inthe

                        Biochemical effects of alcohol and cocaine when usedin

                        Medical consequences of short term and long term useof
                          alcohol and cocaine
                     The principles of treatment for alcohol and cocaineabuse
                        and/or dependence with a focus on treatment of
                        patients who use bothalcohol and cocaine

             The topic is important because: {Slide 3}

                     Alcohol and cocaine are frequently used together

                     Harm from the combination greater than isolated useof
                        either substance

                     Treatment outcomes are different for simultaneous use

                     Therefore, identification of simultaneously use

             The lecture will present data on use, abuse, anddependence.

                     Use of psychoactive substances occurs on a
                        spectrumfrom abstinence to dependence {Slide 4}

                     Problematic use of alcohol [1] {Slide 5}

                            NIAAA recommendations for moderate drinking:

Women 3/occ. and 7/week, Men 4/occ and 14/week,Elderly 1/occ and 7/week

                            Harm without meeting criteria of abuse

                     Abuse - Maladaptive pattern with repetitiveimpairment in
                       at least one area [2]: {Slide 6}
      failure to fulfill role obligations

      recurrent use in hazardous situations

      recurrent substance-related legal problems

      persistent or recurrent social or

Dependence Maladaptive pattern with three or more[2]:
  {Slide 7}



      substance taken in larger amounts/longer times

      desire/attempts cut down

      great deal of time spent obtaining, using,
         orrecovering from substance use

      reduced social, occupational, or

      recurrent use despite physical and
Epidemiology andHistorical

      Historical perspective and trends {Slide 8}


                     Egyptians made wine 3500 BC

                     Distilled spirits over 1000 years ago

                     Prohibition 1919-1933

              Cocaine [3, 4]

                     Alkaloid extracted from coca plant

                     >100 years of use, historically as tonic/elixirand
                        anesthetic, peak use in 1980¹s

      Epidemiology {Slide 9}

              Alcohol 2001 National Household Data [5]

                     48% US population drinks

                     21% (46 million) >5/occasion in the last month

                     6% (13 million) heavy (>5/occasion on 5+days/mo)
              6% (11million abuse/dependence alcohol alone,
                2.4abuse/dependence on alcohol and illicit)

       Cocaine [3, 5]

              2% (4million) tried cocaine

              0.7% abuse or dependent up from 0.5% in 2000

              Data is based on self report. Previous studies
                 have demonstrated thatprevalence of illicit drug
                 use is underestimated when self report is

Combined use {Slide 11}

       Estimated that 75% of cocaine use alcohol
          bothindependently and while using cocaine. [6]

       Drug Abuse Warning Network measures drug
          relatedepisodes in selected large Emergency
          Departments [7]

              cocaine is most common illicit (29% of drug
                 relatedED visits)

              cocaine and alcohol most common combination
                 (13% ofdrug related ED visits)

       Factors leading to high prevalence of combined use[6]
          {Slide 12}
                      Genetic vulnerability to substance dependence
                        4fold increase in alcohol dependence and
                        increase in stimulant abuse anddependence
                        when parent has alcohol dependence

                      Biologic simultaneous use to blunt or

                      Psychosocial increased risk in
                         conductdisorder/antisocial personality disorder

                      Availability, social pressure, cultural factors

Biochemical effects

      Important to understand the biochemical effects ofalcohol and
         cocaine to appropriately identify, treat, and prevent further

      Alcohol [8] {Slide 13}

              Sedative-hypnotic or CNS depressant

              Increase in dopamine and GABA, inhibit NMDA

              Metabolized by liver by alcohol dehydrogenase

      Cocaine {Slide 14}
       Used in two forms hydrochloride salt (nasal and IV)and
          ³freebase² or crack (smoked) [4]

       Highly reinforcing especially with inhalation [8]

       Strong CNS stimulant interferes with reabsorption
          ofdopamine and norepinephrine [8]

       Metabolized in liver by cholinesterase serum halflife 45 to
         90 minutes

Combined {Slide 15}

       Alcohol leads to 30% increase in blood levels ofcocaine if
          given at same time or preceeding [9]

       Liver combines to produce cocaethylene
          increaseddopamine release, possible increase risk
          sudden cardiac death [4, 9]

       Humans cannot distinguish between cocaine
         andcocaethylene [9]

       Chronic alcohol leads to increase brain-to-plasmacocaine
          ratio [10]
Medical Effects andConsequences

      Intoxication {Slide 16}

              Alcohol Intoxication - Short term risk of arrhythmias,
                 respiratory depression, motor vehicle and
                 boatingaccidents, increase homicide and suicide [11]

              Cocaine Intoxication - Short term risk of
                arrhythmias,heart attack (increase factor of 24 in 60
                minutes post ingestion),stroke, psychosis [4, 6, 12]

      Long-term Effects many are similar [4,6,8,9,12]{Slide 17}

              Alcohol [11]

                      CV most important with combined cocaine use
                        (heartattack, atrial arrhythmias, dilated
                        cardiomyopathy, hypertension)

                      Neurologic (stroke, cerebellar, polyneuropathy,
                        dementia, impairedcognitive testing) GI
                        symptoms (hepatitis, cirrhosis, gastritis,
                        ulcers, pancreatitis)

                      GYN/Endocrine (spontaneous abortion,
                        dysfunctional uterine bleeding, fetal
                        alcoholsyndrome, electrolyte and acid/base

                      Psychiatric (depression, anxiety)
                       Cocaine [11]

                              Cardiovascular (dilated
                                 cardiomyopathy,hypertension, arrhythmias)

increased cardiotoxicity with combined use

increased heart rate and oxygen demand

                              Neurologic (stroke, headache, vasculitis, impaired
                                cognitive testing)

                              GYN (spontaneous abortion, placental
                                abruption, fetal defects)

combination more than additive risk birth defects

                              Psychiatric (anxiety, depression, psychosis)

                              Pulmonary (crack lung)

                              Risks intravenous drug use (human
                                 immunodeficeincyvirus, Hepatitis C Virus,
                                 endocarditis, skin infections)

               Combined Psychiatric Effects [9, 14, 15] {Slide 18}

                       More euphorigenic and rewarding increased high

                       Attenuation of alcohol¹s cognitive impairment decreased
                          alcohol sedation

                       Increased interpersonal and physical violence
              Increased sexual risk-related behaviors

              Impulsive decision making, decrease learning/memory


      Overview of Treatment [8] {Slide 19}

              Screening and Intervention

              Recognition and Treatment of Withdrawal


                     Counseling cornerstone

                     Medications - limited role

      Screening identification of disorder [1] {Slide 20}

              Quantity and frequency identifies problematicalcohol use
                and warrants further screening

              Consequences identifies abuse and/or dependence
                andwarrants further screening

              Standardized Screens
                              AUDIT 10 questions good at identifying
                                problematicuse, abuse, and dependence
                                alcohol only [16]

Available online

                              CAGE-AID 4 questions adapted from CAGE good
                                atidentifying abuse and dependence alcohol
                                and drugs [17]

Have you ever tried to Cut-down on your drinking or drug use?

Do you get Annoyed when people talk about your drinking or drug use?

Do you feel Guilty about your drinking or drug use?

Have you ever had an Eye-Opener? (drinking or using drugs first thing inthe

                       Intervention engaging in treatment, making thereferral [1]
                           {Slide 21}

                              Demonstrate empathy

                              Feedback about potential and current

                              Identify willingness to change

                              Provide recommendations and options

                              Discuss patient reactions and responses

                              Arrange follow-up and referral
Withdrawal Alcohol [6, 8, 18] {Slide 22}

        Symptoms maybe mild, moderate, or severe and
          includeanxiety, autonomic disturbances (tachycardia,
          sweating, fever, labile bloodpressure) can be rated
          using Clinical Institute Withdrawal Assessment
          ofAlcohol Scale, Revised (CIWA-Ar) [19]

               Severe: seizures and/or delirium tremens 5%

        Management includes thorough history and
          physical,thiamine, folate, magnesium, and

               Many different regimens available

        Initial treatment can be inpatient or intensiveoutpatient

               Inpatient preferred for severe medical
                  illness,unstable living conditions, poor
                  psychosocial support, history of
                  severewithdrawal, and patients with multiple
                  previous treatment episodes

               Outpatient appropriate for patients with good
                  socialsupport and less co-morbidity

Withdrawal Cocaine [6, 8] {Slide 23}

        Few physical signs

        Initially profound agitation, depression, and drugseeking

        Subsequently depression, anxiety, anhedonia
                        Alcohol may be used by patients to alleviate symptoms

                        Treatment is supportive, aimed at symptoms

               Rehabilitation [8, 20] {Slide 24}


                               Increase motivation for abstinence

                               Help people rebuild their lives

                               Relapse prevention, treatment retention,
                                  andaftercare improve long-term abstinence

                        Counseling techniques {Slide 25}

                               Most are based on Cognitive Behavioral Therapy

Small groups and individual counseling

Focus on past problems and future goals

Important to address relationship, housing, andemployment issues

                               Relapse Prevention

Identify triggers for drug use and develop strategiesfor avoidance

Rehearse plans to regain abstinence in case ofrelapse
                       Counseling techniques [6,8, 21-23] {Slide 26}

                                12-step facilitation abstinence throughself-
                                   motivation and peer support

                                Motivational Enhancement resolve
                                  ambivalence,non-confrontational, develop
                                  discrepancy between current actions and

                                Contingency Management rewards in exchange

                                These techniques have been utilized in many
                                   clinicaltrials including Project Match and the
                                   NIDA Collaborative Cocaine TreatmentTrial

                       Pharmacotherapy some studies promising and
                         ongoingbut not recommended for general use [6, 8,
                         24, 25] {Slide 27}

                                Naltrexone (Trexan or Revia) [26, 27]

Long-acting opiate antagonist

FDA approved 1994

May decrease craving conflicting results

                                Disulfram (Antabuse) {Slide 28}

Aversive agent
Inhibits aldehyde dehydrogenase

Many side effects limit usefulness

                              Both medications studied in cocaine-alcohol users
                                 may reduce use when combined with
                                 behavioral therapy [28]

               Treatment Combined {Slide 29}

                       Characteristics: longer history of drug and alcoholuse,
                         increased financial difficulties, family disruption,
                         poorer outcomes [29]

                       Most studies recruit subjects with single drughistory


                              Abstinence of both emphasized

                              Poorer outcomes  more intensive and flexible

Summary {Slide 30}

               Epidemiology - Alcohol and cocaine use disordersremain
                  significant public health issues
          Biochemical effects Alcohol and cocaine usedsimultaneously
             form cocaethylene

          Medical effects

                   Deleterious consequences - more than additive.



                   Simultaneous intoxication and withdrawal

          Identification, detoxification, rehabilitation andaftercare important
             for treatment, but little data exists on treatment andoutcomes
             for combined disorders

          More research is needed

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