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					    Alcohol and
           Katie McQueen, M.D.
      Baylor College of Medicine

                  Developed for the Alcohol Medical
1                                 Scholars Program
       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

                                           Developed for the Alcohol Medical
2                                                          Scholars Program
       Alcohol and cocaine are frequently used

         Harm is greater
         Treatment outcomes are different

         Identification is important

                                     Developed for the Alcohol Medical
3                                                    Scholars Program
                             Spectrum of Alcohol Use
                               NON-        AT-
                               PROB        RISK ABUSE DEP
                    E           USE        USE

    Use          -                 +           +             +        +
    Consequences -                 -          -/+            +       ++
                 -                             -             +
    Repetition                     -                                  +
    Loss of control, preoccupation, compulsivity, physical dependence +
                                                    Developed for the Alcohol Medical
4                                                                   Scholars Program
    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
                                         Developed for the Alcohol Medical
5                                                        Scholars Program
    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
       Does not meet criteria for DEPENDENCE

                                             Developed for the Alcohol Medical
6                                                            Scholars Program
    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

                                                Developed for the Alcohol Medical
7                                                               Scholars Program
    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
                                             Developed for the Alcohol Medical
8                                                            Scholars Program
    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

                                                  Developed for the Alcohol Medical
9                                                                 Scholars Program
 Epidemiology - Cocaine
    Cocaine National Household Survey–

        2% (4 million) tried cocaine in the last year
        0.7% met criteria abuse or dependence
           In 2000 - 0.5%

                                           Developed for the Alcohol Medical
10                                                         Scholars Program
 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%

                                       Developed for the Alcohol Medical
11                                                     Scholars Program
 Factors - Concomitant Use
    Genetic - vulnerability to substance

    Biologic - blunt or increase effects

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

                                     Developed for the Alcohol Medical
12                                                   Scholars Program
 Biochemical Effects
    Alcohol
        Sedative-hypnotic
        Increase in dopamine and GABA, inhibit
        Metabolized in liver by alcohol

                                       Developed for the Alcohol Medical
13                                                     Scholars Program
 Biochemical Effects
    Cocaine
        Many forms: hydrochloride salt and crack
        Highly reinforcing
        Strong CNS stimulant
        Increase in dopamine and norepinephrine
        Metabolized in liver by cholinesterase

                                       Developed for the Alcohol Medical
14                                                     Scholars Program
 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
                                              Developed for the Alcohol Medical
15                                                            Scholars Program
 Dangers of Intoxication
          Alcohol                  Cocaine
     Arrhythmias              Arrhythmias
     Respiratory depression   Heart attack

     Accidents                Stroke


                                       Developed for the Alcohol Medical
16                                                     Scholars Program
 Dangers of Long-term Use
           Alcohol                 Cocaine
 heart attack           heart attack
 arrhythmias            arrhythmias
 stroke                 stroke
 spontaneous abortion   spontaneous abortion
 birth defects          birth defects
 psychiatric problems   psychiatric problems
 liver disease          crack lung
 pancreatitis           intravenous drug use
                                     Developed for the Alcohol Medical
17                                                   Scholars Program
 Psychiatric Effects - Combined
    More euphorigenic and rewarding
    Attenuation of alcohol’s cognitive
    Violence
    Sexual risk-related behaviors
    Impulsive decision making, impaired
     learning and memory
                                  Developed for the Alcohol Medical
18                                                Scholars Program
 Phases of Treatment
    Screening and intervention

    Recognition and treatment of withdrawal

    Rehabilitation
        Counseling
        Medication

                                  Developed for the Alcohol Medical
19                                                Scholars Program
    Quantity and frequency
    Consequences
    Standardized screening:
        AUDIT

        CAGE-AID

                                    Developed for the Alcohol Medical
20                                                  Scholars Program
    Demonstrate empathy
    Feedback about consequences
    Identify willingness to change
    Recommendations and options
    Discuss patient’s response
    Arrange referral and follow-up

                                  Developed for the Alcohol Medical
21                                                Scholars Program
 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

                                             Developed for the Alcohol Medical
22                                                           Scholars Program
 Withdrawal - Cocaine
    Few physical signs

    Agitation, drug-seeking behavior,
           may lead to drinking

    Treatment supportive and symptomatic

                                   Developed for the Alcohol Medical
23                                                 Scholars Program
 Overview of Rehabilitation
    Principles
        Increase motivation for abstinence

        Help people rebuild their lives

        Relapse prevention and aftercare

                                           Developed for the Alcohol Medical
24                                                         Scholars Program
 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

                                          Developed for the Alcohol Medical
25                                                        Scholars Program
 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

                                        Developed for the Alcohol Medical
26                                                      Scholars Program
 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

                                            Developed for the Alcohol Medical
27                                                          Scholars Program
 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
                                            Developed for the Alcohol Medical
28                                                          Scholars Program
    Alcohol and cocaine use significant public health
    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
                                         Developed for the Alcohol Medical
29                                                       Scholars Program

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