A Primer for Pharmacy Practitioners Wayne State University.ppt

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					 A Primer for Pharmacy Practitioners:
Understanding Your Alcoholic Patients


      Patrick M. Woster, Ph.D.
Department of Pharmaceutical Sciences
       Wayne State University
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The Scope of the Problem
•There are more deaths and disabilities each year in the U.S.
      from substance abuse than from any other cause.

•About 18 million Americans have alcohol problems; about
      5 to 6 million Americans have drug problems.

•More than half of all adults have a family history of alcoholism
      or problem drinking.

•More than nine million children live with a parent dependent
      on alcohol and/or illicit drugs.

                  http://www.ncadd.org/facts/numberoneprob.html
The Consequences
•One-quarter of all emergency room admissions, one-third
      of all suicides, and more than half of all homicides
      and incidents of domestic violence are alcohol-related.

•Heavy drinking contributes to illness in each of the top
      three causes of death: heart disease, cancer and stroke.

•Almost half of all traffic fatalities are alcohol-related.

•Between 48% and 64% of people who die in fires have
      blood alcohol levels indicating intoxication.

•Fetal alcohol syndrome is the leading known cause of
       mental retardation.
                     http://www.ncadd.org/facts/numberoneprob.html
The Cost
•Alcohol and drug abuse costs the American economy an
      estimated $276 billion per year in lost productivity,
      health care expenditures, crime, motor vehicle crashes
      and other conditions.

*Untreated addiction is more expensive than heart disease,
      diabetes and cancer combined.

•Every American adult pays nearly $1,000 per year for the
      damages of addiction.


                      http://www.ncadd.org/facts/numberoneprob.html
“An illness of this sort - and we have come to believe it an illness - involves
those around us in a way no other human sickness can. If a person has
cancer all are sorry for him and no one is angry or hurt. But not so with the
alcoholic illness, for with it there goes the annihilation of all the things
worthwhile in life. It engulfs all whose lives touch the sufferer’s. It brings
misunderstanding, fierce resentment, financial insecurity, disgusted
friends and employers, warped lives of blameless children, sad wives and
parents - anyone can increase this list.”

Alcoholics Anonymous, page 18
The 5 Types of Alcoholic
•Type 1 - Always going on the wagon for keeps, remorseful,
      resolute, but no decision to stop.
•Type 2 - Unwilling to admit he cannot take a drink.
•Type 3 - Believes that after an alcohol-free period, he can
      again drink safely.
•Type 4 - Manic-depressive type, who is least understood.
•Type 5 - Perfectly normal in every respect, except in the way
      alcohol affects him.

Alcoholics Anonymous, page xxviii
Alcoholism is an “Allergy”

  “We believe, and so suggested a few years ago, that the
  action of alcohol on these chronic alcoholics is a
  manifestation of an allergy; that the phenomenon of
  craving is limited to this class and never occurs in the
  average temperate drinker. These allergic types can
  never safely use alcohol in any form at all;……”

  Alcoholics Anonymous, page xxvi
Alcoholism is a Disease
 -Strong genetic component

         Type 1 - passed on from either mother or father
                  symptoms occur later in life
         Type 2 - passed on only from father to son
                  symptoms begin in teens, very persistent

 -Polymorphisms in aldehyde dehydrogenase

 -Production of neuroactive substances in the brain not found
        in non-alcoholics

 There is no cure, and the disease is 100% FATAL if not treated
Genetic Markers for Alcoholism
 -Alcohol dehydrogenase and aldehyde dehydrogenase polymorphisms

         -Orientals often have diminished ADH and ALDH that
                 protects from alcoholism
         -Depressed platelet MAO in Caucasian alcohol abusers, more
                 prominent in Type II

 -Characteristic X-wave EEG in alcoholics after EtOH ingestion

 -Lower platelet adenylate cyclase resulting from overexpressed
        inhibitory G-protein

 -Inheritance of the A1 allele of the D2 dopamine receptor present in
         alcoholics
Acetone and Alcoholism
                                                         O                                            O
                          alcohol                                         aldehyde
     H3C   OH             dehydrogenase          H3C         H            dehydrogenase         H3C       OH



                                                                     -ketothiolase




                      O                                  O       O                              O     O

                H3C       CH3                    H3C                 OH                   H3C             OH

                 acetone                           acetoacetic acid                       -hydroxybutyric acid



                            insufficient enzyme levels




                 SPREE                                                    SHAME
THIQs in Alcoholism                                           OH
                                                                   OH



                             NH2         HO
                                                         NH

          HO                             HO
                OH
                                              tetrahydropapveroline

                     +                                    R
                                              HO
                                                              NH
                     O
                                              HO
               H3C       H
                                         tetrahydroisoquinolines (THIQs)




  -THP and THIQs formed from acetaldehyde and dopamine
  -These analogues stimulate d-opiate receptors, causing release of
          dopamine
  -Endogenous dopamine release stimulates reinforcement center
  -Naloxone-reversible, dose-dependent increase in voluntary
          intake of alcohol
Endogenous Opiates in Alcoholism


-Ethanol ingestion causes increase in # of m and d opiate receptors

-Endorphin and enkephelin synthesis and release altered by EtOH

-Release of -endorphin stimulated by ethanol

-Moderate doses of morphine or met-enkephelin decrease
       self-administration of ethanol in rats

-Narcotic antagonists of some value in reducing voluntary ethanol intake
Acute Alcohol Withdrawal
                                       Group 1

  Tremors, general irritability, nausea, vomiting, flushed,iInjected conjunctivas,
                               tachycardia, anorexia, insomnia
Treatment: Adequate medical examination, adequate rest, good nutrition, multiple
              Vitamins, benzodiazepines PRN for severe tremor.

                                       Group 2

Alcohol Hallucinosis: requently visual illusions, auditory hallucinations despite an
otherwise clear sensorium (most common from is human voices, most prominent at
                        night), other types of hallucinations.
                              Treatment: neuroleptics.

                                       Group 3

 Withdrawal seizures : over 90% of the seizures occur during the 7 - 48 hour period
following the cessation of drinking. Grand mal seizures. In the majority of cases, the
     seizures occur in bursts of 2 - 6. 2% of patients develop status epilepticus.
                              Treament: anticonvulsants
Acute Alcohol Withdrawal (con’t)


 Delirium Tremens: Usually appear 2 - 4 days after cessation of drinking. The
 duration is about 72 hours. Very seldom lasts 4 - 5 weeks. Without treatment,
 between 5 -15% of DT's end fatally.

  Symptoms: Reduced ability to maintain attention, disorganized thinking, reduced
 level of consciousness, vivid hallucinations (mainly visual), delusions, tremor,
 Agitation, increased overactivity of the autonomic nervous system (dilated pupils,
 hypertension, tachycardia, persipration, fever).

 Treatment: drugs that have cross tolerance and dependence with alcohol such as
 benzodiazepines (librium or lorazepam), hydration, thiamine, multiple vitamins.
Acute Alcohol Withdrawal (con’t)

                THE WERNICKE-KORSAKOFF SYNDROME

 Clinical features: Wernicke

 Ocular signs ( Nystagmus: weakness or paralysis of the external rectus,
 weakness or paralysis of conjugate gaze), ataxia, disturbance of consciousness
 and global confusion, drowsiness, stupor & coma

 Clinical features: Korsakoff

 Amnesia, disorientation, confabulation, may have peripheral nerve disease, WK
 gait

 Wernicke-Korsakoff appears to be a genetic problem related to deficiency of
 transketolase. It is more frequently seen in European people or their
 descendants.
Post Acute Withdrawal Syndrome (PAWS)
     -Symptoms peak 3-6 months after abstinence begins

     -Symptoms persist up to 24 months after abstinence begins

     -Symptoms:

                      Inability to solve simple problems
                      Inability to think clearly
                      Emotional overreaction or numbness
                      Sleep disturbances and drinkers dreams
                      Inability to handle stress
                      Memory impairment

     -Important for patient to realize this is transient
Co-Dependency in Alcoholism

                   Co-Dependent Spouses

     The Enabler        The Caretaker         The Controller

                   Co-Dependent Children

                           The Hero
           The Scapegoat                The Lost Child

                           The Mascot



  Co-Dependents will eventually get all of the physical and
  Psychological symptoms of the alcoholic
Relapse
-Recovering people should insist that their care providers take the
       disease seriously

-Seven A’s of Recovery (abstinence, antabuse, AA, aftercare, acceptance,
        avoidance, action)

-Beware the cure - products containing ethanol, or other drugs, can
       precipitate relapse.

-Attitude is all - avoid exhaustion, self-pity, frustration, intolerance,
        cockiness, and above all COMPLACENCY.

-Include family and health care providers
Non-Drug Treatment
                           The Twelve Steps of Alcoholics Anonymous

          1. We admitted we were powerless over alcohol—that our lives had become unmanageable.

               2. Came to believe that a Power greater than ourselves could restore us to sanity.

        3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

                        4. Made a searching and fearless moral inventory of ourselves.

        5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

                   6. Were entirely ready to have God remove all these defects of character.

                              7. Humbly asked Him to remove our shortcomings.

         8. Made a list of all persons we had harmed, and became willing to make amends to them all.

 9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

           10. Continued to take personal inventory and when we were wrong promptly admitted it.

         11. Sought through prayer and meditation to improve our conscious contact with God, as we
              understood Him, praying only for knowledge of His will for us and the power to carry that out.

 12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics,
                                    and to practice these principles in all our affairs.
Pharmaceutical Care in Alcoholism

-Be aware of products that contain ethanol, especially in
      patients taking disulfiram

-Cross-tolerance with other drugs (mood-altering agents,
      anesthetics)

-Highly induced liver enzymes - must monitor drug levels,
      especially with drugs like warfarin
Did You Guess Who the Non-Alcoholic Was?




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