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Alcohol and Cocaine

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Goal - Review important issues in the concomitant use of alcohol and cocaine ... Deleterious effects are more than additive. cardiovascular. psychiatric ... – PowerPoint PPT presentation

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Title: Alcohol and Cocaine


1
Alcohol and Cocaine
  • Katie McQueen, M.D.
  • Baylor College of Medicine

2
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

3
Rationale
  • Alcohol and cocaine are frequently used together
  • Harm is greater
  • Treatment outcomes are different
  • Identification is important

4
Spectrum of Alcohol Use
A B S T I N E N C E
NON-PROBUSE
AT-RISKUSE
ABUSE
DEP
Use Consequences Repetition Loss of control,
preoccupation, compulsivity, physical dependence

- - -
- -
-/ -


5
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

6
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

7
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

8
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 1980s

9
Epidemiology - Alcohol
  • Alcohol National Household Survey - 2001
  • 48 drink
  • 21 gt5 per occasion
  • 6 regularly drink gt5
  • 6 abuse or dependence
  • 11.0 million alcohol alone
  • 2.4 million alcohol and an illicit substance

10
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

11
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

12
Factors - Concomitant Use
  • Genetic - vulnerability to substance dependence
  • Biologic - blunt or increase effects
  • Psychosocial - conduct disorder/antisocial
    personality, availability, social pressure,
    cultural factors

13
Biochemical Effects
  • Alcohol
  • Sedative-hypnotic
  • Increase in dopamine and GABA, inhibit NMDA
  • Metabolized in liver by alcohol dehydrogenase

14
Biochemical Effects
  • Cocaine
  • Many forms hydrochloride salt and crack
  • Highly reinforcing
  • Strong CNS stimulant
  • Increase in dopamine and norepinephrine
  • Metabolized in liver by cholinesterase

15
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

16
Dangers of Intoxication
  • Alcohol
  • Arrhythmias
  • Respiratory depression
  • Accidents
  • Cocaine
  • Arrhythmias
  • Heart attack
  • Stroke
  • Psychosis

17
Dangers of Long-term Use
  • Cocaine
  • heart attack
  • arrhythmias
  • stroke
  • spontaneous abortion
  • birth defects
  • psychiatric problems
  • crack lung
  • intravenous drug use
  • Alcohol
  • heart attack
  • arrhythmias
  • stroke
  • spontaneous abortion
  • birth defects
  • psychiatric problems
  • liver disease
  • pancreatitis

18
Psychiatric Effects - Combined
  • More euphorigenic and rewarding
  • Attenuation of alcohols cognitive impairment
  • Violence
  • Sexual risk-related behaviors
  • Impulsive decision making, impaired learning and
    memory

19
Phases of Treatment
  • Screening and intervention
  • Recognition and treatment of withdrawal
  • Rehabilitation
  • Counseling
  • Medication

20
Screening
  • Quantity and frequency
  • Consequences
  • Standardized screening
  • AUDIT
  • alcoholscreening.org
  • CAGE-AID

21
Intervention
  • Demonstrate empathy
  • Feedback about consequences
  • Identify willingness to change
  • Recommendations and options
  • Discuss patients response
  • Arrange referral and follow-up

22
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

23
Withdrawal - Cocaine
  • Few physical signs
  • Agitation, drug-seeking behavior, depression
  • may lead to drinking
  • Treatment supportive and symptomatic

24
Overview of Rehabilitation
  • Principles
  • Increase motivation for abstinence
  • Help people rebuild their lives
  • Relapse prevention and aftercare

25
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

26
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

27
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

28
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

29
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
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