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

- - -
- -
-/ -


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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

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

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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

13
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

• Alcohol
• Arrhythmias
• Respiratory depression
• Accidents

• Cocaine
• Arrhythmias
• Heart attack
• Stroke
• Psychosis

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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

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Psychiatric Effects - Combined

• More euphorigenic and rewarding
• Attenuation of alcohols 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 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

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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

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

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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