A Primer for Pharmacy Practitioners: Understanding Your Alcoholic Patients

1. A Primer for Pharmacy Practitioners: Understanding Your Alcoholic Patients Patrick M. Woster, Ph.D. Department of Pharmaceutical Sciences Wayne State University

3. 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

4. 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

5. 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

6. “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

7. 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

8. 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

9. 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

10. 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

11. Acetone and Alcoholism

12. THIQs in Alcoholism • 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

13. 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 b-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

14. 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

15. 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.

16. 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.

17. 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

18. 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

19. 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

20. 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.

21. 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

22. Did You Guess Who the Non-Alcoholic Was?