1. Developed for the Alcohol Medical Scholars Program 1 Alcohol and Cocaine Katie McQueen, M.D. Baylor College of Medicine

2. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 3 Rationale Alcohol and cocaine are frequently used together Harm is greater Treatment outcomes are different Identification is important

4. Developed for the Alcohol Medical Scholars Program 4 NON- PROB USE AT- RISK USE ABUSEDEP Use Consequences Repetition Loss of control, preoccupation, compulsivity, physical dependence --- +-- +-/+-+++ +++++ ABSTINENCE Spectrum of Alcohol Use

5. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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 1980’s

9. Developed for the Alcohol Medical Scholars Program 9 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

10. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 13 Biochemical Effects Alcohol Sedative-hypnotic Increase in dopamine and GABA, inhibit NMDA Metabolized in liver by alcohol dehydrogenase

14. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 16 Dangers of Intoxication Alcohol Arrhythmias Respiratory depression Accidents Cocaine Arrhythmias Heart attack Stroke Psychosis

17. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 18 Psychiatric Effects - Combined More euphorigenic and rewarding Attenuation of alcohol’s cognitive impairment Violence Sexual risk-related behaviors Impulsive decision making, impaired learning and memory

19. Developed for the Alcohol Medical Scholars Program 19 Phases of Treatment Screening and intervention Recognition and treatment of withdrawal Rehabilitation Counseling Medication

20. Developed for the Alcohol Medical Scholars Program 20 Screening Quantity and frequency Consequences Standardized screening: AUDIT  alcoholscreening.org CAGE-AID

21. Developed for the Alcohol Medical Scholars Program 21 Intervention Demonstrate empathy Feedback about consequences Identify willingness to change Recommendations and options Discuss patient’s response Arrange referral and follow-up

22. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 23 Withdrawal - Cocaine Few physical signs Agitation, drug-seeking behavior, depression  may lead to drinking Treatment supportive and symptomatic

24. Developed for the Alcohol Medical Scholars Program 24 Overview of Rehabilitation Principles Increase motivation for abstinence Help people rebuild their lives Relapse prevention and aftercare

25. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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. Developed for the Alcohol Medical Scholars Program 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