A Primer for Pharmacy Practitioners:Understanding Your Alcoholic Patients

Patrick M. Woster, Ph.D.Department of Pharmaceutical Sciences

Wayne State University

•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.

The Scope of the Problem

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

•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

The Cost

“An illness of this sort - and we have come to believe it an illness - involvesthose 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 bringsmisunderstanding, fierce resentment, financial insecurity, disgusted friends and employers, warped lives of blameless children, sad wives andparents - anyone can increase this list.”

Alcoholics Anonymous, page 18

Betty Ford Center REHAB FACILITYRancho Mirage, California. Founded in 1982.

Official Website: http://www.bettyfordcenter.org/

Name Occupation Birth Death Known for

Eileen Brennan Actor 3-Sep-1935 Capt. Lewis on Private BenjaminBobby Brown Musician 5-Feb-1969 Still humpin' around after all these yearsGary Busey Actor 29-Jun-1944 The Buddy Holly StoryJohnny Cash Musician 26-Feb-1932 12-Sep-2003 The Man in BlackChevy Chase Comic 8-Oct-1943 SNL alumnus hosted The Chevy Chase ShowAlice Cooper Musician 4-Feb-1948 King of Fake Blood at Rock ConcertsTony Curtis Actor 3-Jun-1925 Houdini and Some Like It HotJohn Daly Sports 28-Apr-1966 Alcoholic golferAndy Gibb Musician 5-Mar-1958 10-Mar-1988 I Just Want To Be Your EverythingDwight Gooden Sports 16-Nov-1964 Pitcher, New York MetsKelsey Grammer Actor 21-Feb-1955 From Cheers to FrasierCorey Haim Actor 23-Dec-1971 One of the CoreysDavid Hasselhoff Actor 17-Jul-1952 Knight Rider, BaywatchMargaux Hemingway Actor 16-Feb-1955 2-Jul-1996 Troubled actress OD'd on klonopinDon Johnson Actor 15-Dec-1949 Miami Vice, Nash BridgesHerb Kelleher Business 12-Mar-1931 Founded Southwest AirlinesPeter Lawford Actor 7-Sep-1923 24-Dec-1984 Rat Pack memberJerry Lee Lewis Musician 29-Sep-1935 Great Balls of FireMickey Mantle Sports 20-Oct-1931 13-Aug-1995 Twelve times in the World SeriesLiza Minnelli Musician 12-Mar-1946 CabaretRobert Mitchum Actor 6-Aug-1917 1-Jul-1997 Cape FearMary Tyler Moore Actor 29-Dec-1936 The Mary Tyler Moore ShowVince Neil Musician 8-Feb-1961 Mötley Crüe vocalistStevie Nicks Musician 26-May-1948 Fleetwood MacOzzy Osbourne Musician 3-Dec-1948 The Prince of DarknessRichard Pryor Comic 1-Dec-1940 Stand-up comic and actor in Stir CrazyBarret Robbins Sports 26-Aug-1973 Superbowl XXXVII no-showNerine Shatner Relative c. 1959 9-Aug-1999 William Shatner's drowned wifeDarryl Strawberry Sports 12-Mar-1962 Troubled former baseball playerPat Summerall Sports 10-May-1930 SportscasterElizabeth Taylor Actor 27-Feb-1932 CleopatraTanya Tucker Musician 10-Oct-1958 Country music singerShelley Winters Actor 18-Aug-1922 A Place in the SunTammy Wynette Musician 5-May-1942 6-Apr-1998 Stand By Your Man

•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

The 5 Types of Alcoholic

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 theaverage temperate drinker. These allergic types cannever 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 fathersymptoms occur later in life

Type 2 - passed on only from father to sonsymptoms begin in teens, very persistent

-Polymorphisms in aldehyde dehydrogenase

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

There is no cure, and the disease is 100% FATAL if not treated

The Jellinek Chart

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

H3C OH H3C H

O

H3C OH

O

alcoholdehydrogenase

aldehydedehydrogenase

H3C CH3

O

H3C

O

OH

O

H3C

O

OH

O

acetone acetoacetic acid !-hydroxybutyric acid

!-ketothiolase

SPREE

insufficient enzyme levels

SHAME

Acetone and Alcoholism

HO

OH

NH2

+

NHHO

HO

OH

OH

tetrahydropapveroline

H3C H

ONH

HO

HO

R

tetrahydroisoquinolines (THIQs)

THIQs in Alcoholism

-THP and THIQs formed from acetaldehyde and dopamine-These analogues stimulate δ-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 µ and δ opiate receptors

-Endorphin and enkephelin synthesis and release altered by EtOH

-Release of β-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

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)

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 consciousnessand global confusion, drowsiness, stupor & coma

Clinical features: Korsakoff

Amnesia, disorientation, confabulation, may have peripheral nerve disease, WKgait

Wernicke-Korsakoff appears to be a genetic problem related to deficiency oftransketolase. It is more frequently seen in European people or theirdescendants.

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 problemsInability to think clearlyEmotional overreaction or numbnessSleep disturbances and drinkers dreamsInability to handle stressMemory impairment

-Important for patient to realize this is transient

Co-Dependency in Alcoholism

Co-Dependent Spouses

Co-Dependent Children

The Enabler The Caretaker The Controller

The Scapegoat

The Hero

The Mascot

The Lost Child

Co-Dependents will eventually get all of the physical andpsychological 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 TreatmentThe 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?