A Primer for Pharmacy Practitioners: Understanding Your Alcoholic Patients

Patrick M. Woster, Ph.D. Department of Pharmaceutical Sciences Wayne State University

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

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

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

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 sufferers. 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

Betty Ford Center REHAB FACILITY Rancho Mirage, California. Founded in 1982. Ofcial Website: http://www.bettyfordcenter.org/ Name Occupation Birth 3-Sep-1935 5-Feb-1969 29-Jun-1944 26-Feb-1932 8-Oct-1943 4-Feb-1948 3-Jun-1925 28-Apr-1966 5-Mar-1958 16-Nov-1964 21-Feb-1955 23-Dec-1971 Actor 16-Feb-1955 15-Dec-1949 12-Mar-1931 7-Sep-1923 29-Sep-1935 20-Oct-1931 12-Mar-1946 6-Aug-1917 29-Dec-1936 8-Feb-1961 26-May-1948 3-Dec-1948 1-Dec-1940 26-Aug-1973 c. 1959 12-Mar-1962 10-May-1930 27-Feb-1932 10-Oct-1958 18-Aug-1922 5-May-1942 Death Known for Capt. Lewis on Private Benjamin Still humpin' around after all these years The Buddy Holly Story The Man in Black SNL alumnus hosted The Chevy Chase Show King of Fake Blood at Rock Concerts Houdini and Some Like It Hot Alcoholic golfer I Just Want To Be Your Everything Pitcher, New York Mets From Cheers to Frasier One of the Coreys Knight Rider, Baywatch Troubled actress OD'd on klonopin Miami Vice, Nash Bridges Founded Southwest Airlines Rat Pack member Great Balls of Fire Twelve times in the World Series Cabaret Cape Fear The Mary Tyler Moore Show Mtley Cre vocalist Fleetwood Mac The Prince of Darkness Stand-up comic and actor in Stir Crazy Superbowl XXXVII no-show William Shatner's drowned wife Troubled former baseball player Sportscaster Cleopatra Country music singer A Place in the Sun Stand By Your Man

Eileen Brennan Actor Bobby Brown Musician Gary Busey Actor Johnny Cash Musician Chevy Chase Comic Alice Cooper Musician Tony Curtis Actor John Daly Sports Andy Gibb Musician Dwight Gooden Sports Kelsey Grammer Actor Corey Haim Actor David Hasselhoff Margaux Hemingway Actor Don Johnson Actor Herb Kelleher Business Peter Lawford Actor Jerry Lee Lewis Musician Mickey Mantle Sports Liza Minnelli Musician Robert Mitchum Actor Mary Tyler Moore Actor Vince Neil Musician Stevie Nicks Musician Ozzy Osbourne Musician Richard Pryor Comic Barret Robbins Sports Nerine Shatner Relative Darryl Strawberry Sports Pat Summerall Sports Elizabeth Taylor Actor Tanya Tucker Musician Shelley Winters Actor Tammy Wynette Musician

12-Sep-2003

10-Mar-1988

17-Jul-1952 2-Jul-1996

24-Dec-1984 13-Aug-1995 1-Jul-1997

9-Aug-1999

6-Apr-1998

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

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

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

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

Acetone and Alcoholism

O H3C OH alcohol dehydrogenase H3C H aldehyde dehydrogenase H3C O OH

!-ketothiolase

O H3C CH3 H3C

O OH H3C

O OH

acetone

acetoacetic acid

!-hydroxybutyric acid

insufficient enzyme levels

SPREE

SHAME

THIQs in Alcoholism
NH2 HO OH + HO O H3C H HO HO HO

OH OH

NH

tetrahydropapveroline R NH

tetrahydroisoquinolines (THIQs)

-THP and THIQs formed from acetaldehyde and dopamine -These analogues stimulate -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 and opiate receptors -Endorphin and enkephelin synthesis and release altered by EtOH -Release of -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

Acute Alcohol Withdrawal (cont)

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 (cont)

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.

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

Co-Dependency in Alcoholism
Co-Dependent Spouses
The Enabler The Caretaker The Controller

Co-Dependent Children
The Hero The Scapegoat The Mascot The Lost Child

Co-Dependents will eventually get all of the physical and psychological symptoms of the alcoholic

Relapse
-Recovering people should insist that their care providers take the disease seriously -Seven As 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 Treatment
The Twelve Steps of Alcoholics Anonymous
1. We admitted we were powerless over alcoholthat 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?