Alcohol & Amphetamines

John R. MartinelliMSIII, SGUSOMBergen Regional Medical CenterDepartment of Psychiatry

Alcohol

Statistics (WHO)

• Globally: 6%

• N. America, Europe, Japan, Australia: 7%

• Eastern Europe and Central Asia: 12%

• UK: 1 in 3 patients = 33%

Statistics (USA)• 3rd leading cause of preventable death• 85,000 deaths per year• 20% of adult hospital inpatients• 1 in 6 patients in community-based primary care practices• More common in lower income and less educated groups• Transition highest for nicotine users>cocaine>alcohol>MJ• Transition risk to dependence among psychiatric patients• M:F = 2.5:1• NativeA > LatinA > WhiteA > AfricanA > AsianA• Cost of $185,000,000,000 (billion)

Diagnosis• CAGE

– Concern– Annoyed– Guilt– Eye Opener

Yes to 2 or more questions =>

Specificity of 76% and a sensitivity of 93% for the identification of excessive drinking

Specificity of 77% and a sensitivity of 91% for the identification of alcoholism

Diagnosis

–Contains 10 questions, 5 possible answers scored 0-4

–Greater sensitivity in populations with a lower prevalence of alcoholism

–Cut-off of 5 -> sensitivity of 84% and specificity of 90%

• AUDIT

Etiology

• Early Onset– Genetic Predisposition

• Late Onset– Psychosocial Factors

Pathophysiology

• Opioids, GABA, glutamate, serotonin, and dopamine

• Elevates opioid levels -> euphoria

• GABA potentiation -> anxiolytic and sedative effects

• Every cellular/organ system (NADH)

• High doses -> coma and death

Pathophysiology

• Cravings– EtOH increases opioid receptors– Potentiates cravings upon discontinuation

• Withdrawal– EtOH inhibits the receptor for glutamate– Long-term -> up-regulation glutamate receptors– Potentiates CNS excitability upon discontinuation

Comorbidities• WHO

– Cirrhosis – 32%– Esophageal cancer – 29%– Liver cancer – 25%– Homicide – 24%– Motor vehicle accidents – 20%– Mouth and oropharyngeal cancers – 19%– Suicide – 11%– Hemorrhagic stroke – 10%– Breast cancer – 7%

• Folate Deficiency/Anemia• Hypertriglyceridemia/Hypercholesterolemia• Bone Marrow Suppression/Immunosuppression• Fetal Alcohol Syndrome• Wernicke – Korsakoff Syndrome• Delirium Tremens

Alcoholic Liver Disease

•Progressive inflammatory liver injury•Subacute fever, leukocytosis, jaundice•Marked impairment of liver function (Bili/COAG)•Elevated LFT’s (AST>ALT, GGT)•Hepatic Encephalopathy•Portal HTN•Steatosis/Fatty Liver•Cirrhosis -> Atrophy

Wernicke-Korsakoff Syndrome

Thiamine (B1) Deficiency (PDH complex)

• Confusion• Memory• Ataxia• Nystagmus• Ophthalmoplegia

Fetal Alcohol Syndrome

• Most severe• Characteristic faces• Growth retardation• CNS involvement• Cognitive impairment• Learning disabilities• Behavioral

Treatment• Brief physician recommendation

• Pharmacologic Therapy– Targeting reward centers (naltrexone)– Targeting craving (acamprosate)

• Substance Abuse and Mental Health Services Administration (SAMSA)– 5 stages of change– Precontemplation -> Contemplation -> Preparation ->

Action -> Maintenance– Group/AA/12 Steps

Methamphetamines

“Crystal Meth”“ICE”

Background• Introduced nearly 100 years ago (Asthma/Rhinitis)• Use has increased rapidly last 10 years• 50 million users worldwide• White males 30-40• Increased adolescent abuse• Euphoria & stimulatory effects• Longer effect than cocaine• Similar toxicity as cocaine• Oral, IV, snorted, or smoked• Cheap and easily produced (ephedrine reduction)

Pathophysiology

• CNS stimulant• Catecholamine reuptake inhibitor• MAOI• Blocks presynaptic vesicular storage• IV/IM peak plasma levels @ 30 minutes• PO peak @ 2-3 hours

Signs & Symptoms

• Central nervous system– Headache– Emotional lability, confusion, psychosis, paranoia,

hypersexuality, and hallucinations– Agitation, violent behavior, self-harm– New-onset seizure, movement disorders– Coma

Signs & Symptoms

• Cardiovascular– Chest pain, aortic dissection, MI– Palpitations, tachyarrhythmia– Dyspnea and edema– Hypertension

• Respiratory– Dyspnea– Wheezing– Pneumothorax

Signs & Symptoms• Gastrointestinal– Abdominal pain– Obstruction

• Renal– ATN

• Skin– Delusional parasitosis– Cellulitis, abscess, necrosis

Signs & Symptoms

• Dental Caries

– Peridental abscess

– METH Mouth

Diagnosis

• Clinical Signs & Symptoms

– History– R/O medical condition– Urine toxicology

Treatment

• Toxicity/Overdose– ABC’s– PEG if toxic oral ingestion– Charcoal if suspect contaminants– Correction of hypertension, hypotension,

hyperthermia, metabolic and electrolyte abnormalities

– Control severe psychiatric agitation (Haloperidol vs Atypicals, Benzo’s, Labetalol)

Treatment

• Difficult to remove patient from subculture

• Detox not associated with decreased abuse

• Residential rehabilitation slight efficacy

References• Vearrier D, Greenberg MI, Miller SN, Okaneku JT, Haggerty DA. Methamphetamine: history, pathophysiology,

adverse health effects, current trends, and hazards associated with the clandestine manufacture of methamphetamine. Dis Mon. Feb 2012;58(2):38-89. [Medline].

• Richards JR, Bretz SW, Johnson EB, Turnipseed SD, Brofeldt BT, Derlet RW. Methamphetamine abuse and emergency department utilization. West J Med. Apr 1999;170(4):198-202. [Medline].

• Cruickshank CC, Dyer KR. A review of the clinical pharmacology of methamphetamine. Addiction. Jul 2009;104(7):1085-99. [Medline].

• Carvalho M, Carmo H, Costa VM, Capela JP, Pontes H, Remião F, et al. Toxicity of amphetamines: an update. Arch Toxicol. Aug 2012;86(8):1167-231. [Medline].

• Richards JR, Brofeldt BT. Patterns of tooth wear associated with methamphetamine use. J Periodontol. Aug 2000;71(8):1371-4. [Medline].

• Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. Mar 10 2004;291(10):1238-45. [Medline].

• Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. Feb 10 2005;352(6):596-607. [Medline]. • Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. The Role of

Biomarkers in the Treatment of Alcohol Use Disorders. US Department of Health and Human Services; September 2006. Pages 1-8. [Full Text].

• Vaillant GE. A long-term follow-up of male alcohol abuse. Arch Gen Psychiatry. Mar 1996;53(3):243-9. [Medline]. • Lopez-Quintero C, Cobos JP, Hasin DS, et al. Probability and predictors of transition from first use to dependence

on nicotine, alcohol, cannabis, and cocaine: Results of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Drug Alcohol Depend. May 1 2011;115(1-2):120-30. [Medline]. [Full Text].

• Enoch MA, Goldman D. Problem drinking and alcoholism: diagnosis and treatment. Am Fam Physician. Feb 1 2002;65(3):441-8. [Medline].

• Sinclair JD. Evidence about the use of naltrexone and for different ways of using it in the treatment of alcoholism. Alcohol Alcohol. Jan-Feb 2001;36(1):2-10. [Medline].