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Alcohol & Amphetamines
John R. Martinelli
MSIII, SGUSOM
Bergen Regional Medical Center
Department 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, metabo
lic 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].

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Alcohol & Amphetamines

  • 1. Alcohol & Amphetamines John R. Martinelli MSIII, SGUSOM Bergen Regional Medical Center Department of Psychiatry
  • 3. Statistics (WHO) • Globally: 6% • N. America, Europe, Japan, Australia: 7% • Eastern Europe and Central Asia: 12% • UK: 1 in 3 patients = 33%
  • 4. 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)
  • 5. 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
  • 6. 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
  • 7. Etiology • Early Onset – Genetic Predisposition • Late Onset – Psychosocial Factors
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. 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
  • 12. Wernicke-Korsakoff Syndrome Thiamine (B1) Deficiency (PDH complex) • Confusion • Memory • Ataxia • Nystagmus • Ophthalmoplegia
  • 13. Fetal Alcohol Syndrome • Most severe • Characteristic faces • Growth retardation • CNS involvement • Cognitive impairment • Learning disabilities • Behavioral
  • 14. 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
  • 16. 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)
  • 17. Pathophysiology • CNS stimulant • Catecholamine reuptake inhibitor • MAOI • Blocks presynaptic vesicular storage • IV/IM peak plasma levels @ 30 minutes • PO peak @ 2-3 hours
  • 18. 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
  • 19. Signs & Symptoms • Cardiovascular – Chest pain, aortic dissection, MI – Palpitations, tachyarrhythmia – Dyspnea and edema – Hypertension • Respiratory – Dyspnea – Wheezing – Pneumothorax
  • 20. Signs & Symptoms • Gastrointestinal – Abdominal pain – Obstruction • Renal – ATN • Skin – Delusional parasitosis – Cellulitis, abscess, necrosis
  • 21. Signs & Symptoms • Dental Caries – Peridental abscess – METH Mouth
  • 22. Diagnosis • Clinical Signs & Symptoms – History – R/O medical condition – Urine toxicology
  • 23. Treatment • Toxicity/Overdose – ABC’s – PEG if toxic oral ingestion – Charcoal if suspect contaminants – Correction of hypertension, hypotension, hyperthermia, metabo lic and electrolyte abnormalities – Control severe psychiatric agitation (Haloperidol vs Atypicals, Benzo’s, Labetalol)
  • 24. Treatment • Difficult to remove patient from subculture • Detox not associated with decreased abuse • Residential rehabilitation slight efficacy
  • 25. 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].