Scheduling of Pharmacist in Alcoholism and its Treatment

Transcription

1 Review Article Scheduling of Pharmacist in Alcoholism and its Treatment Nagaraju B Chief Pharmacist-cum- PhD Scholar, Medical Department (Pharmacy), South Western Railway Divisional Hospital, Bangalore, Karnataka, India. ABSTRACT Alcoholism is a primary, chronic disease with genetic psychological and environmental factors influencing its development. Alcohol abuse affects many people directly or indirectly all over the world. Alcoholism often causes major damage and can also lead to death. Absorption of alcohol begins in stomach within 5-10 minutes of oral ingestion. Primarily alcohol is absorbed from duodenum, but in small amounts from stomach, esophagus and mucous membranes. Over 90% of alcohol in plasma is metabolized in liver by three enzyme systems within hepatocyctes. Alcohol is a CNS depressant that shares many pharmacological properties with non-benzodiazepines sedative- hypnotic drugs. It affects the CNS in dose dependant fashion, producing sedation that progresses to sleep, unconsciousness. Loss of labour, birth defects, liver cirrhosis, and damage from vehicle accidents, are a small portion of the damage caused by alcohol abuse. The damage caused by alcohol abuse affects people physically, emotionally, and economically. Alcohol creates a physical dependence in the drinker, and withdrawal can be life threatening. All this damage is preventable. So when an alcoholic is being withdrawn from alcohol, medication may be necessary in consult with physician and pharmacist. Pharmacotherapy and cognitive behavioral therapy are used separately or collectively. Results can vary depending upon the treatment and patient. The pharmacist plays an important role in the lives of alcoholic patients. Pharmacists can notice a patient s behavior, notice their prescription patterns, and most importantly, the pharmacist is a knowledgeable mentor that many patients look up to. Feeling comfortable with and trusting the pharmacist is very important for the patient. Patients may come to the pharmacist with their problems, and the pharmacist should be able to offer sound medical advice. Key Words: alcoholism, alcohol abuse, pharmacist intervention, pharmacotherapy for alcohol abuse. INTRODUCTION Alcoholism is a primary, chronic disease with genetic psychological and environmental factors influencing its development 1. Alcohol abuse means drinking more alcohol than is socially, psychologically or physically acceptable. Alcoholism is a more serious condition characterized by both physical and psychological dependence. It damages the sufferer s health, social and family life and career. Safe level of drinking for men is less than 21 units/ week and for women is less than 14 units/ week ( 1 unit = 237 ml. of 3% beer ; 8 gms. of beer) 2. Alcoholism is heritable as 50%-60% of first degree relatives of alcoholics become alcohol dependence. Although there are some factors that are believed to precipitate alcohol dependence 3. When we think about the most prevalent life threatening, debilitating and harmful diseases; we think of AIDS, diabetes, heart disease, depression, and others. Very few people acknowledge or are aware of the complete effect of alcoholism, and how it affects individuals, families, friends, strangers, co-workers and society in general. Alcoholism is a worldwide problem of chronic drinking that affects all aspects of one s life. We hear about drunk drivers, automobile accidents and domestic violence associated with alcoholism, but rarely do we look beyond the individual or family perspective, it is a preventable massive expense to individuals, governments and society. We probably don t take the consequences seriously enough because alcoholic beverages are sold openly everywhere and drinking is very much embedded in most cultures and societies. Alcoholism untreated and treated, causes physical, emotional, and economic damage. The extent as to how many people are affected on a daily basis by this disease is innumerable. First, we will take a look at how individuals are affected. From the loss of earnings to the medical expenses, alcoholism can certainly cost an alcoholic an immense amount of money. It has been found that almost two thirds of the costs of alcohol abuse are a result of loss of labour 5. The actual cost that abusers may pay actually is less than this figure; this is due to the fact that their family members and others pick up some of the cost. There are many health problems associated with alcohol abuse. The most prevalent health problems are gastrointestinal. Gastrointestinal Vol. 3 (4) Oct Dec

2 pain, bloating, nausea and vomiting are all associated with alcohol abuse. Alcohol decreases the rate of gastric emptying, increases gastric secretions, and also damages the gastric mucosa. Gastritis and ulcers are common, and with heavy drinkers, pancreatitis is prevalent. The liver is the organ most affected by alcohol. Liver problems are associated with upper-right quadrant pain. There are many liver disorders such as cirrhosis, hepatitis, cholestasis, and portal hypertension 6,7. Alcohol abuse affects the entire body; it causes many cardiovascular, hematological, gynecologic, metabolic and central nervous system problems. Hypertension, stroke, sudden death and heart failure are common cardiovascular disorders associated with alcohol abuse. Long-term alcohol abuse can suppress the production of leukocytes, erythrocytes and platelets. Anaemia is very common, as are many vitamin deficiencies that are due to poor absorption and poor intake of vitamins. The fact that over half the alcoholic s caloric intake is alcohol further displays the problem, which causes electrolyte imbalances and also malnutrition. Alcoholism also affects neurological function, decreasing memory, motor skills, and affecting neuron transmittance. Alcoholism affects all aspects of the abuser, both physically and mentally. Not only can alcohol abuse result in physical problems, it can result in psychological disorders also. Depression affects approximately 33% of problem drinkers. Depression affects the response of patients to treatment and also their relapse rate. The high relapse rate results from negative emotional states and recurrent relapses may cause a feeling of helplessness, causing drinkers to feel that their drinking is out of control and that they will never be able to stop drinking 8. Alcoholism and the side effects associated with it often lead to sudden and early death. Not only does alcoholism affect the abuser, non-abusers are also affected. Family members and household members are affected immensely. Non-abuser victims are directly responsible for 6% of the alcohol related costs, but indirectly much more, with taxpayers picking up the bill that the government has to pay. In addition to adults, children being affected by alcohol abuse and foetuses are also affected by alcohol abuse. Almost 5,000 babies are born each year with Foetal Alcohol Syndrome (FAS). This is approximately one in every 750 births. The rate of FAS is much higher in Native Americans, than that of Caucasian or African-Americans. A child with FAS may have a variety of problems, such as pre-natal and postnatal developmental problems, various facial malformations, various organ malformations, and also central nervous system problems. Foetal Alcohol Effects (FAE) occurs in 3-5 out of 1,000 live births and it results in milder symptoms such as low birth weight. Foetal Alcohol Effects results from pregnant mothers who drink less alcohol than those with FAS children. Additional healthcare, education, attention, etc. are factors affecting the cost of a FAS child to their family, private insurers, Health Maintenance Organizations, and the government 9. This disease is completely preventable, yet alcohol exposure is the most common cause for birth defects. Alcohol abuse during and prior to a pregnancy affects the development of the foetus during pregnancy and for the remainder of its life 10. There are many additional disorders that result from alcoholism, which are additional factors in the cost of alcoholism. Depression, as described previously, is one of the major adverse concerns of problematic alcohol abuse. PHARMACOKINETICS Absorption of alcohol begins in stomach within 5-10 minutes of oral ingestion. Primarily alcohol is absorbed from duodenum, but in small amounts from stomach, esophagus and mucous membranes. Over 90% of alcohol in plasma is metabolized in liver by three enzyme systems within hepatocyctes. Remaining is excreted by lungs, urine and sweat. Metabolism of alcohol follows zero kinetics and volume of distribution is L/kg 3. An increase in alcohol oxidation is observed in chronic alcoholics due to induction of microsomal ethanol oxidation activity. About 10 ml/ hr. of alcohol is oxidized in liver. The acetate formed enters the kreb s cycle producing 7 kcal/ gm. of ethanol 11. PHARMACOLOGY Alcohol as drug Alcohol is a CNS depressant that shares many pharmacological properties with non - benzodiazepines sedative- hypnotic drugs. It affects the CNS in dose dependant fashion, producing sedation that progresses to sleep, unconsciousness, coma, surgical anesthesia, respiratory depression and cardiovascular collapse. Alcohol intake results in an increase in endogenous opiods and this is responsible for euphoria on alcohol assumption. Currently there are no clinically useful antagonists that reverse the pharmacologic effects of alcohol 3. Lethal dose of alcohol in humans is variable, but death occurs when blood levels are mg/dl. Effect of alcoholism on body Chronic alcohol ingestion leads to pancreatitis, gastritis, malnutrition, and cirrhosis of the liver. Excessive ingestion of alcohol produces hypertension, high fat levels in the blood, rhythm disturbances and congestive heart failure. On brain, chronic alcohol ingestion produces depression, memory loss, emotional and sleeps disorders. Prolonged alcohol consumption leads to Vol. 3 (4) Oct Dec

3 impotence and sterility. Alcohols impair psychomotor performance and blunt reflux motor activity. Chronic alcohol ingestion increases the risk of hepatic, pancreatic and oesophageal cancer and can lead to foetal alcohol syndrome during pregnancy, hence is teratogenic 2. Effect of alcoholism on drug therapy Alcohol interacts with more than 150 medications and produces serious liver damage with painkiller acetaminophen. It also decreases effectiveness of anticonvulsants. It is believed to increase drowsiness with antihistamines. It decreases the action of antidepressants. Due to decreased absorption of nutrition there occurs decreased utilization of most vitamins. It also enhances the metabolism of anticoagulants hence diminishes there effect. It reduces the effect of caffeine when taken in chronic case 1. Effect of Alcohol in Sexual Life It is often said that anything when consumed in moderation is less prone to harm you. This concept couldn t be truer for alcohol consumption. It is a well-researched fact that when used in moderation, alcohol can become a handy aid for spicing-up your sex life. Probably, this is the reason why many ancient cultures, including the mighty Romans, referred to wine as a powerful aphrodisiac. Positive effects of consuming alcohol in a restricted manner have been acknowledged by many medical fraternities too. This includes lowering symptoms of cardiovascular diseases and depression. Stress sustained over a period and the fear of not performing well in bed can seriously impact the bedroom performance. Nervousness and unwanted concerns take over factors that often cause temporary bouts of failed erection. These psychological barriers can be alleviated to some extent with alcohol. The idea is to limit the intake so that the consciousness and overall sensibilities are not impaired but the uneasiness is conquered. The minimal amount of alcohol can contribute towards improving sexual life; its detrimental effects take over. Regularly consuming alcohol can impair the body s internal processes that are involved in sexual stimulation, including the manner in which the blood rushes to the penile tissues when the mind is engaged with erotic notions. Further, the body is unable to maintain the required vital capacity that is required to support the increased oxygen uptake required during sex; these symptoms constitute reduced libido levels. While limited amounts of alcohol are a sexual aid, excessive amounts are just the opposite. TREATMENT There are many different treatments for alcoholism, from detoxification to drug therapy and counseling. Treatment varies depending upon the length of illness, additional amount of alcohol-related problems, and whether or not the patient really wants to overcome his addiction. More than 700,000 people receive treatment everyday 12. Patients are either treated on an inpatient or outpatient setting; 13.5% of treated patients receive residential treatment and 86.5% of patients receive outpatient treatment. The commonly used behavioral treatments are cognitive-behavioral therapy, motivational enhancement therapy, and Alcoholics Anonymous sessions. These treatments have an equal amount of effectiveness, as shown in the Project MATCH trial 13. Often, pharmacotherapy can supplement these treatments, these treatments can be very costly, but when factoring in the damage that a lifetime of problem drinking can cause, treatment appears to be quite a bargain. Detoxification is the first step of treatment for many patients. It is a form of medically assisted withdrawal from alcohol. Medication is often required to prevent seizures and hypertension. After an extended period of heavy alcohol abuse people usually experience many alcohol withdrawal symptoms. Detoxification is intended to manage the medical and psychological symptoms of alcohol withdrawal. Patients can be treated by detoxification, in either an inpatient or outpatient setting 14. Treating alcohol-related problems costs society much less than if left untreated. In the 1980s, alcoholism and other addiction problems were thought of as physical problems, with treatment mainly focused on detoxification. More recent research and a greater knowledge of brain biology have evolved addiction treatment to focus on lifetime abstinence. Long-term programs such as twelve-step and mutual help programs focus on lifetime abstinence and preventing relapse. Alcoholics Anonymous (AA) is one the oldest and most popular of the self-help groups for addicts. Established in 1935 and currently having over 2 million members, AA is clinically proven to reduce problem drinking and relapses and also results in a higher level of social functioning. AA is a very cost effective treatment; the program is free to those who want to stop drinking. Donations are accepted and appreciated as they are used to off-set costs of meeting places and coffee. After the success of this twelve-step program, many private inpatient treatments have based their treatment on the ideals of AA 15. Naltrexone is an opioid antagonist approved by the Food and Drug Administration as an adjunct therapy to be used along with conventional psychosocial therapies for alcohol abuse. The Brown University Center for Alcohol and Addictions Studies recently embarked upon a 5- year study of the effect of naltrexone on heavy Vol. 3 (4) Oct Dec

4 social drinkers in their social environment 16. COMBINE is a recent study in progress that combines pharmacological and behavioural therapies for alcohol abuse. The completion of this study will provide researchers in this field with information to treat alcoholic patients more successfully 17. In London, prices were raised on alcoholic beverages to discourage its use. It wasn t until the mid-nineteenth century that chronic alcohol abuse was studied. Some early treatments for alcohol abuse included apomorphine and emetine, which induced vomiting upon the consumption of alcohol. Physicians eventually focused on prophylaxis since positive cures seemed nearly impossible 18. Current treatment of alcoholism involves private rehabilitation, drug therapy, counseling services, Alcoholics Anonymous, etc. Private rehabilitation has had a large increase since the 1970s, where the number of beds in private rehabilitation facilities quadrupled from Many private insurance companies and the federal government bear the cost of this treatment, which is approximately $18,000 per hospital stay. It will be major burden on our healthcare system. It has been found that patients who undergo lengthy inpatient, residential treatments are no better off in overcoming their addiction than those left on their own for treatment. In a study done by George Vaillant, 95% of those treated as an inpatient at an urban hospital had a relapse. In another study done by Helzer et al., findings showed that 93% of the patients at an inner-city hospital were either dead or still abusing alcohol five to seven years after treatment. Those treated at a private rehabilitation facility are more likely to show better results 19. The best treatment for alcoholism is one that teaches life skills without alcohol. Programs need to incorporate training in stress management, life skills, social and negotiation skills, job skills, and work habits 19. Alcohol Related Disorders Definition of alcohol withdrawal includes two main components, 1. History of cessation or reduction in heavy and prolonged alcohol usage. 2. Presence of two or more of the symptoms of alcohol withdrawal 3. Sign and symptoms of alcohol withdrawal and acute alcohol intoxification include, slurred speech, ataxia, nystagmsis, sedation, flushed face, mood change, irritability, euphoria, impaired attention. Withdrawal Tremors, tachycardia, diaphoresis,, labile B.P., anxiety, nausea & vomiting, hallucinations, seizures, hyperthermia, delirium 1. There are certain goals established for alcohol dependent persons trying to decrease or discontinue alcohol intake. 1. Prevention and treatment of withdrawal symptoms (including seizures and delirium tremors) and medical or psychiatric complications 2. Long term abstinence after detoxification. 3. Entry into ongoing medical and alcohol dependence treatment 3. Allopathic Treatment To treat withdrawal symptoms Benzodiazepine and other drugs: They are best controlled by diazepam and chlordiazepoxide and facilitate the action of GABA in CNS, although they have the potential of abuse because of reinforcing effects. Although barbiturates are used in detoxification of withdrawal symptoms but they have low abuse symptoms 3. It is long acting and can be administered by oral, i.m., i.v. route and has well documented anticonvulsant activity 3. But barbiturates pose a greater risk of respiratory depression when combined with alcohol. To help maintain abstinence 1. Disulfiram: Blocks metabolism of ethanol at acetaldehyde stage and thus precipitates disulfiram like reaction. It is given singly oral in doses of 500mg. for 2-3 wks., with maintenance dose of mg/day. 2. Naltrexone : Its combination with psychosocial therapy reduces alcohol craving and decreases the rate relapses. I t is given 50mg. once a day. To treat pre-exciting anxiety or depression Antidepressants: they are used endogenous and for suicidal tendencies. The newer ones have a lower potential for acute toxicity and may represent less risk to a recovering alcoholic. Lithium: Lithium may prevent the progress primary alcoholism. Lithium therapy may support the recovery and might affect the course of alcoholism. The treatment regime It includes fixed scheduled therapy, front loading, and symptom- triggered therapy 3. Fixed scheduled therapy In this regime chlodiazepoxide mg. is given orally every 6 hrs for 1day followed by 2 days at mg. every 6 hrs; this prevent delirium tremors and seizures. Front loading In this regime frequent high dosing of medication is given to treat the early signs and symptoms of withdrawal. Diazepam is given in 20 mg. doses every 2 hrs until resolution of withdrawal symptom is observed. In this regime decreased incidence of withdrawal is observed and intensive monitoring is limited. Vol. 3 (4) Oct Dec

5 Symptom Triggered Therapy It has shorter treatment. Some newer drugs includes nalmefene which give no dose dependant liver toxicity, has greater oral bioavailability, have longer duration of antagonistic action, binds competitively with opiod receptors( that reinforce drinking). Acamprostate, a 5-HT 3 antagonist decreases drinking frequency and enhances abstinence. Another drug, Topiramate, a fructopyranose derivative controls seizures and prevent alcoholic relapse 20. Herbal Treatment Herbs have been used traditionally to treat alcoholism. An ayurvedic formula SKV-An herbal formulation (contains 1-2 % ethanol) obtained by fermentation of cane sugar with resins and 12 herbal ingredients brings down voluntary ethanol ingestion and increases food intake 2. The herbs, Silybium marinum, are used three times a day, to support liver. The root of Taraxacum officinale root three times a day in tea helps to detoxify the liver, Pueraria lobata reduces craving by increasing fluid production by body and Scutellaria laterfolia is used for hysteria, tension and nervous disorders 2. Homeopathic treatment Various drugs used to treat alcoholism are Anticrud, Carboveg, Coffia, Lach, Arsenic, Sulphur, Causticum, Nux vomica (for treating hangover effect). It is required not to take anything 15 min. before or after drug administration. Capsicum is usually taken for stomach pain after heavy drinking. Arsenicum album is taken for anxiety and compulsiveness with nausea, vomiting and diarrhoea 2. Acupuncture treatment Treatment is based on excess or deficiency of vital energy circulating in body (qi). In liver qi deficiency is observed in case of alcoholism while in gall bladder excess qi is observed in alcoholism. The various modes of treatment include needling treatment and moxibustion i.e., powdered leaf of Artemisia vulgaris is burned over specific acupuncture points 2. Behavioral therapies A new study examines the effectiveness of combining communications, cue exposure and coping skills training with naltrexone in the treatment program. The behavioral therapies provide day hospital treatment along with pharmacotherapy after discharge when the patient had brief contact with physician for 12 wks. These include; Motivational enhancement therapy includes exploring the benefits of abstinence; review treatment options and design plan to implement treatment goals. Couples therapy or behavioural marital therapy improves patient condition by strengthening marital relationships through shared activities and teaching communication and conflict evaluation skills. CONCLUSION Alcohol creates a physical dependence in the drinker, and withdrawal can be life threatening. So when an alcoholic is being withdrawn from alcohol, medication may be necessary in consult with physician and pharmacist. The most important part of the treatment for a alcoholic person is to admit in rehabilitation centre and to stop drinking completely. Stopping of drinking is very difficult for a person with alcoholism without help of the friends, family members as well as support groups such as Alcoholics Anonymous. PHARMACIST INTERVENTION Depending on the circumstances of pharmacy practice in different countries, there are several avenues open to the pharmacist. The first step in any treatment is problem recognition and the pharmacist may be in a position to notice excessive sales and use of elixirs or other alcoholcontaining medicines. The pharmacist may want to discuss this with the patient or a relative of the patient. The pharmacist can promise confidential treatment and service, and have information available for referrals to alcoholism treatment clinics. Beyond such recognition of the problem, one can assume that an innocent patient question as to the existence of OTC products to help people with a drinking problem might be a lead to offer help. The next task for the pharmacist is that of educator/counselor and referral agent. The patient needs to know that competent help is available, and where, and what it might involve, and cost. It would be advisable if the pharmacist could ascertain if health insurance may pay for some or all of the fees. A wise pharmacist might attempt to seize the moment by making an appointment for the patient at such a clinic. Thorough pharmaceutical service calls for the pharmacist to follow-up periodically with the patient, probably by telephone, or in-person, and for encouragement to be offered while lauding the already completed steps for the patient. The pharmacist can check that patient s profile in the future to see that medications containing alcohol are avoided. As newer therapies and techniques become known, the pharmacist should take it upon him or herself to stay up-to-date, in order to offer the best and latest information to their patients. Perhaps even 80% to 90% of patients will ignore the pharmacist s advice, but the successfully treated 10 to 20% make that activity worthwhile and valuable to all concerned parties. Vol. 3 (4) Oct Dec

6 REFERENCES 1. Herfindal, Eric T, Gourley DR, Textbook of therapeutics - Drug and Disease Management, Edition 7, Lippincott, New York, 2000, pp Jain UK and Talera D: Alcoholism & its Treatment, The Indian Pharmacist. 2003, 2, Dipiro JT, Talbert RL, Yee GR, Pharmacotherapy- A pathological approach, Edition 2, Mc Graw-Hill, New York, 2005, pp Feng W, Zhou W, Butler JS, Booth B, French M. The impact of problem drinking on employment. Health Economics 2001; 10: National Institute on Drug Abuse, ( 6. Stein M. Medical consequences of substance abuse. Psychiatric Clinics of North America 1999; 22: DiMartini, Weinrieb R, Fireman M. Liver transplantation in patients with alcohol and other substance use disorders. Psychiatric Clinics of North America 2002; 25: Siddharthan G, Hough M, Sitharthan T, Kavanagh D. The alcohol helplessness scale and its prediction of depression among problem drinkers. Journal of Clinical Psychology 2001; 57: National Institute on Alcohol Abuse and Alcoholism ( 10. Thackray H, Tifft C. Fetal Alcohol Syndrome, Pediatrics in Review 2001; 22: Barar FSK, Essentials of Pharmacotherapeutics, Edition 3, S. Chan & Co. Ltd, New Delhi, 2000, pp National Institute on Alcohol Abuse and Alcoholism. Alcohol alert, estimating the economic cost of alcohol abuse 1991, No. 11 PH Fuller R, Hiller-Sturmhofel S. Alcoholism treatment in the United States: An overview. Alcohol Research and Health 1999; 23: Williams, S. introducing an in-patient treatment for alcohol detoxification into a community setting. J Clin Nursing 2001; 10: Chappel J, DuPont R. Twelve-step and mutual-help programs for addictive disorders, Psychiatric Clinics of North America 1999; 22: Kranzler HR, Amin H, Modesto-Lowe V, Oncken C. Pharmacologic treatments for drug and alcohol dependence, Psychiatric Clinics of North America 1999; 22: Bean P, Mattson M. Combined behavioral and pharmacologic treatments of alcoholism. American Clinical Laboratory 2001; 20: Sourina, J. A History of Alcoholism. London: Basil Blackwell Ltd; Peele, S. What we now know about treating alcoholism and other addictions. The Harvard Mental Health Letter 1991; Tripathi, K. D., Essentials of Medical Pharmacology, Edition 5, Jaypee Brothers, New Delhi, pp Vol. 3 (4) Oct Dec