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People who drink or use drugs in a dependent way continue to use or drink despite the fact that bad things are happening. Again, by definition, what looks like tremendously traumatizing events do not result in them stopping drinking or using. Psychological dependence is there with all chemical dependents. An abnormal relationship with the substance is true for everyone who is chemically dependent. That’s different, however, than what we call physical dependence. Physical dependence is a withdrawal syndrome that occurs when you stop the substance. That does not happen with all drugs. That happens with alcohol, nicotine, with caffeine, with the opioids and the other sedative hypnotics. There is not a true physical withdrawal, for example, with amphetamines or with cocaine or with cannabis drug addiction, alcoholism, cocaine, marijuana.
Just to look at some numbers for a second, the prevalence of alcohol abuse or dependence is 14% in the general population. In young white males it’s much higher than that so it varies a little bit depending on your population. The prevalence of other drug abuse or dependence other than alcohol or nicotine would be
Again, let’s compare these three groups. Fifteen to 20 people die prematurely in this country because of their drug use each day, about 300 people die prematurely each day in this country because of their alcohol use and over 1000 people die prematurely each die because of their nicotine use. So if we had to define a drug in terms of volume and mortality of use, clearly nicotine is the drug that causes the most havoc in this country.
Briefly, only one in five alcoholics will ever receive any treatment for their alcoholism. Suicide is very common in this population so if you see a person who has either attempted suicide or is considering suicide, you need to evaluate them for drug or alcohol use. A lot of violence. Homicide, suicide, motor vehicle accidents. A lot of incidences of child abuse. Forty to seventy percent are occurring in homes with drug or alcohol use problems.
So a lot of times the red flag for you that you may be seeing a person with a drug or alcohol use problem is indirect. It’s from abuse, maybe violence in the home. Domestic violence. Other kinds of trauma or falls.
Signs and symptoms of chemical dependency. Denial is one of my favorites because one of the adverse pleasures I get from my work is I love to hear examples of denial because I can then use them in talks like this. "I don’t have a problem, Dr. Grant, because I only drink beer. Of course, I drink a case a day but I only drink beer." "Dr. Grant, I don’t have a problem because I only smoke marijuana." "I don’t have a problem because I don’t drink as much as my dad drank." "I don’t have a problem because I still have a job. In fact, I’m working at a high level job. I’m just using before I go to work, while I’m at work and after work." So, those are all good examples of denial.
Remember I talked about psychological dependence a second ago. What I mean by that is that for the chemically dependent person, the primary relationship in that person’s life is always with the substance. So if I’m chemically dependent, that doesn’t mean that I don’t love my family or that I don’t want to do a good job or be a good mom, but when push comes to shove I can’t guarantee you that I won’t choose alcohol or drugs over all those other important things in my life. In fact, we expect that’s going to happen because the primary relationship is with the substance.
People who are chemically dependent are often thinking about the substance, looking forward to it, planning it, anticipating it and watching the clock even when they are not drinking or using or getting high. So that psychological relationship, that preoccupation or craving or obsession that we talk about is going on even at times when they are not drinking or using.
Tolerance is an important issue because I think it’s an excellent screening question to ask. There is very little denial about tolerance so I ask a lot of questions about tolerance in terms of screening situations. Typically what tolerance means is that I have to use more or I have to use better quality of a substance in order to get high.
So the way I ask the question, and I will use alcohol as an example, is "The first time you drank as a kid, how much did it take for you to get a buzz or to get high?" Most people can remember with some precision how much it took that first time they got a high or they got a buzz when they were drinking beer, as an example. Typically, people will tell me somewhere around two or three or four beers they got a buzz or they got high.
Then I say, "How much does it take to get that same feeling now?" Any increase of 50% or more is considered clinically significant increased tolerance and most times it is two or three or four times the amount. So it’s not unusual for me to hear that someone drinks a case of beer a day and they don’t get intoxicated during the whole day. I know a fellow who drinks 2 or 3 liters of liquor and doesn’t get a buzz or get high. So those are very dramatic examples of changes in tolerance.
The key thing is after about 20 or 30 years of drinking the tolerance will peak out and then it will start to drop off. So you may be seeing an older person, a man in his 50s, 60s or 70s whose tolerance may have been quite high at one point and now has dropped off to say a six pack or so a day in order to get that same high or buzz. So that’s the first thing. Tolerance is a dynamic function that tends to change over time.
The second thing about tolerance is that early high tolerance, especially in male children of male alcoholics is an excellent predictor of future alcoholism. So if you ask a young man, a teenager or young adult, how much they are drinking now to get high and how much their tolerance was when they started drinking, if they are one of those kids who can drink everybody else under the table early on, that’s an excellent predictor of future alcoholism. Again, most people are not embarrassed. They’re actually kind of proud of their tolerance so I think it’s a good screening question.
The third thing about tolerance is that when it goes up to one member of a class of drugs, it goes up to all members of that class. So, for instance, if my tolerance to alcohol is high because I drink a quart of liquor a day and then you have to, say, do an appendectomy on me and you are finding that you have to use very large doses of sedatives, say, something like a benzodiazepine, it may not be because I have been using benzodiazepines. It may be because my tolerance has been jacked up because of my alcohol use. So tolerance tends to go by classes of drugs. So all the sedative hypnotics would be at the same place on this curve at a given time even though I may never have used anything other then alcohol.
The fourth point about tolerance is that it can be at different places across classes of drugs and I will go through the classes in a couple of minutes. But, again, let’s just say I started drinking when I was 15, in my 40s my tolerance may be peaking about right here. But I started using cocaine 5 years ago, so my tolerance to cocaine may be down here. So I may be at different places on the tolerance curve depending on what classes of drugs I’ve been using.
One thing I might mention too is that, for instance, a drug like marijuana, often people will not increase the amount of marijuana they are smoking to get high, they will just look for better and better quality marijuana. So typically what I ask for is the amount they are spending on their marijuana and they usually know what the quality of the marijuana is they are getting. Are they requiring higher quality stuff in order to get high.
People who have drug and alcohol use problems lose control of their use and they usually make rather heroic attempts to try and regain control. They might do things like move. They’ll move to Phoenix because they won’t be alcoholic in Phoenix or move to Omaha because there is no cocaine in Omaha. They change jobs because they won’t use if they are in a car dealership or they may move from liquor to beer. They don’t want to get into trouble anymore so they will just move off the liquor and move to beer. I see that happen fairly often.
They’ll do what we call a geographical cure. That would be the move kind of thing but they may also change partners, change spouses as part of their efforts to control their use. "I drink because of him. Therefore, if I get rid of him, I won’t drink."
People who are chemically dependent start to live outside their value system. They do things they wouldn’t ordinarily do and, again, many of these things you are familiar with. Writing bad checks. Being aggressive or abusive in the home. Pawning household items. I find that people who are chemically dependent often are not paying their child support because the money is going other places. So doing things they wouldn’t ordinarily do and that are clearly outside of their own value system
We know that as with chronic diseases of all types, people who are chemically dependent didn’t choose to be chemically dependent. There appears to be a genetic predisposition to alcohol and drug addiction. Their response to alcohol, their response to cocaine, their response to marijuana is different than it would for the non-alcohol or drug dependent person and willpower isn’t going to change that response.
What are the complications of chemical dependency? Clearly, if the most important relationship in my life is with a drug, then my other relationships are going to suffer. So there is a lot of discord, a lot of family disruption, separation. Divorces are very common. Multiple partners. Often abandonment of children, either emotionally or emotionally and physically.
Often people who are chemically dependent have two sets of friends initially - their clean friends who don’t use and then their using or drinking friends. As time goes by, usually the clean or non-using friends drop off and all you have left are the using friends. I know a lot of times folks are just in tremendous isolation. As an example, I like to give what that is. Often I hear the story about a man who is alcoholic who comes home at night, gets his beer out of the refrigerator, goes and turns on the TV, gets into his recliner and spends all night long drinking, watching TV and sitting in his recliner. He may still be living in that family, he may still physically be in the home but often there is almost no relationship left. He’s living really in tremendous isolation in the midst of that family setting. So, again, that’s a fairly common kind of story that I hear.
A lot of deterioration in school or job performance. Lots of job changes. A lot of chemically dependent folks end up in jobs where there is little accountability, little day to day accountability like insurance sales, real estate sales. Construction work has the highest incidence of chemical dependency. Farming is another good work for folks to get in who have drug or alcohol use problems. There is not often a lot of day to day supervision. Women who are working in the home, caring for their children. Again, a very good place to be if you are chemically dependent because there is not a lot of on site supervision or accountability.
We know that folks who are chemically dependent tend to miss work at lot. Their performance or productivity goes down because they are showing up for work hungover or high. So look for those kinds of things. If you get a lot of calls on Tuesday morning for "return to work" letters. Anybody besides me get those? You know, "I need to go back to work. My boss wants a ‘return to work’ letter." You might start asking the question, "What’s happening? Why is this person staying home from work on Mondays? Why am I getting this rather frantic call for ‘return to work’ letters without any substantial backing to support it?"
Financial losses. Clearly, the more expensive the drug is, the more quickly a person will have financial trouble. So a drug that’s expensive like cocaine or crank, which is usually about $100 a gram, those folks are fairly quickly going to get into financial trouble. If you have a lot of legal problems, those tend to be expensive. So there are typically a lot of financial losses. So I often ask my patients what they own. If at age 40 or 45 after 20 years of working, if they don’t own anything, if they are in debt, if they’ve got a 35-year-old car and they are still renting a one room apartment, you might ask yourself could that be because of their drug or alcohol use.
Clearly, legal difficulties are very frequent in this population. They tend to have a lot of interactions with law enforcement officials around driving or possession charges, non_payment of child support, domestic violence. Those all would be fairly good red flags for you that there is a drug or alcohol use problem.
Then medical complications. Those occur really because the drug itself is toxic, like alcohol or nicotine, because the method of entry is particularly virulent like needle use or because of the effects of the intoxication itself.
One thing I might mention to you is especially in a geriatric population, when there is a person living alone, it may be very hard in that setting to pick up drug or alcohol use problems because there is no one around them to watch them or know how much they are drinking or ingesting. But if an older person falls, that may be the red flag for you that there is a drug or alcohol use problem. That is often the presenting sign, if you will. So you might do drug screens even on your older folks when they’ve had a fall or do an alcohol level and see if perhaps they fell because of intoxication.
Briefly, I will just mention inheritance patterns. There is actually a huge research project going on right now that you’ll be seeing results from in the next few years called the COGA study. That study has shown that there’s at least two sites, one on chromosome 1 and on chromosome 7, that appears to be predictive for alcoholism and a site on chromosome 4 that appears to be protective for alcoholism. It’s a genetic mapping study that is looking at the inheritance patterns of alcoholism. Most people think there’s more than one type of alcoholism just like there’s multiple types, for instance, of breast cancer. So you’ll probably be seeing more work from that particular study.
This is an older study, it was a population based study done in Scandinavian countries so it may not be reproducible in other populations but in this particular study, sons of alcoholics who were raised in adoptive homes were evaluated. Those sons of alcoholics were four times more likely to be alcoholic than sons of non-alcoholics and being raised in an adoptive, non-alcohol using home was not protective. So particularly male sons of male alcoholics tend to be a very high risk group for future alcoholism. So, again, if you have to put a lot of prevention money or if you want to do interventions on particular populations, that would be one population you might consider looking at – the male offspring of male alcoholics.
What’s the overall risk of alcoholism? Well, about 5-10% of all people who will drink will be alcoholic. If you have one parent who is alcoholic, then your risk is about 20%. If you have both parents, then your risk is somewhere between 20 and 50% and if you are the male first degree relative of a male alcoholic, your risk is 50%. So that is a very high risk group for future alcoholism.
Classes of drugs of abuse. Just quickly, the sedative hypnotics would include obviously alcohol, the benzodiazepines, barbiturates and some of the inhalants. Opioids. The ones I see abused the most would be heroin, Dilaudid, Demerol, Percodan and fentanyl. Stimulants. Of course, cocaine. We have a lot of methamphetamines which on the street are called crank or crystal. That can be snorted, smoked, injected or taken orally. Then mild stimulants like nicotine and caffeine. Hallucinogens would include things like LSD, mescaline, mushrooms.
Then just a category of sort of miscellaneous would include things like marijuana or cannabis which has both mild depressant, mild stimulant and mild hallucinogenic properties. PCP, which probably many of you remember from the ‘70s and ‘80s, which is still used a fair amount as an adulterant for things like cocaine. So a lot of what’s being sold as cocaine is really other stuff and some of that stuff is PCP. MDMA which you may have been reading about lately. MDMA is a combination of mescaline and methamphetamine, also called ecstasy on the street. It’s been around for about 20 years or so. A lot of kids like using it and it’s turning up now on the so-called "rave" scene that you may have been seeing on TV or in the news. Then steroids which get a lot of publicity in this day and age because of the athletic use.
Detoxification. Really detoxification, which is managing withdrawal, you need to be familiar with that in terms of some drugs. We’re going to see a true withdrawal, as I said earlier, with the opioids, with the sedative hypnotics and with nicotine. Anybody in here ever gone through nicotine withdrawal? Do you all think that’s a severe withdrawal? It looks very severe to me and I have a lot of respect for people. When I ask this question with medical students, no one will ever raise their hand anymore. It’s like there used to be no denial around nicotine use and now denial is starting to seep into nicotine use, I think. But nicotine withdrawal is a severe withdrawal and I have a lot of respect for it and I manage it typically pharmacologically with the nicotine patch and gum.
Opioid withdrawal, which would be things like heroin withdrawal, is uncomfortable but not life threatening. Sedative hypnotic withdrawal can be fatal. As you know alcohol withdrawal and benzodiazepine withdrawal can have about a 5-15% mortality if it’s untreated.
As health care providers, though, I think you just need to know how to assess for withdrawal and in my view, there’s really only three questions you need to ask to find out whether or not someone is at risk for withdrawal. The first thing is what have they been using. If they are using cocaine, there is no withdrawal so you don’t need to worry about it. I ask them how much and how often they’ve been using. As a rule of thumb there has to be a continuous presence of the substance for 14 days in order to provoke a true physical withdrawal. So if I’m using a short half-life drug like heroin and I’m using it once a day, even if I’ve been using for 20 years, my odds of going into withdrawal are very low because there is a very long period in any 24 hour period when there is no heroin on board.
But if I’m using a long half-life drug like Valium and I’m using it once a day, even as early as two weeks out I could have a true physical withdrawal. I would alert you, if people have been treated with sedatives like Dalmane, Valium or medications like that as part of an acute grief reaction or something, physical withdrawal from the benzodiazepines, especially in older populations, can be very rocky. So I would be very cautious with those older folks, especially if you are withdrawing them off the benzodiazepines.
The last question I ask is what happened the last time they stopped using or drinking the same amount. The best predictor of future withdrawal is what has happened in the past. So if a person tells me they had severe withdrawals, seizures, disorientation, hallucinations the last time they stopped drinking the same amount, then I know they are at very high risk for that same syndrome this time.
Alcoholism in females is a particularly virulent disease. We know that in males, alcoholism tends to shorten the life span about 10 years. In females, it’s 15 years and that’s primarily because women are particularly vulnerable to alcoholic liver disease and alcoholic brain damage at lower equivalent amounts then men would sustain.
Fetal alcohol syndrome. There is a lot of publicity about this and I think rightfully so. It is probably much more common than we’ve noticed in the past. However, the most common thing would be something called fetal alcohol affect – a syndrome that is really intermediate between what would be considered normal functioning and true fetal alcohol syndrome.
My view is that there is probably no safe level of alcohol ingestion during pregnancy but we do know that ingestion of 3 ounces of liquor a day or more poses a particularly high risk for fetal alcohol syndrome. So, clearly, I think the message we need to be giving out is that no alcohol is safe but if a woman has had a drink or two during the course of her pregnancy, I also don’t want to put that woman through months and months of anguish about the possibility of having a fetal alcohol syndrome baby. I mean, just a drink or two typically doesn’t cause fetal alcohol syndrome.
Family disease. I think just briefly I will tell you that alcoholism and drug addiction affects the entire family. My guess is that oftentimes what you are seeing in your practice are not the chemically dependent person themselves but their family members – their spouses, their parents and their children. There is a whole body of literature about what happens to families where there is drug or alcohol addiction in the family.
There has been some personality styles, if you will, that have been described which I think have a lot of validity for this population and I tend to see it a lot. The "enabler" is often the spouse or the parent of the chemically dependent person. That’s the person who actually calls in sick for their chemically dependent family member or in some way makes it easier, if you will, for the drinking or drug use to continue. They may go out and drink with their partner in order to accompany them or protect them or safeguard them. So an enabler is a fairly common personality style that I see.
"Hero" is often one of the elder children in the family. That’s the one who takes care of the family, assumes a parental role, if you will, because one of their parents is no longer functioning well. They are often the excellent student or the great athlete or the student leader. They are often the ones who go to medical school and law school. I won’t ask you to raise your hands but a lot of us turn out to be heroes because of the families that we were raised in.
The "lost child" is more frequently a middle child. This is a child that just withdraws from the family, doesn’t cause any problems and who tends to isolate in the midst of the family. The "mascot" is often a younger child who is a prankster or jokester and, again, none of these are intentional things but it really, in a way, is trying to call attention away from the chemically dependent person.
The "scapegoat" is often the one that ends up in our offices first. That’s the kid that’s in trouble. The mom or dad may bring in their son or daughter because of the son or daughter’s drug or alcohol use or truancy or acting out behavior and we’re supposed to focus on that kid and get them to walk the straight and narrow. But when you do a family history, you find out that one of the parents is chemically dependent and probably this child is acting out as part of the response pattern to that parent’s chemical dependency. So the scapegoat may be the sentinel patient but may not be the person that you need to do the real work on in the family.
What about treatment for chemical dependency? Well, first of all, remember I said earlier it’s a chronic disease so I believe the treatment really requires lifelong management. My view is that once someone is chemically dependent, they require lifelong abstinence from all of what we would call mood altering drugs. So if I’m cocaine dependent, not only do I need to be abstinent from cocaine, I also need to remain abstinent from alcohol and marijuana. That’s the message that we as physicians and health care providers need to be passing along to our patients.
I believe strongly in 12-step programs like Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous. There is very little in healthcare anymore that is free, universally accessible and works as well as 12-step programs. I’ve listed for you up here some of the other ones as well. The middle four like ACA, Alanon, Alatot and Alateen are for family members of folks with drug or alcohol problems. Then there is a whole host of other 12-step programs for people with eating disorders that’s called Overeaters Anonymous, for gambling disorders there’s Gamblers Anonymous. There’s also Smokers Anonymous or Nicotine Anonymous. So there’s a whole plethora of 12-step programs and I strongly endorse them for folks with drug or alcohol use or other compulsive problems.
Pharmacologically. This is a short list as you can see. We don’t have a huge pharmacologic armamentarium to treat the chronic stage of chemical dependency. Obviously, there’s a whole list of medications you would use for detoxification but this is for the ongoing management. I’m going to probably now talk about naltrexone the most because that’s the newest one. You may have read a bit about it in the lay press or the medical literature.
Naltrexone has been around a long time in the management of opioid dependence. It’s a mu-opioid antagonist and it’s now been shown to be effective in treating alcohol dependency. Essentially, naltrexone blocks a lot of the euphoric or the thing that causes the buzz with alcohol. So folks who drink on naltrexone tend to get more sedated but not get a buzz or get high. It tends to diminish the craving for alcohol so it tends to decrease the frequency of relapse and if someone does relapse on it, it tends to be a briefer relapse.
I strongly endorse the use of naltrexone as long as the person is also engaged in some kind of chemical dependency treatment. So I wouldn’t use it as the mainstay of treatment. I would use it as an adjunct to chemical dependency treatment. The most common side effect is a little bit of upset stomach or nausea so the way I typically start it out is give them 25 mg before bed, probably for about three nights, and then if they tolerate that well, go on up to 50 mg at bedtime. We’ve been using it a lot for the last year and half, especially on our folks who had a history of prior relapses or strong cravings to drink alcohol. So I think it is very safe.
In addition to the fact that they need to be in a treatment program, the other thing I would ask you to do is make sure their liver function is adequate before you start them on the naltrexone and then I check their LFTs monthly while they are on the naltrexone. There are some reports of liver function elevation. That’s typically been in fairly obese females but, nevertheless, I do check it monthly. It also gets them back into your office and you can check and see how they are doing with the treatment of their alcoholism.
Disulfiram has been around a long time. It’s also only been shown to be effective in the context of an alcohol treatment program. You know that it’s an adversive kind of agent. If someone drinks while they are on it, they will get sick to their stomach and have palpitations and shortness of breath. Disulfiram is contraindicated in those folks who have atherosclerotic heart disease or any kind of arrhythmia. So you need to stay away from it in that population.
Methadone, of course, is used in the treatment of heroin addiction. It’s probably the most effective treatment for heroin dependence. In Nebraska, in the whole state, there is only one methadone maintenance program so it’s not universally available. But again, I think it’s very useful in that population.
There are some very soft studies that look at desipramine in the management of cocaine dependence. Those studies tend to be very short-lived, like six weeks, and don’t have very good outcome data. That doesn’t mean that they don’t have good outcomes but their data so far has been pretty soft. I very rarely use desipramine but if a person is cocaine dependent and having lots and lots of craving for cocaine, occasionally I will try desipramine at a low dose – about 50 mg at bedtime.
What’s your role in the management of chemical dependency? Well, you need to ask the questions. I think I’ve been pretty clear. The questions I would ask would be questions about tolerance. I also like questions about age of first use because we now know that the earlier the use, the more likely a person has a drug or alcohol use problem. I also ask about nicotine use. If a person is a heavy smoker, they are much more likely to also have other drug or alcohol use problems. Those are the kinds of things I like to ask about.
You need to tell the person that they have a disease. Again, I remember as a resident and an intern very frequently discharging from the hospital someone with Laënnec’s cirrhosis or alcohol induced pancreatitis never mentioning to them the fact that they have a disease called "alcohol dependence". So we need to tell them they have the disease, tell it in a firm way and try and get their family involved.
I discuss treatment with them. Get them an AA meeting list. Arrange for a followup. Don’t neglect your obligation to follow up on this chronic disease as we would other chronic diseases. If they are unwilling to seek treatment, get their family or friends to an interventionist and ensure the patient is adequately treated. Remember, detoxification is only a stabilization procedure. It does not treat the underlying chemical dependency.
This is what you need to check for. Followup appointments. Are they going to meetings? Do they have a sponsor? You need to ask about those things and it is perfectly okay to do so. You need to look for other compulsive behaviors. Daughters of male alcoholics have a high incidence of eating disorders. So, again, if you see a young girl with an eating disorder, you might want to look in the family and check and see especially if the dad has a drinking problem.
Other chemically dependent members of the family, obviously. Treat the family. Even if the person is not willing to get help for their own chemical dependency, the family members can get help at 12-step programs.
I guess one of the most important things is be very, very careful of your use, especially of benzodiazepines. Lots of alcoholics line up outside lots of doctors’ offices on Friday at 4 o’clock and want benzodiazepines. I was a victim of that myself so you need to be very careful about the use of benzodiazepines in your patient population.
You need to be able to evaluate programs like the one I run and the two questions I think would be the most helpful is do they have a family program and do they have at least a six month continuing care program. All the outcome data shows the family program involvement and at least six months of outpatient treatment improved prognosis.
We know that recovery is a lifelong process and so, again, chronic disease. This is going to get better over time. Relapses may occur but that doesn’t mean that you abandon the patient. You continue working with them.