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 The leading web portal for pharmacy resources, news, education and careers March 21, 2018
Pharmacy Choice - Alcoholism Disease State Management - March 21, 2018

Alcoholism Disease State Management

Alcohol Dependence: What Pharmacists Need to Know
by Darrell Hulisz, RPh, PharmD
Associate Professor
Case Western Reserve University School of Medicine

The term alcohol dependence is synonymous with alcoholism. A growing consensus views alcoholism as a chronic disease characterized by craving for alcohol, loss of control of use, physical dependence (presence of withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety after stopping drinking) and tolerance to alcohol. According to the CDC, 13,050 Americans die from alcoholic-related liver disease. The number of alcohol-induced deaths, excluding accidents and homicides is 22,073. Alcohol dependence and abuse cost the US approximately $220 billion annually. Drinking excessively over time has numerous medical consequences including pancreatitis, increased risk of various malignancies, a worsening of hypertension, fetal damge during pregnancy, and may cause cirrhosis of the liver. The psychosocial consequences of alcoholism can devastate the individual and family. An estimated 43% of US adults have had someone related to them who is a current or recovering alcoholic. While estimates vary, approximately 14 million US residents battle an alcohol addiction.

Pharmacists should remind patients that alcohol dependency treatment, such as counseling and/or medications are effective, leading to greater than 60% reductions in alcohol-related problems, 50% reductions in consumption and 30% abstinent or decreasing to moderate drinking. Unfortunately, only 10% of those with alcohol dependence receive appropriate treatment. Effective, comprehensive management of alcoholism is complex, ranging from acute detoxification to marital and family counseling. In addition, many patients need access to psychological, medical / psychiatric, employment, legal, and social services during the recovery process. While supervised 12-step self-help programs, such as Alcoholics Anonymous are the cornerstone of treatment, the addition of pharmacotherapy can help reduce drinking, reduce relapse to heavy drinking, and maintain abstinence.

Several medications are FDA approved for maintenance therapy as adjuncts for treating alcoholism, each having specific advantages depending upon the patient being treated. Acamprosate reduces cravings for alcohol by decreasing the physiological arousal associated with prolonged alcohol withdrawal. Data from recent studies suggest that drinkers with 7-10 days abstinence are more likely to benefit from this medication. Patients who are unable to tolerate naltrexone or who show little response to naltrexone may benefit from a course of acamprosate. Disulfiram can provide a strong deterrent to drinking because of the intense aversive reaction it causes when mixed with alcohol. This medication is likely to provide the greatest benefit when combined with a psychosocial treatment than emphasizes disulfiram compliance. Immediate release, sustained-release and depot injection of naltrexone, provide some relief from cravings and may blunt the pleasurable effects of drinking. Non-compliance with naltrexone greatly reduces the efficacy of this medication, making the once-monthly depot injection more appropriate for those with poor adherence.

Pharmacists are well-aware of the numerous and important drug interactions involving alcohol and should counsel patient accordingly. Since alcohol is a CNS depressant, drugs with sedating properties can potentially interact with alcohol causing increased sedation. Examples include benzodiazepines, tricyclic antidepressants, barbiturates, antihistamines, opiates, muscle relaxants, antipsychotics and anticonvulsants. Sedating drugs can interact in patients with alcohol dependence putting patient at increased risk for ataxia, somnolence, respiratory depression, and motor impairment which can lead to falls, accidents and injury. Excessive use of acetaminophen with regular intake of alcohol increases one’s risk for liver toxicity. A disulfiram reaction (facial flushing, vomiting, tachycardia) can occur if alcohol is ingested with drugs such as metronidazole, sulfonylureas or isoniazid; thus, patients must also be warned about this too.

In addition to routine screening for drug-alcohol interactions, pharmacists with direct patient care should screen patients they suspect for alcohol abuse or dependency. The most widely used tool is called the CAGE questionnaire, whereby the pharmacist can ask the following questions:

  • C - Have you ever felt you should Cut down on your drinking?
  • A - Have people Annoyed you by criticizing your drinking?
  • G - Have you ever felt bad or Guilty about your drinking?
  • E – (Eye opener question) Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
In situations where two or more "yes" answers are given, it is likely that a problem with alcohol exists and pharmacists should consider referring patients back to their primary care physician for diagnosis, or possibly refer patients to self-help programs.

Links - Alcoholism
National Institute on Alcohol Abuse and Alcoholism supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism and alcohol-related problems.

National Council on Alcoholism and Drug Dependence provides education, information, help and hope to the public.

The Association for Addiction Professionals's mission is to lead, unify and empower addiction focused professionals to achieve excellence through education, advocacy, knowledge, standards of practice, ethics, professional development and research.

Alcoholics Anonymous is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.

Al-Anon helps families and friends of alcoholics recover from the effects of living with the problem drinking of a relative or friend. Similarly, Alateen is our recovery program for young people. Alateen groups are sponsored by Al-Anon members.

American Council on Alcoholism is a national non-profit 501(c)3 health organization dedicated to educating the public about the effects of alcohol, alcoholism and alcohol abuse, and the need for prompt, effective, available, and affordable treatment.

National Clearinghouse for Alcohol and Drug Information

National Association for Children of Alcoholics

Center for Substance Abuse Treatment

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