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ce lessonPharmacy Practice national continuing education programA Pharmacist’s Overview of Alcohol Dependence: The Path to AbstinencePharmacotherapy ofconcurrent alcoholdependence anddepressionSelective serotonin reuptakeinhibitors (SSRIs)SSRIs increase serotonin levels by inhibitingserotonin reuptake at the synapse.SSRIs may indirectly improve patientoutcomes in alcohol dependence treatment(e.g., abstinence) by increasingserotonin levels, thus alleviating underlyingdepression. (10) Fluoxetine, sertraline,and citalopram have been studied inclinical trials, with sertraline also impactingon dopamine as well as serotonin.However, the evidence to support theirefficacy is weak. (10)QuetiapineQuetiapine is an atypical antipsychoticwith multiple receptor affinities (predominatelyserotonin and dopamine), whichmay be beneficial in alcohol dependencetreatment. (27) One hypothesis suggestsquetiapine’s benefit is secondary to thestructural similarity of one of its metabolitesto methadone, which may subsequentlyact as a pleasure-reward modulator.(37) Additional effects of quetiapine ondrinking outcomes may be related to itsbeneficial effects on mood, anxiety andsleep, which may help alleviate protractedwithdrawal symptoms as well as addressco-morbidities. 3 The efficacy of quetiapinein treating alcohol dependence was demonstratedin a small placebo-controlledtrial, but further research is warranted. (38)table 6Additional Resources for Pharmacists and PatientsHealth Canada – Alcohol & Drug and Prevention PublicationsA useful website for pharmacists containing information about youth, seniors andspecial populations with alcohol and substance abuse, including rehabilitation.www.hc-sc.gc.ca/hc-ps/pubs/adp-apd/index-eng.phpAlcoholics Anonymous/Al-Anon/AlateenResources for patients and family members seeking support while drinking or when inrecovery.www.alcoholics-anonymous.org; www.al-anon.alateen.org/Centre for Addiction and Mental Health (CAMH)A comprehensive resource for patients interested in learning more about alcoholdependence including diagnosis, impacts, rehabilitation and recovery.www.camh.net/About_Addiction_Mental_Health/AMH101/top_searched_alcohol.htmlNational Institute on Alcohol Abuse and AlcoholismA resource for healthcare professionals including clinical guidelines, pamphlets,brochures and research for helping patients with alcohol dependence.www.niaaa.nih.gov/Pages/default.aspxMedlinePlus (National Institutes of Health) – Alcoholism and Alcohol AbuseAn overview of alcoholism and alcohol abuse for patients, including symptoms, causes,diagnosis, treatment, complications, and support groups.www.nlm.nih.gov/medlineplus/ency/article/000944.htmThe Definition of AddictionA detailed resource for pharmacists addressing alcohol dependence, withdrawalsymptoms, post-acute withdrawal syndrome, and approaches to recovery.www.addictionsandrecovery.org/definition-of-addiction.htmMotheriskA helpful resource and reference with articles for patients and healthcare professionalson the use of alcohol during pregnancy and breastfeeding.www.motherisk.org/women/alcohol.jspProfessionals Health ProgramA resource for pharmacists interested in learning more about the Ontario ProfessionalsHealth Program and its confidential services to assist members suffering from incapacitation,substance use and/or mental health issues.www.ocpinfo.com/client/ocp/OCPHome.nsf/web/ Professionals+Health+ProgramGuidelines for Handling Incapacitated Pharmacists and Pharmacy Co-workersAn Ontario College of Pharmacists document outlining warning signs, duty to report (withscenarios) and the definition and guidelines in defining the “incapacitated pharmacist.”www.phpoma.org/PDF%20files/Pharmacist/ Guidelines_for_Handling_Incapacity.pdfCommunication skills inalcohol dependenceCounselling the patient with alcohol dependencerequires awareness on the part of thepharmacist to ensure that any barriers—including environmental, personal biases,patient, time and behavioural—are removedor minimized. These barriers contribute to90% of the nonverbal communication thatis transferred to the patient. We must beaware of our own belief systems and culturalawareness about alcohol use prior to engagingin dialogue. (39) Awareness of this phenomenonwill diminish the chance of “scolding”or “lecturing” the patient, actions thatadd to their guilt, and shame, which mayincrease the risk of failure of treatment.Empathy and empowerment are keys toprevent adding further “dis-ease” to thedisease of alcohol dependence. Helpfulresources for pharmacists and patients/families are presented in Table 6.MonitoringPhysiological ParametersTLab tests such as liver function tests,mean corpuscle volume, serum alcohollevels, urine specific gravity and bilirubinare usually elevated in a patient whochronically consumes alcohol, while serumB12 and folate are commonly depleted.Test results within normal ranges may provideevidence of continued abstinence,although not definitive. This is coupledwith the patient and family member’supdates to quantify stable recovery. Insome cases, random urine toxicologyscreening may be performed. (40)Psychological ParametersIt is essential for the pharmacist to continuallyquantify and discuss drinkingCE6 pharmacypractice | december 2011answer online at canadianhealthcarenetwork.ca
ehaviours in collaboration with thepatient and/or support system and offerpositive support. The community pharmacistis well-placed to notice adherencewith medication refills, using this interactionto open communication. Integrationand collaboration with the patient arecritical in order to help set the appropriategoals for the reduction or cessation ofalcohol consumption. (1)Patients and their families must be madeaware of the post-acute withdrawal syndrome(PAWS) that may occur within thefirst two years of abstinence, since the developmentof PAWS may result in relapse orits symptoms may be confused with symptomsof relapse. (41) Signs and symptoms ofPAWS include an inability to think clearly,memory problems, emotional overreaction,emotional instability, sleep disturbances,physical coordination problems, andenhanced stress sensitivity. (41) Maintainingregular sleep patterns, diet, exercise, andsocial interactions are more effective thanusing a benzodiazepine. Pharmacotherapyis usually not indicated for PAWS. (41)Addiction in healthprofessionalsSimilar to the general population, evidenceQuestions1. The 12-month prevalence of alcoholdependence in the United States at anypoint in time in the general population is:a) approximately 1%b) approximately 4%c) approximately 15%d) approximately 20%e) approximately 25%2. The one-year incidence of relapsewithout any pharmacological adjunct tobrief behavioural interventions is:a) 60%b) 70%c) 80%d) 90%e) 100%3. Which neurotransmitter systems havebeen implicated in alcohol dependence?a) opioidb) dopaminec) GABAd) all the abovee) b and cA Pharmacist’s Overview of Alcohol Dependence: The Path to Abstinencece lessonPharmacy Practice national continuing education programof substance abuse in health professionalsmay include emotional, behavioural orphysical changes. Emotional changesinclude aggression, burnout, anxiety,depression, paranoia and denial. Behaviouraleffects may manifest as slowed reactiontime, impaired coordination, slurredspeech, irritability, excessive talking,inability to sit still, limited attention span,lack of motivation or lack of energy. Physicaleffects may include weight loss, sweating,chills and the smell of alcohol. Thehealth professional is often able to “function”professionally as work is frequentlythe last aspect of their life to deteriorate.As such, their incapacity may have significantlyescalated before it is recognizedin the workplace. Work-related warningsigns may include: increased disorganization,increased number of prescriptionerrors (dispensing and counselling) or customercomplaints, increased absence anddecreased focus. (42) Resources to assistincapacitated healthcare professionals areincluded in Table 6.ConclusionCommunity pharmacists are well-placedto interact with patients with alcoholdependence. Hospital pharmacists mayAnswer online at www.CanadianHealthcareNetwork.ca, CE section, Quick Search CCCEP #1065-2011-340-I-PCase 1: X is a pharmacist who works with youin a midnight community pharmacy. Lately younotice X is acting more “unpredictably”—taking frequent days off due to migraines,claiming nausea and vomiting, and you noticea regular purchase pattern for dimenhydrinate.However, X is always willing to help out, takeextra shifts, and stay late…you are unable topinpoint the root of your unease.4. Your colleague X is more likely to be:a) maleb) female5. What is a risk factor in patients withalcohol dependence?a) non-smokerb) femalec) professionald) family historyengage in initial dialogue with the patientto determine needs and manage acutewithdrawal symptoms. The communitypharmacist, through dialogue and documentationof patient-centred goals, mayengage in regular follow-up with thesepatients, including monitoring adherencewith prescription refills, especially inthe first year. Pharmacists can alsoaddress concerns about acute and maintenancepharmacotherapies. They canalso direct patients to further educationand enhance awareness of psychosocialor behavioural interventions.Pharmacists can also watch for patientswho seek other substances that producemind-altering effects (i.e., “substituteaddictions”). Common substitute addictivemedications include, but are not limitedto opiates, benzodiazepines, appetite suppressants,cough syrups and antihistamines.(24) Community pharmacists can tryto monitor for misuse of OTC agents andidentify other potential drugs of abuse byrecognizing abnormalities in prescriptionrefill dates or purchase histories. (43) Pharmacistsare also well-placed to providebrief psychosocial intervention as well asoptimize pharmacotherapy, the two cornerstonesof a successful recovery model.6. X is diagnosed with alcohol dependence.When X stops consuming alcohol, X’s bloodpressure is 160/110 mmHg with a heart rateof 115 and X is also experiencing diaphoresis.X may be classified as experiencing:a) mild withdrawalb) moderate withdrawalc) severe withdrawal7. X’s blood test results on admissionreveal elevated liver enzymes indicative ofearly damage and elevated vital signs. Whatwould be the best pharmacotherapy choiceto help manage the acute withdrawal?a) watch and waitb) lorazepam 1 mg orally every 4 hours if neededc) diazepam 5 mg orally every 4 hours if neededd) lorazepam 2–4 mg orally four times daily ifneedede) diazepam 15–20 mg orally four times daily ifneeded8. Supportive interventions for X mayinclude the following:a) thiamine 100 mg oral dailyb) folic acid 1 mg oral dailyc) multivitamin 1 tablet dailyd) all of the abovee) none of the aboveanswer online at canadianhealthcarenetwork.cadecember 2011 | pharmacypractice CE7
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