Risky Drinking

 

The one-question questionnaire.

Answer: Once or twice.

Question: “How many times in the past year have you had 5 or more drinks (for men), or 4 or more drinks (for women) in a single day?"

A recent study published in the Journal of Internal Medicine strongly suggests that this simple question identifies those drinkers at risk for alcohol use disorders roughly 75 % of the time.  While the one-question screening test has been endorsed by both the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) for several years, little clinical evidence existed for assuming that it worked. 

It seems weirdly unrealistic as a standard measure, leaving out, as it does, so many other telling features of active alcoholism. Nonetheless, the group at the Boston University School of Medicine that conducted the research concluded that “the single screening question recommended by the NIAAA accurately identified unhealthy alcohol use in the sample of primary care patients.”

It seems safe to assume that the majority of people who occasionally overdrink are not alcoholics. Is the occasional binge or bender by recreational drinkers really that rare? In a research summary comment on the results, Dr. Peter D. Friedmann opens up the possibility of using the one-question screen to “facilitate more discussion of heavy episodic (binge) drinking, a major source of adverse consequences among nondependent drinkers.”

Five or more drinks, on a single occasion in the past year? Is that really sufficient data? Is a response of  >1 really a genuine cause for concern?

But it gets even stranger. In 2006, the Journal of Studies on Alcohol published a primary care validation study which showed that narrowing the criteria to one incident in three months did not significantly change the results. When the choices available were “within 3 months,” “within 12 months,” “ever,” or “never,” the 3 month and 12 month positive answers were predictive of risky consumption levels about 75% of the time in a study of 625 patients.

One conclusion to be considered is that “normal,” non-alcoholic drinking males rarely—if ever—consume more than 5 drinks in one evening (4 for women). For heavier drinkers, this seems an impossibly Puritan standard, and useless as a diagnostic tool.  As usual, more studies are needed. But the authors of the 2006 paper were confident enough to conclude: “A single question about the last episode of heavy drinking is a sensitive, time-efficient screening instrument that shows promise for increasing alcohol screening in primary care practices.”

Photo Credit: http://talesblog.com/2008/07/19/highlights-of-tales-so-far/

Serotonin Syndrome

Too much of a good thing.

Serotonin syndrome is a rare but potentially deadly condition that results from the combination of two or more serotonin-boosting drugs. Taken in sufficient quantities, the drugs can lead to a serotonin overdose. The symptoms of serotonin syndrome range from mild flushing, muscle jerks, and rapid pulse to fever, hypertension, disorientation, respiratory problems, destruction of red blood cells, seizures, and kidney failure. 

No one knows exactly how often it occurs, since most cases are thought to resolve without further problems within 24 hours after discontinuation of the serotonin-boosting drugs in question. Serotonin syndrome was characterized in animal models years ago, and is probably rare enough to merit little more than a passing notice if not for the variety of serotonin-boosting drugs and medicines continually coming to market. Demerol, the pain reliever, and dextromethorphan, the cough remedy, are another good example of a bad serotonin combination. There is also concern about combining serotonin drugs with over-the-counter diet suppressants. Large hits of Ecstasy or LSD are not recommended, either, although Prozac has long been used informally as a “morning after” drug following a long night on Ecstasy. (Self-prescribing of this kind is foolish and dangerous.) Other problematic combinations include SSRI antidepressants and any of the following: Selegiline (used for Parkinson’s), Linezolid, Risperidone, Haldol, the analgesic Tramadol, Hismanal, St. Johns Wort, certain forms of antiretroviral therapy, and Sumatriptan for migraine.

The most dangerous combination of all is an SSRI medication taken with a strong MAO inhibitor. There have been reports of fatal interactions between SSRIs and MAOIs. MAO inhibiting drugs themselves do not combine well with a long list of other drugs, and there are dietary restrictions that go with taking any monoamine oxidase inhibitor. Here again, prescribers and drug makers have not always taken sufficient care to explain these basic facts to users of prescription MAOIs like Marplan, Parnate, and Nardil. St. John’s Wort and Ecstasy also inhibit monoamine oxidase. Similar problems can occur when MAOIs are combined with stimulants like speed or cocaine.

Foods containing high levels of the amino acid tyramine stimulate the release of norepinephrine, and this buildup can lead to a form of norepinephrine overdose—a hypertensive reaction caused by interaction with MAOIs, which block the reabsorption of norepinephrine. The syndrome is marked by intense headache, nausea, and soaring blood pressure. Serious cases lead to cardiac failure, or intracranial hemorrhage. Foods on the danger list for users of MAO inhibitors include, but are not limited to, large amounts of the following: Chianti wine, vermouth, bean curd, dietary protein supplements, certain cheeses, smoked or aged fish and meat, sausages, sauerkraut, miso soup, and Brewer’s yeast. Drugs to be avoided, in addition to the aforementioned, include Ritalin, asthma inhalers, Tegretol, psuedoephedrine, ephedrine, and others. (As always, check with your doctor about drug combinations).

Not all physicians are familiar with the presenting symptoms of serotonin syndrome (or the details of the MAOI diet). In an emergency, cyproheptadine or propranolol, which are serotonin-blocking drugs, can be administered. Though rare, it is possible to cause serotonin syndrome in drug-sensitive people with high doses of a single serotonin-boosting drug.

From The Chemical Carousel By Dirk Hanson, pp. 281-283.  © Dirk Hanson, 2008.

          

Diurnal Drinking

Casting a light on circadian disruptions.

Scientists and laypeople alike have known for years that the consumption of alcohol interferes with the body’s biological ability to synchronize its daily activities with light. Disruptions of the body clock due to alcohol increase the risk of cancer, depression, and other health problems. Furthermore, a recent animal study showed that the effect of alcohol on sleeping patterns could be detected several days after the last drinking event.

Alcohol’s chronobiological effects grow more profound as steady consumption continues. Previous research has demonstrated the disruptive function of alcohol on melatonin rhythms, body temperature and glucocorticoid release.  Disturbingly, recent research suggests that such disruptions along the hypothalamic-pituitary-adrenal axis may predispose alcoholics to relapse—a vicious hormonal feedback cycle. In a study on hamsters published in the American Journal of Physiology, researchers at Kent State University and the University of Tennessee describe “a feedback cycle of circadian rhythm deterioration and reinforcing alcohol self administration” mediated by glutamate and NMDA-driven “phase resetting of the circadian clock.”

The study separated drinking from non-drinking hamsters, and subjected both groups to light exposure in order to break up the regular diurnal wake/sleep cycle of the animals.  Hamsters that drank only water during the test woke up 72 minutes earlier than normal, while hamsters drinking 20% alcohol did not reset their internal clocks as acutely, waking up only 18 minutes earlier.

However, as Christine Guilfoy wrote for Medical News Today, “When the hamsters were withdrawn from alcohol for 2-3 days and then exposed to the same light treatment again, they woke up much earlier than the animals that had drunk only water. The hamsters that were withdrawn from alcohol woke up 126 minutes sooner compared to the water drinking control group, which advanced 66 minutes. This exaggerated response persisted even up to three days later, when the experiment ended.”

Bearing in mind that drawing conclusions about human brain behavior from animal studies is unavoidably speculative, what possibilities emerge from this study? From the short-term perspective, the researchers note that people who drink alcohol late at night are probably less likely to respond appropriately to light cues, and therefore less likely to keep their biological clocks synchronized over the next 24 hours. Moreover, this circadian disruption from drinking may continue for several days, like jet lag, even after a complete abstention from alcohol.

The researchers also discovered that the drinking animals had fewer bouts of activity during normally active hours, leading to the suggestions that heavy drinkers may be less active during normally active daytime hours, and more active late at night, when chronobiological systems are signaling for sleep. The result: chronic daytime sleepiness.

The major point of the study may be that “brain systems involved with circadian regulation are closely and reciprocally tied to those underlying alcohol abuse,” and that this connection has been underscored “by recent studies showing a link between circadian clock genes and an increased drive for alcohol consumption.”

Treating Addictions [Guest Post]

The ABCs of rehab.

[Journalists like me tend to get immersed in the scientific and medical aspects of addiction. Not a bad thing, to be sure—but sometimes a simpler rendition puts a finer point on the matter. Today’s guest post was contributed by Susan White, who writes on the topic of Becoming a Radiologist.  She welcomes your comments at her email id: susan.white33@gmail.com.]

It’s very easy to find fault and assign blame when you’ve never been in the other person’s shoes; how often have we found ourselves judging people for their bad habits? Why can’t he stop that obnoxious habit? Oh, she’s not strong at all, she cannot stop drinking! I would never sink to the drug-induced state he is in, not even if the worst things were to happen to me – it’s easy to say all these things because we don’t know what an addiction feels like and how hard it is for people to quit. They’re just like you and me; they don’t like the way they are, but their substance abuse controls their bodies, minds and everything they do or say.

To understand an addiction, you need to understand that the body goes through changes, both physiological and psychological. If the addiction is to alcohol, drugs or any other chemical substance, the high euphoric feeling is what makes you go back again and again. But as time goes by, the high decreases and you begin to take in more of the abusive substance in your quest for that initial euphoria. It’s a vicious cycle that feeds itself, and if you stop, you feel withdrawal symptoms because your body is so used to its daily or even hourly fix.

It takes a supreme effort to admit that you have a problem and seek help. Rehab centers work because they make the addict quit cold turkey; they are cloistered and controlled environments where addicts have no access to the abusive substance. The sudden withdrawal causes abnormal reactions in your body, and you’re treated with medicines that help soothe your frayed nerves. When the initial craving subsides, you’re put in therapy and other forms of rehabilitation. Your diet is regulated, and your body slowly starts to recover and rejuvenate. 

The hardest part of rehab however comes when you step out of the cocoon of the de-addiction center and enter the real world. You have to face the demon that had its tentacles around you and fight it down, and for some people, this is where they suffer a relapse. Once they are surrounded by temptation, they succumb and are soon back to their decadent and sorry state. Others however, are made of sterner stuff. They know that they cannot afford to lose control again and they are disciplined enough to say no when they come face to face with temptation.

Addiction, be it to a substance, person or thing, is not something to be taken lightly. Unless admitted to and treated at the earliest, it could end up having serious physical and mental consequences. 

Graphics Credit: http://www.nida.nih.gov/

Gambling Through the Ages

A brief history of playing cards.

In a recent email exchange with NIDA director Nora Volkow, I asked about gambling as a clinical addiction. “It is almost by necessity that we’ll find significant overlaps in the circuits that mediate various forms of compulsive behaviors,” she responded. “We have yet to work out the details and the all important differences, but it stands to reason that there will be many manifestations of what we can call diseases of addiction.”

This got me thinking about the history of addictive drugs, which I researched for my book, The Chemical Carousel.  The litany features long and ultimately unsuccessful histories of campaigns against heroin, against tobacco, against alcohol.

But does fairness demand that we add gambling to the historical list, given the suspicion with which playing cards have been held throughout the ages?

The origin of playing cards is suitable murky, but  they are generally thought to have been invented in China or India in the 10th Century AD, and subsequently refined and redesigned in the Muslim world. By the 1300s, hand-painted playing cards had made it to Europe, mostly affordable only by the nobility. When the advent of woodblock printing brought playing cards to the masses, gambling with cards took on an altogether different reputation. Gambling with cards was banned in Florence, Italy in 1376, followed by Lille, France, then Valencia, Spain, and Ulm, Germany.

The bans proliferated in the 15th Century: In 1404, a bishop in France had to crack down on card gambling among the priesthood. In 1423, St. Bernard of Sienna railed against paying cards so successfully, according to The Standard Hoyle,  that “cards, dice and games of hazard” were gathered up by the townspeople and committed to the bonfire. In 1476, King Ferdinand and Queen Isabella banned gambling with playing cards. None of these prohibitions were even remotely successful, and by the 1600’s the standard “French pack” of 52 cards and four colored suits emerged. They have been the standard in the world’s casinos ever since.

By the 17th Century, card playing was well established in America, despite attempts by the Pilgrims to prevent it. And ministers quickly found that the Indians were deep into dozens of gambling games of their own. Little known fact: The American Stamp Act of 1765,  the very act that got the early patriots so riled up, included taxes on newspapers, legal documents—and playing cards.

Extreme Christmas Lights Syndrome

An addiction to bright lights in the dark.

In 2004, psychologist John M. Grohol wrote a satirical piece for The Psych Central Report. I ran this last year, and it seems appropriate to excerpt it again:

"It is an age-old question that has haunted people since the first string of lights was strung in the 20th century," Grohol wrote. "Why do some people seem to go a little crazy with the amount of lights and displays they put on their homes and lawns? What makes some people think that this is a good idea? This growing phenomenon has turned into a full-blown behavioral addiction for some."

Indeed it has; one with its very own WebRing. It’s the time of year when afflicted people manifest CLA—Christmas Lights Addiction.

"It is an extreme behavior of an otherwise normal expression of a celebration of the holidays,” Grohol continues. “If you're one of these folks who can't live without their million-light holiday display, seek help. Imagine how much better your gift to the world would be if you donated your electricity costs to a local charity or homeless shelter.

"Leave the holiday lighting spectaculars to Radio City Music Hall or professional displays found in most communities done in formal gardens or the like. Let's try and get back to celebrating Christmas in a way that honors the heart of the tradition without turning it into some sort of glitzy and tacky sideshow of lighting horror.

Merry Christmas, Happy Chanukah, and Happy New Years to you All!"

Photo Credit: http://www.collthings.co.uk

Q & A with Nora Volkow

NIDA director discusses cannabis, addiction vaccines, and gambling.

Recently, Addiction Inbox was offered the opportunity to submit questions to Nora Volkow, the director of the National Institute on Drug Abuse (NIDA). Dr. Volkow was kind enough to provide detailed answers by email. In her responses, she reveals a broad clinical understanding of addiction, and speculates on what this brain disorder might mean for “other diseases of addiction” like gambling.

Q: Clinical studies, like those by Barbara Mason at Scripps Institute, have documented a marijuana withdrawal syndrome among a minority of users. Are we prepared to say that marijuana is addictive? Why didn't we identify this syndrome years ago?

Nora Volkow: Absolutely, there is no doubt that some users can become addicted to marijuana. In fact, well over half of the close to 7 million Americans classified with dependence or abuse of an illicit drug are dependent on or abuse marijuana. It is important to clarify that while withdrawal is one of the criteria used to diagnose an addiction (which also includes compulsive use in spite of known adverse consequences), it is possible for an individual to suffer withdrawal symptoms without he or she being addicted to an abused substance.

Now, to answer your specific question, the reason for the relatively late realization that people who abuse marijuana can develop a cannabis withdrawal syndrome (CWS) if they try to quit is probably the result of at least two factors. First is the fact (which you hint at already) that a clinically relevant cannabis withdrawal syndrome may only be expected in a subgroup of cannabis-dependent patients. This may be partially explained by marijuana’s uptake into and slow release from fat cells, which can occur over days or weeks after last use. Thus, cessation of marijuana use may not be so abrupt, and could thereby diminish signs of withdrawal. The second factor relates to the small to negligible associations between recalled and prospectively assessed withdrawal symptoms, which may have precluded many previous, recall-based studies from detecting or properly characterizing CWS. It is also worth pointing out that other addictions (e.g., cocaine) were also not initially thought of as capable of triggering withdrawal symptoms.”

Q: Are there any anti-craving medications you are particularly excited about at this time?

Volkow: In the context of nicotine addiction, we have a host of nicotine replacement options as well as 2 medications that work through different mechanisms—all of which reduce craving and the risk of relapse during a cessation attempt, particularly when combined with some form of behavioral therapy. However, sustained abstinence from nicotine has been difficult to achieve, even with the current therapeutics that are available. So, at this point, I am very excited about a novel approach to the treatment of addiction—an approach that relies on vaccine development. Currently there are anti-nicotine vaccines in clinical testing, which are designed to capture the nicotine molecules while still in the bloodstream, thus blocking their entry in to the brain and inhibiting their behavioral effects. And while these vaccines were not intended specifically to reduce cravings, they appear to be effective in helping subjects who develop a high antibody response sustain abstinence over long periods of time. Even those people with a less robust antibody response to the vaccine, decreased their tobacco use. So this approach appears very promising.

Similarly, in the context of opiate addiction, we are very excited about the cumulative positive results of the clinical experience so far with buprenorphine, a long-acting partial agonist that acts on the same receptors as heroin and morphine, relieving drug cravings without producing the same intense "high" or dangerous side effects.

Q: You have suggested in the past that certain forms of overeating are addictions. There is good evidence for this. What about non-substance addictions, like gambling?

Volkow: The brain is composed of a finite number of circuits, for, for example, rewarding desirable experiences, remembering and learning about salient features and stimuli in the environment, developing emotional connections to other members of the social group, becoming aware of changes in interoceptive (internal) physiological states, etc. These and a few others are the circuits that the “world” acts upon. So it is almost by necessity that we’ll find significant overlaps in the circuits that mediate various forms of compulsive behaviors. We have yet to work out the details and the all important differences, but it stands to reason that there will be many manifestations of what we can call diseases of addiction. Thus, addiction to sex, gambling, alcohol, illicit drugs, shopping, video games, etc. all result from some degree of dysfunction in the ability of the brain to properly process what is salient, accurately predict and value reward, and inhibit emotional reactivity or deleterious behavior.

As we learn more about the significant overlaps at the genetic, neural, circuit, and systems levels we may be able to reap the benefits from complementary research into these various chemical and behavioral addictions.

Photo Credit: http://www.thechallenge.org