Saturday, December 29, 2007

Extra, Extra: College Student Endorses Alcohol Use

The astute may have noticed that many medications warn that they should not be taken with alcohol. The "can I drink while I'm taking this medication?" question is one that I get a lot when I'm working. There are a lot of misconceptions about the effect of alcohol when combined with different drugs; this can be largely attributed to the fact that there are rarely degrees of severity described on "no alcohol" warning labels.

Let's put this another way. I'm an inquisitive youth and always have been, and I'm in my early 20's, the only decade where rebellion is anywhere near as likely as in the teens. I always thought warnings or prohibitions without explanations were patently stupid. You can't just tell me "don't do it." I have to know why I can't do it so that I can decide for myself whether the rule is worth following.

Let me also remind you that you should always follow any precautions listed on medications and consult your doctor or pharmacist instead of taking advice from an anonymous blogger. If I'm your only source of medical information, you should seriously reconsider your actions.

From a counseling perspective, there are two ways to handle the alcohol question. You can assume that all people are good little boys and girls and tell them that should a drop of whisky pass their lips while they're on amoxicillin that they will suffer terrible consequences (this is clearly an exaggeration). Or you can be realistic. Amusingly, most patients are very careful about how they phrase their "can I drink" question. Anecdotally, the most common phrasing is "is it okay if I have a glass of wine with dinner?" Nobody wants to sound like a booze hound who can't put down the liquor when they're sick. I think the lone exception I've seen so far in practice was the fellow who wanted to know if he could keep up his six-beer-a-day habit. That's ten-foot-pole category stuff, there. So many things are wrong that you have no idea where to start and you pray silently to the cosmos that someone else with more time on his hands will refer this man for a different flavor of counseling.

Alcohol is a drug. There are two different categories of drug interactions; pharmacodynamic and pharmacokinetic interactions. P-dyamics is essentially what the drug does to the body, whereas p-kinetics is what the body does to the drug. P-kinetics has four components, absorption, distribution, metabolism, and excretion, often abbreviated ADME. Here's a simplified look at both sides of the equation for alcohol:

P-Dynamics: Alcohol is central nervous system depressant.
P-Kinetics: Alcohol is absorbed through the small intestine, distributed into the blood and other fluid portions of the body, metabolized by liver enzymes into other compounds and excreted in sweat, urine, and saliva.

When we're talking about drug interactions, we have to know if the interactions are dynamic or kinetic. For example:

P-Dynamics: Some antihistamines cause drowsiness. Antidepressants can cause drowsiness. Combining the two produces more drowsiness.
P-Kinetics: Lipitor and other statins are broken down by liver enzymes. Grapefruit juice reduces the action of these enzymes. Combining the two prevents the breakdown of Lipitor, increasing Lipitor levels in the body.

A lot of common drug interactions with alcohol are p-dynamic in nature. Alcohol causes drowsiness, so combining it with other drugs that may cause drowsiness will result in the patient experiencing potentially unexpected levels of sedation. In the case of moderate drinking, most interactions with antihistamines, antidepressants, and anti-anxiety drugs and alcohol fall into this category. You're not going to die if you have a couple beers. But you're going to feel a lot sleepier than you would otherwise.

Painkillers are a slightly different story. Acetaminophen and alcohol are both toxic to the liver, and that toxicity is amplified when the two are used in conjunction. NSAIDs are more likely to cause stomach bleeding when taken with alcohol, which can also damage the lining of the gut. And combining opioids like Vicodin or Oxycontin with alcohol can lead to fatal respiratory depression. Don't do it! It's dangerous!

Most antibiotics do not significantly interact with alcohol, but you aren't doing yourself any favors by drinking while sick. The dehydration caused by alcohol does your body no good in fighting an infection and might also worsen some symptoms of illness. There are a few noteworthy exceptions, however; perhaps the most notorious of these is metronidazole, otherwise known as Flagyl. This is a classic p-kinetic interaction. Metronidazole inhibits aldehyde dehydrogenase, a key enzyme in alcohol metabolism. Without this enzyme, toxic levels of acetaldehyde, a by-product of ethanol breakdown, build up in the body and cause nausea and vomiting, among other potentially more serious symptoms of acetaldehyde toxicity. The reaction in question is often referred to as a disulfiram reaction. If your pharmacist tells you absolutely no drinking while taking an antibiotic, he or she is probably trying to warn you of a potential disulfiram reaction.

The disulfiram reaction can actually be used therapeutically. Ever heard of Antabuse? It's the drug for which the disulfiram reaction was named. When administered to alcoholics, it causes them to become violently ill after consuming alcohol--a form of aversion therapy. Cute, huh?

I don't like seeing patients who are afraid of their medications or who feel that being committed to a particular therapy is going to significantly affect their quality of life. Many people enjoy the occasional drink, and for the vast majority of them, being on medication is no reason to give up that pleasure. Other health complications might be a reason to avoid alcohol, but I've spoken to way too many otherwise healthy people on antidepressants or mood stabilizers that almost pathologically avoided drinking not because they feared it would interfere with their therapy from a mental health perspective but because they were certain that combining alcohol with their medications would be irreversibly harmful or even fatal. With a little time and explanation as to the "whys" behind drug and alcohol interactions, patients can be reassured that they don't have to change their lives to revolve around their medications. And if your doctor or pharmacist hasn't told you why there's a particular warning on your medication, don't hesitate to ask! The more informed you are, the better, especially if you're going to be putting these medications into your body for years to come.

Don't forget that all of this applies primarily to occasional, responsible alcohol use. If you're drinking four or five alcoholic beverages a day, some of your body's metabolic machinery operates under different rules. But don't feel like you have to give up your New Year's bubbly just because you've been prescribed a Z-Pak.

1 comment:

Anonymous said...

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