Med/Psych Update

How to manage medical complications of the 5 most abused substances

Current Psychiatry. 2009 November;8(11):35-47

Raheel Khan, DO

Lenton Joby Morrow, MD

Robert M. McCarron, DO

Monitor for symptoms and lab findings that indicate risk of serious consequences

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References

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3. National Institute on Alcohol Abuse and Alcoholism. How to screen for heavy drinking. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 2005. Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/PocketGuide/pocket_guide5.htm. Accessed September 15, 2008.

4. Zakhari S, Li TK. Determinants of alcohol use and abuse: impact of quantity and frequency patterns on liver disease. Hepatology. 2007;46(6):2032-2039.

5. National Institute on Alcohol Abuse and Alcoholism. Alcohol alert. Alcoholic liver disease. Washington, DC: US Department of Health and Human Services; 2005. Available at: http://pubs.niaaa.nih.gov/publications/aa64/aa64.htm. Accessed August 23, 2009.

6. Spiegel DR, Dhadwal N, Gill F. ‘I’m sober, doctor, really’: best biomarkers for underreported alcohol use. Current Psychiatry. 2008;7(9):15-27.

7. Yang AL, Vadhavkar S, Singh G, et al. Epidemiology of alcohol-related liver and pancreatic disease in the United States. Arch Intern Med. 2008;168(6):649-656.

8. Hvidtfeldt UA, Frederiksen ME, Thysesen LC, et al. Incidence of cardiovascular and cerebrovascular disease in Danish men and women with a prolonged heavy alcohol intake. Alcohol Clin Exp Res. 2008;32(11):1920-1924.

9. Fuchs FD, Chambless LE, Whelton PK, et al. Alcohol consumption and the incidence of hypertension: the Athersclerosis Risk in Communities Study. Hypertension. 2001;37(5):1242-1250.

10. Alcoholic cardiomyopathy. The New York Times Health Guide. Available at: http://health.nytimes.com/health/guides/disease/alcoholic-cardiomyopathy/overview.html. Accessed September 28, 2009.

11. McKenna CJ, Codd MB, McCann HA, et al. Alcohol consumption and idiopathic dilated cardiomyopathy: a case control study. Am Heart J. 1998;135(5 pt 1):833-837.

12. Meyerhoff DJ, Bode C, Nixon SJ, et al. Health risks of chronic moderate and heavy alcohol consumption: how much is too much? Alcohol Clin Exp Res. 2005;29(7):1334-1340.

13. Liappas I, Theotoka I, Kapaki E, et al. Neuropsychological assessment of cognitive function in chronic alcohol-dependent patients and patients with Alzheimer’s disease. In Vivo. 2007;21(6):1115-1118.

14. Johnston LD, O’Malley PM, Bachman JG, et al. Monitoring the Future. National Results on Adolescent Drug Use. Overview of Key Findings, 2007. Bethesda, MD: National Institute on Drug Abuse; 2008. Available at: http://www.monitoringthefuture.org/pubs/monographs/overview2007.pdf. Accessed August 20, 2008.

15. Hales RE, Yudofsky SC, Gabbard GO. The American Psychiatric Publishing textbook of psychiatry. 5th ed. Arlington, VA: American Psychiatric Publishing, Inc.; 2008.

16. Substance Abuse and Mental Health Services Administration. Results from the 2004 National Survey on Drug Use and Health: National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005. NSDUH Series H-28, DHHS Publication No. SMA 05-4062.

17. National Institute on Drug Abuse. Research report series—marijuana abuse. Bethesda, MD: National Institute on Drug Abuse; 2005. Available at: http://www.nida.nih.gov/ResearchReports/Marijuana. Accessed September 1, 2008.

18. Khalsa JH, Genser S, Francis H, et al. Clinical consequences of marijuana. J Clin Pharmacol. 2002;42(suppl 11):7S-10S.

19. Tashkin DP. Smoked marijuana as a cause of lung injury. Monaldi Arch Chest Dis. 2005;63(2):93-100.

20. Korantzopoulos P, Liou T, Papaioannides D, et al. Atrial fibrillation and marijuana smoking. Int J Clin Pract. 2008;62(2):308-313.

21. Jones RT. Cardiovascular system effects of marijuana. J Clin Pharmacol. 2002;42(suppl 11):58S-63S.

22. Harrison GP, Jr, Gruber AJ, Hudson JI, et al. Cognitive measures in long-term cannabis users. J Clin Pharmacol. 2002;42(suppl 11):41S-47S.

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24. National Institute on Drug Abuse. What are the long-term effects of cocaine use? Bethesda, MD: National Institute on Drug Abuse; 1999. Available at: http://www.nida.nih.gov/PDF/RRCocaine.pdf Accessed September 1, 2008.

25. Wang CM, Huang CL, Hu CTS, et al. Medical complications of cocaine abuse. Medical Update for Psychiatrists. 1997;2(2):34-38.

26. Hollander JE, Todd KH, Green G, et al. Chest pain associated with cocaine: an assessment of prevalence in suburban and urban emergency departments. Ann Emerg Med. 1995;26:671-676.

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Individuals who abuse substances often have comorbid psychiatric disorders—80% of alcoholics have another axis I disorder¹—and the reverse also is true. More than one-half of schizophrenia patients and 30% of anxiety and affective disorder patients abuse substances.¹

In addition to worsening psychiatric illnesses and interfering with proper treatment, alcohol and other substances can lead to serious cardiac, neurologic, pulmonary, or gastrointestinal complications that can linger even after your patient stops abusing drugs. This article provides an overview of common medical complications related to using alcohol, marijuana, cocaine, methamphetamines, and opioids.

Alcohol

Because some consequences of alcohol abuse (Table 1) are thought to be dose-dependent, ask about your patient’s alcohol consumption. Moderate drinking is defined as up to 2 drinks/day for men and 1 drink/day for women.² Heavy drinking is ≥5 drinks/day (or ≥15 drinks/week) for men and ≥4/day (or ≥8/week) for women.³ A drink contains 12.5 grams of ethanol and is defined as:

12 oz (360 mL) of beer or wine cooler
5 oz (150 mL) of wine
1.5 oz (45 mL) of 80-proof distilled spirits.³

Clinical Point

Steatosis can occur after just a few days of heavy drinking, but can be reversed with abstinence from alcohol

Gastrointestinal effects. Chronic heavy alcohol consumption can lead to fatty liver (steatosis), alcoholic hepatitis, and cirrhosis. Steatosis—the first stage of alcoholic liver disease—can occur from heavy drinking for just a few days but can be reversed with abstinence from alcohol. Prolonged use can lead to alcoholic hepatitis. Symptoms include nausea, lack of appetite, vomiting, fatigue, abdominal pain and tenderness, spider-like blood vessels, and increased bleeding times.

Abstinence might not reverse liver damage from alcoholic hepatitis, and cirrhosis can still develop. Up to 70% of patients with alcoholic hepatitis will develop cirrhosis.^4,5 Common physical manifestations of cirrhosis include generalized weakness, fatigue, malaise, anorexia with signs of malnutrition, and increased bleeding.

Laboratory findings of elevated aspartate aminotransferase/alanine aminotransferase, gamma-glutamyltransferase, and carbohydrate-deficient transferrin also point to heavy alcohol use.⁶

Acute pancreatitis—the most common cause of hospitalization from alcohol-related GI complications—is seen more often than liver disease.⁷

Cardiovascular effects. Light to moderate drinking may be cardioprotective, but heavy alcohol consumption increases the risk of hypertension and ischemic heart disease.⁸ Incidence of hypertension is two-fold greater in individuals who have >2 drinks/day and highest in those who have >5 drinks/day.⁹

Prolonged excessive alcohol consumption is the leading cause of nonischemic dilated cardiomyopathy. Symptoms of alcoholic cardiomyopathy include fatigue; dyspnea, including paroxysmal nocturnal dyspnea and orthopnea; loss of appetite; irregular pulse; productive cough with pink/frothy material; lower extremity edema; and nocturia.¹⁰ Cardiac function can recover with early diagnosis and alcohol abstinence.¹¹

Cognitive decline. The effects of light drinking on cognitive function are controversial, but heavy consumption—especially at ≥30 drinks/week—is known to cause impairment.¹² Alcohol-dependent individuals have been shown to have impaired verbal fluency, working memory, and frontal function as is seen in Alzheimer’s disease.¹³ One possible factor contributing to cognitive dysfunction is cortical volume loss in chronic alcoholics.¹²

To read how nicotine plus alcohol increases the risk of heart disease and brain atrophy, click here.

To read about the medical complications of nicotine, click here.

Table 1

Medical complications of alcohol abuse

Cardiovascular: Cardiomyopathy; hypertension; ischemic heart disease; acute myocardial infarction
Gastrointestinal: Alcohol hepatitis; cirrhosis of the liver; pancreatitis; cancer of the mouth, larynx, pharynx, esophagus, liver, and colon/rectum/appendix
Neurologic: Wernicke’s encephalopathy; Korsakoff’s syndrome; decline in cognitive abilities; decreased gray and white matter; increased ventricular and sulcal volume; peripheral neuropathy
Other: Renal dysfunction; osteoporosis; breast cancer

Marijuana

Marijuana is the most commonly abused illicit substance worldwide, and data show an increasing prevalence of marijuana abuse and dependence (32% of U.S. 12th graders endorsed its use in 2007).¹⁴

In many populations marijuana use seems to precede use of cocaine, opioids, or other substances.¹⁵ Although the concept of marijuana as a “gateway drug” is still debated, consider the possibility that your patients who use marijuana also are using other illicit substances. In a 2004 survey, 19% of marijuana users admitted to use of other illicit drugs.¹⁶ Although many people consider marijuana a “safe” drug, it can cause adverse effects (Table 2).

Pulmonary complications. Even infrequent marijuana use can lead to burning and stinging of the mouth and throat, usually accompanied by a heavy cough. Regular users may develop complications similar to chronic tobacco use: daily cough, chronic phlegm production, susceptibility to lung infections (such as acute bronchitis), and potential for airway obstruction.^17,18

Marijuana use can double or triple the risk of cancer of the respiratory tract and lungs.¹⁹ Tetrahydrocannabinol—the active chemical in marijuana—might contribute to this risk because it can augment oxidative stress, lead to mitochondrial dysfunction, and inhibit apoptosis.¹⁹