Quick Notes about Alcohol Abuse and Drug Interactions
- Substances for which pharmacotherapy is available: mnemonic “OAT”; opioids, alcohol, and tobacco. That’s ALL.
- Substances for which Pharmacotherapy is Not Available: Cocaine, Methamphetamine, Hallucinogens, Cannabis, Solvents/Inhalants, & Fentanyl. There is NO Narcan, antidote, or anything that will stop or reverse their effects.
Alcohol Side-Effects
- Early: anxiety, irritability, tremor, HA, insomnia, nausea, tachycardia, HTN, hyperthermia, hyperactive reflexes.
- Seizures: generally seen 24-48 hours, most often grand mal.
- Withdrawal Delirium (DTs): generally between 48-72 hours, altered mental status, hallucinations, marked autonomic instability. Life-threatening/ICU admit.
Alcohol Withdrawal, CIWA (Clinical Institute Withdrawal Assessment for Alcohol) Protocol:
- Assigns numerical values to orientation, N/V, tremor, sweating, anxiety, agitation, tactile/ auditory/ visual disturbances, and HA.
- A q hour or more assessment (depends on severity and facility)
- The total score of > 10 indicates more severe withdrawal. ICU admit
- Based on the severity of withdrawal or history of previous withdrawal seizures or DTs, med therapy can be scheduled or symptom-triggered
Withdrawal Medications
- Benzodiazepines: reduce risk of SZ; provide comfort/sedation
- Anticonvulsants (Carbamazepine or Valproic acid): reduce risk of SZ and helpful for protracted withdrawal
- Thiamine supplementation: decrease thiamine deficiency risks (Wernicke/Korsakoff)
Caution Patients about Common Food–PSY Drug Interactions
- Grapefruit Juice: may alter the bioavailability of many psychotropics by inhibiting cytochrome P450 (CYP) 3A4 and 1A2 isoforms, interfering with prehepatic metabolism, and enteric absorption. Common medications affected by this interaction include alprazolam, buspirone, sertraline, carbamazepine, and methadone.1 Patient should be advised about eating grapefruit or drinking grapefruit juice as it could require dose adjustment to avoid drug toxicity.
- Table salt: Lithium is a salt, and less table salt intake could cause lithium levels to rise and vice versa. Lithium and other salts compete for absorption and secretion in the renal tubules, which are responsible for this interaction. Therefore, it is advisable to keep a stable salt intake throughout treatment. Patients should be cautioned about eating salty foods during the summer because excessive sweating could lead to lithium intoxication.
- Caffeine: is a widely used stimulant; however, it can decrease blood lithium levels and block clozapine clearance via inhibition of the CYP1A2 enzyme. Excessive caffeine intake can lead to clozapine toxicity.
- Beef liver, aged sausage and cheese, and wine contain tyramine: Tyramine is broken down by monoamine oxidase (MAO) enzymes in the body, which is inhibited by MAO inhibitors (MAOI) such as phenelzine and selegiline. A patient taking an MAOI cannot catabolize tyramine and other amines. These exogenous amines could cause a life-threatening hyperadrenergic crisis. Physicians should educate their patients about the MAOI diet and monitor adherence to the food avoidance list.
- St. John’s wort: a herb commonly used for treating mild depression. It is a strong inducer of the CYP3A4 enzyme and reduces plasma concentrations and could decrease the clinical effectiveness of aripiprazole, quetiapine, alprazolam, and oxycodone. It could interact with serotonin reuptake inhibitors causing serotonin syndrome.
- Full vs empty stomach: Food is known to affect bioavailability and enteral absorption of different psychotropics. Some medications are best taken on a full stomach and some on an empty one. For example, the antipsychotic ziprasidone should be taken with meals of at least 500 calories for optimal and consistent bioavailability. Benzodiazepines are rapidly absorbed when taken on an empty stomach.
