New Year’s Kisses & Pain Medication Don’t Go Well With Alcohol

You did it! You survived Christmas! We hope you had an excellent time getting together with friends and family as well as having a lovely time at all your Christmas parties. We also hope our blog post, “’Tis the Season! How Alcohol Can Interact with Your Pain Medications” brought you some solace in understanding how alcohol may not be your best drink of choice if taking a pain medication. Given that New Year’s Eve is today where tonight is a night that is all too familiar for partying with alcohol, we would like to go a little deeper into how alcohol is processed in the body as well as provide three major classes of pain medications and their specific interaction with alcohol. Overall, we hope that this furthers your understanding of the medications you may be taking and how alcohol can leave you with dire side effects.

Alcohol Ingestion, Absorption, & Distribution in the Body

When alcohol is ingested through the mouth, a small amount is immediately broken down in the stomach. Most of the remaining alcohol is then absorbed into the bloodstream from the gastrointestinal tract where alcohol circulating in the blood is transported to the liver, where several enzymes break it down. The activities of these enzymes may vary from person to person, contributing to the observed variations in alcohol elimination rates among individuals. While in the liver, alcohol is metabolized by specific enzymes into acetaldehyde. Acetaldehyde is a toxic substance that may contribute to many of alcohol’s adverse effects (several medications can inhibit these reactions thereby inducing a flushing reaction in all people who consume alcohol after taking those drugs). The acetaldehyde is then transported out of the liver and into the blood system where it is distributed throughout the body. The takeaway message here is: the stronger your New Year’s Eve cocktail, the higher the concentration of alcohol will remain in your circulatory system.

Specific Medication-Alcohol Interactions

Interactions between alcohol and medication can occur in a variety of situations that differ based on the timing of alcohol, drug consumption, gender, weight, and age. Many classes of prescription and non-prescription pain medications can interact with alcohol. The drug classes we would like to discuss are opioids, benzodiazepines, and over-the-counter (OTC) anti-inflammatory agents.

  1. Opioids. Opioids are agents with opium-like effects (e.g. sedation, pain relief, and euphoria) that are used as pain medications. Alcohol enhances opioids’ sedating effects and may cause extreme drowsiness. Consuming large amounts of alcohol and opioids are potentially lethal because they can reduce the cough reflex and breathing functions; as a result, you are putting yourself at risk of getting foods, fluids, or other objects stuck in your airways. Certain opioid pain medications (e.g. codeine, propoxyphene, and oxycodone) are manufactured as combination products containing acetaminophen. These combinations can be particularly harmful when combined with alcohol because they provide “hidden” doses of acetaminophen (see below).
  2. Benzodiazepines. This class is categorized as sedative-hypnotic agents and act through the same brain molecules, as does alcohol. Studies have shown that concurrent consumption of moderate amounts of alcohol while taking a benzodiazepine can cause synergistic sedative effects, leading to substantial central nervous system impairment. It is worth noting that benzodiazepines can impair memory, as can alcohol. Consequently, the combination of these medications with alcohol may exacerbate this memory-impairing effect.
  3. Non-Steroidal Anti-Inflammatory Drugs (NSAID’s). Many people frequently use NSAID’s (aspirin, acetaminophen, ibuprofen, naproxen, indomethacin, and diclofenac) for headaches, minor aches & pains, arthritis, and other disorders of the muscles and bones. Nonetheless, NSAID’s have been associated with an increased risk of ulcers and gastrointestinal bleeding. Alcohol may exacerbate these risks by enhancing the ability of these medications to damage the lining of the stomach. Aspirin, indomethacin, and ibuprofen may cause prolonged bleeding by inhibiting the function of certain blood cells involved in blood clot formation, which is enhanced by concurrent alcohol use. Furthermore, people should be aware that over-the-counter combination cough, cold, and flu medications might contain aspirin, acetaminophen, or ibuprofen, all of which might contribute to serious health consequences when combined with alcohol. Also, alcohol consumption may result in the accumulation of toxic substances (i.e. acetaldehyde). Therefore, patients also using opioid-acetaminophen combination products should be cautioned about restricting the total amount of acetaminophen they ingest daily.

We understand there is quite a bit of medical terminology in each medication-alcohol interactions. In no way is anyone expected to remember all of that information; but what we would like you to remember is that alcohol consumed alongside pain medications can have disadvantageous effects on your physical, mental, and emotional state. By seeking the help of a pain management physician you have made a commitment to live a quality life free of pain, and we salute you! Undertaking activities that deviate from your goal for complete pain relief hurts not only you but also your friends and family. If you’re currently taking any of the medication we mentioned above, alcohol does not have to be in your New Years’ plans to have an excellent time. There are so many alternatives that you could opt for, which not only keep you social but also keep you on the right track for your pain therapeutic regimen. So from us here at Pain Consultants of Arizona, we all wish you and your family a happy New Year! What is an alternative that you turn to rather than alcohol at a party? Let us know and see you in 2017!

Tags: alcohol, pain management, medications, new years, opioids, nsaids, anti-inflammatory

References:

  1. Berkow R, ed. Drugs and the liver. In: The Merck Manual. 16th ed. Rahway, NJ: Merck & Co., Inc;1992:781.
  2. Emanuele, N.V., al. Consequences of alcohol use in diabetics. Alcohol Health & Research World 22(3):211–219, 1998.
  3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118–145. e10.
  4. Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125(1–2):8–18
  5. Kuffner EK, Dart RC, Bogdan GM, Hill RE, Casper E, Darton L. Effect of maximal daily doses of acetaminophen on the liver of alcoholic patients. A randomized, double-blind, placebo-controlled trial. Arch Intern Med 2001;161:2247-2252.
  6. Levitt, M.D., al. Use of a two- compartment model to assess the pharmacokinetics of human ethanol metabolism. Alcoholism: Clinical and Experimental Research 22:1680– 1688, 1998
  7. Manyike PT, Kharasch ED, Kalhorn TF, et al. Contribution of CYP2E1 and CYP3A to acetaminophen reactive metabolite formation. Clin Pharmacol Ther 2000;67:275-282.
  8. Nemeroff CB, DeVane CL, Pollock BG. Newer antidepressants and the cytochrome P450 system. Am J Psychiatry. 1996;153(3):311–320.
  9. Niemela, O., al. Early alcoholic liver injury: Formation of protein adducts with acetaldehyde and lipid peroxidation products, and expression of CYP2E1 and CYP3A. Alcoholism: Clinical and Experimental Research 22:2118–2124, 1998.

‘Tis the Season! How Alcohol Can Interact With Your Pain Medications

Introduction

It’s that time of year again where we spend time with families, coworkers, and friends all throughout this Christmas Season. We will assume that you will be attending at least one Holiday function where more than likely alcohol will be present. So, in light of the Holiday spirits (no pun intended), we would like to discuss why alcohol might not be your best beverage of choice if you are currently taking any medications. Alcohol is a big part of many types of holiday celebrations, but unfortunately, alcohol can interact in less than stellar ways with pain medications. Interactions between alcohol and a medication can occur in a variety of situations that differ based on the timing of alcohol, medication consumption, gender, weight, and age. Many classes of prescription and non-prescription pain medications can interact with alcohol. For example, opioids, muscle relaxants, narcotics, benzodiazepines, over-the-counter (OTC) anti-inflammatory agents, and antidepressants all interact with alcohol in a specific manner than can wreak havoc on your body. Alcohol can cause extended release formulations of pain medications to release all at once, and some short-acting formulations to release more quickly than normal, a phenomenon called “dose dumping.” Dose dumping can lead to rapidly increased levels of the medications in the system, resulting in overdose and possibly death. So let’s jump right into discussing alcohol & pain medication interactions.

Acetaminophen: A Real Life Example of a Drug-Alcohol Interaction

Let’s use drugs containing acetaminophen as an example. Certain opioid pain medications (e.g. codeine, propoxyphene, and oxycodone) are manufactured as combination products containing acetaminophen. These combinations can be particularly harmful when combined with alcohol because they provide “hidden” doses of acetaminophen that can cause drowsiness, sedation, and decreased motor skills. Acetaminophen also increases gastric emptying, leading to faster alcohol absorption in the small intestine; may also inhibit important gastric hormones. Alcohol enhances acetaminophen metabolism into a toxic product, potentially causing liver damage.

Conclusion

You might be thinking, “ Well, I do take a medication but this is only for people who drink a lot of alcohol”. Unfortunately, this is not the case. In fact, most of the data on alcohol-medication interactions was done on those who drank moderate levels of alcohol. Thus please be aware that any level of alcohol may interact with your medications. As alternatives to alcohol try virgin cocktails, non-alcoholic beer, sparkling non-alcoholic cider, sparkling water, and eggnog without the alcohol. All are festive, and allow you to blend in with the crowd. Nonetheless, if you do drink, please make sure to have a ride. Alcohol-medication interactions can exacerbate medication’s adverse side effects (drowsiness, dizziness, euphoria, etc.). We hope this in-depth explanation of the effects of alcohol will help you in making the decision about drinking. Have a blast at all your holiday parties this year and try to play it safe if you are taking any sort of medicines. From all of us here at Pain Consultants of Arizona, we wish you and your family a Merry Christmas!

Tags: alcohol, pain management, medications, Christmas, opioids

References:

  1. Berkow R, ed. Drugs and the liver. In: The Merck Manual. 16th ed. Rahway, NJ: Merck & Co., Inc;1992:781.
  2. Emanuele, N.V., al. Consequences of alcohol use in diabetics. Alcohol Health & Research World 22(3):211–219, 1998.
  3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118–145. e10.
  4. Jones JD, Mogali S, Comer SD. Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend. 2012;125(1–2):8–18
  5. Kuffner EK, Dart RC, Bogdan GM, Hill RE, Casper E, Darton L. Effect of maximal daily doses of acetaminophen on the liver of alcoholic patients. A randomized, double-blind, placebo-controlled trial. Arch Intern Med 2001;161:2247-2252.
  6. Levitt, M.D., al. Use of a two- compartment model to assess the pharmacokinetics of human ethanol metabolism. Alcoholism: Clinical and Experimental Research 22:1680– 1688, 1998
  7. Manyike PT, Kharasch ED, Kalhorn TF, et al. Contribution of CYP2E1 and CYP3A to acetaminophen reactive metabolite formation. Clin Pharmacol Ther 2000;67:275-282.
  8. Nemeroff CB, DeVane CL, Pollock BG. Newer antidepressants and the cytochrome P450 system. Am J Psychiatry. 1996;153(3):311–320.
  9. Niemela, O., al. Early alcoholic liver injury: Formation of protein adducts with acetaldehyde and lipid peroxidation products, and expression of CYP2E1 and CYP3A. Alcoholism: Clinical and Experimental Research 22:2118–2124, 1998.

Why Would I Need To Take A Drug Test For Pain Management?

It’s never a favorable feeling when you feel disconnected from your healthcare management. Unfortunately, there still exists a gap between the treatment/procedures a given patient receives and the patient education and engagement of those treatments. One example that we would bring more insight to is why your pain management doctor may ask for you to provide a urine-drug test. It has been estimated that 20% patients with non-cancer pain or pain-related diagnoses are prescribed opioids in office-based settings. From 2007–2012, the rate of opioid prescribing has steadily increased among specialists more likely to manage acute and chronic pain. If you are currently taking an opioid or certain non-opioid pain medications, your doctor may at some point request you provide a urine drug test. So let’s quickly detail what the urine-drug test is and then provide some reasons why it is important to your pain management treatment.

What Is A Urine-Drug Test?

You would be correct in assuming this procedure tests drug levels in the body through a urine sample. But let’s get a little more technical as to the mechanics of a urine-drug test. Once a urine sample is collected, it is sent to a certified laboratory where the sample is analyzed using laboratory methods known as immunoassay and chromatographic methods (e.g., liquid chromatography with mass spectrometry detection) to yield high detection sensitivity and drug specificity. The test will also determine the concentration of a given medication; the higher the dose of a medication, the higher the concentration will appear on the test. The results are then shipped back to your physician where they will overview the results with you as well as determine what the next step should be in your pain management treatment.

Why Is A Urine-Drug Test Being Done?

There are three main reasons why a urine-drug test is completed for a clinical setting. In general, the test will provide objective evidence and documentation that you are properly taking your medication, and not taking any substance that you are not prescribed. It’s a tool that physicians use to keep you safe, other patients safe, and themselves safe.

  1. Allows your physician to determine the right dose for your medication. When a medication is ingested and absorbed into the blood system, it will travel to the liver where specific metabolic enzymes will convert the medication into its metabolites. These metabolites are what are tested in a urine-drug test. Our DNA dictates as to how [active] our liver enzymes are at metabolizing a drug. Some people are slow metabolizers, meaning it takes longer to form a metabolite; some people are fast metabolizers, meaning a metabolite is formed much more rapid when compared to a normal metabolizer. Let’s use dilauded as an example. Two people are both given a 1mg dose of dilauded. One patient is a slow metabolizer where a lower concentration of dilauded’s metabolites will appear in a urine-drug test when compared to a patient who is normal. Because of a lower concentration of the metabolites, this patient is not receiving the full analgesic-effect of this dose. Thus the physician may determine to either increase the dose or alternate to a different medication.
  2. Determines If You Are Correctly Taking A Drug & Being Honest About It. Misuse of drugs can be accidental or intentional – unfortunately, it can also be fatal. A urine-drug test will report whether you are taking a medication at the prescribed dose and at the proper time. Your physician may decide to remove this medication from your drug therapy or change the dose depending on why the drug was not originally being taken properly.
  3. Determines If You Are Taking Any Illicit or Other Non-Prescribed Drugs. One chronic pain study found that many patients fail to report their drug use, especially illicit drugs. Abusing an illicit or non-prescribed drug can also be fatal, depending on the drugs involved. If potentially fatal drugs are being taken, your physician will do what they can to minimize the risk, and there is no way of telling by looking at a person what the risk for that person is. Because the potential consequences of medication abuse are so serious, i.e. death, your doctor may be required to test a patient who is prescribed an opioid.

We would like to point out that due to the advancements of technology, your doctor may choose to do a saliva, buccal cheek swab, or hair follicle test rather than a urine- test. Although these are different methods, the test still provides the same results so do not be too concerned with the method of testing your doctor may chose to do. Drug testing for opioid or other pain drugs is an important tool that healthcare providers can use to assess drug therapy treatment compliance and opioid misuse; however, no diagnostic test is perfect. It is sometimes possible to “game” the system, and avoid being detected for a while, although who are you really helping with that strategy? If you have trouble managing your medications or your pain, or you are using illegal or non-prescribed drugs, talk to your provider and get help! You don’t have to go it alone.

Tags: urine-drug test, medication, opioids, pain management, healthcare, technology

References:

  1. Centers for Disease Control and Prevention. Vital Signs: Variation Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines — United States, 2012. MMWR 2014; 63(26):563-568.
  2. Cone EJ, Caplan YH. Urine toxicology testing in chronic pain management. Postgrad Med. 2009;121(4):91–102
  3. Daubresse M, Chang H, Yu Y, Viswanathan S, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000 – 2010.  Medical Care 2013; 51(10): 870-878.
  4. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS. Validity of selfreported drug use in chronic pain patients. Clin J Pain. 1999;15(3):184–91.
  5. Frenk SM, Porter KS, and Paulozzi LJ. Prescription Opioid Analgesic Use Among Adults: United States, 1999 – 2012., National Center for Health Statistics Data Brief, February 2015.
  6. Romano G, Barbera N, Lombardo I. Hair testing for drugs of abuse: evaluation of external cocaine contamination and risk of false positives. Forensic Sci Int. 2001;123(2-3):119–129.

4 Reasons Nutrition Is Vital When Living with Osteoarthritis

Introduction

Did you know a study done in 2005 reported that approximately 26.9 million American adults suffer from osteoarthritis where this conservative number of people suffering from this degenerative arthritic joint disease has only exponentially increased over the years? But why is that? Studies have shown that arthritis is twice as high in obese people as in those with a healthy weight since the extra weight puts pressure on your joints. Thus is it due to the rise in obesity? Maybe partly due to people retiring at a much later age putting more stress on their joints and bones? In this post we will not speculate as to “what” is causing an increase in osteoarthritis, but rather “how” osteoarthritis symptoms can be reduced and in some cases, prevented. If you suffer from osteoarthritis, then you are well aware that it is a disease where a loss of cartilage in the joints can bring severe inflammation and excruciating pain. Thus we would like to provide you with some handy nutrition and exercise tips (and why they are important) to help you manage this condition to live an enjoyable and healthy life. Nutrition is important to osteoarthritis patients for even small nutritional changes may reduce pain associated with osteoarthritis. However, it is in your best interest to consult your healthcare provider first before implementing any of these tips.

Nutrition Can Keep Your Bones & Cartilage Strong

Eating a sensible diet, focused on musculoskeletal rigidity, may aid in keeping your bones and cartilage durable. For example, studies have shown that foods high in antioxidants as well as in glucosamine may help reduce, if not repair, tissue damage caused by osteoarthritis. For adding antioxidants to your diet, try to add fruits and vegetables; for example, blueberries and leafy greens. For glucosamine, try to incorporate shellfish such as crab, lobster, or shrimp.

Nutrition Can Control Inflammation

Controlling your diet can help to control general inflammation in the body. Certain foods such as sugary foods, fried foods, and refined foods have been shown to increase inflammation in the body. Do your best to reduce if not avoid foods of this nature. On the contrary, numerous studies have also documented many foods that have anti-inflammatory effects. Foods high in omega-3 fatty acids (e.g. salmon & tuna), as well as spices such as ginger and turmeric, may help in reducing inflammation. It is important to note that [fat] is not a bad thing to have in your diet. To contrary belief, healthy fats can actually aid in weight loss. Just be sure the foods you choice are of the healthy-type of fat; for example, the fish we just mentioned, avocados, nut butters, almonds, and olive oil to name a few.

Nutrition Can Aid In Weight Loss

Having an appropriate weight for your body may reduce stress on your bones and joints, especially the weight-bearing joints as in your pelvis or knees. Removing excess weight from your body not only removes added stress on these joints but may also reduce pain. To lose weight, you must expend more calories (through exercise or hypo-caloric diet) than you are consuming. Thus for weight loss or weight-maintenance (if you are at an appropriate weight), eating a diet high in nutrient-dense foods will provide the right amount of calories without over consuming. Furthermore, studies have shown that people who continue to eat processed foods, fried foods, sugar and red meat are more likely to develop rheumatoid arthritis over people eating a diet of fresh fruits, vegetables, fish, and white meats.

Nutrition Can Get You Moving

Physical activity may help to maintain joint mobility where nutrition plays a vital role in how active we are. For example, the more fatty and fried foods that we eat, the more sluggish and worn-down we feel. On the contrary, eating nutrient-dense foods provides the minerals and vitamins to not only give us the ability to exercise but may also promote the motivation to exercise. This motivation in itself is significant for research has shown that 40% of women and 56% of men with osteoarthritis exercise less than 10 minutes a week, given the misconception that exercise wears down joints. In fact, physical activity may also reduce the risk of developing osteoarthritis in the first place. Frequently recommended activities are ones that put minimal stress on the body’s joints; for example, swimming and bicycling. Try to avoid intense activities that may injure or strain the joint cartilage. Exercise is beneficial when performed at a level that does not stress the joints.

We must stress how important it is to consult your doctor before implementing any of the above nutritional tips. Your healthcare provider can help you pick and choose which foods will work best for you and reducing the symptoms of osteoarthritis. We hope this quick overview of how nutrition can reverse the effects of osteoarthritis. What nutritional changes have helped reduce your symptoms of osteoarthritis? Let us know!

 Tags: osteoarthritis, nutrition, exercise, activity, inflammation, anti-inflammation, knee pain, pelvic pain, joints, obesity, diet

 References:

  1. Arita M, Bianchini F, Aliberti J, Sher A, Chiang N, Hong S, Yang R, Petasis NA, Serhan CN. Stereochemical assignment, antiinflammatory properties, and receptor for the omega-3 lipid mediator resolvin E1. J Exp Med. 2005;201:713–722. doi: 10.1084/jem.20042031.
  2. German B, Schiffrin EJ, Reniero R, Mollet B, Pfeifer A, Neeser JR. The development of functional foods: lessons from the gut. Trends Biotechnol. 1999;17:492–499. doi: 10.1016/S0167-7799(99)01380-3.
  3. Leeb BF, Schweitzer H, Montag K, Smolen JS. A metaanalysis of chondroitin sulfate in the treatment of osteoarthritis. J Rheumatol. 2000;27:205–211.
  4. McAlindon T, Felson DT. Nutrition: risk factors for osteoarthritis. Ann Rheum Dis. 1997;56:397–400.
  5. McAlindon TE, Jacques P, Zhang Y, Hannan MT, Aliabadi P, Weissman B, Rush D, Levy D, Felson DT. Do antioxidant micronutrients protect against the development and progression of knee osteoarthritis? Arthritis Rheum. 1996;39:648–656.
  6. Yelin E. The economics of osteoarthritis. In: Brandt KD, Doherty M, Lohmander LS, editor. Osteoarthritis. Oxford: Oxford University Press; 2003. pp. 17–21.