Friday, March 8, 2013

Alcohol: The Elephant in the Pain Clinic

Alcohol DeathWith all the angst these days about prescription drug abuse, researchers, government agencies, and the public are overlooking (or ignoring) a much larger problem: alcohol. Worldwide, the use, misuse, and abuse of alcohol — and associated burdens of disease and injury — have reached pandemic proportions. And, alcohol use may be one of the greatest factors hindering effective and safe pain management, as well as a significant contributor to overdoses and deaths among patients with pain.

Unhealthy alcohol consumption is a global problem — the 3rd leading cause of disease and injury, after tobacco smoking and high blood pressure — as reported by the Centre for Addiction and Mental Health (CAMH) in an advance online edition of the journal Addiction [Shield et al. 2013]. This latest research was part of the latest Global Burden of Disease study, which examined a total of 241 countries and territories.

“Alcohol consumption has been found to cause more than 200 different diseases and injuries,” said lead author of the study, Kevin Shield, in a news release [here]. “These include not only well-known outcomes of drinking such as liver cirrhosis or traffic accidents, but also several types of cancer, such as female breast cancer.”

Some findings of the study, which estimated alcohol consumption by country or region, include:

  • North Americans in general, and Canadians in particular, drink more than 50% above the global average, and show a more detrimental drinking pattern than most European Union countries, with more bingeing.

  • Drinkers in Europe (Eastern and Central) and sub-Saharan Africa (Southern and West) are the world’s heaviest consumers of alcohol, on average.

  • People in Eastern Europe and Southern Sub-Saharan Africa consumed alcohol in the unhealthiest manner, as they frequently consumed large quantities, drank to intoxication, engaged in prolonged binges, and consumed alcohol mainly outside of meals.

  • People in North Africa, the Middle East, and South Asia consumed the least amount of alcohol and had the greatest numbers of life-time abstainers.

Overall, roughly 40% of the world's adult population drinks alcoholic beverages and the average consumption per drinker is approximately 17 liters (≈4.5 US gallons) per year. About 46% of all adults are life-time abstainers and 14% are former drinkers; however, the prevalence of abstention, level of alcohol consumption, and patterns of drinking vary widely across regions of the world.

In a separate international study — considering risks of various drugs in terms of physical, psychological, and social harms — alcohol topped the list of 20 hazardous substances of abuse [see UPDATE here]. It was judged as most damaging to the individual and others overall; nearly a third higher in scoring than the next two most harmful drugs, heroin and crack cocaine.

According to government survey data, in the United States more than 15 million persons abuse or are addicted to alcohol, and another 3+ million have substance-use disorders involving both alcohol and illicit drugs, [see UPDATE here]. These figures, combined with the 58 million persons who are occasional binge drinkers and 17 million reporting regular heavy drinking, amounts to about 93 million persons with alcohol-use issues of some concern.

In a recent Pain-Topics UPDATE [here], we noted that in the U.S. there were 40,393 alcohol-induced deaths in 2010, or 5% more than overdose deaths attributed to all other drugs. That year, there were 15,990 deaths due to alcoholic liver disease alone, almost matching the 16,651 deaths associated with all prescription opioids. Yet, deaths associated with alcohol do not get anywhere near the mass media and other attention devoted to opioids and other Rx drugs.

There were 38,329 non-alcohol-drug overdose deaths in the U.S. in 2010 and the vast majority involved multiple agents, often including prescription drugs used in pain management. Opioid analgesics as a sole agent were reported in only 13% of all drug deaths. Frequently, alcohol is present to some extent in opioid and other drug-related deaths, but may go unreported as a causative or even a contributing agent in coroner or medical examiner records.

Alcohol used as a strategy for self-managing pain, usually in conjunction with prescribed medications, has been reported in 12% to 28% of patients being treated for pain:

  • In one study, described in an UPDATE [here], it was found that 12% of patients being treated for pain consumed alcohol along with prescribed opioids and/or sedatives. These persons were more likely to be male, prescribed lower daily opioid doses, and unexpectedly had lower average pain intensity levels and tended toward being less depressed.

  • Another large study, interviewing more than 4,300 adults with various types of pain [see UPDATE here], found that more than a quarter of participants (28%) misused alcohol as a pain management strategy. Such use was more frequent in men than women, in non-Hispanic whites, in younger persons, and among those with more education and making greater income.

  • In a study of 343 U.S. veterans being treated for pain, more than 35% reported using an “aberrant” pain management strategy, including the use of alcohol (24%), street drugs (11.7%), and/or sharing prescriptions (16.3%) [Goebel et al. 2011]. Having a substance use disorder and poorer mental health were significantly associate with alcohol misuse for pain.

Prescription drugs combined with alcohol are not the only concern. The popular OTC analgesic acetaminophen (or, paracetamol) is the leading cause of acute liver failure in the U.S., contributing to more than 30,000 hospitalizations annually [see UPDATE here]. The hepatotoxicity of acetaminophen is greatly increased in persons who regularly consume alcohol, and this is a root cause of many accidental acetaminophen poisonings.

Some experts in the field have proposed that there is a neurobiological linkage between alcohol dependence and a diverse spectrum of pain conditions [Egil et al. 2012]. They propose a model whereby episodes of alcohol intoxication and withdrawal interact with neural mechanisms involved in chronic pain states, along with related anxiety and depression. In this regard, for example, there is some limited clinical research evidence that aberrant alcohol consumption may be associated with the development of complex and chronic lower back pain [Ferreira et al. 2012].

Overall, the prevalence of alcohol use and misuse among persons with pain presents a significantly large population at high risk for adverse interactions — including potential overdose and death — when these persons are treated with a variety of medications for pain and associated symptoms. Still unknown is the number of casual or social drinkers who increase their alcohol intake to cope with the discomfort and stress of pain, thereby risking adverse consequences when alcohol is combined with their medications.

Healthcare providers need to be aware of (and test for) their patients’ use of alcohol to any extent concomitant with pain medications, assess patients for psychosocial impairment due to alcohol, counsel them on the hazards of alcohol use during pain therapy, and when appropriate make adjustments to pain treatment or refer patients to outside support services. At the same time, government agencies and policy makers need to recognize the major role alcohol plays in overdoses and deaths that have been largely attributed solely to other drugs.

Many prescription medications that are effective and safe when prescribed properly and used as directed — eg, opioids, benzodiazepines, sedatives, and other CNS or psychotropic agents — may become poisonous and highly lethal when combined with alcohol. The so-called epidemic of analgesic drug overdoses and deaths will not be resolved, or even diminished, without thoroughly educating persons of all ages regarding the potentially severe consequences of combining even relatively small amounts of alcohol with other drugs.

> Egli M, Koob GF, Edwards S. Alcohol dependence as a chronic pain disorder. Neurosci Biobehav Rev. 2012;36(10):2179-2192 [
> Ferreira PH, Pinheiro MB, Machado GC, Ferreira ML. Is alcohol intake associated with low back pain? A systematic review of observational studies. Man Ther. 2012(Nov 9); online ahead of print [
> Goebel JR, Compton P, Zubkoff L, et al. Prescription sharing, alcohol use, and street drug use to manage pain among veterans. J Pain Symptom Manage. 2011;41(5):848-858 [
> Shield K, Rylett M, Gmel Gs, et al. Global alcohol exposure estimates by country, territory and region for 2005 – a contribution to the Comparative Risk Assessment for the 2010 Global Burden of Disease Study. Addiction. 2013(Mar 4);online ahead of print [

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