Alcohol and Medication

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Hello Sobertown,

Today we will delve into the world of internal interactions between alcohol and medications. Every second many thousands of billions of chemical reactions are occurring within our cells and while many of these processes may be standard operating procedure for our cells there are many reactions which involve the interaction of different chemicals which we introduce to our body. Foods interact with medications, nutritional supplements or herbals interact with other supplements, supplements interact with food, medications interact with foods and then there is alcohol, it interacts with everything. Basically our body and its normal process of dealing with that which we introduce to its system may be altered depending on the mixture of what we throw at it at the same time, basically when we drink alcohol we cause vast amounts of alterations to the way in which many foods or medicines act within our body. Sometimes these interactions are nullifying, sometimes the interactions are beneficial and sometimes the interaction is harmful and in some cases even deadly such as the interaction between alcohol and some prescription medications or even over the counter medications or herbal and nutritional supplements.

Every single day, countless individuals swallow various prescription medications down with no real thought to what it may mean in relation to their lifestyle or concurrent consumption of other substances, continuing habits outside of their medication use which may have a demonstrable effect on their health or bodily function and in some cases which may even be fatal.

Two main types of interaction occur between medication and alcohol in the body. Type one is called pharmacokinetic interaction and the other type is called Pharmacodynamic interaction. Pharmacokinetic interaction is where alcohol interferes with the metabolism of the medication and Pharmacodynamic is where alcohol enhances the effect of the medication. Both can be harmful or detrimental but through differing pathways. Pharmacokinetic interactions primarily occur within the liver where the enzymes which process the medication may be affected and sometimes involve the same enzymes as those which process alcohol. Pharmacodynamic interactions relate most often to the nervous system and are especially prevalent when we look at sedatives whose action can be pharmacodynamically increased by the use of alcohol posing a threat to the individual who may be creating an overdose of sorts in the sedative action of the medication. Types of prescription medications which interact with alcohol are numerous “antibiotics, antidepressants, antihistamines, barbiturates, benzodiazepines, histamine H2 receptor antagonists, muscle relaxants, non narcotic pain medications and anti-inflammatory agents, opioids, and warfarin. In addition, many over-the-counter and herbal medications can cause negative effects when taken with alcohol” (1)

How many of us would have used at least one of these varieties of medication legitimately and either gambled it or simply not realised that we should avoid using alcohol during the use of these drugs? Most of us would be the likely answer, while specific instruction to avoid alcohol is frequently overlooked at prescription and distribution of the drug. I should note, this information is based on research articles and is not to be considered medical advice nor will I be listing specific drug names or chemical names instead I will be listing symptoms and potential interactions with alcohol based on broad medication uses so that if you the listener feel you need further information based on your medication you can delve into this with your medical practitioner, pharmacist or other relevant professional, safe to say though, the best thing to do to avoid interactions with alcohol is do not drink alcohol, in fact how about this, the best way to be great, feel great, avoid disease and maximise the awesomeness of your life in general is to not drink alcohol. Back to it then.

Alcohol metabolism involves a process called first pass metabolism, this is as it sounds, first pass metabolism is the percentage of alcohol which is processed primarily by the liver as the first passage of alcohol laden blood filters through the liver after we drink. During this first pass only a fraction of the alcohol is able to be processed by the liver and the remainder passes through into general circulation to reach all other body tissues except for bone and fat tissue and to recirculate for processing after the first pass. First pass metabolism is usually only able to process about 10% of alcohol in the blood or less depending on multiple factors. Some research suggests that there are medications which block this first pass metabolism of alcohol, essentially if this is blocked then the level of alcohol in the blood will be higher than it normally would be had the medication not blocked the initial metabolism. The mechanism for this occurrence is primarily due to the medication having the effect of blocking the action of alcohol dehydrogenase, this is an enzyme whose action is to break down alcohol and so a medication which blocks the action of alcohol dehydrogenase logically would prevent processing of alcohol and result in the affected body becoming more intoxicated than it normally would. Medications which block alcohol dehydrogenase include aspirin and some medications which are used to treat heartburn and ulcers. This includes multiple very common medications for very common symptoms, some figures suggest 20-30% of American adults experience heartburn regularly for which many have used medication, it is worth noting different types of heartburn medication work through different actions and so not all medications treating these symptoms have this interaction with alcohol. So a quick review, some medications stop or reduce the action of the enzyme which breaks down alcohol effectively making you more drunk than you otherwise would be, and just a note, yes this is a bad thing, not a good thing.

Some medications speed up gastric emptying, this is the process whereby the stomach sends its contents to the duodenum which is the first section of the small intestine after the stomach, it is here that the surface area increases and alcohol can be absorbed into the blood more rapidly, so a medication which increases gastric emptying can increase the rate of alcohol entering the blood and as such this causes the first pass metabolism to be less effective at eliminating alcohol from the blood also, creating a greater level of intoxication for the same amount of alcohol consumed. Medications which cause increased gastric emptying include medicines aimed at stomach problems such as GERD (Gastroesophageal-Reflux-Disease) and some anti-biotic medications. When I attended high school and university it was often a brag to suggest you were sick and had been prescribed antibiotics and that you were still going to drink because you were such a fucking legend and didn’t care that you were supposed to abstain from alcohol while on the medication, what a legendary act that was, what a bunch of dick heads we were, I digress. So it would seem based on some research that yes, consuming alcohol while taking some forms of antibiotics, not all, but some can cause you to become more intoxicated than usual due to increased gastric emptying which reduces the efficacy of first pass liver metabolism of alcohol. In addition to this, animal studies have found that rats which were given anti-biotics which reduced bacteria in the colon showed reduced elimination of alcohol and if this result were to be the same in humans then anti-biotics would have the effect of reducing alcohol processing ability in the body potentially through another mechanism secondary to increased gastric emptying. Both result in a reduced capacity for the body to clear alcohol once consumed. This to reiterate is bad.

At this point in the article we need to discuss the differences between moderate and heavy drinkers, in moderate drinkers almost all of the alcohol should be processed in the liver by the enzyme alcohol dehydrogenase however in heavy long term drinkers there is sometimes a difference in enzyme processing of alcohol. There is another enzyme called cytochrome P450 which is actually a system of two enzymes which can potentially metabolise alcohol as well, it can also metabolise acetaldehyde, the breakdown product of alcohol and can break down the pain medication acetaminophen, the antibiotic isoniazid, and the barbiturate phenobarbital (1). Due to this ability the cytochrome p450 enzyme plays a major role in medication - alcohol interactions. Back to the difference between moderate and heavy drinkers, as stated moderate drinkers use alcohol dehydrogenase to process alcohol however in heavy drinkers one of the enzymes which forms the group of cytochrome p450 enzymes can be increased in its activity by ten times the normal level meaning this is then processing alcohol at an increased rate to what it should be. What this change in enzyme activity does in the heavy drinker is that it means two things, one is that this means the heavy drinker WHEN SOBER processes many types of medications at an increased rate making these medications less effective BUT then when the heavy drinker is DRUNK or DRINKING these medications breakdown becomes slowed because the overactive enzyme is then essentially bogged down processing alcohol when alcohol dehydrogenase should be but is not, and the medication is not processed. This is a bad outcome either way, drugs are designed and prescribed based on normal operating conditions within a body, based on standards and not based on the fact that in heavy drinkers depending on whether they are drinking or sober the medication may either be broken down too rapidly or too slowly. Both of these differences can have very negative or even fatal effects whereby the individual might have minimal medication effect where it is needed which is dangerous OR may have slowed breakdown causing a potential increase in the drug remaining in a system and leaving the potential for accumulation or overdose. As I said, both are poor outcomes. What this outlines is that the question of drinking alcohol and medication does not simply come down to avoiding alcohol at the time of taking the medication and expecting everything will be fine if you do, what this states is that long term changes due to drinking in-fact cause alteration to your enzyme actions which make it dangerous or ineffective to use certain medication whether drinking or sober, your long term drinking could be preventing your medication from working. On this, firstly, our medical professionals very much need to be aware of these points, I know this is a small sample size but I asked two medical doctors personally did you know this, they both did NOT know of this potential enzyme adaptation and I spoke to a pharmacist also asking if they convey this information to people, they do NOT convey this to people because the drugs having these effects relevant to them are numerous. The problem with drinking causing the effect of future poor processing of some medications is that for medical doctors or pharmacists to be able to safely prescribe and distribute medication knowing it will have the desired effect they would have to know who of their patients and customers are heavy drinkers and potentially at risk and heavy drinkers can be the most secretive, deceptive concealers of their habits even when they desire not to be. Just a point here, look your doctor in the eye and be honest with them and yourself about your levels of alcohol consumption, if you don’t, they can not make the best decisions for you and can not prescribe medication safely. If you drink at unsafe levels and tell them and they say this isn’t a problem, hey, maybe find a new doctor because it is and research is vast in showing this fact.

Just when you think there can’t be any further mechanisms of interaction between alcohol and medications, think again. We each have a basal metabolic rate, this is the amount of calories we require daily to sustain, well, life processes. Our metabolic rate also dictates factors such as breakdown of medications, when we drink alcohol our metabolic rate is altered and it is slowed. This may have the effect in some people, especially those with a low metabolic rate to begin with of reducing medication processing and in turn having potentially harmful effects.

When we metabolise alcohol, the alcohol is converted to acetaldehyde (a baddie, check out my previous article on ethanol and acetaldehyde), the acetaldehyde is broken down by an enzyme called aldehyde dehydrogenase 2 at low levels and when acetaldehyde reaches high levels another enzyme called aldehyde dehydrogenase 1 becomes active and breaks it down also. Acetaldehyde accumulation in the body is bad news but among other things it causes the individual to become very flushed red involving facial flushing and often nausea. Approximately 40% of Asians lack aldehyde dehydrogenase 2 activity due to an inactive gene and so these individuals flush when consuming alcohol as their alcohol is converted to acetaldehyde and the acetaldehyde accumulates in the body. While some people lack the enzyme activity to process acetaldehyde, some medications as a direct or a side effect prevent activity of this enzyme, in these situations it is clear we simple should not be drinking as these medications will prevent the harmful acetaldehyde from being processed in the body causing a lot of harm. One medication common name Antabuse, specifically exploits this effect with the goal of making the drinker feel basically awful when the drink and feel acetaldehyde and its effects accumulate in the body. Medications which induce a change reducing activity in the aldehyde enzymes include some diabetes medication, cardiovascular medications, non steroidal anti-inflammatories and also multiple types of anti-biotics. “These reactions not only are unpleasant but also can result in serious medical consequences. For example, flushing is associated with a widening (i.e., dilation) of the blood vessels, low blood pressure, and rapid heartbeat, all of which can be dangerous in patients with coronary artery disease” (1).

Alcohol reduces the liver’s ability to eliminate various substances from the body. Alcohol affects the livers redox state and reduces glutathione levels. The redox state is the concentration of two substances in the cell, NAD+ and NADH, ill spare you the full name. These are needed for the functioning of many enzymes. Alcohol being processed by alcohol dehydrogenase enzyme (remember this is the primary enzyme tasked with breaking down alcohol) causes an imbalance where it increases the level of NADH in the cells then when NADH is increased this has the effect of stimulating the generation of fat molecules interfering with the ability of other liver enzymes to break down fat molecules and produce glucose and this causes metabolic changes affecting general metabolism and function. Aside from these changes in metabolism being caused by alcohol an increase in NADH in the liver cells can prevent the production of glucuronic acid, this is an acid which needs to be attached to some medications for them to be eliminated and excreted from the body. SO a quick summary of this information, drinking causes an imbalance to the redox state preventing proper function of enzymes which are needed to process medications as well as changing metabolism due to increased production of fat molecules and prevents production of an acid needed to excrete some medications. Glutathione is an antioxidant which prevents some reactive molecules from damaging the cells. Alcohol and some medications can cause reactive oxygen species which cause oxidative stress within cells so while increased oxidative stress occurs due to some medications and alcohol to compound this problem alcohol also reduces glutathione levels especially within the mitochondria of cells (which is the cells power plant) and since glutathione is a substance whose action is to reduce oxidative stress causing a doubling up of allowed cell damage.

SO far we have primarily discussed the pharmacokinetic interactions, now to pharmacodynamic interactions. When pharmacodynamic interactions occur the action is not through alteration of enzyme function as we have previously covered but though an addictive effect which is primarily through action on the central nervous system. When this occurs the alcohol use increases the drug effects without actually changing its concentration in our blood. Some medications in these instances act on cell receptors which are the same as the receptors influenced by alcohol. Anti-depressants are a class of medication of which some specific types have an interactions with alcohol especially atypical anti-depressants. Anti-depressants vary in their activity with some having a sedative effect and some an excitatory effect, medications with a sedative effect will interact with alcohol by having an enhanced level of sedation to that which is desired. Some atypical anti-depressants also act in a way such that they can induce severe high blood pressure when consumed with tyramine, tyramine is present in red wine and so people using these forms of medications should absolutely avoid red wine. Antihistamines can have a sedative effect, drowsiness and low blood pressure as side effects, these medications can act in a pharmacodynamic way with alcohol whereby the sedation is increased potentially dangerously. Barbiturates are sedative, sleep inducing medications, some barbiturates activate the same molecules in the nervous system as alcohol enhancing the sedative side effects which can be very harmful or deadly as the severity of the effect is largely unknown and variable depending on alcohol consumption levels and the individual. Benzodiazepines have a hypnotic effect and their effects are also exacerbated by alcohol use, aside from this both alcohol and benzodiazepines have been shown to have the effect of impairing memory and as such they synergistically increase this effect when used in conjunction with one another and this is how the effect has terribly been manipulated in date rape situations whereby specific benzodiazepines and alcohol are mixed together to cause severe sedative and memory affecting results. Muscle relaxants when taken with alcohol can create a reaction with a narcotic like effect, a very undesirable one whereby extreme weakness, agitation and confusion can occur among other side effects. Some anti-inflammatories accompany an increased risk of ulcers when taken with alcohol. Aspirin and ibuprofen cause increased bleeding when taken with alcohol. Acetaminophen can have toxic effects on the liver when taken with alcohol. Opioids and alcohol taken together have a distressingly increased sedative effect and can be lethal as together they can the cough reflex and breathing functions causing people to be at risk of having things stuck in the airways and not being able to clear them as well as simply being unable to breathe. Warfarin is an anti-coagulant whose desired effects are diminished by alcohol in even small quantities and allows increased bleeding.

Quote: “Pharmacodynamic interactions can occur with intermittent alcohol consumption and even after a single episode of drinking” (1).

Over the counter and herbal products also have wide and varied interactions with alcohol. Quote: “Organic substances from plants. Herbal medications currently are widely used, and many people assume that because these products are “natural,” they also are safe to use. This assumption may not always be correct, however. For example, chamomile, echinacea, and valerian commonly are used as sleep aids, and like prescription and OTC products that cause sedation, these herbal products may produce enhanced sedative effects in the CNS when combined with alcohol. In addition, liver toxicities caused by various natural products have now been identified (Heathcote and Wanless 1995), and their combination with alcohol may enhance potential adverse effects”. (1).

Some health conditions should have particular attention payed to them with regards to the need to avoid alcohol consumption. Diabetes: Alcohol consumption can lead to even higher or lower levels of blood glucose depending on other factors. Hyperlipidaemia: This is increased levels of fat molecules in the blood which alcohol consumptions further increases and worsens. Hypertension: Alcohol causes dose dependant increases in blood pressure and as such is a significant risk in those with high blood pressure. Hepatitis C infection: Alcohol can increase the levels of liver damage in hepatitis C to a severe or fatal level.

When I was young I spent plenty of time listening to a band named static-X, in 2014 I heard the news that the front man Wayne Static had died, this was very sad news to me, I had spent many hours listening to this man and his band produce their particular form of art. Wayne Static died through combining prescription medications with alcohol and had ceased using any recreational drugs years prior. Static is one of many, many individuals who lost their life when they mixed medication with alcohol use and a very large number of noteworthy and famous individuals have left us in this same way.

Sobertown, this is sobering. The more we peek behind the curtain and look into the physiology of what alcohol does to us the more shocking it truly is. I can not believe incredibly broad nature of the damage alcohol consumption causes at both a moderate levels but especially high level of use, and high levels are truly easy to reach. Sobertown, this shit is awful, no more heads in the sand pretending, this shit is just terrible. Please, if you are still drinking be honest with your practitioners about your drinking, seek help and if you are using any medication and drinking then as a general rule do not simply expect there to be no interaction between the two which could potentially cause you real harm, the interactions between alcohol and medications are vast and common and alterations in medication processing may even be present during sober periods due to alcohol induced changes to the body. The fact is almost all varieties of medication include some or many specific medications which have negative interactions with alcohol and these interactions can go both ways, they can dangerously increase medication action or they can nullify its effects making the medication effectively useless. Many modes of interaction occur also, we covered increased gastric emptying, reduced first pass metabolism, prevention of enzyme function, change in metabolism and reduction in anti-oxidant levels as well as dangerously adding to sedative effects or causing failure of choke reflexes and even respiratory function among others leading to outcomes such as liver toxicity, harm through lack of medication or overdose and even death. This is broad, real and relevant Sobertown.

I hope this information helps you to see the internal nature of alcohol and the way that is affects our body and organs with its broad firebombed napalm effect and how it can interact with medications to do very real harm to your body.

Thanks Sobertown,

The Sobertown Blog articles and recordings are created as a means of assisting others in achieving and maintaining sobriety and freedom from alcohol. Experiences, entries, research and article content are that of the author and should be applied in a safe manner deemed best by the reader and applied safely, if relevant, with medical oversight. This is not medical advice and the author is not a medical doctor. No advice within is based on or crosses over with the authors profession or professional opinion as an AHPRA registered allied health practitioner or FA registered exercise professional.

REFERENCE

(1): Weathermon R, Crabb DW. Alcohol and Medication Interactions. Alcohol Research and Health. Taken from https://pubs.niaaa.nih.gov/publications/arh23-1/40-54.pdf on 12/10/2021.