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This article was originally published in Diabetes Health in November, 2003.
Perhaps more than anyone, people with diabetes know that the motto “Just say no” often doesn’t work.
No birthday cake?
No cookies and milk with a friend?
No milkshake at McDonald’s?
People with diabetes are as susceptible as anyone to the lure of indulging in junk food. But they can also fall prey to the temptations of getting drunk, smoking cigarettes and marijuana, snorting cocaine, taking Ecstasy and shooting up heroin.
All of these substances are harmful. But just how harmful? And how do they affect blood glucose control?
The Politics and Ethics of Researching Illegal Drugs
The effects of alcohol and nicotine on diabetes are well documented. But the role of marijuana, cocaine and other illicit substances remains less clear.
Uncovering the impact of illicit drugs on blood glucose levels is a difficult task for several reasons.
Most significantly, the drugs are illegal. And that illegality sets up political, ethical and financial obstacles to conducting the kind of controlled, double-blinded studies that produce usable data.
Representatives from the U.S. National Institutes of Health (NIH), the American Diabetes Association (ADA), and the Juvenile Diabetes Research Foundation (JDRF) report that they are unaware of any such studies on the topic of illicit drug use and blood glucose control.
Nonetheless, some diabetes professionals, convinced of the need for such information, have combined their experiences, anecdotal research and knowledge about the general effects of illegal substances to reach some conclusions.
‘It’s Part of Our World’
Dr. Stuart J. Brink, senior endocrinologist at the New England Diabetes and Endocrinology Center and associate clinical professor of pediatrics at Tufts University School of Medicine in Boston, wrote about his findings in the 1987 book “Pediatric and Adolescent Diabetes Mellitus” (Year Book Medical).
“Good people,” he noted, will nevertheless sometimes “get drunk and get high. It’s part of our world, and people with diabetes do it too.” In the early 1980s, Keith Campbell, a pharmacist and diabetes educator, summarized interviews with 100 users of illicit drugs at Emory University Hospital in Atlanta, Georgia. People with diabetes certainly made up a portion of that group.
In the first of a three-part series titled “Recreational Drugs and Diabetes,” published in several medical journals in the mid-1980s, Campbell wrote:
“If a high percentage of individuals in society at large use drugs for recreational purposes, it seems logical to assume that the same would hold true for a similar percentage of patients with diabetes. This can cause a problem for the patient with diabetes, and it seems to be a subject that is difficult to discuss with the healthcare advisor. The difficulty in communication between diabetic patients and healthcare practitioners regarding recreational drug use results in a system that basically avoids the problem.”
‘Getting Stoned Is Far Safer for People With Diabetes Than Getting Drunk’
Brink agrees that alcohol and illegal drug use by people with diabetes isn’t studied or talked about enough. But the subject comes up every day in his practice, which includes more than 400 pediatric, adolescent and young adult patients. For up to 90 percent of his teen patients, alcohol and drug use is an issue, albeit mostly related to peer pressure.
“Getting stoned is far safer for people with diabetes than getting drunk, and that’s the kind of medical fact parents don’t like to hear because it sounds like you’re giving permission,” he says. “I give information, and I give choices. Ultimately, [my patients] have to decide.”
Brink notes that certain drugs can slightly raise or lower blood glucose. Uppers, for example, such as cocaine, can raise blood glucose.
Although marijuana is not considered an upper, it seems to increase blood glucose slightly.
But Brink and others have found that the actual effect of a given substance is extremely variable from person to person. In addition, the potency of illegal substances varies widely because they are manufactured illicitly, without controls or standards. Medical professionals emphasize that people with diabetes must always be sure to test blood glucose if they are using an illicit drug.
Harmful in Many Ways
“People want to know, how many drinks can I have? Or how many joints can I smoke? And is it going to kill me?” reports Campbell, who is also associate dean and professor of pharmacotherapy at Washington State University in Pullman, Washington.
“It depends on a lot of things,” he explains. “Pharmacologically, there’s really only a minor effect [of drugs on blood glucose], but the effect on the brain is the real concern.”
In fact, Campbell stresses, diminished brainpower and subsequent diabetes mismanagement are the chief culprits in pushing blood glucose way out of range.
A 1998 study published in the Archives of Internal Medicine determined that cocaine use was a risk factor for diabetic ketoacidosis, either because of its effects on counter-regulatory hormones or because of the individual’s subsequent tendency to omit insulin doses.
According to Diabetes New Zealand, a national nonprofit organization, taking street drugs or marijuana can indirectly affect blood glucose levels because of the drugs’ effect on the brain. For example, users might not recognize symptoms of low blood glucose (hypoglycemia) or might mistake such symptoms for the effects of the drug.
Marijuana might cause a user to eat more food, whereas cocaine use might result in a lowered appetite.
Ecstasy can produce seemingly boundless energy, although the user may not feel the need for rest or food-a situation that can lead to hypoglycemia.
For people with diabetes, fluctuations in the amount of food eaten or energy expended require frequent blood glucose testing and the ability to make important decisions about insulin and food intake. Illicit drugs, however, can affect an individual’s perception of reality and time as well as his or her judgment.
Despite recreational drugs’ profound impact on the brain, Brink advises users to test blood glucose often and react accordingly. He and other diabetes professionals acknowledge the irony, but stick by the advice because it’s the best they can offer if their attempts to counsel patients to avoid illicit substances don’t work.
Campbell believes that most recreational drug users are capable of diabetes management.
“Those who are experimenting and not addicted are capable of following that advice,” he says.
Some Drugs Make Complications Worse
Beyond the effect on blood glucose or brainpower, certain drugs can exacerbate diabetes-related complications.
Researchers at McLean Hospital in Belmont, Massachusetts, writing in the May 2002 issue of the American Journal of Cardiology, report that frequent cocaine use “triggers a dangerous series of events linked to risk of heart attack and stroke.” Cocaine constricts blood vessels and increases blood pressure-adding to the increased risk of heart attack and stroke that people with diabetes already face.
Alcohol: A Legal Drug
Because alcohol is legal, its effect on diabetes control, including the increased risk of hypoglycemia up to 24 hours after consumption, has been well documented.
As Richard Furlanetto, scientific director of the Juvenile Diabetes Research Foundation, observes, the effect of alcohol is easy to predict, but the extent of the effect can be more complicated.
“Everyone needs to know their own body’s reaction to alcohol,” Furlanetto cautions. “My message is to [drink] with friends, in moderation, and learn what is safe for you.”
According to Diabetes New Zealand, alcohol is the most common drug that can put you at risk of hypoglycemia because it blocks the liver’s ability to produce glycogen. Glycogen is a storage form of carbohydrate found in the liver and muscles, which can be needed to quickly raise blood glucose levels. In addition, alcohol blunts an individual’s ability to manage diabetes care and recognize hypoglycemia.
Brink argues that alcohol use is particularly dangerous for people with diabetes because of its lingering effect and its impact on the liver. Also, alcohol prevents the liver from responding to a glucagon injection, which is used to treat severe alcohol induced hypoglycemia.
“The liver gets busy” dealing with the alcohol, he explains, “and if you need it to make glycogen, you’re in deep trouble. What would be a mild hypoglycemic situation becomes the devil.”
Despite the problems, there seem to be potential health benefits associated with mild drinking for people both with and without diabetes. Some studies have shown that, in adults with diabetes, regular consumption of light to moderate amounts of alcohol is associated with reduced risk of heart disease, possibly related to an increase in HDL (“good”) cholesterol.
Some people with diabetes should not drink at all, however. This group includes individuals who also have liver disease, high triglyceride levels, pancreatitis, or heart or kidney diseases; pregnant women; type 1s who are prone to hypoglycemia; type 2s who have chlorpropamide-alcohol flush; or anyone who has suffered from alcoholism.
Alcohol - More Foe Than Friend
If you plan to drink, the American Diabetes Association (ADA) recommends that you do the following:
· Obtain your doctor’s approval
· Discuss medication interactions with your doctor
· Consume alcohol with food
· Limit your daily intake to one drink for adult women and two drinks for adult men (12 oz of beer, 5 oz of wine, or 1.5 oz of distilled spirits), since the specific effects of alcohol on people with diabetes are related to how much they consume
· Avoid mixes containing sugar
· Test your blood glucose regularly and often
Jean Betschart Roemer, MSN, RN, CPNP, CDE, author of “In Control: A Guide for Teens With Diabetes” (Wiley, 1995) and “Type 2 Diabetes in Teens: Secrets for Success” (Wiley, 2002), adds this advice:
· Always wear your medical ID
· Sip your beverage slowly
· Make your own drink so that you know what it contains
· Test your blood glucose especially often if you are exercising or dancing
· Set an alarm and check your blood glucose during the night after drinking
· Drink with a friend or someone who knows about your diabetes and how to treat low blood glucose
· Never drink and drive
Effects of Legal and Illegal Substances on Diabetes Control
· Impairs judgment; can affect an individual’s resolve to maintain tight control.
· Burns like fat and contains almost as many calories per gram as fat (7 calories per gram of alcohol, 9 calories per gram of fat).
· Promotes hypoglycemia and impairs the manufacture, storage and release of glycogen. (Even one alcoholic beverage on an empty stomach can send blood glucose plummeting, raising the risk of sudden hypoglycemia and possibly even loss of consciousness. The risk of low blood glucose can persist for hours after alcohol consumption, especially if little or no food is consumed.)
· Could delay needed treatment for low blood glucose, since hypoglycemia and inebriation appear deceptively similar.
· Interacts with other drugs such as chlorpropamide. (Some diabetes medications stipulate limits on alcohol consumption.)
· Serves as a potent vasoconstrictor (narrowing fragile blood vessels).
· Significantly influences oral and intravenous glucose tolerance tests.
· Increases the risk of eye disease, kidney disease and impotence.
· Can decrease insulin absorption.
· Increases the risk of high blood pressure, heart disease and stroke.
· Can exacerbate nerve disease.
· Increases the risk of limb amputation. (Smokers account for an estimated 95 percent of all diabetic limb amputations.)
· (Its effect is highly related to dosage, but the strength of the main active chemical in marijuana, known as THC, delta-9-tetrahydrocannabinol can vary widely.)
· Some users report that smoking Marijuana lowers their blood glucose by 40 points, which can lead to hypoglycemia
· Causes problems with memory, concentration, sensory and time perception, coordinated movement and problem solving, which may affect control.
· Increases appetite and can cause overeating and subsequent hyperglycemia.
· Impairs short-term memory during intoxication.
· Can cause profound impairment when mixed with alcohol.
· Can impair glucose tolerance and cause hyperglycemia when heavily used.
· Can increase blood glucose and change eating habits.
· Can cause high blood glucose as a result of increased liver glycogen breakdown (highly variable among individuals).
· Alters perception, which can affect the ability to manage diabetes.
· Can change eating habits, which can affect blood glucose.
· Alters perception, which can affect the ability to manage diabetes.
SOURCES: Gopi Memorial Hospital, India; “Recreational Drugs and Diabetes,” by R. Keith Campbell, RPh, and Gwen G. Rushman, MN, Practical Diabetology, September/October 1985; Diabetes New Zealand; American Diabetes Association.
What Alcohol and Drugs Can Do to You - A Tale of Two People With Diabetes
In 1984, Mary Tyler Moore became the first person with diabetes and substance abuse problems to seek help at the Betty Ford Center. Moore broke her silence about her drug and alcohol addiction, and its successful treatment, in her 1995 autobiography “After All” (Bantam Dell). She has continued her successful acting career and now serves as the international chairman of the Juvenile Diabetes Research Foundation.
Moore’s story is just one example of how someone with diabetes can overcome drug and alcohol problems.
A 44-year-old Southern California man we’ll call James is another.
James has had diabetes for 30 years. He has impaired kidney function, some signs of retinopathy and celiac disease. He doesn’t know whether his complications from diabetes are related to his abuse of several drugs, including cocaine, Vicodin, Valium and amphetamines.
Before his recovery more than a year ago, James often missed appointments with his Los Angeles endocrinologist, Anne Peters Harmel. When he did manage to arrive at her office, it was abundantly clear that he was out of control.
He sporadically tested his blood glucose and lied to Harmel about why things were going wrong. While using drugs, James suffered severe lows and highs, resulting in two car accidents. Once he ended up in the hospital for four days with ketoacidosis.
“I tended to not notice hypos as much. The drugs would cover up or confuse the symptoms,” James recalls. “On amphetamines, my blood glucose could be in the teens or 20s, and I would be totally functioning. I would test my blood glucose, and it was 17, and I had just driven home. It’s like [the drugs] made you more capable of walking closer to the edge of the cliff.”
Once he told the truth about his drug use and got treatment, James and his doctor could begin treating his diabetes.
Harmel admits that trying to help James was difficult, to say the least.
“I tried to give general guidelines about being sure he ate something and gave his insulin. But I felt that my advice wouldn’t be followed when he was at his worst. I would get calls from ERs or rehab centers rather than seeing him in clinic. I think the best I could do was to make sure he wore his MedicAlert bracelet and hope that if he went into DKA, someone would take him to the ER.
“Fortunately, rehab worked, and now he is able to take care of his diabetes again.”
Endocrinologist Stuart Brink points out that James’s story is a good example of how a drug addict who has diabetes differs from someone who is capable of testing blood glucose and managing diabetes while using recreational drugs.
“Hard drug addicts are much different than those experimenting or occasionally getting stoned,” Brink notes. “When you’re an addict, taking care of your diabetes is so far down the priority list. The next hit is life or death. The [chronic complications of] diabetes don’t hit for another 20 years.”