In 2023 a new set of Canadian Guidelines for the Management of Alcohol Use Disorders put a serious problem on the radar for doctors that few of them likely expected. See Antidepressants, Alcohol and Anne-Marie.
The antidepressants doctors commonly prescribed, often telling people these medicines would help them manage their alcohol issues, were likely causing the problem – increasing the alcohol use the doctors fondly imagined they might be treating,
The idea that antidepressants might trigger alcohol use disorders will come as no surprise to readers of RxISK and DH Blogs Anne-Marie put this problem on the RxISK radar over a decade ago – Driven to Drink. She has since drawn attention to a significant public health toll linked to women in particular drink driving and having serious accidents that impact not only on their lives but also the lives of others.
The cause that Anne-Marie brought to the consciousness of some of us has more recently been picked up and championed by Evan Wood in Vancouver all the way into Canadian Guidelines on alcohol use disorders – Antidepressants and Alcohol.
There is an extraordinary contrast here. Faced with a wink and a nod to something that sounded vaguely sensible – that antidepressants might help because people use alcohol to soothe their nerves or moodiness – doctors jumped on board and dished these drugs out by the bucket-load. Doctors, in contrast, have been much slower to follow the compelling evidence Evan has faced them with – that what might appear to be common sense does not apply in this case.
It’s not just doctors, who have jumped onto this bandwagon without looking for a shred of evidence beyond common sense. In 2024, the NHS in Britain set about reviewing the detection and management of alcohol use disorders in the UK. The draft proposals did not mention antidepressant induced problems. The focus was on whether there might be some trauma in this or a prior life that needed tackling in order to put things right. This is a recipe for counsellors and therapists referring people to doctors to get scripts for antidepressants in order to facilitate a therapy that isn’t making much difference.
The Airlie Bird gets the Worm
Given this example, it seems easy to make a case that faced with problems, just like the famous bird, medical birds often bury their heads in the sand. Except this is unkind to ostriches. Unlike doctors, ostriches are not hiding from predators or problems. They are digging nests and turning eggs.
This image, designed to illustrate male medical ignorance about women’s medical issues, comes from the Airlie Family Medicine clinic website, in Victoria Australia.
Having made the point about ostriches and doctors, the efforts of two extraordinary people, Evan and Anne-Marie, one of them a doctor and a man, likely supplemented by the efforts of others in the background, have created a platform for saving lives and preventing a lot of misery, perhaps especially among women.
SSRI induced alcoholism is not just a women’s issue but it may be more important for women, as increasingly younger women are more likely to start taking SSRIs than men. These SSRIs may be leading not just to alcohol services having to deal with an increasing number of women but also medical services across the board dealing with women for liver disease serious enough to require liver transplants, and other alcohol linked medical problems.
BBC’s Hazel Martin produced an extraordinary Panorama programme on the growing problem of liver disease among young women in Britain- See I had no idea social drinking would damage my liver. As Hazel makes clear, her interest in the issue stemmed from an alcohol consumption that didn’t seem more than social. But it did lead to liver problems and her discovery that these are more likely to be triggered by much lower levels of alcohol intake in women than men.
The figures for alcohol related medical problems in other countries, along with Hazel’s efforts beyond the UK to draw attention to the problem, are leading to a growing awareness that this is not just a British problem. Other countries are also affected. The problem, however, is not universal – it’s primarily a white woman’s problem. At present other communities are less likely to take alcohol – or SSRIs.
A Hair of the Doc that Bit You?
One of the ways we can all contribute is by getting SNOMED and MedDRA codes for antidepressant induced alcohol use disorders. SNOMED codes are useful for filing reports in our medical records, and with our doctors. MedDRA codes help with filing reports to regulators – FDA, EMA, MHRA, TGA etc. See SNOMED – Having an Impact.
We need to hAir the problem.
Using the RxISK Drug Search Tool, it is difficult to find any evidence of antidepressant induced alcohol use disorders. Rather than search by drug, you have to put in alcohol use disorder as a side effect and see what drugs come up linked to it.
There are 471 reports at the moment, which suggests FDA have only recently been getting reports of this problem. Their first reports date from 2017. Since 2017, reporting has increased from 3 to over 20 per year, but this can only be a fraction of the tip of the iceberg.
Roughly 1 in 10 reports are linked to an SSRI. Roughly 1 in 5 link to SSRIs and analgesics like tramadol and acetaminophen/paracetamol (Tylenol/Lemsip/Panadol etc). Tramadol is easily explained – it’s an SSRI.
Tylenol is intriguing. It comes with prominent liver damage warnings. For decades, as a result of being consumed with alcohol or in overdose, it has been among the commonest triggers to a liver transplant.
What’s intriguing about this?
Despite it being among the best-selling and most consumed drugs in the world for several decades, neither Johnson and Johnson who make Tylenol, nor any of the many other companies in any of the countries where it is among the most consumed drugs – especially in pregnancy – can tell any of us how it works.
This has to be a crazy statement doesn’t it?
Nope. Go to the website for JandJ, or Kenvue, a JnJ offspring, and search for the company view on how Tylenol works. They used to waffle about Aspirin like actions on Cox 1 and Cox 2 systems and about prostaglandins and then began talking about central, maybe opioid-lite mechanisms, but lately the websites officially concede that no-one knows how Tylenol works.
Acetaminophen/Paracetamol is not an SSRI but it does bind to serotonergic receptors and reuptake sites and it produces a similar numbing of emotions to the numbing we get with SSRIs along with sexual difficulties and loss of libido.
In addition, of course, SSRI and related drugs are used in the management of pain. SSRIs are not particularly analgesic but like Tylenol they seem to make us less bothered about or emotionally numb to the pains we have.
We are applying for SNOMED and MedDRA codes and will post them here but there are lots of other codes to apply – such as aripiprazole induced amphetamine use, alcohol abuse, gambling, for instance.
Let’s see how the ‘authorities’ respond to asks for codes for SSRI – induced problems. Strictly speaking everything reported to FDA’s MedWatch (on RxISK) is drug-induced or potentially drug-induced. Akathisia is a MedDRA event – SSRI-induced akathisia isn’t.
Alcohol Mysteries
Weeks after Anne-Marie reported her SSRI driving her to drink, another report – Every Drink Spiked – added to the story.
Petra was stopped by the police – her blood alcohol level was right on the legal driving limit. She was mystified – she had had almost nothing to drink. Her father was also mystified and set about investigating and established that the duloxetine she was taking had caused her blood alcohol level to double compared with the levels she had when not on duloxetine.
In several cases since then, the same changes have been observed under police supervision and have contributed to people not being sentenced as they might otherwise have been.
No-one knows how this increased blood alcohol levels while on an SSRI happens at least to some of us but likely not all of us. Chat GPT, Grok etc have been interrogated and come up with nothing except referring you to Every Drink Spiked on DH.org.
We can speculate about common liver effects or interactions. A failure of SSRIs to break down normally can lead to damaging radicals that can cause liver damage. But no-one is looking at any of these things.
The extraordinary thing about this is that here is an event that definitely happens in some of us sitting in broad daylight, which could be used to prevent some of us going to jail, or losing our jobs, or injuring others but everyone just walks by.
For the last decade, I’ve been expecting a reaction among researchers like the reaction among gardeners below. Scientists are not supposed to be able to tolerate an unexplained something sitting there right in front of them. Science and gorgeous gardens wouldn’t exist if science and gardening enthusiasts ignored things like this.
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