contemporary treatments in the field of alcohol misuse dr farrukh alam consultant psychiatrist...

Contemporary Treatments in the Field of Alcohol Misuse

Dr Farrukh Alam

Consultant Psychiatrist

Director of Addictions

No evidence of efficacy

• Anti anxiety medications

• Confrontational interventions

• Educational films/lectures

• Electrical aversion therapies

• General counselling

• Insight - orientated Psychotherapy

Insufficient evidence of efficacy

• Alcoholics Anonymous

• Minnesota Model of Residential Treatments

• Halfway Houses

• Acupuncture

Drinking typology

• Type 1: Excessive drinkers with no or few alcohol - related problems and low levels of dependence

• Type 2: Individuals with definite alcohol - related problems but only moderate levels of dependence

• Type 3: Individuals with definite alcohol - related problems and severe dependence

Good evidence of effectiveness psychological models

Brief interventions

- Minimal intervention

- Brief motivational interviewing

Self control training

Stress management

Six elements commonly included in minimal interventions (FRAMES)

• FEEDBACK of personal risk or impairment• Emphasis is on personal RESPONSIBILTY• Clear ADVICE to change• A MENU of alternative change options• Therapeutic EMPATHY as a counselling style• Enhancement of SELF EFFICACY or optimism

Miller & Sanchez (1993)

Minimal intervention

• Effective in populations not seeking treatment - especially men

• Effectiveness in treatment - seeking populations equivocal

• Settings: Primary care, General hospital

• Intervention:

assessment of alcohol intake

information on harmful/hazardous drinking

clear advice for individual

plus/minus booklets

plus/minus details of local services

Minimal interventions

• Shorter duration } than

• Lower intensity } conventional

• Cheaper to implement } treatments

• Generalist workers

• Non - specialist settings

• Target population

Motivational interviewing

• Practical and acceptable technique for individuals who are reluctant to change and ambivalent about change

• Draws on strategies from:

client-centred counselling

cognitive therapy

systems theory

social psychology of persuasion

Self control training

• Setting limits on number of drinks• Self monitoring of drink behaviour• Altering rate of drinking• Developing assertiveness in refusing drinks• Setting up a reward system for achieving goals• Becoming aware of antecedents to overdrinking• Learning coping skills other than drinking

Strategies to aid controlled drinking

• Practice techniques for coping with triggers

• Avoid high risk settings

• Set limits

• Keep a drinking diary

• Avoid round drinking

• Have a non-alcoholic spacer between drinks

• Pace drinking

• Eat food before or during drinking

• Avoid heavy drinking acquaintances

• “Don’t drink to solve problems”

Good evidence of effective pharmacological treatments

• Detoxification

Chlordiazepoxide

• Abstinence phase

Disulfiram (Antabuse)

Naltrexone (Nalorex)

Acamprosate (Campral EC)

Assisted withdrawal in hospital

• History of withdrawal seizures

• Signs of delirium

• Medical complications

• Psychiatric complications

• Lack of support

• Failure of community detoxification

Disulfiram (Antabuse)• Accidentally discovered in 1948(Denmark)

• Inhibits aldehyde dehydrogenase

• Causes build-up of acetaldehyde after ingestion of alcohol:

single drink - mild facial flushing, tachycardia

further consumption - exacerbation of symptoms: palpitations, breathlessness, nausea, vomiting, headache

• Reaction starts within 10-30 minutes

• Reaction can last for several hours• Severity of reaction varies greatly

Disulfiram (Antabuse)• Daily dose:

- 100-200 mg daily

- some individuals tolerate up to 500mg daily

• Absorbed slowly

• Must be taken for a few day’s to build up a satisfactory level

• Side effects: lethargy& fatigue, vomiting, unpleasant taste in mouth, halitosis, impotence, unexplained breathlessness

• Rarer side effects: psychosis, allergic dermatitis, peripheral neuropathy, hepatic cell damage

• Drug interactions: enhances effect of warfarin, inhibits metabolism of tricyclic antidepressants, phenytoin and benzodiazepines

Disulfiram: How Effective?Studies mostly

• of short duration

• used small number of “severe alcoholics”

• not methodologically sound (relied on self report, compliance not measured)

• associated with some form of coercion (courts, clinics, doctors)

Results equivocal

Strategies to enhance Disulfiram compliance

• Home-based “contracting” programme (spouse or partner must be present while they take disulfiram)

• “Antabuse contract” as part of behavioural marital therapy

• Supervised disulfiram as condition of a probation order in maintaining abstinence in habitually disordered offenders

• Staff supervision (written contract)

• Community Reinforcement Approach (Azrin et al 1982)

• Counselling ( Chick et al 1992)

Subcutaneous Disulfiram

• No benefit found in a randomised controlled study

• Poor/erratic absorption

• Risk of infection

Naltrexone

• Orally active opioid receptor antagonist

• Adjunct to out-patient psycho-social treatment

• Improved abstinence, prevented relapse and deceased alcohol consumption in 2 American studies (Volpicelli et al,1992; O’Malley et al 1992)

AcamprosateCalcium bis acetyl homotaurine

• Developed from taurine

• Chemical structure similar to GABA, glutamic acid & taurine

• Increases GABA function in vitro

• Decreases NMDA function in vitro• May reduce craving associated with

conditioned withdrawal

Acamprosate

Pharmacokinetics

• absorbed slowly across GIT

• steady state levels achieved by 7th day of administration

• not influenced by liver disease

Conclusion

• 20% of adults in UK consume 80% of the alcohol

• 4.7% of the UK population over 16 maybe dependent on alcohol

• EFFECTIVE TREATMENT IS AVAILABLE FOR ALCOHOL DEPENDENCE