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