Contemporary Treatments in the Field of Alcohol Misuse

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 individualplus/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)

Acamprosate Calcium 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

Contemporary Treatments in the Field of Alcohol Misuse