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

Disulfiram (Antabuse) Daily dose: 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