Upload
verity-mcgee
View
214
Download
1
Tags:
Embed Size (px)
Citation preview
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