Jonathan Chick

Safety issues concerning the use of disulfiram in treating alcohol dependence

Disulfiram is known to cause hepatitis, which is sometimes fatal. The best estimate of the frequency of disulfiram-induced fatal hepatitis is 1 case in 30 000 patients treated/year. Its appears to be more common in patients given disulfiram for the treatment of nickel sensitivity. Frequent blood testing for liver function is probably not necessary, but patients taking disulfiram should be in regular contact with a physician.There are rare reports of psychosis and confusional states in conjunction with disulfiram treatment and peripheral neuropathy and optic neuritis have been reported; these effects are dose-related. Psychiatric complications appear to be more common with the use of disulfiram in India than in Western countries. Of the less serious adverse effects, tiredness, headache and sleepiness are the most common.Deaths from the disulfiram-alcohol (ethanol) interaction have not been reported in recent years, possibly because the dosages used are lower than those used 40 years ago, and patients with cardiac disease are now excluded from treatment. There is no evidence to suggest that disulfiram causes cancer. Of note, there are drug interactions with compounds that utilise the cytochrome P450 enzyme system.Disulfiram can be viewed as a drug with a moderate record of adverse effects. Alcohol dependence, for which it can be a helpful treatment, is associated with a high morbidity and mortality.

Can Light or Moderate Drinking Benefit Mental Health

Observational studies in several cultures show light and moderate drinking to be associated with better emotional and social adjustment than abstinence. However, adjustments for pre-existing personality characteristics and socialisation need to be made, and abstainers who are ex-drinkers must be excluded. There is still insufficient evidence to suggest that emotional health can be improved by light or moderate drinking. For cognition, consumption of up to 65 g/day is not associated with chronic inefficiencies. With regard to cognitive decline in older people, emerging evidence suggests the possibility that such decline may be reduced by light drinking. The elderly in institutions probably benefit from a ‘social hour’ when alcoholic beverage is available. Doctors considering giving advice to drink to improve health should be very cautious and note a number of caveats.

Estimating Alcohol Consumption

Alcohol use is one of the two main aetiologies of acute pancreatitis. Detection of excessive alcohol consumption is problematic, illustrated by the fact that self-reports of alcohol consumption account for only approximately 50% of the reported sales of alcohol. To improve the reliability, structured questionnaires and various biochemical markers have been developed to estimate alcohol consumption objectively. Further, the pattern of drinking and level of consumption within the past 2 weeks may alter the clinical picture of the acute pancreatitis. The aim of this paper is to remind the clinician of the importance of accurate and complete history, the need to document the actual alcohol consumption, pattern of drinking, clinical signs of alcoholism and to use biochemical tests and sometimes questionnaires.

Prognostic factors during outpatient treatment for alcohol dependence: cohort study with 6 months of treatment follow-up.

AIMSnTo identify prognostic factors to outpatient alcohol treatment on admission as well as during the treatment period.nnnMETHODSnA cohort study of n = 209 alcoholic patients (DSM-IV) during 6 months of outpatient treatment. Eight medical doctors from two hospitals were involved. Co-responsible participation in treatment was a necessary condition. At admission, we documented socio demographic factors, use of other drugs and severity of alcohol consumption. During the 6 months, we observed medication for prevention of alcohol relapse [disulfiram (DIS), acamprosate], number of sessions with the doctor, number of phases of the consultation and medication for depression. Primary outcome variables were time to first heavy relapse and abstinence of heavy alcohol consumption. These were measured with Timeline Followback. Five or more alcohol units of 10 g in one relapse day were considered heavy relapse.nnnRESULTSnThe patients were 84% males, with 41 years median age; the median alcohol consumption was 192 g per day with a median duration of 13 years of heavy consumption. The median education was 6 years with 61% of the patients from lower socio-economic levels. The Kaplan-Meier heavy relapse rate at 6 months was 23%. On admission to treatment, female gender, lower socio-economic levels, cocaine use, >20 years of consumption, gamma glutamyl transferase values above normal and five or more alcohol-related problems on the Alcohol-Related Problem Questionnaire predicted worse outcomes. Having a full-time job and shorter abstinence time before treatment (until 7 days) predicted better outcomes. During the 6 months, we found that DIS for <120 days was a prognostic factor of worse outcomes. DIS for at least 120 days, >50% of adherence to consultations and more than two phases on each consultation predicted better outcomes. The combined sensitivity and specificity for DIS for at least 120 days, >50% of adherence to consultations and more than two phases on consultation regarding abstinence from heavy relapse were respectively 100 and 71%.nnnCONCLUSIONSnDuring 6 months of outpatient treatment, longer adherence to DIS and consultations as well as more phases in a consultation involving necessarily a co-responsible predict a good outcome independently of the patient features at admission.

Revealing Alcohol Abuse: To Ask or to Test?

This article represents the proceedings of a symposium at the 2004 ISBRA Congress in Heidelberg/Mannheim, Germany. The chairs were C. Alling and R. A. Harris. The presentations were (1) Advantage and Disadvantage of Tests for Self-Reported Intake in Different Settings, by J. D. Chick; (2) Update on the Use of Biological Markers to Monitor Outcome in Alcoholism Clinical Treatment Trials, by R. Anton; (3) Identification of Alcohol Biomarkers Using Genomic and Proteomic Approaches, by R. D. Mayfield; (4) Use of Biomarkers as Secondary or Primary Outcome Measures in Alcoholism Treatment Trials, by M. Salaspuro; and (5) Use of Tests for Drink-Drive Offenders: A European Perspective, by A. Helander.

Can Alcohol Dependent Patients Adhere to an ‘As-Needed' Medication Regimen?

A pooled analysis of ‘as-needed medication use data from 1,276 patients in two randomised, double-blind, placebo-controlled, parallel-group trials of nalmefene in the treatment of alcohol dependence was performed to explore whether an ‘as-needed regimen is an acceptable and feasible strategy in patients seeking help for alcohol dependence. Adherence was defined as alcohol consumption and medication intake, or no alcohol consumption (with or without medication intake). Nalmefene was taken on approximately half of the study days; placebo was taken more often than nalmefene (52.8 vs. 64.5% of days, respectively). In each treatment group medication intake appeared to vary according to patients needs in that intake correlated with the baseline drinking pattern. Sixty-eight percent of the nalmefene-treated patients (78% of the study completers) adhered to the as-needed treatment regimen on at least 80% of the study days. In conclusion, as-needed use is a feasible, patient-centred approach that engages patients with alcohol dependence in the active management of their illness.