Colin Brewer, M.D.
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Alcoholism: Clinical & Experimental Research
Studies investigating the long-term outcomes of alcoholism treatment are rare and inconsistent. A nine-year study in the January issue of Alcoholism: Clinical & Experimental Research investigates the occurrence of abstinence, lapse, and relapse among chronic alcoholics while exploring the role that "alcohol deterrents" (ADs) – specifically, disulfiram and calcium carbimide – may play. Results indicate that ADs can help achieve an abstinence rate of more than 50 percent.
"Although up to 30 percent of patients may claim to be abstinent two to three years after treatment," said Hannelore Ehrenreich, head of the division of clinical neuroscience at the Max-Planck-Institute of Experimental Medicine in Germany and corresponding author for the study, "objective laboratory data indicate that only six to 20 percent of patients are abstinent two years after therapy. These results reflect therapists' clinical experience that alcoholism is a chronic and relapsing disease … similar to other chronic conditions such as hypertension or diabetes, and should be accepted as a disorder that requires long-term or life-long treatment. This study is the first report on supervised, long-term administration of ADs, with a focus on the psychological rather than the pharmacological action of ADs."
Alcohol deterrents seem to be more widely accepted and used in Europe than they are in North America, said Colin Brewer, research director of the Stapleford Centre in London. "I have co-authored a study showing that the three 'Anglo-Saxon' countries examined – the U.K, U.S. and New Zealand – had the lowest use," he said. "Furthermore, a recent U.S. study showed that addiction specialists prescribed disulfiram or naltrexone for fewer than 15 percent of their alcoholic patients. Conversely, disulfiram use is certainly common in Spain, Portugal, Germany, Austria and Scandinavia."
Researchers analyzed data gathered from 1993 to 2002, when 180 chronic alcoholics were consecutively admitted to a two-year comprehensive integrated treatment program called the Outpatient Longterm Intensive Therapy for Alcoholics (OLITA). Carefully prepared and supervised intake of disulfiram or calcium carbimide is a major component of the program. Given that an earlier study showed that 30 OLITA patients achieved higher abstinence rates than case controls in other programs, the authors wanted to extend their investigation to all 180 patients for seven years following treatment, with a specific focus on the role of disulfiram or calcium carbimide in relapse prevention and maintenance of long-term abstinence.
"We found an abstinence rate of more than 50 percent among the patients studied," said Ehrenreich. "Long-term use of ADs appeared to be well-tolerated. Abstinence rates were better in patients who stayed on alcohol deterrents for more than 20 months as compared to patients who terminated intake at 13 to 20 months."
Ehrenreich said that the data imply a psychological rather than a pharmacological action of ADs. "First, the longer the intake, the more likely is a patient to stay continuously abstinent even after termination of ADs," she said. "Second, the dose of ADs is as irrelevant as the experience of a subsequent reaction for ADs to be effective. Third, sham-ADs are as efficient as disulfiram or calcium carbimide, provided that the use is repeatedly explained and continuously guided and encouraged."
"The psychological role that ADs may play in relapse prevention is one of the most interesting aspects of the study," added Brewer. "These results support the theory that prolonged abstinence achieved with disulfiram automatically leads to the consolidation of the habit of abstinence. Practice makes perfect. The longer people abstain, the longer they will abstain. In addition, deterrent drugs clearly do deter. Supposedly deterrent drugs also deter but they only deter because there is a real pharmacological reaction. The analogy here is with speed cameras. We know that inactive cameras also deter but only because drivers can't know they are inactive unless they put them to the test. In both contexts, people are reluctant to make the experiment."
Although ADs are the focus of this study, said Ehrenreich, other treatment components of the OLITA program are just as important, and help to explain the psychological role that ADs play in relapse prevention. "These include strict abstinence orientation, high frequency short-term individual contacts, supportive, non-confronting counselling, therapist rotation, emergency service and crisis interventions, social re-integration, long-term treatment and subsequent life-long check-up visits, as well as a concept that recognizes 'alcohol relapse' as an emergency," she said. "Related to this relapse model, we developed what we call 'aggressive aftercare,' consisting of therapeutic interventions to immediately interrupt beginning, and prevent threatening, relapses. Patients who miss a therapeutic contact are contacted through spontaneous house visits, telephone calls or mail to continue therapy or to restart abstinence."
"Supervision may seem labour-intensive," observed Brewer, "but if the labour is already there, as it is in the clinic, or if one can involve family, workmates or probation services in supervision, as should be routine, it needs no extra resources. Supervised disulfiram may be particularly effective in patients who have not responded to conventional treatments. We urgently need an effective disulfiram implant, for the same reasons that naltrexone implants have been developed. There should also be more trials of probation-linked disulfiram, since alcohol-related crime is a very important issue. This study suggests that if alcoholic offenders take disulfiram regularly, even reluctantly, they will not get drunk if the dose is adequate. That should revolutionize the management of such offenders. Similar trials with naltrexone in heroin-related offenders have been very effective with no negative results."
"Our results support a major clinical implication," said Ehrenreich, "that severe alcoholism is a chronic and relapsing disease. Only long-term treatment, followed by life-long attending of check-up sessions and self-help group participation will guarantee long-term recovery. Supervised intake of ADs can easily and successfully be integrated into a comprehensive and structured outpatient long-term treatment program. The strategy of deterrence works if therapists disengage from the emphasis of pharmacological effects of disulfiram and make full use of the psychological actions of this drug."
Alcoholism: Clinical & Experimental Research (ACER) is the official journal of the Research Society on Alcoholism and the International Society for Biomedical Research on Alcoholism. Co-authors of the ACER paper, "Follow-up of 180 Alcoholic Patients for Up to Seven Years after Outpatient Treatment: Impact of Alcohol Deterrents on Outcome," were: Henning Krampe, Sabina Stawicki, Thilo Wagner, Claudia Bartels, Carlotta Aust, Eckart Rüther, and Wolfgang Poser of the Department of Psychiatry and Psychotherapy at Georg-August-University and the Max-Planck-Institute of Experimental Medicine in Goettingen, Germany. The study was funded by the German Ministry of Health.
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