Alcohol deterrents—specifically, disulfiram and calcium carbimide—can help achieve an abstinence rate higher than 50% in chronic alcoholism, according to the results of a nine-year study investigating the long-term outcomes of treatment of the addiction. "Although up to 30% of patients may claim to be abstinent two to three years after treatment, objective laboratory data indicate that only 6% to 20% of patients are abstinent two years after therapy," said Hannelore Ehrenreich, MD, DVM, Chief of the Division of Clinical Neuroscience at the Max Planck Institute for Experimental Medicine in Munich and corresponding author for the study. "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 lifelong treatment. This study is the first report on supervised, long-term administration of alcohol deterrents, with a focus on the psychological rather than the pharmacological action of alcohol deterrents."

Alcohol deterrents seem to be more widely accepted and used in Europe than in North America, added Colin Brewer, MD, Research Director of the Stapleford Centre in London. "I have coauthored a study showing that the three Anglo-Saxon countries examined—the United Kingdom, the United States, and New Zealand—had the lowest use," he said. "Furthermore, a recent US study showed that addiction specialists prescribed disulfiram or naltrexone for fewer than 15% of their alcoholic patients. Conversely, disulfiram use is certainly common in Spain, Portugal, Germany, Austria, and Scandinavia."

OLITA

In their study, published in the January Alcoholism: Clinical and Experimental Research, Dr. Ehrenreich and colleagues analyzed data gathered from 1993 to 2002, when 180 patients with chronic alcoholism were consecutively admitted to a two-year comprehensive integrated treatment program called the Outpatient Long-term 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% among the patients studied," reported Dr. Ehrenreich. "Long-term use of alcohol deterrents 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."

MIND OVER BODY?

Dr. Ehrenreich said that the data imply a psychological rather than a pharmacologic action of alcohol deterrents. "First, the longer the intake, the greater the likelihood that a patient will stay continuously abstinent even after termination of alcohol deterrents. Second, the dose of alcohol deterrents is as irrelevant as the experience of a subsequent reaction for alcohol deterrents to be effective. Third, sham alcohol deterrents are as efficient as disulfiram or calcium carbimide, provided that the use is repeatedly explained and continuously guided and encouraged," explained Dr. Ehrenreich.

"The psychological role that alcohol deterrents may play in relapse prevention is one of the most interesting aspects of the study," added Dr. 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," he emphasized.

"In addition, deterrent drugs clearly do deter," Dr. Brewer continued. "‘Supposedly’ deterrent drugs also deter—but they only deter because there is a real psychological reaction." He offered the analogy of police enforcement of speed limits. Inactive radar guns also deter people from speeding but only because drivers can’t know the radar guns are inactive unless they put them to the test. "In both contexts, people are reluctant to make the experiment," he said.

AGGRESSIVE AFTERCARE

Although alcohol deterrents were the focus of this study, said Dr. Ehrenreich, other treatment components of the OLITA program are just as important and help to explain the psychological role that alcohol deterrents play in relapse prevention. "These include strict abstinence orientation, high-frequency short-term individual contacts, supportive, nonconfronting counseling, therapist rotation, emergency service and crisis interventions, social reintegration, long-term treatment, and subsequent lifelong checkup 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 [reached] through spontaneous house visits, telephone calls, or mail to continue therapy or to restart abstinence."

Dr. Brewer added, "Supervision may seem labor-intensive; but if the labor 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 alcohol abusers take disulfiram regularly, even reluctantly, they will not [become intoxicated] if the dose is adequate. That should revolutionize the management of such offenders. Similar trials with naltrexone in heroin abusers have been very effective with no negative results."

Dr. Ehrenreich concluded, "Our results support a major clinical implication that severe alcoholism is a chronic and relapsing disease. Only long-term treatment, followed by lifelong attending of checkup sessions and self-help group participation, will guarantee long-term recovery. Supervised intake of alcohol deterrents 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."

Suggested Reading
Buonopane A, Petrakis IL. Pharmacotherapy of alcohol use disorders. Subst Use Misuse. 2005;40:2001-2020.
Hermos JA, Young MM, Gagnon DR, Fiore LD. Patterns of dispensed disulfiram and naltrexone for alcoholism treatment in a veteran patient population. Alcohol Clin Exp Res. 2004;28:1229-1235.
Krampe H, Stawicki S, Wagner T, et al. Follow-up of 180 alcoholic patients for up to 7 years after outpatient treatment: impact of alcohol deterrents on outcome. Alcohol Clin Exp Res. 2006;30:86-95.
Wagner T, Krampe H, Stawicki S, et al. Substantial decrease of psychiatric comorbidity in chronic alcoholics upon integrated outpatient treatment: results of a prospective study. J Psychiatr Res. 2004;38:619-635.
Williams SH. Medications for treating alcohol dependence. Am Fam Physician. 2005;72:1775-1780.

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