disulfiram comparative studies and experiences from clinical practice
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DISULFIRAM Comparative Studies and Experiences from Clinical Practice . Dr. Avinash De Sousa. My work in India. State government aided hospital. Private psychiatric set up – nursing home . Out patient private practice. Private general hospital with a large psychiatric set up.

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my work in india
My work in India
  • State government aided hospital.
  • Private psychiatric set up – nursing home.
  • Out patient private practice.
  • Private general hospital with a large psychiatric set up.
alcohol dependence in india
Alcohol Dependence in India
  • No major research available on long term management till last five years.
  • Few doctors interested in specializing in addiction medicine.
  • Indian culture and alcohol dependence.
disulfiram in india
Disulfiram in India
  • Cheaper alternative to Naltrexone, Acamprosate and Topiramate.
  • Alcoholism is a very rampant problems and most patients are the sole bread winners.
  • Abstinence is very important for work.
  • Lack of aided psychiatric services.
disulfiram in india1
Disulfiram in India
  • Though cheaper – few psychiatrists are comfortable with usage.
  • Side effects are rare – hepatotoxicity or neuropathy.
  • Complicated alcohol withdrawals are common in our practice.
  • Disulfiram induced confusion or psychosis.
the indian studies
The Indian Studies
  • Three open randomized trials (2004-2008)

Naltrexone VS Disulfiram

Acamprosate VS Disulfiram

Topiramate VS Disulfiram

  • Conditions in the study were similar to routine clinical practice in India.
  • All patients – underwent detoxification.
  • Randomized but open study.
inclusion criteria
Inclusion Criteria
  • Age between 18-65 years.
  • DSM-IV criteria for alcohol dependence.
  • All had a stable and supportive family environment.
  • One responsible family member.
  • Importance of supervised Disulfiram therapy
exclusion criteria
Exclusion Criteria
  • Other substance use disorders other than Nicotine Dependence.
  • Any co-morbid psychiatric disorder.
  • Any medical condition that would interfere with compliance.
  • Elevated liver functions.
  • Previous treatment with the 2 drugs of the study.
methodology
Methodology
  • Subjects informed about the study and the drugs involved.
  • Need for a family member to be present on regular follow up.
  • Importance of psychoeducation in Disulfiram therapy.
procedure assessments
Procedure & Assessments
  • Addiction Severity Index.
  • Severity of Alcohol Dependence Scale.
  • Scale to measure the 3 parameters of craving frequency, duration and intensity – (Anton).
  • Baseline liver function tests.
  • Calendar to record alcohol consumption.
dose of medication used
Dose of medication used
  • 50mg of Naltrexone once a day.
  • 250mg of Disulfiram once a day.
  • 666mg of Acamprosate thrice daily.
  • 50mg Topiramate thrice daily.
  • NTX and DSF taken as a single daily dose in the morning after breakfast with a family member to observe that the patient takes the medicine.
follow ups
Follow ups
  • Weekly for the first 3 months.
  • Fortnightly till the end of the study.
  • Transport paid by us – other incentive offered.
  • Supportive group psychotherapy – once a week – less structured than in a classical de-addiction programme – emphasis on compliance.
additional medications
Additional medications
  • Sertraline 50-100mg and
  • Escitalopram5-10mg in case of depression.
  • Duloxetine 20-40mg per day in the Topiramate study.
  • Zolpidem 5-10mg at night in case of insomnia.
  • No benzodiazepines were prescribed.
outcome measures
Outcome measures
  • Accumulated days of abstinence.
  • Days until the first relapse (defined as consuming more than 5 alcoholic drinks or 40gm alcohol in 24 hours).
outcome measures1
Outcome Measures
  • Craving measures.
  • GGT measured every 3 months.
  • Discontinuation of treatment.
  • Drop out from the study
discussion
Discussion
  • All three drugs were well tolerated.
  • Larger studies across diverse populations of patients are needed to replicate and strengthen these results.
  • Family support in India is strong – exploiting this resource is a must in the successful use of Disulfiram.
other studies done by us
Other studies done by us
  • Disulfiram superior to Naltrexone in elderly alcoholics.

(Journal of Pakistan Psychiatric Society 2009)

  • Disulfiram superior to Naltrexone in adolescent alcohol dependence patients.

(Journal of Substance Use 2006)

  • Disulfiramsuperior to Naltrexone in female alcoholics.

(unpublished work)

studies in progress
Studies in progress
  • Disulfiram versus a Combined Naltrexone and Acamprosate regime
  • Does Acamprosate addition enhance Disulfiram therapy.
  • Disulfiram and Psychotherapy.

(All studies would be complete by 2011-2012)

other pivotal studies
Other pivotal studies
  • The Helsinki Disulfiram study.
  • Disulfiram superior to Acamprosate.
  • OLITA Study.
  • Other small but important studies.
limitations
Limitations
  • Open studies rather than a blinded ones. Hypothetically a bias may have been introduced.
  • No laboratory marker used to assess compliance.
  • Good primary support group leading to fewer drop outs.
  • Stringent inclusion criteria.
other issues in disulfiram therapy
Other issues in Disulfiram therapy
  • Incorporating Disulfiram into psychotherapy.
  • Disulfiram in patients with comorbid psychiatric disorders.
  • Where does Disulfiram stand today in the modern pharmacotherapy of alcoholism.
conclusions
Conclusions
  • Disulfiram is a treatment option that cannot be ignored.
  • Psychiatrists worldwide need to be trained.
  • Oral DisulfiramVS Long acting Naltrexone or Naltrexone implants
  • Effective compliance monitoring.
acknowledgements
Acknowledgements
  • The Stapleford Conference and its organizers.
  • My parents who have taught me most of my psychiatry.
  • My country that gives me enough freedom and patients who trust me fully.
  • Everyone here who made me feel at home.
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