Supervised disulfiram in relapse prevention in alcohol-dependent patients suffering from comorbid borderline personality disorder--a case series

The Association Between Impulsivity and Relapse in Patients With Alcohol Use Disorder: A Literature Review

AIM

Impulsivity has been identified as a key relapse risk factor in patients with alcohol use disorder (AUD); however, the inherent characteristics of this relationship have been largely understudied. The heterogeneity of AUD and variation in impulsivity constructs require careful consideration to inform future work examining the relationship. This study sought to review empirical findings examining facets of impulsivity and AUD relapse.

METHODS

A systematic search strategy was employed to capture studies on impulsivity measures related to AUD relapse. Impulsivity measures were qualitatively organized in terms of 'trait impulsivity'-typically measured by self-report questionnaires-and 'behavioural impulsivity', i.e. 'motor impulsivity', 'impulsive choice' and 'reflection impulsivity, assessed with cognitive-behavioural tasks.

RESULTS

Seventeen peer-reviewed papers were identified. Relapse outcomes varied substantially in relation to impulsivity measures. Twelve papers included aspects of 'trait impulsivity', and nine studies included 'behavioural impulsivity' measures, from which five studies dealt with the 'impulsive choice' subcategory. The Barratt Impulsivity Scale was the self-report questionnaire that was most frequently used.

CONCLUSIONS

All three included facets of impulsivity ('trait-, motor- and impulsive choice impulsivity') were associated with AUD relapse, but none seemed to be superior to another. This study confirmed that research on the relation between impulsivity and AUD relapse is relatively scarce. Future research and treatment options are proposed.

Pattern of prescription, dispensation and administration of disulfiram among patients with alcohol use disorder attending a general hospital psychiatry unit in rural India

INTRODUCTION

Disulfiram was the first medication approved to treat alcohol dependence and has been found to be safe and efficacious. This cross sectional, observational, qualitative study was conducted with the aim to assess the pattern of dispensation of disulfiram among patients with alcohol use disorder (AUD).

MATERIAL AND METHODS

Data was collected using a customized questionnaire consisting of 32 questions regarding socio-demographic characteristics, psychiatric history, pattern of dispensation of disulfiram/disulfiram-like product (DLP) and related knowledge. Descriptive statistics and frequency distribution tables were used for analysing the data using Microsoft Excel 2013.

RESULTS

Thirty seven percent (n=100) of the total patients with ADS (n=268) screened had a history of administration of disulfiram/DLP. Tablets were the commonest (60%) formulation of disulfiram/DLP advised by the dispenser, only 4% of whom were psychiatrists. Surreptitious administration was preferred by family members (76%). Majority of the patients (44%) received the medication only once or twice.

LIMITATIONS

The actual product - disulfiram and/or DLP - could not be chemically tested to confirm the identity. Considering the socio-economic and cultural background where the study was conducted, it would be difficult to generalize the findings.

DISCUSSION

Disulfiram/DLP was prescribed by physicians and faith healers alike. They seem to promote surreptitious administration of disulfiram with full agreement of relatives, thereby potentially exposing the patient to life threatening complications. Hence it is recommended that disulfiram prescription should involve stricter guidelines and DLP like kudzu in traditional/herbal products should also be brought under the same purview as disulfiram.

Treatment for comorbid borderline personality disorder and alcohol use disorders: a review of the evidence and future recommendations

There is a high degree of comorbidity between borderline personality disorder (BPD) and alcohol use disorders (AUDs). There is some evidence that this pattern of comorbidity may be associated with poorer prognosis. Although there are many different psychotherapeutic and pharmacological treatments for BPD and AUDs when they occur alone, there are very few treatment options when they occur together. The objective of this article was to review the existing treatment options-both psychotherapeutic and pharmacological-for patients with dual diagnoses of BPD and AUDs and to explore alternative treatment options that warrant further study. There have been a number of studies that have examined the efficacy of specific psychotherapies targeting drinking among patients with comorbid BPD; however, their efficacy in reducing BPD symptoms is unknown. There are also three psychotherapies that were specifically developed for patients with BPD and substance use disorders (SUDs), but only one of these (Dynamic Deconstructive Psychotherapy) has been tested among patients with dual diagnoses of BPD and AUDs. Research on pharmacotherapy for dual diagnoses of BPD and AUD is scarce, and no study has yet explored medication options that can concurrently manage symptoms of BPD and decrease alcohol consumption. Interestingly, there is growing evidence that anticonvulsants and second generation antipsychotics, the recent medications of choice for the management of BPD symptoms, may also reduce alcohol craving and consumption. Although premature, these findings are encouraging especially for this population of patients for whom treatment options are very limited.

Critical thoughts on current rodent models for evaluating potential treatments of alcohol addiction and withdrawal

Despite years of neurobiological research that have helped to identify potential therapeutic targets, we do not have a reliable pharmacological treatment for alcoholism. There are a range of possible explanations for this failure, including arguments that alcoholism is a spectrum disorder and that different population subtypes may respond to different treatments. This view is supported by categorisations such as early- and late-onset alcoholism, whilst multifactorial genetic factors may also alter responsivity to pharmacological agents. Furthermore, experience of alcohol withdrawal may play a role in future drinking in a way that may distinguish alcoholism from other forms of addiction. Additionally, our neurobiological models, based largely upon results from rodent studies, may not mimic specific aspects of the human condition and may reflect different underlying phenomena and biological processes from the clinical pattern. As a result, potential treatments may be targeting inappropriate aspects of alcohol-related behaviours. Instead, we suggest a more profitable approach is (a) to identify well-defined intermediate behavioural phenotypes in human experimental models that reflect defined aspects of the human clinical disorder and (b) to develop animal models that are homologous with those phenotypes in terms of psychological processes and underlying neurobiological mechanisms. This review describes an array of animal models currently used in the addiction field and what they tell us about alcoholism. We will then examine how established pharmacological agents have been developed using only a limited number of these models, before describing some alternative novel approaches to achieving homology between animal and human experimental measures.

Effect of the threat of a disulfiram-ethanol reaction on cue reactivity in alcoholics

RATIONALE

Little is known about the effect of disulfiram on subjective and autonomic nervous system cue reactivity in the laboratory. The dissuasive psychological effect manifested as a threat would seem to prevail over the pharmacological effect.

OBJECTIVES

The primary objective was to determine whether there was a difference in cue reactivity responses during a threat condition compared to a neutral condition during alcohol cue exposure.

METHODS

In a crossover randomized study, participants received threat and neutral messages during two cue exposure sessions. The threat condition consisted of leading the patients to believe they had ingested 500 mg of disulfiram and the neutral condition of informing them that they had ingested a placebo, while in both condition they received the same placebo.

RESULTS

Physiological cue reactivity was demonstrated by a decrease in diastolic blood pressure during the threat compared to the neutral condition (p=0.04). Heart rate and subjective cue reactivity measures remained unchanged. There was a negative affect (assessed by the Positive and Negative Affect Scale) by condition by exposure interaction.

CONCLUSIONS

The threat of a disulfiram-ethanol reaction appears to affect cue reactivity physiologically rather than subjectively. While the data does not show changes in subjective ratings, it is possible that there are alternative beneficial effects arising from other cognitive processes that are not captivated by self-reported craving scales, reflected by decreases in negative affect and blood pressure. From this perspective, disulfiram might be recast to be more acceptable to patients.