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Axelrath S. Disulfiram Should Remain Second-line Treatment for Most Patients with Alcohol Use Disorder. J Addict Med 2024:01271255-990000000-00368. [PMID: 39150144 DOI: 10.1097/adm.0000000000001360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Alcohol use disorder (AUD) is responsible for a significant burden of medical, economic, and social harm globally and across the United States. Currently, only three FDA-approved medications for AUD are available, and most patients with AUD never receive pharmacotherapy. Disulfiram, the first medication that FDA approved for treatment of AUD, is recommended as a second-line treatment option by several national treatment guidelines citing safety concerns and lack of high-quality comparative studies. In this issue, Holt argues that disulfiram should be reclassified as a first-line treatment for AUD based on promising open-label randomized controlled trials (RCTs) for disulfiram as a behavioral intervention. Review of the literature suggests that disulfiram can be a useful treatment for a highly selected group of patients with no medical or psychiatric contraindications, high motivation for abstinence, and adequate family support. Unfortunately, many patients with AUD, a disorder characterized by high rates of medical and psychiatric multimorbidity and social vulnerability, fall outside of this narrow selection criteria. Prescribers should consider other FDA-approved medications as first-line treatment options for most patients with AUD, reserving disulfiram for the rare patients in whom the potential for benefit clearly outweighs risk of harm.
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Abstract
Alcohol use disorder (AUD) is a highly prevalent but severely under-treated disorder, with only three widely-approved pharmacotherapies. Given that AUD is a very heterogeneous disorder, it is unlikely that one single medication will be effective for all individuals with an AUD. As such, there is a need to develop new, more effective, and diverse pharmacological treatment options for AUD with the hopes of increasing utilization and improving care. In this qualitative literature review, we discuss the efficacy, mechanism of action, and tolerability of approved, repurposed, and novel pharmacotherapies for the treatment of AUD with a clinical perspective. Pharmacotherapies discussed include: disulfiram, acamprosate, naltrexone, nalmefene, topiramate, gabapentin, varenicline, baclofen, sodium oxybate, aripiprazole, ondansetron, mifepristone, ibudilast, suvorexant, prazosin, doxazosin, N-acetylcysteine, GET73, ASP8062, ABT-436, PF-5190457, and cannabidiol. Overall, many repurposed and novel agents discussed in this review demonstrate clinical effectiveness and promise for the future of AUD treatment. Importantly, these medications also offer potential improvements towards the advancement of precision medicine and personalized treatment for the heterogeneous AUD population. However, there remains a great need to improve access to treatment, increase the menu of approved pharmacological treatments, and de-stigmatize and increase treatment-seeking for AUD.
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Pontzen N, Schomerus G, Steinberg H. [The Practice of Medicinal Alcohol Withdrawal in the Psychiatry of the GDR - The Methods of Aversion and Disulfiram Treatment]. PSYCHIATRISCHE PRAXIS 2021; 49:375-381. [PMID: 34921367 DOI: 10.1055/a-1667-9569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The aversion and disulfiram treatment used for alcohol withdrawal in the GDR are described in their mode of action, application and in their therapeutic outcome. METHOD In this literature study primarily works published in the GDR itself were identified, analysed and contextualised. RESULTS While aversion therapy caused aversion to alcohol through the development of a conditioned reflex, disulfiram has an alcohol-sensitising effect. In therapeutic practice, the aversion therapy was largely replaced by disulfiram during the 1970 s, although there was no general guideline for its use. Disulfiram therapy could prove itself as a drug adjuvant, but was successively marginalised by psycho- and socio-therapeutic approaches. CONCLUSION Both aversion and disulfiram therapy were the central drug procedures for the treatment of people with alcohol problems in the GDR psychiatric system, were applied inconsistently, and complemented a complex therapeutic regime.
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Affiliation(s)
- Nadja Pontzen
- Forschungsstelle für die Geschichte der Psychiatrie, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Medizinische Fakultät der Universität Leipzig
| | - Georg Schomerus
- Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Leipzig
| | - Holger Steinberg
- Forschungsstelle für die Geschichte der Psychiatrie, Klinik und Poliklinik für Psychiatrie und Psychotherapie, Medizinische Fakultät der Universität Leipzig
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Segher K, Huys L, Desmet T, Steen E, Chys S, Buylaert W, De Paepe P. Recognition of a disulfiram ethanol reaction in the emergency department is not always straightforward. PLoS One 2020; 15:e0243222. [PMID: 33270785 PMCID: PMC7714420 DOI: 10.1371/journal.pone.0243222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 11/17/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Disulfiram is an adjunct in the treatment of alcohol use disorders, but case reports indicate that disulfiram ethanol reactions are not always recognized in the emergency department. Our first aim is to remind of this risk with two case reports of life-threatening reactions not immediately considered by the emergency physician. The second aim is to estimate the probability that a disulfiram reaction goes unrecognized with the use of a retrospective study of patients admitted to the emergency department. METHODS Clinical files of patients admitted between October 1, 2010 and September 30, 2014 to the emergency department were retrospectively screened for the key words "ethanol use" and "disulfiram". Their diagnoses were then scored by a panel regarding the probability of an interaction. RESULTS Seventy-nine patients were included, and a disulfiram-ethanol reaction was scored as either 'highly likely', 'likely' or 'possible' in 54.4% and as 'doubtful' or 'certainly not present' in 45.6% of the patients. The interrater agreement was 0.71 (95% CI: 0.64-0.79). The diagnosis was not considered or only after a delay in 44.2% of the patients with a 'possible' to 'highly likely' disulfiram interaction. One patient with a disulfiram overdose died and was considered as a 'possible' interaction. DISCUSSION AND CONCLUSIONS A disulfiram ethanol interaction can be life threatening and failure to consider the diagnosis in the emergency department seems frequent. Prospective studies with documentation of the intake of disulfiram and evaluation of the value of acetaldehyde as a biomarker are needed to determine the precise incidence. Improving knowledge of disulfiram interactions and adequate history taking of disulfiram intake may improve the care for patients.
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Affiliation(s)
- Kristof Segher
- Department of Emergency Medicine, AZ Alma, Eeklo, Belgium
| | - Liesbeth Huys
- Department of Pharmacy, Ghent University Hospital, Ghent, Belgium
| | - Tania Desmet
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Evi Steen
- Department of Emergency Medicine, AZ Sint-Jan, Brugge, Belgium
| | - Stefanie Chys
- Department of Emergency Medicine, Algemeen Stedelijk Ziekenhuis (ASZ), Aalst, Belgium
| | - Walter Buylaert
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
| | - Peter De Paepe
- Department of Emergency Medicine, Ghent University Hospital, Ghent, Belgium
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Soyka M, Mutschler J. Treatment-refractory substance use disorder: Focus on alcohol, opioids, and cocaine. Prog Neuropsychopharmacol Biol Psychiatry 2016; 70:148-61. [PMID: 26577297 DOI: 10.1016/j.pnpbp.2015.11.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/23/2015] [Accepted: 11/11/2015] [Indexed: 12/20/2022]
Abstract
Substance use disorders are common, but only a small minority of patients receive adequate treatment. Although psychosocial therapies are effective, relapse is common. This review focusses on novel pharmacological and other treatments for patients with alcohol, opioid, or cocaine use disorders who do not respond to conventional treatments. Disulfiram, acamprosate, and the opioid antagonist naltrexone have been approved for the treatment of alcoholism. A novel, "as needed" approach is the use of the mu-opioid antagonist and partial kappa agonist nalmefene to reduce alcohol consumption. Other novel pharmacological approaches include the GABA-B receptor agonist baclofen, anticonvulsants such as topiramate and gabapentin, the partial nicotine receptor agonist varenicline, and other drugs. For opioid dependence, opioid agonist therapy with methadone or buprenorphine is the first-line treatment option. Other options include oral or depot naltrexone, morphine sulfate, depot or implant formulations, and heroin (diacetylmorphine) in treatment-refractory patients. To date, no pharmacological treatment has been approved for cocaine addiction; however, 3 potential pharmacological treatments are being studied, disulfiram, methylphenidate, and modafinil. Pharmacogenetic approaches may help to optimize treatment response in otherwise treatment-refractory patients and to identify which patients are more likely to respond to treatment, and neuromodulation techniques such as repeated transcranial magnetic stimulation and deep brain stimulation also may play a role in the treatment of substance use disorders. Although no magic bullet is in sight for treatment-refractory patients, some novel medications and brain stimulation techniques have the potential to enrich treatment options at least for some patients.
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Affiliation(s)
- Michael Soyka
- Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstrasse 7, 80336 Munich, Germany; Privatklinik Meiringen, Postfach 612, CH-3860 Meiringen, Switzerland.
| | - Jochen Mutschler
- Center for Addictive Disorders, Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Selnaustrasse 9, 8001 Zurich, Switzerland
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Caputo F, Vignoli T, Grignaschi A, Cibin M, Addolorato G, Bernardi M. Pharmacological management of alcohol dependence: from mono-therapy to pharmacogenetics and beyond. Eur Neuropsychopharmacol 2014; 24:181-91. [PMID: 24182622 DOI: 10.1016/j.euroneuro.2013.10.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 10/06/2013] [Accepted: 10/09/2013] [Indexed: 01/01/2023]
Abstract
Almost 10% of the world's population is affected by alcohol use disorders, and the treatment of alcohol dependence (AD) still remains a challenge. Patients with AD can differ in many traits. Three drugs (disulfiram, naltrexone, and acamprosate) have been approved by the FDA for the treatment of AD, and in some European countries sodium oxybate is also approved for this purpose. Combined pharmacological therapy has not provided such convincing results. Considering the fact that the "ideal" and effective drug for all types of alcoholic patients does not exists, the future challenge will be to identify a personalized approach. Recent data has shown that this objective can be achieved by investigating the genetic variability of the patient. Moreover, the use of replacement molecules can probably be considered an advantageous therapeutic opportunity (i.e. sodium oxybate). In addition, reduction of alcohol consumption is increasingly accepted as a viable treatment goal, and the use of nalmefene "as-needed" (a pharmacological approach similar to naltrexone, but, possibly, with lower hepatotoxicity) may help in the treatment of AD. Thus, it is important to stress that a pharmacological approach to treat AD should be preceded by the definition of patient characteristics; this may help in the choice of the most appropriate drug and it can be done more easily when more pharmacological options approved for the treatment of AD are also available.
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Affiliation(s)
- Fabio Caputo
- Department of Internal Medicine, SS Annunziata Hospital, Cento, Ferrara, Italy; "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Italy.
| | - Teo Vignoli
- Unit for Addiction Treatment, Department of Mental Health, Lugo, Ravenna, Italy
| | - Alice Grignaschi
- "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Italy
| | - Mauro Cibin
- Department of Addictive Behaviours, Dolo, Venice, Italy
| | | | - Mauro Bernardi
- "G. Fontana" Centre for the Study and Multidisciplinary Treatment of Alcohol Addiction, Department of Clinical Medicine, University of Bologna, Italy
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Wackernah RC, Minnick MJ, Clapp P. Alcohol use disorder: pathophysiology, effects, and pharmacologic options for treatment. Subst Abuse Rehabil 2014; 5:1-12. [PMID: 24648792 PMCID: PMC3931699 DOI: 10.2147/sar.s37907] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Alcohol use disorders (AUD) continue to be a concerning health issue worldwide. Harmful alcohol use leads to 2.5 million deaths annually worldwide. Multiple options exist for the management of dependence on alcohol, not all of which are approved by drug-regulating agencies. Current practice in treating AUD does not reflect the diversity of pharmacologic options that have potential to provide benefit, and guidance for clinicians is limited. Few medications are approved for treatment of AUD, and these have exhibited small and/or inconsistent effects in broad patient populations with diverse drinking patterns. The need for continued research into the treatment of this disease is evident in order to provide patients with more specific and effective options. This review describes the neurobiological mechanisms of AUD that are amenable to treatment and drug therapies that target pathophysiological conditions of AUD to reduce drinking. In addition, current literature on pharmacologic (both approved and non-approved) treatment options for AUD offered in the United States and elsewhere are reviewed. The aim is to inform clinicians regarding the options for alcohol abuse treatment, keeping in mind that not all treatments are completely successful in reducing craving or heavy drinking or increasing abstinence.
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Affiliation(s)
- Robin C Wackernah
- Department of Pharmacy Practice, School of Pharmacy, Rueckert-Hartman College for Health Professions, Regis University, Denver, CO, USA
| | - Matthew J Minnick
- Department of Pharmacy Practice, School of Pharmacy, Rueckert-Hartman College for Health Professions, Regis University, Denver, CO, USA
| | - Peter Clapp
- Department of Pharmaceutical Sciences, School of Pharmacy, Rueckert-Hartman College for Health Professions, Regis University, Denver, CO, USA
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Clapp P. Current progress in pharmacologic treatment strategies for alcohol dependence. Expert Rev Clin Pharmacol 2013; 5:427-35. [PMID: 22943122 DOI: 10.1586/ecp.12.31] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Alcoholism is a progressive neurological disorder that represents one of the leading preventable causes of morbidity and mortality in the USA. Individuals with alcohol dependence may exhibit differences in their sensitivity to intoxication, the age at which they begin heavy drinking or the presentation of comorbid psychiatric illness. The heterogeneous nature of the disorder has complicated efforts to predict treatment outcomes, indicating a need for improved diagnostic and therapeutic approaches. Pharmaceutical development has focused on treating the symptoms of alcohol withdrawal, reducing consumption of and craving for alcohol, preventing relapse and treating associated psychiatric problems. Current therapies may be optimized by combining psychosocial and pharmacologic approaches to treat alcoholic patients with the most appropriate regimen to achieve the desired therapeutic outcome. This article will describe the neurobiological mechanisms of dependence on alcohol in brief and review major medications approved for the treatment of alcoholism with regard to recent clinical evidence for the therapeutic efficacy of each agent. Investigations on the use of drugs with other indications (e.g., antidepressants and anticonvulsants) to target alcohol-dependent subtypes will also be discussed.
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Affiliation(s)
- Peter Clapp
- Regis University School of Pharmacy, Rueckert-Hartman College of Health Professions, Denver, CO, USA.
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Mutschler J, Eifler S, Dirican G, Grosshans M, Kiefer F, Rössler W, Diehl A. Functional Social Support within a Medical Supervised Outpatient Treatment Program. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2012; 39:44-9. [DOI: 10.3109/00952990.2012.677889] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Jochen Mutschler
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, University of Heidelberg,
Mannheim, Germany
- Department of General and Social Psychiatry, Psychiatric University Hospital Zurich,
Zürich, Switzerland
| | - Sarah Eifler
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, University of Heidelberg,
Mannheim, Germany
| | - Gülseren Dirican
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, University of Heidelberg,
Mannheim, Germany
| | - Martin Grosshans
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, University of Heidelberg,
Mannheim, Germany
| | - Falk Kiefer
- Department of Addictive Behavior and Addiction Medicine, Central Institute of Mental Health, University of Heidelberg,
Mannheim, Germany
| | - Wulf Rössler
- Department of General and Social Psychiatry, Psychiatric University Hospital Zurich,
Zürich, Switzerland
| | - Alexander Diehl
- Department of Psychiatry, Klinikum Braunschweig, Academic Teaching Hospital,
Braunschweig, Germany
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