Disulfiram is far better than its reputation?
Disulfiram (Antabuse) is far better than its reputation and deserve to be highlighted in a different way than what is currently happening in Läkemedelsboken, in Wise list and the Karolinska Institute's courses in dependent learning.
Disulfiram in Läkemedelsboken 2009-2010
In the chapter on addictions at page 1011, it can be read under the heading 'Pharmacological long-term treatment with relapse", "Acamprosate and Naltrexone are equivalent - Disulfiram, is the odd' preparation with the weakest evidence based on modern criteria". "Even Stockholm County Council disparages the value of Disulfiram treatment when the Wise list no longer recommends the preparation. We wish to state categorically assert that this view is incorrect and not based on scientific evidence or clinical experience, and that, if put into practice, can be seriously detrimental to alcohol dependence patients.
Disulfiram in Wise list
Wise list refers inter alia to the MPA treatment guidelines from 2006 and the Board's national guidelines. In none of these documents are found, however, support the view that squares out of Wise list or Läkemedelsboken. Thus one finds in the MPA recommendations that "Disulfiram, Acamprosate and Naltrexone all have a place in therapy" (recommendation grade A) and in the national guidelines that "Disulfiram has been shown to have effect when the intake is under the supervision of another person, preferably a processor.
Other Disulfiram studies
In addition, there are currently more certainly open, but randomized comparative studies which clearly shows that Disulfiram in clinical practice has the same good therapeutic potential, if not better, than both Acamprosate as Naltrexone have. In Laaksonens et al very ambitious trearmsstudie, (Disulfiram vs Naltrexone vs Acamprosate) with about 80 patients in each arm, one finds for example that Disulfiram is significantly better than both Naltrexone and Acamprosate regarding time to first intake of more than 60 g alcohol, time to ingestion of alcohol at all and the number of sober days, while retention was similar across groups.
Further more, the reputed Kiefer Group recently conducted a retrospective study of 353 alcohol-dependent patients and reached the following conclusion: "This Study Supports the thesis That supervised DSF [Disulfiram] is an important component of alcoholism treatment, and it Appears to Be more Effective Than the treatment with ACP [Acamprosate] Particularly in patients with a long duration of alcohol dependence.
Our many colleagues' clinical experience is also in full compliance with these reports. For example, North Hem Clinic in Gothenburg, where the two of us are active, have Disulfiram treatment, supervised both by a Disulfiram clinic as through relatives, supervisors, etc., for decades been a very useful tool in the treatment program for alcoholics used in this clinic. The same experience is reported from Addiction Centre in Malmö and Mary Depending Cent-place in Stockholm. Treatment with Disulfiram in Probation provides many inmates with alcohol to get leave.
It has also been mentioned in various contexts, including the dependent courses Karolinska Institute conveys that Disulfiram has no effect on the brain. This is also a myth that we want to dispel. Disulfiram has, through its Cu2 +-chelating ability, an inhibitory effect on the enzyme dopamine b-hydroxylase, an enzyme that converts dopamine to norepinephrine in the brain, leading to an imbalance between the noradrenergic and dopaminergic networks. This mechanism may be one of many explanations for the Disulfiram shown to have positive therapeutic effects even in the treatment of opioid and alcohol addiction, in studies using advanced statistical analysis did not suggest that these effects would be secondary to a reduction in alcohol consumption.
Conclusion on Disulfiram
Of course, there are several confounding factors that might explain that Disulfiram appears to be better than both Naltrexone as Acamprosate, but in our determination that they can not justify a dismissal of Disulfiram as an important component of a treatment program for alcoholics.
On the basis of the above, we therefore urge those responsible for Läkemedelsboken, Wise list and Dependent courses at KI to reconsider its negative attitude to Disulfiram and, not least for patients' sake, promptly make the necessary changes to it must be scientifically and clinically credible.
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