Dr. Avinash De Sousa

 State government aided hospital.  Private psychiatric set up – nursing home.  Out patient private practice.  Private general hospital with a large psychiatric set up.

 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.

 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.

 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.

 Three open randomized trials ( ) 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.

 Age between years.  DSM-IV criteria for alcohol dependence.  All had a stable and supportive family environment.  One responsible family member.  Importance of supervised Disulfiram therapy

 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.

 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.

 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.

 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.

 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.

 Sertraline mg and  Escitalopram 5-10mg 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.

 Accumulated days of abstinence.  Days until the first relapse (defined as consuming more than 5 alcoholic drinks or 40gm alcohol in 24 hours).

 Craving measures.  GGT measured every 3 months.  Discontinuation of treatment.  Drop out from the study

 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.

 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)  Disulfiram superior to Naltrexone in female alcoholics. (unpublished work)

 Disulfiram versus a Combined Naltrexone and Acamprosate regime  Does Acamprosate addition enhance Disulfiram therapy.  Disulfiram and Psychotherapy. (All studies would be complete by )

 The Helsinki Disulfiram study.  Disulfiram superior to Acamprosate.  OLITA Study.  Other small but important studies.

 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.

 Incorporating Disulfiram into psychotherapy.  Disulfiram in patients with comorbid psychiatric disorders.  Where does Disulfiram stand today in the modern pharmacotherapy of alcoholism.

 Disulfiram is a treatment option that cannot be ignored.  Psychiatrists worldwide need to be trained.  Oral Disulfiram VS Long acting Naltrexone or Naltrexone implants  Effective compliance monitoring.

 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.