A number of methods have proved valuable in the shortand long-term management of alcoholic patients. The more important of these are admission to a detoxification or special hospital unit, rehabilitative therapy, aversion treatment, the use of disulfiram (Antabuse), and the participation in self-help organizations for recovery from alcoholism. Detoxification clinics and special hospital units for the treatment of alcoholism are now widely available. The physician should be aware of the community resources available for the management of this problem and should be prepared to take advantage of them in appropriate cases. Most inpatient programs include individual and group counseling, didactics about the illness and recovery, and family intervention. Outpatient treatment (of individuals or groups) is widely available, either from specialized facilities or from specialized therapists in general mental health facilities; family counseling is usually offered as well and is often beneficial. Most professional alcoholism treatment in the United States includes an introduction to the methods and utilization of Alcoholics Anonymous (AA; see below).
Disulfiram, less used in recent years, interferes with the metabolism of alcohol, so that a patient who takes both alcohol and disulfiram accumulates an inordinate amount of acetaldehyde in the tissues, resulting in nausea, vomiting, and hypotension, sometimes pronounced in degree. It is no longer considered necessary to demonstrate these effects to patients; it is sufficient to warn them of the severe reactions that may result if they drink while they have the drug in their bodies.
The opioid antagonist naltrexone (50 mg/d orally) or a long-acting injectable formulation has also been used for this purpose, with overall favorable results in numerous trials. The depot injectable form has the advantage of improving compliance in this population that is difficult to treat and to retain in clinical trials. The relevant trials and clinical implementation of naltrexone for alcohol dependence are summarized by Anton (2008). In Europe, modest success has been achieved with the GABA and glutamate modulator acamprosate (2,000 mg daily), but this drug is not yet available in the United States and some trials have shown it to be ineffective. Putatively, a novel approach has been to block the addicting effects of alcohol on the mesolimbic dopaminergic system by the use of anticonvulsants such as topiramate. Johnson and colleagues were able to demonstrate a reduction in alcoholic intake in patients taking this drug, in comparison to placebo, albeit over only a 12-week period. The use of these medications and the possible reasons for conflicting results between studies are given in a review by Swift. A complex randomized trial conducted by Anton and colleagues (2006) compared naltrexone, cognitive-behavioral therapy, and both, and found that abstinence was most likely, in the short period of 4 months, with the drug alone or when combined with the psychologic therapy; those who received the cognitive therapy but neither naltrexone or a placebo pill did somewhat worse.
Treatment with disulfiram is instituted only after the patient has been sober for several days, preferably longer. It should never be given to patients with cardiac or advanced liver disease. Should the patient drink while taking disulfiram, the ensuing reaction is usually severe enough to require medical attention, and a protracted spree can thus be prevented. Disulfiram may cause a polyneuropathy if continued over months or years, but this is a rare complication.