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Acamprosate is a drug that can increase abstinence rates. Its mechanism is not clearly defined, though it appears to block the excitatory activity in the brain (via NMDA Glutamate) and enhance the inhibitory system modulated by BAGA. It appears to have an effect on reducing cravings. Acamprosate is more effective alongside psychosocial interventions, and should not be prescribed in isolation. In addition to increasing the likelihood of abstinence, acamprosate has also been shown to reduce the number of drinks and number of drinking days in somebody who lapses to drinking, and such persons have reported that they do not need as much alcohol to gain the same level of feeling they desire. Acamprosate is given as two tablets (333 mg each) three times a day for those who weight 60 kg or more. Two tablets should be taken in the morning, and one tablet Midday and at night time. Renal function should be checked, ideally prior to commencing acamprosate -- and it is not recommended to be prescribed, if serum creatinine level is greater than 120 µ/l.
Side effects: On the whole acamprosate is a safe drug and side effects are generally minimal and transient in nature. Gasto-intestinal problems such as diarrhoea, nausea are most common, but rarely prevent continuation with the drug. The only contraindication to prescribing is in those who have severe liver damage (Childs-Pugh, grade C). Acamprosate can be prescribed by a GP, after liaising with Alcohol & Drug Treatment Service in your area.
Disulfiram is a drug that can help people stay abstinent from alcohol. It blocks one of the key metabolising enzymes of alcohol which leads to a build-up of acetaldehyde resulting in flushing, nausea, vomiting and cardiac instability. This so-called 'Antabuse reaction’ can be dangerous but rarely fatal. A person taking disulfiram must, therefore, be alcohol free before starting the medication and also since the enzymes are inhibited for some time after stopping disulfiram, must remain alcohol free for up to one week. Generally speaking Disulfiram is given to people who are struggling to remain sober and the fear of an adverse reaction to alcohol helps them to not go back to drinking again. Evidence suggests, it is most effective, if it taken in a supervised fashion – and this might be taken by the treatment provider or more usually by a carer.
Side effects: Due to the nature of the ‘Antabuse reaction’, it should not be prescribed to people with cardio vascular problems, including high blood pressure, history of stroke or heart attack, evidence of psychosis, epilepsy or diagnosis of Emotionally Unstable Personality Disorder (EUPD) because of impulsivity. Clearly, Disulfiram is dangerous in these conditions and should not be given to people with such a risk. Caution should also be used in those with a history of medical problems resulting in kidney or liver disease and those with diabetes. It is also not recommended for someone who is pregnant. Fulminant liver failure – in every rare instance [1 per every 20,000 treatments a year] Disulfiram can cause severe and rapid onset hepatotoxicity. If the patient on Disulfiram develops jaundice it should be stopped immediately and urgent medical advice sought. Prescribing may be taken into consideration for recovering from alcohol misuse person who is struggling to abstain and is motivated to remain sober. It is recommended to be used as an adjunct medication, rather than as a ‘magic pill’. Before starting someone on Disulfiram, Liver Function Test, U&Es and BP should be checked. The person who is to be prescribed Disulfiram needs to be made aware about the interaction with alcohol including those with some products that may contain alcohol such as:
mouthwashes and cough medicines.
In addition, some foods contain alcohol e.g. vinegar, cakes, etc.
If the individual who takes Disulfiram has consumed alcohol on top of the medication without an adverse reaction, then its effectiveness is likely to be reduced. Prescribing should stop and alternatives should be reviewed. Disulfiram can be prescribed by a GP (following the initiation by a specialist e.g. Drug & Alcohol Recovery Service).