Conclusions ment of these conditions must form an integral part The medical approach to alcoholism should include: of our ultimate responsibility: to rehabilitate the 1. Establishment of rational, sound criteria for treat- alcoholic patient. ment and identification of those patients who should be treated in-hospital or as out-patients. Bibliography 2. Evaluation of present treatment techniques and 1. Greenberg, L.: in "Alcohol and Civilization" ed. their improvement through controlled experimenta- S. P. Lucia, New York: McGraw-Hill, 1963. tion. Acute treatment and long-term rehabilitation 2. Koppanyi, T.: Problems in Acute Alcohol Poison- are not the exclusive responsibility of specialized ing. Quart. Stud. Alc. Suppl. No. 1, 1961. treatment facilities, but of all medical and other pro- J. fessionals in any community. 3. Thompson, G.: Alcoholism. Springfield: C. Thom- 3. Thorough study and evaluation of hospitalized as Publ. 1956. patients. 4. Goldberg, M., Hehir, R., and Hurowitz, M.: Intra- 4. Recognition that acute treatment, whether in or venous Triiodethyronine in acute Alcoholic Intoxica- out of hospital, could be the initial motivating force tion. New Eng. J. Med. 263: 1336-1339, 1960. to our ultimate goal of long-range treatment and re- 5. Newman, H. W., and Smith, M. E.: Triiodethyro- habilitation of the alcoholic patient. nine in Acute Alcoholic Intoxication. Nature 183: 689-690, 1959. Abstract The management of acute alcoholic conditions (acute Note: alcohol intoxication and acute alcohol withdrawal The complete bibliography (references 6-23) is avail- syndrome) is discussed. It is emphasized that the treat- able from CANADIAN FAMILY PHYSICIAN. Protective Drugs in Alcoholism Treatment PAUL DEVENYI, MD

CHRONIC ALCOHOLISM IS AN INTERNATIONAL PROBLEM. They are used as a "chemical fence" or an insurance It is often referred to as a "disease" nowadays, al- policy against drinking, since the patient knows that though physicians tend to shy away from it for sev- as long as the drug is in his system, he cannot drink, eral reasons. One is that it is a poorly defined clinical or if he does, he will be in trouble. entity and they have not been equipped with clearly outlined thrapeutic methods to deal with it effectively. Interference With Metabolism Another reason is that treating alcoholics is often an There are two kinds of protective drugs on the mar- unrewarding experience: these patients are demand- ket: disulfiram (Antabuse, Ayerst) and citrated ing, call at inconvenient times, do not pay their bills calcium carbimide (Temposil, Lederle). Their basic and do not get well. Furthermore, in spite of the over- pharmacological action is interference with the emphasized and over-simplified "disease concept", al- metabolism of acetaldehyde which is the first inter- coholism is being recognized as multifaceted, complex mediary product of alcohol oxidation. As a result, disorder in which socio-economic and psychological acetaldehyde concentration is increased in the blood, factors operate in addition to the physical-physiol- causing vasodilation, flushing, pounding headache, ogical ones. The problem is being approached by choking sensation, chest pain, nausea and vomiting. multiprofessional teams in which the physician has a Disulfiram was developed in Denmark in 1948.2 definite, if limited, role.' Since then, it has become a widely used aid in the The management of the acutely ill alcoholic indi- treatment of alcoholism. In the early years, higher vidual-both severe intoxication and subsequent with- doses were used, which accounted for some of its un- drawal syndrome-is clearly a medical responsibility. desirable side effects. With lower doses, side effects This, however, is a relatively simple, effective and seldom occur.3 self-limited phase of the management. After an alco- We begin therapy with 500 mgm. daily as a single holic has been helped through the acute illness, and dose and after five to seven days, reduce it to 250 his physical health restored, comes the more difficult mgm. daily on which the patient is maintained for task of keeping him sober. At this stage, non-medical an indefinite period. Perhaps the best time to take it professionals, even non-professionals-such as Alcoho- is at bedtime, because of its tendency to cause drowsi- lics Anonymous-have to assume an increasing help- ness, although with the above dosage this is very in- ing role, but physicians can continue to be of some frequently encountered. The patient is given ample assistance. One of the few specific aids in the doctor's explanation about the drug and is warned that it is armamantarium is the prescription of so-called "pro- slow to leave the body. If he drinks, he may still get tective drugs". an unpleasant reaction a week after he took his last Protective drugs against alcohol are defined as sub- pill. Besides drowsiness, other undesirable effects of stances that interfere with the metabolism of alcohol the drug have been reported, such as a metallic or in the body, thus causing an unpleasant reaction. garlicky taste or odor, decrease of sexual potency and

32 CANADIAN FAMILY PHYSICIAN * APRIL, 1969 dermatitis which probably represents a rare hyper- Before these drugs are prescribed, we make sure sensitivity reaction. Toxic psychosis has been de- that the patient acknowledges the existence of a scribed, (4) although there is still some controversy drinking problem and wants to give up alcohol. We about whether those cases represent true toxicity or point out to him that in spite of his best intentions, an underlying psychosis unmasked by abstinence. We abstaining may not be easy. The protective drugs act should emphasize that in our hands the drug turned as an insurance. They may give him peace of mind, out to be quite safe and side effects were seldom en- since once he takes his pill, he has no more decisions countered. to make that day-he knows he cannot drink. We try to convince the patient that the drug will help him, Contraindication but we do not push the issue too far. If he is still re- Hypersensitivity to disulfiram constitutes an absolute luctant and uses the familiar excuse of "trying to contraindication. Cardiovascular disease is often men- do it on his own", we let him go. Once he has been tioned as one of the major relative contraindications, exposed to the idea of these drugs, he will likely come not because the drug itself is contraindicated, but if forward and ask for them, if he failed on his own. the patient takes a drink, the ensuing reaction with We encourage our patients to take the drug them- its sudden hypotension may be dangerous. Psychotic selves and not to let their spouses "spoon feed" it to tendencies, severe renal damage or active liver disease them, since in our experience this can only cause re- may be considered among relative contraindications, sentment in an otherwise well-intentioned patient. although we should point out that we do not hesitate We have known alcoholics, who originally wanted to to give it to patients with alcoholic fatty liver or take disulfiram on their own, but because their wives stable cirrhosis in whom further drinking may be overenthusiastically administered it, they cheated in much more damaging to the liver than disulfiram it- every possible way: holding it under their tongues self. One of our major prerequisities for prescribing and later spitting it out, vomiting it up or even re- it is that the patient accepts the idea voluntarily. placing it in the box with sodium bicarbonate tablets. Citrated calcium carbimide was developed in Can- We most certainly discourage the wives (or hus- ada in 1956.5 It is an addition to, or alternative for, bands) to try to mix the drug in the patient's coffee: disulfiram therapy and the difference between the two That doesn't work. drugs should be understood. Several centres still insist on giving a "test reaction" Citrated calcium carbimide causes a similar reac- to patients on protective drugs; that is, giving them a tion to disulfiram with alcohol, but the reaction is measured dose of alcohol. We ourselves do not use less predictable-and often milder. Its absorption and this method; our patients take our word for it that if accumulation is much faster-a matter of hours-and they drink, they will be sick. so is its elimination. Thus, a reaction with alcohol The length of treatment cannot be stated in defi- may occur in people who took citrated calcium car- nite terms. One should insist that the patient should bimide, within a few hours, whereas they may have stay on the drug for at least six to 12 months or for as to take disulfiram for several days before any effect long as he and/or the physician thinks it necessary. All patients on protective drugs should carry a will take place6. By the same token, alcohol will of likely cause no reaction 24 hours after the last cal- card to this effect which also states that in case cium carbimide dose, whereas reaction could occur sickness or emergency alcohol should not be given. several days after disulfiram was discontinued. Cit- The severity of reaction with alcohol shows some rated calcium carbimide has virtually no side effects. individual variations, but in most cases the disulfiram- Disulfiram is the cheaper of the two drugs. alcohol reaction will be severe enough to get the pa- tient to the emergency department of a hospital. The usual dose of citrated calcium carbimide is 50 the mgm. twice daily. In certain cases, oxygen administration and usual anti-shock measures will be necessary. Injection of an antihistamine often gives fast symptomatic relief. Which One to Choose? Ascorbic acid and iron salts have been recommended Of the two available protective drugs, our first choice as inactivators of disulfiram, thus shortening the re- in the majority of cases is disulfiram, because of its action period. 4 more predictable effect, its more prolonged action and lower cost. Citrated calcium carbimide however, has Abstract a definite place in therapy, under the following con- The clinical application of the protective drugs (di- ditions: sulfiram and citrated calcium carbimide) is discussed a) When hypersensitivity to disulfiram is present. of chronic b) When side effects make the discontinuation of di- as therapeutic aids in the management sulfiram necessary. alcoholism. c) When immediate protection is desired, citrated calcium carbimide can be administered along with Bibliography disulfiram for the first few days and thereafter, only 1. Devenyi, P.: Medical Treatment and Study of Al- the latter has to be continued. coholism Addictions, 15 No. 4: 1, 1968. d) In cardiovascular disease, both drugs have to be 2. Hald, J. and Jacobsen, E.: Drug sensitizing organ- given with caution, but the lesser reaction of alcohol ism to ethyl alcohol. Lancet, 2B, 1001, 1948. with citrated calcium carbimide may make it the References 3-6 available from CANADIAN FAMILY drug of choice if this kind of protection is desirable. PHYSICIAN.

CANADIAN FAMILY PHYSICIAN * APRIL, 1969