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      Packages of Care for Alcohol Use Disorders in Low- And Middle-Income Countries

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      Author(s): 1 , * , 1 , 2 , 3
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      Publication date (Electronic):
      Journal: PLoS Medicine
      Publisher: Public Library of Science

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          Abstract

          In the fourth in a series of six articles on packages of care for mental disorders in low- and middle-income countries, Vivek Benegal and colleagues discuss the treatment of alcohol use disorders.

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          Alcohol and public health.

          Robin Room, Thomas Babor, Jürgen Rehm (2005)
          Alcoholic beverages, and the problems they engender, have been familiar fixtures in human societies since the beginning of recorded history. We review advances in alcohol science in terms of three topics: the epidemiology of alcohol's role in health and illness; the treatment of alcohol use disorders in a public health perspective; and policy research and options. Research has contributed substantially to our understanding of the relation of drinking to specific disorders, and has shown that the relation between alcohol consumption and health outcomes is complex and multidimensional. Alcohol is causally related to more than 60 different medical conditions. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension. Treatment research shows that early intervention in primary care is feasible and effective, and a variety of behavioural and pharmacological interventions are available to treat alcohol dependence. This evidence suggests that treatment of alcohol-related problems should be incorporated into a public health response to alcohol problems. Additionally, evidence-based preventive measures are available at both the individual and population levels, with alcohol taxes, restrictions on alcohol availability, and drinking-driving countermeasures among the most effective policy options. Despite the scientific advances, alcohol problems continue to present a major challenge to medicine and public health, in part because population-based public health approaches have been neglected in favour of approaches oriented to the individual that tend to be more palliative than preventative.
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            Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial.

            Helen Pettinati, Stephanie O’Malley, W. Ehrich … (2005)
            Alcohol dependence is a common disorder associated with significant morbidity and mortality. Naltrexone, an opioid antagonist, has been shown to be effective for treatment of alcohol dependence. However, adherence to daily oral pharmacotherapy can be problematic, and clinical acceptance and utility of oral naltrexone have been limited. To determine efficacy and tolerability of a long-acting intramuscular formulation of naltrexone for treatment of alcohol-dependent patients. A 6-month, randomized, double-blind, placebo-controlled trial conducted between February 2002 and September 2003 at 24 US public hospitals, private and Veterans Administration clinics, and tertiary care medical centers. Of the 899 individuals screened, 627 who were diagnosed as being actively drinking alcohol-dependent adults were randomized to receive treatment and 624 received at least 1 injection. An intramuscular injection of 380 mg of long-acting naltrexone (n = 205) or 190 mg of long-acting naltrexone (n = 210) or a matching volume of placebo (n = 209) each administered monthly and combined with 12 sessions of low-intensity psychosocial intervention. The event rate of heavy drinking days in the intent-to-treat population. Compared with placebo, 380 mg of long-acting naltrexone resulted in a 25% decrease in the event rate of heavy drinking days (P = .02) [corrected] and 190 mg of naltrexone resulted in a 17% decrease (P = .07). Sex and pretreatment abstinence each showed significant interaction with the medication group on treatment outcome, with men and those with lead-in abstinence both exhibiting greater treatment effects. Discontinuation due to adverse events occurred in 14.1% in the 380-mg and 6.7% in the 190-mg group and 6.7% in the placebo group. Overall, rate and time to treatment discontinuation were similar among treatment groups. Long-acting naltrexone was well tolerated and resulted in reductions in heavy drinking among treatment-seeking alcohol-dependent patients during 6 months of therapy. These data indicate that long-acting naltrexone can be of benefit in the treatment of alcohol dependence.
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              Oral topiramate for treatment of alcohol dependence: a randomised controlled trial.

              Eric Johnson, Luyan Ma, C C DiClemente … (2003)
              Topiramate, a sulphamate fructopyranose derivative, might antagonise alcohol's rewarding effects associated with abuse liability by inhibiting mesocorticolimbic dopamine release via the contemporaneous facilitation of gamma-amino-butyric acid activity and inhibition of glutamate function. We aimed to see whether topiramate was more effective than placebo as a treatment for alcohol dependence. We did a double-blind randomised controlled 12-week clinical trial comparing oral topiramate and placebo for treatment of 150 individuals with alcohol dependence. Of these 150 individuals, 75 were assigned to receive topiramate (escalating dose of 25-300 mg per day) and 75 had placebo as an adjunct to weekly standardised medication compliance management. Primary efficacy variables were: self-reported drinking (drinks per day, drinks per drinking day, percentage of heavy drinking days, percentage of days abstinent) and plasma gamma-glutamyl transferase, an objective index of alcohol consumption. The secondary efficacy variable was self-reported craving. At study end, participants on topiramate, compared with those on placebo, had 2.88 (95% CI -4.50 to -1.27) fewer drinks per day (p=0.0006), 3.10 (-4.88 to -1.31) fewer drinks per drinking day (p=0.0009), 27.6% fewer heavy drinking days (p=0.0003), 26.2% more days abstinent (p=0.0003), and a log plasma gamma-glutamyl transferase ratio of 0.07 (-0.11 to -0.02) less (p=0.0046). Topiramate-induced differences in craving were also significantly greater than those of placebo, of similar magnitude to the self-reported drinking changes, and highly correlated with them. Topiramate (up to 300 mg per day) is more efficacious than placebo as an adjunct to standardised medication compliance management in treatment of alcohol dependence.
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                Author and article information

                Contributors
                : Role: Academic Editor
                Journal
                Journal ID (nlm-ta): PLoS Med
                Journal ID (publisher-id): PLoS
                Journal ID (pmc): plosmed
                Title: PLoS Medicine
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Print): 1549-1277
                ISSN (Electronic): 1549-1676
                Publication date Collection: October 2009
                Publication date (Print): October 2009
                Publication date (Electronic): 27 October 2009
                Volume: 6
                Issue: 10
                Electronic Location Identifier: e1000170
                Affiliations
                [1 ]Deaddiction Centre, National Institute of Mental Health and Neurosciences, Bangalore, India
                [2 ]University of Uyo, Uyo, Nigeria
                [3 ]Centre for Research and Information on Substance Abuse (CRISA), Uyo, Nigeria
                London School of Hygiene and Tropical Medicine, United Kingdom
                Author notes

                ICMJE criteria for authorship read and met: VB PKC ISO. Wrote the first draft of the paper: VB PKC. Contributed to the writing of the paper: VB PKC ISO.

                Article
                Publisher ID: 09-PLME-ND-1917R1
                DOI: 10.1371/journal.pmed.1000170
                PMC ID: 2761617
                PubMed ID: 19859536
                SO-VID: 730b4c4b-eac1-44b4-9d15-b77a665b9b4f
                Copyright © Benegal et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Related
                Packages of Care for Depression in Low- and Middle-Income CountriesPackages of Care for Epilepsy in Low- and Middle-Income CountriesPackages of Care for Schizophrenia in Low- and Middle-Income CountriesPackages of Care for Mental, Neurological, and Substance Use Disorders in Low- and Middle-Income Countries
                Page count
                Pages: 7
                Categories
                Subject: Neglected Diseases
                Subject: Mental Health/Substance Abuse
                Subject: Public Health and Epidemiology/Social and Behavioral Determinants of Health

                ScienceOpen disciplines: Medicine
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                ScienceOpen disciplines: Medicine

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