The Stapleford Centre, 25a Eccleston Street, London SW1W 9NP, UK
(Received 19 March 2003; accepted 19 March 2003)
The Randomised Controlled Trial by Niederhofer et al.(2003) describing the successful use of cyanamide in a group of alcohol-misusing adolescents, is further and convincing evidence of the effectiveness of deterrent or antagonist medication in the management of some types of substance misuse. However, despite the obvious similarities in mode of action between cyanamide and disulfiram, I am puzzled that the above authors made absolutely no mention of the use of disulfiram in treatment.
Ironically, their only reference to disulfiram is to a paper which compares its hepatotoxicity with that of cyanamide. Yet the literature strongly suggests that, whereas cyanamide causes histological changes in many patients, disulfiram causes only rare and idiosyncratic hepatotoxicity, which is commoner in women and is probably due to nickel sensitivity from costume jewellery (Brewer and Hardt, 1999).
Although Niederhofer et al.(2003) did not specifically mention it, their paper gives the impression that the patients in this study were subjected to unusually high levels of supervision and control and that the treatment programme did not ignore the very important issue of compliance with medication. This necessarily involves a degree of supervision. Perhaps the main reason for the relatively infrequent use of deterrent medication is the failure of many reviewers of the literature to note the crucial distinction between those studies in which the administration of medication was supervised, which are almost universally positive at statistically significant levels, and those studies in which medication was unsupervised, which almost universally show no more effectiveness than placebo medication (Brewer et al., 2000
; Brewer and Streel, 2003
). Niederhofer et al.(2003)
rightly draw attention to the probable superiority of deterrent medications to drugs, such as naltrexone and acamprosate, in alcoholism treatment. They could have strengthened their argument by mentioning studies comparing disulfiram with naltrexone or acamprosate which support that view (see, e.g. Carroll et al., 1993
)
Finally, it would be interesting to know why Niederhofer et al.(2003) chose a drug which needs to be given three times daily when they could have used disulfiram, which only needs to be given once daily or even thrice weekly. Nevertheless, I congratulate them on a well-planned study in a group of patients who are often resistant to treatment. The above authors stated that alcoholism in adolescence is very likely to become an important problem within the next few decades. Perhaps the youth of Salzburg are unusually docile: many of us in Britain would say that the problem is already important and has a significant and unpleasant impact on the life of our cities.
REFERENCES
Brewer, C. and Hardt, F. (1999) Preventing disulfiram hepatitis in alcohol abusers: inappropriate guidelines and the significance of nickel allergy. Addiction Biology 4, 303308.[CrossRef][ISI]
Brewer, C., Meyers, R. J. and Johnsen, J. (2000) Does disulfiram help to prevent relapse in alcohol abuse? CNS Drugs 14, 329341.[ISI]
Brewer, C. and Streel, E. (2003) Learning the language of abstinence in addiction treatment: some similarities between relapse-prevention with disulfiram, naltrexone and other pharmacological antagonists and intensive immersion methods of foreign language teaching. Substance Abuse 24, (in press).
Carroll, K., Ziedonis, D., OMalley, S., McCance-Katz, E., Gordon, L. and Rounsaville, B. (1993) Pharmacologic interventions for alcohol and cocaine abusing individuals: A pilot study of disulfiram vs naltrexone. American Journal of Addictions 2, 7779.
Niederhofer, H., Staffen, W. and Mair, A. (2003) Comparison of cyanamide and placebo in the treatment of alcohol dependence of adolescents. Alcohol and Alcoholism 38, 5053.
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