Why is Disulfiram Superior to Acamprosate in the Routine Clinical Setting? A Retrospective Long-term Study in 353 Alcohol-dependent Patients

Alexander Diehl; Lisa Ulmer; Jochen Mutschler; Hans Herre; Bertram Krumm; Bernhard Croissant; Karl Mann; Falk Kiefer

Disclosures

Alcohol Alcohol. 2010;45(3):271-277. 

In This Article

Discussion

This retrospective study of pharmacotherapeutic relapse prevention within routine treatment of alcohol dependence suggests that supervised treatment with DSF is more effective than treatment (unsupervised) with ACP, a conclusion supported by the fact that subjects receiving treatment with DSF tended to have had at baseline a longer duration of alcohol dependence, higher amounts of daily alcohol consumption and more previous detoxification treatments than the ACP patients. These baseline differences are not surprising since in Germany as well as in several other countries, DSF is usually not a first choice treatment, which results in a selection of patients with a longer and more unfavourable course of disease. Nevertheless, patients receiving supervised DSF treatment benefited and in fact showed better outcomes than subjects given ACP treatment. More precisely, subjects from the DSF group show longer time to the first alcohol relapse and a higher cumulative alcohol abstinence achieved within outpatient treatment. Furthermore, the rate of participation in the outpatient treatment programme is higher in patients assigned to DSF compared to patients assigned to ACP. Our evaluation in routine care adds to the results of several randomized trials (Carroll et al., 1993; de Sousa and de Sousa, 2004, 2005; Laaksonen et al., 2008), which found that supervised DSF tends to be more effective than ACP or NTX.

It seems probable that these results are due not only to the pharmacotherapy per se but also because of the close monitoring and high-frequency contact between patient and professional, which is necessary for successful treatment with DSF. Indeed, we are not only testing the effect of these pharmacological substances but also differences between the treatment package in which DSF and ACP are usually embedded. The non-pharmacological, psychological parts of these packages differ significantly between DSF and ACP (Ehrenreich and Krampe, 2004). The high-frequency contact with professionals in the supervised DSF concept persists despite more adverse drug reactions in the DSF group. Krampe et al. (2006) reason that a supervised long-term DSF treatment implies a psychological rather than a pharmacological action of DSF.

One may argue that the methodological limitations inherent in retrospective, non-randomized, single-site clinical studies limit the comparability of our data to results of controlled clinical trials. However, these types of treatment correspond to clinical practice that is common at our facility as well as in many facilities in Europe.

Besides the presented differences between the DSF and the ACP treatment groups, there may be other differences that we have not measured between the treatment groups as well as between the subjects that participated in the follow-up and those who did not. Although we cannot claim exclusion of confounding variables (in particular we do not have a baseline measure of patients' commitment to abstinence, a factor which might have led more committed patients to request disulfiram), we believe our results may be more practically relevant as well as generalizable than those from purer clinical studies.

Referring to the predictors of outcome, the association between better outcome and younger age and lower vocational education might be due to a willingness to accept the treatment setting. However, these sociodemographic predictors are inconsistent and should not be over-interpreted. From among the medical history and sociodemographic variables that we examined, only the variable 'duration of alcohol dependence' significantly predicted both the primary and secondary outcome measures.

Concordant with our own earlier results (Diehl et al., 2007; Mann et al., 2005), longer duration of alcohol dependence predicted a favourable treatment outcome in the DSF group. In contrast, in the ACP group a shorter duration of alcohol dependence predicted a better outcome. If this opposed association is not only a result of selection effects, predictive impact of the duration of alcohol dependence might enable an allocation to the most promising treatment. An undertaking to attend supervised DSF treatment is probably more readily accepted by patients with a longer duration of alcohol dependence.

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