Alcohol dependence: an action plan and a contract care physician / patient

Once a problem is identified alcohol dependence in a patient and that it agrees to be treated, the doctor who will take charge must establish a proper plan of action in the long term, including the pre-weaning, weaning and post-weaning, and a therapeutic contract with him, based on the existing arsenal of drugs, a medical monitoring support and a possible cognitive and behavioral therapy, Thursday stressed Dr Philippe Batel, head of alcoholism service Beaujon Hospital (Clichy, Hauts-de-Seine), at a press conference organized in Paris by the pharmaceutical company Bristol-Myers Squibb.

The Action Plan

"After a preparatory phase called pre-weaning, weaning which extends over a week (from D0 to D8) and can be done in the hospital or outpatient, in which the objective is to fight against addiction physics, followed by a phase of post-weaning whose purpose is to maintain abstinence (the most difficult to obtain results) and fight against the psychological and behavioral dependence, suggesting a patient support in the long term "recalls the psychiatrist alcohologist.

Faced with these necessities of care, there is a medical monitoring single or cognitive behavioral therapy accompanying options, such (to discuss with the patient at the beginning of the treatment even if it is delayed after the withdrawal phase), and medication options based on the use of naltrexone, acamprosate or both partners.

Psychological support seems essential because for people dependent on alcohol, you will have after the withdrawal phase, "managing the urge to drink, dinner with friends, refusal to drink alcohol (because any recovery, even after a long period of abstinence, followed in 80% relapse): this is where - according to the offer of course, and the geographical situation of the patient - cognitive behavioral therapy, which addresses these issues in eight sessions over two months, which includes acting on cognition (that is to say the ways of thinking), "says Dr. Batel.

Psychological support is therefore to assist the person in his gradual change in the perception of alcohol as an imaginary and behavioral point of view.

"Moreover, there is evidence that drug treatment effectively helps to reduce appetite for alcohol. Yet too few patients benefit and too many are prescribed an 'old' drug meprobamate (Equanil *) , which is further characterized by a strong hepatotoxicity by its effectiveness, "laments the specialist.

For Dr. Batel, "there is no reason to deny drugs that work like naltrexone (Revia *) and acamprosate, although the first was demonstrated in a study called Combine and published in the Journal of the American Medical Association (JAMA), greater than the second (which, incidentally, is administered at 4 to 6 tablets per day depending on the size of the patient, versus a single tablet for naltrexone) "efficiency.

Naltrexone: effective in maintaining abstinence and relapse prevention

This randomized double-blind study focused on 1,383 subjects (428 women and 955 men, mean age 44 years) weaned shortly before inclusion.

Participants with a diagnosis of alcohol dependence was established on specific criteria (DSM-IV), were divided into several groups according to whether they received different treatment strategies, describes Dr. Batel:

- A group of 607 patients undergoing medical supervision, with a 12-week follow-up, combined with pharmacological treatment (153 patients on placebo, or inactive substance-, 152 other acamprosate, naltrexone 154 to 100 mg / d (in the authorization or AMM-marketing-product, the dose is 50 mg / day for 3 months, note) and 148 receiving both drugs;

- A group of 619 patients undergoing medical supervision and pharmacological treatment (156 placebo, 151 acamprosate, naltrexone 155 and 155 taking both products) associated with behavioral therapy;

- A group of 157 patients receiving only behavioral therapy.

The primary evaluation criteria included the percentage of days abstinent alcohol and time to first relapse, and the secondary endpoints included including the number of drinks per day may be taken and the number of days massive alcohol per month.

"Overall, says the doctor, all the studied therapeutic strategies help patients stay sober, since the percentage of alcohol-free days increased in all groups. But in terms of benefits for the patient, two strategies have revealed a particularly superiority naltrexone alone or combined with behavioral therapy. "

More specifically, the average percentage of days abstinent at the end of treatment is higher in the groups followed a behavioral therapy and / or treatment with naltrexone. "Behavioral therapy seems to be effective with a positive effect of naltrexone," says Dr. Batel.

In terms of relapse (return of excessive alcohol consumption), "the results are most interesting naltrexone, although overall, all approaches work," he continues.

However, severe relapse and return to drinking behavior occur more often in patients receiving only behavioral therapy (about 80%) compared to those treated with medication and behavioral therapy and monitored medically (71.2 %).

"Under naltrexone, the risk of relapse and actually decrease the time between abstinence and recovery of the first glass is delayed: gold, this delay is a real opportunity, during which the health professional can work with the patient to increase the level of confidence and help to further increase the time before another relapse, "said the specialist. According to him, like smoking cessation, relapse are also part of the course of alcoholism.

In terms of management of alcohol dependence, Dr. Batel estimated to conclude that courses should be provided for the compulsory curriculum of general medicine as an option and therefore the exclusive initiative of the volunteer. "This specialty is relatively unknown. Proof of relationship to alcohol is not yet analyzed in the alcohol-dependent patients admitted for a condition precisely related to their alcoholism. Similarly, querying and information alcohol consumption are not yet a reflex in general.

The doctor is concerned that the issue of alcohol is less discussed than tobacco citing as an example that of "the pregnant woman who is always warning against the dangers of smoking, but not always against those of alcohol" . Thus four babies per 1,000 births are born carrying a fetal alcohol syndrome (FAS).

"It is important that physicians subject themselves to carry out at least once a year, an assessment of the relation that each of their patients with alcohol, through a standardized questionnaire, the same way that systematic measurement of the blood pressure of a woman over 70 years. because the impact of a practitioner asking about alcohol consumption is much more stronger than the spouse or employer, "says he