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Researchers: Giles Newton-Howes, William Levack, Rachel Tester, Moira Gilmour, Sam McBride

N on-physiological mechanisms influencing disulfiram treatment for alcohol use disorder: A grounded theory study. Researchers: Giles Newton-Howes, William Levack, Rachel Tester, Moira Gilmour, Sam McBride. A septuagenarian drug Lancet 1948. Clinical safety concerns.

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Researchers: Giles Newton-Howes, William Levack, Rachel Tester, Moira Gilmour, Sam McBride

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  1. Non-physiological mechanisms influencing disulfiram treatment for alcohol use disorder: A grounded theory study Researchers: Giles Newton-Howes, William Levack, Rachel Tester, Moira Gilmour, Sam McBride

  2. A septuagenarian drugLancet 1948

  3. Clinical safety concerns • Fulminant hepatitis (1:25,000) • Initial high dose prescribing (3000mg cf 200mg) contributed to severity of ethanol-disulfiram reaction including neurological, hepatotoxic side effects and death.

  4. Uncertain efficacy “Using a randomized, controlled, blinded study design, we did not find that disulfiram provided additional benefit to the treatment services provided at our nine clinics in aiding our patients to remain completely abstinent or in delaying the time to relapse.” Fuller RK, Branchey L, Brightwell DR, Derman RM, Emrick CD, Iber FL, et al. Disulfiram treatment of alcoholism: a Veterans Administration cooperative study. Jama. 1986;256(11):1449-55.

  5. Re-evaluation “In terms of the primary outcome, we found that disulfiram had a significantly better effect on abstinence when compared with placebo, none, or other treatment in 6 of the 10 studies” Jørgensen CH, Pedersen B, Tønnesen H. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcoholism: Clinical and Experimental Research. 2011;35(10):1749-58.

  6. Mechanism of action • Mode of action of Disulfiram thought to be independent of pharmacological effect (Fuller 1986 ) • Effectiveness relies upon supervision however no consensus as to what components of supervision are important (Jørgensen et.al. 2011) • Brewer (2000) described three components of action: surrendering control, likelihood of aversive reaction and involvement of others • No qualitative data to support any of this

  7. Objectives • To examine what non-physiological mechanisms influence the successful use of disulfiram in treatment of alcohol use disorder in a disulfiram clinic in New Zealand.

  8. Grounded theory

  9. Methods • Grounded theory methodology • Patients recruited from Antabuse clinic • Purposeful recruitment, aiming for 20, done 6 • Semi-structured in depth interviews with concurrent data analysis

  10. Results

  11. Major Themes1.Role of antabuse in recovery • There’s the- for me, anyway, there’s the physiological side was one thing, but there’s the whole psychological side of alcoholism as well, in terms of like anxiety, I think paranoia. I used to go through- you know, some quite heavy depression when I was going through withdrawal. So there’s all those things for me, they were far, far bigger part of the recovery process than just the physiological thing. (PT02)

  12. Major themes2. Antabuse clinic as a path to recovery • Not just the Antabuse, it was part of the- going in there, and saying hello to everybody, you know, you get to know everybody when you go in every day. (PT01) • I: Yeah? In what way has it been positive? • P: Just that thing- just the constant reminder. (PT01)

  13. Major themes2. antabuse clinic as a path to recovery • I found the monitoring, I found it useful, and one of the things I asked for, you know, on the day they discharged me, was they keep this graph of you know, your liver enzyme levels. You know, and I said ‘hey, you know, that’s something tangible for me. (PT02)

  14. Major themes3. Antabuse clinic as a barrier to . recovery • So you know, they agreed that I should (take it) myself, you know is the next step, next logical step, hey, don’t go to the chemist every day. You know, get a supply, and take them yourself. So they- it sort of fell apart there, aye. And I know they’re really busy, (chuckles) you know, it’s certainly not a criticism of them, but- and I haven’t followed that up. But they said they’d send a prescription to my pharmacy, saying ‘hey, it’s changed now, it’s not take on premises and take away. It’s hey, take away.’ You know.

  15. Major themes4. The use of metaphor • I would say it’s a tool in a toolbox. It’s a handy thing, and it’s kind of like the little policeman that is your policeman. Cause that’s what he is really, he’s a little policeman. He can- he’s kind of like- you put him on guard. You take him, and you say- well by taking it, you’re saying ‘well, if I do decide that I’m going to be drink- I’ll be sick. So do I want to be sick?’ Because it’s that whole reward thing. So in other words- well, the Antabuse is the sabotage mechanism (PT01)

  16. Tensions • When is good / right time to take Antabuse – only when you’re ready to stop, (at rock bottom) and don’t want to or cannot carry on, vs the earlier the better, just even to have a decent break from drinking & experience some recovery. • Discharge procedures – “pushed out” vs encouraged to come off vs stay on “a bit longer, a bit longer…” • Going to the chemist is a benefit vs a hassle / daily reminder of shameful problem. • Level of coercion – take decision away from people vs give as option

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