Letters to the Editor
Prevention of Relapse in Alcohol Dependence
TO THE EDITOR: Drs. Miller and Gold1 present a thorough discussion of the pharmacotherapy for withdrawal syndromes, the medications for the prevention of relapse and the psychosocial treatment of alcohol dependence. It is the absence of a prime treatment factor, Al-Anon, that I wish to discuss.
Al-Anon is a 12-step program designed to help the family and friends of the alcoholic patient. Al-Anon teaches the family and friends how to recover from their reactions to this disease. This family recovery allows the alcoholic patient to return from treatment to a safe, supportive environment. The outcome is not only positive for the alcoholic, but is also positive for the family.
I would encourage colleagues to attend an Al-Anon meeting. It only takes one hour. Health Partners Family Medicine Residency Program in St. Paul, Minn., has encouraged all of its residents to attend at least one Al-Anon meeting. During 15 years, not a single resident failed to be deeply impressed.
J. ANTHONY MALERICH, JR., M.D.
9595 Baker Ct.
Inver Grove Heights, MN 55077REFERENCE
- Miller NS, Gold MS. Management of withdrawal syndromes and relapse prevention in drug and alcohol dependence. Am Fam Physician 1998;58:
139-46.IN REPLY: I feel, as does the American Society of Addiction Medicine, that disulfiram should not be the first step in the treatment of alcoholism.1 Rather, I would use naltrexone or acamprosate as pharmacologic treatments that reduce the risk of relapse when used as part of an abstinence-based treatment regimen for alcoholism.
Naltrexone, an opioid antagonist, was the first medication in 50 years to be approved by the Food and Drug Administration for the treatment of alcoholism. Taking 50 mg of naltrexone per day for three months reduces alcohol intake and decreases relapse to heavy drinking. Patients treated with naltrexone report decreased cravings for alcohol before, during and after a relapse. Naltrexone may be especially effective in patients with a family history of alcoholism. Before the introduction of naltrexone, pharmacologic treatments for alcohol dependence showed disappointing results.2 Naltrexone has improved treatment outcome, but compliance and relapse after discontinuation of treatment remain problematic.
The most recent treatment for alcoholism is acamprosate. It reduces acute alcohol withdrawal and may reduce protracted withdrawal, thus explaining its novel efficacy in reducing relapse rates. Acamprosate appears to interact with the glutamate receptor and may also have effects elsewhere.3 These newer treatments have numerous safety and efficacy advantages over disulfiram. Disadvantages of naltrexone and acamprosate include cost, availability on formulary and side effects.
The success of any pharmacologic treatment still depends on patient compliance. Among patients using disulfiram who have experienced long-term abstinence, disulfiram is frequently the reason for an office visit or the patients' treatment of choice. In such instances, treatment compliance may be outstanding. Naltrexone, acamprosate and disulfiram have been tested as adjuncts to 12-step programs and other psychosocial treatments and not the other way around. Alcoholics are more likely to go to Alcoholics Anonymous than to receive any other type of treatment program or to consult with their physician.4
I agree with Dr. Malerich that the list of medications used to treat alcoholism is short, including only disulfiram, naltrexone and acamprosate. Antidepressants may reduce depressive symptoms in alcoholics, but these agents are not treatments for alcoholism. I am unfamiliar with direct treatment comparison of patients with alcohol dependence randomly assigned to treatment with naltrexone or acamprosate versus disulfiram. This type of research is necessary before we can decide which treatments are ideal for which patients, and when.
At this point, no single treatment for alcohol dependence has proven to be more effective than any other, and prospective matching of patient to treatment has, thus far, been disappointing. Previous treatment success or patient confidence in the success of treatment with disulfiram, as well as the cost and unavailability of alternatives, has kept disulfiram in the pharmacopoeia. Detoxification is not treatment. Treatment happens after detoxification to prevent a relapse and rebuild a healthy, productive life. Twelve-step programs, such as Alcoholics Anonymous, Al-Anon, Narcotics Anonymous and Cocaine Anonymous, are the most cost-effective and widely available form of long-term support for patients in recovery.5
As with other chronic diseases, such as diabetes, the need for continuity of care, monitoring of progress and referral when necessary make addiction a primary care disease. Relapse prevention in alcoholism is similar to that in diabetes or hypertension. The physician must work within the therapeutic relationship, maintain a nonjudgmental attitude, communicate empathy and reinforce meeting participation and behavioral changes while working with the patient and the family.6
MARK S. GOLD, M.D.
University of Florida Brain Institute
P.O. Box 100256
Gainesville, FL 32610REFERENCES
- Gold MS. Drug abuse: review of drugs of abuse and treatments. In: Rakel RE, ed. Conn's current therapy, 1998: latest approved methods of treatment for the practicing physician. Philadelphia: Saunders, 1998:1123-32.
- Volpicelli JR,Volpicelli LA, O'Brien CP. Medical management of alcohol dependence: clinical use and limitations of naltrexone treatment. Alcohol Alcohol 1995;30:789-98.
- Littleton J. Acamprosate in alcohol dependence: how does it work? Addiction 1995;90:1179-88.
- Weisner C, Greenfield T, Room R. Trends in the treatment of alcohol problems in the US general population, 1979 through 1990. Am J Public Health 1995;85:55-60 [Published erratum appears in Am J Public Health 1996;86:331].
- Friedmann PD, Saitz R, Samet JH. Management of adults recovering from alcohol or other drug problems: relapse prevention in primary care. JAMA 1998;279:1227-31.
- Kimball HR,Young PR. A statement on the generalist physician from the American Boards of Family Practice and Internal Medicine. JAMA 1994; 271:315-6.
Management of Gastroenteritis in Breast-Fed Children
TO THE EDITOR: I would like to commend Drs. Eliason and Lewan for their excellent review of the diagnosis and treatment of gastroenteritis in children.1 The authors point out that oral rehydration solutions are useful in treating children with mild dehydration. The solutions allow a rapid return to full formula feedings and the ability to continue the use of milk containing lactose. However, the treatment of gastroenteritis and mild dehydration in children who are breast feeding is not addressed in this article.
Many cases of both viral and bacterial infectious diarrhea might be prevented2 or their courses considerably lessened by breast feeding.3 If criteria for the use of oral rehydration1 are met in a child who is breast feeding, continued breast feeding is the preferred method for oral rehydration. Not only does breast milk provide the proper concentrations of electrolytes, but it also provides nutrition in the form of easily digestible proteins and fats.4
Since many breast-fed children refuse all oral intake except breast feeding while they are ill, increasing the frequency of feedings increases the mother's milk supply to meet the child's increased needs. Of course, the child's hydration status should be closely monitored. Even if intravenous hydration becomes necessary, breast feeding can and should continue,5 for all of the above reasons. If the mother is unable to stay in the hospital with the child around the clock, expressed breast milk may be used for oral feedings. In addition to the risks to the child, abrupt weaning would place the mother at risk for engorgement, obstructed lactiferous ducts and mastitis.
REBECCA B. SAENZ, M.D.
Department of Family Medicine
University of Mississippi Medical Center
2500 North State Street
Jackson, MS 39216REFERENCES
- Eliason BC, Lewan RB. Gastroenteritis in children: principles of diagnosis and treatment. Am Fam Physician 1998;58:1769-76.
- Riordan J, Auerbach KG. Breastfeeding and human lactation. Boston: Jones and Bartlett, 1998: 142-3.
- Duffy LC, Byers TE, Riepenhoff-Talty M, La Scolea LJ, Zielezny M, Ogra PL. The effects of infant feeding on rotavirus-induced gastroenteritis: a prospective study. Am J Public Health 1986;76:259-63.
- Lawrence RA. Breastfeeding: a guide for the medical profession. 4th ed. St. Louis: Mosby, 1994:91-148.
- Scariati PD, Grummer-Strawn LM, Fein SB. A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics 1997;99:E5.
IN REPLY: We certainly agree with Dr. Saenz that breast feeding is important as a means of both preventing problems with diarrhea in young children and providing nutrition to children who have gastroenteritis. Perhaps we did not sufficiently emphasize breast feeding for gastroenteritis in children,1 but the importance of continued oral nutrition was emphasized. The final paragraph contained the following statement:
"Children with severe diarrhea need adequate nutrition in order to restore their digestive abilities, to recover from their illness and to prevent development of so-called 'starvation diarrhea.' 2 Unless children have severe vomiting, they should not be deprived of nutrition for longer than one to two days. Breast feeding should continue. Special elemental formulas may be needed at times to provide nutrition until clinical recovery is adequate." 1
B. CLAIR ELIASON, M.D.
Medical College of Wisconsin
1000 N. 92nd St.
Milwaukee, WI 53226-0509RICHARD B. LEWAN, M.D.
Waukesha Family Practice Center
Waukesha, WIREFERENCES
- Eliason BC, Lewan RB. Gastroenteritis in children: principles of diagnosis and treatment. Am Fam Physician 1998;58:1769-76.
- DeWitt TG. Acute diarrhea in children. Pediatr Rev 1989;11:6-13 [Published erratum appears in Pediatr Rev 1989;11:124].
Corrections
An entry for "Diary from a Week in Practice" (January 1, 1999, page 71) contained an incorrect dose for a misoprostil tablet inserted vaginally for cervical ripening. In the Tuesday column, the dose of misoprostil in the fifth to the last sentence, 10th line from the bottom, should have been 50 µg.
The item titled "Annual Mammographic Screening in Older Women," appearing in "Tips from Other Journals" (October 1, 1998, page 1192), contained an incorrect statement about Medicare reimbursement for mammogram screening. As of January 1, 1998, Medicare started reimbursing for annual screening mammograms for women ages 40 years and older; in addition, the deductible was waived for screening mammograms.
Send letters to Jay Siwek, M.D., Editor, American Family Physician, 8880 Ward Pkwy., Kansas City, MO 64114; fax: 816-333-0303; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.
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