Table 8

 Pharmacological treatments used in alcohol dependence

Acamprosate: Blocks GABA and reduces NMDA receptor glutamate related excitation. It may have an effect on calcium influx, and it has been proposed as having a potentially neuroprotective role in detoxification. It does not interact with alcohol, and is prescribed post detoxification in specialist centres as an aid to maintaining abstinence
Disulfiram: Blocks aldehyde dehydrogenase, an enzyme involved in the metabolism of alcohol, leading to a build up of acetaldehyde if alcohol is taken. This leads to an unpleasant reaction where the patient will flush, experience headache, palpitations, nausea, vomiting, and, with large doses, arrhythmias, hypotension, and collapse. It is used in well motivated patients where compliance can be supervised by a partner, colleague or by healthcare staff. Because of the nature of the disulfiram reaction it should not be used in those who would be susceptible to cardiovascular disruption. Psychosis, pregnancy, and breastfeeding are also contraindications. Patients should carry a card warning of the administration of alcohol as it can be present in preparations such as mouthwashes and toiletries.
Naltrexone: Antagonises endogenous opioids such as β endorphin and encephalins. By opposing mediators of the pleasurable effects of alcohol it can make alcohol use less rewarding and prevent excessive single session consumption. Naltrexone is not licensed for the treatment of alcohol use in Britain, but is prescribed in some specialist centres and has a growing evidence base. It is mainly used in “binge” drinkers to attenuate the length and severity of their binges