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Aversion therapy for alcohol dependence is a very old therapy which appears to be very effective. Unfortunately, it has never been tested in any random assignment study. The premier organization doing aversion therapy for alcohol and drug dependence in the U.S. is Schick-Shadel Hospital in Seattle (206-244-8100, 1-800-272-8464). Their 10-day program combines five sessions of emetine aversion therapy (every other day) with other interventions. They have publish several studies showing a very high success rate, much higher than the average in the field. Faradic aversion is used for illicit drug abuse and occasionally for alcohol. Aversion therapy has been used on an out-patient basis but it has not been widely reported. There is no reason to think that in-patient hospitalization is required, although the whole procedure requires being at the clinic for five hours on the five days of aversion therapy. I hope to be offering emetine aversion therapy in the near future. For people unable to afford in-patient treatment, out-patient therapy will be available close to home. Emetine, Faradic Aversion Therapy Better: 249 inpatients treated in multimodal program for alcoholism including aversion therapy with 12 months of follow-up were compared on 17 variables with matched patients from a national treatment outcome registry. The latter received inpatient treatment that emphasized individual and group counseling as the primary therapeutic elements. Patients treated with aversion therapy had higher alcohol abstinence rates at 6 and 12 months (p < 0.01). Abstinence rates from all mood-altering chemicals were higher in the aversion group at 6 months (p < 0.05) but not at 12 months. There was no significant difference between chemical and faradic aversion outcomes when analyzed separately. Schick-Shadel, Six- and twelve-month abstinence rates in inpatient alcoholics treated with either faradic aversion or chemical aversion compared with matched inpatients from a treatment registry. Smith JW, Frawley PJ, Polissar NL. J Addict Dis 1997;16(1):5-24 (apparently same study in Alcohol Clin Exp Res 1991 Oct;15(5):862-70); Emetine, Faradic Aversion Therapy Good Long-Term Success: A sample of 600 patients in a multimodal treatment program of aversion therapy and narcotherapy had a follow-up of averaging 15 months later by an independent research organization of 427 patients (71.2%). Of these, 65.1% were totally abstinent for 1 year after treatment and 60.2% were abstinent until follow-up. Fifty-two percent of the alcoholics were using or dependent on other drugs at admission. Seventy-five of these treated for cocaine dependence and 47 treated for marijuana dependence. The cocaine 12 month and "total" abstinence rates for the 49 contacted patients were 83.7% and 81.6%, respectively. The marijuana 12 month and "total" abstinence rates for the 30 contacted patients was 70.0% for both groups. Abstinence rates for alcohol and/or other drugs were also calculated including noncontacted patients who had chart documented evidence of relapse. The most powerful predictor of success was whether or not all urges to drink or use had been eliminated. Of additional importance was the use of support groups and reinforcement treatments after completion of the initial hospitalization. The two most prominent factors initiating a relapse were intrapersonal stress from work or marriage/family relationships and interpersonal stressors such as being around others who were drinking/using or being at a celebration or special event. The two factors were of equal importance in the alcoholics. However, interpersonal determinants were far more important in the cocaine and marijuana treated patients. Increased utilization of reinforcement treatments was associated with decreased urges to drink/use and increased abstinence rates. In contrast, increased frequency of support group utilization was associated with increased urges to drink/use and lower abstinence rates. J Subst Abuse Treat 1993 Jul-Aug;10(4):359-69. Ed: Without a randomized comparison with an alternative treatment, it is hard to evaluate what appears to be excellent results. Elderly Patients Did as Well with Emetine Aversion: A report of 87 alcohol dependent patients over age 64 reports elderly alcoholic patients were treated as successfully as younger patients. Their abstinence percentage combined for the two treatment years was 65.4% continuous sobriety over a 12-month follow-up period. Raleigh Hills Hospital-Portland. Medical-behavioral treatment of the older alcoholic patient. Wiens AN, Menustik CE, Miller SI, Schmitz RE. Am J Drug Alcohol Abuse. 1982-83;9(4):461-75 Emetine Aversion Therapy: A report on 82 patients after 10-day in-patient treatment for alcoholism with pharmacologic aversion therapy in a multimodal program. Patients with more extensive pretreatment experiences with alcohol-associated nausea and greater involvement in antisocial conduct appeared to be less susceptible to PAT conditioning. Washington Univ. Pharmacological aversion treatment of alcohol dependence. I. Production and prediction of conditioned alcohol aversion. Howard MO. Am J Drug Alcohol Abuse. 2001 Aug;27(3):561-85. howard@gwbmail.wustl.edu Emetine in Ipecac: Each 30 cc. of Ipecac contains 21 mg. of emetine. Ipecac myopathies have been reported in patients with anorexia nervosa who chronically abuse ipecac to self-induce vomiting. Emetine Aversion Therapy: Very Rare Side-effects: Two female patients with a history of alcohol abuse developed proximal painful muscle weakness following aversion therapy with emetine hydrochloride. Ipecac contains the alkaloid emetine which is a skeletal and cardiac muscle toxin when ingested chronically. The myopathy is reversible upon discontinuation of the drug. In addition to limb weakness, myalgias, elevation in CK, and myopathic EMG changes are common elements of ipecac myopathy. Histopathologic studies in humans disclosed a non-inflammatory myopathy with cores, multi-cores, and usually cytoplasmic bodies. In one report of two cases, one resolved in less than a month and the other took several months. Emetine myopathy: two case reports with pathobiochemical analysis. Sugie H, Russin R, Verity MA. Muscle Nerve. 1984 Jan;7(1):54-9
Emetine Review: Emetine has been used for medicinal purposes for centuries: initially as a treatment of diarrhea and amebic dysentery and, more recently, to decontaminate the stomach after self-poisoning. In 1965, it was made a non-prescription drug by the FDA so that it would be readily available to families with young children. However, its importance has dramatically declined due to the increased use of activated charcoal to treat poisonings. Ipecac produces nausea and vomiting both by direct irritative effects on the gastrointestinal tract as well as by stimulation of the chemoreceptive trigger zone in the brain. Although most of the emetine is vomited up, some does get absorbed and has a very long half life measured in weeks. Contraindications to administration of ipecac in alcoholism treatment included a hemorrhagic diathesis, i.e. a tendency to bleed from esophageal blood vessels. Emesis occurs in more than 90% of patients when used at recommended doses. Fifty percent of patients vomit in less than 20 minutes and 90% by 30 minutes. On average there are 3 or 4 bouts of emesis and emesis lasts for less than 2 hours. The safety of ipecac has been studied and confirmed numerous times. Side-effects the therapeutic use of ipecac include drowsiness which occurs in 5 -21% of patients (mostly children) and diarrhea which occurs in 8-13% of patients. Rare reported side effects include Mallory-Weiss tear of the esophagus, pneumomediastinum, hemorrhagic gastritis, intracranial hemorrhage, and death. Most deaths have been due to the accidental use of a version that was 14 times more potent which is no longer on the market. Chronic misuse of ipecac is now the most common cause of morbidity and mortality from ipecac. Several deaths have been reported with a total cumulative dose of emetine of 600 mgs or less but most deaths have been noted at cumulative doses of more than 1.25 grams. EKG is a sensitive and early index of cardiotoxicity. Changes include T wave flattening and inversion in all leads and prolongation of the Q T interval. EKG alterations tend to persist even after ipecac is stopped. (33) In addition to cardiac toxicity, there are neuromuscular effects that consist of weakness, aching, tenderness and stiffness of skeletal muscles- especially those of the neck and extremities. (From Holly E. Perry, MD, the Massachusetts Poison Control System: http://www.maripoisoncenter.com/ctr/9510ipecac.html )
Emetine Used in Russia as a Treatment of Alcoholism: The absorption of a little emetine in emetine aversion therapy might actually be a good thing. According to Russian physicians, after the standard anti-alcohol therapy, activity of alcohol dehydrogenase remains high or even increased, and pathological alcohol addiction also increased. Emetine normalizes the activity of alcohol dehydrogenase and suppresses pathological alcohol addiction. They report in an uncontrolled study that after this therapy more than 50% patients achieved stable remissions from alcoholism over 1 year, which indicated high efficiency of the proposed method. Maintenance of homeostasis of endogenous ethanol as a method for the therapy of alcoholism. Nikolaenko VN. Bull Exp Biol Med. 2001 Mar;131(3):231-3
Emetine Aversion Equaled by Faradic Aversion: Using small electrical shocks proved as successful as emetine. A comparison of two aversion treatment methods for alcoholism. Jackson TR, Smith JW. J Stud Alcohol. 1978 Jan;39(1):187-91
http://www.findarticles.com/cf_dls/m0978/3_27/77480938/p1/article.jhtml Amer J Drug Alc Abuse, August, 2001 Routine
physicians' orders for PAT are presented by session in Table 3. Physicians'
orders were occasionally modified; Table 4 presents data for actual dose by PAT
session.Table 3. Routine Physicians' Orders for Pharmacological Aversion Pilocarpine hydrochloride 6.62 6.62 9.95 13.24 16.57 Ephedrine sulfate 19.84 19.84 29.79 39.68 49.68 Butterfly Oral emetine 0 31.45 31.45 31.45 31.45 tartar emetic 0 23.72 71.15 118.58 142.45 (Antimony potassium tartrate http://wardsci.com/product.asp?pn=9700902
$8.01 for 25 g.) Table 4. Actual Drug Dose by Pharmacological Aversion Therapy Session (N = 82) Drug (mg) (N) 1 2 3 Oral emetine 85 (79)(a) 85 (77) 68 (1) Hydrochloride 127.5 (3) 127.5 (2) 85 (73) 170 (2) 127.5 (5) 170.0 (1) 212.5 (1) Pilocarpine 0 (20) 0 (21) 0 (28) hydrochloride 6.62 (62) 6.62 (60) 9.95 (53) Ephedrine 0 (20) 0 (21) 0 (28) sulfate Butterfly Tartar emetic 0 (82) 0 (3) 0 (9) 23.72 (78) 71.15 (72) Oral emetine 0 (81) 0 (2) 0 (8) 85 (1) 31.45 (78) 31.45 (70) 85 (1) 48.45 (2) 85 (1) Drug (mg) (N) 4 5 Oral emetine 68 (2) 42.5 (1) Hydrochloride 85 (71) 68 (1) 127.5 (7) 85 (68) 212.5 (1) 127.5 (7) 170.0 (1) 212.5 (2) Pilocarpine 0 (31) 0 (31) hydrochloride 13.24 (50) 16.57 (49) Ephedrine 0 (31) 0 (31) sulfate Butterfly Tartar emetic 0 (19) 0 (27) 71.15 (1) 23.72 (1) 118.58 (61) 71.15 (1) 142.45 (51) Oral emetine 0 (15) 31.45 (62) 0 (22) 48.45 (2) 31.45 (55) 85 (2) 48.45 (1) 85 (2) The standard treatment regimen of Schick-Shadel consists of five aversion therapy (PAT) conditioning trials delivered over a 10-day period. Conditioning sessions were conducted on alternating days. Patients fast for 6 hours before PAT during which time they are encouraged to drink a large quantity of liquids. This procedure reduced the likelihood of aspiration of stomach contents during PAT. The treatment protocol is explained to patients, and they are then taken to the treatment room, which has shelves displaying many types of alcoholic beverage containers and cutouts of liquor ads on the walls. The patient is seated in a chair with an attached emesis basin. He or she then receives an oral dose of emetine hydrochloride in a glass filled with 600 ml of saline solution; intramuscular injections of pilocarpine hydrochloride (to close the pyloric sphincter and thereby retard the absorption of alcohol) and ephedrine sulfate (to control hypotension) are given. Emesis occurs 5 to 8 minutes following emetine administration. Shortly before the expected onset of nausea, the therapist administering the treatment pours a drink of the patient's preferred alcoholic beverage (PAB) and mixed it with an equal amount of warm water. The patient is instructed to smell the beverage (on a saturated cloth), swishes it around in his or her mouth, and then spits it out. This protocol ensured that patients had seen, smelled, and tasted the alcoholic beverage prior to nausea onset. Later in the session (approximately 5-10 minutes), the procedure is changed such that alcoholic beverages are swallowed instead of spit out. The alcoholic beverage consumed is quickly regurgitated; thus, little alcohol is absorbed. After a PAT session of 20 to 30 minutes, the patient returns to his or her room, where 30 minutes later a drink of the patient's PAB was given containing oral emetine and tartar emetic. This emetic/alcoholic drink, which induces nausea lasting up to 3 hours, is known euphemistically as a "butterfly" and is administered following sessions 2-5. During the first conditioning session, the patient consumes a total of 4 drinks of his or her PAB. During sessions 2-5, patients are exposed to many different types of beer, wine, and distilled spirits to generalize the conditioned aversion to a range of alcoholic flavors. During each conditioning trial, however, patients are exposed to their PAB. There were 20 alcoholic drinks administered during session 5. Carbonated beverages are not mixed with the alcohol, and ice is not added; both are associated with appropriate nonalcoholic drinks and reduce the salience of the odor and taste of alcoholic beverages. Warm water is mixed with the alcoholic beverages to enhance their odor and flavor. Comprehensive Drinker Profile The Comprehensive Drinker Profile (CDP) is a structured interview that assesses demographic and drinking history variables (17). Michigan Alcoholism Screening Test The MAST is a 25-item questionnaire that assesses problems attendant to heavy drinking. Scores range from 0 to 53 and reflect a unidimensional construct indicating degree of alcohol dependence (18). Drug Abuse Screening Test The DAST is a 20-item self, report scale that provides an index of problems related to drug misuse (19). Subjects respond "yes" or "no" to each item, and scores range from 0 to 20. Preconditioning Unconditioned Stimulus Familiarity Scale Items
Item
1. When you drink alcohol, how often do you become sick to your
stomach and vomit?
2. When you drink alcohol, how often do you become nauseous?
3. How often have you gotten sick and vomited in the past year?
4. How often have you felt nauseous in the past year?
5. When you drink and become sick and vomit, do you stop drinking?
6. Do you usually quit drinking after you have gotten sick and
vomited because of drinking too much?
7. When you think about drinking now, do you feel nauseous?
Alcohol Dependence Scale The Alcohol Dependence Scale (ADS) is a 25-item scale that assesses a general alcohol dependence factor. Total scores range from 0 to 47 (21). Social Support Questionnaire The Social Support Questionnaire (SSQ) is a 27-item scale that assesses perceived number of, and satisfaction with, available social supports (22). Scores range from 27 to 162. Life Experiences Survey The Life Experiences Survey (LES) is a measure that requires patients to indicate which life events they experienced during the past year, whether they viewed each event positively or negatively, and how they judged the impact of each event at the time it occurred. Ratings were made using a 7-point scale, ranging from extremely negative (-3) to extremely positive (+ 3). Four measures were derived: positive and negative life experiences scores for the 6- and 12-month periods preceding treatment (23). http://www.findarticles.com/cf_dls/m0978/3_27/77480938/p10/article.jhtml?term= Thomas E. Radecki, M.D., J.D. www.modern-psychiatry.com
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