Download Conditioning

The Antabuse-Myth
Why disulfiram cannot work
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Mark et al., 2009
Disulfiram prescriptions
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USA, 2007
ƒ 25% of patients treated for
alcohol received disulfiram
Side effects disulfiram
headaches
fatigue
garlic-like taste
sexual
problems
Allergic
dermatitis
ƒ Fatal toxic hepatitis
ƒ 1 : 30 000 per treatment year
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Is disulfiram effective?
Can disulfiram be effective?
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How can pharmacotherapy act?
1. Direct pharmacological effect
physical/psychological
states
Adaptations
(biochemical,
physiological,
behavioral)
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2. Indirect effect
How can pharmacotherapy act?
1. Direct pharmacological effect
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Practice Guidelines APA
Controlled trials have not demonstrated any
advantage of disulfiram over placebo in
achieving total abstinence, delaying relapse,
or improving employment status or social
stability …
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Guidelines WFSBP
ƒ Data on the efficacy of disulfiram are mixed
ƒ Compelling evidence that disulfiram increases
abstinence rates is lacking
ƒ The efficacy evidence for disulfiram is
inconsistent and … there is more often negative
evidence on other outcome measures such as
relapse
http://addictologie.hug-ge.ch
The „Package-Hypothesis“
Disulfiram
=
<
+
Disulfiram
+ supervision
?
+
Control-treatment
Control-treatment
+ supervision
The pharmacological anomaly
pharmacological effect
effective
Pharmakon
no
pharmacological effect
not effective
pharmacological effect
not effective
Disulfiram
no
pharmacological effect
effective
How can pharmacotherapy act?
1. Direct pharmacological effect
physical/psychological
states
Adaptations
(biochemical,
physiological,
behavioral)
http://addictologie.hug-ge.ch
2. Indirect effect
Psychological hypotheses
ƒ Conditioning
ƒ Classical
ƒ Instrumental
ƒ Deterrence
ƒ Cognitive trigger
http://addictologie.hug-ge.ch
Psychological hypotheses
ƒ Conditioning
ƒ Classical
ƒ Instrumental
ƒ Deterrence
ƒ Cognitive trigger
http://addictologie.hug-ge.ch
http://addictologie.hug-ge.ch
Classical conditioning
Before
conditioning
Neutral
stimulus
During
conditioning
+
After
conditioning
Conditioned
stimulus
Conditioned
response
Classical conditioning
Before
conditioning
Neutral
stimulus
During
conditioning
+
After
conditioning
Conditioned
stimulus
Conditioned
response
How it is applied
Before
conditioning
Neutral
stimulus
During
conditioning
+
After
conditioning
Conditioned
stimulus
Conditioned
response
How it is applied
Before
conditioning
Neutral
stimulus
During
conditioning
+
After
conditioning
Conditioned
stimulus
Conditioned
response
http://addictologie.hug-ge.ch
http://addictologie.hug-ge.ch
Operant conditioning
ƒ Association between action and
unconditioned stimulus
ƒ Investigates the learning of voluntary
responses
ƒ Reward or punishment
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Reinforcement vs punishment
+
Add stimulus
Substract
stimulus
Increase
behavior
Positive Reinforcement
Reward
Negative
Reinforcement
“Escape”
Punishment
Removal Punishment
Decrease
behavior
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Swiss Compendium
(≈Drugs@FDA)
ƒ…reaction appears generally 5–10
minutes after ingestion of alcohol …
ƒ After having experienced such an episode,
the patient will be reticent to consume
alcohol again (aversion reaction).
http://addictologie.hug-ge.ch
Operant conditioning by punishment
n Probability
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Operant conditioning by punishment
n Probability
Alcohol-Disulfiram
Reaction
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Which schedule for a good effect ?
Begin with continuous punition
…
Best for getting a new behavior
started
Schedule of choice for punishment
New behavior can extinguish quickly
once reinforcement stops
Stabilize with intermittent punition
…
http://addictologie.hug-ge.ch
Quite resistant to extinction
Most reinforcers in human
relationships are on a variable
schedule
“Gamblers schedule”
Psychological hypotheses
ƒ Conditioning
ƒ Classical
ƒ Instrumental
ƒ Deterrence
ƒ Cognitive trigger
http://addictologie.hug-ge.ch
Deterrence
ƒ Guidelines WFSBP: The rationale for using the medication is to
deter the patient from drinking alcohol again
ƒ APA guideline : The purpose of disulfirame is not to make the
patient ill but to prevent the patient from drinking impulsively
because he or she knows the symptoms that will result from
drinking while taking disulfirame.
http://addictologie.hug-ge.ch
Deterrence: factors
ƒ Certainty
ƒ Severity
ƒ Celerity
http://addictologie.hug-ge.ch
Certainty
+
+
+
+
+
+
+
+
+
+
+
+
http://addictologie.hug-ge.ch
Severity
Flushing
Racing heart
http://addictologie.hug-ge.ch
Headache
Dizziness
Hypotension
Nausea
vomiting
Celerity
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Deterrence: Assumptions
ƒ Assumes rationality
ƒ Behavior can be prevented through altering cost/
benefit ratios
http://addictologie.hug-ge.ch
Deterrence: who responds
Sensible to
deterrence
Not really sensible
to deterrence
http://addictologie.hug-ge.ch
Deterrence: who would respond
Sensible to
deterrence
Not really sensible
to deterrence
http://addictologie.hug-ge.ch
Psychological hypotheses
ƒ Conditioning
ƒ Classical
ƒ Instrumental
ƒ Deterrence
ƒ Cognitive trigger
http://addictologie.hug-ge.ch
Decision training
ƒ Disulfiram as “cognitive trigger”
http://addictologie.hug-ge.ch
Alternative decision trainings
Other cognitive triggers
Exposition training
Biofeedback
Behavioral contracting
http://addictologie.hug-ge.ch
Conclusions
ƒ Disulfiram as pharmacotherapy
ƒ Anomaly
ƒ Classical or operational conditioning
ƒ Lack of training
ƒ Deterrence
ƒ Addiction ' Irrationality concerning alcohol
ƒ Conscience triggering
ƒ Alternatives without pharmacological risks
http://addictologie.hug-ge.ch
Please avoid fallacious arguments
Proof by example-fallacy (cherry picking)
Red herring fallacies
Appeal to ignorance
E.g. patients’ demand
Argumentum ad populum
Argumentum ad verecundiam (Appeal to authority)
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14-18 Oct 2012, Geneva