through the glass darkly, the history of treating the ... · through the glass darkly, the history...

Through the Glass Darkly, the History of Treating the

Alcoholic

Michael Hodgman MD

Sunday, February 17, 2013

Objectives

• Describe the early 19th century American response to inebriety

• Review drugs commonly used in later 19th century and early 20th century to treat alcoholism

• Review two treatments, the Keeley Gold Cure and the Belladonna Cure

• Discuss Aversion Therapy


Early America• fermented beverages a staple of daily life

early America

• potable water often lacking or suspect

• distillation also takes off in 18th century Colonial America, early years nation

• rum, apple jack, whiskies and ryes

• increasing consumption of and preference for distilled spirits in the later 18th century

Lender ME, Martin JK. (1982) Drinking in America. The Free Press, New York


spirits wine cider ethanol

1790 5.1 0.6 32.0 5.8

1810 8.7 0.4 31.3 7.1

1830 9.5 0.5 27.0 7.1

beer

2009 1.8 3.0 26.0 2.3

Per capita consumption in gallons

age ≥ 15 except 2009, age ≥ 14 years

Lender ME, Martin JK. (1982) Drinking in America. The Free Press, New YorkNational Institute on Alcohol Abuse and Alcoholism, Surveillance Report #92, August 2011


0

2

4

6

8

1790 1810 1830 1850 1870 1890

per

capi

ta a

lcoh

ol c

onsu

mpt

ion,

gal

lons

2009

adapted from Lender ME, Martin JK. (1982) Drinking in America. The Free Press, New York


Inebriety 1800• a sin, a moral failing; or as a vice, a

crime

• 1780s Methodist Church and Quakers encourage followers to abstain distilled liquors

• early 1800s evangelicals take up cause

• abstinence from distilled drink evolves to total abstinence

Addiction 2006;101:788-792

White W. (2009) in R. Ries, D. Fiellin, S. Miller, & R. Saitz, Ed. Principles of Addiction Medicine, 4th ed., Baltimore


Inebriety 1800

• Washingtonians, a more secular organization, also formed to aid the inebriate, 1840s

• both evangelical and secular groups utilize fellowship and support, as aids in recovery

• Washingtonians establish home for recovering inebriates

http://farm6.staticflickr.com

White W. (2009) in R. Ries, D. Fiellin, S. Miller, & R. Saitz, Ed. Principles of Addiction Medicine, 4th ed., Baltimore


http://farm6.staticflickr.com/

http://farm6.staticflickr.com/

American Association for the Cure of Inebriety, 1870

1. Inebriety is a disease

2. It is curable as other diseases are

3. The tendency to this disease may be either inherited or acquired

4. Alcohol is a poison

5. All methods so far have failed and establishment of specialized hospitals for the treatment of inebriety is a necessity

6. All cities should have hospitals for the treatment of inebriates, and states hospitals as well for more permanent detention and treatment

7. Civil authorities provide the means for scientific treatment in hospitals and asylums

8. Officers of such hospitals and asylums have the authority to retain patients for a sufficient length of time for their permanent cure

T. D. Crothers, Introduction,The Disease of Inebriety from Alcohol, Opium and Other Narcotic Drugs. (1893). E.B. Treat, Publisher, New York, 1893


Asylum Treatment• Acute detoxification

• rid the body of toxins, remove craving for alcohol

• Rehabilitation and convalescence

• regimen of planned activities, diet, exercise

• daily prayer

• support groups, fellowship

• publicly funded asylums usually included work and occupational training

• Duration treatment months to year, or longerSunday, February 17, 2013

New York State Inebriate Asylum

• 1859 NY State allocates a portion of liquor tax to fund

• Asylum opens in 1864

• NY State legislature grants courts power to commit people to inebriate asylum

• Operational for 14 years, controversies over patient treatment and financial difficulties lead to closure and conversion to state insane asylum in 1879

http://nyslandmarks.com

S. W. Tracy 2005. Alcoholism in America. Johns Hopkins Press, Baltimore


http://nyslandmarks.com/

http://nyslandmarks.com/

State Inebriate Asylums

• conflicted history

• critics

• it is not a disease

• involuntary commitment hot button issue

• duration therapy an issue, elopement problems

• state funding fickle

• many evolve to private treatment facilities

• or mission redefined by state


Inebriety management, later 19th century

• state asylums

• private lodges, half way houses

• municipal hospitals inebriate wards

• private clinics, hospitals, sanatariums

• patent medicines

• (jail)


Inebriate Pharmacopoeia• anticholinergics

• belladonna

• atropine

• hyoscyamine

• hyoscine (scopolamine)

• stimulants

• strychnine

• digitalis

• arsenic


Inebriate Pharmacopoeia• sedatives

• chloral hydrate

• chloramid

• bromides

• trional

• hedonal

• Veronal (barbital)

• paraldehyde

• apomorphine


Inebriate Pharmacopoeia• purgatives

• emetics

• diaphoretics

• extract ipecacuanha

• aloe

• cinchona, quinine

• willow bark

• gentian, ginger

• mercurials

• capsicum

• camphor

• many other herbal extracts, tinctures


Inebriate Pharmacopoeia• ethanol

• opioids

• Erythroxylum coca

• Cannabis indica


Inebriate treatment• Commonly included an anticholinergic with strychnine

• dosed to anticholinergic signs and slight muscular twitching and increased reflex activity

• for “breaking the patient off from drinking”

• and to remedy craving, “maintaining him for a time in a state of indifference as regards alcohol”

• Dr. Hare notes in cases with delirium, as to the exact nature of the delirium, atropine or delirium tremens, “there remains some doubt”

• strychnine added to “fortify” weakened nervous system and heart

Frances Hare M.D. (1913) On Alcoholism P. Blakiston’s Son & Co. Boston, pg. 227


• addiction reward pathways involve dopamine release in nucleus accumbens

• glycine receptors are located in nucleus accumbens

• administration of strychnine via microdialysis to nucleus accumbens in rats prevents rise in local dopamine concentrations following ethanol


• apomorphine

• sedating

• potent emetic

• risk of asphyxia and aspiration

• 1/20 to 1/10 gr apomorphine

• “a few minutes after the injection there is sharp emesis lasting a very short time, followed at once by a sleep of one, two, or three hours. On awakening there is a great change in the patient’s demeanor..”

Inebriate Pharmacopoeia

JWA Cooper (1913) Pathological Inebriety. Baillierre, Tindall and Cox, London., pg. 106


1890s treatment

• purgatives at onset

• atropine with strychnine SQ and a bitter, cinchona bark

• dose to anti-cholinergic toxicity

• atropine and strychnine continued for 4 to 6 weeks

• diet: Bovril with plasmon

• Insomnia: potassium bromide

• if DTs

• hold atropine

• morphine, whiskey

C A McBride. BMJ, April 30, 1904: 1006-1008


Blue Hill Sanatarium

• reasonable quantities of alcohol over first several days

• “I consider it a positively inhumane practice to suddenly and completely withdraw alcohol from those who have been drinking long and hard”

• alcohol substitutes

• hyoscyamus, camphor, capsicum, ammonia, valerian, ginger, “and the like”

• strychnine, nitroglycerin “to sustain, steady and strengthen” the heart

• digitalis, strophanthus, sparteine, cactus grand also employed

Boston Medical and Surgical Journal (NEJM)1901;45:208-210


Blue Hill Sanatarium• Delirium Tremens

• chloral +/- potassium bromide

• avoid chloral if a weak heart

• hyoscine hydrobromate (scopolamine) and musk preferred as next line agents

• musk: essential oil from Nardostachys jatamansi, of Valerian family

• Spikenard, nard oil

• musk “prohibitively expensive”Boston Medical and Surgical Journal

(NEJM)1901;45:208-210


Washingtonian Home

• Delirium Tremens

• Well ventilated, strong and secure room, no furniture, no restraints, mattress on floor

• “the muscular movements of the patient should be completely untrammeled”

• ad lib food and cold water

• no alcohol, no sedatives



Washingtonian Home

• Delirium Tremens (cont.)

• capsicum and nux vomica

• “to stimulate secretions”

• “tones and directly braces the disordered nerves”

• for “lagging heart”: digitalis and cold showers

• For “impending delirium tremens”: paraldehyde



Delirium Tremens

• Jail treatment, Dr. George Grant

• no physical restraints, padded room

• bromide of potash every 3 hours with milk

• digitalis, strychnine and nitroglycerin

• aromatic spirits of ammonia and tincture of capsicum

Boston Medical and Surgical Journal (NEJM)1901;45:215


The Keeley Cure

• Leslie E. Keeley, Civil War Army Surgeon, graduate Rush Medical College Chicago

• Cure of Inebriety: Double Chloride of Gold and Sodium

• Leslie E. Keeley Gold Cure Institute for the Treatment of Inebriates opens Dwight, IL, 1879

Morgan HW. Illinois Historical Journal 1989:87:147-166WW White. Slaying the Dragon: The History of Addiction Treatment and Recovery in America (1998). Lighthouse Institute, Bloomington


Keeley Cure• Initially a 4 week program

• outpatient program

• treatment

• 4 shots daily: various amounts of red liquid, blue liquid and white liquid

• oral potion q 2 hours while awake

• alcohol intake not restricted at onset, allowed only at facility

• apomorphine added to alcohol


Keeley Institute, Dwight

• 4 weeks $100

• lodging $21/week Livingston Hotel or ~ $6-8 weekly boarding house

• personal attendant $3 daily

Morgan HW. Illinois Historical Journal 1989:87:147-166


Keeley Cure• shots

• strychnine

• permanganate of potash

• double chloride of gold and sodium

• apomorphine

• liquid potion

• strychnine

• anticholinergics

• aloe

• quinine

• double chloride of gold and sodium

• ginger

• ErythroxylonMorgan HW. Illinois Historical Journal 1989:87:147-166

BMJ July 9, 1892:85-86


• July 1892 meeting in London, Society for the Study of Inebriety

• 61.3% water

• 27.55% ethanol

• 6% sugar

• chiretta bitters, mineral salts and limeBMJ July 9, 1892, p. 85-86

Keeley Potion, bottle # 1


• Cure rate of 95% claimed = cure from craving

• the inebriate “might return to his cups by re-learning to drink through much the same process of first effort”

• “When you all go out into the new life, I will have placed you exactly where you were before taking your first drink”

• Christian Advocate: cure rate 51%

Keeley Cure

Medical Age, 1892;10:55


Morgan HW. Illinois Historical Journal 1989:87:147-166WW White. Slaying the Dragon: The History of Addiction Treatment and Recovery in America (1998). Lighthouse Institute, Bloomington

Meyer Brothers Druggist, 1907, V 28, pg. 336

Keeley Cure

• Success of program

• fellowship and camaraderie

• placebo effect of daily line up for shots

• follow up program in place to follow and contact graduates

• Introduces day treatment, open facility model


Success breeds imitation• Gatlin Institute

• Garten Cure

• Dr. Haines Golden Remedy

• Geneva Gold Cure

• Boston Bichloride of Gold Company

• National Bi-Chloride of Gold Company

• Baker-Rose Gold Cure

• Key Cure

WW White. Slaying the Dragon: The History of Addiction Treatment and Recovery in America (1998). Lighthouse Institute, Bloomington


Towns-Lambert Treatment

• 1901 Charles B. Towns Hospital open on Central Park West

• “the belladonna cure”

• Dr. Alexander Lambert comes on as physician

• No proprietary potions or secret formulas are used

• more accepted by medical community

• Short inpatient treatment for alcohol, opiates and other drugs

• 3-5 day treatment for alcoholic; longer for opiate addiction S. W. Tracy 2005. Alcoholism in America. Johns Hopkins

Press, Baltimore



• Belladonna mixture

• belladonna, hyoscyamus

• Xanthoxylum americanum

• dose hourly to anticholinergic signs, then reduced schedule

• Clean out

• 4 or 5 Compound Cathartic pills with 5 gr blue mass

• repeat q 12 hours first several days, until “green, mucus stool”

• soap suds enemas

A. O’Malley M.D., The Cure of Alcoholism (1913) B. Herder, St. LouisJWA Cooper (1913) Pathological Inebriety. Baillierre, Tindall and Cox,

London.Sunday, February 17, 2013


• blue mass

• blue mass = Pil. Mass Hydrarg = 32-34% elemental Hg

• Compound Cathartic pills

• variety plant derived cathartics, laxatives, ginger, capsicum

• hydrarg. chlorid. mitis. (calomel)

• +/- ext. res. podophylli



• hypnotics as needed

• strychnine usually given as well for alcoholism

• weak and elderly

• 1-2 oz. whiskey in milk 3-4 times day 1, taper day 2

• If DTs: chloral hydrate, morphine +/- paraldehyde

• 1930s: colloidal iodine and gold also part of treatment

JWA Cooper (1913) Pathological Inebriety. Baillierre, Tindall and Cox, London.

Silkworth WD. Medical Record 1937;145:321-324


“This treatment is not an infallible cure for alcoholism; for there is no such thing, short of the grave. This treatment does obliterate the craving, and establishes a patient’s self-confidence to go on without alcohol; it will do all that can be done for a man who honestly desires to be helped; but as sure as that man lives, and just so long as he lives, he cannot touch alcohol in any form whatever without danger of a relapse”

Dr. Alexander Lambert

JWA Cooper (1913) Pathological Inebriety. Baillierre, Tindall and Cox, London, pg 135


• sight, smell or taste of alcohol leads to conditioned reflex of nausea and vomiting

• Keeley and others practiced this surreptitiously with covert use apomorphine, ipecac

• electric shock conditioning tried by Russians and in US

• spinning in chair

• “Anectine apnea”

• disulfiram

Aversion therapy

Lemere F. Br J Addiction 1987;82:257-258


• Administered emetine, pilocarpine and ephedrine IV

• patient told medication is a mild stimulant for treatment (deception)

• “alarming though not dangerous collapse may follow injudicious administration of the suggested medication”

• Onset N/V in 2-8 minutes

• essential action: give drink within moments of onset

• once emesis complete, more drink, more emesis, repeat...

• then Ewald tube with warm water lavageAm J Med Sci 1940; 199:802-810


• onset nausea may be hastened with oral emetine 1-2 gr (65-130 mg) in whiskey

• if inadequate degree nausea, apomorphine added to IV preparation

• 30% patients treated such experience bradycardia and syncope

• avoid pilocarpine with this approach

Am J Med Sci 1940; 199:802-810


Kattwinkel EE. NEJM 1949;240:995-997


Disulfiram

• FDA approval 1951

• doses used at time greater than today

• aversion conditioning with test dose ethanol under medical supervision

• first American death from this practice reported 1952

• psychological deterrence now used

J Clin Psychopharmacol 2006;26:290-302


Other therapies

• Hyper-immunization horses

• Metrazol (pentylenetetrazol) induced seizures

• Benzedrine

• Pentothal interviews

• Hypnosis

Quarterly J Studies on Alcohol1941(2):98-176


Other 20th century advances

• Alcoholics Anonymous

• Employee assistance programs

• Insurance coverage for treatment alcoholism

• Therapy with short term inpatient care followed by comprehensive outpatient program: Minnesota Model


Alcoholism 2013• In US, adults with prior alcohol dependence

• 18% remain abstinent

• 18% drink socially

• Fellowship and support through organizations such as AA remain most important treatment modality

• 62% remain in remission at 3 years

• Three medications approved for management of alcohol dependency

• disulfiram, naltrexone and acamprosate

NEJM 2013;368:365-373


http://strangemaps.files.wordpress.com/2008/03/1090955355579125-1.jpg

Life is an Ocean, both extant and wide;Manʼs the Ship, that doth oʼer its surface glide;Happiness the Port, we ever strive to find;Temperance must be the Pilot, to navigate the mind;Reason then takes the helm, free from doubt,To steer the course – as by Heaven pointed out.

Howe’s Street Anchor Press, Boston, ~ 1846




through the glass darkly, the history of treating the ... · through the glass darkly, the history...

Documents