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Alcohol dependence is widespread, and poses a major health-care burden world-wide. In countries such as India, its public health impact is enormous and the response inadequate and fragmentary, particularly in terms of alcohol dependence treatment [1]. While there is a growing number of treatment centres in both the public and private sectors, there is a huge treatment gap, which leads in turn to dependence on unauthentic sources of medicine [2]. Many people in such countries turn to traditional practitioners either out of choice or desperation and various herbal powders and traditional medicines are often prescribed for excessive alcohol consumption [3,4].

During our follow-up of alcohol-dependent patients who had dropped out of routine follow-up at the Center for Addiction Medicine at the National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, we observed that in five cases the desperate family members had contacted ‘traditional’ practitioners in their vicinity. They had been sold certain powders, green or white in colour, stored either in sealed pouches (approximately 2.5 g) or wrapped in paper (approximately 1.5–2.5 g). The agencies selling such products even advertise them locally as indigenous treatments for alcoholism. It was noted that these five patients were living in different parts of Bangalore and had obtained such preparations from different sources. The families administered one or two packets of such powders surreptitiously to the alcohol-using family member. Our counsellor collected four such samples for chemical analysis for composition of these drug samples and comparison with known modern drugs.

For all our experiments, analytical-grade chemicals and solvents were used. Standard colour-detection based tests and high performance thin layer chromatography (HPTLC) analysis indicated the absence of opiates, amphetamines and benzodiazepines [5]. Conversely, the sample was positive for Van-Urk reaction, indicating the presence of sulphur-containing compounds. The palladium chloride test [6] identified the unknown compound as disulfiram.

In order to validate the results, disulfiram standard and unknown samples were processed on the automated HPTLC system (CAMAG, Muttenz, Switzerland). The unknown samples showed a single peak with Rf∼0.78–0.80, thus confirming the presence of disulfiram. The recovery of disulfiram in the powder was found to be 99.8–101%. Based on the calibration curve of disulfiram standard, the concentration of disulfiram in all four unknown samples was determined to be approximately 1000 mg/g, which is fourfold higher than the concentration in the commercially available drug (250 mg/g). The daily dosage for the traditional powder (1.5–2.5 g at 1000 mg/g = 1500–2500 mg per day) was observed to be six- to 10-fold higher than the usual daily dose of 250 mg prescribed at our centre. Interestingly, the packets were sold at about five times the cost of disulfiram in standard pharmacies.

Our findings highlight that disulfiram can be detected rapidly and accurately by the HPTLC and also the need to examine medications from unauthorized and inauthentic sources for their content. However, the inference should not be misconstrued as an attempt to undermine the contribution of herbal medicine and traditional drugs in treating alcohol dependence. It is important that such medicines are subjected to clinical trials leading to safe drugs for alcohol dependence and inauthentic drugs are investigated thoroughly for chemical composition, dosage and potential toxicity.

The low cost of disulfiram makes it a pragmatic drug of choice in settings where abstinence is the expected outcome. However, instances of surreptitious disulfiram administration by unregistered medical practitioners have been reported [7]. Higher concentrations of disulfiram can prove harmful to patients, as disulfiram is known to cause hepatotoxicity, neuropathy, psychosis and confusional states [8].

Our findings highlight the need for educating patients and their families about alcoholism treatments to ensure that they are not exploited and patients are protected from exposure to potentially deleterious treatments.

Acknowledgment

  1. Top of page
  2. Declarations of interest
  3. Acknowledgment
  4. References

The authors thank the de-addiction counselor Vatsala for motivating caregivers to provide samples for analysis.

References

  1. Top of page
  2. Declarations of interest
  3. Acknowledgment
  4. References
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