Alcohol dependence syndrome managed with homoeopathic medicine Bufo Rana – An evidence-based case report

INTRODUCTION

The term dependence syndrome is defined in the International Classification of Diseases (ICD)-10 as a cluster of physiological, behavioural and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of dependence syndrome is the desire to take psychoactive drugs, alcohol or tobacco.^[1] Alcohol dependence syndrome (ADS) is a chronic disease in which a person craves alcohol and is unable to control their drinking. The diagnosis code for ADS per the ICD-10 classification of mental diseases is F10.2 [Table 1]. Alcohol consumption becomes a problem when the individual engages in a problematic drinking pattern that puts them at risk of developing adverse health events.^[2] ADS typically includes a strong desire to consume alcohol, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to alcohol use than to other activities and obligations, increased tolerance and sometimes, a physiological withdrawal state.^[3] The National Mental Health Survey of India 2015-16 found that the ADS prevalence is 9% in adult men.^[4] The global burden of disease and injury attributable to alcohol is 4.5%.^[5] Alcohol consumption affects not only individuals but also others in the form of financial burden in families, domestic violence,^[6] road accidents^[7] and several other issues.^[8]

Screening instruments such as the cutting down, annoyance by criticism, guilty feeling and eye-openers scale (CAGE) and the alcohol use disorder identification test are standardised tools that have been readily and frequently used to assess the severity of dependence in India.^[9] The severity of alcohol dependence questionnaire (SADQ) was developed by Stockwell et al.^[7] to determine the extent of addiction amongst individuals who had been diagnosed with alcohol dependency.^[9] The conventional treatment utilises several medications for detoxification, craving reduction and withdrawal management. However, these treatments may cause adverse effects, including sweating, nausea, vomiting, facial flushing, tachycardia, hyperventilation, shortness of breath and hypotension. In severe drug reactions, cardiac arrhythmias, myocardial infarction, seizures and death can occur.^[10] Rogers concluded in a paper that homoeopathy can provide a valid and effective therapy to help patients break the cycle of alcohol dependence.^[11] Although there is ample literature on homoeopathy, most of them addresses withdrawal management^[12-14] and craving reduction.^[15] A randomised comparative trial in the management of alcohol dependence concluded that individualised homoeopathic treatment is not inferior to standard allopathic treatment in the management of patients with ADS.^[16] However, the sample size was small, and an extensive research gap exists due to the scarcity of studies on this condition. Some homoeopathic medicines are useful in treating ADS, and Bufo Rana is one of them. Published literature regarding the usefulness of Bufo Rana in treating ADS could not be retrieved from online databases of PUBMED, MEDLINE and DOAJ. However, in the homoeopathic Materia Medica, Bufo Rana is described as having the ability to treat the desire for intoxicating drinks and its effects, alcoholism, epilepsy, impotence and disposition for masturbation.^[17] Hence, this case report is intended to describe the management of ADS without adverse effects and emphasises the usefulness of Bufo Rana in treating ADS.

CASE REPORT

A 35-year-old male patient presented with an irresistible desire to take alcohol and withdrawal symptoms of tremors in abstinence at the outpatient department (OPD) of the National Homoeopathy Research Institute in Mental Health, Kottayam.

Physical generals

The patient was lean with premature grey hair. He was a non-vegetarian. He had a reduced appetite and showed intolerance to spicy food, which caused heartburn. Bowel movements were regular but with hard stools during the morning. Perspiration was diminished. Sleep disturbed. His thermals were chilly.

Upon examination, he was found to be underweight, with a body mass index of 18 kg/m². The patient was afebrile and showed moderate conjunctival pallor and grade 2 clubbing.

• Investigations: Haemoglobin 9.3 g/L [Figure 1].

• Diagnosis: ADS based on the ICD-10 classification and anaemia.

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Figure 1:

Blood investigations details.

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Therapeutic intervention

All the characteristic symptoms were converted to rubrics. Schroyens, Synthesis Treasure Edition, Zeus soft srl, Isnes, Belgium, was used for repertorisation [Figure 2].^[18] Based on this totality, nux vomica 1 M 2 doses, twice in a day (BD) was administered on December 14, 2022. In response, he showed improvement in his complaints with abstinence from alcohol for approximately about 2 months. Subsequently, he again started drinking alcohol without control, and then, the patient was admitted to the inpatient department (IPD) on June 16^th, 2023. Based on the repertorisation results [Figure 2] and characteristic symptoms, we administered Bufo Rana 200 (Manufactured by Willmar Schwabe Pvt. Ltd.,), 1 dose, in the morning. Placebo was also administered twice a day for 3 days. The follow-up was assessed every day or as required during IPD admission and once in 2 weeks or 1 month at OPD. Meditation and counselling were advised to overcome the craving for alcohol.

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Figure 2:

Repertorisation chart. Red-4, yellow-3, green-2, blue-1.

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Results

After the Bufo Rana intervention, remarkable improvement was found in alcohol craving and dependence and associated complaints, and later, the patient was discharged with moderate improvement. The patient’s alcohol dependence was assessed with SADQ, the score was changed from 46 to 2 and the scores were assessed before, after 3 and 6 months of treatment [Figures 3-5]. The detailed follow-up and outcomes are presented in Table 2. The causal attribution for the outcome changes was assessed using the Modified Naranjo Criteria for Homeopathy-Causal Attribution Inventory.^[19] The score was +9, close to the maximum (13), showing the positive relationship between the intervention and the outcome [Table 3].

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Figure 3:

Severity of alcohol dependence questionnaire assessment May 17, 2023.

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Figure 4:

Severity of alcohol dependence questionnaire assessment September 15, 2023.

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Figure 5:

Severity of alcohol dependence questionnaire assessment December 8, 2023.

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Table 2: Follow-up.

Date	Observation	Advise	Remarks
December 14, 2022 OPD	Alcohol craving, sleep disturbance, violent anger, Headache>vomiting, haemorrhoids, sneezing<dust	1. Nux vomica 1 M, 2 doses 2. Placebo tablets TDS 3. Review after 1 month	Based on the totality of symptoms
May 17, 2023 OPD	Alcohol drinking stopped for 2 months and started again. Now, severe dependence as per the SADQ, trembling of hands, headache, sleep disturbance and acidity	1. Nux vomica 1M, 1 dose, HS 2. Placebo tablets TDS 3. Review after 2 weeks	Based on the acute totality
June 16, 2023 IPD	The patient reported with severe alcohol dependence, alcohol use out of control	1. Advised to admit to IPD 2. Nux vomica 1M, 1 dose HS 3. Placebo tablets TDS 4. CBC, ESR, LFT, RFT, FBS, Lipid profile
June 17, 2023	Headache in the occipital region<coughing, cold exposure. Anger and irritation, craving alcohol and tremors of hands persisted. Hard stool passed with straining. Blood investigation reveals moderate anaemia	1. Nux vomica 1M, one dose, HS 2. Meditation and counselling 3. Nutritious food contains rich iron and vitamins	All complaints persisted the same. Medicine was repeated HS
June 18, 2023	Alcohol craving and tremors of hands continued. Headache<straining, working on the laptop for a long time. on the occipital region−<7 pm	1. Placebo 1 dose, HS 2. Placebo tablets TDS	No positive change was found, so the case was retaken
June 19, 2023	Craving for alcohol, tremors of hands, increased desire for masturbation, wants solitude to indulge in masturbation. Spends 1–2 h masturbating. Headache on the occipital region reduced. Sleep disturbed	1. Bufo rana 30/1D (1-0-0) 2. Placebo tablets TDS 3. Meditation	Based on characteristic symptoms and repertorisation results
June 20, 2023	Craving for alcohol reduced Tremor of hands reduced Weakness reduced Headache-mild pain in left eye and occiput <afternoon, coughing	1. Placebo/2D (1-0-1) 2. Placebo tablets TDS 3. Meditation
June 21, 2023	Headache reduced Tremor of hands-reduced No craving for alcohol No auditory hallucinations General good	1. Placebo/2D (1-0-1) 2. Placebo tablets TDS 3. Meditation
June 22, 2023	The patient feels better generally The tremor of hands reduced than before. No craving for alcohol Anxiety reduced. Appetite and sleep improved	1. Placebo/2D (1-0-1) 2. Placebo tablets TDS 3. Meditation
June 23, 2023	Headache better Tremor of hands reduced No craving for alcohol. The desire for masturbation persists Feeling tense at 11 PM. Sleeping well	1. Bufo rana 30/1D (1-0-0) 2. Placebo tablets TDS 3. Meditation	Repeat Rx
June 24, 2023	Generally, feeling better Headache relieved Tremor of hands reduced No craving for alcohol and smoking	1. Placebo 2D (1-0-1) 2. Placebo tablets TDS
June 25, 2023	Generally better Sleep-slept well No headache Tremor of hands reduced No craving for alcohol	1. Placebo 2D (1-0-1) 2. Placebo tablets TDS
June 26, 2023	Generally better. Sleep good Tremor of hands reduced Masturbating tendency reduced No craving for alcohol	1. 2D (1-0-1) 2. Placebo tablets TDS
June 27, 2023	Generally better Tremor of hands reduced No craving for alcohol	1. Placebo 2D (1-0-1) 2. Placebo tablets TDS
June 28, 2023	Generally better No craving for alcohol	1. Placebo 2D (1-0-1) 2. Placebo tablets TDS
June 29, 2023	Sleeplessness yesterday night, headache at vertex region, >after sleep. Mild craving for alcohol	1. Bufo rana 30/1 D (1-0-0) 2. tablets TDS	Repeat Rx
June 30, 2023	Generals are good. Sleep good	1. Placebo/2 D (1-0-1) 2. Placebo tablets TDS 3. Review after 2 weeks	The patient was discharged on the June 30th, 2023 with marked improvement with the following advice
July 12, 2023 OPD	The patient consumed beer the previous night on account of family problems. Headache has been present since morning, along with vomiting	1. vomica 200/4 doses (4 hourly) 2. Placebo tablets TDS	Acute prescription
August 02, 2023	Craving for alcohol-reduced Sleeplessness Hb 9.8 gm/L	1. Placebo 1 dose 2. Placebo tablets TDS
August 16, 2023	Mild craving for alcohol. Sleeplessness. Hearing voices	1. Bufo rana 200/1 dose 2. Placebo tablets TDS
September 15, 2023	Didn’t consume alcohol since last visit but occasionally mild craving for alcohol, sleep good	1. Placebo/1 dose 2. Placebo tablets TDS
October 06, 2023	Consumption of beer once, anxiety about disease. Headache. Sleep good. Hb 11.3 gm/L	1. Bufo rana 200/1 dose 2. Placebo tablets TDS	Repeat Rx
October 27, 2023	Generals good, no complaints	1. Placebo/1 dose 2. Placebo tablets TDS
December 08, 2023	General good, no complaints	1. Placebo/1 dose 2. Placebo tablets TDS

OPD: Outpatient department, IPD: Inpatient department, CBC: Complete blood count, ESR: erythrocyte sedimentation rate, LFT: Liver function test, RFT: Renal function test, FBS: Fasting blood sugar, SADQ: Severity of alcohol dependence questionnaire, TDS: Thrice in a day, HS: At bedtime

Table 3: Modified Naranjo criteria for homoeopathy case report.

Domains	Yes	No	Not sure or N/A	Score for successfully treated case	Justification
Was there any improvement in the main symptom or condition for which homoeopathic medicine was prescribed?	+2	–1	0	2	Alcohol use, craving and withdrawal symptoms relieved
Did the clinical improvement occur within a plausible time frame relative to the medicine intake?	+1	–2	0	1	Marked improvement evident in 1 month
Was there a homoeopathic aggravation of symptoms?	+1	0	0	0	Not sure
Did the effect encompass more than the main symptom or condition (i.e., were other symptoms not related to the main presenting complaint improved or changed)?	+1	0	0	1	Along with ADS, haemorrhoids also relieved
Did overall well-being improve? (suggest using a validated scale or mention about changes in physical, emotional and behavioural elements)	+1	0	0	1	Generally, the patient improved
Direction of cure: Did some symptoms improve in the opposite order of the development of symptoms of the disease?	+1	0	0	0	Not sure
Direction of cure: Did at least one of the following aspects apply to the order of improvement in symptoms? From organs of more importance to those of less importance? From deeper to more superficial aspects of the individual? From the top downward?	+1	0	0	0	Not sure
Did old symptoms (defined as non-seasonal and non-cyclical symptoms previously thought to be resolved) reappear temporarily during improvement?	+1	0	0	0	Not observed
Are there alternative causes (i.e., other than the medicine) that, with a high probability, could, have produced the improvement? (consider the course of disease, other forms of treatment and other clinically relevant interventions)	−3	+1	0	1	Not at all
Was the health improvement confirmed by any objective evidence? (e.g., investigations, clinical examination, etc.)	+2	0	0	2	Confirmed
Did repeat dosing, if conducted, create similar clinical improvement?	+1	0	0	1	Medicine repeated as required
Total score (Maximum score -13, Minimum-6)				9	Causal attribution established

ADS: Alcohol dependence syndrome, N/A: Not applicable

DISCUSSION

A key defining aspect of dependence syndrome is the compelling desire, often intense and at times overwhelming, to consume psychoactive drugs, alcohol or tobacco, regardless of whether they were prescribed medically.^[1] Physical manifestations vary depending on the specific substance used, while psychological disturbances such as anxiety, depression and sleep disorders are commonly associated with withdrawal. In this case, the patient responded to nux vomica 1M that was the first prescription. However, the positive effects did not last, and he was admitted to the IPD, where Bufo Rana was prescribed, which settled the symptoms. Nux vomica initially showed some positive effects but failed to give significant relief in subsequent follow-ups. On the other hand, Bufo Rana covered most of the characteristic symptoms, acted effectively and resulted in a long-lasting positive response. In Aphorism 164, Dr Hahnemann stressed the peculiar, uncommon and characteristic symptoms relevant to the cure.^[20] In homoeopathy, Bufo Rana is used for treating desired intoxicating drinks and their effects, alcoholism, epilepsy, impotence and disposition for masturbation.^[17] Kent explained characteristic symptoms of Bufo Rana in lectures on Homoeopathic Materia Medica as ‘desires solitude to practice masturbation’. This alone throws light upon the nature of the remedy, the lack of control over sexual longings to perverted practices and vices.^[21] In a total of 1 year of treatment with Bufo Rana, the patient could reduce the craving for alcohol and dependence. Hence, this case proves the usefulness of Bufo Rana in treating ADS. However, as this is a single case study and ADS is associated with a variable and unpredictable relapse of craving, well-designed randomised control studies with longer follow-ups may be taken up for scientific validation.

CONCLUSION

A significant reduction in alcohol dependence without a remarkable craving for alcohol in the observation period is the documentary evidence. This case showed the positive role of the homoeopathic medicine Bufo Rana in treating ADS.