Disulfiram was the first drug approved for the treatment of alcohol use disorders. For more than 60 years, people recovering from alcoholism have taken disulfiram or the brand name Antabuse to reduce their desire for alcohol.
Unlike the drug acamprosate, disulfiram doesn’t treat alcoholism by reducing cravings. Its effects are psychological. Disulfiram and Antabuse are used to discourage alcohol consumption. The drugs cause adverse reactions, such as sweating, chest pain and nausea, when consumed with alcohol. People who take disulfiram don’t want to experience those unpleasant reactions, so they are inclined not to drink.
The reactions are caused by acetaldehyde, a poisonous chemical that is produced when the body metabolizes alcohol. Disulfiram disrupts the way the body breaks down alcohol, causing acetaldehyde levels to build up.
Consuming high doses of alcohol after taking large doses of disulfiram can result in severe side effects and life-threatening reactions. The disulfiram label contains a black-box warning, the strongest U.S. Food and Drug Administration warning, about the risks of the drug.
Disulfiram should never be administered to a patient who is in a state of alcohol intoxication or without the patient’s full knowledge. The physician should instruct relatives accordingly.
Although the drug is still used by some therapists and addiction counselors today, it has lost popularity because of poor compliance. It’s most effective when taken by people who are motivated to maintain sobriety and supervised by a doctor or spouse.
Like other medication-assisted treatments, disulfiram is more effective when it’s taken alongside behavioral therapies that treat the underlying causes of alcoholism. The drug does not cause tolerance and may be taken until long-term sobriety is maintained. Many people take disulfiram for several months or years. Some individuals in long-term recovery take the drug when they anticipate a high-risk situation or craving is about to occur.
Disulfiram interrupts the way the body metabolizes alcohol, causing unpleasant reactions. Understanding this process helps discourage patients from drinking and increase their motivation to sustain sobriety. However, the physical effects are delayed, and it’s difficult to predict when they’ll occur.
Reactions to alcohol usually begin between 10 and 30 minutes after a person drinks. The severity of the reaction depends on individual characteristics, the dosage of disulfiram and the amount of alcohol consumed.
Common reactions caused by disulfiram and alcohol include:
High doses of disulfiram and alcohol can cause severe reactions, including respiratory depression, heart arrhythmia, seizure, unconsciousness and death. Severe reactions are uncommon when disulfiram is taken as prescribed. The unpleasant side effects usually last for between 30 and 60 minutes, but severe reactions can last several hours.
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It can take the body up to two weeks to metabolize alcohol normally after the last dose of disulfiram, so individuals who consume alcohol during that time period may experience unpleasant reactions.
Even when alcohol isn’t consumed, disulfiram can cause minor side effects, including:
If side effects continue or become more severe, patients should speak with their health care provider.
Some individuals should never take disulfiram, and others should use extra caution when taking the drug. Do not take disulfiram if you have a nickel allergy, a sulfur allergy or a hypersensitivity to disulfiram or other derivatives of thiuram, which are commonly found in rubber.
Patients with the following conditions or circumstances should be cautious when taking disulfiram:
Women who are nursing should not take disulfiram. Mothers can take the prescription drug once they discontinue nursing.
Disulfiram may interact with several medications, disrupting their effectiveness or causing adverse events.
Medications known to interact with disulfiram include:
Before taking disulfiram, patients should tell their health provider if they heave heart disease, kidney disease, thyroid problems, epilepsy, liver disease, diabetes or a history of mental health concerns.
Disulfiram should never be taken by individuals under the influence of alcohol. The side effects of the interaction between alcohol and disulfiram are the same regardless of which substance is consumed first. That’s why disulfiram is prescribed only to people who have maintained at least 12 hours of sobriety.
Other candidates for disulfiram include those who are:
Doctors educate patients about the risks of mixing alcohol with disulfiram before prescribing the drug. They may perform a breathalyzer test, physical exam or a pregnancy test to ensure disulfiram use is safe. Health providers may not require supervised consumption of disulfiram, but many doctors and therapists strongly recommend supervised treatment to encourage compliance.
Most people begin with a 250 mg dose taken once a day for one to two weeks. The smallest known effective dose is 125 mg, and the maximum dose per day is 500 mg. If patients miss a dose, they should take it as soon as they remember unless it’s almost time for the next dose. They should never take a double dose of the medication.
The drug is available only in tablet form in the United States. It can be swallowed or crushed and consumed with water, milk, tea, coffee, fruit juice or a soft drink.
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The effectiveness of disulfiram treatment is influenced by compliance and motivation for treatment. The first group of researchers to study disulfiram treatment for alcohol dependence used high doses (between 1,000 and 3,000 mg daily) to ensure strong reactions to alcohol.
The scholars wanted to know if people with alcohol use disorders could be conditioned to avoid alcohol if they were exposed to unpleasant reactions when they drank. However, the addiction treatment community shifted away from aversion therapy because of the severe side effects associated with high doses of disulfiram and alcohol.
Today, disulfiram is more commonly used to support abstinence. Supervised consumption of disulfiram is associated with higher rates of abstinence than unsupervised treatment, according to a 2014 meta-analysis published in PLoS One.
Court-ordered treatment that requires supervised use of disulfiram has also been shown to increase compliance, according to a 2004 study. Social support, supervision from a spouse, behavioral therapy and establishing a contract with a patient may also increase the effectiveness of disulfiram.
Some experts have criticized disulfiram use because of low rates of compliance, especially in outpatient and primary care settings. Use of the drug has also been criticized because of the serious side effects and reactions associated with it.
When disulfiram is taken in therapeutic doses, the risk of serious side effects is uncommon. However, individuals taking the medication should be aware of its risks. With motivation and supervision, disulfiram and Antabuse can aid in recovery from alcoholism.