From the Guidelines
Disulfiram (Antabuse) is not recommended as a first-line treatment for alcohol use disorder due to limited evidence of its effectiveness and potential hepatotoxicity, as noted in the most recent study from 2020 1. Instead, acamprosate has been found to be the only intervention with enough high-quality evidence to support its use in maintaining alcohol abstinence, as shown in a systematic review and network meta-analysis from 2020 1. The standard treatment approach for alcohol use disorder should prioritize medications with a stronger evidence base, such as acamprosate, and combine them with counseling and support groups to achieve the best outcomes. Key considerations in the management of alcohol use disorder include:
- Assessing the patient's motivation and readiness for treatment
- Evaluating the presence of any underlying medical or psychiatric conditions that may impact treatment
- Selecting a medication with a strong evidence base, such as acamprosate
- Combining medication with counseling and support groups to achieve the best outcomes
- Monitoring the patient's progress and adjusting the treatment plan as needed. It is essential to prioritize the patient's safety and well-being, particularly in cases where disulfiram may be contraindicated due to severe cardiac disease, psychosis, or pregnancy, as noted in previous studies 1. Ultimately, the goal of treatment should be to achieve and maintain abstinence, reduce the risk of relapse, and improve the patient's overall quality of life, as emphasized in the guidelines from 2020 1.
From the FDA Drug Label
Disulfiram is an aid in the management of selected chronic alcohol patients who want to remain in a state of enforced sobriety so that supportive and psychotherapeutic treatment may be applied to best advantage. Disulfiram produces a sensitivity to alcohol which results in a highly unpleasant reaction when the patient under treatment ingests even small amounts of alcohol.
Disulfiram (Antabuse®) is used as an aid in the management of chronic alcoholism. It works by producing a sensitivity to alcohol, resulting in an unpleasant reaction when alcohol is consumed. The goal of Disulfiram is to help patients remain in a state of enforced sobriety, allowing for supportive and psychotherapeutic treatment to be applied effectively 2.
- Key points:
- Disulfiram is not a cure for alcoholism
- It is unlikely to have a substantive effect on drinking patterns without proper motivation and supportive therapy
- Disulfiram blocks the oxidation of alcohol, resulting in the accumulation of acetaldehyde in the blood, which produces unpleasant symptoms 2
From the Research
Effectiveness of Disulfiram for Alcoholism
- Disulfiram is a potent alcohol-sensitizing drug, but its effectiveness in treating alcoholism remains unproven after 40 years of use 3.
- The clinical utility of disulfiram is more closely associated with nonpharmacological factors, such as social class, patient compliance, and treatment structure, rather than its aversive biochemistry 3.
- Disulfiram is not effective as a sole alternative to a structured treatment program, but it retains a place in standard alcoholism treatment programs for selected patients 3.
Patient Selection Criteria for Disulfiram
- Proposed selection criteria for disulfiram include patients who can tolerate a treatment relationship, are relapse-prone, have failed with less structured approaches, are in early abstinence and crisis, or are in established recovery with individual or group psychotherapy as a relapse risk 3.
- Disulfiram is most useful early in treatment to establish sobriety and allow time for other support structures to take hold 3.
- Prescriptions should be short-term and not allow automatic refills, with supervision and monitoring to increase compliance 3.
Comparison with Other Pharmacological Agents
- A meta-analysis found that acamprosate and naltrexone were more effective than disulfiram in supporting continuous abstinence, but disulfiram appeared to be effective when intake was supervised 4.
- Disulfiram was found to be equal or superior to other pharmacological agents, such as naltrexone, acamprosate, topiramate, and gamma-hydroxybutyrate, in some clinical trials 5.
Safety and Tolerability of Disulfiram
- Disulfiram has a unique safety profile that needs to be balanced with the treatment objective, individual patient preferences, and comorbid conditions 6.
- Supervised low-dose disulfiram (not more than 100mg/d) is suggested to be the most effective and safe approach, integrated into psychotherapeutic alcoholism therapy 5.