From the Guidelines
Disulfiram (Antabuse) is not recommended for patients who will require opioid medications for surgery, and instead, the patient should consider alternative medications such as naltrexone or acamprosate for alcohol dependence treatment before back surgery. The primary concern with disulfiram is not a direct interaction with opioids, but rather the potential for severe reactions with alcohol-containing medications that may be used during the perioperative period 1. According to recent guidelines, all patients undergoing surgery should be assumed to be at risk of developing persistent postoperative opioid use and opioid-induced ventilatory impairment, and therefore, alternative strategies for pain management should be considered 1.
Some key points to consider in the management of this patient include:
- Optimizing management of pre-operative pain and psychological risk-factors before surgery, including weaning of opioids where possible 1
- Using multimodal analgesia to reduce the amount and duration of opioids required to restore function 1
- Avoiding long-acting opioids for acute postoperative pain 1
- Considering alternative medications for alcohol dependence treatment, such as naltrexone (oral 50mg daily or monthly injectable Vivitrol) or acamprosate (666mg three times daily), which do not interact with opioids or have a lower risk of adverse reactions 1.
It is essential for the patient to discuss these medication options with both their addiction specialist and surgeon to create a coordinated treatment plan that addresses both alcohol dependence and post-surgical pain management needs. By prioritizing the patient's safety and well-being, we can minimize the risks associated with opioid use and disulfiram therapy, and optimize their overall outcome.
From the FDA Drug Label
WARNINGS Disulfiram should never be administered to a patient when he is in a state of alcohol intoxication, or without his full knowledge. The Disulfiram-Alcohol Reaction Disulfiram plus alcohol, even small amounts, produce flushing, throbbing in head and neck, throbbing headache, respiratory difficulty, nausea, copious vomiting, sweating, thirst, chest pain, palpitation, dyspnea, hyperventilation, tachycardia, hypotension, syncope, marked uneasiness, weakness, vertigo, blurred vision, and confusion Concomitant Conditions Because of the possibility of an accidental disulfiram-alcohol reaction, disulfiram should be used with extreme caution in patients with any of the following conditions: diabetes mellitus, hypothyroidism, epilepsy, cerebral damage, chronic and acute nephritis, hepatic cirrhosis or insufficiency.
The patient cannot have disulfiram (Antabuse) if he will need opioid-type medications for his upcoming back surgery, as there is no information in the label about the safety of concomitant use of disulfiram with opioids.
- Key consideration: The label does not provide guidance on the use of disulfiram in patients who require opioid-type medications.
- Alternative options are not specified in the label, and therefore, no conclusion can be drawn about better options for this patient. 2
From the Research
Alternatives to Disulfiram for Alcohol Dependence
The patient's requirement for opioid-type medications for upcoming back surgery while seeking treatment for alcohol dependence poses a challenge. Considering the patient's need, alternatives to disulfiram (Antabuse) can be explored.
- Acamprosate: This medication has been shown to be effective in supporting continuous abstinence and increasing the total number of abstinence days 3.
- Naltrexone: Naltrexone is another option that has been found to be effective in reducing craving and preventing relapse in alcohol-dependent patients 3, 4.
Considerations for Disulfiram Use
While disulfiram can be effective for some patients, its use requires careful consideration, especially in cases where patients may require opioid-type medications.
- Supervision and Monitoring: Disulfiram is most effective when intake is supervised, and patients are closely monitored 5, 6.
- Side Effects and Tolerability: Disulfiram has been associated with more side effects compared to naltrexone, which may impact patient compliance 4.
Pharmacotherapies for Alcohol Use Disorder
The US Food and Drug Administration (FDA) has approved disulfiram, naltrexone, and acamprosate for the treatment of alcohol use disorder.
- Evidence-Based Treatments: These medications have been shown to be effective in reducing alcohol consumption and preventing relapse 3, 7, 4.
- Individualized Treatment: While pharmacogenetic testing is not currently recommended for treatment individualization, a structured treatment program with supervision and monitoring can improve patient outcomes 6, 7.