Disulfiram (Antabuse)

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.
BLACK-BOX WARNING FOR DISULFIRAM:
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.
How Disulfiram Works

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:

 Sweating

 Flushed skin

 Trouble breathing

 Blurred vision

 Thirst

 Nausea

 Vomiting

 Chest pain

 Throbbing in the neck or head

 Vertigo

 Confusion

 Weakness

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.

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:

 Headache

 Drowsiness
 Acne

 Impotence

 Metallic taste in the mouth

 Skin rash

If side effects continue or become more severe, patients should speak with their health care
provider.
Interactions & Warnings

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:
PSYCHOSIS
Patients with a history of psychosis should take disulfiram only when they’re stable.

SEVERE MYOCARDIAL DISEASE OR CORONARY OCCLUSION

Disulfiram should be used only when the risk of alcohol consumption outweighs the risk
of interactions with these conditions.

PREGNANCY
The risk to the baby is unknown, and inpatient rehab is a preferred treatment approach
over disulfiram for pregnant women with alcohol use problems.

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:

 Coumadin (warfarin)

 Dilantin (phenytoin)

 Elavil (amitriptyline)

 Flagyl (metronidazole)

 Isoniazid

 Librium (chlordiazepoxide)

 Norpramin (desipramine)

 Rifadin (rifampin)

 Theophylline

 Tofranil (imipramine)

 Tricyclic antidepressants

 Valium (diazepam)

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.
Who Should Take Disulfiram?

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:

 Motivated and committed to sobriety

 Aware of the consequences of drinking while taking disulfiram

 Open to taking it with supervision

 Free of conditions or medications contraindicated by the drug

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.

Does Disulfiram Help Alcoholics Stay Sober?

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.