Antabuse: It has it's uses but not for detox
Updated: Oct 4
Antabuse: It has its uses but is not a detox medication. The best piece of advice I can give in relation to Antabuse is: Avoid it! Well, at first, anyway. If it was the panacea everyone thought, it was then I would be stacking shelves in a supermarket. As with other medications, Antabuse has its uses. However, you cannot use it to detox, and it can never replace the therapy needed to make a meaningful, sustained recovery. If such medications were the panacea some people believe them to be, drug and alcohol centers would not exist. While it certainly has its uses, it must be seen as adjunctive to underlying therapy in a rehab center. https://www.ncbi.nlm.nih.gov/books/NBK64036/ In the United Kingdom, medicines should only be prescribed in line with the guidelines of the National Institute of Health and Care Excellence: NICE https://bnf.nice.org.uk/drugs/disulfiram/ These guidelines are clear that this drug should only be initiated under “expert supervision”. In other words, by a consultant psychiatrist as an inpatient. Prescribing clinicians, such as I, have the discretion to outside of these guidelines. This is known as “off label” prescribing (dose more than recommended guidelines) or “unlicensed” (Prescribed for a purpose not originally intended) A good example is Duloxetine for non—diabetic neuropathy. https://www.londonpainclinic.com/medication/duloxetine-and-diabetic-neuropathic-pain/ How does it work? Without wishing to get too technical, Alcohol is converted to Acetaldehyde. It is this mechanism that Antabuse works on. The Maudsley Prescribing Guidelines in Psychiatry 14th Edition (https://onlinelibrary.wiley.com/doi/book/10.1002/9781119870203) The drug reduces the ability of the body to metabolize Acetaldehyde leading to:
Arrhythmia (irregular heartbeat)
Hypo tension (low blood pressure
While Antabuse is prescribed for a patient, it is common practice (with the patient's consent) to hand it to the loved one looking after the patient. Antabuse, like any drug, only works if you take it. People, sometimes, plan their relapses, so would simply stop taking it a day before relapsing. It is a very expensive drug. Up to 500MG a day is the usual amount taken and it cannot be given on a standard National Health Service green FP10 prescription. There may, and I stress may, be occasions where local drug and alcohol services, commissioned by local authorities, are funded to provide it. However, this would not be an initial treatment and clients will be expected to take part in group work and individual sessions long before it is even considered. As mentioned, it is secondary to underlying therapy and, if needed, a medically supervised detox. It is adjunctive: Not a first line treatment. Before considering if a patient is suitable for Antabuse, it is necessary to determine, firstly, if they have an alcohol problem. The current phrase is alcohol use disorder: A pattern of problematic pattern of alcohol use leading to significant impairment or distress. https://bestpractice.bmj.com/topics/en-gb/198 This is a medical condition that manifests when someone's consumption of alcohol causes them serious problems. While it can be a long-term condition, it can also be lifelong and may even re-present itself after a period of treatment.
What are the symptoms?
You want to stop or reduce but can not.
You drink for longer than you intend to do
A lot of time is spent both obtaining it and recovering from it’s effects
You have a very strong urge to drink or crave alcohol.
A persons job, education and/or family life suffers as a result of their alcohol consumption
Despite damage to relationships because of alcohol, a person continues to drink
Alcohol consumption has stopped someone doing things they enjoy
Drinking has put someone at risk due to alcohol (ie drink driving,unsafe sex, unsafe activities)
Despite your doctor telling you not to, you continue to drink.
A tolerance to alcohol has been developed
When you drink it does not give you the same effects as it used to.
If you do not drink, you develop signs of withdrawal (nausea, sweating, tremor, anxiety, etc)
In order to stop these signs of withdrawal you have to drink alcohol
Roughly speaking, if you develop two of three of the above a diagnosis of mild alcohol use disorder would be made. Four or five would be mild and six or more would be considered severe. https://effectivehealthcare.ahrq.gov/products/alcohol-misuse-drug-therapy/consumer
Antabuse is not the only prescription medication that can be used for patients with alcohol use disorder. There are some good ones and some not so good ones. Antabuse could be described as both. It is designed to stop alcohol dependent patients from consuming alcohol but in a potent and dramatic way. To put it bluntly, it will poison you if you consume alcohol. Indeed, if you took one tablet today and had a drink in the next few days, life will be very uncomfortable. Some ethic groups react very badly to alcohol, this is due to a genetic condition that prevents them from completely metabolizing alcohol. Antabuse acts is a very similar fashion. https://www.acsh.org/news/2018/03/01/antabuse-very-good-pill-stop-drinking-dont-cheat-12631 There is nothing new about Antabuse. It was first discovered back in 1881 but was largely ignored by the scientific community. Its ability to be of use in the treatment of alcohol use disorder was discovered solely by accident. Antabuse was originally designed to speed up the vulcanization of rubber. At the plant there was a medical doctor, E.E Williams, who was confused as to why the workers, when they consumed alcohol, became acutely unwell. It was this unusual phenomenon that led to Dr Williams making a connection between Antabuse and alcohol treatment. However, he did not act upon this accidental discovery. Until 1945 Disulfiram was used to treat skin infestations such as scabies. This was until a Danish biochemist, Erik Jacobsen, was trying to source a drug that could be used to treat intestinal worms. He tried taking some himself but did so after drinking some wine hence why it is called Antabuse, or in Danish, Antabus. He obtained a patient in 1952. Indeed, such was its popularity in Denmark, it still accounts for 20% of the worldwide use of the drug. https://www.northpointseattle.com/blog/antabuse-explained-effective-treatment-alcoholics/ Positive aspects of taking Antabuse
There is no argument that Antabuse does what it is prescribed for: If you take it and then drink, you will become unwell. Of this there is no doubt. There are various research papers that show that patients who take deterrent medications, such as Antabuse, will remain abstinent for up to 50% more of the time.
When patients are craving alcohol, antabuse can provide an extra “buffer” and it is not unknown for patients to keep a supply for times of heightened stress.
Antabuse reacts to even the smallest amounts of alcohol. If you take it, no amount of alcohol can be tolerated by the body: You cannot cheat with Antabuse!
Once taken, it can stay in the body for up to two weeks and will still be effective for this period. This means that, if you take it and consume any alcohol, at all, for (roughly) the next two weeks, it will make you feel very unwell.
By taking antabuse, and thus refraining from alcohol, it is possible that a patient will see a reduction in inflict drug use (if applicable) this is because a large number of those who are dependent on alcohol are also dependent on drugs. Alcohol use, even minimal to moderate use, can increase drug use. While I am not a fan of internet chat rooms, even a quick perusal of them indicate a high level of patient satisfaction when taking Antabuse. However, while there are some distinct positives when taking Antabuse, there are also some limitations to using it that patients also need to be aware of. The most important thing to be aware of is that it can not be used as a detox. It is neither designed, not will it work for those in withdrawal. Antabuse chemical construction and method of action is solely around making someone feel uncomfortable if they consume alcohol. While people who experience alcohol cravings take antabuse because they want the effects it has if they drink, in itself, Antabuse will not have any impact on cravings by itself. A person who is experiencing cravings will still feel the urge to drink. What will stop them is the unpleasant effects of alcohol consumption after taking Antabuse. Due to the mechanism of antabuse, indeed the intended effects, it can very seriously impinge on people’s lives. There are very many products that become impossible to either use or be around. There are so many examples but the main ones are:
Alcohol hand gel
After shave, perfume, cologne
Anti diarrheal medication
Over the counter cough syrups and cold remedies
Car windscreen washer fluid
Certain HIV medications
Some blood thinning medication
In addition, there are some foods and beverages that can not be used as they have alcohol in them:
This could mean that a patient on Antabuse who uses mouthwash before putting on aftershave then goes to a party where there is a BBQ they could end up in A+E. However, this is not the biggest issues with Antabuse. By taking it, a patient knows what is going to happen. Therefore, it is not uncommon for patients not to take it simply because they want to drink and wish to avoid the effects. Giving a prescription to a patient in no way ensures adherence. Indeed, a study in 2009 found that up to 80% of patients who are prescribed antabuse don’t take it. https://www.northpointseattle.com/blog/antabuse-explained-effective-treatment-alcoholics/
The difficulty is that the burden of responsibility lies, solely, with the patient. If they don’t want to take it: they don’t take it. Is antabuse all I need to curb my drinking?
As I said at the start, if this was the case I would be working in Aldi, not that there is anything wrong with that. Any addiction can be a progressive illness that requires appropriate intervention and significant lifestyle changes in order to manage the disease. Clearly, Disulfiram has it’s uses. It can protect a patient from physically refraining from drinking alcohol. This, in turn, can assist in helping people achieve what is known as emotional sobriety. This can be explained as when a person understands what triggers and/or factors led to dependence on alcohol, by using Antabuse a patient can learn how to protect themselves from factors that can lead to an episode of drinking. It is a tool in a tool box of recovery aids that is adjunctive to residential treatment and underlying therapeutic approaches. Can anyone take it?
The short answer is, No.
As we have seen, the side effects can be wide ranging. As such there are a few underlying conditions that preclude people from using Antabuse. These include:
In addition, patients taking Phenytoin for epilepsy cannot take Antabuse and neither can those on certain blood thinning medications It is interesting to note that, during the worldwide SARS-2/COVID-19 pandemic, Antabuse was investigated as a drug to combat the pandemic. Indeed, the esteemed Harvard medical school and Boston children’s hospitals both undertook in depth research on the effects of the drug on the disease. Indeed, studies indicated that those taking Antabuse were less likely to get infected, and less likely to succumb to the disease, than those who did not. overdose As with any prescribed medication, there is a potential for overdosing. A dose of up to 6 grams a day is not considered to be toxic in humans. Should someone overdose on Antabuse, the following symptoms are common:
Loss of consciousness
Tragically, a significant overdose can be fatal due to respiratory arrest and pathological lesions on many major organs. https://www.medsafe.govt.nz/profs/datasheet/a/antabusetab.pdf Antidepressants and Antabuse Some patients will present to services with depression as well as alcohol use disorder. The question then arises: is it safe to prescribe Antabuse as well as antidepressants, at the same time? Animal, as well as human, studies indicate that certain, older, type anti-depressants are not safe to take with Antabuse. For example, Mono amine oxidase inhibitors should not be taken. In addition, tricyclic antidepressants are also contraindicated when taking Antabuse. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2004.00597.x
How much Antabuse should someone be prescribed? The guidelines are an initial dose of 800MG (four 200MG tablets) every day for two three days. This can then be reduced by 200MG a day until a dose of 200MG is achieved. This is usually maintained for about six weeks to six months. A consultant review should then be undertaken. Some patients will need higher doses but should be kept under strict medical supervision. What about an implant? Clearly, by having an implant, there is no argument as to whether (or not) someone has taken their medication. This stops people substituting the tablets for vitamins so as to demonstrate to loved ones that they are taking their medication. The implant is called Esperal and will last, on average, about 12 months. The only problem is that patients have been known to remove them. As previously discussed, Antabuse is not a magic bullet.
The famous, or infamous, footballer, George Best, had an Antabuse implant but still drank. A well known consultant, Dr Kris Zakrewski, at the time stated that “These implants are a purely chemical terror based medication. https://www.theguardian.com/science/2003/jul/17/thisweekssciencequestions. He went on to explain that the effects of an implant vary, from patient to patient, and that for up to 50% of patients who experiment with alcohol (with an implant) will see what they can get away with. Implants are fitted under the skin of the abdomen: directly above the stomach. It works, as with any implant, by slowing releasing the drug. Some clinicians see implants of Antabuse as a discredited treatment and that the side effects, which is why people take it in the first place, are exaggerated. However, for those who can afford it, an implant is a low cost option which can be used in conjunction with other treatment options. Recent research has shown that it has a superiority over other medications prescribed for alcohol use disorder such as acamprosate, naltrexone and topiramate. https://www.tandfonline.com/doi/pdf/10.5455/bcp.20120903122839 Future uses As with the research, discussed above, on Antabuse and SARS/2-COVID-19, researchers have been looking into potential other uses for Antabuse. Indeed, a team at the University of Berkley have begun to test the drugs ability to treat vision loss. They found that Antabuse decreases the body’s ability to make retinoic acid, which is linked to vision loss. They found that, after being given antabuse, near blind mice were far more able to detect images on a computer screen to those who were not. https://www.fiercebiotech.com/research/drug-designed-help-alcoholics-might-be-key-treating-progressive-blindness What the key to recovery? As with any addiction, becoming sober, and maintaining sobriety stems from when a patient is fully engaged and active in their own recovery. Antabuse has it’s part to play, but it is adjunctive and secondary to underlying residential treatment and, if necessary, a supervised detox. It can be used as an outpatient, under consultant supervision. A standalone treatment? No. A useful aid? Yes.