Antabuse is the brand name for disulfiram, the first prescription medication created to treat alcohol use disorder (AUD). The substance was discovered as early as 1881, but it was not applied to human consumption until Danish scientists observed that people who consumed disulfiram and drank alcohol experienced very unpleasant side effects, particularly intense nausea and vomiting. Although Alcoholics Anonymous (AA) had been offering support groups for people working to end AUD, pharmaceutical approaches to treating alcohol dependence, cravings, and addiction were unknown at the time.
By 1951, the United States Food and Drug Administration (FDA now, USDA at the time) had approved disulfiram specifically to prevent people struggling with AUD from drinking. The medication works by teaching individuals that they will experience illness if they consume alcohol.
There are an estimated 15.1 million adults, ages 18 and older, in the United States who struggle with alcohol use disorder; however, there are only around 250,000 prescriptions for disulfiram. This aversion drug has been prescribed to tread AUD for decades, but recent analyses of relapse rates show that there is little to no difference between Antabuse and a placebo. Additionally, Antabuse can lead to some dangerous side effects, so it is rarely prescribed compared to other AUD treatment medications, especially naltrexone and acamprosate.
How Does Antabuse Work?
The drug disulfiram works by disrupting how the liver processes alcohol. Typically, the liver uses enzymes to first break alcohol down into acetaldehyde, then further into acetate. If one has existing liver problems or is taking medications that are processed through the liver, then these enzymes may be disrupted, which can lead to negative interactions with alcohol, including queasiness.
Antabuse is designed to disrupt the breakdown of acetaldehyde into acetate, causing a buildup of acetaldehyde in the blood. With a spike of acetaldehyde in the body, the individual will experience physical sensations, including:
- Chest pain
- Trouble breathing
- A choking sensation
- Flushing or warmth in the face
- Physical weakness
- Increased anxiety
- Blurry vision
Antabuse is an aversion drug, meaning it causes negative consequences that should, eventually, become associated with negative behaviors, like consuming too much alcohol. The intention is that, when a person drinks, they will immediately feel sick; over time, they will associate alcohol with illness rather than pleasure.
In order to begin Antabuse treatment, the individual must have stopped drinking for at least 12 hours or until their blood alcohol concentration (BAC) returns to zero. A physician working to prescribe disulfiram should check their patient for heart conditions or arrhythmias, as disulfiram can alter heartbeat. The individual must not have a disulfiram allergy, which can result in life-threatening consequences.
The Side Effects and Risks of Antabuse
There are some common side effects associated with Antabuse, including:
- Signs of an allergic reaction, including trouble breathing
- Unusual behaviors or thoughts
- Extreme exhaustion
- Extreme physical weakness
- Shallow, irregular, or very weak breathing
- Slow or irregular heartbeat, or weak pulse
- Extreme chest pain radiating to the shoulder and/or the jaw
- Loss of appetite
- Upset stomach, nausea, or vomiting, with no alcohol or other interacting drugs consumed
- Dark-colored urine
- Yellowing of the skin or eyes due to liver damage (jaundice)
- Eye pain or sudden loss of vision
If these do not resolve, or they worsen, the prescribing physician can adjust the dose.
One of the main criticisms of Antabuse as a treatment for alcohol use disorder or dependence is that the drug takes 10-30 minutes for the liver to begin metabolizing alcohol, which means that disulfiram will take some time to cause the side effects that make alcohol unenjoyable. A person relapsing into alcohol abuse may consume a lot of alcohol during this time and experience intense effects from Antabuse, which could be severe enough to require hospitalization.
Disulfiram does not treat withdrawal from alcohol, which can have life-threatening side effects, nor does it stop cravings. While it was a breakthrough in treating AUD, and it has had an impact on the modern understanding of addiction in general, this medication is inappropriate for many people. It may work for some, but doctors who prescribe addiction treatments are not likely to start with Antabuse.
Controversy around Antabuse Prescriptions
There are two conditions in which Antabuse is most effective: for older adults who struggle with frequent relapse and for those who are motivated to continue taking it. While therapists and physicians have reported success in helping many people overcome AUD with Antabuse, other surveys suggest that the drug does not work as well as hoped. Like all medications used to treat addiction, Antabuse works only when coupled with therapy so individuals can understand their addiction and change their behaviors.
A psychoanalyst in New York City, Ruth Fox, was the first American to prescribe Antabuse to her patients to end alcohol addiction in 1949. She quickly found that she had to cut down the doses she was prescribing because her clients experienced side effects even though they did not consume alcohol. She also provided therapy to these clients while they took Antabuse. Reportedly, she successfully treated 2,500 individuals over her career.
However, a study published in 1980 found that people who took Antabuse could get some euphoric intoxication from consuming small amounts of alcohol and avoid the negative Antabuse side effects. This could be dangerous, not just because too much alcohol will trigger vomiting, but because a person is more likely to begin abusing both substances, eventually quit Antabuse, and continue drinking.
Not only is it possible to overdose on Antabuse, it is also possible that taking a lot of the substance and consuming too much alcohol could lead to death.
Although few doctors recommend Antabuse as a treatment for alcohol use disorder, the medication is still prescribed to treat those who may not have responded to other treatments in the past. It could also be used for appropriate candidates as an ongoing form of treatment after relapse. The choice to use Antabuse is very personal, and it comes down to an informed conversation between an individual and their doctor.