thvpnai39dExcessive use of alcohol can have tragic consequences.  Careers, families and health are too often needlessly destroyed.  Craving and denial can be so powerful that alcoholism’s victims become locked in its embrace with little hope for escape unless they find help.

It’s easy to be fooled by alcoholism.  This great imposter can mimic mild to severe states of anxiety and depression, confusing even the most discerning observer.  Two weeks without a drop are often needed to know if there’s more going on than simple alcohol overuse.  On its own, simple alcohol overuse can result in symptoms of panic and despair rivaling the most severe cases of genetically driven mental illness.

Whether someone suffers with alcohol overuse alone or if it’s accompanied by another type of distress, the first step is conceptually simple but not easy – to stop drinking and to stay stopped.  Abstinence is the only sure way to be free of alcohol’s cunning and determined grasp.

Some people become aware that their drinking has gotten out of hand, while others need firm encouragement to realize they have a problem and to find a way out.  Most people start by trying to control their drinking.  If they don’t have genetic alcoholism or if they haven’t set the machinery of alcoholism in motion, they sometimes succeed.  By lowering stress and working through relationship drama, they sometimes manage to reduce their urge and curtail their use.  Many people, however, go through several attempts to restrict their drinking before realizing their drinking pattern is beyond their control.


Then what?


Some people turn to sober friends and go to AA for support.  Others seek counseling.  Some, who drink large amounts, must go for detox.  Medical detoxification may be needed for someone who drinks more than a pint of spirits, a liter of wine or a 6 pack of beer per day.  Without medically supervised detoxification, the risk of seizures or more severe complications of withdrawal may be too great.  Anyone unsure of their detox status should seek professional advice.

Repetitive efforts to abstain from alcohol and achieve sobriety sometimes results in success.  Too many times, however, tragedy strikes before the person has managed to establish a solid foothold in sobriety.  Automobile accidents, suicide, job firings and relationship unraveling can happen before some people manage to achieve sobriety.


There’s a path to sobriety often forgotten by harried clinicians or their patients:  disulfiram.  For many years and for many people, disulfiram (brand name Antabuse) has offered a quick way to become abstinent, the first step in the path to sobriety.

Within the context of a Three-Layered Healing Plan (see my blog at for more), disulfiram (Antabuse) is a Layer Three (Restoration with Medicine) decision.  I recommend you not rush this decision but consider it carefully.  In most cases, people are able to achieve a sober lifestyle with AA and, as needed, counseling.  Sometimes, however, particularly with stubborn cases of genetic alcoholism, people cycle through detox, counseling, and rehab numerous times.  They and their families can feel frustrated, desperate and scared.  Although there’s no guarantee that it will work, disulfiram (Antabuse) sometimes helps to create a period of abstinence long enough for the healing assists of healthy lifestyle, counseling guidance and spiritual AA guidance to take effect.

Disulfiram works by blocking aldehyde dehydrogenase, the enzyme that clears away acetyladehyde, a product of first stage of alcohol metabolism.  Acetyladehyde is a toxic molecule that, when not metabolized away, results in a severe reaction of facial flushing, accelerated heart rate, projectile vomiting and panic.  Anyone who drinks alcohol while under the influence of disulfiram, is unlikely to repeat the behavior because the disulfiram reaction is so severe.

Disulfiram mimics a genetic state called Asian flushing syndrome.  Although not restricted to Asians, a significant percentage (36%) of East Asians lack the gene that manufactures the enzyme that gets rid of acetyladehyde.  Because they can’t get rid of acetyladehyde, anyone with this genetic trait cannot tolerate alcohol.  If they were to develop an addiction, it would not be alcoholism.

Mimicing this genetic state by blocking the metabolism of acetyladehyde, disulfiram (Antabuse) leads to a nonnegotiable abstinence from alcohol.  This crude but very effective solution ensures abstinence for as long as disulfiram (Antabuse) is taken.  Plus, there’s a bonus:  the effect of disulfiram (Antabuse) lasts at least one week and often up to two weeks after the last dose of disulfiram is taken.  Even if someone thinks they want to return to drinking, this gives them time to reconsider their decision.


The disulfiram/alcohol reaction was first observed in an American tire factory in 1937.  Disulfiram, a sulfa compound, was used in the vulcanization (rubber manufacturing) process.  Factory workers inhaling disulfiram during their shifts were unpleasantly surprised they could not enjoy a drink after work because the disulfiram they inhaled on the job caused an unpleasant (and embarrassing) reaction at the bar.  This observation was reported by the occupational physician at the factory.  Later, in 1949, the molecule, was finally understood and isolated and was sold as Antabuse.


The dose of disulfiram (Antabuse) that works for most people is 250 mg taken at any time with or without food.  Occasionally people discover after taking alcohol, intentionally or not, that 250 mg is not sufficient to cause the full reaction.  In such cases, increasing the dose to 500 mg almost always works.

The disulfiram/alcohol reaction is unforgettable.  Within minutes skin flushing is accompanied by an accelerated pulse.  This is followed by intense vomiting and a sensation of panic.  It can be so bad that many people believe they are going to die and go to an Emergency Department for help.  Death is rare but disulfiram should not be used or should be used with caution for someone with a heart condition.

Although rare, if someone has an allergic reaction (rash, hives, and especially if trouble breathing), they should go to an Emergency Department for IV antihistamines and an anaphylactic reaction protocol.   Although there have been reports of liver toxicity, it appears that in most cases, the toxicity was caused by alcohol.  I have safely given disulfiram to people with cirrhosis but insist they be under the watchful eye of a gastroenterologist.

I caution people to not have a drink at least 12 hours before their first dose of Antabuse and then to avoid alcohol completely.  I write on a card or on a blank prescription that I have prescribed disulfiram for them and tell them to keep it with their health insurance card.   In case they have a severe reaction and pass out, Emergency Room staff will know the combination of disulfiram and alcohol may be a factor.

I caution people not to have rum cake (sometimes the rum is added after the cake is removed from the oven), to avoid ice cream cordials (liquor added), chocolates that may have liquor inside and never drink from the punch bowl at a party.  Some people who take disulfiram spray perfume or cologne on their hair rather than on their skin to avoid absorbing the alcohol in liquid fragrances.  They also ask for betadine rather than alcohol swabs when giving blood.  Those precautions I feel are unnecessary but some people feel safer by following them.  Please consult with your prescriber or pharmacist for additional information about the safe use of disulfiram.  Anyone considering using disulfiram (Antabuse) should do so only with the guidance of a prescriber knowledgeable about its use.

Disulfiram (Antabuse) can be a useful tool for ensuring abstinence until a program of recovery is undertaken and a state of sobriety established.  Some people use disulfiram only when they think a big event might lead them to drink.  They start it one week before the event (birthday, wedding, holiday gathering) and stop it after their urge has diminished and the immediate risk of relapse has passed.


Abstaining from alcohol with the help of disulfiram (Antabuse) should not be confused with sobriety.  Sobriety is a state of acceptance of the condition of alcoholism and surrender to a higher power to help maintain abstinence.  This is most often achieved by a recovery-oriented lifestyle, including active AA participation and the development of a daily ritual of reflection and renewed commitment to not drink.  Working with a “sponsor” (mentor) in AA, provides the guidance most people need to fully benefit from what AA has to offer.  Unfortunately, alcoholism has no cure and its management requires a lifetime of vigilance.

The spiritual guidance of AA harmonizes well with the emotional and cognitive guidance provided by psychotherapy.  In fact, it’s a good idea to add therapy to whatever efforts are being used to ensure abstinence and sobriety.  The top priority however, for anyone afflicted with alcoholism, must be abstinence.  Without it, any accomplishments, made in therapy are too easily thwarted by alcoholism’s relentless potential for relapse.  For someone who has trouble sustaining abstinence long enough to establish sobriety and a daily program of recovery, disulfiram (Antabuse) can be a useful tool.