Antabuse is the well-known trade name for the chemical compound disulfiram. It comes in tablet form. By itself it produces no effects. However, it interferes with the way the body deals with alcohol. When alcohol is metabolized in the body it is oxidized to carbon dioxide and water. At an intermediate stage in this chemical process a toxic substance, acetaldehyde, is formed but it is so rapidly broken down that no ill effects are felt. When a person drinks on top of antabuse, this process is blocked, so that the acetaldehyde from alcohol is only slowly
broken down and its level in the blood rises. Accumulating acetaldehyde brings about a sequence of physical sensations which each patient learns for himself. The patient learns what his particular response is because he is given a test reaction by the doctor at hospital. The purpose of this is not only to teach him what to expect but also to enable the doctor to cut the reaction short if it is unduly severe. The patient takes a tablet each morning for at least three days and is then given two to four ounces of spirits. The reaction begins about ten minues after taking alcohol and lasts about an hour. If unduly distressing it can be promptly terminated by drugs which counteract the unpleasant effects. The aim of the test is not to terrify the person taking it (this is in no way an aversion’ treatment), but to let him learn from personal experience how he can use antabuse to stop drinking. He is prevented from drinking by the knowledge that alcohol will no longer achieve its pleasurable effect.
No patient should use the drug unless he has had an antabuse test. The first symptom to occur in the antabuse-alcohol reaction is flushing and warmth of the face. Then a pounding is felt at the temples as the heart beat accelerates. A headache commonly develops. Another common effect is a catch in the breath, as if there is some sort of obstruction in the windpipe; there may be coughing or a choking sensation. The patient becomes uncomfortably aware of his breathing because he has to work harder to take in the necessary air. There is generally an emotional accompaniment to the reaction; this is probably a direct effect of the acetaldehyde in the circulation, which may produce an anxious feeling.
The effects of antabuse occur if alcohol is taken within about three days after a tablet is taken. Once this period has elapsed, and the drug has been totally excreted from the system, no farther adverse reactions will occur with drinking. The treatment plan calls for one tablet to be taken every morning. The bottle should have its unvarying place with the shaving kit or on the breakfast table and every morning the tablet may thus be taken without deliberation or inner debate. To those who protest against placing reliance on a pill rather than on willpower, alcoholics who have found antabuse a worthy aid reply that they use their will power to remember to take the tablet every morning.
Those helped most by antabuse are the alcoholics who for many months after becoming abstinent continue to have strong craving for alcohol. They emphasize eloquently that they regularly want a drink very badly indeed. For them antabuse provides a sort of chemical guard. The real value to the abstinent alcoholic of an antabuse regime is that in the event of a crisis which he is tempted to resolve through drinking he will have to wait for three days while antabuse is being eliminated from the system. By then he may have taken steps to resolve the difficulty, and decided to resume the antabuse instead of his drinking. In the early stages of treatment antabuse may be relied on heavily by patients who can scarcely believe that it will prove possible for them to remain abstinent by their own efforts. They feel they cannot undertake never to use alcohol again and are reassured both by the knowledge that, temporarily at any rate, it is impossible for them to drink, and also, paradoxically, by the information that they have only to leave off antabuse for three days, and it will be possible for them to drink again should such relief become imperative.
Occasionally antabuse itself, even if the patient does not drink, may produce mildly unpleasant effects in certain individuals who are hypersensitive. Theseeffectsincludeskinrashes, a state of lethargy, headache, a metallic taste in the mouth, stomach discomfort and, rarely, a confusional episode. Such reactions, although infrequent, are another reason why the drug should only be used under experienced medical supervision. The reactions can be treated easily, and other drugs similar in action to disulfiram may be substituted. Abstem (citrated calcium carbimide) is the most widely used alternative to antabuse.
Antabuse, correctly used, reduces the likelihood of impulsive drinking. It is only part of a comprehensive treatment programme but for some patients it may be lifesaving. These people consider that only the daily antabuse tablet, the antabuse habit, stands between their present sobriety and the resumption of uncontrolled drinking. Once having taken the tablet they have made their decision for that day. At a time when temptation is lowest they protect themselves against craving that might arise later on, for instance from the otherwise overwhelming attraction of the smell that wafts towards them from an open public-house door as they pass along the street.
How long should the automatic taking of antabuse continue ? Six months, a year, for ever? No general answer can be given. Some give up the tablets soon and stay well. Often discussion makes it clear that the patient considers stopping antabuse at a time of particular strain, such as trouble at work or disturbance in a personal relationship. Of course this is just the time not to stop. The decision is best made j ointly by patient and physician. It is important to make sure that the patient’s decision to do without does not coincide with his turning over in his mind the possibility that he might be one of those legendary alcoholics who just conceivably could risk an occasional drink.
There is no justification for supposing that only the weak require antabuse, and that to use it is to rely on a crutch. Each patient’s alcoholism is an individual matter. Some alcoholics electing to rely on antabuse are among the most resolute and self-explorative patients we have known. They view antabuse as an important medical discovery (they only wish that a drug was also discovered which could reduce the discomfort of craving). They use the analogy that if one were entering malarial country one would take prophylactic quinine; for them, going about the streets is to venture into disease territory.
Because antabuse may be bought over the counter of a chemist’s shop three warnings should be given. It is unwise and may be extremely dangerous to start taking antabuse without having been physically examined and without having had a trial reaction watched by a doctor. After having had some drinks it is unsafe to take antabuse until the alcohol has been eliminated from the body; generally it is wise to wait twenty-four hours after the last drink. Lastly, the alcoholic has to know that he is on tablets; to do as some wives have done and give antabuse to someone surreptitiouslyis not only misguided but dangerous.