Patient education is an extremely important component of therapy. Patients must be thoroughly informed about the potential hazards of treatment, including severe and potentially fatal reactions. Patients should be made aware that the effects of disulfiram will persist about 2 weeks after the last dose, and hence continued abstinence from all sources of alcohol is necessary. This includes cough syrups and alcohol applied to the skin in aftershave and colognes. Individuals using disulfiram should be encouraged to carry identification indicating their status.
Black Box Warning: Disulfiram
Disulfiram should never be administered to a patient experiencing alcohol intoxication because this may cause a potentially fatal reaction.
Preparations, Dosage, and Administration
See Table 31.3 for preparations, dosage, and administration.
TABLE 31.3
Preparations, Dosage, and Administration
| Drug | Preparations | Usual Adult Dosage |
| Disulfiram [Antabuse] | 250- and 500-mg tablets | Initial dosage 500 mg PO daily for 1–2 wk Maintenance dose 125–500 mg PO daily |
| Naltrexone [ReVia] | 50-mg tablets | 50 mg PO daily |
| Naltrexone [Vivitrol] | Solution for IM injection | 380 mg IM every 4 wk |
| Acamprosate [Campral] | 333-mg delayed-release tablets | 666 mg PO three times daily, taken with meals |
Naltrexone
Naltrexone [ReVia, Vivitrol] is a pure opioid antagonist that decreases craving for alcohol and blocks alcohol’s reinforcing (pleasurable) effects. Alcoholics report that naltrexone decreases their “high.” Although the mechanism underlying these effects is uncertain, one possibility is blockade of dopamine release secondary to blockade of opioid receptors. Naltrexone is generally well tolerated. Nausea is the most common adverse effect, followed by headache, anxiety, and sedation. Because naltrexone is an opioid antagonist, the drug will precipitate withdrawal if given to a patient who is opioid dependent. Conversely, if a patient taking naltrexone needs emergency treatment with an opioid analgesic, high doses of the opioid will be required.
Naltrexone was approved for alcoholism on the basis of randomized clinical trials that combined extensive counseling along with the drug. In these trials, naltrexone cut the relapse rate by 50%. Compared with patients taking placebo, those taking naltrexone reported less craving for alcohol, fewer days drinking, fewer drinks per occasion, and reduced severity of alcohol-related problems. In contrast to the original trials, a more recent trial, conducted by the U.S. Department of Veterans Affairs, failed to show any benefit of naltrexone in maintaining abstinence. Why did naltrexone work in the original trials but not in the more recent one? The most likely reason is that the subjects in the two trials were very different: the alcoholic veterans suffered from long-term alcoholism, had little or no social support, and received minimal counseling during the trial, whereas subjects in the earlier studies were younger, had good support systems, and received extensive counseling along with naltrexone. Hence the new study does not prove that naltrexone doesn’t work. Rather, it only proves that naltrexone doesn’t work for all drinkers, and doesn’t work in the absence of adequate counseling. The basic pharmacology of naltrexone is discussed in Chapter 22.
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