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• W2084264358 abstract "The three commentators raise important issues about the use of disulfiram. Professor Poikolainen is correct that our knowledge about all aspects of diulfiram administration is incomplete. He asks if a test could be developed to ascertain the risk of a significant disulfiram–ethanol reaction (DER) if the patient takes disulfiram. When disulfiram was first used, patients were given a dose of alcohol after having been administered disulfiram so that they would experience a DER. Doing this should address two other of Professor Poikolainen's points. One, it should aid in the tailoring of the dose and two, it might make supervised disufiram more effective. On this latter point Professor Poikolainen is correct that a randomized controlled trial is necessary to determine this. A disadvantage to doing a controlled DER is that it is time-consuming and may not be practical in a busy clinic. Professor Poikolainen also suggests that the estimate of adverse reactions to disulfiram may be higher than that reported by Poulsen et al. (1992) because they were based on spontaneous reports by physicians. He suggests that prospective monitoring of large patient cohorts would be helpful to determine the true incidence of adverse reactions. In the Veterans Administration clinical trial of disulfiram (Fuller et al. 1986), except for drowsiness adverse reactions were not more commonly reported by patients prescribed 250 mg disulfiram than were reported by patients prescribed 1 mg disulfiram (essentially a placebo). Prospective monitoring of large cohorts of patients would be useful in this regard. This would require the cooperation of many clinics. Professor Poikolainen also points out that nickel sensitivity should be taken into account when counseling patients about taking disulfiram. This is prudent advice. Professsors Ehrenreich and Krampe say that the psychological effects of disulfiram extend beyond its pharmacological effect. Disulfiram is unlike any other medication in that it works by the threat of a DER rather than a direct pharmacological effect. Professors Ehrenreich and Krampe suggest that specific therapist techniques should be used with the supervised administration of disulfiram. These include repeated explanation of the action of disulfiram by the therapist followed by the patient repeating the information and by asking the patient to promise to stop taking the drug before drinking. This last piece of advice is in contrast to professor Poikolainen's statement that the experience of the DER speaks louder than words (although Professor Poikolainen advocates that the DER be experienced in a safe and controlled environment). Also Professors Ehrenreich and Krampe advocate that a ritual be developed around the supervised administration of disulfiram, i.e. the patient is challenged each time to actively decide against alcohol and is praised for taking disulfiram. These suggestions sound plausible, but a randomized clinical trial of supervised disulfiram with and without these techniques is needed to be certain that they are necessary. Professor Chick has found that disulfiram can be used in patients with elevation of their transaminases but without other signs of liver decompensation, provided that the patients are monitored closely. Saxon et al. (1998) have also concluded that it is safe to prescribe disulfiram to patients with ‘moderately’ elevated transaminase levels provided that monitoring of liver function tests are performed. We may have been too cautious in recommending that disulfiram not be prescribed to those with abnormal liver function tests. However, in the Saxon et al. (1998) study marked elevations of transaminases occurred more frequently in those with elevated baseline transaminases than those without elevated pretreatment transaminase levels. Each physician will have to weigh the risks and benefits of prescribing disulfiram for each patient. While we acknowledge the importance of the clinical experience of Professor Chick and others, we are still of the opinion that we would not prescribe disulfiram to those with abnormal liver tests. He also describes variations of the supervised administration of disulfiram. In his experience some patients benefit from visiting the clinic three times a week with only very brief contact with the nurse. This is in contrast to the more formal method of supervised disulifiram advocated by Ehrenreich and Krampe. Which method is correct? A randomized clinical trial is would be helpful. Also, different patients may benefit from different strategies, as Professor Chick suggests for other types of patients. Professor Chick ends by stating that disulfiram is not a cure. It is an aid to provide a period of sobriety for the patient to make changes in their lives. We wholeheartedly agree. The experience in Gottingen and Edinburgh shows that supervised disulfiram is being used and answers the question in our title as to whether disulfiram has a role in treatment today. Future work will show whether disulfiram adds to the effectiveness of newer medications for the treatment of alcohol dependence." @default.
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• W2084264358 date "2004-01-01" @default.
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• W2084264358 title "Disulfiram in the treatment of drinking problems: a response to commentaries" @default.
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