Disulfiram (antabuse) contracts in treatment of alcoholism

Although studies repeatedly demonstrate that alcoholics who consistently take disulfiram experience more favorable drinking outcomes, serious problems with compliance among the majority of alcoholic patients have reduced the effectiveness of disulfiram as a therapeutic adjunct. In general, alcoholism counseling with disulfiram simply prescribed seems no more effective than counseling without disulfiram (Fuller et al. 1986). Problems with compliance as well as problems with acceptance by patients and likely by clinical staff reduce the utility of disulfiram in the treatment of alcoholism. Implants, incentives, and various forms of observed or supervised disulfiram have been studied as possible solutions to the problems with compliance. Disulfiram implants appear largely ineffective due to failure to release adequate levels of disulfiram and risks of surgical complications and rejection. Newer techniques (see Allen and Litten 1992) may ultimately lead to a more effective implant. Incentives with personally relevant and obvious reinforcement value such as money, avoidance of incarceration, remaining employed, and continuation of methadone for opiate addicts, have been used effectively. Enhancement strategies with less tangible incentives also show promise. Among these are feedback on results of biochemical measures of disulfiram compliance and continuation in a familiar treatment program. Although each of the studies of incentives suffers from specific methodological limitations, the findings uniformly demonstrate better disulfiram compliance, less drinking, and better clinical outcomes for those who received a meaningful incentive for taking disulfiram. External monitoring of the patient taking disulfiram to assure compliance is typically used in studies evaluating incentives for taking the medication. Observed or supervised disulfiram in its own right and without tangible incentives also has received increasing attention as a method for enhancing compliance. Incorporation of such a strategy would seem to have potential for wide applicability in alcoholism treatment programs. Three forms of supervised disulfiram have been studied: (1) a written disulfiram contract, such as in BMT, with instructions about the benefits of the disulfiram contract and methods to establish disulfiram use as a daily habit and specifying that the alcoholic will take disulfiram daily while the spouse observes, that the couple will mutually thank each other, and that they will refrain from arguments or discussions about the alcoholic's drinking; (2) the disulfiram contract used in CRA, which is identical in form to the BMT contract except that talk about drinking is not prohibited; and (3) supervised disulfiram without a written contract, special instructions, or explicit verbal thanking. Studies of these three forms of observed disulfiram have been among the better controlled studies. Each approach has produced very promising results. A disulfiram contract with BMT produced less short-term drinking than disulfiram accompanied either by couples or individual counseling. Unfortunately, the superior BMT drinking results eroded because many couples discontinued their disulfiram contract after treatment ended (O'Farrell et al. 1985, 1992). Adding couples RP sessions after BMT led to better fulfillment of the disulfiram contract and better drinking and marital outcomes than BMT alone. These better RP outcomes persisted for 18 to 24 months after BMT for the entire sample and throughout the entire 30-month followup after BMT for those with more severe drinking and marital problems (O'Farrell et al. 1993). Thus, disulfiram contracts used with BMT are associated with less drinking and greater disulfiram compliance, while the specific contribution of disulfiram contracts to BMT remains to be investigated.(ABSTRACT TRUNCATED AT 400 WORDS)