COMMUNITY MENTAL HEALTH SERVICES OF MUSKEGON COUNTY

Practice Guideline

Prepared By: No. 12-001 Effective: August 23, 1999

Mike Zambiasi
Ron Kidder
Garland Kilgore
Robert Bultema
Joy Garrett-Jones

_______________________________________
Michael G. Zambiasi, Chairperson
Antabuse Protocol

SUBJECT: Antabuse Protocol

Approved By:

_______________________________________
M. Munawar Butt, Medical Director

_______________________________________
James Borushko, Director

I. PRACTICE GUIDELINE:

Antabuse (Disulfiram) protocol.

II. PURPOSE:

To enable the agency to provide consistent, safe, and effective use of Disulfiram
(Antabuse) for clients.

III: APPLICATION:
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Antabuse Protocol
August 23, 1999
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This practice guideline applies to all CMH employees and contract providers.

IV: PROTOCOL:

A. Assessment

1. Anyone can initiate a request for an assessment for Disulfiram use

by contacting CMHS staff, including the client, family, friends,
courts, and medical or mental health care staff (case manager,
therapist, psychologist, nurse, physician, physician assistant, etc.).

2. The client shall undergo three assessments and some lab tests prior
to Disulfiram use.

a. A substance abuse specialist (SAS) shall evaluate the

client’s alcohol problem, using an interview and perhaps
screening instruments such as CAGE or HEAT.

b. A CMHS psychiatrist or physician assistant (PA) shall

evaluate for psychiatric appropriateness and capacity to use
Disulfiram.

(1.) If requested by the psychiatrist or PA, a CMHS

nurse shall complete a health profile.

c. A medical physician or PA or nurse practitioner (NP) shall

conduct a physical examination.

(1.) Releases of Information shall be obtained.

d. Tests shall include the following:

(1.) Pregnancy test, if the client is capable of getting

pregnant.

(2.) Lab work shall include CBC, liver function tests,

total protein, albumin, cholesterol, triglycerides,
electrolytes, BUN, creatinine.

(3.) An ECG shall be obtained within the previous six

months.
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Antabuse Protocol
August 23, 1999
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e. Once the assessments and lab are complete, the psychiatrist

shall decide if Disulfiram is appropriate.

(1.) Any one of the assessors may “veto” the use of

Antabuse by a written statement to the psychiatrist.

3. The Behavior Support Committee shall approve the use of

Disulfiram.

a. A behavior treatment plan may be written and implemented

by a CMHS psychologist, which describes provisions of
positive reinforcement for behaviors to achieve and
maintain sobriety/abstinence.

b. In some cases, a behavior treatment plan may be

determined to be unworkable or inappropriate, but this shall
not preclude the continued use of Disulfiram.

B. Treatment and Monitoring

1. The CMHS psychiatrist or PA or nurse shall provide complete

information (orally and in writing) about the medication and its
effects and side effects, and the client shall give informed consent
to take Disulfiram.

a. Incompetency (defined as either the legal [has a guardian]

or clinical [not yet adjudicated] inability to give informed
consent) is an absolute contraindication to the use of
Disulfiram.

2. The CMHS psychiatrist or PA shall prescribe Disulfiram. Only in

rare circumstances will the medical (primary care) physician
prescribe Disulfiram for a CMHS client.

3. A Disulfiram Medic-Alert bracelet shall be recommended but not

required.

4. The client shall be seen at least monthly by a CMHS nurse (or

physician or PA) for routine monitoring, including blood pressure
monitoring.
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Antabuse Protocol
August 23, 1999
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5. The client shall be seen at least quarterly by the prescribing

psychiatrist or PA.

6. Liver function tests (LFTs: AST, GGT, alkaline phosphatase),

cholesterol, and triglycerides, and other studies as indicated
medically, shall be obtained by CMHS staff every six months after
treatment is indicated.

7. Disulfiram use shall preferably be conducted in parallel with other

ongoing substance abuse (dual diagnosis) treatment by CMHS
and/or other agencies unless jointly waived by the substance abuse
counselor and psychiatrist.

a. Psychotherapy (individual or group) shall be considered but

is not mandatory.

b. Participation in a twelve-step program is strongly

recommended.

c. Intensive outpatient program is recommended.

V: REFERENCES:

1. American Psychiatric Association Practice Guidelines, 1996.

2. Physician’s Desk Reference, 1999.
3. See Attachment No. 1.

/lm
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Antabuse Protocol
August 23, 1999
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Attachment No. 1

General Guidelines for Dosing,

Predictors of Outcome, and Contraindications

A. Dosing

1. The usual dosage is 250-500 mgs. daily as a single dose in the morning.

2. Bedtime dosing is acceptable if the medication is sedating.

3. Higher doses (up to 750 mgs. daily) are feasible if the client shows a
tolerance to the effects of Disulfiram.

4. 500 mgs. every other day may be as effective as 250 mgs. daily.

5. Lower doses (e.g. 125 mgs.) may be feasible.

B. General predictors of successful Disulfiram use include the following:

1. Good working relationship with treatment team.

a. Compliance with medications and appointments.

2. The client is relapse-prone but remains in treatment and is motivated to be

abstinent.

a. The client has relapsed using less structured approaches to

sobriety.

b. The client is in early abstinence and in a crisis or under severe

stress.

c. The client requests Disulfiram or, at minimum, wants to use it.

3. Other predictors of positive outcome include:

a. The client is older (>40), male, and has a long history of

alcoholism.

b. The client is socially stable.

c. The client is cognitively intact.

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Antabuse Protocol
August 23, 1999
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C. Contradictions for the prescribing of Disulfiram include the following:

1. Absolute contraindications.

a. Hypersensitivity to Disulfiram or other thiuram derivatives used in

pesticides and rubber vulcanization (rubber contact dermatitis).

b. Pregnancy, or the imminent desire to become pregnant.

c. Incomplete (legal [has a guardian] or clinical [not yet adjudicated]:

inability to give informed consent.

2. Relative contraindications.

a. Acute or severe medical illness.

b. Severe myocardial disease: angina, coronary artery disease,

cardiac dysrhythmias, cardiomyopathy, etc.

c. Severe pulmonary disease: asthma, pulmonary insufficiency, etc.

d. Severe liver disease: acute hepatitis, cirrhosis, ascites, etc.

e. Severe or chronic renal failure.

f. Severe or poorly controlled seizure disorder.

3. Possible contraindications.

a. The client is unable to stop drinking alcohol or products containing

alcohol.

b. Acute psychosis.

1. A psychotic thought disorder (e.g. schizophrenia), without

acute psychosis, is not a contraindication.

2. Disulfiram is believed to cause or exacerbate psychosis by

one or more of the following mechanisms:

(a.) The formation of carbon disulfide (CS2) from the

metabolism of Disulfiram, which can cause
delirium.
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Antabuse Protocol
August 23, 1999
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(b.) The increase in dopamine from the blockade of

dopamine beta hydroxylase (DBH, which catalyzes
the conversion of dopamine to norepinephrine).

(c.) The increase in dopamine from the inhibition of

oxidative hepatic metabolism.
 (d.) The increase in dopamine from the inhibition of
monoamine oxidase (MAO).

c. Neurological disorders, such as neuropathy, dementia, etc.

d. Concomitant use of drugs requiring oxidative metabolism (levels

will increase): tricyclics, barbiturates, benzodiazepines (not Serax,
Ativan, Restoril), Dilantin (diphenylhydantoin), rifampicin,
Coumadin (warfarin), etc.

e. Psychiatric instability: poor impulse control, suicidality,

personality disorder(s), depression, etc.

f. Social factors: poor or non-compliance with medications or

treatment, poor or no support system, severe denial of alcoholism,
etc.