Supervised disulfiram as adjunct to psychotherapy in alcoholism treatment.

Supervised intake of the alcohol deterrent (AD) disulfiram has proven to be an effective adjunct to biopsychosocial alcoholism therapy for more than 60 years. This article summarizes disulfiram literature between 1937 and 2000 and reviews 13 clinical trials of disulfiram in alcoholism treatment from the years 2000 to 2008. After giving an update of general safety issues and recent case reports concerning safety problems with disulfiram, we focus on the introduction of psychotherapeutic application of supervised disulfiram. The results of our review show: (1) Disulfiram proved to be an effective therapeutic tool in all clinical studies published from 2000 to 2008. (2) Comparisons with other pharmacological agents - naltrexone, acamprosate, topiramate and gamma-hydroxybutyrate - indicate that disulfiram was equal in two trials but superior in the majority of trials. (3) Therapy programs that make use of the psychological effects of supervised disulfiram have - independently of the dose - better results than programs that neglect psychological effects. As a consequence, we suggest that supervised low-dose disulfiram (not more than 100mg/d), will show highest success when it is carefully integrated into psychotherapeutic alcoholism therapy. The major program of psychotherapy with disulfiram comprises the steps "Initial psychoeducation about the effect of disulfiram and its therapeutic implications", "Advanced psychoeducation", and "Disulfiram as coping skill and extension of repertoire of coping skills". As psychological mechanisms of supervised disulfiram we suggest: (1) deterrence; (2) (auto)suggestion; (3) therapeutic ritual around (4) a frequently renewed active decision process; (5) continuous reinforcement of a sober lifestyle and development of new coping skills.