Question 1

A 52-year-old man with severe AUD has achieved 2 weeks of abstinence after inpatient detoxification. He is attending IOP and is motivated. He has compensated cirrhosis (Child-Pugh A) with mildly elevated transaminases. He has no history of opioid use. Which AUD medication is most appropriate?

Accepted Answer

He has liver disease (compensated cirrhosis with elevated transaminases), which makes both naltrexone (hepatotoxicity warning) and disulfiram (hepatotoxic) higher-risk options. Acamprosate is renally excreted with no hepatic metabolism, it is the AUD medication safest for patients with liver disease. Check baseline renal function (creatinine/CrCl) before starting, as acamprosate is contraindicated in severe renal impairment. This is the clinical scenario where liver disease status is the key differentiator in AUD medication selection. The patient who most needs AUD pharmacotherapy (liver disease from chronic alcohol use) is the patient whose liver cannot safely process the alternatives.

Question 2

A patient on disulfiram calls in a panic: "I forgot I was on Antabuse and had a glass of wine at dinner 20 minutes ago. My face is bright red, I feel nauseous, and my heart is racing. Am I going to die?" How do you assess and respond?

Accepted Answer

He is experiencing the disulfiram-ethanol reaction, which is the expected pharmacological consequence of consuming alcohol while on disulfiram. The severity depends on the amount of alcohol consumed and his disulfiram dose. A single glass of wine in an otherwise healthy person typically produces a moderate reaction (flushing, nausea, tachycardia, headache) that is self-limiting over 30 minutes to several hours as acetaldehyde is eventually metabolized through alternative pathways. Assess: Is he having chest pain, difficulty breathing, or feeling faint? Does he have cardiovascular disease? If symptoms are limited to flushing, nausea, and tachycardia without chest pain, syncope, or respiratory distress, supportive care (hydration, rest, monitoring) may be sufficient with clear return precautions. If symptoms are severe, worsening, or he has cardiac risk factors, emergency evaluation is appropriate. The DER severity exists on a spectrum. Not every reaction is a medical emergency, but every reaction requires clinical assessment of severity and risk factors.

Question 3

A couple presents to your clinic. The wife says: "I want you to put my husband on Antabuse. He keeps relapsing and I'm tired of it. He agrees, right, honey?" The husband looks at the floor and says "yeah, sure." He has no supervised dosing plan, no current therapist, and has not attempted naltrexone or acamprosate. He had his last drink yesterday. Is disulfiram appropriate?

Accepted Answer

This is not an appropriate scenario for disulfiram, for multiple reasons. His apparent consent is not genuine, his body language and reluctant agreement suggest he is being pressured rather than making an autonomous, informed decision. Disulfiram requires genuine motivation because the patient can simply stop taking it; coerced use predicts nonadherence. He has no supervised dosing plan beyond his wife's demand, no current therapeutic support, and has not tried first-line medications (naltrexone, acamprosate) that work through mechanisms that do not require this level of patient commitment. He also drank yesterday, disulfiram cannot be started until he is fully abstinent. The appropriate response: explore his own treatment goals privately (without his wife present), discuss the full range of AUD pharmacotherapy options, and address the relationship dynamics that may be complicating his treatment engagement. Disulfiram requires genuine, informed consent and a clinical assessment of motivation, support, and readiness.

Disulfiram

Side Effects Worth Knowing

Hepatotoxicity

Metallic or garlic-like taste

Drowsiness/fatigue

Headache

Skin eruptions

Peripheral neuropathy

Optic neuritis

Psychiatric effects

The disulfiram-ethanol reaction

References & Further Reading