Surreptitious use of disulfiram
Disulfiram is one of the most important drugs used in the management of alcohol use disorders (1). It is of significance as a treatment modality especially in low and middle income countries like India, as it is a cheaper pharmacological option compared to other medications like naltrexone and acamprosate. The efficacy of disulfiram has been documented in meta-analysis (2). The medication acts as a deterrent agent, due to precipitation of a disulfiram ethanol reaction (DER) when alcohol is consumed. The medication is typically started after taking informed consent and requires regular supervision, which is fairly possible in the usual family setting in India.
However, surreptitious administration of disulfiram by family members to unsuspecting patients has also been a matter of concern (3). In practice, many of us have come across women giving disulfiram to alcohol abusing husbands without their knowledge and precipitating DER in them. Usually, the distraught family members of alcohol abusers approach a physician in the patient’s absence. Disulfiram, commonly referred to as ‘reaction ki dawai’ (medication causing reaction), is thereafter given to the patient surreptitiously mixed with food or fluids. The patient starts to have a DER after consuming alcohol and quits alcohol use in many cases. Giving disulfiram in such a manner may possibly help some alcohol-dependent patients, especially those who are poorly motivated to quit drinking. However, at times, the patient then drinks larger amounts of alcohol to numb the discomforting DER symptoms, leading to severe reaction and possibly a fatal outcome. Thus, there is a potential risk of overenthusiastic family members causing grave harm to the patient in the hope of ‘helping’. Apart from DER, chronic administration of disulfiram can also cause other drug related side effects.
Such surreptitious administration of disulfiram raises a few questions. Could prescribing in such a manner be considered ethical, especially when the patient is always too inebriated or unmotivated to co-operate with treatment? From a utilitarian perspective, the ends justify the means, i.e. since surreptitious administering of disulfiram helps in quitting alcohol, it serves the purpose and is justified. From a Kantian (deontological) perspective, some forms of conduct are obligatory irrespective of the consequences. Under such principles, stealthy efforts to help patients in potentially dangerous ways are better avoided, so that faith in the medical profession is maintained. Following the four tenets of medical ethics (4), prescribing disulfiram to unwitting patients severely compromises the autonomy of the patient. However, sometimes schizophrenic patients are admitted against their will to prevent harm to themselves and others. The therapist may be acting in a beneficent and non-maleficent manner, but not according the patient’s wishes. Following similar logic, should perpetually inebriated patients be afforded ‘help’ at least temporarily, especially when they harm others (recurrent fights, drunken driving) or themselves (drinking despite having liver impairment and haematemesis)? It must be recognised that giving patients possibly harmful treatment without their knowledge is a form of coercion which may lead to subsequent distrust and resentment towards doctors and undermine the efforts of the medical profession. It seems a better option to assess the capacity of the patients to consent, and resort to other means of treatment like motivational interviewing when they refuse such treatment outright. Also, efforts must be made to regulate supply to prevent administration of disulfiram to unwitting patients.
Siddharth Sarkar, Senior Resident, Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh INDIA 160 015, e-mail: firstname.lastname@example.org
- Garbutt JC, West SL, Carey TS, Lohr KN, Crews FT. Pharmacological treatment of alcohol dependence: a review of the evidence. JAMA 1999 Apr;281(14):1318-25.
- Jorgensen CH, Pedersen B, Tonnesen H. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcohol Clin Exp Res. 2011Oct;35(10):1749-58.
- Manjunatha N, Vidyendaran R, Rao MG, Kulkarni GB, Muralidharan K, John JP, Amar BR, Jain S. Subacute vocal cord paralysis, facial palsy and paraesthesias of lower limbs following surreptitious administration of disulfiram. J Neurol Neurosurg Psychiatry. 2010 Dec;81(12):1409-10.
- Gillon R. Medical ethics: four principles plus attention to scope. BMJ 1994 Jul 18; 309(8948):184.