Does disulfiram help to prevent relapse in alcohol abuse?

When taken in an adequate dose, disulfiram usually deters the drinking of a lcohol by the threat or experience of an unpleasant reaction. However, unle ss its consumption is carefully supervised by a third party as part of the formal or im-plied therapeutic contract, it is usually discontinued and the deterrent effect is therefore lost. In most studies, disulfiram administra tion has not been supervised and most reviews fail to stress the crucial im portance of supervision. Unsupervised disulfiram has little or no specific effect. We have therefore reviewed all published clinical studies in which there was evidence that attempts had been made to ensure that disulfiram ad ministration was directly supervised at least once a week. We found 13 cont rolled and 5 uncontrolled studies. All but one study reported positive find ings, which were usually both statistically and clinically significant in c ontrolled evaluations. In the sole exception, involving 'skid-row alcoholic s', it seems that adequate supervision was not achieved. In general, the be tter the supervision, the better the outcome. Provided that attention is paid to the details of supervision and that supe rvisors are given appropriate training, supervised disulfiram is a simple a nd effective addition to psychosocial treatment programmes. Compared with u nsupervised disulfiram or no disulfiram control groups, it reduces drinking , prolongs remissions, improves treatment retention and facilitates complia nce with psychosocial interventions such as community reinforcement, marita l and network therapies. The supervisor may be a health professional, workm ate, probation officer or hostel worker but is usually a family member. Tre atment should probably continue for a minimum of 12 months. Supervised disu lfiram appears to be more effective than supervised naltrexone and may be m ore effective than unsupervised acamprosate. The crucial importance of supe rvising the consumption of disulfiram has been overlooked or minimised by m any reviewers.