Disulfiram Should Remain Second-line Treatment for Most Patients With Alcohol Use Disorder

Alcohol use disorder (AUD) is responsible for a significant burden of medical, economic, and social harm globally and across the United States. Currently, only three FDA-approved medications for AUD are available, and most patients with AUD never receive pharmacotherapy. Disulfiram, the first medication that FDA approved for treatment of AUD, is recommended as a second-line treatment option by several national treatment guidelines citing safety concerns and lack of high-quality comparative studies. In this issue, Holt argues that disulfiram should be reclassified as a first-line treatment for AUD based on promising open-label randomized controlled trials (RCTs) for disulfiram as a behavioral intervention. Review of the literature suggests that disulfiram can be a useful treatment for a highly selected group of patients with no medical or psychiatric contraindications, high motivation for abstinence, and adequate family support. Unfortunately, many patients with AUD, a disorder characterized by high rates of medical and psychiatric multimorbidity and social vulnerability, fall outside of this narrow selection criteria. Prescribers should consider other FDA-approved medications as first-line treatment options for most patients with AUD, reserving disulfiram for the rare patients in whom the potential for benefit clearly outweighs risk of harm.