Skinner 2014: disulfiram worked in open-label trials, not blinded ones

What they tested

The authors pooled 22 randomized trials that compared disulfiram with any control group in people with alcohol problems. Each trial's own main outcome was used.

They compared blinded trials, where patients don't know whether they're on the real drug, with open-label trials, where they do. Their idea was that in a blinded trial everyone fears a reaction to alcohol, so the threat is spread across all groups. They also looked at supervision, studies of people who used cocaine, and the type of control group.

What they found

Overall, disulfiram had a higher success rate than control groups, with an effect size (Hedges' g, a standard measure of how big a difference is) of .58.

When blind and open-label trials were split, only open-label trials showed disulfiram ahead (g = .70). Blinded trials showed no effect.

Disulfiram also came out ahead when the control group got naltrexone (g = .77), acamprosate (g = .76) or no disulfiram (g = .43).

The authors concluded that blinded trials can't detect disulfiram's effect, and that in open-label, supervised studies disulfiram is safe and effective compared with other abstinence medicines or no disulfiram.

Limits

• 89% of participants were men.
• The trials differed a lot from each other, with high heterogeneity in most subgroups.
• The case for disulfiram rests on open-label trials, where patients and staff know who is on which treatment.

What it means if you're considering naltrexone

For someone choosing between naltrexone and disulfiram, this review suggests disulfiram can work when you know you're taking it and someone supervises the doses. The authors argue the threat of a reaction is part of how it works. In the trials that compared the two drugs, disulfiram came out ahead.

The site's disulfiram comparison notes that those naltrexone comparisons were open-label, that three were Indian trials where family members supervised doses, and that both US guidelines still rate naltrexone higher for alcohol use disorder.