Alexander DeLuca, M.D.
My Experience with Antabuse
by James Cannon; Director of
Management Network, Inc; 2004-04-04. Originally posted: 2004-09-20. Minor
The scores of problem drinkers, who I have known, share many common experiences. Their behavior can be categorized into several patterns or syndromes. I have observed at least three distinct patters that can be further broken down into sub-patterns. What I have observed to be common among all problem drinkers is the use of alcohol to manage emotions, often without the drinker realizing it.
Discovering the exact role that alcohol is playing in the management of emotions, even discovering what these emotions are, can be very difficult. This process is made more difficult if alcohol remains part of the coping process.
Recently I experimented with Antabuse, a drug with a single effect. It makes drinking alcoholic beverages an unpleasant experience. Those who are familiar with Antabuse often think that this is its sole benefit. Actually it is much more useful than that.
Taking Antabuse is a proactive way of achieving abstinence for whatever timeframe the problem drinker seems appropriate. For me, it was a useful tool. It removed the alcohol factor from my emotional life. The results were useful and unexpected.
Chronic, Binge and Bender
The first type of problem drinker is the chronic drinker who drinks almost everyday, often at levels above what is considered healthy. This type of drinker rarely experiences any dramatic life problems because of their drinking. The harm associated with this pattern is protracted and affects long-term health and quality of life.
The second type is the binge drinker who, most of the time may drink very moderately or not at all. Periodically and regularly they drink far in excess of what is safe. During these binges their behavior is often dangerous and embarrassing. Often they drink to state of blackout when memories of what happened during the drinking episode are lost.
The third type of problem drinkers are those who go on benders. In the 19th Century they were called dipsomanics. Like the binge drinker, they often drink very moderately or not at all for long periods of time. Periodically, and often with an astronomical regularity, they drink in dangerous excess as if drinking alcohol was as vital to survival as breathing oxygen. The drinking orgies continue for several days or weeks.
I first developed this bender pattern after exposure to traditional treatment and its abstinence only solution. One could argue that a causal relationship exists between the two events.
Brief Drinking History
Two things changed my perception of the harmlessness of my drinking habit. First I realized that I was drinking more than anyone else I knew. This included several people who enjoyed reputations as ‘big drinkers’. The second indication that my drinking had become problematic was my wife’s increasing discomfort with it. Her background is Mediterranean. Mine is Irish. She was completely unfamiliar with this drinking pattern in a family situation where small children were present. She objected to it.
Perhaps related to her objections, I began to engage in periodic binge episodes when I did get drunk. Though not devastating, the binges were not harmless.
At this point I decided to explore the possibility that I had a drinking problem, and asked for help doing so. This request led me to my introduction to traditional treatment.
At first, abstinence was very pleasant. This pleasure was sufficient to temporarily offset the frustrating cyclical irrationality of the 12 step experience. However, after three months of traditional treatment, the experience became disturbing. It seemed so foolish that I decided to drink. I suffered what G.Alan Marlatt refers to as the “Abstinence Violation Effect”.
I submitted to traditional treatment in a vulnerable state of mind, and was highly suggestible. I accepted everything that was said as true and factual. Once I started drinking, it seemed pointless to stop. If everything that I had learned in traditional treatment were true, if I were an alcoholic, if abstinence was the only solution, if drinking at all would send me to the gutter in a beer barrel and I had had a drink, the only reasonable course of action, after I had violated my abstinence, was to enjoy the ride. I did.
I did nothing but drink for two weeks. I did not work, nor interact with my family in any meaningful way. I did not work. I just drank.
This was my first bender, different from a binge because of its long duration. Once I stopped drinking, I returned to abstinence with deep remorse and shame. A few months later I was off on another bender. This pattern of abstinence, followed by a drinking bender, remains with me after many years.
While on a bender, nothing mattered but getting another drink. I would lie. I would not show up when and where I was expected and needed. Everything took second place to alcohol. The bender would end when I realized that my physical health was beginning to fail. I did not want to deal with my life, but I also did not want to die.
After so many years of suffering this cycle, and many different treatment approaches, Antabuse seemed a harmless next step.
The bender, and all those that preceded it had burned all trust in my significant relationships, including those with my wife, children, business associates, and perhaps most importantly, with myself.
Taking Antabuse on a regular basis (250 mg per day) offered an effective way to restore functional, if conditional, trust in these relationships. Though I knew that my core problem was not alcohol, alcohol abuse, and while on a bender, dependence, had become a severe secondary problem. To those around me, it seemed the primary problem, and I was able to acknowledge and understand their perspective.
A physician, who was also a friend, offered to manage my experiment with Antabuse. The planned duration of the Antabuse experiment needed to be determined. My initial plan was to take the Antabuse and remain abstinent for ‘as long as it takes’ to solve this problem. He rejected that time frame, and suggested that I commit to 90 days on the drug. At that time, we would evaluate the situation, and extend the commitment if it seemed appropriate.
This simple condition offered by the doctor dispelled my prejudices against the drug. It was no longer punishment or insult. It was a tool that I was using of my own free will to accomplish a specific objectives. By removing the alcohol factor, it would restore functional trust in my primary relationships and I could be certain that a drinking episode would not complicate my life.
He wrote the prescription. A measure of ambivalence prevented my rushing to the nearest pharmacy to have the prescription filled. Several conditions governing my decision remained unresolved. The primary reason for taking the drug was to provide a level of comfort for people close to me who depended on my availability. While on a bender, I became completely unavailable to anyone. My significant others were not persuaded that Antabuse provided any surety. Taking the drug for the sake of the relationships was futile.
The primary reason for taking the drug was to establish this minimal level of trust. This objective would not be met, and I was about to abandon the experiment. However, for reasons that remain unclear, I decided that I would take the first step and start the protocol for my own benefit. No negative side effects of the protocol could be as bad as the effects of the most recent bender. And I was free to stop at any time.
I filled the prescription. I swallowed the pill as I was finishing my first cup of coffee every morning.
They stories are misleading. This is what actually happens.
Alcohol is metabolized by the liver enzyme alcohol dehydrogenase into acetaldehyde. Acetaldehyde is toxic. Any concentration of it in the blood causes unpleasant physiological events: rapid increase in blood flow to the skin of the face, neck, and chest, rapid heartbeat, headache, nausea, and extreme drowsiness. The intensity of these effects is determined by the individual’s metabolism and the concentration of acetaldehyde in the blood.
Acetaldehyde is metabolized by another enzyme called aldehyde dehydrogenase into acetate, which is essentially harmless and eventually metabolized into carbon dioxide and water.
Antabuse blocks production of the enzyme aldehyde dehydrogenase. The acetaldehyde remains in the system. The concentration of acetaldehyde in the blood increases according to the amount of alcohol consumed, as do the unpleasant effects it causes. The experience of drinking alcoholic beverages, which is normally pleasant, becomes unpleasant.
alcohol + (Enzyme: alcohol dehydrogenase)= acetaldehyde
acetaldehyde + (Enzyme: aldehyde dehydrogenase) = acetate (= acetic acid = vinegar)
Taking a drink
Having no idea how I would react to alcohol, I poured one shot of Vodka into 12 oz of seltzer, drank half, and lay down on my bed to watch a movie.
Fifteen minutes later I felt some mild pressure on the back of my neck. The mild euphoria I always experience half way through my first drink was absent. I drank the second half of the vodka mix. Within 10 minutes the pressure had increased and spread to my head. My eyes felt scratchy. Looking at myself in a mirror across the room, I noticed that my eyes were rather bloodshot. I rose to take a closer look. My footing was shaky.
Up close, my eyes looked more bloodshot than they had ever been. The capillaries in the whites were so engorged that they resembled ivy growing on a wall.
That was enough.
Knowledge trumps belief, and experience trumps knowledge. I had experienced the Antabuse reaction to alcohol ingestion. I now knew that, while I was on Antabuse, a beverage containing alcohol would be an unpleasant experience, not the pleasant one that I had learned to expect. The experience was not horrible or life threatening. It was simply unpleasant. Taking another drink held no appeal whatsoever.
The knowledge that the drug was in my system, and inhibiting my ability to ingest alcohol in any quantity, forced a new perspective during decision-making processes.
Decision-making is often a conversation that I have with myself. Different aspects of my personality often have conflicting preferences when a decision must be made. Hal Stone created a model for illustrating this process called internal voice dialogs and describes it in “Embracing Our Selves”. This model best illustrates my most useful experiences with Antabuse.
In Stone’s model, each voice represents a different aspect of a unified personality. All functional adults have a manager; the voice that makes us presentable to the community. Most people have a protector whose position in decision making is the avoidance of situations that have proven to be painful or destructive. Many people have an impish voice that often speaks for things that could be perceived as inappropriate. The impish voices express the desire for the entire chocolate cake, a weekend of gambling with no credit limit, or a sexual interlude with the stranger across the room The managing and protective voices often find this impish voice too embarrassing for real life and disown it, ignoring any perspectives offered by this important aspect of an integrated personality.
The aspect of my personality that has this impish voice has earned the name Phantom Priapism. It plays an important role in my experience with Antabuse, and with my drinking history.
While on Antabuse another voice was added to my internal dialogs. It is the voice of Antabuse itself.
Chronic and Binge drinking
I would look at the time, see that it was 11:45 am, and think, it's almost noon, and it will be time for a beer.
A business associate would frustrate me and I would think, it's time to visit McCann's for a pint.
Friday morning would arrive. I would think, let's wrap this week up and find a new piece of this town to paint red.
One of my daughters would make a demand, and would think, I'll do that and then crack open a Coors.
So many things, in fact, almost anything that stirred any emotion at all, both pleasant and uncomfortable, stirred my desire for a drink. Once I realized the cause and effect between emotions and alcohol, I acknowledged it, and became fully aware of it.
Then the constant thinking about alcohol stopped.
Until that experience, I had been unaware of how insinuated alcohol had become in my emotional life.
How Antabuse facilitated this regression remains unclear. Perhaps being truly free of any risk of overdrinking allowed my emotions to flow more freely. I was not on guard against a drinking episode. The Antabuse was on guard for me. My energy was liberated to explore my emotional reactions to life.
Liberation of energy
Bender pattern drinking had one benefit. Most of the time, drinking was not an issue. I just would not drink, and I would not think about drinking. Much to my detriment, the inevitable outcome of these extended abstinence periods was a very destructive bender. Whatever need or desire alcohol filled for me was deferred until a breaking point was reached, and then the desire, filled by alcohol, was satisfied all at once.
One solution to this unhealthy osculation was to drink more regularly in controlled quantities. This requires a great deal of planning and then discipline. One must decide when to drink, and how much on that occasion.
If a week is full of good drinking occations, on which one would the ration of alcohol be better spent. To drink on all occasions, would require that only one or two drinks be consumed at each.
A drinking occasion may be fraught with overindulgence opportunities and triggers. Should drinking be attempted or just avoided.
Perhaps the occasion should be avoided.
Making these decisions can be as exhausting as deciding which college to attend.
This experience creates chronic ambivalence. Antabuse provided the benefit of making one simple decision that would resolve the ambivalence for several days.
This liberated a great deal of energy and decision making time for more productive pursuits. Each morning, as I was finishing my first cup of coffee, I would decide to take the pill, take it, and all further discussion was mute.
Potential drinking occasions would present themselves. Instead of spending energy deciding whether to drink and how much, I was free to objectively explore the nature of the drinking opportunity and its meaning to my emotional life.
For many reasons, my home life developed an imbalanced cycle. I have a wife and four daughters. The girls are all teenagers. Most of my time was spent creating order. They would then enjoy the chaos that my order afforded them.
One particular Saturday, one of our home computer workstations developed a serious glitch that resulted from one of the girls downloading an unfriendly file and another abusing the hardware. I had spent an hour correcting the problem and was about to set everything right when my youngest sat down at the keyboard, and with a few careless key strokes, undid all the repair work.
I was furious but silent. This was my typical response to having my boundaries violated.
The situation triggered an internal voice dialog. The first voice to speak was the Manager who keeps my world in relative order. Two other voices joined in quickly. The entire dialog lasted less than second in real time. Perhaps it was less than a half second.
The Manager was angry: " I cannot and will not tolerate this complete disregard for the effort and time that I put into keeping their (my family's) environment in order. I grocery shop for them, I do their laundry, I maintain the computers, the cars, the televisions, and all other mechanical devises. I manage the household budget and magically stretch it so that no one lacks for what they need or even want. To thank me, often when I am in the middle of creating or restoring order to their world, they enter and enjoy some chaos. I never wanted this job, I hate having it, and I really hate how they completely deny my contributions and consider me nothing but a hopeless drunk on whom they have mercy and allow me to sleep in their home."
The next voice to speak was the impish Phantom: "Just calm down. They don't know us, and they clearly don't understand our needs and desires. They are children. Don't get angry at them. We just need to take care of ourselves. There is a great party this coming Tuesday with that networking group. They (my family) won't be there. There will lots to drink and plenty of females who will appreciate you. We'll take care of ourselves then. For now, just fix the fucking computer and let's get on to Tuesday."
Up to this point, I was completely unaware of this internal dialog. My conscious mind was still simply angry and busy fixing the computer.
Then the new voice of Antabuse spoke: "That party sounds great, but as long as you have me along the drinking is not going to be too much fun, and you can't get rid of me by Tuesday"
That snapped the entire dialog into my conscious mind. My head literally lifted from the work that I was doing and I said outload, "What the hell was that?"
Perhaps for the first time in all the years of my marriage, I was fully aware of how I was coping with the stresses of fatherhood. I had acquiesced to fatherhood. I had not chosen it. When my wife, my then girlfriend, became pregnant and decided that it was time for her to be a mother, I did not perceive that I had a choice regarding accepting responsibility for the child. I was the father, and would be the child's father. My father had been the perfect role model of stability and responsibility. Within a week, and perhaps not much to my liking, I became him.
The three party internal voice dialog between the Manager, the Phantom and the Antabuse begged a question. For how many years had the Manager and the Phantom been discussing this issue without my conscious awareness of it?
If this dialogs had been taking place in my subconscious mind it would help explain the progression of my drinking problem.
The marriage effectively began once I accepted responsibility for my first child. The first evidence of a drinking problem appeared shortly after she was born. The chronic drinking became more common and intense, periodically flashing into binges. That was shortly after my fourth daughter was born. That was when I was introduced to traditional treatment and the benders began.
It had been a good and valuable experiment. I had gained insight into my lesser drinking triggers. I had enjoyed and benefited from experiencing the energy made available during decision making processes regarding drinking. I had clarified a significant emotional conflict that had been a crippling source of ambivalence. These were good, and perhaps wonderful things.
However, I still resented taking the drug. Because of the positive experience, I no longer considered it a punitive sentence or the last resort of the hopeless. My experience altered my perception. Now it seemed like a brace, bridle or blinder that led me to places in my mind that I had not successfully explored. It had been a very useful tool; a tool that I would recommend to many others who were struggling with a drinking problem.
One man in his early thirties had been coming to meetings for almost 18 months. What he shared crystallized a concept that many others had been alluding to. His background was very similar to mine, and he enjoyed rich relationships with many members of his extended family.
Traditional thought holds that people who are unwilling or unable to remove alcohol from their lives are simply dependent on, or addicted to the alcohol. This was not true for this man. He had a very full life without alcohol. It included employment, being a musician, and many non-drinking friends. The one place where alcohol was always present was at family gatherings.
When he decided that alcohol was becoming problematic for him, he was aware that he would be coerced into removing it from his life completely if he sought traditional treatment. He resisted this and chose to work on his problem with an MM support group where that condition would not be imposed on him.
When he had successfully removed alcohol from his life for extended periods of time, he realized the true source of his ambivalence about abstaining for life. In his mind and heart, giving up alcohol for life was equivalent to ending the full and rich relationships that he enjoyed with his extended family.
When he shared this insight with me, I recalled the utter sadness that I felt during my early time in traditional treatment. I clearly remember mourning the loss of my relationship with my extended family. Then I began to mourn and resent the loss of all my relationships. Most of them, if not all, including my relationship with my wife and daughters, required alcohol as and an activating agent for any experience of happiness or sadness. On further reflection I realized that the only time that I felt any pleasant emotions, and felt human at all, was after I had had a drink.
When I was told that I needed be abstinent from alcohol for the rest of my life, I was by extension, being told to abandon my emotional life. Assuming that my experience is not unique, it is a small wonder that so many avoid seeking help for a drinking problem.
Being unable to access or experience emotions without alcohol may not be ideal, but it is real for many, if not a majority of problem drinkers. It remains true for me today.
I want to feel human. I want to feel emotions. I do not need to feel them. I want them. The distinction between need and want has become very important. I need a car, but I want a Viper. I need food, but I want a prime rib. I need to channel my instinct to procreate, but I want sex.
Two internal voices that I described earlier, the Manager and the Phantom express my needs and wants respectively. The Manager recognizes a need, and makes arrangements to fill the need. The Phantom defines what I want. Over the years, the Phantom has been increasingly ingored by the Manager and the Phantoms expression of desires has been suppressed. More plainly stated, I have been denying myself access to my desires, and have focused solely on my needs. This suppression of desire contributed to my drinking problem and was brought to my awareness while on Antabuse.
My decision to end the Antabuse protocol was based on desire. I never wanted to be on Antabuse. Many people around me, including my own internal Manager argued well that my need to be free of alcohol related problems in my life would best be served by continuing to take the drug.
Here was a typical case of conflict between need and desire. I needed to be free of alcohol related problems, but I wanted to achieve that freedom by a method other than abstinence, especially forced abstinence. Having learned that categorical suppression of desire was extremely dangerous for me, I decided to do what I wanted, and end the protocol.
A clear awareness of the mind state that I enter prior to a bender is now a part of my conscious experience.
Chronic and binge drinking were no longer problems. They had been displaced by the catastrophic benders. While on Antabuse, I had gained clear insight into the emotional sources of the benders, but it did not provide a solution.
The solution is beyond the scope of what Antabuse can provide. Antabuse helped me define the problem, but the solution will require continuing to understand the emotional imbalances that have shaped my current character, developing strategies for restoring the balance and then actually executing these strategies.
This process remains imperative. If I do not begin to live a more balanced life, and access a fuller emotional spectrum, the benders will return.