Highlights & Basics
- Alcohol use disorder (AUD) is a problematic pattern of alcohol use leading to significant impairment or distress. Unhealthy alcohol use includes the spectrum of at-risk drinking and alcohol use disorders.
- Unhealthy alcohol use is defined by more than 3 drinks per day or 7 per week for women and more than 4 drinks per day or 14 per week for men. To differentiate between at-risk drinking and alcohol use disorder, the DSM-5-TR criteria should be used.
- Unhealthy alcohol use is underdiagnosed and undertreated.
- Treatments should be driven by a patient's alcohol-related goals and the evidence behind them. Treatments include psychosocial therapies, medication, or both. Medications used include naltrexone, acamprosate, disulfiram, gabapentin, and topiramate.
Quick Reference
History & Exam
Key Factors
withdrawal
tolerance
increased/decreased liver size, jaundice, ascites
Other Factors
insomnia
erectile dysfunction
nicotine use disorder
gastrointestinal distress
muscle cramps, pain, tenderness, altered sensory perception
hypertension and tachycardia
impaired nutritional status
broad-based gait
Diagnostics Tests
1st Tests to Order
diagnostic interview
alcohol level (breath and blood)
Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)
Other Tests to consider
carbohydrate-deficient transferrin (CDT)
gamma glutamyl transpeptidase (gamma-GT), alanine aminotransferase (ALT), aspartate aminotransferase (AST)
CBC
urinary ethyl glucuronide
Treatment Options
ongoing
at-risk drinking
brief interventions
management of medical comorbidities
motivational interviewing
management of medical comorbidities
alcohol use disorder: nonpregnant adult with no concurrent opioid use or mental health diagnosis
psychosocial treatment
management of medical comorbidities
naltrexone
management of medical comorbidities
psychosocial treatment
topiramate
management of medical comorbidities
psychosocial treatment
gabapentin
management of medical comorbidities
psychosocial treatment
acamprosate
management of medical comorbidities
psychosocial treatment
disulfiram
management of medical comorbidities
psychosocial treatment
Definition
Classifications
Diagnostic and statistical manual of mental disorders, 5th edition, text revision (DSM-5-TR)
- A problematic pattern of alcohol use over a 12-month period that results in clinically significant impairment or distress.
- At least 2 of 11 diagnostic criteria must be met. See Criteria .
International statistical classification of diseases, 11th edition (ICD-11)
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Images
Treatment overview
FRAMES method for brief intervention
Nonpharmacologic approaches can be useful for many patients with alcohol use disorder, as they provide strategies to help patients avoid returning to alcohol use, enhance self-efficacy, and reduce the impact of stressors that can precipitate return to use
Summary of medications, their mechanism of action, and the number needed to treat to reduce heavy drinking and to achieve abstinence
Diagnostic Approach
History/interview
Physical exam
- Vital signs may reveal tachycardia and/or hypertension.
- When cirrhosis due to alcohol intake has occurred, other features can be present, including underweight status/anorexia; jaundice; enlarged, tender liver or diminished liver size; and ascites.
- Indicators of neurologic damage related to alcohol use may be present in heavy use. These may include altered sensation (peripheral neuropathy, particularly in lower extremities), muscle tenderness to palpation (myopathy), and a broad-based gait.
Laboratory studies
- Alcohol (ethanol) levels in blood, breath, or other body fluids can provide information about current blood alcohol concentrations.[39] A high blood alcohol concentration (e.g., >200 mg/dL) with minimal signs of intoxication may indicate tolerance to alcohol effects, but does not diagnose alcohol use disorder.
- Several tests can indicate cumulative alcohol exposure over longer time periods. Liver function tests (alanine aminotransferase [ALT], aspartate aminotransferase [AST], and gamma glutamyl transpeptidase [gamma-GT]) may be useful for assessing liver damage. Elevated gamma-GT, in particular, correlates with alcohol consumption and is sometimes used to monitor drinking behavior. In the authors' experience, gamma-GT should normalize within 2-6 weeks of abstinence, while AST and ALT remain elevated for variable amounts of time and may not return to baseline.
- Urine ethyl glucuronide testing by liquid chromatography-mass spectrometry can detect very small levels of alcohol in the urine within several days of consumption, but incidental use of alcohol-containing products (e.g., hand sanitizers, cosmetics, etc.) can lead to false positives.[40]
- A complete blood count can assess alcohol-related bone marrow suppression, particularly macrocytosis.
- The most sensitive test for heavy drinking is carbohydrate-deficient transferrin (CDT), which utilizes alcohol inhibition of the transfer of sugars to glycoproteins.[41] CDT is less sensitive in women.
Risk Factors
History & Exam
Tests
Differential Diagnosis
Differentiating Signs/Symptoms
- Symptoms of alcohol use disorder (including those of intoxication/withdrawal) may be confused with symptoms of other psychiatric disorders. Furthermore, several psychiatric disorders (e.g., schizophrenia, bipolar disorder, PTSD) can co-occur with alcohol use disorder.
- Differentiating signs and symptoms depend on the type of psychiatric disorder present. Definitive diagnosis is often difficult and requires multiple visits. Observation over weeks to months may be necessary to clarify underlying psychiatric diagnoses. However, co-treatment generally has better outcomes than waiting for patients to stop drinking before making a diagnosis or starting psychiatric treatment, and therefore treatment should not be withheld until patients stop drinking.
Other substance use disorders (especially sedatives)
Differentiating Signs/Symptoms
- Sedating substances or medications (e.g., benzodiazepines, barbiturates, opioids, muscle relaxers) may have similar signs and symptoms as alcohol use disorder, or may be used together with alcohol.
- Use of these substances with alcohol may pose a risk for overdose complications (e.g., respiratory depression).
Differentiating Tests
- DSM-5-TR criteria for substance use disorders other than alcohol.[3]
- Urine and/or blood toxicologies indicating presence of other substances is not diagnostic.
Criteria
- Alcohol used in larger amounts or over a longer period of time than intended
- Persistent desire or unsuccessful attempts to cut down or control alcohol use
- Significant time spent obtaining, using, and recovering from the effects of alcohol
- Craving or strong desire to use alcohol
- Recurrent alcohol use leading to failure to fulfill major role obligations at work, school, or home
- Recurrent use of alcohol, despite having persistent or recurring social or interpersonal problems caused or worsened by alcohol
- Continued alcohol use despite having persistent or recurring physical or psychological problems caused or worsened by alcohol
- Giving up or reducing important social, occupational, or recreational activities due to alcohol use
- Recurrent alcohol use in hazardous situations
- Continued alcohol use despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol
- Tolerance: markedly increased amounts of alcohol are needed to achieve intoxication or the desired effect, or continued use of the same amount of alcohol achieves a markedly diminished effect
- Withdrawal: there is the characteristic alcohol withdrawal syndrome, or alcohol is taken to relieve or avoid withdrawal symptoms.
- A pattern of alcohol use that has caused damage to a person's physical or mental health or has resulted in behavior leading to harm to the health of others.
- The pattern of alcohol use is evident over a period of at least 12 months if substance use is episodic or at least 1 month if use is continuous.
- Harm to health of the individual occurs due to one or more of the following:
- Behavior related to intoxication
- Direct or secondary toxic effects on body organs and systems
- A harmful route of administration.
- Harm to health of others includes any form of physical harm, including trauma, or mental disorder that is directly attributable to behavior-related to alcohol intoxication on the part of the person to whom the diagnosis of harmful pattern of use of alcohol applies.
- Alcohol dependence is a disorder of regulation of alcohol use arising from repeated or continuous use of alcohol.
- The characteristic feature is a strong internal drive to use alcohol, which is manifested by impaired ability to control use, increasing priority given to use over other activities, and persistence of use despite harm or negative consequences. These experiences are often accompanied by a subjective sensation of urge or craving to use alcohol.
- Physiologic features of dependence may also be present, including tolerance to the effects of alcohol, withdrawal symptoms following cessation or reduction in use of alcohol, or repeated use of alcohol or pharmacologically similar substances to prevent or alleviate withdrawal symptoms.
- The features of dependence are usually evident over a period of at least 12 months but the diagnosis may be made if alcohol use is continuous (daily or almost daily) for at least 3 months.
- For men, consuming more than 4 drinks on any day or more than 14 drinks per week
- For women, consuming more than 3 drinks on any day or more than 7 drinks per week.
Screening
- As part of a routine examination
- Prior to prescribing a medication that interacts with alcohol
- In the emergency department or trauma center (especially with presentations secondary to trauma/injuries, violence)[56]
- During pregnancy
- When there are health problems that might be alcohol-related (e.g., cardiac arrhythmia, dyspepsia, liver disease, hypertension, depression, anxiety, insomnia, trauma).
Treatment Approach
- Brief intervention, particularly in unhealthy alcohol use and mild alcohol use disorder
- Individual therapy
- Psychosocial support
- Medications to support reduced alcohol intake and abstinence
- Ongoing support to help the patient maintain their goals regarding alcohol intake.
- Withdrawal risk
- Biomedical conditions or complications
- Stability of co-occurring mood disorders and cognitive status
- Readiness to change
- Likelihood of return to use
- Living environment and psychosocial support.
Management of withdrawal
Brief interventions
Motivational interviewing
Psychosocial interventions
Pharmacologic treatment
- Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[74] It is particularly useful in patients with a family history of alcohol use disorder and in those with significant alcohol cravings.[12] [40] [55] Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[75] [76] [77] Treatment with naltrexone reduces heavy drinking days, improves abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[78] In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[79] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[80] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
- Gabapentin reduces heavy drinking days and return to drinking in patients with prominent alcohol withdrawal symptoms. The exact mechanism of gabapentin is not known, but it appears to inhibit the release of excitatory neurotransmitters. In an RCT of 96 individuals with alcohol use disorder, gabapentin resulted in a statistically significant decrease in heavy drinking days (NNT 5) and preventing return to use (NNT 6) for patients with high baseline alcohol withdrawal symptoms.[81] As a result, in patients with symptoms of alcohol withdrawal, gabapentin is emerging as an effective treatment, either as monotherapy or in conjunction with naltrexone.[40] [82] The main side effects of gabapentin are dizziness, drowsiness, and nausea. Patients should be counseled that abrupt cessation of gabapentin can lower the seizure threshold.
- Topiramate is an anticonvulsant that has been shown in RCTs to decrease craving and withdrawal symptoms and significantly improve physical and psychosocial wellbeing of patients with alcohol use disorder, compared with placebo (NNT 3 to reduce heavy drinking, NNT 7 to achieve abstinence).[83] [84] [85] [86] [87] It decreases percentage of heavy drinking days by >23% and increases abstinent days by almost 3 days.[88] Importantly, efficacy was established in subjects who were drinking at the time of starting the medication.[89] One study has shown that only individuals who are homozygous for the gene that codes for the kainate receptor protein had a reduction in heavy drinking days with topiramate treatment.[90] The benefits of topiramate should be weighed against the number needed to harm given its high side effect profile, including blurred vision, paresthesias, poor memory, and loss of coordination.
- Acamprosate normalizes glutamate and gamma-aminobutyric acid neurotransmitter systems in the central nervous system. It is thought that these actions reduce ongoing symptoms associated with alcohol abstinence (e.g., anxiety, insomnia) and cravings. Pill burden may reduce its effectiveness. It is primarily metabolized by the kidneys, and a dose reduction may be required in patients with renal impairment (its use is contraindicated if creatinine clearance is <30 mL/minute).[40] Acamprosate increases the rate and duration of abstinence, compared with placebo.[91] [92] Acamprosate is safe to use in patients who are actively drinking, but evidence for its use is from trials with people who have already stopped drinking. The NNT is 12 to prevent return to any drinking.[79] Naltrexone and acamprosate are equally efficacious.[79]
- Disulfiram blocks the catabolic pathway of alcohol by inhibiting aldehyde dehydrogenase, thereby increasing acetaldehyde levels following alcohol ingestion. The disulfiram-alcohol reaction can produce a number of somatic effects: vasomotor symptoms (flushing), cardiovascular symptoms (tachycardia, hypotension), digestive symptoms (nausea, vomiting, diarrhea), headache, respiratory depression, and malaise. These symptoms are generally transient, but serious reactions may occur that require urgent medical treatment. Disulfiram is prescribed for those intending to abstain from alcohol use, acting through negative reinforcement to promote abstinence. Trials to support disulfiram use are limited. One meta-analysis showed that disulfiram was more effective than placebo, acamprosate, or naltrexone in open-label RCTs, but not in blinded RCTs.[93] Blinded studies are difficult to conduct, because the effectiveness of disulfiram depends on the patient's anticipation of somatic effects. Disulfiram therapy was more effective when supervised.[93]
Management of medical comorbidities
Pregnant women
Adolescents
Concurrent opioid use
Concurrent mental health diagnosis
Treatment Options
at-risk drinking
brief interventions
Comments
- People with unhealthy alcohol use that do not meet alcohol use disorder criteria can often be treated with a brief intervention. These interventions are typically 5-15 minutes long, follow a structured outline, provide education, and may or may not include follow-up treatment. In patients with at-risk drinking, these interventions reduce total alcohol consumed.[64] [65]
- Brief interventions can consist of one or more sessions in the physician's office or in a hospital setting (e.g., emergency department or inpatient unit), during which education and feedback about the patient's alcohol use and its consequences are provided in a supportive and empathic fashion. Brief interventions may be improved by follow-up; for instance, one multisite randomized controlled trial in the trauma setting showed improvement in several drinking measures at up to 12 months for patients who received an individualized follow-up phone call in addition to brief motivational interviewing, compared with those who just received the interview.[66] A formal means of assessing the effectiveness of the plan and follow-up visits with the physician should be part of the plan.[67] Though brief interventions are easy to administer, they go beyond simply telling patients to reduce their alcohol use: in studies of their effectiveness, clinicians were trained to provide structured feedback based on an individual's risk and desire to change their behavior. One commonly used structure is the FRAMES method: Feedback, Responsibility, Advice, Menu of options, Empathic style, Self-efficacy.
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
motivational interviewing
Comments
- Motivational interviewing, a technique that assists the patient in identifying their own goals, is an effective, patient-centered way of engaging patients in treatment and reducing substance use.[68] Motivational interviewing requires clinicians to avoid confronting, labeling, or directing the patient, but rather to elicit the patient's ambivalence and support his/her motivation to change through open-ended questions, affirmations, reflective statements, and summarizing.
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
alcohol use disorder: nonpregnant adult with no concurrent opioid use or mental health diagnosis
psychosocial treatment
Comments
- Nonpharmacologic approaches can be useful for many patients with alcohol use disorder, as they provide strategies to help patients avoid returning to alcohol use, enhance self-efficacy, and reduce the impact of stressors that can precipitate return to use. Interventions may be individual or group-based. There is no strong evidence for any one approach, and therefore the patient's preference should guide treatment choice.[69]
- Outpatient and intensive outpatient addiction treatment programs typically include treatment sessions scheduled from once- or twice-weekly to several times a week, with treatment extending over several weeks to months (or longer). The interventions provided may include: cognitive behavioral therapy (to assist patients in coping with thoughts of return to alcohol use and negative cognitions), counseling strategies (return-to-use prevention, coping with stressors, forming beneficial relationships), and referral of patients to self-help groups, such as Alcoholics Anonymous (AA).[12] [70] [71] In a meta-analysis of 6 studies, the addition of manualized cognitive behavioral therapy did not improve return-to-use rates when added to naltrexone therapy.[72]
- AA, founded in 1939, is the most common program. Its primary goal is to help individuals maintain total abstinence from alcohol and other addictive substances.Alcoholics Anonymous Self-help programs such as AA can provide valuable additional support for many patients and their families. Patients indicating benefit from support group attendance should be encouraged to attend the group meetings over an extended timeframe; some patients may benefit from attending indefinitely. In one large randomized controlled trial (RCT), AA improved drinking outcomes, largely through improvements in adaptive social network changes and social self-efficacy.[73] Each AA group is independent, so patients should be encouraged to try several if one is not a good fit. For those who have negative experiences or views of AA, it is important that clinicians are aware of alternatives, such as Smart Recovery groups.
- Reassess every 3 months for worsening use or harms of alcohol.
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
naltrexone
Primary Options
- naltrexone
50 mg orally once daily; 380 mg intramuscularly every 4 weeks
- naltrexone
Comments
- Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[74] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol use disorder and in those with significant alcohol cravings.[12] [40] [55]
- Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[75] [76] [77]
- Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[78] In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[79] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[80] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
topiramate
Primary Options
- topiramate
100-150 mg orally (immediate-release) twice daily
- topiramate
Comments
- It decreases percentage of heavy drinking days by >23% and increases abstinent days by almost 3 days.[88] Importantly, efficacy was established in subjects who were drinking at the time of starting the medication.[89] One study has shown that only individuals who are homozygous for the gene that codes for the kainate receptor protein had a reduction in heavy drinking days with topiramate treatment.[90]
- The benefits of topiramate should be weighed against the number needed to harm given its high side effect profile, including blurred vision, paresthesias, poor memory, and loss of coordination.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
gabapentin
Primary Options
- gabapentin
300-600 mg orally three times daily
- gabapentin
Comments
- Gabapentin reduces heavy drinking days and return to drinking in patients with prominent alcohol withdrawal symptoms. The exact mechanism of gabapentin is not known, but it appears to inhibit the release of excitatory neurotransmitters. In an RCT of 96 individuals with alcohol use disorder, gabapentin resulted in a statistically significant decrease in heavy drinking days (NNT 5) and preventing return to use (NNT 6) for patients with high baseline alcohol withdrawal symptoms.[81] As a result, in patients with symptoms of alcohol withdrawal, gabapentin is emerging as an effective treatment, either as monotherapy or in conjunction with naltrexone.[40] [82] The main side effects of gabapentin are dizziness, drowsiness, and nausea. Patients should be counseled that abrupt cessation of gabapentin can lower the seizure threshold.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
acamprosate
Primary Options
- acamprosate
666 mg orally three times daily
- acamprosate
Comments
- Acamprosate normalizes glutamate and gamma-aminobutyric acid neurotransmitter systems in the central nervous system. It is thought that these actions reduce ongoing symptoms associated with alcohol abstinence (e.g., anxiety, insomnia) and cravings. Pill burden may reduce its effectiveness. It is primarily metabolized by the kidneys, and a dose reduction may be required in patients with renal impairment (its use is contraindicated if creatinine clearance is <30 mL/minute).[40] Acamprosate increases the rate and duration of abstinence, compared with placebo.[91] [92] Acamprosate is safe to use in patients who are actively drinking, but evidence for its use is from trials with people who have already stopped drinking. The number needed to treat is 12 to prevent return to any drinking.[79]
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
disulfiram
Primary Options
- disulfiram
125-500 mg orally once daily in the morning
- disulfiram
Comments
- Disulfiram blocks the catabolic pathway of alcohol by inhibiting aldehyde dehydrogenase, thereby increasing acetaldehyde levels following alcohol ingestion.
- The disulfiram-alcohol reaction can produce a number of somatic effects: vasomotor symptoms (flushing), cardiovascular symptoms (tachycardia, hypotension), digestive symptoms (nausea, vomiting, diarrhea), headache, respiratory depression, and malaise. These symptoms are generally transient, but serious reactions may occur that require urgent medical treatment.
- Disulfiram is prescribed for those intending to abstain from alcohol use, acting through negative reinforcement to promote abstinence. Trials to support disulfiram use are limited. One meta-analysis showed that disulfiram was more effective than placebo, acamprosate, or naltrexone in open-label RCTs, but not in blinded RCTs.[93] Blinded studies are difficult to conduct, because the effectiveness of disulfiram depends on the patient's anticipation of somatic effects. Disulfiram therapy was more effective when supervised.[93]
management of medical comorbidities
Comments
- Patients with unhealthy alcohol use often have coexisting high blood pressure, insomnia, weight gain, cognitive disturbances, gastrointestinal distress, and cardiac arrhythmias. It is important to emphasize that many of these conditions may worsen with alcohol use, even at low levels. Management of physical comorbidities and timely integrated care is important to improve the wellbeing of the patient.[94] Chronic care management reduces harms of alcohol use disorder in patients with medical comorbidities.[95]
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
alcohol use disorder: nonpregnant adult with concurrent opioid use
psychosocial treatment
Comments
- Several step-by-step treatment recommendations have been developed to integrate psychosocial therapies with pharmacologic therapies for alcohol and drug use disorders.[103] [104] These procedures include patient education, personalized feedback, emotional support, medication monitoring, and motivational enhancement.National Institute on Alcohol Abuse and Alcoholism (NIAAA)
acamprosate
Primary Options
- acamprosate
666 mg orally three times daily
- acamprosate
Comments
- Acamprosate normalizes glutamate and gamma-aminobutyric acid neurotransmitter systems in the central nervous system. It is thought that these actions reduce ongoing symptoms associated with alcohol abstinence (e.g., anxiety, insomnia) and cravings. Pill burden may reduce its effectiveness. It is primarily metabolized by the kidneys, and a dose reduction may be required in patients with renal impairment (its use is contraindicated if creatinine clearance is <30 mL/minute).[40] Acamprosate increases the rate and duration of abstinence, compared with placebo.[91] [92] Acamprosate is safe to use in patients who are actively drinking, but evidence for its use is from trials with people who have already stopped drinking. The number needed to treat is 12 to prevent return to any drinking.[79]
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
gabapentin
Primary Options
- gabapentin
300-600 mg orally three times daily
- gabapentin
Comments
- Gabapentin reduces heavy drinking days and return to drinking in patients with prominent alcohol withdrawal symptoms. The exact mechanism of gabapentin is not known, but it appears to inhibit the release of excitatory neurotransmitters. In a randomized controlled trial (RCT) of 96 individuals with alcohol use disorder, gabapentin resulted in a statistically significant decrease in heavy drinking days (NNT 5) and preventing return to use (NNT 6) for patients with high baseline alcohol withdrawal symptoms.[81] As a result, in patients with symptoms of alcohol withdrawal, gabapentin is emerging as an effective treatment, either as monotherapy or in conjunction with naltrexone.[40] [82] The main side effects of gabapentin are dizziness, drowsiness, and nausea. Patients should be counseled that abrupt cessation of gabapentin can lower the seizure threshold.
- Evidence indicates that patients with opioid use disorder and polydrug users are at risk for gabapentin misuse and clinicians should monitor usage closely.[105]
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
topiramate
Primary Options
- topiramate
100-150 mg orally (immediate-release) twice daily
- topiramate
Comments
- It decreases percentage of heavy drinking days by >23% and increases abstinent days by almost 3 days.[88] Importantly, efficacy was established in subjects who were drinking at the time of starting the medication.[89] One study has shown that only individuals who are homozygous for the gene that codes for the kainate receptor protein had a reduction in heavy drinking days with topiramate treatment.[90]
- The benefits of topiramate should be weighed against the number needed to harm given its high side effect profile, including blurred vision, paresthesias, poor memory, and loss of coordination.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
disulfiram
Primary Options
- disulfiram
125-500 mg orally once daily in the morning
- disulfiram
Comments
- Disulfiram blocks the catabolic pathway of alcohol by inhibiting aldehyde dehydrogenase, thereby increasing acetaldehyde levels following alcohol ingestion.
- The disulfiram-alcohol reaction can produce a number of somatic effects: vasomotor symptoms (flushing), cardiovascular symptoms (tachycardia, hypotension), digestive symptoms (nausea, vomiting, diarrhea), headache, respiratory depression, and malaise. These symptoms are generally transient, but serious reactions may occur that require urgent medical treatment.
- Disulfiram is prescribed for those intending to abstain from alcohol use, acting through negative reinforcement to promote abstinence. Trials to support disulfiram use are limited. One meta-analysis showed that disulfiram was more effective than placebo, acamprosate, or naltrexone in open-label RCTs, but not in blinded RCTs.[93] Blinded studies are difficult to conduct, because the effectiveness of disulfiram depends on the patient's anticipation of somatic effects. Disulfiram therapy was more effective when supervised.[93]
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
alcohol use disorder: nonpregnant adult with concurrent mental health diagnosis
psychosocial treatment
Comments
- Nonpharmacologic approaches can be useful for many patients with alcohol use disorder, as they provide strategies to help patients avoid returning to alcohol use, enhance self-efficacy, and reduce the impact of stressors that can precipitate return to use. Interventions may be individual or group-based. There is no strong evidence for any one approach, and therefore the patient's preference should guide treatment choice.[69]
- Outpatient and intensive outpatient addiction treatment programs typically include treatment sessions scheduled from once- or twice-weekly to several times a week, with treatment extending over several weeks to months (or longer). The interventions provided may include: cognitive behavioral therapy (to assist patients in coping with thoughts of return to alcohol use and negative cognitions), counseling strategies (return-to-use prevention, coping with stressors, forming beneficial relationships), and referral of patients to self-help groups, such as Alcoholics Anonymous (AA).[12] [70] [71] In a meta-analysis of 6 studies, the addition of manualized cognitive behavioral therapy did not improve return-to-use rates when added to naltrexone therapy.[72]
- AA, founded in 1939, is the most common program. Its primary goal is to help individuals maintain total abstinence from alcohol and other addictive substances.Alcoholics Anonymous Self-help programs such as AA can provide valuable additional support for many patients and their families. Patients indicating benefit from support group attendance should be encouraged to attend the group meetings over an extended timeframe; some patients may benefit from attending indefinitely. In one large randomized controlled trial (RCT), AA improved drinking outcomes, largely through improvements in adaptive social network changes and social self-efficacy.[73] Each AA group is independent, so patients should be encouraged to try several if one is not a good fit. For those who have negative experiences or views of AA, it is important that clinicians are aware of alternatives, such as Smart Recovery groups.
- Reassess every 3 months for worsening use or harms of alcohol.
management of mental health diagnoses
Comments
- Symptoms of alcohol use disorder (including those of intoxication/withdrawal) may be confused with symptoms of other psychiatric disorders. Furthermore, other psychiatric disorders can co-occur with alcohol use disorder. Observation over days to weeks to months may be necessary to clarify underlying psychiatric diagnoses. However, co-treatment generally has better outcomes than waiting for patients to stop drinking before making a diagnosis or starting psychiatric treatment; therefore, treatment should not be withheld until patients stop drinking.
- A meta-analysis of 15 RCTs demonstrated reduced alcohol use and improved psychiatric outcomes when co-occurring depressive and anxiety disorders were treated concurrently with alcohol use disorder.[106]
- Treatment options depend on diagnosis and may include antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) have demonstrated efficacy in alcohol use disorder for patients with comorbid depression. Sertraline, when compared with placebo, decreases the proportion of days drinking during treatment and increases the number of patients who had continuous abstinence. Its efficacy was higher in those with more mild alcohol use disorder.[107] Trials of fluoxetine for alcohol use disorder achieved similar results, suggesting that fluoxetine may also be effective in mild alcohol use disorder.[108] However, not all studies have supported the utility of SSRIs for treating alcohol use disorder. A study of fluoxetine for people with alcohol use disorder and co-occurring depression demonstrated no benefit of fluoxetine versus placebo on either depression or drinking.[109]
- For more details on management of depression see Depression in adults .
naltrexone
Primary Options
- naltrexone
50 mg orally once daily; 380 mg intramuscularly every 4 weeks
- naltrexone
Comments
- Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[74] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol use disorder and in those with significant alcohol cravings.[12] [40] [55]
- Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[75] [76] [77]
- Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[78] In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[79] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[80] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of mental health diagnoses
Comments
- Symptoms of alcohol use disorder (including those of intoxication/withdrawal) may be confused with symptoms of other psychiatric disorders. Furthermore, other psychiatric disorders can co-occur with alcohol use disorder. Observation over days to weeks to months may be necessary to clarify underlying psychiatric diagnoses. However, co-treatment generally has better outcomes than waiting for patients to stop drinking before making a diagnosis or starting psychiatric treatment; therefore, treatment should not be withheld until patients stop drinking.
- A meta-analysis of 15 RCTs demonstrated reduced alcohol use and improved psychiatric outcomes when co-occurring depressive and anxiety disorders were treated concurrently with alcohol use disorder.[106]
- Treatment options depend on diagnosis and may include antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) have demonstrated efficacy in alcohol use disorder for patients with comorbid depression. Sertraline, when compared with placebo, decreases the proportion of days drinking during treatment and increases the number of patients who had continuous abstinence. Its efficacy was higher in those with more mild alcohol use disorder.[107] Trials of fluoxetine for alcohol use disorder achieved similar results, suggesting that fluoxetine may also be effective in mild alcohol use disorder.[108] However, not all studies have supported the utility of SSRIs for treating alcohol use disorder. A study of fluoxetine for people with alcohol use disorder and co-occurring depression demonstrated no benefit of fluoxetine versus placebo on either depression or drinking.[109]
- For more details on management of depression see Depression in adults .
gabapentin
Primary Options
- gabapentin
300-600 mg orally three times daily
- gabapentin
Comments
- Gabapentin reduces heavy drinking days and return to drinking in patients with prominent alcohol withdrawal symptoms. The exact mechanism of gabapentin is not known, but it appears to inhibit the release of excitatory neurotransmitters. In an RCT of 96 individuals with alcohol use disorder, gabapentin resulted in a statistically significant decrease in heavy drinking days (NNT 5) and preventing return to use (NNT 6) for patients with high baseline alcohol withdrawal symptoms.[81] As a result, in patients with symptoms of alcohol withdrawal, gabapentin is emerging as an effective treatment, either as monotherapy or in conjunction with naltrexone.[40] [82]
- The main side effects of gabapentin are dizziness, drowsiness, and nausea. Patients should be counseled that abrupt cessation of gabapentin can lower the seizure threshold.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of mental health diagnoses
Comments
- Symptoms of alcohol use disorder (including those of intoxication/withdrawal) may be confused with symptoms of other psychiatric disorders. Furthermore, other psychiatric disorders can co-occur with alcohol use disorder. Observation over days to weeks to months may be necessary to clarify underlying psychiatric diagnoses. However, co-treatment generally has better outcomes than waiting for patients to stop drinking before making a diagnosis or starting psychiatric treatment; therefore, treatment should not be withheld until patients stop drinking.
- A meta-analysis of 15 RCTs demonstrated reduced alcohol use and improved psychiatric outcomes when co-occurring depressive and anxiety disorders were treated concurrently with alcohol use disorder.[106]
- Treatment options depend on diagnosis and may include antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) have demonstrated efficacy in alcohol use disorder for patients with comorbid depression. Sertraline, when compared with placebo, decreases the proportion of days drinking during treatment and increases the number of patients who had continuous abstinence. Its efficacy was higher in those with more mild alcohol use disorder.[107] Trials of fluoxetine for alcohol use disorder achieved similar results, suggesting that fluoxetine may also be effective in mild alcohol use disorder.[108] However, not all studies have supported the utility of SSRIs for treating alcohol use disorder. A study of fluoxetine for people with alcohol use disorder and co-occurring depression demonstrated no benefit of fluoxetine versus placebo on either depression or drinking.[109]
- For more details on management of depression see Depression in adults .
topiramate
Primary Options
- topiramate
100-150 mg orally (immediate-release) twice daily
- topiramate
Comments
- It decreases percentage of heavy drinking days by >23% and increases abstinent days by almost 3 days.[88] Importantly, efficacy was established in subjects who were drinking at the time of starting the medication.[89] One study has shown that only individuals who are homozygous for the gene that codes for the kainate receptor protein had a reduction in heavy drinking days with topiramate treatment.[90]
- The benefits of topiramate should be weighed against the number needed to harm given its high side effect profile, including blurred vision, paresthesias, poor memory, and loss of coordination.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of mental health diagnoses
Comments
- Symptoms of alcohol use disorder (including those of intoxication/withdrawal) may be confused with symptoms of other psychiatric disorders. Furthermore, other psychiatric disorders can co-occur with alcohol use disorder. Observation over days to weeks to months may be necessary to clarify underlying psychiatric diagnoses. However, co-treatment generally has better outcomes than waiting for patients to stop drinking before making a diagnosis or starting psychiatric treatment; therefore, treatment should not be withheld until patients stop drinking.
- A meta-analysis of 15 RCTs demonstrated reduced alcohol use and improved psychiatric outcomes when co-occurring depressive and anxiety disorders were treated concurrently with alcohol use disorder.[106]
- Treatment options depend on diagnosis and may include antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) have demonstrated efficacy in alcohol use disorder for patients with comorbid depression. Sertraline, when compared with placebo, decreases the proportion of days drinking during treatment and increases the number of patients who had continuous abstinence. Its efficacy was higher in those with more mild alcohol use disorder.[107] Trials of fluoxetine for alcohol use disorder achieved similar results, suggesting that fluoxetine may also be effective in mild alcohol use disorder.[108] However, not all studies have supported the utility of SSRIs for treating alcohol use disorder. A study of fluoxetine for people with alcohol use disorder and co-occurring depression demonstrated no benefit of fluoxetine versus placebo on either depression or drinking.[109]
- For more details on management of depression see Depression in adults .
disulfiram
Primary Options
- disulfiram
125-500 mg orally once daily in the morning
- disulfiram
Comments
- Disulfiram blocks the catabolic pathway of alcohol by inhibiting aldehyde dehydrogenase, thereby increasing acetaldehyde levels following alcohol ingestion.
- The disulfiram-alcohol reaction can produce a number of somatic effects: vasomotor symptoms (flushing), cardiovascular symptoms (tachycardia, hypotension), digestive symptoms (nausea, vomiting, diarrhea), headache, respiratory depression, and malaise. These symptoms are generally transient, but serious reactions may occur that require urgent medical treatment.
- Disulfiram is prescribed for those intending to abstain from alcohol use, acting through negative reinforcement to promote abstinence. Trials to support disulfiram use are limited. One meta-analysis showed that disulfiram was more effective than placebo, acamprosate, or naltrexone in open-label RCTs, but not in blinded RCTs.[93] Blinded studies are difficult to conduct, because the effectiveness of disulfiram depends on the patient's anticipation of somatic effects. Disulfiram therapy was more effective when supervised.[93]
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
management of mental health diagnoses
Comments
- Symptoms of alcohol use disorder (including those of intoxication/withdrawal) may be confused with symptoms of other psychiatric disorders. Furthermore, other psychiatric disorders can co-occur with alcohol use disorder. Observation over days to weeks to months may be necessary to clarify underlying psychiatric diagnoses. However, co-treatment generally has better outcomes than waiting for patients to stop drinking before making a diagnosis or starting psychiatric treatment; therefore, treatment should not be withheld until patients stop drinking.
- A meta-analysis of 15 RCTs demonstrated reduced alcohol use and improved psychiatric outcomes when co-occurring depressive and anxiety disorders were treated concurrently with alcohol use disorder.[106]
- Treatment options depend on diagnosis and may include antidepressants. Selective serotonin-reuptake inhibitors (SSRIs) have demonstrated efficacy in alcohol use disorder for patients with comorbid depression. Sertraline, when compared with placebo, decreases the proportion of days drinking during treatment and increases the number of patients who had continuous abstinence. Its efficacy was higher in those with more mild alcohol use disorder.[107] Trials of fluoxetine for alcohol use disorder achieved similar results, suggesting that fluoxetine may also be effective in mild alcohol use disorder.[108] However, not all studies have supported the utility of SSRIs for treating alcohol use disorder. A study of fluoxetine for people with alcohol use disorder and co-occurring depression demonstrated no benefit of fluoxetine versus placebo on either depression or drinking.[109]
- For more details on management of depression see Depression in adults .
alcohol use disorder: nonpregnant adolescent
psychosocial treatment
Comments
- A meta-analysis of 16 studies demonstrated that psychosocial interventions are effective in reducing adolescent alcohol use, with individual-directed treatments possibly having a greater effect than family-based ones. Interventions with large effect sizes included brief motivational interviewing, cognitive behavioral therapy with 12 steps, cognitive behavioral therapy with aftercare, multidimensional family therapy, brief interventions with the adolescent, and brief interventions with the adolescent and a parent.[100]
- Group therapy-based treatments may be effective for adolescents, but safety should be considered and these modalities require further investigation.[101]
naltrexone
Primary Options
- naltrexone
50 mg orally once daily; 380 mg intramuscularly every 4 weeks
- naltrexone
Comments
- Naltrexone is the best studied medication to support reduced alcohol intake and abstinence in adolescents, and has been found to reduce cravings in adolescents in a few small trials.[102]
- Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[74] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol use disorder and in those with significant alcohol cravings.[12] [40] [55]
- Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[75] [76] [77]
- Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[78] In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[79] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[80] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
acamprosate
Primary Options
- acamprosate
666 mg orally three times daily
- acamprosate
Comments
- Acamprosate normalizes glutamate and gamma-aminobutyric acid neurotransmitter systems in the central nervous system. It is thought that these actions reduce ongoing symptoms associated with alcohol abstinence (e.g., anxiety, insomnia) and cravings. Pill burden may reduce its effectiveness. It is primarily metabolized by the kidneys, and a dose reduction may be required in patients with renal impairment (its use is contraindicated if creatinine clearance is <30 mL/minute).[40] Acamprosate increases the rate and duration of abstinence, compared with placebo.[91] [92] Acamprosate is safe to use in patients who are actively drinking, but evidence for its use is from trials with people who have already stopped drinking. The number needed to treat is 12 to prevent return to any drinking.[79]
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
alcohol use disorder: pregnant
psychosocial treatment
Comments
- Outpatient and intensive outpatient addiction treatment programs typically include treatment sessions scheduled from once- or twice-weekly to several times a week, with treatment extending over several weeks to months (or longer). The interventions provided may include: cognitive behavioral therapy (to assist patients in coping with thoughts of return to alcohol use and negative cognitions), counseling strategies (return-to-use prevention, coping with stressors, forming beneficial relationships), and referral of patients to self-help groups, such as Alcoholics Anonymous (AA).[12] [70] [71] In a meta-analysis of 6 studies, the addition of manualized cognitive behavioral therapy did not improve return-to-use rates when added to naltrexone therapy.[72]
- AA, founded in 1939, is the most common program. Its primary goal is to help individuals maintain total abstinence from alcohol and other addictive substances.Alcoholics Anonymous Self-help programs such as AA can provide valuable additional support for many patients and their families. Patients indicating benefit from support group attendance should be encouraged to attend the group meetings over an extended timeframe; some patients may benefit from attending indefinitely. In one large randomized controlled trial (RCT), AA improved drinking outcomes, largely through improvements in adaptive social network changes and social self-efficacy.[73] Each AA group is independent, so patients should be encouraged to try several if one is not a good fit. For those who have negative experiences or views of AA, it is important that clinicians are aware of alternatives, such as Smart Recovery groups.
- Reassess every 3 months for worsening use or harms of alcohol.
naltrexone
Primary Options
- naltrexone
50 mg orally once daily; 380 mg intramuscularly every 4 weeks
- naltrexone
Comments
- There are no RCTs evaluating the effectiveness of pharmacologic interventions to improve maternal, birth, and infant outcomes in pregnant women enrolled in alcohol treatment programs.[97] Given the impact of alcohol on pregnancy, however, medications should be considered for women who are pregnant and are unable to stop drinking without pharmacologic support.
- Naltrexone is the best-studied in pregnant patients, although primarily in opioid use disorder, and is not associated with birth defects.[98] It is generally recommended to switch to the oral formulation at 36 weeks' gestation to allow for effective pain management at birth.
- Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[74] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol use disorder and in those with significant alcohol cravings.[12] [40] [55]
- Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[75] [76] [77]
- Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[78] In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[79] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[80] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
gabapentin
Primary Options
- gabapentin
300-600 mg orally three times daily
- gabapentin
Comments
- There are no RCTs evaluating the effectiveness of pharmacologic interventions to improve maternal, birth, and infant outcomes in pregnant women enrolled in alcohol treatment programs.[97] Given the impact of alcohol on pregnancy, however, medications should be considered for women who are pregnant and are unable to stop drinking without pharmacologic support.
- Gabapentin may lead to withdrawal in neonates, especially in pregnant women with co-occurring alcohol use disorder.
- Gabapentin reduces heavy drinking days and return to drinking in patients with prominent alcohol withdrawal symptoms. The exact mechanism of gabapentin is not known, but it appears to inhibit the release of excitatory neurotransmitters. In an RCT of 96 individuals with alcohol use disorder, gabapentin resulted in a statistically significant decrease in heavy drinking days (NNT 5) and preventing return to use (NNT 6) for patients with high baseline alcohol withdrawal symptoms.[81] As a result, in patients with symptoms of alcohol withdrawal, gabapentin is emerging as an effective treatment, either as monotherapy or in conjunction with naltrexone.[40] [82]
- The main side effects of gabapentin are dizziness, drowsiness, and nausea. Patients should be counseled that abrupt cessation of gabapentin can lower the seizure threshold.
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
acamprosate
Primary Options
- acamprosate
666 mg orally three times daily
- acamprosate
Comments
- There are no RCTs evaluating the effectiveness of pharmacologic interventions to improve maternal, birth, and infant outcomes in pregnant women enrolled in alcohol treatment programs.[97] Given the impact of alcohol on pregnancy, however, medications should be considered for women who are pregnant and are unable to stop drinking without pharmacologic support.
- Acamprosate is an option in pregnant women if the benefits outweigh the risks, but its efficacy is unclear.
- Acamprosate normalizes glutamate and gamma-aminobutyric acid neurotransmitter systems in the central nervous system. It is thought that these actions reduce ongoing symptoms associated with alcohol abstinence (e.g., anxiety, insomnia) and cravings. Pill burden may reduce its effectiveness. It is primarily metabolized by the kidneys, and a dose reduction may be required in patients with renal impairment (its use is contraindicated if creatinine clearance is <30 mL/minute).[40] Acamprosate increases the rate and duration of abstinence, compared with placebo.[91] [92] Acamprosate is safe to use in patients who are actively drinking, but evidence for its use is from trials with people who have already stopped drinking. The number needed to treat is 12 to prevent return to any drinking.[79]
- Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[62] Further treatment is determined through shared decision-making.
psychosocial treatment
Comments
- The use of medications does not preclude other psychosocial support; and psychosocial support does not preclude the use of medications. Indeed, the greatest efficacy may be seen in patients using a combination of medication and psychosocial treatment.[62]
Emerging Tx
Ondansetron
Computer and internet-based interventions
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Diagnostic
Summary
Classification and diagnostic tool on psychiatric disorders.Published by
American Psychiatric Association
Published
2022
Summary
Recommendations on screening for unhealthy alcohol use in primary care settings.Published by
US Preventive Services Task Force
Published
2018
Summary
Standard diagnostic tool for epidemiology, health management, and clinical purposes.Published by
World Health Organization
Published
2022
Summary
UK guideline for diagnosis of alcohol use disorders.Published by
National Institute for Health and Care Excellence
Published
2011
Treatment
Summary
Options for pharmacologic treatment of alcohol use disorder.Published by
American Psychiatric Association
Published
2018
Summary
This global strategy focuses on 10 key areas of policy options and interventions at the national and global level.Published by
World Health Organization
Published
2010