What are the treatment options for alcohol (ethanol) cessation?

From the Guidelines

Alcohol cessation treatment should prioritize acamprosate as the primary medication for maintaining abstinence, due to its high-quality evidence and effectiveness in clinical practice. According to the most recent and highest quality study 1, acamprosate is the only intervention with enough high-quality evidence to conclude that it is better at maintaining alcohol abstinence than placebo.

Key Considerations

• Medically supervised detoxification is often necessary to manage withdrawal symptoms safely, using medications like benzodiazepines (e.g., diazepam or chlordiazepoxide) 1.
• For long-term maintenance therapy, FDA-approved medications include naltrexone, acamprosate, and disulfiram, which can be used in combination with counseling and support 1.
• Psychological interventions like cognitive-behavioral therapy, motivational enhancement therapy, and support groups such as Alcoholics Anonymous are essential components of treatment.
• Addressing nutritional deficiencies with thiamine and multivitamins, as well as treating co-occurring mental health conditions, is crucial for overall recovery.

Treatment Approach

• The most effective approach combines medications with counseling and support, tailored to individual needs, with treatment typically lasting at least 3-6 months initially.
• Acamprosate (666mg three times daily) is recommended as the primary medication for maintaining abstinence, due to its high-quality evidence and effectiveness in clinical practice 1.
• Naltrexone (50mg daily oral or 380mg monthly injection) and disulfiram (250-500mg daily) can be considered as alternative or adjunctive treatments, depending on individual patient needs and preferences 1.

From the FDA Drug Label

Acamprosate calcium delayed-release tablets are indicated for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. Treatment with acamprosate calcium delayed-release tablets should be part of a comprehensive management program that includes psychosocial support A dose of 50 mg once daily is recommended for most patients Naltrexone hydrochloride should be considered as only one of many factors determining the success of treatment of alcoholism.

• Acamprosate and naltrexone are two medications used for alcohol cessation treatment.
• Acamprosate is indicated for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation.
• Naltrexone is recommended at a dose of 50 mg once daily for most patients.
• Both medications should be used as part of a comprehensive psychosocial treatment program 2, 3.

From the Research

Alcohol Cessation Treatment Options

• There are several pharmacological and psychosocial interventions available for the treatment of alcohol use disorder, including acamprosate, naltrexone, and disulfiram 4, 5, 6, 7, 8.
• A meta-analysis of 16 randomized controlled trials of acamprosate, 18 of naltrexone, and 7 of disulfiram found that acamprosate and naltrexone were 52% and 27% better than placebo in supporting continuous abstinence, respectively 4.
• Another study found that combining medical treatment with cognitive behavioral therapy (CBT) can affect patients' quality of life, symptoms of depression, and smoking habits, with all three study groups showing a significant reduction in drinking from baseline to the end of the study 5.

Efficacy of Combined Interventions

• A study found that combined pharmacologic and psychosocial interventions may be associated with a greater reduction in harmful alcohol use compared to psychosocial intervention alone, with a standardized mean difference of -0.43 (95% CI: -0.61 to -0.24) 6.
• Another study found that the addition of both naltrexone and acamprosate resulted in measurable benefit and was well tolerated, with significant differences observed across all outcome indices compared to patients who declined medication 7.

Pharmacotherapy for Alcohol Use Disorder

• A systematic review and meta-analysis found that oral naltrexone at 50 mg/d and acamprosate are first-line pharmacotherapies for alcohol use disorder, with numbers needed to treat to prevent 1 person from returning to any drinking of 11 (95% CI, 1-32) for acamprosate and 18 (95% CI, 4-32) for oral naltrexone 8.
• The review also found that injectable naltrexone was associated with fewer drinking days over the 30-day treatment period, with a weighted mean difference of -4.99 days (95% CI: -9.49 to -0.49 days) 8.