From the Guidelines
When giving alcohol cessation advice, start with a compassionate, non-judgmental approach that acknowledges the difficulty of quitting, and recommend total alcohol abstinence as the most effective treatment, especially for patients with alcoholic liver disease, as supported by the most recent and highest quality study 1. To implement this approach, first assess the person's drinking patterns and readiness to change using a reliable screening tool such as the AUDIT, which is considered the 'gold standard' for screening alcohol abuse and dependence 1. For those with mild to moderate alcohol use disorder, recommend gradually reducing intake rather than stopping abruptly, which can cause dangerous withdrawal symptoms. For those with severe dependence, suggest medically supervised detoxification, and consider using medications such as acamprosate to reduce cravings, as it has been found to be the only intervention with enough high-quality evidence to conclude that it is better at maintaining alcohol abstinence than placebo 1. Additionally, recommend behavioral support through counseling, cognitive behavioral therapy, or support groups like Alcoholics Anonymous, and encourage lifestyle changes including avoiding drinking triggers, developing healthy coping mechanisms, staying hydrated, improving nutrition, and establishing regular sleep patterns. Regular follow-up is essential to monitor progress, adjust treatment plans, and prevent relapse, and can be guided by the 5 A's behavioral counseling framework: assess, advise, agree, assist, and arrange 1. It is also important to consider the potential benefits and limitations of different interventions, such as brief motivational interventions, which can be effective in reducing alcohol consumption, but may not be sufficient for patients with severe dependence 1. Overall, a comprehensive approach that addresses both the physical dependence and psychological aspects of alcohol use disorder is crucial for increasing the chances of successful long-term recovery.
From the FDA Drug Label
• Advise patients that acamprosate calcium delayed-release tablets have been shown to help maintain abstinence only when used as a part of a treatment program that includes counseling and support. To give alcohol cessation advice, counseling and support should be included as part of the treatment program, in addition to medication such as acamprosate calcium delayed-release tablets 2.
- Patients should be reminded to discuss any renewed drinking with their physicians.
- Patients should be advised to continue therapy as directed, even in the event of relapse.
From the Research
Alcohol Cessation Advice
When providing alcohol cessation advice, several factors should be considered, including the individual's drinking habits, motivation to quit, and potential underlying health conditions.
- The US Preventive Services Task Force recommends screening for unhealthy alcohol use in primary care settings in adults 18 years or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use 3.
- Medications such as disulfiram, naltrexone, and acamprosate can be effective in treating alcohol use disorder, with naltrexone being more efficacious in reducing heavy drinking and craving, and acamprosate being more efficacious in promoting abstinence 4, 5.
- Combining acamprosate and naltrexone may be a viable treatment option, as they have different pharmacological profiles and potentially different effects on drinking outcomes, and pharmacokinetic and pharmacodynamic studies have reported an increase in acamprosate plasma levels with no clinically significant elevation in adverse events when the two drugs are used in combination 6.
- Behavioral counseling interventions, such as Alcoholics Anonymous (AA) and Twelve-Step Facilitation (TSF) interventions, can also be effective in achieving important outcomes, including abstinence, reduced drinking intensity, and reduced alcohol-related consequences 7.
Treatment Approaches
Different treatment approaches may be suitable for different individuals, and a comprehensive assessment of the individual's needs and circumstances should be conducted to determine the most appropriate treatment plan.
- Manualized AA/TSF interventions have been shown to be more effective than other established treatments, such as cognitive behavioral therapy (CBT), for increasing abstinence 7.
- Non-manualized AA/TSF may perform as well as other established treatments, and AA/TSF interventions, both manualized and non-manualized, may be at least as effective as other treatments for other alcohol-related outcomes 7.
- The use of anticonvulsants, such as baclofen, for the treatment of alcohol use disorder is also being explored, although currently, none are FDA approved for this indication 4.