What is the recommended approach for managing suspected alcohol abuse?

From the Guidelines

The most effective approach for managing suspected alcohol abuse is to start with screening using the AUDIT test, followed by brief motivational interventions, and consideration of medication such as naltrexone, acamprosate, or disulfiram for reducing alcohol consumption and preventing relapse, as recommended by 1. When managing suspected alcohol abuse, several key steps can be taken to address the issue effectively.

• Screening for alcohol abuse should be routinely performed by physicians using reliable tools, with the AUDIT test being considered the 'gold standard' for screening alcohol abuse and dependence, as noted in 1.
• For patients with acute withdrawal syndrome, benzodiazepines are the treatment of choice, as stated in 1.
• In patients with alcoholic liver disease (ALD), total alcohol abstinence is recommended to prevent disease progression, as emphasized in 1 and 1.
• Brief motivational interventions should be used in the medical management of alcohol use disorders, as recommended in 1.
• Medication options such as disulfiram, naltrexone, and acamprosate, combined with counseling, can reduce alcohol consumption and prevent relapse in alcohol-dependent patients without advanced ALD, as noted in 1 and 1.
• However, these medications may not be suitable for patients with advanced ALD due to potential side effects, and alternative options like baclofen may be considered, as suggested in 1.
• A comprehensive approach to managing alcohol abuse should include addressing co-occurring mental health conditions, providing ongoing support, and monitoring for relapse, as these factors are crucial for achieving and maintaining abstinence, and improving overall quality of life, as implied by the recommendations in 1 and 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Disulfiram should never be administered until the patient has abstained from alcohol for at least 12 hours. Management of Disulfiram-Alcohol Reaction In severe reactions, whether caused by an excessive test dose or by the patient’s unsupervised ingestion of alcohol, supportive measures to restore blood pressure and treat shock should be instituted.

The recommended approach for managing suspected alcohol abuse with disulfiram includes:

• Ensuring the patient has abstained from alcohol for at least 12 hours before administering disulfiram
• Supervised administration of disulfiram, with a maximum of 500 mg daily for the first one to two weeks
• Monitoring for signs of disulfiram-alcohol reaction, and having a plan in place for managing severe reactions, including:
  • Supportive measures to restore blood pressure and treat shock
  • Administration of oxygen, carbogen, vitamin C, and ephedrine sulfate as needed
  • Monitoring potassium levels, particularly in patients on digitalis 2

From the Research

Managing Suspected Alcohol Abuse

The recommended approach for managing suspected alcohol abuse involves a combination of screening, assessment, and laboratory tests.

• Screening for unhealthy drinking habits should be done at least yearly using validated screening tests 3.
• Patients who present with medical or psychosocial problems that might be related to alcohol use should also be screened.
• Laboratory tests such as complete blood count and liver transaminase levels, including γ-glutamyl transpeptidase, can help assess liver function and detect potential liver damage 3.

Laboratory Markers of Alcohol Abuse

Several laboratory markers can provide objective information about alcohol use and abuse, including:

• Serum carbohydrate-deficient transferrin (CDT), which has a greater overall marker potential than other existing tests 4.
• Liver enzyme activities such as GGT, ALT, and AST, which can indicate liver damage and are important screening tools for detecting liver disease 5.
• Blood ethanol and its specific metabolites, such as ethyl glucuronide and phosphatidylethanol, which can provide information on the specific role of ethanol consumption behind hepatotoxicity 5.

Assessment and Diagnosis

A thorough assessment and diagnosis of alcohol use disorder (AUD) should be made using the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, criteria 3.

• Patients with AUD should be categorized as having mild, moderate, or severe AUD.
• A brief physical examination and laboratory tests should be conducted to assess complete blood count and liver transaminase levels.
• Screening for other substance use, concurrent disorders, and trauma should also be done 3.