Treatment of Alcoholism
For alcohol use disorder, initiate acamprosate 666 mg three times daily immediately after detoxification as first-line pharmacotherapy, combined with cognitive behavioral therapy or another evidence-based psychosocial intervention. 1
Medically Supervised Detoxification
Before starting maintenance pharmacotherapy, patients must complete alcohol detoxification with benzodiazepines (chlordiazepoxide, diazepam, or lorazepam) as the drugs of choice for managing withdrawal symptoms and preventing seizures and delirium tremens 2. Acamprosate and other maintenance medications are only effective in patients who have already achieved abstinence - they do not work during active drinking 1.
First-Line Pharmacotherapy: Acamprosate
Acamprosate is the only medication with sufficient evidence demonstrating superiority over placebo for maintaining abstinence in primary care settings 3. The FDA-approved dosing is 666 mg (two 333 mg tablets) three times daily, initiated as soon as possible after withdrawal when abstinence is achieved 1.
Key advantages of acamprosate:
- Moderate-quality evidence for efficacy (the highest quality among all options) 3
- Number needed to treat = 11 to prevent one person from returning to any drinking 4
- Can be continued even if patient relapses 1
- Main side effect is diarrhea (risk ratio 1.58) 4
Critical caveat: Reduce dose to 333 mg three times daily in moderate renal impairment (CrCl 30-50 mL/min); contraindicated in severe renal impairment (CrCl ≤30 mL/min) 1.
Second-Line Pharmacotherapy: Oral Naltrexone
If acamprosate is contraindicated or ineffective, use oral naltrexone 50 mg daily 4. This has:
- Number needed to treat = 18 to prevent return to any drinking 4
- Number needed to treat = 11 to prevent return to heavy drinking 4
- Higher rates of nausea (risk ratio 1.73) and vomiting (risk ratio 1.53) compared to placebo 4
Injectable naltrexone reduces drinking days by approximately 5 days per month but has less robust evidence 4.
Third-Line Options
Disulfiram is FDA-approved but functions as an aversive agent requiring high patient motivation and supervised administration 5. The FDA label explicitly states it "is not a cure for alcoholism" and "when used alone, without proper motivation and supportive therapy, it is unlikely that it will have any substantive effect" 5. Reserve this for highly motivated patients with supervision mechanisms in place.
Important limitation: The evidence for naltrexone and disulfiram in maintaining abstinence is uncertain compared to acamprosate's established benefit 3.
Essential Psychosocial Component
Pharmacotherapy must be combined with evidence-based psychosocial intervention - this is non-negotiable per FDA labeling 1. The combination of pharmacotherapy plus cognitive behavioral therapy shows moderate-quality evidence of benefit over usual care plus pharmacotherapy (effect size 0.18-0.28) 6.
Acceptable alternatives to CBT include:
- Motivational enhancement therapy
- Contingency management
- Other structured evidence-based therapies 6
The key point: Pharmacotherapy plus any evidence-based psychosocial therapy outperforms pharmacotherapy plus nonspecific counseling or usual clinical management 6.
Common Pitfalls to Avoid
Starting pharmacotherapy during active drinking - Acamprosate efficacy has not been demonstrated in patients who haven't undergone detoxification 1
Using pharmacotherapy alone without psychosocial support - This violates FDA labeling and reduces efficacy 1
Stopping acamprosate if patient relapses - Continue the medication through relapses 1
Overlooking renal function - Always check creatinine clearance before prescribing acamprosate 1
Expecting immediate results - Maintenance therapy is long-term; acamprosate shows benefits extending beyond 12 months 3
Monitoring for Suicidality
Screen for depression and suicidal ideation regularly - acamprosate-treated patients showed higher rates of suicidal events than placebo (2.4% vs 0.8% in year-long studies), including completed suicides in 0.13% 1.