What medications should be prescribed to patients with chronic alcoholism to prevent withdrawal symptoms and for deterrence?

From the Guidelines

For patients with chronic alcoholism, acamprosate is the most recommended medication to prevent withdrawal symptoms and for deterrence, as it has been shown to be effective in reducing relapse rates and improving abstinence, as supported by the most recent and highest quality study 1. When managing withdrawal symptoms, benzodiazepines are the first-line treatment, with longer-acting options like diazepam (5-10mg every 6 hours) or chlordiazepoxide (25-100mg every 6 hours) typically used for 3-7 days with tapering doses based on symptom severity. For long-term deterrence, medications such as naltrexone (50mg daily oral or 380mg monthly injection) and disulfiram (250-500mg daily) can be considered, but acamprosate (666mg three times daily) is the preferred choice due to its efficacy in maintaining alcohol abstinence, as shown in the 2020 systematic review and network meta-analysis 1. Key points to consider when prescribing medications for chronic alcoholism include:

• Individualizing treatment based on patient characteristics, comorbidities, and medication adherence potential
• Regular monitoring for side effects and effectiveness
• Combining medications with counseling and support groups for optimal outcomes
• Considering the potential side effects of medications, such as hepatocellular injury with naltrexone, and adjusting treatment plans accordingly, as recommended by the 2010 study 1 and the 2012 clinical practical guidelines 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 Chlordiazepoxide Hydrochloride and Clidinium Bromide Capsules may produce physical dependence from continued therapy.

• Medications for prevention of withdrawal symptoms and deterrence in chronic alcoholism:
  • Acamprosate: for maintenance of abstinence from alcohol in patients with alcohol dependence
  • Chlordiazepoxide: may be used for prevention of withdrawal symptoms, but it has a potential for abuse and addiction
• Key considerations:
  • Acamprosate should be part of a comprehensive management program that includes psychosocial support 2
  • Chlordiazepoxide may produce physical dependence and should be used with caution, with a gradual taper to discontinue or reduce the dosage 3

From the Research

Medications for Preventing Withdrawal Symptoms

• Benzodiazepines, such as chlordiazepoxide, diazepam, and lorazepam, are commonly used to prevent and treat symptoms of alcohol withdrawal 4, 5, 6, 7, 8
• Symptom-triggered dosing, based on a withdrawal rating scale, is optimal for minimizing the total benzodiazepine dosage 4
• Long-acting benzodiazepines, such as chlordiazepoxide, are preferred in uncomplicated patients 4

Medications for Deterrence

• Disulfiram, an aversive deterrent, can be useful in highly motivated patients and when compliance-enhancing strategies are used 4, 7
• Naltrexone can reduce the frequency of relapse and is useful in the broader population of patients entering treatment for alcohol dependence 4, 7
• Acamprosate can stabilize the physiology of post-acute withdrawal and reduce the frequency of relapse 4

Additional Considerations

• Thiamine should be administered routinely before the administration of intravenous fluids to prevent the development of Wernicke's encephalopathy and Wernicke-Korsakoff syndrome 4
• Psychiatric comorbidity, especially depression, is common and should be addressed concurrently with treatment for alcohol dependence 4
• Prescription of addictive substances, including benzodiazepines, should be avoided beyond the period of acute detoxification, and closely monitored if necessary 4