What is the recommended treatment approach for alcohol abuse?

Treatment Approach for Alcohol Abuse

The recommended treatment approach for alcohol abuse includes benzodiazepines for withdrawal management, FDA-approved medications like acamprosate, naltrexone, or disulfiram for relapse prevention, and structured psychosocial interventions including mutual help groups like Alcoholics Anonymous. 1, 2

Screening and Assessment

• Use validated screening tools to identify alcohol use disorders:
  • AUDIT (Alcohol Use Disorders Identification Test)
  • AUDIT-C (shortened version)
  • ASSIST (Alcohol, Smoking and Substance Involvement Screening Test)
• A score of >8 on AUDIT indicates moderate alcohol withdrawal syndrome (AWS)
• A score of ≥15 indicates severe AWS 1

Management of Alcohol Withdrawal Syndrome (AWS)

Pharmacological Treatment

1. Benzodiazepines are the gold standard for AWS management 1, 3:

   • Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide better protection against seizures and delirium
   • Short-acting benzodiazepines (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction
   • Symptom-triggered regimens are preferred over fixed-dose schedules 4

2. Dosing recommendations 1:

   • Chlordiazepoxide: 25-100 mg orally every 4-6 hours
   • Diazepam: 5-10 mg orally/IV/IM every 6-8 hours
   • Lorazepam: 1-4 mg orally/IV/IM every 4-8 hours

3. Thiamine supplementation 1:

   • All patients should receive thiamine (100-300 mg/day)
   • High-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy should receive parenteral thiamine

4. Treatment setting 1:

   • Outpatient treatment is more cost-effective for mild to moderate withdrawal
   • Inpatient treatment is recommended for:
     • Severe withdrawal with complications (delirium, seizures)
     • Physical/psychiatric comorbidities
     • Inadequate social support

Caution

• Antipsychotic medications should not be used as stand-alone treatments for AWS 1
• They should only be used as adjuncts to benzodiazepines in severe withdrawal delirium that hasn't responded to adequate benzodiazepine doses

Relapse Prevention

Pharmacological Interventions

1. Naltrexone 1, 5:

   • FDA-approved for alcohol dependence
   • Reduces alcohol craving and heavy drinking days
   • Dosage: 50 mg daily after withdrawal symptoms resolve
   • Clinical trials showed lower relapse rates (21% vs. 41%) and less alcohol craving 5
   • Not recommended in patients with alcoholic liver disease due to risk of hepatotoxicity 1

2. Acamprosate 1, 2:

   • Effective for maintaining abstinence
   • Initiated 3-7 days after last alcohol consumption
   • Dosage: 1,998 mg/day (body weight ≥60 kg) or 1,332 mg/day (body weight <60 kg)
   • Treatment duration: 3-6 months 1

3. Disulfiram 1:

   • Causes unpleasant reaction when alcohol is consumed
   • Effective in highly motivated patients with supervision
   • Less commonly used due to compliance issues and side effects 1

4. Baclofen 1:

   • Promising option for patients with alcoholic liver disease
   • May be safer in patients with cirrhosis
   • Dosage not exceeding 80 mg/day as per French ANSM recommendation 1

Psychosocial Interventions

1. Brief interventions 1, 2:

   • Effective for hazardous and harmful drinking
   • 5-30 minute sessions with individualized feedback
   • Clear advice on reducing consumption

2. Structured psychological support 1:

   • Individual psychotherapy with cognitive behavioral therapy
   • Motivational enhancement techniques
   • Coping skills training
   • Social skills training

3. Mutual help groups 1, 2:

   • Alcoholics Anonymous (AA) is strongly recommended
   • Healthcare providers should familiarize themselves with local groups
   • Family members should be encouraged to engage with support groups

4. Family involvement 1:

   • Family education and therapy
   • Coordination with community alcohol counseling centers

Treatment Algorithm

1. Assess severity of alcohol use disorder and withdrawal risk
2. Manage withdrawal symptoms with appropriate benzodiazepines and thiamine
3. After withdrawal (7-10 days), initiate relapse prevention medication:
   • For patients without liver disease: Naltrexone or acamprosate
   • For patients with liver disease: Consider baclofen
   • For highly motivated patients with supervision: Consider disulfiram
4. Implement psychosocial interventions concurrently
5. Encourage participation in mutual help groups
6. Monitor progress and adjust treatment as needed

Common Pitfalls to Avoid

• Failing to provide thiamine supplementation, which can lead to Wernicke's encephalopathy
• Using antipsychotics alone for withdrawal management
• Not addressing psychiatric comorbidities
• Inadequate dosing of benzodiazepines during severe withdrawal
• Lack of follow-up after acute withdrawal management
• Not involving family members in the treatment process
• Failing to coordinate between addiction specialists and other healthcare providers 1