What is the recommended treatment for alcohol use disorder?

Treatment of Alcohol Use Disorder

The recommended treatment for alcohol use disorder (AUD) includes alcohol abstinence as the primary goal, supported by a combination of benzodiazepines for withdrawal management, FDA-approved medications like naltrexone or acamprosate for relapse prevention, and psychosocial interventions such as brief interventions, cognitive behavioral therapy, and mutual support groups. 1, 2

Alcohol Withdrawal Management

Assessment and Initial Treatment

• Use the Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar) to guide treatment:
  • CIWA-Ar ≤7: Mild withdrawal - Monitor, may not require medication
  • CIWA-Ar 8-14: Moderate withdrawal - Initiate benzodiazepine treatment
  • CIWA-Ar ≥15: Severe withdrawal - Aggressive benzodiazepine treatment, consider inpatient management 2

Medication Protocol for Withdrawal

• Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome (AWS) 1, 2:
  • Chlordiazepoxide: 25-100 mg PO every 4-6 hours
  • Diazepam: 5-10 mg PO/IV/IM every 6-8 hours
  • Lorazepam: 1-4 mg PO/IV/IM every 4-8 hours

Nutritional Support During Withdrawal

• Thiamine supplementation (100-300 mg/day) is essential before administering glucose-containing fluids to prevent Wernicke encephalopathy 1, 2
• Provide fluids, electrolytes (especially magnesium), and vitamins in a comfortable environment 1
• Recommended caloric intake: 35-40 kcal/kg/day
• Recommended protein intake: 1.2-1.5 g/kg/day 1, 2

Long-term Treatment for Alcohol Use Disorder

Pharmacological Treatment for Maintaining Abstinence

1. FDA-approved medications:

   • Naltrexone: 50 mg once daily; reduces likelihood of return to drinking by 5% and binge-drinking risk by 10% 3, 4
   • Acamprosate: 666 mg three times daily; reduces withdrawal effects and craving 1

2. Other medications with evidence:

   • Baclofen: 30-60 mg/day; GABA-B receptor agonist shown to be effective in patients with alcoholic liver disease 1
   • Gabapentin: 600-1,800 mg/day; may be considered for post-acute withdrawal symptoms 1, 2

Medication Selection Considerations

• For patients with liver disease, baclofen and acamprosate are preferred options 1, 5
• Naltrexone should be used with caution in patients with liver disease due to potential hepatotoxicity 1, 3
• Disulfiram is not recommended for patients with alcoholic liver disease 1

Psychosocial Interventions

Brief Interventions

• FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) is effective for reducing risky drinking behavior 1
• Brief interventions have been shown to lower morbidity and mortality related to drinking 1

Structured Psychosocial Treatments

• Cognitive behavioral therapy
• Motivational enhancement therapy
• 12-step facilitation therapy
• Social skills training
• Coping skills training 1

Support Groups

• Alcoholics Anonymous and other mutual aid groups are recommended as part of ongoing recovery support 1, 2

Integrated Treatment Approach

1. Initial phase: Manage withdrawal symptoms with benzodiazepines and nutritional support
2. Early recovery phase: Start pharmacotherapy (naltrexone, acamprosate, or baclofen) combined with psychosocial interventions
3. Maintenance phase: Continue medications for 3-12 months with ongoing psychosocial support

Special Considerations

Patients with Liver Disease

• Alcohol abstinence is the most important treatment for patients with alcoholic liver disease 1
• Baclofen has shown efficacy in patients with liver cirrhosis 1
• Acamprosate is primarily renally excreted and has no reported instances of hepatotoxicity 1, 5

Treatment Barriers and Solutions

• Despite evidence of effectiveness, medications are prescribed to less than 9% of patients who could benefit 4
• Integrating AUD treatment with medical care remains the best option for management of advanced alcoholic liver disease and AUD 1
• Addressing stigma and increasing screening in primary care settings can help close the treatment gap 6, 7

Monitoring and Follow-up

• Daily follow-up until withdrawal symptoms subside
• Regular monitoring for medication adherence, abstinence status, and signs of complications
• Ongoing psychosocial support to maintain abstinence and prevent relapse

The evidence clearly shows that a combination of pharmacotherapy and psychosocial interventions is more effective than either approach alone, with alcohol abstinence being the primary goal, especially for patients with liver disease 1, 5.