What is the first step in treating alcohol use disorder?

First-Line Treatment for Alcohol Use Disorder

The first step in treating alcohol use disorder (AUD) is universal screening followed by brief intervention for those with risky alcohol use, and referral to specialized treatment for those with moderate to severe AUD. 1

Screening and Assessment

Recommended Screening Tools:

• AUDIT (Alcohol Use Disorders Identification Test): Most comprehensive screening tool 1, 2
  • Score ≥8 in men up to 60 years or ≥4 in women, adolescents, or men over 60 years indicates problematic alcohol use 2
• CAGE Questionnaire: Simple 4-question tool 1
  • Two or more "yes" responses indicate an alcohol use disorder 1

Assessment of Severity:

According to DSM-5 criteria, AUD severity is classified as 1, 2:

• Mild: 2-3 symptoms
• Moderate: 4-5 symptoms
• Severe: ≥6 symptoms

Treatment Algorithm Based on Severity

1. For Risky Drinking (Pre-AUD):

• Brief behavioral counseling interventions 1
• Education about safe drinking limits
• Follow-up to assess progress

2. For Mild AUD (2-3 symptoms):

• Brief interventions based on motivational interviewing 2
• Regular follow-up
• Consider psychosocial support

3. For Moderate AUD (4-5 symptoms):

• Pharmacotherapy options:
  • First-line: Naltrexone (50mg daily) 2
  • Alternative: Gabapentin (target dose 1800mg/day divided into three doses) 2
• Combined with psychosocial interventions (CBT) 2

4. For Severe AUD (≥6 symptoms):

• Managed withdrawal if needed (using benzodiazepines) 2
• Pharmacotherapy:
  • Naltrexone (50mg daily) - reduces probability of drinking by 5% and risk of excessive drinking by 10% 2
  • Acamprosate (666mg three times daily) - helps maintain abstinence 2
• Intensive psychosocial treatment
• Consider referral to specialized addiction treatment 1

Management of Alcohol Withdrawal

For patients requiring detoxification:

1. Assess withdrawal severity using CIWA-Ar score 2:

   • Mild (≤7): Monitor, may not require medication
   • Moderate (8-14): Initiate benzodiazepine treatment
   • Severe (≥15): Aggressive benzodiazepine treatment, consider inpatient management

2. Essential nutritional support:

   • Thiamine 100-300mg/day for 4-12 weeks (before giving dextrose-containing solutions) 2
   • Protein 1.2-1.5g/kg/day and calories 35-40 kcal/kg/day 2

Psychosocial Interventions

• Cognitive-Behavioral Therapy (CBT): Particularly effective for patients who drink to cope with negative emotions 2
• Motivational Interviewing: Effective for patients ambivalent about quitting alcohol 2
• Web-based relapse prevention therapy (e-RPT): Emerging option for improved accessibility 3

Common Pitfalls and Caveats

1. Undertreatment: Despite effective medications being available, only 1.6% of Americans with AUD receive pharmacotherapy 4

2. Overlooking comorbidities: Depression and anxiety often co-occur with AUD and require concurrent treatment

3. Inadequate follow-up: AUD is a chronic relapsing condition requiring long-term monitoring and support

4. Failing to address nutritional deficiencies: Thiamine supplementation is critical to prevent Wernicke's encephalopathy 2

5. Ignoring liver status: For patients with liver disease, acamprosate or baclofen may be safer options than naltrexone 2

The treatment of AUD requires a systematic approach beginning with proper screening and assessment, followed by appropriate interventions based on severity. While pharmacotherapy significantly improves outcomes, it should always be combined with psychosocial interventions for optimal results.