What is the recommended management for a patient with alcohol use disorder consuming 72 drinks per week?

Management of Severe Alcohol Use Disorder (72 drinks/week)

The patient with severe alcohol use disorder consuming 72 drinks per week requires immediate medically supervised detoxification followed by comprehensive treatment including pharmacotherapy (preferably baclofen for those with liver disease) and psychosocial interventions to achieve complete abstinence.

Assessment and Initial Management

Severity Classification

• 72 drinks/week far exceeds the thresholds for heavy alcohol use defined by NIAAA (>15 drinks/week for men, >8 drinks/week for women) 1
• This consumption level (72 drinks/week) indicates severe alcohol use disorder and places the patient at extremely high risk for:
  • Alcohol-related liver disease
  • Cardiovascular complications
  • Neurological damage
  • Multiple cancers
  • Significant mortality risk

Immediate Intervention

1. Medically Supervised Detoxification
   • Given the high consumption (72 drinks/week), outpatient detoxification is contraindicated due to risk of severe withdrawal 2
   • Inpatient detoxification is necessary to safely manage withdrawal symptoms and prevent complications like seizures or delirium tremens
   • Benzodiazepines are the treatment of choice for alcohol withdrawal using a symptom-triggered approach 3
   • Thiamine supplementation (100-300mg/day) is essential to prevent Wernicke's encephalopathy 3

Pharmacotherapy for Maintenance

After successful detoxification, implement pharmacotherapy based on liver status:

For Patients Without Liver Disease:

• First-line option: Naltrexone 50mg daily 4
  • Reduces relapse to heavy drinking by 29% 3
  • Requires monitoring of liver function tests due to potential hepatotoxicity 3

For Patients With Liver Disease:

• First-line option: Baclofen starting at 5-10mg TID, titrating as needed 3

  • Only medication proven effective specifically for patients with alcoholic cirrhosis 3
  • No hepatotoxicity concerns
  • Monitor for sedation, especially if hepatic encephalopathy is present

• Alternative option: Acamprosate 666mg TID 3

  • Effective for maintaining abstinence
  • No hepatotoxicity concerns
  • Safe in liver disease due to lack of hepatic metabolism

Medications to Avoid:

• Disulfiram is contraindicated due to high risk of hepatotoxicity, especially with this level of consumption 5, 3

Psychosocial Interventions

Implement multiple evidence-based approaches:

1. Cognitive Behavioral Therapy (CBT)

   • Identify triggers for drinking
   • Develop coping strategies
   • Prevent relapse 3

2. Motivational Enhancement Therapy

   • Resolve ambivalence about treatment
   • Enhance motivation for change 3

3. Support Groups

   • Alcoholics Anonymous or similar peer support groups
   • Regular attendance correlates with better outcomes 3

4. Family Therapy

   • Educate family members about alcohol use disorder
   • Develop supportive home environment 3

Nutritional Support

• Protein intake: 1.2-1.5 g/kg/day
• Caloric intake: 35-40 kcal/day
• Consider more frequent, smaller meals if needed 3
• Supplement with B vitamins, particularly thiamine

Monitoring and Follow-up

1. Regular liver function tests

   • Especially important with naltrexone therapy
   • Monitor for medication side effects and assess compliance with abstinence 3

2. Screen for complications

   • Hepatic encephalopathy
   • Varices
   • Ascites
   • Nutritional deficiencies

3. Adjust treatment plan based on response and compliance

   • Consider alternative or combination therapy if first-line medication fails
   • Intensify psychosocial support if needed

Common Pitfalls to Avoid

1. Underestimating withdrawal risk - At 72 drinks/week, severe withdrawal is likely and requires medical supervision
2. Inadequate nutritional support - Malnutrition is common and requires aggressive correction
3. Prescribing hepatotoxic medications - Avoid disulfiram and use naltrexone cautiously
4. Focusing only on pharmacotherapy - Combined approach with psychosocial interventions is essential
5. Setting unrealistic goals - Complete abstinence should be the goal, not reduced drinking, given the severity

Long-term Management

• Continued pharmacotherapy for at least 6-12 months
• Ongoing participation in psychosocial interventions
• Regular monitoring of liver function and overall health
• Address comorbid psychiatric conditions
• Develop strategies for relapse prevention

The French Association for the Study of the Liver recommends complete abstinence as the goal, particularly since this consumption level (72 drinks/week) far exceeds their maximum recommendation of 21 standard drinks/week for males and 14 standard drinks/week for females 1.