What is the treatment approach for a patient with moderate alcohol use disorder?

Treatment Approach for Moderate Alcohol Use Disorder

The treatment of moderate alcohol use disorder should include a combination of pharmacotherapy (with naltrexone, acamprosate, or baclofen) and psychosocial interventions such as motivational interviewing and cognitive-behavioral therapy to reduce mortality and improve quality of life. 1

Pharmacotherapy Options

First-line Medications

1. Naltrexone (50 mg daily)

   • Reduces risk of heavy drinking and return to any drinking 2
   • Proven superior to placebo in clinical trials with higher abstention rates (51% vs 23%) and lower relapse rates (31% vs 60%) 2
   • Caution needed in patients with liver disease due to hepatic metabolism 1

2. Acamprosate

   • Safe option for patients with liver disease due to lack of hepatic metabolism 1
   • Particularly effective for maintaining abstinence in patients who have already stopped drinking 3

3. Baclofen

   • Only medication with proven efficacy and safety specifically in patients with liver disease 1
   • High-certainty evidence shows it increases percentage of days abstinent 4
   • Moderate-certainty evidence indicates it probably decreases risk of relapse 4

Alternative Options

• Gabapentin (600-1,800 mg/day) - Reduces heavy drinking days 3
• Topiramate (75-400 mg/day) - Moderate evidence supports its use in decreasing heavy drinking days 3

Psychosocial Interventions

Brief Interventions

• Assessment and feedback alone can positively influence reduction of alcohol use 5
• Brief motivational interventions following the "five A's" model reduce drinking by an average of 57g per week 1
• FRAMES model (Feedback, Responsibility, Advice, Menu of alternatives, Empathy, Self-efficacy) is effective 1

Structured Therapy

1. Motivational Interviewing

   • Particularly effective for patients ambivalent about alcohol cessation 5, 1
   • Helps patients recognize problems and develop commitment to change 6

2. Cognitive-Behavioral Therapy (CBT)

   • Focuses on pathological consumption patterns and development of self-control skills 1
   • Particularly effective for patients who drink to cope with negative emotions 1

3. Support Groups

   • Mutual aid societies (e.g., Alcoholics Anonymous) and group therapies beneficial for chronic alcoholism 1

Monitoring and Follow-up

Biomarkers for Monitoring

• Phosphatidylethanol (PEth) - Half-life of 10-14 days, high sensitivity (91-100%) and specificity (77-96%) 5
• Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS) - Detectable in urine for up to 3 days after drinking 5
• These biomarkers are not affected by liver disease and are preferable for monitoring 5

Treatment Phases

1. Initial Phase

   • Manage withdrawal symptoms if present
   • Provide nutritional support and thiamine supplementation

2. Early Recovery Phase

   • Start pharmacotherapy combined with psychosocial interventions
   • Address comorbid conditions

3. Maintenance Phase

   • Continue medications for 3-12 months
   • Ongoing psychosocial support and regular follow-up

Important Considerations

Comorbidities

• Alcohol use disorder is associated with depressive episodes, severe anxiety, insomnia, and suicide 7
• Continued heavy alcohol use shortens onset of heart disease, stroke, cancers, and liver cirrhosis 7
• For patients with comorbid depression, antidepressants may help decrease alcohol intake 3

Common Pitfalls to Avoid

1. Undertreatment

   • Only 7.3% of Americans with alcohol use disorder receive any treatment, and only 1.6% receive medications 3
   • Ensure comprehensive treatment that includes both pharmacotherapy and psychosocial interventions

2. Ignoring Liver Function

   • For patients with liver disease, baclofen is the safest option with primarily renal excretion 1
   • Monitor liver function when using naltrexone in patients with liver concerns 2

3. Failing to Address Motivation

   • Fluctuating or limited motivation to change alcohol use is common 5
   • Use specific health events such as hospital admissions as opportunities to capitalize on motivation 5

4. Stigma

   • Stigma remains an issue for those experiencing alcohol use disorder 5
   • Provide equity of access to services and avoid perpetuating stigmatizing behaviors

By implementing this comprehensive approach that combines appropriate pharmacotherapy with evidence-based psychosocial interventions, clinicians can significantly improve outcomes for patients with moderate alcohol use disorder, reducing mortality and enhancing quality of life.