What are the treatment options for alcohol use disorder?

Treatment Options for Alcohol Use Disorder

The most effective treatment for alcohol use disorder combines pharmacotherapy with evidence-based psychosocial interventions such as Cognitive Behavioral Therapy (CBT) or another evidence-based therapy, rather than usual clinical management or nonspecific counseling services alone. 1, 2

Pharmacotherapy Options

FDA-Approved Medications

1. Naltrexone (First-line)

   • Oral: 50 mg once daily
   • Injectable: Monthly intramuscular injection
   • Benefits: Reduces risk of heavy drinking and return to any drinking 3
   • Mechanism: Opioid antagonist that blocks alcohol's pleasurable effects
   • Caution: Requires hepatic monitoring; contraindicated in patients taking opioids or with acute hepatitis 3

2. Acamprosate

   • Particularly useful for patients with liver disease as it has no hepatic metabolism 2
   • Helps maintain abstinence in patients who have already stopped drinking
   • Typically dosed three times daily

3. Disulfiram

   • Creates unpleasant reaction when alcohol is consumed
   • Limited evidence for effectiveness outside supervised settings 4
   • Most effective with highly motivated patients and compliance-enhancing strategies

Off-Label Medications with Evidence

1. Baclofen

   • Only medication with proven efficacy and safety specifically in patients with liver disease 2
   • Increases percentage of days abstinent (high-certainty evidence)
   • Decreases risk of relapse (moderate-certainty evidence)

2. Gabapentin (600-1,800 mg/day)

   • Effective for reducing heavy drinking days 2, 4
   • Good option for patients with renal function concerns

3. Topiramate (75-400 mg/day)

   • Moderate evidence for decreasing heavy drinking days 2, 4
   • Alternative for patients who don't respond to first-line treatments

Psychosocial Interventions

1. Cognitive Behavioral Therapy (CBT)

   • Focuses on pathological consumption patterns and developing self-control skills 2
   • Particularly effective for patients who drink to cope with negative emotions
   • Combined with pharmacotherapy shows superior outcomes compared to usual care plus pharmacotherapy 1

2. Motivational Interviewing

   • Particularly effective for patients ambivalent about alcohol cessation 2
   • Helps patients recognize problems and develop commitment to change
   • Brief motivational interventions following the "five A's" model can reduce drinking by an average of 57g per week

3. Support Groups

   • Mutual aid societies (e.g., Alcoholics Anonymous)
   • Group therapies beneficial for patients with chronic alcoholism 2

4. Integrated Treatment Models

   • FRAMES model (Feedback, Responsibility, Advice, Menu of alternatives, Empathy, Self-efficacy) 2
   • Combined approaches show best outcomes

Treatment Algorithm

Phase 1: Initial Management

1. Assess withdrawal risk using CIWA-Ar score:

   • ≤7 (Mild): Monitor, may not require medication
   • 8-14 (Moderate): Initiate benzodiazepine treatment
   • ≥15 (Severe): Aggressive benzodiazepine treatment, consider inpatient management 2

2. Provide nutritional support:

   • Thiamine 100-300 mg IV before giving glucose
   • Adequate protein (1.2-1.5 g/kg/day) and calories (35-40 kcal/kg/day)
   • Electrolyte replacement (potassium, phosphorus, magnesium) 2

Phase 2: Early Recovery

1. Start pharmacotherapy:

   • First-line: Naltrexone 50 mg daily (if no liver concerns) 3
   • Alternative for liver disease: Baclofen or acamprosate 2

2. Begin psychosocial intervention:

   • CBT or another evidence-based therapy
   • Support group participation

Phase 3: Maintenance

1. Continue medications for 3-12 months
2. Ongoing psychosocial support
3. Regular monitoring using biomarkers:
   • Phosphatidylethanol (PEth): Half-life 10-14 days, high sensitivity (91-100%)
   • Ethyl Glucuronide (EtG) and Ethyl Sulfate (EtS): Detectable in urine for up to 3 days 2

Important Clinical Considerations

1. Before starting naltrexone:

   • Ensure patient is opioid-free for 7-10 days
   • Consider naloxone challenge test if occult opioid dependence is suspected 3

2. Treatment efficacy monitoring:

   • Regular follow-up appointments
   • Laboratory monitoring (liver function for naltrexone, renal function for acamprosate)
   • Assessment of medication adherence

3. Common pitfalls to avoid:

   • Prescribing medications without psychosocial support
   • Failing to monitor for medication side effects
   • Not addressing comorbid psychiatric conditions
   • Discontinuing treatment prematurely (optimal duration is at least 3-12 months) 2

Despite the availability of effective treatments, only 7.3% of Americans with alcohol use disorder receive any treatment, and only 1.6% are prescribed medications 4. This highlights the need for improved recognition and comprehensive treatment of this common disorder.