What is the treatment for alcohol abuse?

Treatment for Alcohol Abuse

The most effective treatment for alcohol abuse is a combination of pharmacotherapy (particularly naltrexone or baclofen) with cognitive behavioral therapy (CBT) or another evidence-based psychotherapy, rather than usual care or non-specific counseling services. 1

Pharmacotherapy Options

First-line Medications

1. Naltrexone:

   • Dosage: 50 mg once daily for 12 weeks 2
   • Mechanism: Blocks opioid receptors, reducing alcohol craving and pleasure from drinking
   • Evidence: Reduces relapse rates (31% vs 60%), increases abstention rates (51% vs 23%), and decreases drinking days compared to placebo 2
   • Best for: Patients who want to reduce heavy drinking days
   • Contraindications: Opioid use, severe liver disease

2. Baclofen:

   • Dosage: Start at 5 mg TID, titrate up to 10 mg TID 3
   • Mechanism: GABA-B receptor agonist
   • Best for: Patients with liver disease (preferred medication for this population)

3. Acamprosate:

   • Dosage: 666 mg TID for patients ≥60 kg 3
   • Mechanism: Modulates glutamate neurotransmission
   • Best for: Patients who have already achieved abstinence and want to maintain it
   • Advantage: Safe in liver disease

Second-line Medications

1. Disulfiram:
   • Contraindicated in decompensated hepatic disease 3
   • Mechanism: Causes unpleasant reaction when alcohol is consumed
   • Limited evidence of effectiveness outside supervised settings 4

Psychosocial Interventions

Cognitive Behavioral Therapy (CBT)

• Meta-analysis shows CBT combined with pharmacotherapy is superior to usual care plus pharmacotherapy (g range, 0.18-0.28) 1
• Particularly effective for patients who drink to cope with negative emotions 3
• Focuses on identifying triggers and developing coping skills

Motivational Interviewing

• Effective for patients ambivalent about alcohol cessation 3
• Helps patients recognize problems and develop commitment to change

Support Groups

• Alcoholics Anonymous and other peer support groups recommended as adjuncts to formal treatment 3

Treatment Algorithm

Step 1: Assessment and Stabilization

• 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 3
• Provide thiamine supplementation: 100-300 mg IV three times daily for high-risk patients, followed by oral maintenance of 50-100 mg daily 3
• For patients with liver disease: Use short-acting benzodiazepines (oxazepam or lorazepam) 3

Step 2: Initiate Combined Treatment

• Start pharmacotherapy based on patient profile:
  • No liver disease: Naltrexone 50 mg daily
  • With liver disease: Baclofen starting at 5 mg TID
  • Already abstinent: Acamprosate 666 mg TID
• Begin CBT or another evidence-based therapy concurrently
  • CBT is equally effective as other evidence-based therapies when combined with pharmacotherapy 1
  • Schedule regular sessions (typically weekly)

Step 3: Maintenance and Monitoring

• Continue medications for 3-12 months with ongoing psychosocial support 3
• Monitor using biomarkers such as Phosphatidylethanol (PEth), Ethyl Glucuronide (EtG), and Ethyl Sulfate (EtS) 3
• Schedule follow-up liver function tests in 2-4 weeks for patients with alcoholic liver disease 3

Nutritional Support

• Ensure adequate protein intake (1.2-1.5 g/kg/day) and caloric intake (35-40 kcal/day) 3
• Supplement with B vitamins, particularly thiamine, folate, and multivitamins 3

Common Pitfalls to Avoid

1. Prescribing medications without psychosocial support - Combined treatment is superior to either alone 1
2. Discontinuing treatment prematurely - Optimal duration is at least 3-12 months 3
3. Failing to address comorbid psychiatric conditions - These can trigger relapse if untreated
4. Not monitoring for medication side effects - Regular follow-up is essential
5. Overreliance on disulfiram - Limited evidence supports its effectiveness outside supervised settings 4

Special Considerations

• For patients with liver disease, baclofen is the preferred medication 3
• Naltrexone and disulfiram are contraindicated in decompensated hepatic disease 3
• The COMBINE study showed that naltrexone with medical management could be effectively delivered in primary care settings, serving patients who might otherwise not receive treatment 5

The evidence clearly demonstrates that combining pharmacotherapy with evidence-based psychotherapy is more effective than either approach alone, with naltrexone and CBT showing particularly strong evidence of efficacy 1, 5.