What are the recommended treatments for alcohol use disorder?

Recommended Treatments for Alcohol Use Disorder

For alcohol use disorder (AUD), the recommended treatment approach combines pharmacotherapy with psychosocial interventions, with naltrexone, acamprosate, and disulfiram being the first-line FDA-approved medications, and cognitive behavioral therapy (CBT) as the first-line psychosocial intervention. 1, 2, 3

Pharmacotherapy Options

FDA-Approved Medications

1. Naltrexone

   • Dosage: 50 mg once daily 2
   • Primary benefit: Prevents relapse to heavy drinking 1, 4
   • Contraindication: Decompensated liver disease, current opioid use 1, 2
   • Special consideration: Requires 7-10 day opioid-free period before initiation 2

2. Acamprosate

   • Dosage: 666 mg three times daily 1
   • Primary benefit: Helps maintain abstinence 1, 4
   • Best for: Patients who are already abstinent 1

3. Disulfiram

   • Primary benefit: Creates aversive reaction to alcohol
   • Limitation: Only recommended in close supervision settings where patients are motivated for abstinence 4
   • Contraindication: Decompensated liver disease 1

Off-Label Medications with Evidence

1. Baclofen

   • Dosage: Starting at 5 mg TID, titrating up to 10 mg TID 1
   • Best for: Patients with liver disease 1
   • Note: Mixed results in clinical trials 5

2. Topiramate

   • Evidence: Effective in improving drinking-related outcomes 5
   • Note: Complex side effect profile; should not be first-line 4

3. Gabapentin

   • Evidence: Effective in improving drinking-related outcomes 5

Psychosocial Interventions

1. Cognitive Behavioral Therapy (CBT)

   • Evidence level: A (highest) 4
   • Primary benefit: First-line psychosocial intervention; most effective when combined with pharmacotherapy 1, 4
   • Best for: Addressing depressive thought patterns and drinking behaviors 1

2. Motivational Interviewing

   • Evidence level: A 4
   • Primary benefit: Effective in short term and for less severe dependence 1, 4
   • Best for: Patients ambivalent about alcohol cessation 1

3. Peer Support Programs

   • Examples: Alcoholics Anonymous, SMART Recovery
   • Evidence level: A 4
   • Primary benefit: Effective at maintaining abstinence or reducing drinking 4

4. Residential Rehabilitation

   • Evidence level: D 4
   • Best for: Moderate-to-severe dependence requiring structured setting 4

Treatment Algorithm

Step 1: Withdrawal Management (if needed)

• Use tapering diazepam regimens 4
• Most cases can be managed in ambulatory setting with appropriate support 4
• For severe withdrawal: inpatient management with aggressive benzodiazepine treatment 1
• Always provide thiamine supplementation, particularly for malnourished patients 6, 1

Step 2: Initiate Pharmacotherapy + Psychosocial Treatment

• For patients without liver disease: Naltrexone 50 mg daily + CBT 1, 2
• For patients with liver disease: Baclofen starting at 5 mg TID + CBT 1
• For patients already abstinent: Acamprosate 666 mg TID + CBT 1

Step 3: Monitoring and Maintenance

• Continue medications for 3-12 months 1
• Regular monitoring using biomarkers (PEth, EtG, EtS) 1
• Ongoing psychosocial support 1, 4

Special Populations Considerations

1. Pregnant women

   • Advise complete abstinence; no safe level of alcohol consumption 4
   • Hospital admission for alcohol-dependent pregnant women 4

2. Patients with liver disease

   • Prefer baclofen as it is non-hepatotoxic 1
   • Avoid naltrexone, disulfiram in decompensated liver disease 1

3. Older adults

   • Screen all patients over 50 years 4
   • Consider shorter-acting benzodiazepines for withdrawal 4

Common Pitfalls to Avoid

• Prescribing medications without psychosocial support 1
• Failing to monitor for medication side effects 1
• Not addressing comorbid psychiatric conditions 1, 4
• Discontinuing treatment prematurely (optimal duration is at least 3-12 months) 1
• Inadequate nutritional support, especially thiamine supplementation 6, 1
• Overlooking the need for family involvement in treatment 6

Despite the availability of effective treatments, medications are prescribed to less than 9% of patients who would benefit from them 3. Combining pharmacotherapy with appropriate psychosocial interventions provides the best outcomes for patients with alcohol use disorder.