What are the recommended treatments for alcohol use disorder?

Treatment of Alcohol Use Disorder

The most effective treatment for alcohol use disorder (AUD) combines pharmacotherapy (particularly naltrexone or acamprosate) with evidence-based behavioral therapy such as cognitive behavioral therapy (CBT), rather than medication or psychosocial interventions alone. 1

Pharmacological Treatment Options

• FDA-approved medications for AUD include disulfiram, naltrexone (oral and injectable), and acamprosate 2
• Naltrexone (50mg daily) reduces the risk of relapse to heavy drinking and drinking frequency but has limited effect on complete abstinence 3
• Naltrexone is contraindicated in patients with alcoholic liver disease due to hepatotoxicity concerns 2, 1
• Acamprosate (666mg three times daily) is effective for maintaining abstinence and has no reported instances of hepatotoxicity, making it safer for patients with liver disease 2, 1
• Baclofen (30-60mg daily) has shown benefit in a single RCT specifically for patients with alcoholic liver disease 2
• Non-FDA approved medications with evidence of efficacy include gabapentin (600-1,800mg daily) and topiramate (75-400mg daily) 2, 4

Psychosocial Interventions

• Cognitive Behavioral Therapy (CBT) is a first-line behavioral approach for AUD treatment 2, 1
• Motivational interviewing is particularly effective for patients ambivalent about alcohol cessation 2
• Brief interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) are effective in reducing risky drinking behavior 2
• Other effective approaches include:
  • Motivational Enhancement Therapy (MET) 2
  • 12-step facilitation programs 2, 5
  • Social skills and coping skills training 2
  • Family/couples counseling 2

Treatment Algorithm

1. Assessment and Diagnosis

   • Evaluate severity of AUD and assess for comorbidities 1
   • Screen for liver disease to guide medication selection 2

2. Medication Selection

   • For patients without liver disease: Naltrexone 50mg daily (oral) or 380mg monthly (injectable) 3
   • For patients with liver disease: Acamprosate 666mg three times daily or baclofen 30-60mg daily 2, 1
   • Treatment duration typically 3-6 months 1, 3

3. Behavioral Intervention

   • Implement CBT or another evidence-based therapy concurrently with medication 2, 1
   • For patients ambivalent about treatment, begin with motivational interviewing 2
   • Integrate AUD treatment with medical care for best outcomes 2

4. Monitoring and Support

   • Regular follow-up to assess medication compliance and effectiveness 3
   • Consider community-based support groups to enhance outcomes 3, 2

Common Pitfalls to Avoid

• Relying solely on pharmacotherapy without behavioral interventions significantly reduces treatment effectiveness 2, 1
• Using naltrexone in patients with active liver disease can worsen hepatic function 2, 1
• Discontinuing treatment prematurely (before 3-6 months) reduces long-term success rates 1, 3
• Failing to address underlying psychosocial factors and support systems 2, 1
• Not implementing compliance-enhancing techniques for medication adherence 3
• Overlooking the value of integrating AUD treatment with regular medical care 2

Special Considerations

• For patients with alcoholic liver disease, baclofen has the strongest evidence among medications 2
• Combined pharmacotherapy and CBT shows greater benefit than usual care with pharmacotherapy alone 2, 6
• The NIAAA Alcohol Treatment Navigator is a valuable resource for patients and families seeking treatment options 2
• Disulfiram is not recommended for patients with alcoholic liver disease 2, 7