What is the treatment for alcohol use disorder?

Treatment of Alcohol Use Disorder

Psychosocial interventions combined with pharmacotherapy form the foundation of alcohol use disorder treatment, with abstinence being the single most important factor for improving survival and quality of life. 1

Initial Screening and Assessment

All patients should be screened for alcohol use disorder using validated questionnaires such as AUDIT (Alcohol Use Disorders Identification Test), with scores ≥4 on AUDIT-C or >8 on full AUDIT indicating hazardous drinking requiring intervention. 1 Alcohol biomarkers including phosphatidylethanol (PEth), urine ethyl glucuronide (EtG), and ethyl sulfate (EtS) can aid diagnosis and monitor recovery, as these are not affected by liver disease. 1

Management of Alcohol Withdrawal Syndrome

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal, effectively reducing withdrawal symptoms and preventing seizures and delirium tremens. 1, 2

• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide better protection against seizures and delirium. 1
• Short and intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction. 1
• Antipsychotic medications should NOT be used as stand-alone treatment but only as adjunct to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses. 1
• Anticonvulsants should NOT be used following alcohol withdrawal seizures for prevention of further seizures. 1

Thiamine Administration - Critical Priority

All patients undergoing withdrawal must receive thiamine to prevent Wernicke's encephalopathy, and thiamine must be administered BEFORE any glucose-containing fluids. 2

• Dosing: 100-300 mg/day for 4-12 weeks for prevention; 100-500 mg/day for 12-24 weeks for established Wernicke's encephalopathy. 2
• Intravenous route is preferred initially due to poor gastrointestinal absorption in alcoholic patients. 2
• Patients at high risk (malnourished, severe withdrawal) or with suspected Wernicke's encephalopathy require parenteral thiamine. 1

Psychosocial Interventions

Multidisciplinary management with addiction specialists and referral to treatment is mandatory, particularly for patients with moderate to severe AUD or clinically evident alcohol-associated liver disease. 1

• Brief interventions (5-30 minutes) incorporating individualized feedback and advice should be offered to all patients with hazardous drinking. 1
• Motivational interviewing and motivational enhancement therapy help patients ambivalent about cessation change their behaviors. 1
• Cognitive-behavioral therapy (CBT) targets mechanisms of behavior change and prevents relapse. 1
• Integrating AUD treatment with medical care remains the best option for advanced alcohol-associated liver disease. 1
• Patients should be encouraged to engage with mutual help groups such as Alcoholics Anonymous, with monitoring of impact. 1

Pharmacotherapy for Relapse Prevention

Three FDA-approved medications—naltrexone, acamprosate, and disulfiram—should be offered as part of treatment to reduce relapse, with the decision based on patient preferences, motivation, availability, and liver function status. 1

FDA-Approved Medications

Naltrexone (50 mg/day orally or 380 mg monthly injectable):

• Opioid receptor antagonist that reduces heavy drinking days and supports abstinence. 1, 3, 4
• NOT studied specifically in patients with alcohol-associated liver disease; hepatotoxicity concerns exist. 1
• Contraindicated in patients currently using opioids or with acute hepatitis. 3
• Highly extracted drug (>98% metabolized) with both hepatic and extrahepatic metabolism. 3

Acamprosate (666 mg three times daily):

• NMDA receptor antagonist useful for maintaining abstinence after resolution of withdrawal symptoms. 1, 2, 4
• Renally excreted with no hepatic metabolism, making it safer in liver disease. 1
• No reported instances of hepatotoxicity. 1
• Strong evidence for preventing return-to-use in currently abstinent patients. 4

Disulfiram:

• NOT recommended for patients with alcohol-associated liver disease due to hepatotoxicity and association with fetal abnormalities. 1
• Little evidence supports effectiveness outside supervised settings. 4

Off-Label Medications with Evidence

Gabapentin (600-1,800 mg/day):

• Modulates GABA activity; strong evidence for reducing heavy-drinking days. 1, 4
• Renally excreted; monitor closely for renal dysfunction and worsening mental status/sedation. 1

Baclofen (30-60 mg/day):

• GABA-B receptor agonist; single RCT showed benefit in patients with alcohol-associated liver disease. 1
• May be effective for maintaining abstinence in patients with cirrhosis. 2
• Use with caution as it may accumulate and potentially cause neonatal withdrawal syndrome in pregnancy. 1

Topiramate (75-400 mg/day):

• GABA action augmentation and glutamate antagonism; moderate evidence for decreasing heavy-drinking days. 1, 4, 5

Medications to Avoid

• Naltrexone and nalmefene have limited data in pregnancy; disulfiram is contraindicated. 1
• Antidepressants do NOT decrease alcohol use in patients without mood disorders. 4

Special Populations

Patients with alcohol-associated liver disease:

• Abstinence is the most important treatment factor for improving survival. 1, 2
• Acamprosate and baclofen are preferred due to safer hepatic profiles. 1, 2
• Avoid disulfiram and use naltrexone with extreme caution. 1

Pregnant women:

• Psychosocial treatment is first-line intervention. 1
• Disulfiram is contraindicated; baclofen should be used with caution. 1
• Benzodiazepines for withdrawal syndrome management. 1

Common Pitfalls

• Failing to administer thiamine before glucose-containing fluids precipitates acute thiamine deficiency. 2
• Using antipsychotics as monotherapy for withdrawal increases complications without addressing core pathophysiology. 1
• Prescribing disulfiram to patients with liver disease causes additional hepatotoxicity. 1
• Underutilizing pharmacotherapy—only 1.6% of Americans with AUD receive medications despite strong evidence. 4
• Treating alcohol use without addressing co-occurring psychiatric conditions reduces treatment effectiveness. 6