What is the treatment for alcohol use disorder?

Treatment of Alcohol Use Disorder

The treatment of alcohol use disorder requires a comprehensive approach combining psychosocial interventions with FDA-approved pharmacotherapy (naltrexone, acamprosate, or disulfiram), with benzodiazepines as the gold standard for managing acute withdrawal symptoms. 1

Initial Assessment and Screening

• Screen all patients using validated questionnaires such as AUDIT, where scores ≥4 on AUDIT-C or >8 on full AUDIT indicate hazardous drinking requiring intervention. 1
• Use alcohol biomarkers including phosphatidylethanol (PEth), urine ethyl glucuronide (EtG), and ethyl sulfate (EtS) to aid diagnosis and monitor recovery, as these are not affected by liver disease. 1

Management of Acute Alcohol Withdrawal

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, 2
• Short-acting agents (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction. 2
• In cirrhotic patients, more than 70% do not require pharmacological treatment of withdrawal, so benzodiazepines should only be given if symptomatic. 3
• Treatment duration should be limited to 10-14 days to prevent iatrogenic dependence. 2
• 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

Thiamine Administration (Critical)

Thiamine must be administered to all patients to prevent Wernicke's encephalopathy, a potentially fatal complication. 1, 4, 2

• Dosing: 100-300 mg/day for 4-12 weeks for prevention. 1, 4
• Thiamine must be given before any dextrose-containing solutions, as intravenous glucose can precipitate acute thiamine deficiency. 4, 2
• The intravenous route is preferred for initial treatment due to potentially poor gastrointestinal absorption in alcoholic patients. 4

Psychosocial Interventions

• 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
• Refer patients with moderate to severe AUD or clinically evident alcohol-associated liver disease to addiction specialists for multidisciplinary management. 1

Pharmacotherapy for Relapse Prevention

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

Naltrexone (First-Line Option)

• Dosing: 50 mg/day orally or 380 mg monthly injectable formulation. 1
• Reduces the likelihood of return to any drinking by 5% and binge-drinking risk by 10%. 5
• Naltrexone undergoes rapid and nearly complete absorption with approximately 96% of the dose absorbed from the gastrointestinal tract, with peak plasma levels occurring within one hour. 6
• Contraindication: Hepatotoxicity concerns limit use in patients with significant liver disease. 1
• Naltrexone is highly extracted (>98% metabolized) with both hepatic and extrahepatic sites of drug metabolism. 6

Acamprosate (Preferred in Liver Disease)

• Dosing: 666 mg three times daily. 1
• Useful for maintaining abstinence after resolution of withdrawal symptoms. 1, 4
• Acamprosate has a safer hepatic profile and is preferred in patients with alcohol-associated liver disease. 1

Disulfiram (Limited Use)

• NOT recommended for patients with alcohol-associated liver disease due to hepatotoxicity and association with fetal abnormalities. 1
• Little evidence supports its effectiveness outside of supervised settings. 7

Off-Label Medications with Strong Evidence

• Topiramate demonstrates consistent small to moderate effects in reducing the frequency of drinking and/or heavy drinking. 8, 7
• Gabapentin reduces heavy-drinking days with strong evidence supporting its use. 7
• Baclofen may be effective for maintaining abstinence in patients with cirrhosis and has a safer hepatic profile. 1, 4

Special Populations

Patients with Alcohol-Associated Liver Disease

• Abstinence is the most important treatment factor for improving survival in patients with alcohol-associated liver disease. 1, 4
• Persistent consumption of more than two standard drinks/day is independently associated with mortality in cirrhotic patients. 3
• Acamprosate and baclofen are preferred due to safer hepatic profiles. 1
• Avoid disulfiram due to hepatotoxicity. 1

Pregnant Women

• Psychosocial treatment is the first-line intervention for pregnant women with AUD. 1
• Disulfiram is contraindicated in pregnancy. 1

Common Pitfalls to Avoid

• Do not use antipsychotics as monotherapy for alcohol withdrawal—they must be combined with benzodiazepines. 1
• Do not administer glucose-containing fluids before thiamine, as this can precipitate Wernicke's encephalopathy. 4, 2
• Do not overlook pharmacotherapy—medications are prescribed to less than 9% of patients who would benefit, despite evidence of clinically meaningful effects. 5
• Do not assume all cirrhotic patients need benzodiazepines for withdrawal—over 70% do not require pharmacological treatment. 3