Treatment of Alcohol Addiction
Recommended Treatment Approach
Combine pharmacotherapy (naltrexone or acamprosate) with cognitive behavioral therapy (CBT) as first-line treatment for alcohol addiction, rather than using either medication or psychosocial interventions alone. 1
Initial Assessment: Screen for Liver Disease
- Screen all patients for liver disease before selecting pharmacotherapy, as this determines medication safety and selection 1, 2
- Naltrexone is contraindicated in patients with alcoholic liver disease due to hepatotoxicity risk 1, 3, 2
Pharmacotherapy Selection Algorithm
For Patients WITHOUT Liver Disease:
- Prescribe naltrexone 50 mg orally once daily as the preferred first-line medication 1, 2, 4
- Alternative: naltrexone 380 mg intramuscular injection monthly 2
- Naltrexone reduces relapse to heavy drinking and drinking frequency but does not substantially enhance complete abstinence 5
- Ensure patients are opioid-free (including tramadol) for minimum 7-10 days before starting naltrexone to avoid precipitated withdrawal 4
For Patients WITH Liver Disease:
- Prescribe acamprosate 666 mg three times daily (1998 mg/day for patients ≥60 kg, or 1332 mg/day for <60 kg) 6, 1, 2
- Acamprosate has no reported hepatotoxicity and is safe in liver disease 1
- Initiate acamprosate 3-7 days after last alcohol consumption and after withdrawal symptoms resolve 1
- Alternative: baclofen 30-60 mg daily has the strongest evidence among medications for alcoholic liver disease 1, 2
Disulfiram:
- Disulfiram can be offered as an alternative option, though evidence is mixed (grade B) 6, 5
- Most effective when each dose is supervised to ensure compliance 6
Duration of Pharmacotherapy
- Continue medication for 3-6 months minimum 1, 3, 2
- Discontinuing treatment prematurely reduces effectiveness 1, 2
Psychosocial Interventions (Essential Component)
Cognitive Behavioral Therapy:
- Implement CBT as first-line behavioral approach to provide training in behavioral self-control skills 1, 2
- CBT combined with pharmacotherapy shows greater benefit than pharmacotherapy alone 1, 2
Motivational Interviewing:
Brief Interventions (For Mild Cases):
- Deliver brief interventions using the FRAMES model in a single 5-30 minute session incorporating individualized feedback and advice on reducing or stopping consumption 6, 3
- Brief interventions are effective at reducing morbidity and mortality in hazardous drinkers and mild alcohol use disorder 3
Mutual Help Groups:
- Actively encourage engagement with Alcoholics Anonymous (AA) as it is highly effective and should be routinely recommended 6, 3
- Family members should also be encouraged to engage with appropriate mutual help groups 6
Management of Acute Alcohol Withdrawal
- Administer benzodiazepines as front-line medication for managing withdrawal, alleviating discomfort, and preventing seizures and delirium tremens 3, 2
- Long-acting benzodiazepines provide superior protection against seizures and delirium 2
- Short/intermediate-acting benzodiazepines are safer in elderly patients and those with hepatic dysfunction 2
- Limit benzodiazepine treatment to 7-10 days to avoid dependence 2
- Provide oral thiamine to all patients during withdrawal management 6
- Patients at high risk (malnourished, severe withdrawal) or with suspected Wernicke's encephalopathy require parenteral thiamine 6
- Manage patients at risk of severe withdrawal, those with concurrent serious physical/psychiatric disorders, or those lacking adequate support in an inpatient setting 6, 3
Evidence Quality for Pharmacotherapy
- Acamprosate has the highest quality evidence (grade A) for maintaining abstinence in primary care settings 6, 3
- Naltrexone has strong evidence (grade A) for reducing relapse to heavy drinking 5
- Treatment as usual, flupenthixol, and galantamine showed reduced odds of relapse compared to placebo, though confidence in evidence was low to very low for most interventions 6
Critical Pitfalls to Avoid
- Never rely solely on pharmacotherapy without behavioral interventions - this significantly reduces treatment effectiveness 1, 2
- Never use naltrexone in patients with active liver disease - it can worsen hepatic function due to hepatotoxicity 1, 3, 2
- Never discontinue treatment prematurely - optimal duration is 3-6 months 1, 2
- Never ignore family dynamics and social support systems - failing to address these negatively impacts treatment outcomes 1, 2
- Never rely on AA attendance alone for patients with severe dependence or significant psychiatric comorbidities - these patients require more intensive professional treatment 3