What is the treatment for alcoholism?

Treatment of Alcohol Use Disorder

The treatment of alcoholism requires strict abstinence as the cornerstone, combined with naltrexone 50 mg daily (or acamprosate/baclofen if liver disease is present) plus cognitive behavioral therapy or motivational interviewing, with benzodiazepines for acute withdrawal management. 1, 2

Initial Assessment and Screening

Before initiating any pharmacotherapy, screen for alcoholic liver disease using AST, ALT, and clinical assessment, as this determines medication selection. 1, 2 Naltrexone causes hepatocellular injury and undergoes hepatic metabolism, making it contraindicated in patients with active liver disease. 1, 3

Use the AUDIT (Alcohol Use Disorders Identification Test) as the gold standard screening tool to quantify severity. 1, 4

Acute Withdrawal Management

Benzodiazepines are the gold standard for alcohol withdrawal syndrome, as they reduce withdrawal symptoms and prevent seizures and delirium tremens. 1, 2, 4

• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide superior protection against seizures and delirium tremens. 1, 2
• Short/intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction. 1, 2
• Limit benzodiazepine treatment to 7-10 days to avoid dependence. 2
• Always provide thiamine supplementation to prevent Wernicke's encephalopathy—use parenteral thiamine for high-risk patients (malnourished, chronic heavy use). 2, 4

Ensure patients are opioid-free for a minimum of 7-10 days before starting naltrexone to avoid precipitated withdrawal. 3 Patients transitioning from buprenorphine or methadone may require up to 2 weeks opioid-free. 3

Pharmacotherapy for Relapse Prevention

For Patients WITHOUT Liver Disease:

Naltrexone 50 mg daily is the preferred first-line pharmacotherapy. 2, 3, 5 The COMBINE study demonstrated that naltrexone plus medical management achieved 80.6% days abstinent and reduced risk of heavy drinking (hazard ratio 0.72). 5

• Dosing: 50 mg once daily orally, or 380 mg monthly intramuscular injection. 1, 2
• Mechanism: Opioid receptor antagonist that controls alcohol craving. 1
• Duration: Minimum 12 weeks, though longer treatment (3-6 months) is recommended. 2, 3
• Critical warning: Naltrexone is 98% metabolized hepatically and causes hepatotoxicity—monitor liver function and discontinue if AST/ALT elevate. 1, 3

For Patients WITH Alcoholic Liver Disease:

Acamprosate 666 mg three times daily (1998 mg total daily) is the preferred option for patients with liver disease. 1, 2, 6

• Mechanism: NMDA receptor antagonist that reduces withdrawal symptoms and alcohol craving. 1
• Critical advantage: No hepatic metabolism and no reported hepatotoxicity, making it safe even in advanced liver disease. 1, 6
• Most effective for maintaining abstinence in recently abstinent patients rather than inducing initial abstinence. 1, 4

Baclofen 30-60 mg daily is the second-line option and has the strongest evidence specifically in patients with alcoholic liver disease. 1, 2, 6

• Mechanism: GABA-B receptor agonist. 1
• The only medication tested in randomized controlled trials specifically in patients with cirrhosis and alcohol use disorder. 1

Medications to Avoid:

• Disulfiram should NOT be used in patients with liver disease due to poor tolerability and hepatotoxicity risk. 1, 4
• Gabapentin (600-1800 mg daily) and topiramate (75-400 mg daily) are third-line options but have not been studied in alcoholic liver disease. 1, 6

Psychosocial and Behavioral Interventions

Pharmacotherapy alone is insufficient—always combine with behavioral interventions, as this significantly improves outcomes. 2, 4, 5

First-Line Behavioral Approaches:

• Cognitive Behavioral Therapy (CBT): Focuses on identifying triggers, developing coping strategies, and restructuring thought patterns around alcohol use. 1, 2, 4
• Motivational Interviewing: Particularly effective for patients ambivalent about cessation, using the FRAMES model (Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy). 1, 4, 6
• Brief motivational interventions: Should be routinely implemented in all healthcare settings, as they reduce alcohol consumption and related morbidity/mortality. 4

Additional Support:

• Actively encourage engagement with mutual help groups such as Alcoholics Anonymous—these programs help maintain long-term abstinence. 4, 7, 8
• Family/couples counseling and network therapy strengthen support systems during maintenance. 1, 4
• Integrating alcohol use disorder treatment with medical care is the best option for management of advanced alcoholic liver disease, though this may not be practical in all settings. 1, 4

Treatment Algorithm

1. Screen for liver disease (AST, ALT, clinical assessment). 1, 2
2. If acute withdrawal present: Initiate benzodiazepines (long-acting preferred unless elderly/hepatic dysfunction) plus thiamine. 1, 2, 4
3. Ensure opioid-free period of 7-10 days before naltrexone (up to 2 weeks if transitioning from buprenorphine/methadone). 3
4. If NO liver disease: Start naltrexone 50 mg daily plus CBT or motivational interviewing. 2, 5
5. If liver disease present: Start acamprosate 666 mg three times daily (or baclofen 30-60 mg daily) plus CBT or motivational interviewing. 1, 2, 6
6. Continue treatment for minimum 3-6 months with ongoing behavioral support. 2, 9
7. Encourage participation in Alcoholics Anonymous or other mutual help groups for long-term maintenance. 4, 7

Critical Pitfalls to Avoid

• Never use naltrexone in patients with active liver disease or elevated transaminases—this causes hepatocellular injury and can precipitate liver failure. 1, 3
• Never rely solely on pharmacotherapy without behavioral interventions—the COMBINE study showed that combining naltrexone with medical management and behavioral therapy achieved the best outcomes. 2, 5
• Never start naltrexone without ensuring adequate opioid-free period—this precipitates severe withdrawal that can be life-threatening. 3
• Never discontinue treatment prematurely—alcohol use disorder is a chronic relapsing condition requiring extended treatment (minimum 3-6 months, often longer). 2, 9
• Screen for psychiatric comorbidities (anxiety, depression, PTSD) as these are highly prevalent in alcoholics and require concurrent treatment. 1, 6
• Address family dynamics and social support systems, as these significantly impact treatment success. 2, 4

Abstinence as the Foundation

Abstinence is the single most important therapeutic intervention and must be strictly recommended, as continued alcohol use is associated with disease progression, increased portal hypertensive bleeding, and worsened short-term and long-term survival. 1 Abstinence improves histological features of hepatic injury, reduces portal pressure, decreases progression to cirrhosis, and improves survival at all stages. 1 In 66% of abstaining patients, significant improvement occurs within 3 months. 1