What are the recommended treatments for alcohol addiction?

Treatment of Alcohol Addiction

Recommended Treatment Approach

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

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Pharmacotherapy Selection Algorithm

Step 1: Screen for Liver Disease

The presence or absence of liver disease determines medication selection, as naltrexone is contraindicated in patients with alcoholic liver disease due to hepatotoxicity risk. 1, 2

Step 2: Choose Medication Based on Liver Function

For patients WITHOUT liver disease:

• First-line: Naltrexone 50 mg once daily 1, 3

  • Acts as an opioid antagonist that blocks the pleasurable effects or "high" associated with drinking 2
  • Reduces relapse rates by approximately 50% compared to placebo 4
  • Most effective when craving levels are high 5
  • Common side effect is nausea 4

• Alternative: Acamprosate 1,998 mg daily (for patients ≥60 kg) or 1,332 mg daily (for patients <60 kg) 1

  • Modulates glutamate receptors to reduce withdrawal symptoms and craving 2
  • Has no reported hepatotoxicity 1
  • Should be initiated 3-7 days after last alcohol consumption and after withdrawal symptoms resolve 1

For patients WITH liver disease:

• First-line: Acamprosate 666 mg three times daily (1,998 mg total daily) 1, 2

  • Safe in liver disease with no hepatotoxicity risk 1
  • Effective for maintaining abstinence up to 12 months 2

• Alternative: Baclofen 30-60 mg daily 1

  • GABAB receptor agonist particularly useful in advanced liver disease 2
  • Has shown efficacy in promoting abstinence in alcoholic cirrhotic patients 2

• Avoid: Naltrexone and disulfiram are contraindicated due to potential hepatotoxicity 1, 2

Step 3: Treatment Duration

Continue pharmacotherapy for 3-6 months minimum. 1, 2 Discontinuing treatment prematurely reduces effectiveness. 1

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Psychosocial Interventions (Essential Component)

Cognitive Behavioral Therapy (CBT) is the first-line behavioral approach and must be combined with pharmacotherapy. 1

• Provides training in behavioral self-control skills to achieve and maintain abstinence 1
• When combined with naltrexone, CBT shows superior outcomes compared to naltrexone alone 6
• The CBT-naltrexone combination results in fewer relapses, longer time between relapses, and better overall outcomes 6

Brief Motivational Interventions:

• Should be routinely used in medical management 7
• Effective in reducing drinking by an average of 57 g per week in men 7
• Use the "Five As" model: Ask about use, Advice to quit or reduce, Assess willingness, Assist to quit or reduce, Arrange follow-up 7

Alcoholics Anonymous (AA):

• Highly effective and should be routinely recommended 1
• Family members should also engage with appropriate mutual help groups 1

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Management of Acute Alcohol Withdrawal

Before initiating pharmacotherapy for addiction, manage withdrawal syndrome:

• Benzodiazepines are the treatment of choice for acute withdrawal syndrome 7
• Thiamine 100-300 mg daily for 4-12 weeks must be provided to all patients to prevent Wernicke's encephalopathy 2
• Critical: Administer thiamine BEFORE any glucose-containing IV fluids 2
• Patients at risk of severe withdrawal, those with concurrent serious physical/psychiatric disorders, or those lacking adequate support require inpatient management 1

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Ensuring Opioid-Free Status Before Naltrexone

Patients must be opioid-free (including tramadol) for a minimum of 7-10 days before starting naltrexone to avoid precipitated withdrawal. 3

• Patients transitioning from buprenorphine or methadone may be vulnerable to precipitated withdrawal for up to 2 weeks 3
• Consider naloxone challenge test if occult opioid dependence is suspected 3
• Do NOT initiate naltrexone if withdrawal signs are observed 3

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Common Pitfalls to Avoid

• Never rely solely on pharmacotherapy without behavioral interventions - this significantly reduces treatment effectiveness 1
• Never prescribe naltrexone to patients with active liver disease - use acamprosate or baclofen instead 1, 2
• Never discontinue treatment prematurely - optimal duration is 3-6 months minimum 1
• Never fail to screen for liver disease before medication selection - this determines which medications are safe 1
• Never neglect family dynamics and social support systems - these impact treatment outcomes 1
• Never forget to administer thiamine before glucose-containing fluids - this prevents Wernicke's encephalopathy 2

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Screening and Monitoring

• Use AUDIT (Alcohol Use Disorders Identification Test) as the gold standard screening tool 7
• Drinking habits must be routinely screened by physicians 7
• Monitor for medication compliance using compliance-enhancing techniques 7, 3
• Total alcohol abstinence is the most effective recommendation for patients with alcoholic liver disease 7