What is the recommended treatment approach for a patient with alcohol use disorder?

Treatment of Alcohol Use Disorder

Recommended Treatment Approach

The optimal treatment for alcohol use disorder requires combined pharmacotherapy (naltrexone or acamprosate) plus evidence-based behavioral therapy such as cognitive behavioral therapy (CBT), rather than either intervention alone. 1

Pharmacotherapy Selection Algorithm

For Patients WITHOUT Liver Disease:

• Prescribe naltrexone 50 mg once daily as first-line pharmacotherapy 1, 2, 3
• Naltrexone blocks opioid receptors, reducing the pleasurable effects of alcohol and controlling cravings 2
• Naltrexone reduces return-to-any-drinking by 5% and binge-drinking risk by 10% 4
• Alternative: Acamprosate 1,998 mg daily (666 mg three times daily) if naltrexone is not tolerated 1, 2

For Patients WITH Liver Disease:

• Prescribe acamprosate 1,998 mg daily (666 mg three times daily) as first-line therapy 1, 2
• Acamprosate has no reported hepatotoxicity and is safe in liver disease 1, 2
• Acamprosate modulates glutamate receptors to reduce withdrawal symptoms and cravings 2
• Alternative: Baclofen 30-60 mg daily, which has the strongest evidence among medications for alcoholic liver disease 1
• CRITICAL: Never prescribe naltrexone to patients with severe liver disease due to hepatotoxicity risk 1, 2

Medication Initiation Requirements:

• Patients must be opioid-free for minimum 7-10 days before starting naltrexone 3
• Perform naloxone challenge test if occult opioid dependence is suspected 3
• For acamprosate, initiate 3-7 days after last alcohol consumption and after withdrawal symptoms resolve 1

Treatment Duration:

• Continue pharmacotherapy for 3-6 months minimum 1, 2
• Premature discontinuation significantly reduces treatment effectiveness 1

Behavioral Interventions (MANDATORY Component)

Cognitive behavioral therapy (CBT) must be combined with pharmacotherapy - medication alone is insufficient and significantly reduces treatment effectiveness 5, 1

Evidence-Based Behavioral Options:

• CBT as first-line behavioral approach - provides training in behavioral self-control skills to achieve and maintain abstinence 5, 1
• Combined CBT plus pharmacotherapy shows superior efficacy compared to usual care plus pharmacotherapy alone 5
• Alternative evidence-based therapies include motivational enhancement therapy or contingency management, which perform equivalently to CBT when combined with pharmacotherapy 5

Brief Interventions:

• Implement FRAMES model in single 5-30 minute sessions for hazardous drinkers and mild AUD 1
• FRAMES includes: individualized Feedback, advice on Reducing consumption, Assessment of willingness, Assistance to quit/reduce, and Arrange follow-up 1
• Brief motivational interventions reduce drinking by average of 57 g per week in men 1

Mutual Support Groups:

• Actively encourage engagement with Alcoholics Anonymous (AA) - highly effective and should be routinely recommended 1
• Family members should also engage with appropriate mutual help groups 1

Management of Acute Alcohol Withdrawal

Inpatient vs Outpatient Decision:

• Manage in inpatient setting if: severe withdrawal risk, concurrent serious physical/psychiatric disorders, or inadequate social support 1

Withdrawal Pharmacotherapy:

• Benzodiazepines are the treatment of choice for acute withdrawal syndrome 1, 2
• Administer thiamine 100-300 mg daily for 4-12 weeks to ALL patients during withdrawal 1, 2
• CRITICAL: Give thiamine BEFORE any glucose-containing IV fluids to prevent Wernicke's encephalopathy 1, 2
• Patients at high risk or with suspected Wernicke's encephalopathy require parenteral thiamine 1

Screening and Assessment

• Use AUDIT (Alcohol Use Disorders Identification Test) as gold standard screening tool 1
• Screen for liver disease before medication selection to guide appropriate pharmacotherapy choice 1

Common Pitfalls to Avoid

• Never prescribe pharmacotherapy without behavioral interventions - this significantly reduces treatment effectiveness 1, 2
• Never use naltrexone in patients with active liver disease - can worsen hepatic function 1, 2
• Never use disulfiram in patients with advanced liver disease - potential hepatotoxicity 2
• Never discontinue treatment prematurely - optimal duration is 3-6 months minimum 1, 2
• Never fail to address family dynamics and social support systems - negatively impacts treatment outcomes 1
• Never initiate naltrexone without ensuring 7-10 day opioid-free period - risk of precipitated withdrawal 3

Alternative Pharmacotherapy Options

Second-Line Medications (when first-line options fail or are contraindicated):

• Topiramate (off-label) - increases abstinence and reduces heavy drinking days 2, 6
• Gabapentin (off-label) - reduces heavy-drinking days 6
• Disulfiram - creates aversive reaction to alcohol but only effective in supervised settings where compliance can be monitored 1, 2

Combination Therapy:

• Acamprosate plus naltrexone shows superior efficacy (OR 3.68) compared to either medication alone 2

Treatment Goals

• Total alcohol abstinence is the most effective recommendation, especially for patients with alcoholic liver disease 1
• Complete abstinence should be recommended as lifetime goal after alcoholic hepatitis episode 2