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

Treatment of Alcohol Use Disorder

The recommended treatment approach combines benzodiazepines for acute withdrawal management, followed by pharmacotherapy (naltrexone, acamprosate, or baclofen) integrated with psychosocial interventions for long-term relapse prevention. 1

Acute Withdrawal Management

First-Line Pharmacotherapy

• Benzodiazepines are the gold standard for alcohol withdrawal syndrome, providing superior protection against seizures and delirium tremens. 2, 1
• Long-acting benzodiazepines (diazepam 5-10 mg every 6-8 hours or chlordiazepoxide 25-100 mg every 4-6 hours) should be used for most patients due to better seizure prophylaxis through gradual self-tapering. 2, 1
• Switch to intermediate-acting benzodiazepines (lorazepam 1-4 mg every 4-8 hours) in patients with advanced age, hepatic dysfunction, or severe medical comorbidities to prevent drug accumulation. 2, 1
• Use symptom-triggered dosing guided by CIWA-Ar scores rather than fixed schedules: scores >8 require pharmacological intervention, scores ≥15 indicate severe withdrawal requiring aggressive treatment. 1

Essential Adjunctive Therapy

• Administer thiamine to all patients undergoing withdrawal to prevent Wernicke's encephalopathy: oral thiamine 100-300 mg/day for standard cases. 2
• Give parenteral thiamine 100-500 mg/day to high-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy. 2
• Thiamine must be given before IV glucose administration, as glucose can precipitate acute thiamine deficiency. 2

Treatment Setting Determination

• Admit to inpatient setting if patients have: risk of severe withdrawal, concurrent serious physical/psychiatric disorders, lack of adequate social support, or history of withdrawal seizures/delirium tremens. 2, 1
• Outpatient management is appropriate for mild-to-moderate withdrawal with stable medical/psychiatric status and adequate support. 1

Long-Term Relapse Prevention Pharmacotherapy

First-Line Medication Selection

• Naltrexone 50 mg daily is the preferred first-line agent after acute withdrawal resolves, reducing return to any drinking by 5% and binge-drinking risk by 10%. 2, 1, 3
• Avoid naltrexone in patients with alcoholic liver disease or elevated liver enzymes (>3× normal) due to hepatotoxicity risk. 2, 1
• Ensure patients are opioid-free for minimum 7-10 days before starting naltrexone to prevent precipitated withdrawal. 3

Alternative Pharmacotherapy Options

• Acamprosate 666 mg three times daily (1,998 mg/day for patients ≥60 kg, reduced by one-third for <60 kg) is the preferred alternative, particularly in patients with liver disease, as it has no reported hepatotoxicity and undergoes renal excretion only. 2, 1
• Start acamprosate 3-7 days after last alcohol consumption once withdrawal symptoms resolve, continuing for 3-6 months. 2
• Baclofen 30-60 mg/day is specifically recommended for patients with cirrhosis, as it reduces alcohol craving and maintains abstinence without hepatotoxicity concerns. 2, 1
• Disulfiram should be avoided in patients with severe alcoholic liver disease due to hepatotoxicity risk and is generally not recommended due to limited efficacy outside supervised settings. 2, 4

Duration and Monitoring

• Continue pharmacotherapy for minimum 3-6 months, with potential extension to 12 months based on patient response. 2
• Dispense psychoactive medications in small quantities or supervise each dose to reduce misuse risk. 2

Psychosocial Interventions

Structured Psychological Approaches

• Integrate alcohol use disorder treatment with medical care, combining pharmacotherapy with psychosocial support for optimal outcomes. 2, 1
• Offer cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), or motivational interviewing as part of comprehensive treatment. 2, 1, 5
• Brief interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) are effective for hazardous drinkers and mild ALD, delivered in 5-30 minute sessions. 2

Family and Community Support

• Involve family members in treatment where appropriate and offer support to family members in their own right. 2
• Encourage engagement with mutual help groups like Alcoholics Anonymous as adjunctive support, monitoring impact on patient outcomes. 2, 1
• Family members should also be encouraged to engage with appropriate mutual help groups. 2

Critical Pitfalls to Avoid

Medication Safety

• Never prescribe naltrexone or disulfiram to patients with alcoholic liver disease or cirrhosis—use acamprosate or baclofen instead. 2, 1
• Do not extend benzodiazepine prescriptions beyond 7-14 days, as this increases dependence risk, particularly in patients with alcohol use disorder. 1
• Avoid antipsychotics as stand-alone medications for withdrawal; use only as adjunct to benzodiazepines in severe delirium unresponsive to adequate benzodiazepine doses. 2
• Do not use anticonvulsants following alcohol withdrawal seizure for prevention of further withdrawal seizures. 2

Treatment Approach Errors

• Do not delay thiamine administration in high-risk patients or those with suspected Wernicke's encephalopathy, as this can cause irreversible neurological damage. 1
• Avoid initiating relapse prevention medications during first 3 months when mortality is primarily related to hepatitis severity rather than relapse. 6
• Do not fail to provide medium-to-long-term support after initial detoxification, as abstinence maintenance requires ongoing care beyond acute treatment. 6, 7