What are the appropriate management and treatment strategies for a patient with a history of alcohol use disorder?

Management of Alcohol Use Disorder

For patients with alcohol use disorder, implement a structured approach beginning with screening using AUDIT, followed by benzodiazepines for withdrawal management, thiamine supplementation, brief motivational intervention, and pharmacotherapy with naltrexone 50 mg daily (or baclofen if liver disease present), combined with referral to outpatient addiction specialists and mutual help groups. 1

Immediate Assessment and Withdrawal Management

Screen for Withdrawal Syndrome

• Assess for withdrawal symptoms within 6-24 hours of last drink, including elevated blood pressure and pulse, tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting 1
• Recognize that symptoms can progress to severe forms including delirium tremens, seizures, coma, cardiac arrest, and death 1
• Patients at risk of severe withdrawal, concurrent serious physical or psychiatric disorders, or who lack adequate support should be managed in an inpatient setting 2

Administer Thiamine Before Glucose

• Provide thiamine 100-300 mg/day before any glucose-containing IV fluids to prevent Wernicke encephalopathy 1
• This is mandatory and must precede glucose administration 1
• Patients at high risk (malnourished, severe withdrawal) or with suspected Wernicke's encephalopathy require parenteral thiamine 2

Treat Withdrawal with Benzodiazepines

• Benzodiazepines are the gold standard treatment for alcohol withdrawal syndrome, reducing both withdrawal symptoms and risk of seizures and delirium tremens 1
• Short or intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer in patients with potential hepatic dysfunction 1
• Dispense psychoactive medications in small quantities or supervise each dose to reduce misuse risk 2

Critical Pitfall: Antipsychotic medications should not be used as stand-alone medications for alcohol withdrawal; use only as adjunct to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses 2

Critical Pitfall: Anticonvulsants should not be used following an alcohol withdrawal seizure for prevention of further alcohol withdrawal seizures 2

Screening for Severity and Comorbidities

Use AUDIT Screening Tool

• Administer the AUDIT (Alcohol Use Disorders Identification Test) as the gold standard screening tool 1
• Scores ≥8 for men or ≥4 for women indicate positive screening requiring intervention 1

Assess Psychiatric Comorbidities

• Screen for anxiety disorders, affective disorders, depression, and PTSD, as up to 50% of patients with alcohol use disorder have concurrent psychiatric conditions 1
• Assess for nicotine dependence, as up to 80% of patients with alcohol use disorder are heavy smokers 1

Brief Motivational Intervention

Deliver FRAMES Model Intervention

• Implement brief motivational intervention using the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) 1
• This approach has proven efficacy in reducing alcohol consumption and related morbidity and mortality 1
• Brief multicontact behavioral counseling interventions outperform single-session interventions 3

Pharmacotherapy for Relapse Prevention

First-Line: Naltrexone

• Initiate naltrexone 50 mg daily before discharge 1
• Naltrexone reduces relapse to heavy drinking and drinking frequency, with a 5% reduction in likelihood of return to any drinking and 10% reduction in binge-drinking risk 4
• Ensure patient is opioid-free (including tramadol) for minimum 7-10 days before starting naltrexone 5

Critical Contraindication: Avoid naltrexone in patients with suspected or confirmed alcoholic liver disease due to hepatotoxicity risk 1

Alternative for Advanced Liver Disease: Baclofen

• Use baclofen instead of naltrexone in patients with advanced liver disease 1
• Titrate up to 80 mg/day over 12 weeks 1
• Baclofen is safe and effective for preventing alcohol relapse in advanced alcoholic liver disease 1

Other FDA-Approved Options

• Acamprosate helps maintain abstinence, particularly in recently abstinent patients 3
• Disulfiram should only be used in supervised settings with highly motivated patients 3
• Disulfiram should never be administered until patient has abstained from alcohol for at least 12 hours 6
• Initial disulfiram dose is 500 mg daily for 1-2 weeks, then maintenance dose of 250 mg daily 6

Critical Pitfall: Despite strong evidence for medication efficacy, only 1.6% of Americans with alcohol use disorder receive medications 3, 4

Psychosocial Support and Follow-Up

Routine Psychosocial Support

• Psychosocial support should be routinely offered to all alcohol dependent patients 2
• Where providers have capacity, implement more structured psychological interventions such as motivational techniques 2
• Involve family members in treatment when appropriate, and offer support to family members in their own right 2

Connect to Mutual Help Groups

• Actively encourage engagement with Alcoholics Anonymous or SMART Recovery, which demonstrate 50% abstinence rates at one year 1
• Familiarize yourself with locally available mutual help groups and monitor the impact of attending the group 2
• Family members should also be encouraged to engage with appropriate mutual help groups 2

Arrange Outpatient Follow-Up

• Connect patients to outpatient addiction specialists (psychiatrists, psychologists, social workers) for continued treatment 1
• Provide information about local treatment resources using SAMHSA Treatment Locator 1
• Arrange follow-up within 1-3 months to assess progress 1

Special Considerations

Pain Management

• Prioritize nonpharmacologic interventions for pain management 1
• Use opioid analgesics as safe alternatives to NSAIDs in this population if pain medication is necessary 1

Treatment Duration

• Daily, uninterrupted administration of medications must continue until the patient is fully recovered socially and a basis for permanent self-control is established 6
• Maintenance therapy may be required for months or even years depending on the individual patient 6
• Recognize that alcohol use disorders are chronic, recurring conditions involving multiple cycles of treatment, abstinence, and relapse 7

Critical Reminder: Never rely on pharmacotherapy alone; psychosocial interventions are equally essential 1