What is the recommended frequency for administering supplements to patients with alcohol, cocaine, and cannabis use disorders?

Acamprosate Dosing for Alcohol Use Disorder

For patients with alcohol use disorder, acamprosate should be administered at 666 mg three times daily (total 1998 mg/day), regardless of concurrent cocaine or cannabis use. 1

Standard Dosing Regimen

• Acamprosate is dosed at 666 mg orally three times daily for all patients with alcohol use disorder 1
• This medication is most effective for maintaining abstinence in already-detoxified patients, not for acute withdrawal management 1
• Treatment duration typically lasts 3-6 months, with high-quality evidence showing superiority over placebo 1

Key Clinical Considerations

For Concurrent Cocaine Use

• No FDA-approved pharmacologic treatment exists for cocaine dependence in primary care settings 2, 1
• For patients with co-occurring alcohol and cocaine use, consider initiating disulfiram (250 mg/day) as first-line therapy since it may address both substances 1
• Adding naltrexone (100 mg/day) to disulfiram can be considered for dual substance use 1
• Behavioral therapies remain the evidence-based standard for cocaine dependence 2, 1

For Concurrent Cannabis Use

• No specific pharmacotherapy is recommended for cannabis use disorders 2
• Brief psychosocial interventions modeled on motivational principles should be offered for cannabis use disorders 2
• The acamprosate dosing (666 mg three times daily) remains unchanged regardless of cannabis use 1

Essential Concurrent Interventions

Thiamine Supplementation (Critical)

• All patients with alcohol use disorder require thiamine supplementation 2, 1
• Dosing: 100-300 mg/day orally for prevention; 100-500 mg/day for treatment of Wernicke's encephalopathy 1
• Thiamine must be administered BEFORE any IV glucose-containing fluids to prevent precipitating Wernicke's encephalopathy 1

Psychosocial Support

• Medications should never be prescribed without concurrent psychosocial support, as pharmacotherapy alone has limited efficacy 1
• Combined cognitive behavioral therapy (CBT) and pharmacotherapy shows superior outcomes compared to usual care alone 2
• Motivational techniques and family involvement should be considered where providers have capacity 2

Critical Pitfalls to Avoid

• Do NOT adjust acamprosate dosing based on concurrent substance use - the standard 666 mg three times daily applies universally 1
• Do NOT withhold or delay thiamine in at-risk patients, as Wernicke's encephalopathy is preventable but potentially fatal 1
• Do NOT give glucose before thiamine in at-risk patients 1
• Do NOT use acamprosate for acute withdrawal management - it is for relapse prevention in detoxified patients 1

When to Refer to Specialist

• Co-occurring alcohol or benzodiazepine abuse with cocaine use warrants specialist referral 2, 1
• Uncontrolled or unstable psychiatric disorder requires specialist management 2, 1
• Treatment failure in office-based setting indicates need for higher level of care 2, 1
• Patients at risk of severe withdrawal or lacking adequate support should preferably be managed in inpatient settings 2, 1