What is the recommended outpatient management for an adult patient with moderate to severe alcohol use disorder?

Outpatient Management of Moderate to Severe Alcohol Use Disorder

For adults with moderate to severe alcohol use disorder, initiate naltrexone 50 mg daily as first-line pharmacotherapy combined with psychosocial interventions, reserving inpatient management only for those at risk of severe withdrawal complications, lacking adequate social support, or with concurrent serious medical/psychiatric disorders. 1

Initial Assessment and Risk Stratification

Determine treatment setting based on withdrawal risk and social factors:

• Outpatient management is appropriate for patients with: 1

  • Mild-to-moderate withdrawal symptoms (CIWA-Ar score <15)
  • Stable medical and psychiatric status
  • Adequate social support and reliable supervision
  • No history of severe withdrawal complications (seizures, delirium tremens)

• Inpatient management is required for patients with: 2, 1

  • Risk of severe withdrawal complications
  • Concurrent serious physical or psychiatric disorders
  • Inadequate social support or unreliable supervision
  • CIWA-Ar scores ≥15 indicating severe withdrawal

Acute Withdrawal Management (Days 1-7)

Benzodiazepines are the gold standard first-line treatment for alcohol withdrawal syndrome: 1, 3

• Long-acting benzodiazepines (diazepam, chlordiazepoxide) are preferred for most patients as they provide superior protection against seizures and delirium tremens through gradual self-tapering 1

• Switch to intermediate-acting benzodiazepines (lorazepam, oxazepam) in patients with advanced age, hepatic dysfunction, or severe medical comorbidities to avoid drug accumulation 1, 3

• Use symptom-triggered dosing guided by CIWA-Ar scale rather than fixed-dose schedules to prevent drug accumulation while ensuring adequate symptom control 1

  • CIWA-Ar score >8: moderate withdrawal requiring pharmacological intervention
  • CIWA-Ar score ≥15: severe withdrawal requiring aggressive treatment

• Limit benzodiazepine prescriptions to 7-14 days maximum to avoid dependence, particularly critical in patients with alcohol use disorder who are at higher risk of benzodiazepine abuse 1, 3

Thiamine supplementation is mandatory: 1, 3

• All patients should receive oral thiamine supplementation
• High-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy require parenteral thiamine immediately—do not delay administration as this can lead to irreversible neurological damage 1

Long-Term Pharmacotherapy for Relapse Prevention (After Acute Withdrawal Resolves)

Naltrexone 50 mg daily is the first-line medication for most patients: 1, 4, 5

• Reduces return to any drinking by 5% and binge-drinking risk by 10% 1, 5
• Initiate after ensuring patient is opioid-free for minimum 7-10 days (including tramadol) 4
• Contraindicated in patients with alcoholic liver disease or cirrhosis due to hepatotoxicity risk 1, 3

Alternative pharmacotherapy options:

• Acamprosate 666 mg three times daily is preferred for patients with liver disease, as it has no reported hepatotoxicity and undergoes renal excretion only 1, 3

  • Dose: 1,998 mg/day for patients ≥60 kg; reduce by one-third for <60 kg 3
  • Duration: 3-6 months minimum 3

• Baclofen 30-60 mg/day (up to 80 mg/day) is particularly effective for patients with cirrhosis, reducing alcohol craving and maintaining abstinence 1, 3

• Disulfiram should be avoided in patients with severe alcoholic liver disease due to possible hepatotoxicity 3, 6

  • If used: never administer until patient has abstained from alcohol for at least 12 hours 6
  • Initial dose: 500 mg daily for 1-2 weeks, then maintenance 250 mg daily 6

Psychosocial Interventions (Concurrent with Pharmacotherapy)

Combine pharmacotherapy with structured psychosocial support for optimal outcomes: 1

• Offer cognitive-behavioral therapy (CBT), motivational enhancement therapy (MET), or motivational interviewing as part of comprehensive treatment 1

• Encourage engagement with mutual help groups like Alcoholics Anonymous as adjunctive support 1, 3

• Brief interventions (15-minute personalized counseling) are effective in primary care for reducing excessive consumption 3

Monitoring and Follow-Up

Daily monitoring is required during acute withdrawal phase: 7, 8

• Monitor patients daily for up to 5 days after last drink to verify symptom improvement and evaluate need for additional treatment 7
• Assess CIWA-Ar scores to guide treatment intensity adjustments 1

Long-term follow-up structure: 9

• Treatment should be viewed as chronic disease management requiring ongoing care, not a single intervention
• Provide continuum of care that blurs distinction between initial and continuing care to prolong treatment participation 9

Critical Pitfalls to Avoid

Medication-related errors: 1, 3

• Never prescribe naltrexone or disulfiram in patients with alcoholic liver disease or cirrhosis—use acamprosate or baclofen instead 1, 3
• Never extend benzodiazepine prescriptions beyond 7-14 days as this increases dependence risk 1, 3
• Never delay thiamine administration in high-risk patients or those with suspected Wernicke's encephalopathy 1

Assessment errors: 2

• Screen all patients with substance use disorders for intimate partner violence, as rates exceed 50% in some settings with drug use disorders 2
• Screen for comorbid mental health disorders, as primary disorders generally predate substance misuse and require standard psychological and pharmacologic therapies 2

Treatment approach errors: 3, 9

• Do not fail to provide medium-to-long-term support after initial detoxification, as abstinence maintenance requires ongoing care 3
• Do not overlook concurrent substance use disorders that may complicate recovery 3