What is the recommended treatment approach for an adult with alcohol use disorder, including first‑line pharmacologic options and psychosocial interventions?

Treatment for Alcohol Use Disorder

The optimal treatment for alcohol use disorder combines FDA-approved pharmacotherapy (naltrexone, acamprosate, or disulfiram) with evidence-based behavioral therapy such as cognitive behavioral therapy (CBT), rather than either intervention alone. 1, 2

First-Line Pharmacotherapy Selection

The choice of medication depends primarily on liver function status:

For Patients WITHOUT Liver Disease:

• Naltrexone 50 mg once daily is the preferred first-line agent, reducing return to any drinking by 5% and binge-drinking risk by 10% compared to placebo. 2, 3
• Naltrexone is contraindicated in patients with alcoholic liver disease due to hepatotoxicity risk. 2
• Long-acting injectable naltrexone (once monthly) shows 25% greater reduction in heavy drinking versus placebo and may improve adherence. 4, 5

For Patients WITH Liver Disease:

• Acamprosate 666 mg three times daily (1998 mg/day for patients ≥60 kg) is the safest option, as it has no reported hepatotoxicity and is safe in liver disease. 2, 6
• Acamprosate should be initiated 3-7 days after last alcohol consumption, once withdrawal symptoms have resolved. 2, 6
• For patients <60 kg, reduce dose to 1332 mg/day (444 mg three times daily). 2
• Baclofen 30-60 mg daily is an alternative with the strongest evidence specifically in alcoholic liver disease. 2

Alternative Option:

• Disulfiram can be offered when supervised dosing is feasible, though evidence quality is mixed (Grade B). 1, 2
• Most effective when each dose is directly observed to ensure compliance. 1

Dosing Adjustments:

• Moderate renal impairment (CrCl 30-50 mL/min): Reduce acamprosate to 333 mg three times daily. 6
• Severe renal impairment (CrCl ≤30 mL/min): Acamprosate is contraindicated. 6

Psychosocial Interventions (Required Component)

Pharmacotherapy must be combined with behavioral interventions - medication alone is insufficient and significantly reduces treatment effectiveness. 1, 2

First-Line Behavioral Therapy:

• Cognitive Behavioral Therapy (CBT) is the first-line behavioral approach, providing training in behavioral self-control skills targeting cognitive, affective, and environmental risks for substance use. 1, 2
• CBT combined with pharmacotherapy shows significantly greater benefit (effect size 0.18-0.28) than usual care plus pharmacotherapy alone. 1
• CBT performs equivalently to other evidence-based modalities (motivational enhancement therapy, contingency management) when combined with pharmacotherapy. 1

Alternative Evidence-Based Therapies:

• Motivational Enhancement Therapy (MET) is particularly effective for patients ambivalent about alcohol cessation. 2
• Brief interventions using the FRAMES model (Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy) in a single 5-30 minute session reduces drinking by an average of 57 g per week in men. 2
• Brief interventions are effective for hazardous drinkers and mild AUD, incorporating individualized feedback and advice on reducing or stopping consumption. 2

Mutual Help Groups:

• Actively encourage engagement with Alcoholics Anonymous (AA), which is highly effective and should be routinely recommended. 1, 2
• Family members should also be encouraged to engage with appropriate mutual help groups (e.g., Al-Anon). 1, 2

Management of Acute Alcohol Withdrawal

Before initiating relapse prevention pharmacotherapy, manage withdrawal if present:

• Benzodiazepines are the front-line medication for alcohol withdrawal, alleviating discomfort and preventing/treating seizures and delirium. 1, 2
• Lorazepam is specifically recommended for patients with hepatic dysfunction, advanced age, or serious medical comorbidities, as short-acting benzodiazepines are safer than long-acting agents in liver disease. 7
• Use symptom-triggered dosing based on CIWA-Ar scores. 7
• Provide oral thiamine 100-300 mg/day to all patients during withdrawal management, before any glucose-containing IV fluids. 2, 7
• Patients at high risk (malnourished, severe withdrawal) or with suspected Wernicke's encephalopathy require parenteral thiamine. 1
• Manage patients at risk of severe withdrawal, those with concurrent serious physical/psychiatric disorders, or those lacking adequate support in an inpatient setting. 1, 2

Treatment Duration and Monitoring

• Treatment period typically lasts 3-6 months for optimal effectiveness. 2
• Maintain treatment even if the patient relapses during the treatment period. 6
• Monitor for suicidality and depression, as suicidal events are more common in acamprosate-treated patients (1.4% vs 0.5% in short-term studies). 6

Critical Pitfalls to Avoid

• Never rely solely on pharmacotherapy without behavioral interventions - this significantly reduces treatment effectiveness and is not recommended. 1, 2
• Never use naltrexone in patients with active liver disease - it is contraindicated due to hepatotoxicity risk. 2
• Never discontinue treatment prematurely - optimal duration is 3-6 months, and early discontinuation reduces effectiveness. 2
• Never fail to address family dynamics and social support systems - this negatively impacts treatment outcomes. 2
• Never use antipsychotic medications as stand-alone treatment for alcohol withdrawal - they should only be used as adjunct to benzodiazepines in severe withdrawal delirium unresponsive to adequate benzodiazepine doses. 1
• Never use anticonvulsants following an alcohol withdrawal seizure for prevention of further withdrawal seizures. 1

Screening and Assessment

• Use the AUDIT (Alcohol Use Disorders Identification Test) as the gold standard screening tool for alcohol use disorders. 2
• Assess for liver disease to guide medication selection between naltrexone and acamprosate. 2
• Evaluate severity of dependence and assess for concurrent psychiatric or medical comorbidities. 1