For an adult patient diagnosed with alcohol dependence, what are the recommended initial steps including comprehensive assessment, baseline laboratory tests, first‑line pharmacologic agents (naltrexone, acamprosate, disulfiram) and psychosocial therapies?

Management of Alcohol Dependence

Best practice for alcohol dependence requires combining FDA-approved pharmacotherapy (naltrexone, acamprosate, or disulfiram) with evidence-based psychosocial interventions—specifically cognitive behavioral therapy or brief motivational interventions—rather than pharmacotherapy alone or with nonspecific counseling. 1

Initial Assessment and Baseline Testing

Screening and Diagnosis

• Use the AUDIT (Alcohol Use Disorders Identification Test) as the gold standard screening tool to identify alcohol dependence 2
• Assess for withdrawal risk, concurrent medical/psychiatric disorders, and adequacy of social support to determine appropriate treatment setting 1

Baseline Laboratory Evaluation

• Obtain liver function tests (AST, ALT, bilirubin) to assess for alcoholic liver disease, as this determines pharmacotherapy selection 1, 2
• Check nutritional status including thiamine, vitamin B12, folate, and other vitamin deficiencies common in alcohol dependence 1
• Evaluate for malnutrition which significantly affects ALD complications and requires protein intake of 1.2-1.5 g/kg/day and 35-40 kcal/kg/day 1

Acute Withdrawal Management

Benzodiazepines are the front-line medication for alcohol withdrawal, alleviating discomfort and preventing seizures and delirium. 1

• Administer oral thiamine to all patients during withdrawal 1, 2
• Give parenteral thiamine to high-risk patients (malnourished, severe withdrawal) or those with suspected Wernicke's encephalopathy 1
• Antipsychotics should only be used as adjunct to benzodiazepines in severe delirium unresponsive to adequate benzodiazepine doses, never as stand-alone treatment 1
• Anticonvulsants should not be used for preventing further alcohol withdrawal seizures 1
• Manage patients at risk of severe withdrawal or with serious comorbidities in an inpatient setting 1

First-Line Pharmacotherapy for Relapse Prevention

Medication Selection Algorithm

For patients WITHOUT advanced liver disease:

Naltrexone (50mg daily) is recommended for patients aiming to reduce heavy drinking who do not have severe liver disease or ongoing opioid needs 2, 3

• Reduces return to any drinking by 5% and binge-drinking risk by 10% 2
• Reduces relapse to heavy drinking and drinking frequency 2
• Works by blocking opioid-mediated alcohol rewards 4

Acamprosate is recommended for patients who have achieved abstinence and wish to maintain it 1, 2, 3

• Particularly effective in recently abstinent patients 2
• Normalizes NMDA-mediated glutamatergic dysregulation occurring in withdrawal and early abstinence 4
• More cost-effective worldwide 5

Disulfiram should only be used in supervised settings with highly motivated patients 1, 2

• No longer considered first-line due to compliance difficulties and toxicity 3
• Most successful when combined with behavioral marital therapy plus disulfiram contract 6

For patients WITH advanced alcoholic liver disease:

Baclofen is the only safe and effective option to prevent relapse in advanced ALD 1, 2

• Naltrexone and acamprosate must be avoided in advanced ALD due to potential hepatotoxicity 2

Critical Implementation Point

Only 1.6% of Americans with alcohol use disorder receive FDA-approved medications despite strong evidence for efficacy—pharmacotherapy must always be combined with counseling. 2

First-Line Psychosocial Interventions

Brief Motivational Interventions (Primary Approach)

Brief multicontact behavioral counseling interventions are superior to single-session interventions and should be routinely implemented. 2

• Produce 12% absolute increase in proportion reporting no heavy drinking episodes at 1 year 2
• Reduce total weekly alcohol consumption by approximately 3.6 drinks per week at 12-month follow-up 2

Use the FRAMES model (Feedback, Responsibility, Advice, Menu, Empathy, Self-efficacy) as structured approach: 1, 2

• Provide feedback about dangers of continued drinking
• Emphasize patient's responsibility for choices and consequences
• Advise abstinence
• Provide menu of alternatives
• Empathize with patient's perspective
• Encourage self-motivation for abstinence

Alternative: Five A's approach (Ask, Advise, Assess, Assist, Arrange) 2

Cognitive Behavioral Therapy

Combined CBT and pharmacotherapy demonstrates superior efficacy compared to usual care plus pharmacotherapy alone (effect size g=0.18-0.28). 1

• CBT combined with naltrexone or acamprosate shows particularly successful outcomes 6
• CBT targets cognitive, affective, and environmental risks for substance use 1
• Provides training in behavioral self-control skills for abstinence or harm reduction 1
• Effect sizes are approximately 5 times higher when CBT is combined with pharmacotherapy versus stand-alone 1

Important Caveat on Psychotherapy Selection

CBT does not perform better than other evidence-based modalities (motivational enhancement therapy, contingency management) when combined with pharmacotherapy 1

• The key is combining pharmacotherapy with any evidence-based therapy rather than usual clinical management or nonspecific counseling 1

Mutual Help Groups

Actively encourage engagement with Alcoholics Anonymous or other mutual help groups. 1, 2

• Healthcare providers should familiarize themselves with locally available groups 1
• Monitor impact of group attendance on patient outcomes 1
• Encourage family members to engage with appropriate mutual help groups 1

Family Involvement

Involve family members in treatment when appropriate and offer support to family members in their own right. 1, 2

• Family education and therapy provide significant benefit 1
• Behavioral marital therapy combined with disulfiram contract shows particularly strong outcomes 6
• Coordinate with community alcohol counseling centers for regular abstinence meetings and family meetings 1

Common Pitfalls to Avoid

• Never use pharmacotherapy without psychosocial intervention—the combination is essential for efficacy 1, 2
• Do not prescribe naltrexone or acamprosate in advanced liver disease—use baclofen instead 1, 2
• Avoid single-session brief interventions—multicontact interventions are significantly more effective 2
• Do not use antipsychotics as stand-alone treatment for withdrawal—benzodiazepines are first-line 1
• Never skip thiamine supplementation—all patients need oral thiamine, high-risk patients need parenteral 1, 2