What are the treatment options for Ethanol (EtOH) addiction?

From the Guidelines

Alcohol addiction treatment should prioritize acamprosate (666mg three times daily) as the primary medication to maintain abstinence, due to its high-quality evidence showing superiority over placebo 1. When considering treatment for alcohol addiction, it's essential to address both the physical and psychological aspects of the disorder.

• For acute alcohol withdrawal, benzodiazepines like diazepam (5-10mg every 6 hours) or lorazepam (1-2mg every 6 hours) are first-line medications, tapered over 3-7 days to prevent seizures and delirium tremens 1.
• After detoxification, medications to reduce cravings include naltrexone (50mg daily), which blocks opioid receptors, and disulfiram (250-500mg daily), which causes unpleasant reactions if alcohol is consumed.
• Psychological treatments are essential components, particularly cognitive-behavioral therapy (CBT) and motivational enhancement therapy, typically conducted in 12-16 weekly sessions, which have been shown to be effective when combined with pharmacotherapy 1.
• Support groups like Alcoholics Anonymous provide ongoing community support. Treatment should be individualized based on severity, comorbidities, and patient preferences.
• The most effective approaches combine medications with counseling and support groups, as alcohol addiction affects both brain chemistry and behavior patterns.
• Early intervention improves outcomes, and treatment often requires multiple attempts, with relapse viewed as part of the recovery process rather than failure. It's crucial to note that while other interventions may be promising, acamprosate is currently the only intervention with enough high-quality evidence to support its use in maintaining alcohol abstinence 1.

From the FDA Drug Label

Acamprosate calcium delayed-release tablets are indicated for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. The recommended dose of acamprosate calcium delayed-release tablets is two 333 mg tablets (each dose should total 666 mg) taken three times daily. Treatment with acamprosate calcium delayed-release tablets should be initiated as soon as possible after the period of alcohol withdrawal, when the patient has achieved abstinence, and should be maintained if the patient relapses. Naltrexone hydrochloride has not been shown to cause significant increases in complaints in placebo-controlled trials in patients known to be free of opioids for more than 7 to 10 days

Etoh addiction treatment options include:

• Acamprosate: indicated for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation 2
• Naltrexone: may be used as an adjunctive treatment of alcohol dependence, although it has not been shown to cause significant increases in complaints in placebo-controlled trials in patients known to be free of opioids for more than 7 to 10 days 3 Key considerations:
• Acamprosate should be used as part of a comprehensive psychosocial treatment program 2
• Naltrexone may precipitate or exacerbate abstinence signs and symptoms in any individual who is not completely free of exogenous opioids 3

From the Research

Etoh Addiction Treatment Options

• There are several medication options available for the treatment of alcohol dependence, including acamprosate, naltrexone, and disulfiram 4, 5, 6, 7, 8.
• A study published in 2006 found that combined acamprosate and naltrexone, with cognitive behavioural therapy, is superior to either medication alone for alcohol abstinence 4.
• A meta-analysis published in 2011 found that acamprosate and naltrexone were 52% and 27% better than placebo, respectively, in supporting continuous abstinence 5.
• A randomized, multicentre, open-label, comparative trial published in 2008 found that disulfiram was more effective in reducing heavy drinking days and average weekly alcohol consumption, and increasing time to first drink, compared to naltrexone and acamprosate 6.
• A narrative review published in 2023 found that psychotherapy is the mainstay of treatment for alcoholism, and that few drugs, such as acamprosate, disulfiram, and naltrexone, are approved for use in augmentation of this treatment 7.
• A double-blind, placebo-controlled study published in 2003 found that naltrexone, acamprosate, and the combined medication were significantly more effective than placebo in preventing relapse, and that the combined medication was most effective 8.

Comparison of Medications

• Naltrexone and acamprosate have been shown to be effective in relapse prevention of alcoholism, but it remains uncertain whether they are equally efficient 5, 8.
• A study published in 2006 found that naltrexone with CBT is as effective as combined medication with CBT, but the trend favours combination medication 4.
• A meta-analysis published in 2011 found that acamprosate increased the total number of abstinence days by 14% compared to placebo 5.
• Disulfiram has been shown to be effective in reducing heavy drinking days and average weekly alcohol consumption, but its effectiveness is dependent on supervised intake 6.

Future Perspectives

• Despite the availability of several medication options, there is still a need for more effective treatments for alcohol dependence 7.
• Recent reports in the literature suggest that psychoactive substances such as psilocybin and MDMA may be a breakthrough in the modern treatment of alcohol abuse, but more research is needed before these treatments can be widely available 7.