What are the optimal treatment options for an adult with Alcohol Use Disorder in sustained remission who now has anxiety and agitation, emphasizing non‑addictive therapies?

Treatment of Anxiety and Agitation in Patients with AUD in Sustained Remission

For a patient with alcohol use disorder in sustained remission presenting with anxiety and agitation, prioritize non-addictive pharmacotherapy with gabapentin (300-900 mg daily) combined with cognitive behavioral therapy, while strictly avoiding benzodiazepines due to cross-addiction risk. 1, 2

Initial Assessment and Diagnostic Considerations

• Determine whether anxiety is independent or substance-induced by evaluating the temporal relationship between alcohol use and anxiety symptoms. 3 Independent anxiety disorders typically predate alcohol use or persist beyond 4 weeks of sustained abstinence, whereas substance-induced anxiety should have resolved within this timeframe. 3

• Verify sustained remission status (≥12 months without meeting DSM-5 substance use disorder criteria except craving) to confirm the patient is not experiencing subclinical relapse or withdrawal-related symptoms. 3

• Screen for concurrent substance use including benzodiazepines, opioids, or other substances that may complicate the clinical picture and treatment approach. 1, 4

First-Line Pharmacotherapy: Gabapentin

Gabapentin is the preferred medication because it addresses both anxiety symptoms and reduces alcohol craving without addiction potential. 1, 2

• Start gabapentin 300 mg three times daily, titrating up to 900-1800 mg daily in divided doses based on symptom response. 1, 2

• Gabapentin has preliminary evidence of synergistic effects in comorbid AUD-anxiety disorder, making it uniquely suited for this population. 1

• This medication can be safely used long-term without risk of dependence, unlike benzodiazepines. 2

Psychosocial Interventions

Cognitive behavioral therapy should be initiated immediately as first-line behavioral treatment, providing training in self-control skills to manage both anxiety triggers and alcohol cravings. 5, 1

• CBT combined with pharmacotherapy produces superior outcomes compared to medication alone (effect size 0.18-0.28). 5

• Integrated psychotherapy that simultaneously addresses both the anxiety disorder and AUD is more effective than treating each condition sequentially. 1, 4

• Actively encourage continued engagement with Alcoholics Anonymous or other mutual help groups, as this significantly improves long-term recovery rates. 5, 6

Medications to Avoid

Do not prescribe benzodiazepines even for severe anxiety, as they carry high cross-addiction risk in patients with AUD and can trigger relapse. 1, 2, 4

Avoid selective serotonin reuptake inhibitors (SSRIs) despite their common use in anxiety disorders, as meta-analysis evidence shows they do not improve outcomes in comorbid AUD-anxiety disorder and may worsen alcohol-related outcomes in some individuals. 1

Maintenance of Alcohol Abstinence

• Continue or initiate naltrexone 50 mg daily (if not contraindicated by liver disease) to reduce alcohol craving and prevent relapse during this vulnerable period. 5, 6

• Acamprosate 666 mg three times daily is an alternative if liver disease is present, as it has no hepatotoxicity and maintains abstinence effectively. 5, 6

• These medications should be continued for 3-6 months minimum, as premature discontinuation reduces effectiveness. 5

Common Pitfalls to Avoid

• Never rely solely on pharmacotherapy without concurrent behavioral intervention, as this markedly diminishes treatment effectiveness. 5, 6

• Do not prescribe benzodiazepines even for short-term use, as patients with AUD history have heightened vulnerability to benzodiazepine dependence. 1, 2

• Avoid treating anxiety and AUD sequentially; integrated simultaneous treatment produces better outcomes than addressing one disorder at a time. 1, 4

• Do not assume anxiety will spontaneously resolve with continued abstinence alone; independent anxiety disorders require active treatment even in sustained remission. 3, 4

Monitoring and Follow-Up

• Schedule weekly follow-up initially to assess medication response, anxiety symptom severity, and any emergence of alcohol cravings. 5

• Monitor for any return to alcohol use, as anxiety and agitation can be early warning signs of impending relapse. 3, 4

• Reassess diagnosis if symptoms do not improve within 4-6 weeks, as this may indicate inadequate treatment or misdiagnosis. 3