What is the recommended evaluation and treatment plan for an adult with alcohol use disorder, including withdrawal management, medication selection based on hepatic and renal function, and psychosocial interventions?

Evaluation and Treatment of Alcohol Use Disorder

For adults with alcohol use disorder, screen for liver disease first to guide medication selection: use naltrexone 50 mg daily as first-line for those without liver disease, or acamprosate 666 mg three times daily for those with liver disease, always combined with cognitive behavioral therapy or motivational interviewing. 1, 2

Initial Evaluation

Diagnostic Assessment

• Diagnose AUD using DSM criteria requiring at least 2 of 11 symptoms in the past year, with severity graded as mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6+ symptoms) 3
• Key symptoms include: taking alcohol in larger amounts than intended, persistent desire to cut down, time spent obtaining/using alcohol, craving, failure to fulfill obligations, continued use despite problems, tolerance, and withdrawal 3

Critical Pre-Treatment Screening

• Assess liver function (AST, ALT, bilirubin) and renal function before selecting pharmacotherapy, as this determines medication safety and choice 4, 1
• Screen for co-occurring psychiatric disorders (depression, anxiety, PTSD, bipolar disorder) which are more common in AUD and require concurrent treatment 4
• Use AUDIT (Alcohol Use Disorders Identification Test) as the gold standard screening tool 2
• Consider biomarkers (GGT, CDT) as adjuncts to clinical assessment, but never rely on them alone—they should be discussed with patients beforehand to maintain therapeutic alliance 3

Acute Withdrawal Management

Benzodiazepine Protocol

• Benzodiazepines are the gold standard for alcohol withdrawal syndrome, reducing seizure risk and preventing delirium tremens 1
• Use long-acting benzodiazepines (chlordiazepoxide, diazepam) for most patients as they provide superior protection against seizures and delirium 1
• Switch to short/intermediate-acting benzodiazepines (lorazepam, oxazepam) in elderly patients or those with hepatic dysfunction 1
• Limit benzodiazepine treatment to 7-10 days maximum to prevent dependence 1

Essential Supplementation

• Provide thiamine supplementation to all patients to prevent Wernicke's encephalopathy, with parenteral administration for high-risk patients 1, 2

Pharmacotherapy for Relapse Prevention

Algorithm Based on Liver Function

For patients WITHOUT liver disease:

• Naltrexone 50 mg daily (oral) or 380 mg monthly (intramuscular injection) is first-line 1, 2, 5
• Naltrexone reduces return to any drinking (number needed to treat = 18) and return to heavy drinking (number needed to treat = 11) 5
• Injectable naltrexone reduces drinking days by approximately 5 days per month 5
• Common adverse effects: nausea (risk ratio 1.73) and vomiting (risk ratio 1.53) 5

For patients WITH alcoholic liver disease or elevated transaminases:

• Acamprosate 666 mg three times daily (1998 mg total daily) is first-line 4, 1, 2
• Acamprosate has critical advantages: no hepatic metabolism, no hepatotoxicity, safe even with advanced liver disease 4
• Works through NMDA receptor antagonism (different mechanism than naltrexone), particularly effective for maintaining abstinence in recently abstinent patients 4, 2
• Number needed to treat to prevent return to any drinking = 11 5
• Common adverse effect: diarrhea (risk ratio 1.58) 5
• Baclofen 30-60 mg daily is second-line if acamprosate fails, with strongest evidence specifically in alcoholic liver disease 4, 1, 2

Critical Contraindications

• Never use naltrexone in patients with active liver disease or elevated transaminases due to hepatotoxicity risk and hepatic metabolism 4, 1, 2
• If liver enzymes become elevated during naltrexone treatment, discontinue immediately and switch to acamprosate or baclofen 4

Treatment Duration

• Continue pharmacotherapy for 3-6 months minimum, with longer duration for severe AUD 1

Naltrexone-Resistant Cases

• Add acamprosate 666 mg three times daily to existing naltrexone for complementary effects through different mechanisms 4
• If combination fails, add baclofen 30-60 mg daily as second-line 4
• Consider gabapentin 600-1800 mg daily or topiramate 75-400 mg daily as third-line options 4, 6

Psychosocial Interventions (Mandatory Component)

First-Line Behavioral Approaches

• Cognitive Behavioral Therapy (CBT) is first-line and must be combined with pharmacotherapy—never use medication alone 1, 2
• CBT focuses on identifying triggers, developing coping strategies, and restructuring thought patterns around alcohol use 4
• Brief multicontact behavioral counseling interventions outperform single-session interventions, increasing no-heavy-drinking episodes by 12% absolute increase and reducing weekly consumption by 3.6 drinks at 12 months 2

Motivational Approaches

• Use motivational interviewing for patients ambivalent about cessation, employing the FRAMES model: Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy 4, 1, 2
• Motivational enhancement therapy strengthens commitment to change during contemplation/preparation stages 2

Additional Interventions

• Encourage engagement with mutual help groups (Alcoholics Anonymous) as peer support has strong evidence 1, 2
• Implement contingency management providing tangible rewards for verified abstinence in patients not responding to traditional approaches 4
• Include family/couples counseling when appropriate to strengthen support systems 1, 2

Common Pitfalls to Avoid

• Never rely solely on pharmacotherapy without behavioral interventions—this significantly reduces treatment effectiveness 1
• Never use naltrexone without first checking liver function—it causes hepatocellular injury 4, 1
• Never discontinue treatment prematurely—minimum 3-6 months required 1
• Never use biomarkers alone to confirm or refute alcohol use—combine with clinical interview and physical exam 3
• Never ignore co-occurring psychiatric disorders—they require concurrent treatment 4
• Screen for intimate partner violence as both victim and perpetrator risk is increased, which may be a barrier to treatment engagement 4