Treatment for
Alcohol Use Disorders
In the United States, alcohol use disorders had 12-month prevalence rates of 4.65% alcohol abuse and 3.81% alcohol dependence from 2001 to 2002. Self-reported drinking (2010) among those age 12 years and older indicates that 23% binge drink (more than five drinks per drinking day), and nearly 7% are heavy drinkers (binge drink on five or more days per month); yet fewer than 2% of the population needing substance use treatment receives treatment.
Screening for alcohol use disorders
identifies individuals at risk for developing alcohol-related problems and
those already meeting criteria for an alcohol use disorder. Evidence-based
screening, brief intervention, referral to treatment (SBIRT) is recommended for
all patients and results in earlier intervention for at-risk drinkers and
reduced drinking among those with an alcohol use disorder.
Treatment for at-risk drinkers
generally involves education about risk factors for developing alcohol use
disorders and alcohol-related problems, a review of the National Institute on
Alcohol Abuse and Alcoholism (NIAAA) guidelines to “low-risk” drinking, and a
brief intervention consisting of clear advice to reduce or abstain from
drinking and referral to self-help tools, such as keeping a drinking calendar,
writing down reasons to reduce or stop, setting weekly reduction goals that are
reviewed with a clinician or supportive peer, reducing stress, cultivating
healthy leisure activities and sober social supports, and considering mutual-
help groups, such as Alcoholics Anonymous (AA) or SMART Recovery.
Treatment for alcohol use disorders
begins with an assessment of whether medical detoxification is required for
physiologic dependence at risk for dangerous alcohol withdrawal syndromes; this
is especially important for patients with co-occurring hypertension, diabetes
mellitus, seizure disorder, and history of suicidality. Detoxification may be
monitored on an outpatient basis, but many patients will require inpatient
detoxification to prevent relapse to drinking. Medically stabilized patients
with alcohol use disorders are referred to professional counseling for drinking
reduction and relapse prevention and to mutual-help groups (participation in AA
doubles the efficacy of professional counseling). For alcohol-dependent
individuals, abstinence from alcohol is most effective at maintaining recovery
gains.
Primary care physicians have a
prominent role in treating alcohol dependence using medical management (MM)
models of care. MM consists of (1) frequent visits to assess progress
and health, (2) education about alcohol use disorders, (3) prescribing
and monitoring tolerance and adherence to an alcohol treatment medication,
(4) facilitating weekly drinking goals and recovery behaviors, (5) encouraging
participation in mutual-help or specialty counseling if indicated,
and (6) screening and treating disorders that commonly co-occur with
alcohol use disorders (e.g., medical, mental illness, domestic violence).
There are three FDA-approved and one non–FDA approved medications to treat
alcohol dependence. Medications are reviewed briefly below.
Naltrexone. An antagonist at central mu-opioid receptors,
naltrexone attenuates opioid-mediated reward of drinking and clinically
reduces alcohol cravings, relapse, and drinking days, and it increases the
probability of containing recurrent drinking to a brief episode rather than
full relapse. Naltrexone is available in daily oral dosage and in an extended-release monthly intramuscular
formulation that improves adherence. It poses hepatotoxicity risk and is
contraindicated in those with hepatic disease and those requiring narcotic
analgesia. Naltrexone is currently the only evidence-based medication for
geriatric alcohol dependence.
Acamprosate
(N-Acetylhomotaurine). A
glutamate neuromodulator, acamprosate is an abstinence-promoting medication appropriate
for patients who have achieved early abstinence. It increases time to first
drinking recurrence. It is metabolized within the kidney, providing a good
choice for those with hepatic disease. However, it has poor bioavailability, and
the required TID dosing may pose adherence risks.
Disulfiram. This aldehyde dehydrogenase inhibitor prevents
the final metabolic conversion of ethanol to water; usage results in
accumulation of toxic acetaldehyde metabolites, leading to flushing, headache,
hypertension, sweating, and nausea/vomiting. Disulfiram is most effective at reducing anticipated
rewards of alcohol and thus reducing drinking days. Adherence is
problematic, and there is a 1 in 50,000 risk of idiopathic fulminant
hepatotoxicity; thus careful hepatic monitoring is required. It is contraindicated
in those with autonomic instability (e.g., diabetes). It is a preferred
treatment for impaired professionals and parents at risk of losing child
custody.
Topiramate. Topiramate is a non–FDA-approved but
evidence-based medication that reduces drinking in treatment-seeking
alcohol-dependent patients.
This GABAergic potentiator can be administered to treatment-seeking patients with alcohol dependence who are actively drinking but want to reduce and are willing to commit to drinking reduction goals and medication adherence. Topiramate reduces heavy drinking days and promotes abstinence. Because of its renal metabolism, it is contraindicated with renal calculi or glaucoma.
