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.