Alcoholism Management

Aka: Alcoholism Management, Problem Drinking Management, Alcohol Dependence Management, Alcohol Abuse Management, Alcohol Use Disorder Management, Medications for Alcohol Use Disorder

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II. Protocol: Problem Drinking (Brief Intervention)

  1. See Chemical Dependency Brief Counseling
  2. Evaluate baseline, then again in 3 months
  3. Track patient progress
    1. Metrics for the last month
      1. Number of Alcohol free days
      2. Number of heavy drinking days
      3. Maximum number of drinks in one day
    2. Lab markers
      1. Biomarkers of Alcohol Use
        1. Urine Ethyl Glucuronide (C1987551)
        2. Urine Ethyl Sulfate
        3. Phospatidylethanol
      2. Other markers
        1. Serum Gamma glutamyl transferase (GGT)
        2. Carbohydrate deficient Transferrin

III. Protocol: Alcohol Use Disorder

  1. Initial Management
    1. Alcohol Detoxification
    2. Alcohol Withdrawal Protocol
  2. Long-Term Abstinence Programs (12 step programs appear most effective)
    1. Alcoholics Anonymous
    2. Sponsor
    3. Treatment Program
    4. Halfway House
  3. Medications
    1. See Medications below
    2. Offer medications (except Disulfiram) even for those continuing to drink
  4. Follow-up
    1. Reevaluate at 1 to 4 weeks after initial evaluation

IV. Management: Medications

  1. Indications: Alcohol Use Disorder
    1. Sustain abstinence in patients who have stopped drinking completely
    2. Decrease heavy Alcohol use and drinking days in those continuing to drink
  2. General
    1. High relapse rate after 3 months (best combined with treatment and aftercare as above)
    2. Continue medications for 6 to 12 months after patients stop drinking
    3. Best evidence is for Naltrexone and Topiramate
    4. Consider Naltrexone with either Acamprosate or Topiramate (generics for all are available)
  3. Primary Strategy: Choose 1 to 2 agents
    1. Naltrexone
      1. Avoid in active Opioid Use Disorder or need for Opioid Analgesics
      2. Avoid in decompensated Cirrhosis, Acute Hepatitis or Acute Liver Failure
    2. Acamprosate
      1. Effective in maintaining abstinence
      2. Consider in combination with Naltrexone if abstaining from Alcohol
      3. If continuing to drink or CKD4-5, use Naltrexone with Topiramate or Gabapentin instead
    3. Gabapentin
      1. Consider reducing withdrawal symptoms (acute and post-acute)
      2. May decrease heavy drinking days
    4. Topiramate
      1. May decrease the number of drinking days, heavy drinking days and number of drinks per day
  4. Specific populations
    1. Pregnancy
      1. No Medications for Alcohol Use Disorder have been established as safe in pregnancy
      2. Primary management is behavioral, although medications may be considered in severe Alcohol Use Disorder
        1. Naltrexone may be safe in pregnancy, but studies are lacking
        2. Avoid Topiramate and Gabapentin in pregnancy (Teratogenic)
    2. Teens
      1. Large, high quality studies are lacking in this population
      2. However, Naltrexone is likely safe and effective in this population
      3. Hammond (2016) Child Adolesc Psychiatr Clin North Am 25(4): 685-711 [PubMed]
      4. Deas (2005) Child Adolesc Psychiatr Clin North Am 15(5): 723-8 [PubMed]
    3. Comorbid Opioid Use Disorder
      1. Naltrexone monthly IM has FDA indication for Opioid Use Disorder
      2. Naltrexone is contraindicated with Opioids
        1. Opioids must be stopped at least 4-7 days before Naltrexone
        2. Buprenorphine and Methadone are first-line, very effective agents in Opioid Use Disorder
      3. Gabapentin has abuse potential when combined with Opioids
      4. Consider Topiramate or Acamprosate in comorbid AUD and Major Depression
    4. Comorbid Major Depression
      1. Specific evidence for Sertraline, Fluoxetine and Venlafaxine in combined AUD and Major Depression
      2. Treating comorbid depression may help sustain abstinence and reduce number of drinking days
      3. Agabio (2018) Cochrane Database Syst Rev (4): CD008581 [PubMed]

V. Medications: First-Line

  1. Naltrexone (Vivitrol, Revia)
    1. Mechanism
      1. Blocks Opioid receptors
      2. Decreases pleasure from Alcohol (which would normally stimulate endogenous Opioids)
    2. Dosing
      1. Oral: 50 mg orally daily ($50/month in 2019)
      2. IM: Vivitrol once monthly IM ($1500/month in 2019)
    3. Efficacy
      1. Effective in reducing Alcohol use in non-abstaining patients
      2. Prevents relapse in one in 20 patients with 3 months of use
      3. Effective in short-term, but not in long-term
    4. Contraindications
      1. Avoid in daily Opioid use (precipitates withdrawal)
      2. Avoid in significant hepatic Impairment
        1. However hepatic panel is NOT required prior to starting medication
        2. Avoid when liver transaminases >5 fold higher than the upper limit of normal
        3. Consider monitoring Liver Function Tests
  2. Acamprosate (Campral)
    1. Mechanism
      1. Calcium channel modulator
      2. Balances GABA and glutamate Neurotransmitters
      3. Reduces anxiety from abstinence (with better efficacy in abstinence than Naltrexone)
    2. Efficacy
      1. May prevent relapse in one in 12 patients with 3-6 months of use
    3. Dosing
      1. Two 333 mg tabs orally three times daily ($200/month in 2019)
      2. Decrease dose in GFR <50 ml/min (and avoid in GFR <30 ml/min)
    4. Adverse Effects
      1. Risk of lower complicance due to a very large tablet taken 3 times daily
      2. Safe in severe liver disease

VI. Medications: Second-Line

  1. Topiramate (Topamax)
    1. Decreases Alcohol use severity and heavy, binge drinking
    2. Improves abstinence, well being, quality of life in Alcoholics
    3. Requires dose titration, and adverse effects may limit use (e.g. sedation)
    4. Johnson (2004) Arch Gen Psychiatry 61:905-12 [PubMed]
  2. Gabapentin (Neurontin) or Pregabalin (Lyrica)
    1. May be combined with other agents (e.g. Naltrexone)
    2. Risk of misuse, especially with Opioids
    3. Dosing
      1. Alone: 600 to 1200 mg orally three times daily
      2. With Topiramate: 600 mg orally three times daily
  3. Baclofen
    1. May extend period of abstinence (and Alcohol free days in those continuing to drink)
    2. Dosing
      1. Start 5 mg orally three times daily
      2. Titrate to reduced Alcohol cravings (40-75 mg/day divided three times daily)
    3. References
      1. Agabio (2023) Cochrane Database Syst Rev 1(1):CD012557 +PMID: 36637087 [PubMed]
  4. Other medications that may be effective
    1. Ondanestron
    2. Selective Serotonin Reuptake Inhibitors (SSRI)
      1. Consider especially if comorbid depression
      2. Prozac often used, but other SSRIs effective
      3. Naranjo (2001) J Clin Psychiatry 62:18-25 [PubMed]

VII. Medications: Agents to Avoid

  1. Disulfiram (Antabuse)
    1. Taken 250 to 500 mg orally daily
    2. Not recommended due to risk and uncertain benefit

VIII. Resources

  1. See Chemical Dependency Resources
  2. See Alcoholism for Alcohol specific resources

IX. Precautions

  1. Vitamin Deficiency is common (Vitamins A, C, B1, B3, B6, B9, B12)
    1. See Alcohol Dependence
  2. Major Depression is common in recovering Alcoholics
    1. Treating Depression may lower risk of relapse
    2. Hasin (2002) Arch Gen Psychiatry 59:794-800 [PubMed]

X. References

  1. (2019) Presc Lett 26(2): 11
  2. (2024) Presc Lett 31(1): 3-4
  3. Sarmiento (Oct 2000) Federal Practitioner, p.45-50
  4. Strayer in Swadron (2023) EM:Rap 23(6): 9-11
  5. Enoch (2002) Am Fam Physician 65(3):441-50 [PubMed]
  6. Fleming (1997) JAMA 277:1039-45 [PubMed]
  7. Poorman (2024) Am Fam Physician 109(1): 71-8 [PubMed]
  8. Willenbring (2009) Am Fam Physician 80(1): 44-50 [PubMed]
  9. Winslow (2016) Am Fam Physician 93(6): 457-65 [PubMed]

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