II. Protocol: Brief Intervention for Problem Drinking

  1. See Chemical Dependency Brief Counseling
  2. 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. Adjunctive Medications for abstinence
    1. General
      1. High relapse rate after 3 months
      2. Best evidence is for Naltrexone and Topiramate
      3. Consider Naltrexone with either Campral or Topiramate (generics for all are available)
    2. First line
      1. Naltrexone (Vivitrol, Revia)
        1. Blocks Opioid receptors
        2. Decreases pleasure from Alcohol
        3. Effective in reducing Alcohol use in non-abstaining patients
        4. Prevents relapse in one in 20 patients with 3 months of use
        5. Dosing
          1. Oral: 50 mg orally daily ($50/month in 2019)
          2. IM: Vivitrol once monthly IM ($1500/month in 2019)
        6. Effective in short-term, but not in long-term
      2. Campral (Acamprosate)
        1. Balances GABA and glutamate Neurotransmitters
        2. Reduces anxiety from abstinence (with better efficacy in abstinence than Naltrexone)
        3. May prevent relapse in one in 12 patients with 3-6 months of use
        4. Dosing: 2 tabs orally three times daily ($200/month in 2019)
          1. Risk of lower complicance due to a very large tablet taken 3 times daily
    3. Second line agents to consider
      1. 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]
      2. 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
        4. Johnson (2004) Arch Gen Psychiatry 61:905-12 [PubMed]
    4. Other medications that may be effective
      1. Gabapentin (Neurontin) or Pregabalin (Lyrica)
        1. Risk of misuse, especially with Opioids
      2. Ondanestron
    5. Agents to avoid
      1. Baclofen (insufficient evidence)
      2. Disulfiram (Antabuse)
        1. Taken 250 to 500 mg orally daily
        2. Not recommended due to risk and uncertain benefit

IV. Resources

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

V. 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]

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