Diagnosis and Pharmacotherapy of Alcohol Use Disorder
abstract
This abstract is available on the publisher's site.
Access this abstract nowImportance
Alcohol consumption is associated with 88 000 US deaths annually. Although routine screening for heavy alcohol use can identify patients with alcohol use disorder (AUD) and has been recommended, only 1 in 6 US adults report ever having been asked by a health professional about their drinking behavior. Alcohol use disorder, a problematic pattern of alcohol use accompanied by clinically significant impairment or distress, is present in up to 14% of US adults during a 1-year period, although only about 8% of affected individuals are treated in an alcohol treatment facility.
Observations
Four medications are approved by the US Food and Drug Administration to treat AUD: disulfiram, naltrexone (oral and long-acting injectable formulations), and acamprosate. However, patients with AUD most commonly receive counseling. Medications are prescribed to less than 9% of patients who are likely to benefit from them, given evidence that they exert clinically meaningful effects and their inclusion in clinical practice guidelines as first-line treatments for moderate to severe AUD. Naltrexone, which can be given once daily, reduces the likelihood of a return to any drinking by 5% and binge-drinking risk by 10%. Randomized clinical trials also show that some medications approved for other indications, including seizure disorder (eg, topiramate), are efficacious in treating AUD. Currently, there is not sufficient evidence to support the use of pharmacogenetics to personalize AUD treatments.
Conclusions and Relevance
Alcohol consumption is associated with a high rate of morbidity and mortality, and heavy alcohol use is the major risk factor for AUD. Simple, valid screening methods can be used to identify patients with heavy alcohol use, who can then be evaluated for the presence of an AUD. Patients receiving a diagnosis of the disorder should be given brief counseling and prescribed a first-line medication (eg, naltrexone) or referred for a more intensive psychosocial intervention.
Click on any of these tags to subscribe to Topic Alerts. Once subscribed, you can get a single, daily email any time PracticeUpdate publishes content on the topics that interest you.
Visit your Preferences and Settings section to Manage All Topic Alerts
Additional Info
Disclosure statements are available on the authors' profiles:
Pharmaceutical treatment for alcoholism
Pharmaceutical treatment of alcoholism is only prescribed for <9% of people with alcohol use disorder (AUD) who may benefit. Granted, behavioral therapies such as brief behavioral intervention, cognitive behavioral therapy, and programs such as Alcoholics Anonymous are much more effective than drug therapy, but adding pharmaceutical therapy may add to the abstinence rates.
There are four drugs that have FDA approval for AUD, which include disulfiram, naltrexone, long-acting injectable naltrexone, and acamprosate.
And there are four commonly used drugs that are not FDA-approved for AUD. These include baclofen, gabapentin, topiramate, and nalmefene.
After review of the evidence for these drugs, the authors recommend the following pharmaceutical strategy based on tolerance and effectiveness when used with counseling and social support.
Start with naltrexone, which reduces the dopamine reward produced with alcohol use. Start at 25 mg once daily for 3 days, then increase to 50 mg for 4 days, and then maintain at 100 mg after a week of titration. Compared with placebo, naltrexone has the following side effects: somnolence (29.5% vs 17.8%), nausea (25.8% vs 16.3%), vomiting (16.9% vs 10.4%), decreased appetite (17.7% vs 11.8%), abdominal pain (15.9% vs 7.5%), insomnia (16.4% vs 13.4%), and dizziness (11.9% vs 6.2%).
After 1 month of therapy, if naltrexone is determined to be ineffective, then stop it and start topiramate. Start with 25 mg once a day and slowly titrate up to a maximum of 100 mg twice a day. Compared with placebo, topiramate has the following side effects: paresthesia (50.8% vs 10.6%), dysgeusia (23.0% vs 4.8%), anorexia (19.7% vs 6.9%), difficulty with concentration or attention (14.8% vs 3.2%), nervousness (14.2% vs 7.5%), dizziness (11.5% vs 5.3%), and pruritus (10.4% vs 1.1%).
In general, if your patient drinks for the “high” associated with alcohol, then start with naltrexone. If he/she has more challenges with cravings, start with topiramate.
If we are going to “stack the deck” in favor of long-term abstinence, we will have our patients with AUD explore underlying triggers with a behaviorist, we will encourage social support and guidance with Alcoholics Anonymous and primary healthcare, and we can use appropriate pharmaceuticals to support their success. And most importantly, many patients just need someone to believe in them.