Alcohol use disorder

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Definition

Management

  • Based on stage of change
  • Pre-contemplative
    • Screening, Brief Intervention, and Referral to Treatment (SBIRT)
  • Contemplative
    • Motivational enhancement
  • Action
    • Residential treatment
    • Alcoholics Anonymous
    • Medications (concurrent with psychosocial interventions)

Medications

Naltrexone

  • First-line; anti-craving opioid antagonist
  • Can continue drinking but should commit to weekly counseling
  • Reduces the total amount of alcohol consumed, but may not help with abstinence
    • NNT 20 for any drinking
    • NNT 12 for heavy drinking and cravings
  • Contraindications: opioid use, liver disease
  • Adverse effects: nausea, sleepiness
  • Start 25mg daily for 4 days then increase to 50mg daily
  • Requires EAP approval, otherwise ~$300/mo

Gabapentin

  • Abstinent for 3 days, then start 300mg HS and increase by 300mg daily up to 300mg TID or 600mg TID
  • NNT 8 for abstinence
  • NNT 5 for reducing heavy drinking
  • Adverse effects: insomnia, drowsiness

Acamprosate

  • Helps with abstinence and relapse prevention
  • Requires 4 days of abstinence prior to start
  • On ODB after naltrexone
  • NNT 12 for maintaining abstinence, no effect on heavy drinking
  • Beware in renal disease, has GI side effects

Topiramate

  • Glutamate antagonist and GABA agonist
  • Start 25mg PO BID and titrate weekly by 25mg

Baclofen

  • Has street value and can cause dependence
  • Start 5mg TID and titrate up by 5mg
  • Beware in renal disease

Ondansetron

  • Limited but promising data

Disulfiram

Case management

Day programs

Maintenance

  • Relapse prevention