Alcohol use disorder

Definition

• Substance use disorder of alcohol

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
  • 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

• Relapse prevention
• 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

Maintenance

• Relapse prevention