Alcohol Use Disorder: Medical Treatment
The type of medical treatment you receive for your alcohol use disorder (AUD) will depend on the severity of your symptoms, the presence of co-occurring medical and psychological conditions, and your goals. Medical treatment of alcohol use disorder should always be accompanied by appropriate psychosocial treatments as well.
Treating Withdrawal Symptoms
First, it’s critical to identify and treat withdrawal symptoms from alcohol use disorder. Most people who stop drinking alcohol will experience mild to moderate symptoms, such as: anxiety, irritability, shakiness, fatigue, mood swings, inability to think clearly, sweating, headache, difficulty sleeping, nausea, vomiting, decreased appetite, increased heart rate, and tremors.
Sometimes, individuals don’t need any medical treatment. Other times, the doctor will prescribe medication on an outpatient basis. It’s helpful to have a loved one stay with you during this time.
The treatment of choice is benzodiazepines, which help to reduce agitation and prevent more severe withdrawal symptoms, such as seizures and delirium tremens (DT). The latter can be life-threatening, and constitutes a medical emergency. Symptoms can include agitation, profound confusion, disorientation, hallucinations, fever, hypertension, and autonomic hyperactivity (high pulse rate, blood pressure and rate of breathing). DT affects about 5 percent of individuals withdrawing from alcohol.
In general, long-acting benzodiazepines—such as diazepam and chlordiazepoxide—are preferred, because they have a lower chance of recurrent withdrawal and seizures. However, if individuals have advanced cirrhosis or acute alcoholic hepatitis (inflammation of the liver), the doctor will prescribe the benzodiazepines lorazepam or oxazepam.
Individuals with moderate to severe withdrawal symptoms must be closely monitored, and often require hospitalization. Individuals at high risk for complications might be placed in the ICU. Doctors will use one of two approaches to treat withdrawal: a symptom-triggered approach, which means providing medication when you exhibit symptoms, conducting regular evaluations with a standardized screening tool; and a fixed schedule, which involves giving medication at fixed intervals even when you don’t show symptoms. Research suggests that a symptom-triggered approach may be best (leading to less medication).
Individuals with AUD are often deficient in vital nutrients, so medical treatment also includes administering supplements, such as thiamine (100 mg) and folic acid (1 mg). Thiamine helps to lower the risk of Wernicke encephalopathy, a neurological disorder caused by thiamine deficiency. Symptoms include: balance and movement issues, confusion, double vision, fainting, faster heartbeat, low blood pressure and lack of energy. If not treated right away, Wernicke encephalopathy can progress into Korsakoff syndrome, which can shatter short-term memory and create gaps in long-term memory.
Medication for Alcohol Use Disorder (AUD)
When treating AUD, the American Psychiatric Association (APA) recommends that physicians create a comprehensive, person-centered treatment plan that includes evidence-based treatment. In other words, you and your doctor should collaborate on your treatment, which starts with identifying your goals. Those goals might include completely abstaining from alcohol, decreasing drinking, or not drinking in high-risk situations, such as while working, driving or watching your kids. Below are medications that your doctor might prescribe:
Naltrexone & Acamprosate
The U.S. Food and Drug Administration (FDA) has approved naltrexone and acamprosate to treat AUD. According to research, both medications are effective and well-tolerated. The APA recommends offering them to individuals with moderate to severe AUD (though it might be appropriate in some mild cases).
Naltrexone has been linked to fewer drinking days, and a reduction in returning to drinking. It’s also believed to decrease cravings. Naltrexone is available as a daily oral medication (recommended dose is 50 mg, but some people might need up to 100 mg); or a monthly depot intramuscular injection (at 380 mg).
Naltrexone is an opioid receptor antagonist, which means that it blocks the effects of opioids. Because of this, naltrexone shouldn’t be prescribed to people who use opioids or have a need for opioids (e.g., you take opioid painkillers for chronic pain).
If your doctor still prescribes naltrexone, it’s important to stop taking an opioid medication 7 to 14 days prior to starting naltrexone. Also, naltrexone isn’t prescribed for people with acute hepatitis (inflammation of the liver caused by an infection) or liver failure.
Acamprosate is effective when administered at 666 mg three times a day. Most experts suggest starting the medication as soon as abstinence is achieved, and continuing even if a relapse occurs. Outside the U.S., acamprosate is administered at the hospital after detoxification and abstinence.
How acamprosate works isn’t clear. It might modulate the neurotransmitter glutamate and prevent withdrawal symptoms. The APA noted that individuals taking acamprosate were less likely to return to drinking after they achieved abstinence, and had a decrease in the number of drinking days (though research on the number of heavy drinking days was mixed).
However, because acamprosate is eliminated by the kidneys, it’s not recommended for people with severe renal impairment. It’s also not recommended as a first-line treatment for individuals with mild to moderate renal impairment. If acamprosate is used, the dose must be reduced.
Overall, your doctor will pick which medication to use based on various factors, such as: availability, side effects, potential risks, the presence of co-occurring conditions, and/or the specific features of AUD, such as craving.
Your doctor also will use individual factors to determine the duration of treatment, such as: your preference, the severity of AUD, history of relapses, your response and tolerability, and potential consequences of relapse.
Topiramate & Gabapentin
These medications are used for moderate to severe AUD, as well. They’ll typically be prescribed after trials of naltrexone and acamprosate (unless you prefer to start with one of these instead). As with the above medications, the duration of treatment will depend on individual factors.
Topiramate is an anticonvulsant medication that’s usually prescribed for preventing epileptic seizures and migraine headaches. Some studies have shown that topiramate may reduce the number of heavy drinking days and drinking days. Some also have shown a decrease in drinks per day and experiences of craving, along with an improvement in abstinence. Topiramate is typically given at 200-300 mg daily.
Gabapentin also is an anticonvulsant medication typically prescribed for epileptic seizures and to relieve pain from shingles and other conditions. Research has found that at doses between 900 mg and 1800 mg a day, gabapentin was linked to abstinence, along with a reduction in heavy drinking days, drinking quantity, frequency, craving, insomnia and GGT (gamma-glutamyl transferase, an enzyme primarily produced by the liver, which is used to detect liver damage).
However, over the years, cases of misuse have been increasingly reported. Some states have established regulations for the monitoring and control of gabapentin. Authors of a 2017 study concluded that gabapentinoids, including gabapentin, should be avoided in patients with a history of substance use disorder, or if prescribed, closely and carefully monitored.
Because gabapentin is eliminated by the kidneys, the dose needs to be adjusted in people with renal impairment.
Disulfiram (Antabuse) was the first medication approved by the FDA to treat chronic alcohol dependence. The APA suggests that physicians offer disulfiram to individuals with moderate to severe AUD who are solely seeking abstinence from alcohol. That’s because if you consume alcohol within 12 to 24 hours of taking disulfiram, you’ll experience a toxic reaction, including tachycardia (a fast resting heart rate), flushing, headache, nausea, and vomiting.
You can get this same reaction when you ingest anything with alcohol in it, such as some mouthwashes, cold remedies, medications and food, or use alcohol-based hand sanitizer. For instance, the oral solution of the HIV medication ritonavir contains 43 percent alcohol. Reactions can occur up to 14 days after taking disulfiram.
A typical dose is 250 mg daily (but the range is 125 to 500 mg). Because there’s no evidence on the duration of treatment, as with the medications above, your doctor will base their decision on individual factors.
Before starting treatment, it’s important for your doctor to assess your liver chemistry. Disulfiram has been linked to mild elevated liver enzymes in a quarter of patients. Also, because of the risk of tachycardia with alcohol use, disulfiram might not be prescribed to individuals with cardiovascular issues. Disulfiram isn’t recommended for people with a seizure disorder because of the possibility of accidental disulfiram-alcohol reactions, and it should be used with caution if someone has diabetes or other conditions that cause autonomic neuropathy.
For more on symptoms, please see symptoms of alcohol and substance abuse.
While medication is effective in treating alcohol use disorder, psychosocial treatments are critical in maintaining recovery. Learn more about psychosocial treatments for AUD.
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