treatment options for alcohol use...

Treatment Options for Alcohol Use Disorder

Acamprosate

Acamprosate is a derivative of the amino acid taurine and, like alcohol, both reduces excitatory glutamate neurotransmission and enhances inhibitory GABA neurotransmission. In particular, it seems to block mGlureceptors and perhaps also NMDA receptors.

Dosing and Use

Pearls

Side Effects and Safety

Special Populations

Formulations:Tablet: 333 mg

Dosage Range:666 mg 3 times daily (>60 kg)666 mg 2 times daily (<60 kg)

Limited available data in patients with cardiac impairment

Approved For:Maintenance of alcohol abstinence

Suicidal ideation and behavior

Dose adjustment not generally necessary for patients with hepatic impairment

Pregnancy risk category C (some animal studies show adverse ef fects; no controlled studies in humans)

Safety and ef f icacy have not been established

Serves as “artif icial alcohol”; may be less ef fective in situations in which the patient has not yet abstained; patients should continue treatment even if relapse occurs but should disclose any new drinking; dosing schedule may af fect adherence; generally well tolerated, with diarrhea as the most common side ef fect; no known interactions with psychotropic medications (not metabolized by hepatic enzymes; does not inhibit/induce hepatic enzymes)

Do not use if patient has severe renal impairment

For moderate renal impairment, recommended dose is 333 mg three times daily; contraindicated in severe impairment

Naltrexone

Alcohol either acts directly upon mu opioid receptors or causes release of endogenous opioids; in either case, the result is increased dopamine release to the nucleus accumbens. Naltrexoneblocks mu opioid receptors, and thus theoretically reduces the euphoria and high of drinking.

Dosing and Use

Pearls


Special Populations

Formulations:Tablets: 25 mg, 50 mg, 100 mgOral solution: 12 mg/0.6 mLIntramuscular: 380 mg/vial

Dosage Range:Oral: 50 mg/dayInjection: 380 mg every 4 weeks

Limited available data in patients with cardiac impairment

Approved For:Alcohol dependenceBlockade of effects of exogenously administered opioids (oral only)

Eosinophilic pneumonia, hepatocellular injury (at excessive doses), severe injection site reactions requiring surgery

Dose adjustment not generally necessary for mild hepatic impairment; not studied in severe hepatic impairment; contraindicated in acute hepatitis or liver failure



Can be used for patients who have achieved abstinence, are trying to achieve abstinence, or are trying to reduce heavy drinking; less ef fective in patients who are not abstinent at the time of treatment initiation; adherence is greatly increased with the injectable formulation; side ef fects include nausea, vomiting, and site reactions (injection); may be preferred treatment if goal is reduced-risk drinking; can block ef fects of opioid-containing medications; some patients complain of apathy with chronic treatment

Do not use if patient: is taking opioid analgesics, is currently dependent on opioids or is in acute opiate withdrawal, has failed the naloxone challenge, or has a positive urine screen for opioids

Dose adjustment not generally necessary for mild renal impairment; not studied in moderate to severe impairment

Disulfiram

Alcohol is metabolized to acetaldehyde, which in turn is metabolized by aldehyde dehydrogenase. Disulf iram is an irreversible inhibitor of aldehydedehydrogenase, thereby blocking this second-stage metabolism. When alcohol is consumed in a patient taking disulf iram, toxic levels of acetaldehyde build up, which leads to f lushing, tachycardia, nausea, vomiting, and other symptoms.

Dosing and Use

Pearls


Special Populations

Formulations:Tablet: 250 mg, 500 mg

Dosage Range:250–500 mg/day, one-year duration

Contraindicated in patients with severe cardiovascular disease

Approved For:Maintenance of alcohol abstinence

Myocardial infarction, congestive heart failure, respiratory depression, hepatotoxicity

Not recommended for patients with hepatic insuf f iciency or cirrhosis



Disulf iram should not be given to a patient in a state of alcohol intoxication or without the patient’s full knowledge; the patient should not take disulf iramfor at least 12 hours af ter drinking; a reaction may occur for up to 2 weeks af ter disulf iram is stopped; the patient should be advised not to consume any food or beverages containing alcohol; the patient should carry an emergency card stating that s/he is taking disulf iram; common side ef fects include metallic taste, dermatitis, and sedation; not recommended for patients older than age 60 or for those with severe pulmonary disease, chronic renal failure, diabetes, peripheral neuropathy, seizures, cirrhosis, or portal hypertension

Contraindicated in patients taking metronidazole, amprenavir, ritonavir, or sertraline, and in those with psychosis or cardiovascular disease

Not recommended for patients with chronic renal failure

Topiramate

Like alcohol, topiramate both reduces excitatory glutamate neurotransmission and enhances inhibitory GABA neurotransmission. It is also a carbonic anhydrase inhibitor.

Dosing and Use

Pearls


Special Populations

Formulations:Tablets: 25 mg, 100 mg, 200 mgSprinkle capsule: 15 mg, 25 mg

Dosage Range:Up to 300 mg/day; requires slow upward titration to reduce side ef fects

Use with caution in patients with cardiac impairment

Approved For:Multiple seizure disorders; migraine prophylaxisNot approved for alcohol use disorder

Metabolic acidosis, kidney stones, secondary narrow-angle closure glaucoma, oligohidrosis and hyperthermia (more common in children), rare activation of suicidal ideation and behavior

Use with caution in patients with hepatic impairment


Approved for use in children age 2 and older for treatment of seizures; clearance is increased in pediatric patients

May be useful for patients who have achieved abstinence, are trying to achieve abstinence, or are trying to reduce heavy drinking; may be useful as an adjunct agent; side ef fects include sedation, nausea, and weight loss; can cause metabolic acidosis or kidney stones; adverse ef fects may be dose dependent

No absolute contraindications other than allergy to topiramate

Lower dose by half for patients with renal impairment

Presented at the 2011 NEI Global Psychopharmacology Congress.

Alcohol Withdrawal Syndrome

Symptoms begin within a few hours of discontinuation and may last a few days to a week

Outpatient Treatment

For patients with:Mild to moderate AWS (tremor, elevated pulse rate and blood

pressure, sweating, agitation, nervousness, sleeplessness, anxiety, and depression)

Consists of :Relief of immediate symptoms, prevention of complications,

and initiation of rehabilitationSupportive care and repletion of nutrient, f luid, or mineral

def iciencies (especially vitamin B)Benzodiazepines

Alternative options may include carbamazepine, valproate, or topiramate

Inpatient Treatment

For patients with:Severe AWS (hallucinations, delirium tremens, psychotic

symptoms, and seizures)Extremely high alcohol intake

Signif icant psychiatric symptoms

Psychosocial + Pharmacologic

Pharmacotherapy is good for:

Patients with active alcohol dependencePatients who have stopped drinking but have cravings or slips

Patients who have previously failed to respond to psychosocial approaches

Psychotherapeutic or psychosocial approaches can:

Increase motivation for abstinenceImprove motivation for medication adherence

Improve overall outcomes

Motivational Enhancement Therapy

Motivational interviewing is patient-focused counseling with the direct goal of enhancing one’s motivation to change by helping explore and resolve ambivalence (e.g., “I want to stop drinking, but I’m afraid I’ll be awkward in social situations”). Although it was originally developed to help individuals with problem drinking, it can be used in the treatment of patients with other forms of substance abuse and dependence. With motivational interviewing the clinician is a facilitator, helping the patient identify, articulate, and resolve his or her own ambivalence without direct persuasion, confrontation, or coercion.

Motivational enhancement therapy (MET) is an adaptation of motivational interviewing in which the therapist uses feedback to strengthen the patient’s own motivation and commitment to change.

12-Step Facilitation and 12-Step Fellowships

Twelve-Step Facilitation (TSF) consists of a structured, manual-driven approach to facilitating early recovery f rom alcohol abuse/alcoholism and other drug abuse/addiction. Its purpose is to help patients accept their need to abstain and to actively participate in 12-step fellowships (such as Alcoholics Anonymous, or AA) as a means of maintaining abstinence. It is intended to be implemented on an individual basis in 12 to 15 sessions and is based in the 12 steps and traditions of AA.

Although mutual support groups such as 12-step fellowships can be very benef icial in helping patients with substance use disorder, these programs are based on the premise that addiction is an illness in which those af f licted are unable to control their use of the drug. As such, they typically require complete abstinence as the goal. This may therefore pose conf lict for patients with alcohol use disorder who are attempting reduced-risk drinking.

Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is based on the premise that our behaviors stem f rom our thoughts and beliefs, and therefore that negative thoughts can lead to maladaptive behavior. CBT is designed to modify the behaviors and thoughts/beliefs that contribute to substance abuse and dependence. CBT helps patients identify triggers for substance use, such as particular people or places or even emotions, and helps them develop techniques to avoid those triggers or, if unavoidable, to cope with them.

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treatment options for alcohol use...

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