Review of Medication-Assisted Treatment Guidelines and Measures for Opioid and Alcohol Use. Appendix B. Medication-assisted Treatment for Alcohol Use Clinical Guidelines: Verbatium Excerpts From Relevant Guideline Sections

11/25/2015

LIST OF TABLES

  • TABLE B.1: SAMHSA and NIAAA: Brief Guide to Medication for the Treatment of Alcohol Use Disorder
  • TABLE B.2: NICE: Technology Appraisal Guidance of Nalmefene for Reducing Alcohol Consumption in People with Alcohol Dependence
  • TABLE B.3: WHO: Guidelines for the Identification and Management of Substance Use and SUD in Pregnancy
  • TABLE B.4: BAP Recommendations: Updated Evidence-Based Guidelines for the Pharmacological Management of Substance Abuse, Harmful Use, Addiction and Co-morbidity
  • TABLE B.5: Substance Misuse and Alcohol Use Disorders: Evidence-Based Geriatric Nursing Protocols for Best Practice
  • TABLE B.6: NICE: Alcohol-Use Disorders Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence
  • TABLE B.7: Medical Services Commission, British Columbia: Problem Drinking
TABLE B.1. SAMHSA and NIAAA: Brief Guide to Medication for the Treatment of Alcohol Use Disorder
Year Care Setting Guideline Source
of Information1
Statement Grade and
Rating Scale Definition
FDA-Approved
Medications
Psychosocial Treatment Guideline Statement
2015 Not specified Consensus Not rated. Yes. Yes--Generic recommendation. Assessment

The following steps are recommended for initiating treatment with any of the medications approved for the management of moderate or severe alcohol use disorder or the prevention of relapse to alcohol use:[1,2,7]

Educate the patient about MAT and the specific medication being recommended.

Obtain informed consent for MAT.

Complete a medical, psychiatric, and substance use history, including history of CVD, diabetes, thyroid disease, seizure disorder, CNS impairment, and kidney or liver disease.

Determine which prescription and OTC medications the patient is taking, including herbal preparations.

Perform a physical examination, baseline liver and kidney function tests, urine toxicology screen, and (in women) a pregnancy test.

Assess the patient for allergies to the proposed medication and to other medications.

For women, assess reproductive status, including current pregnancy or plans to become pregnant or to breastfeed.

            TREATMENT FOR ALCOHOL DEPENDENCE
Initiating Treatment with Disulfiram

Steps in initiating treatment with disulfiram are as follows:[2,55,56]

Wait until the patient has abstained from alcohol for at least 12 hours and/or until the breath or blood alcohol level is zero.

Perform an electrocardiogram if clinically indicated (e.g., in a patient with a history of heart disease).

Confirm the absence of allergy to disulfiram.

Perform the following tests to confirm abstinence and determine baselines after stabilization:

a. Breath or blood alcohol tests, if clinically indicated to confirm abstinence

b. Liver function tests: alanine aminotransferase, aspartate aminotransferase, GGT, alkaline phosphatase, lactate dehydrogenase, bilirubin, total protein, albumin, prothrombin time

c. Complete blood count and routine chemistries, if clinically indicated

d. Kidney function tests: routine blood urea nitrogen, creatinine

Initiating Treatment with Naltrexone

Naltrexone has not been shown to be effective in patients who are drinking at treatment initiation.

The clinician should consider how best to induct a prospective patient into treatment with extended-release injectable naltrexone.

Advise all patients being treated for alcohol use disorder that it is imperative to notify health care providers of any recent use of opioids or any history of opioid use disorder before starting extended-release injectable naltrexone, to avoid precipitation of opioid withdrawal. A urine drug screen should be conducted to verify abstinence before beginning induction.[80] If patients are to be treated for both alcohol and opioid SUD, they should be off all opioids, including prescription opioid analgesics, for a minimum of 7-10 days before starting naltrexone.[81] Patients transitioning from opioid agonist therapy to extended-release injectable naltrexone may be vulnerable to precipitation of withdrawal symptoms for as long as 2 weeks. Ensure that patients understand that withdrawal precipitated by administration of an opioid antagonist is different from the experience of spontaneous withdrawal that occurs with discontinuation of opioids in a dependent individual. Withdrawal precipitated by an opioid antagonist may be severe enough to require hospitalization.

When discontinuing naltrexone for patients with a history of co-occurring opioid use disorder, advice on opioid overdose prevention should be provided. After a period of abstinence from opioids, tolerance is greatly reduced. This means a previously tolerated amount of opioid could result in opioid overdose. Patients discontinuing opioid antagonist therapy in order to receive pain management with opioid analgesics should also be advised of this risk. Consider providing patients at risk of opioid overdose with a prescription for naloxone. SAMHSA's Opioid Overdose Toolkit includes strategies for developing such a plan to address emergency reversal of actual or suspected opioid overdose.[82]

Pre-treatment with oral naltrexone is not required before induction onto extended-release injectable naltrexone.

Dosing and Administration. For appropriate candidates, the recommended dose of extended-release injectable naltrexone is 380mg, delivered intramuscularly approximately every 30 days, alternating buttocks for each subsequent injection. See original guidelines for more information.

Initiating Treatment with Acamprosate

Acamprosate typically is initiated 5 days after the cessation of alcohol use. The drug typically reaches full effectiveness in 5-8 days.[2,75,76]

Acamprosate therapy should be continued even if a patient relapses to alcohol use.[1]

Psychosocial Treatments. Psychosocial treatments can enhance adherence to the treatment plan, including use of prescribed medications, and thus improve treatment outcomes. Conversely, to the extent that they reduce craving and help patients maintain abstinence, medications may help patients be more receptive to psychosocial interventions.[2,28]

Almost all studies of medications for the treatment of alcohol use disorder have included some type of counseling, and it is recommended that all patients for whom these medications are prescribed receive at least brief counseling. Evidence is accumulating that weekly or biweekly brief (i.e., 15-20 minutes) counseling sessions combined with use of a medication is an effective treatment for many patients in early recovery.[2,7,9] This counseling typically focuses on encouraging abstinence, adherence to the medication regimen, and participation in mutual-help groups.

Although psychiatrists may be able to deliver psychosocial therapies on-site, most clinicians need to refer patients for individual or group therapy.

Treating Adolescents and Young Adults

Empirical validation of the value of MAT in adolescents is lacking. Moreover, none of the available medications is approved by the FDA for use in people younger than age 18. Therefore, younger adolescents in need of treatment should be referred to a clinician or program specializing in adolescent addiction.[1,33]

However, in older adolescents and young adults, the limitations of available psychosocial interventions for youth and the demonstrated effectiveness of pharmacologic interventions in adults suggest that it may be reasonable to consider pharmacologic treatments for patients in this age group.[34,35]

There are no specific safety contraindications for older adolescents/young adults for the medications discussed here, and available information supports the safe and judicious use of medications in this population.[36] This is particularly true of older adolescents and young adults who have severe alcohol use disorder, as well as those who have not achieved success with psychosocial interventions alone and those who exhibit more adult patterns of moderate and severe alcohol use disorder.[37]

See original guidelines for guidelines on withdrawal, special populations, monitoring and many more topics.

  1. Full guideline can be found at http://store.samhsa.gov/shin/content/SMA15-4907/SMA15-4907.pdf. Text footnotes are from original guideline.

 

TABLE B.2. NICE: Technology Appraisal Guidance of Nalmefene for Reducing Alcohol Consumption in People with Alcohol Dependence
Year Care Setting Guideline Source
of Information1
Statement Grade and
Rating Scale Definition
FDA-Approved
Medications
Psychosocial Treatment Guideline Statement
2014 Not specified Committee review of a literature review and results from 3 RCTs. The committee functioned in a manner similar to NQF measure review committees. Not provided. No. Nalmefene is approved for use in Europe. The FDA has not approved its use in treating people with alcohol dependence. Yes--Generic recommendation. Nalmefene is recommended within its marketing authorisation, as an option for reducing alcohol consumption, for people with alcohol dependence:
  • Who have a high drinking risk level (defined as alcohol consumption of more than 60g/day for men and more than 40g/day for women, according to the WHO's drinking risk levels) without physical withdrawal symptoms.
  • Who do not require immediate detoxification.

The marketing authorisation states that nalmefene should:

  • Only be prescribed in conjunction with continuous psychosocial support focused on treatment adherence and reducing alcohol consumption.
  • Be initiated only in patients who continue to have a high drinking risk level 2 weeks after initial assessment.
  1. Full guideline can be found at https://www.nice.org.uk/guidance/ta325/chapter/1-Guidance.

 

TABLE B.3. WHO: Guidelines for the Identification and Management of Substance Use and SUD in Pregnancy
Year Care Setting Guideline Source
of Information1
Statement Grade and
Rating Scale Definition
FDA-Approved
Medications
Psychosocial Treatment Guideline Statement
2014 Inpatient Literature Review Generally strong recommendations with very low quality of evidence.

GRADE Working Group Grades of Evidence

High quality: Further research is very unlikely to change confidence in the estimate of effect.

Moderate quality: Further research is likely to have an important impact on confidence in the estimate of effect and may change the estimate.

Low quality: Further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change the estimate.

Very low quality: The GDG is very uncertain about the estimate.

Strength of Recommendation

Strong: The GDG was confident that the quality of the evidence of effect, combined with certainty about the values, preferences, benefits and feasibility, made this a recommendation that should be done in most circumstances and settings.

Conditional: There was less certainty about the quality of the evidence and values, preferences, benefits and feasibility of this recommendation. Thus, there may be circumstances or settings in which it should not apply.

Yes, in certain situations.

Benzodiazepines are a FDA-pregnancy category D drug, meaning "there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks."

Yes--CBT, CM, motivational interview/ enhancement. Recommendation 4

Health care providers should, at the earliest opportunity, advise pregnant women dependent on alcohol or drugs to cease their alcohol or drug use and offer, or refer to, detoxification services under medical supervision where necessary and applicable. (Strength of recommendation: Strong; Quality of evidence: Very low)

Remarks

Pregnant women dependent on alcohol or drugs who agree to undergo detoxification should be offered the supported withdrawal from substance use in an inpatient or hospital facility, if medically indicated.

Detoxification can be undertaken at any stage in pregnancy, but at no stage should antagonists (such as naloxone, or naltrexone--in the case of opioid withdrawal) be used to accelerate the detoxification process.

Equal attention should be paid to the health of mother and fetus during detoxification and treatment adjusted accordingly.

The exceptions to this recommendation are opioid and benzodiazepine dependence, which are covered by Recommendations 5 and 6 separately.

It was decided that this recommendation should be strong, despite the very low quality of evidence of the effectiveness of the health care intervention because there is clear evidence of harm to the fetus of ongoing maternal substance use, and the benefit to both mother and fetus of ceasing alcohol and/or substance use under medical supervision strongly outweighs any potential harms.

Recommendation 7

Pregnant women who develop withdrawal symptoms following the cessation of alcohol consumption should be managed with the short-term use of a long-acting benzodiazepine. (Strength of recommendation: Strong; Quality of evidence: Very low)

Remarks

Management of alcohol withdrawal usually also includes administration of thiamine.

Alcohol withdrawal management may be facilitated by the use of an alcohol-withdrawal scale such as the CIWA-Ar.

Inpatient care should be considered in the withdrawal management of pregnant women with alcohol dependence.

Alcohol withdrawal can be a severe and even life-threatening condition, provoking seizures and delirium. Evidence from non-pregnant populations has demonstrated the effectiveness of long-acting benzodiazepines for preventing seizures and delirium in alcohol withdrawal. Given the severity of alcohol withdrawal, and the lack of significant harm from short-term benzodiazepine use, and the evidence supporting the use of benzodiazepines in the management of alcohol withdrawal in the general population, the GDG decided that this recommendation should be strong despite the low quality of evidence in pregnant women.

Recommendation 10

Given that the safety and efficacy of medications for the treatment of alcohol dependence has not been established in pregnancy, an individual risk-benefit analysis should be conducted for each woman. (Strength of recommendation: Conditional; Quality of evidence: Very low)

Remarks

Pregnant patients with alcohol dependence should be offered psychosocial interventions.

The recommendation was considered conditional given the complete lack of research on this issue.

See alcohol table for mutually relevant guidelines and original guidelines for full guidelines.

  1. Full guideline can be found at http://www.guideline.gov/content.aspx?id=48894&search=(%22naltrexone%22+OR+%22buprenorphine%22+OR+%22methadone%22). Many of these guidelines were based upon a consensus process informed by the literature reviews.

 

TABLE B.4. BAP Recommendations: Updated Evidence-Based Guidelines for the Pharmacological Management of Substance Abuse, Harmful Use, Addiction and Co-morbidity
Year Care Setting Guideline Source
of Information1
Statement Grade and
Rating Scale Definition
FDA-Approved
Medications
Psychosocial Treatment Guideline Statement
2012 Inpatient, ambulatory Literature Review Statement grade varies based upon the specific guidance. See the "Guideline Statement" column for individual grades.

Categories of evidence for causal relationships and treatment:

Ia: Evidence from meta-analysis of randomised controlled trials.

Ib: Evidence from at least 1 randomised controlled trial.

IIa: Evidence from at least 1 controlled study without randomization.

IIb: Evidence from at least 1 other type of quasi-experimental study. III: Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies.

IV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities.

Proposed categories of evidence for observational relationships:

I: Evidence from large representative population samples.

II: Evidence from small, well-designed, but not necessarily representative samples.

III: Evidence from non-representative surveys, case reports.

IV: Evidence from expert committee reports or opinions and/or clinical experience of respected authorities.

Strength of recommendation

A: Directly based on category I evidence.

B: Directly based on category II evidence or extrapolated recommendation from category I evidence.

C: Directly based on category III evidence or extrapolated recommendation from category I or II evidence.

D: Directly based on category IV evidence or extrapolated recommendation from category I, II or III evidence.

S: Standard of care.

Yes. It also includes, carbamazepine, and clomethiazole, which are not FDA-approved. Yes, it is indirectly suggested in the "evidence section" preceding the guidelines and notes that all pharmacotherapies for treatment for alcohol discussion have been studied in combination with psychosocial treatment and medical treatment alone is not recommended. DETOXIFICATION
Treatment Regimens

Benzodiazepines are efficacious in reducing signs and symptoms of withdrawal (A); fixed-dose regimens are recommended for routine use with symptom-triggered dosing reserved for use only with adequate monitoring (D).

Carbamazepine has also been shown to be equally efficacious to benzodiazepines (A).

Clomethiazole is reserved for inpatient settings only after due consideration of its safety (A).

          TREATMENT FOR ALCOHOL DEPENDENCE
Recommendations: preventing relapse, maintaining abstinence

Acamprosate can be used to improve abstinence rates (A). It should be continued if the person starts drinking, since there is evidence that acamprosate reduces alcohol consumption (A), at least for a period to assess whether there is overall patient benefit attributable to acamprosate.

Naltrexone can be used to reduce risk of lapse becoming a relapse, but there is less evidence to support its use in maintaining abstinence (A). Naltrexone may therefore be a better choice if someone is "sampling" alcohol regularly but wishes to be abstinent.

For acamprosate and naltrexone there is no consistent evidence to suggest which types of patient will respond, and relapse prevention medication should be offered to/considered for everyone who is alcohol-dependent wanting to be abstinent (A).

Disulfiram is effective if intake is witnessed. Disulfiram can be offered as a treatment option for patients who intend to maintain abstinence, and for whom there are no contraindications (B).

Baclofen should be considered if a patient wants to be abstinent, has high levels of anxiety and has not benefited from or is unable to take acamprosate, naltrexone or disulfiram (C).

SSRIs should be avoided, or used with caution in type 2 alcoholism (B).

Recommendations: alcohol and pregnancy

Women and men are advised not to drink alcohol when trying to conceive (S).

Pregnant women with symptomatic withdrawal should be offered medical cover for their detoxification, ideally as an inpatient (D).

Starting relapse prevention medication should be avoided, although if already successfully established on relapse prevention medication, patients' needs should be assessed on a case-by-case analysis (D).

See original guidelines for full guidelines. See opioid table for guidelines for adolescents.

  1. Full guideline can be found at http://www.ncbi.nlm.nih.gov/pubmed/22628390. Many of these guidelines were based upon a consensus process informed by the literature reviews.

 

TABLE B.5. Substance Misuse and Alcohol Use Disorders: Evidence-Based Geriatric Nursing Protocols for Best Practices
Year Care Setting Guideline Source
of Information1
Statement Grade and
Rating Scale Definition
FDA-Approved
Medications
Psychosocial Treatment Guideline Statement
2008, Revised 2012 Not specified Literature Review Statement grade varies based upon the specific guidance. See the "Guideline Statement" column for individual grades.

Level I: Systematic reviews (integrative/ meta-analyses/ clinical practice guidelines based on systematic reviews).

Level II: Single experimental study (RCTs).

Level III: Quasi-experimental studies.

Level IV: Non-experimental studies.

Level V: Care report/program evaluation/narrative literature reviews.

Level VI: Opinions of respected authorities/ consensus panels.

Yes. Yes--Recommended, group psychotherapy-CBT promising in older adults. ASSESSMENT
Parameters of Assessment
  • Screening for alcohol, tobacco, and other drug use is recommended for all community-dwelling and hospitalized older adults. It is essential that the nurse:
  • State the purpose of questions about substances used and link them to health and safety.
  • Be empathic and non-judgmental; avoid stigmatic terms such as alcoholic.
  • Ask the questions when the patient is alcohol-free and drug-free.
  • Inquire re: patient's understanding of the question (Aalto, Pekuri, & Seppä, 2003 [Level III]).

Assessment and screening tools:

  • The QF Index (Khavari & Farber, 1978 [Level VI]): Review all classes of drugs: alcohol, nicotine, illicit drugs, prescription drugs, OTC drugs, and vitamin supplements, for each drug used. Record the types of drugs, including types of beverages; Frequency: the number of occasions on which the drug is consumed (daily, weekly, monthly); Amount of drug consumed on each occasion during the last 30 days. The psychological function, what the drugs does for the individual, is also important to identify. The QF Index tool should be part of the intake nursing history. The "brown bag" approach is also useful. Ask the patient to bring all drugs and supplements he or she uses in a brown bag to the interview.
  • SMAST-G: Highly valid and reliable, this is a 10-item tool that can be used in all settings. Three minutes for administration. This instrument is derived from the MAST-G with a sensitivity of 93.6% and positive predictive value of 87.2% (Blow et al., 1992 [Level III]).
  • AUDIT: This 10-item questionnaire has good validity in ethnically mixed groups and scores classify alcohol use as hazardous, harmful, or dependent. Administration: 2 minutes. Sensitivity scores range 0.74-0.84% and specificity around 0.90% in mixed age and ethnic groups (Allen et al., 1997 [Level III]). This instrument is highly effective for use with older adults (Roberts, Marshall, & MacDonald, 2005 [Level III]). Its derivative, the AUDIT-C, is composed of 3 questions that have proved equally valid in detecting an alcohol-related problem.
  • Atypical presentation: Men and women older than 65 years may have substance use and dependence problems even though the signs and symptoms may be less numerous than those listed in the DSM-IV TR.
  • Signs of CNS intoxication (i.e., slurred speech, drowsiness, unsteady gait, decreased reaction time, impaired judgment, disinhibition, ataxia):
  • Assess by individual or collateral (speaking with family members) data collection, detail the consumption of amount and type of depressant medications including alcohol, sedatives, hypnotics, and opioid or synthetic opioid analgesics.
  • Obtain a blood alcohol level. Marked intoxication 0.3-0.4%, toxic effects occur at 0.4-0.5%, coma and death at 0.5% or higher.
  • Assess vital signs and determine respiratory, cardiac, or neurological depression.
  • Assess for existing medical conditions, including depression.
  • Arrange for emergency room or hospitalization treatment as necessary.
  • Obtain urine for toxicology, if possible.
  • Assess for delirium that can be confused with intoxication and withdrawal in the older adult.
  • At-risk drinking is regular consumption of alcohol in excess of 1 drink per day for 7 days a week or more than 3 drinks on any 1 occasion.
  • Assess for readiness to change behavior using stages of change model (Prochaska & Di Clemente, 1992 [Level II]).
  • Is drinker concerned about amount or consequences of the drinking? Has she or he contemplated cutting down?
  • Does she or he have a plan for cutting down or stopping consumption?
  • Has she or he previously stopped but then resumed risky drinking?
  • Personalized feedback and on "at-risk drinking" results in a reduction in at-risk drinking among older primary care patients.
            DETOXIFICATION
  • Treatment of acute alcohol withdrawal syndrome (guidelines are modified for other CNS depressant drugs such as barbiturates, heroin, sedative-hypnotics):
  • Assess for risk factors: (a) previous episodes of detoxification; (b) recent heavy drinking; (c) medical co-morbidities including liver disease, pneumonia, and anemia; and (d) previous history of seizures or delirium (Wetterling et al., 2006 [Level III]).
  • Assess for extreme CNS stimulation and a minor withdrawal syndrome evidenced in tremors, disorientation, tachycardia, irritability, anxiety, insomnia, and moderate diaphoresis. When these signs are not detected, life-threatening situations for older adults often result. When these signs are not detected, life-threatening situations for older adults often result. Withdrawal, occurring 24-72 hours after the last drink, can progress to seizures, hallucinosis, withdrawal delirium, extreme hypertension, and profuse diarrhea 4-8 hours and for up to 72 hours following cessation of alcohol intake (DTs).
  • Assess neurological signs, using the CIWA-Ar. This CIWA-Ar is a 10-item rating scale that delineates symptoms of gastric distress, perceptual distortions, cognitive impairment, anxiety, agitation, and headache (Sullivan et al., 1989 [Level III]).
  • Medicate with a short-acting benzodiazepine (lorazepam or oxazepam) in doses titrated to patient's score on the CIWA-Ar, patient's age and weight; use one-third to one-half recommended dose (Amato et al., 2010 [Level I]). Continue CIWA-Ar to monitor treatment response.
  • Provide emotional support and frequent reorientation in a cool, low stimulation setting; monitor hydration and nutritional intake. Give therapeutic dose of thiamine and multivitamins.
  • Reported sleep disturbance, anxiety, depression, problems with attention and concentration (acute care): Assess for neuropsychiatric conditions using the mental status exam, Geriatric Depression Scale, or Hamilton Anxiety Scale.
  • Obtain sleep history because drugs disrupt sleep patterns in older persons.
  • Assess intake of all drugs, including alcohol, OTC, prescription, herbal and food supplements, and nicotine. Use "brown bag" strategy.
  • If positive for alcohol use, assess for last time of use and amount used.
  • Assess for alcohol or sedative drug withdrawal as indicated.
            TREATMENT FOR ALCOHOL DEPENDENCE
Treatment and relapse prevention
  • Monitor pharmacologic treatment such as naltrexone as short-term treatment for alcohol dependence. The benefits of this treatment are dependent on adherence and psychosocial treatment should accompany its use (WHO, 2000 [Level I]).

See guidelines related to psychosocial treatment in opioid table.

  1. Full guideline can be found at http://www.guideline.gov/content.aspx?id=43939&search=(%22naltrexone%22+OR+%22buprenorphine%22+OR+%22methadone%22). Many of these guidelines were based upon a consensus process informed by the literature reviews.

 

TABLE B.6. NICE: Alcohol-Use Disorders Diagnosis, Assessment and Management of Harmful Drinking and Alcohol Dependence
Year Care Setting Guideline Source
of Information1
Statement Grade and
Rating Scale Definition
FDA-Approved
Medications
Psychosocial Treatment Guideline Statement
2011 Outpatient, inpatient, residential Literature Review and informal consensus Not provided. Ratings of the individual studies can be found on the NICE Web site. Yes; it also includes carbamazepine, and clomethiazole, which are not FDA-approved. Yes--Recommend individual psychological intervention (CBTs, behavioral therapies or social network and environment-based therapies) or behavioural couples therapy with MAT. ASSESSMENT EXCERPTS
Brief Triage Assessment

1.2.2.5 All adults who misuse alcohol who are referred to specialist alcohol services should have a brief triage assessment to assess:

  • The pattern and severity of the alcohol misuse (using AUDIT) and severity of dependence (using SADQ).
  • The need for urgent treatment including assisted withdrawal.
  • Any associated risks to self or others.
  • The presence of any co-morbidities or other factors that may need further specialist assessment or intervention.

Agree the initial treatment plan, taking into account the service user's preferences and outcomes of any previous treatment.

Comprehensive Assessment

1.2.2.6 Consider a comprehensive assessment for all adults referred to specialist alcohol services who score more than 15 on the AUDIT. A comprehensive assessment should assess multiple areas of need, be structured in a clinical interview, use relevant and validated clinical tools (see 1.2.1.4), and cover the following areas:

Alcohol use, including:

  • Consumption: historical and recent patterns of drinking (using, for example, a retrospective drinking diary), and if possible, additional information (for example, from a family member or carer).
  • Dependence (using, for example, SADQ or LDQ).
  • Alcohol-related problems (using, for example, APQ).
  • Other drug misuse, including OTC medication.
  • Physical health problems.
  • Psychological and social problems.
  • Cognitive function (using, for example, the MMSE).
  • Readiness and belief in ability to change.

1.2.2.7 Assess co-morbid mental health problems as part of any comprehensive assessment, and throughout care for the alcohol misuse, because many co-morbid problems (though not all) will improve with treatment for alcohol misuse. Use the assessment of co-morbid mental health problems to inform the development of the overall care plan.

1.2.2.8 For service users whose co-morbid mental health problems do not significantly improve after abstinence from alcohol (typically after 3-4 weeks), consider providing or referring for specific treatment (see the relevant NICE guideline for the particular disorder).

1.2.2.9 Consider measuring breath alcohol as part of the management of assisted withdrawal. However, breath alcohol should not usually be measured for routine assessment and monitoring in alcohol treatment programmes.

1.2.2.10 Consider blood tests to help identify physical health needs, but do not use blood tests routinely for the identification and diagnosis of alcohol use disorders.

1.2.2.11 Consider brief measures of cognitive functioning (for example, MMSE) to help with treatment planning. Formal measures of cognitive functioning should usually only be performed if impairment persists after a period of abstinence or a significant reduction in alcohol intake.

1.3.2 Care coordination and case management

Care coordination is the routine coordination by any staff involved in the care and treatment of a person who misuses alcohol. Case management is a more intensive process concerned with delivering all aspects of care, including assessment, treatment, monitoring and follow-up.

1.3.2.1 Care coordination should be part of the routine care of all service users in specialist alcohol services and should:

  • Be provided throughout the whole period of care, including aftercare.
  • Be delivered by appropriately trained and competent staff working in specialist alcohol services.
  • Include the coordination of assessment, interventions and monitoring of progress, and coordination with other agencies.

1.3.2.2 Consider case management to increase engagement in treatment for people who have moderate-to-severe alcohol dependence and who are considered at risk of dropping out of treatment or who have a previous history of poor engagement. If case management is provided it should be throughout the whole period of care, including aftercare.

1.3.2.3 Case management should be delivered in the context of Tier 3 interventions by staff who take responsibility for the overall coordination of care and should include:

  • A comprehensive assessment of needs.
  • Development of an individualised care plan in collaboration with the service user and relevant others (including families and carers and other staff involved in the service user's care).
  • Coordination of the care plan to deliver a seamless multiagency and integrated care pathway and maximisation of engagement, including the use of motivational interviewing approaches.
  • Monitoring of the impact of interventions and revision of the care plan when necessary.

1.3.3 Interventions for harmful drinking and mild alcohol dependence

1.3.3.1 For harmful drinkers and people with mild alcohol dependence, offer a psychological intervention (such as cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol-related cognitions, behaviour, problems and social networks.

1.3.3.2 For harmful drinkers and people with mild alcohol dependence who have a regular partner who is willing to participate in treatment, offer behavioural couples therapy.

For harmful drinkers and people with mild alcohol dependence who have not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention, consider offering acamprosate[6] or oral naltrexone[7] in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) or behavioural couples therapy (see Section 1.3.6 for pharmacological interventions).

Delivering psychological interventions

1.3.3.3 Cognitive behavioural therapies focused on alcohol-related problems should usually consist of 1 60-minute session per week for 12 weeks.

1.3.3.4 Behavioural therapies focused on alcohol-related problems should usually consist of 1 60-minute session per week for 12 weeks.

1.3.3.5 Social network and environment-based therapies focused on alcohol-related problems should usually consist of 8 50-minute sessions over 12 weeks.

1.3.3.6 Behavioural couples therapy should be focused on alcohol-related problems and their impact on relationships. It should aim for abstinence, or a level of drinking pre-determined and agreed by the therapist and the service user to be reasonable and safe. It should usually consist of 1 60-minute session per week for 12 weeks.

1.3.4 Assessment and interventions for assisted alcohol withdrawal

See Section 1.3.7 for assessment for assisted withdrawal in children and young people.

1.3.4.1 For service users who typically drink over 15 units of alcohol per day and/or who score 20 or more on the AUDIT, consider offering:

  • An assessment for and delivery of a community-based assisted withdrawal.
  • Assessment and management in specialist alcohol services if there are safety concerns (see 1.3.4.5) about a community-based assisted withdrawal.

1.3.4.2 Service users who need assisted withdrawal should usually be offered a community-based programme, which should vary in intensity according to the severity of the dependence, available social support and the presence of co-morbidities.

  • For people with mild to moderate dependence, offer an outpatient-based assisted withdrawal programme in which contact between staff and the service user averages 2-4 meetings per week over the first week.
  • For people with mild to moderate dependence and complex needs[8], or severe dependence, offer an intensive community programme following assisted withdrawal in which the service user may attend a day programme lasting 4-7 days per week over a 3-week period.

1.3.4.3 Outpatient-based community assisted withdrawal programmes should consist of a drug regimen (see 1.3.5) and psychosocial support including motivational interviewing (see 1.3.1.1).

1.3.4.4 Intensive community programmes following assisted withdrawal should consist of a drug regimen (see 1.3.6) supported by psychological interventions including individual treatments (see 1.3.6), group treatments, psychoeducational interventions, help to attend self-help groups, family and carer support and involvement, and case management (see 1.3.2.2).

1.3.4.5 Consider inpatient or residential assisted withdrawal if a service user meets 1 or more of the following criteria. They:

  • Drink over 30 units of alcohol per day.
  • Have a score of more than 30 on the SADQ. Have a history of epilepsy, or experience of withdrawal-related seizures or DTs during previous assisted withdrawal programmes.
  • Need concurrent withdrawal from alcohol and benzodiazepines.
  • Regularly drink 15-30 units of alcohol per day and have:
    -- Significant psychiatric or physical co-morbidities (for example, chronic severe depression, psychosis, malnutrition, congestive cardiac failure, unstable angina, chronic liver disease).
    -- A significant learning disability or cognitive impairment.

1.3.4.6 Consider a lower threshold for inpatient or residential assisted withdrawal in vulnerable groups, for example, homeless and older people.

            DETOXIFICATION
1.3.5 Drug regimens for assisted withdrawal

1.3.5.1 When conducting community-based assisted withdrawal programmes, use fixed-dose medication regimens[9].

1.3.5.2 Fixed-dose or symptom-triggered medication regimens[10] can be used in assisted withdrawal programmes in inpatient or residential settings. If a symptom-triggered regimen is used, all staff should be competent in monitoring symptoms effectively and the unit should have sufficient resources to allow them to do so frequently and safely.

1.3.5.3 Prescribe and administer medication for assisted withdrawal within a standard clinical protocol. The preferred medication for assisted withdrawal is a benzodiazepine (chlordiazepoxide or diazepam).

1.3.5.4 In a fixed-dose regimen, titrate the initial dose of medication to the severity of alcohol dependence and/or regular daily level of alcohol consumption. In severe alcohol dependence higher doses will be required to adequately control withdrawal and should be prescribed according to the SPC. Make sure there is adequate supervision if high doses are administered. Gradually reduce the dose of the benzodiazepine over 7-10 days to avoid alcohol withdrawal recurring.

1.3.5.5 When managing alcohol withdrawal in the community, avoid giving people who misuse alcohol large quantities of medication to take home to prevent overdose or diversion[11]. Prescribe for installment dispensing, with no more than 2 days' medication supplied at any time.

1.3.5.6 In a community-based assisted withdrawal programme, monitor the service user every other day during assisted withdrawal. A family member or carer should preferably oversee the administration of medication. Adjust the dose if severe withdrawal symptoms or over-sedation occur.

1.3.5.7 Do not offer clomethiazole for community-based assisted withdrawal because of the risk of overdose and misuse.

1.3.5.8 For service users having assisted withdrawal, particularly those who are more severely alcohol-dependent or those undergoing a symptom-triggered regimen, consider using a formal measure of withdrawal symptoms such as the CIWA-Ar.

1.3.5.9 Be aware that benzodiazepine doses may need to be reduced for children and young people[12], older people, and people with liver impairment (see 1.3.5.10).

1.3.5.10 If benzodiazepines are used for people with liver impairment, consider 1 requiring limited liver metabolism (for example, lorazepam); start with a reduced dose and monitor liver function carefully. Avoid using benzodiazepines for people with severe liver impairment.

1.3.5.11 When managing withdrawal from co-existing benzodiazepine and alcohol dependence increase the dose of benzodiazepine medication used for withdrawal. Calculate the initial daily dose based on the requirements for alcohol withdrawal plus the equivalent regularly used daily dose of benzodiazepine[13]. This is best managed with 1 benzodiazepine (chlordiazepoxide or diazepam) rather than multiple benzodiazepines. Inpatient withdrawal regimens should last for 2-3 weeks or longer, depending on the severity of co-existing benzodiazepine dependence. When withdrawal is managed in the community, and/or where there is a high level of benzodiazepine dependence, the regimen should last for longer than 3 weeks, tailored to the service user's symptoms and discomfort.

1.3.5.12 For managing unplanned acute alcohol withdrawal and complications including DTs and withdrawal-related seizures, refer to NICE clinical guideline 100.

            TREATMENT FOR ALCOHOL DEPENDENCE
1.3.6 Interventions for moderate and severe alcohol dependence after successful withdrawal

1.3.6.1 After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone[7] in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol misuse (see Section 1.3.3).

1.3.6.2 After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone[7] in combination with behavioural couples therapy to service users who have a regular partner and whose partner is willing to participate in treatment (see Section 1.3.3).

1.3.6.3 After a successful withdrawal for people with moderate and severe alcohol dependence, consider offering disulfiram[14] in combination with a psychological intervention to service users who:

  • Have a goal of abstinence but for whom acamprosate and oral naltrexone are not suitable.
  • Prefer disulfiram and understand the relative risks of taking the drug (see 1.3.6.12).

Delivering pharmacological interventions

1.3.6.4 Before starting treatment with acamprosate, oral naltrexone or disulfiram, conduct a comprehensive medical assessment (baseline urea and electrolytes and liver function tests including GGT). In particular, consider any contraindications or cautions (see the SPC), and discuss these with the service user.

Acamprosate

1.3.6.5 If using acamprosate, start treatment as soon as possible after assisted withdrawal. Usually prescribe at a dose of 1998mg (666mg 3 times a day) unless the service user weighs less than 60kg, and then a maximum of 1332mg should be prescribed per day. Acamprosate should:

  • Usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it[15].
  • Be stopped if drinking persists 4-6 weeks after starting the drug.

1.3.6.6 Service users taking acamprosate should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood tests routinely, but consider them to monitor for recovery of liver function and as a motivational aid for service users to show improvement.

Naltrexone

1.3.6.7 If using oral naltrexone[7], start treatment after assisted withdrawal. Start prescribing at a dose of 25mg/day and aim for a maintenance dose of 50mg/day. Draw the service user's attention to the information card that is issued with oral naltrexone about its impact on opioid-based analgesics. Oral naltrexone should:

  • Usually be prescribed for up to 6 months, or longer for those benefiting from the drug who want to continue with it.
  • Be stopped if drinking persists 4-6 weeks after starting the drug.

1.3.6.8 Service users taking oral naltrexone[7] should stay under supervision, at least monthly, for 6 months, and at reduced but regular intervals if the drug is continued after 6 months. Do not use blood tests routinely, but consider them for older people, for people with obesity, for monitoring recovery of liver function and as a motivational aid for service users to show improvement. If the service user feels unwell advise them to stop the oral naltrexone immediately.

Disulfiram

1.3.6.9 If using disulfiram, start treatment at least 24 hours after the last alcoholic drink consumed. Usually prescribe at a dose of 200mg/day. For service users who continue to drink, if a dose of 200mg (taken regularly for at least 1 week) does not cause a sufficiently unpleasant reaction to deter drinking, consider increasing the dose in consultation with the service user.

1.3.6.10 Before starting treatment with disulfiram, test liver function, urea and electrolytes to assess for liver or renal impairment. Check the SPC for warnings and contraindications in pregnancy and in the following conditions: a history of severe mental illness, stroke, heart disease or hypertension.

1.3.6.11 Make sure that service users taking disulfiram:

  • Stay under supervision, at least every 2 weeks for the first 2 months, then monthly for the following 4 months.
  • If possible, have a family member or carer, who is properly informed about the use of disulfiram, oversee the administration of the drug.
  • Are medically monitored at least every 6 months after the initial 6 months of treatment and monitoring.

1.3.6.12 Warn service users taking disulfiram, and their families and carers, about:

  • The interaction between disulfiram and alcohol (which may also be found in food, perfume, aerosol sprays and so on), the symptoms of which may include flushing, nausea, palpitations and, more seriously, arrhythmias, hypotension and collapse.
  • The rapid and unpredictable onset of the rare complication of hepatotoxicity; advise service users that if they feel unwell or develop a fever or jaundice that they should stop taking disulfiram and seek urgent medical attention.

Drugs not to be routinely used for the treatment of alcohol misuse

1.3.6.13 Do not use antidepressants (including SSRIs) routinely for the treatment of alcohol misuse alone.

1.3.6.14 Do not use GHB for the treatment of alcohol misuse.

1.3.6.15 Benzodiazepines should only be used for managing alcohol withdrawal and not as ongoing treatment for alcohol dependence.

1.3.7 Special considerations for children and young people who misuse alcohol

Assessment and referral of children and young people

1.3.7.1 If alcohol misuse is identified as a potential problem, with potential physical, psychological, educational or social consequences, in children and young people aged 10-17 years, conduct an initial brief assessment to assess:

  • The duration and severity of the alcohol misuse (the standard adult threshold on the AUDIT for referral and intervention should be lowered for young people aged 10-16 years because of the more harmful effects of a given level of alcohol consumption in this population)
  • Any associated health and social problems
  • The potential need for assisted withdrawal.

1.3.7.2 Refer all children and young people aged 10-15 years to a specialist CAMHS for a comprehensive assessment of their needs, if their alcohol misuse is associated with physical, psychological, educational and social problems and/or co-morbid drug misuse.

1.3.7.3 When considering referral to CAMHS for young people aged 16-17 years who misuse alcohol, use the same referral criteria as for adults (see Section 1.2.2).

1.3.7.4 A comprehensive assessment for children and young people (supported if possible by additional information from a parent or carer) should assess multiple areas of need, be structured around a clinical interview using a validated clinical tool (such as the ADI or the T-ASI), and cover the following areas:

  • Consumption, dependence features and patterns of drinking.
  • Co-morbid substance misuse (consumption and dependence features) and associated problems.
  • Mental and physical health problems.
  • Peer relationships and social and family functioning.
  • Developmental and cognitive needs, and educational attainment and attendance.
  • History of abuse and trauma.
  • Risk to self and others.
  • Readiness to change and belief in the ability to change.
  • Obtaining consent to treatment.
  • Developing a care plan and risk-management plan.

Assisted withdrawal in children and young people

1.3.7.5 Offer inpatient care to children and young people aged 10-17 years who need assisted withdrawal.

1.3.7.6 Base assisted withdrawal for children and young people aged 10-17 years on the recommendations for adults (see 1.3.5) and in NICE clinical guideline 100. Consult the SPC and adjust drug regimens to take account of age, height and body mass, and stage of development of the child or young person[16].

Promoting abstinence and preventing relapse in children and young people.

1.3.7.7 For all children and young people aged 10-17 years who misuse alcohol, the goal of treatment should usually be abstinence in the first instance.

1.3.7.8 For children and young people aged 10-17 years who misuse alcohol offer:

  • Individual cognitive behavioural therapy for those with limited co-morbidities and good social support.
  • Multicomponent programmes (such as multidimensional family therapy, brief strategic family therapy, functional family therapy or multisystemic therapy) for those with significant co-morbidities and/or limited social support.

1.3.7.9 After a careful review of the risks and benefits, specialists may consider offering acamprosate[15] or oral naltrexone[7] in combination with cognitive behavioural therapy to young people aged 16-17 years who have not engaged with or benefited from a multicomponent treatment programme.

Delivering psychological and psychosocial interventions for children and young people

1.3.7.10 Multidimensional family therapy should usually consist of 12-15 family-focused structured treatment sessions over 12 weeks. There should be a strong emphasis on care coordination and, if necessary, crisis management. As well as family sessions, individual interventions may be provided for both the child or young person and the parents. The intervention should aim to improve:

  • Alcohol and drug misuse.
  • The child or young person's educational and social behavior.
  • Parental well-being and parenting skills.
  • Relationships with the wider social system.

1.3.7.11 Brief strategic family therapy should usually consist of fortnightly meetings over 3 months. It should focus on:

  • Engaging and supporting the family.
  • Using the support of the wider social and educational system.
  • Identifying maladaptive family interactions.
  • Promoting new and more adaptive family interactions.

1.3.7.12 Functional family therapy should be conducted over 3 months by health or social care staff. It should focus on improving interactions within the family, including:

  • Engaging and motivating the family in treatment (enhancing perception that change is possible, positive reframing and establishing a positive alliance).
  • Problem-solving and behaviour change through parent training and communication training.
  • Promoting generalisation of change in specific behaviours to broader contexts, both within the family and the community (such as schools).

1.3.7.13 Multisystemic therapy should be provided over 3-6 months by a dedicated member of staff with a low caseload (typically 3-6 cases). It should:

  • Focus specifically on problem-solving approaches with the family.
  • Use the resources of peer groups, schools and the wider community.

1.3.8 Interventions for conditions co-morbid with alcohol misuse

1.3.8.1 For people who misuse alcohol and have co-morbid depression or anxiety disorders, treat the alcohol misuse first as this may lead to significant improvement in the depression and anxiety. If depression or anxiety continues after 3-4 weeks of abstinence from alcohol, assess the depression or anxiety and consider referral and treatment in line with the relevant NICE guideline for the particular disorder[17].

1.3.8.2 Refer people who misuse alcohol and have a significant co-morbid mental health disorder, and those assessed to be at high risk of suicide, to a psychiatrist to make sure that effective assessment, treatment and risk-management plans are in place.

1.3.8.3 For the treatment of co-morbid mental health disorders refer to the relevant NICE guideline for the particular disorder, and:

  • For alcohol misuse co-morbid with opioid misuse actively treat both conditions; take into account the increased risk of mortality with taking alcohol and opioids together[18].
  • For alcohol misuse co-morbid with stimulant, cannabis[19] or benzodiazepine misuse actively treat both conditions.

Service users who have been dependent on alcohol will need to be abstinent, or have very significantly reduced their drinking, to benefit from psychological interventions for co-morbid mental health disorders.

1.3.8.4 For co-morbid alcohol and nicotine dependence, encourage service users to stop smoking and refer to 'Brief interventions and referral for smoking cessation in primary care and other settings' (NICE public health guidance 1).

See original guidelines for full guidelines, including more guidelines on assessment.

  1. Full guideline can be found at http://www.guideline.gov/content.aspx?id=34834&search=(%22naltrexone%22+OR+%22buprenorphine%22+OR+%22methadone%22).

 

TABLE B.7. Medical Services Commission, British Columbia: Problem Drinking
Year Care Setting Guideline Source
of Information1
Statement Grade and
Rating Scale Definition
FDA-Approved
Medications
Psychosocial Treatment Guideline Statement
2011 Ambulatory Literature Review Not rated. Yes. Yes--Generic recommendation (addiction counseling). See original guidelines for screening and assessment guidelines.

Problem Drinking Part 2--Brief Intervention

Note: If a patient is being seen for another problem, it may be necessary for screening to be done at the first appointment and intervention done at a follow-up appointment.

Selected interventions should be based on the assessment completed during the screening (see "Problem Drinking Part 1--Screening and Assessment" recommendations above). Although alcohol misuse is a spectrum disorder, positive screens will fall into 1 of 3 categories indicated above (at-risk drinking, alcohol abuse, alcohol dependence).

Practitioners may wish to use the "Brief Intervention Follow-up Note" provided with the guideline.

Intervention for Alcohol Abuse (See also the "Brief Intervention for At-Risk Drinking [No Abuse or Dependence]" algorithm in the original guideline document.)

Physicians are advised to take the following steps when conducting an intervention:

1. State your conclusion and recommendation clearly:

  • "I believe that you have an alcohol use disorder. I strongly recommend that you stop drinking and I'm willing to help."
  • Relate to the patient's concerns and medical findings if present.

2. Negotiate a goal and develop a plan:

  • Abstaining is the safest course for most patients with alcohol use disorders.
  • Patients who have milder forms of abuse or dependence and are unwilling to abstain may be successful at cutting down.

3. Consider referring to external or community resources:

  • Alcohol and drug counselor, addiction medicine physician.
  • Community groups such as AA.
  • See CHARD.

For abuse: If patient will not abstain, advise cutting down to established drinking limits. Provide follow-up and support.

Intervention for Alcohol Dependence

For dependence, complete the following in addition to steps 1-3 above:

4. For patients who have dependence: •Monitor for withdrawal--15-20% of alcohol-dependent drinkers require inpatient withdrawal. Refer to "Problem Drinking Part 3--Office-Based Management of Alcohol Withdrawal and Prescribing Medications for Alcohol Dependence" below.

5. Prescribing Medications for Alcohol Dependence Medication, in conjunction with psychosocial interventions, can play a valuable part in the management of alcohol dependence. See "Problem Drinking Part 3--Office-Based Management of Alcohol Withdrawal and Prescribing Medications for Alcohol Dependence" below for more information on prescribing medications.

6. Arrange follow-up appointments, including medication management support if needed. See "Problem Drinking Part 3--Office-Based Management of Alcohol Withdrawal and Prescribing Medications for Alcohol Dependence" below. To support behaviour change, consider seeing patient at least once every 14 days in initial period.

For dependence: Advise abstinence with medication support.

Follow-up and Support (see the "Follow-up and Support" algorithm in the original guideline document).

REMINDER: Document alcohol use and review goals at each visit (use the "Brief Intervention Follow-up Note" in the original guideline document). If the patient is receiving a medication for alcohol dependence, medication management support should be provided.

Prescribing Medications for Alcohol Dependence

Three medications are currently available:

  • Naltrexone*: Blocks euphoria associated with alcohol use. Contraindicated in patients taking opiates.
  • Acamprosate*: Reduces chronic withdrawal symptoms.
  • Disulfiram: Adversive agent, causes nausea, vomiting, dysphoria with alcohol use and requires abstinence and counseling before initiation. Disulfiram should be used with caution.

*Not covered, product(s) are under review.

Why Should Medications Be Considered for Treating an Alcohol Use Disorder?

Consider pharmacotherapy for all patients with alcohol dependency. Patients who fail to respond to psychosocial approaches and/or addiction counselling are particularly strong candidates. The above medications can be used immediately following withdrawal or any time thereafter; however, these medications should be used in conjunction with addiction counselling and other psychosocial supports.

Must Patients Agree to Abstain?

No matter which alcohol dependence medication is used, patients who have a goal of abstinence, or who can abstain even for a few days prior to starting the medication, are likely to have better outcomes. Still, it is best to determine individual goals with each patient. Some patients may not be willing to endorse abstinence as a goal, especially at first. However, abstinence remains the optimal outcome.

A patient's willingness to abstain has important implications for the choice of medication. For example, a study of oral naltrexone demonstrated a modest reduction in the risk of heavy drinking in people with mild dependence who chose to cut down rather than abstain. Acamprosate is approved for use in patients who are abstinent at the start of treatment. Total abstinence is needed with disulfiram. Disulfiram is contraindicated in patients who continue to drink, because a disulfiram-alcohol reaction occurs with any alcohol intake.

Which of the Medications Should Be Prescribed? (See Appendix A: "Prescription Medication Table for Alcohol Dependence" in Part 3 of the original guideline document.)

Which medication to use will depend on clinical judgment and patient preference. Each has a different mechanism of action. Some patients may respond better to 1 type of medication than another.

Naltrexone

Naltrexone works by blocking the euphoria associated with alcohol use. Its use is contraindicated in patients taking opiates. Oral naltrexone is associated with lower percentage drinking days, fewer drinks per drinking day, and longer times to relapse. It is most effective in patients with strong cravings. Efficacy beyond 12 weeks has not been established. Although it is especially helpful for curbing consumption in patients who have drinking "slips" it may also be considered in patients who are motivated, have intense cravings and are not using or going to be using opioids. It appears to be less effective in maintenance of abstinence as meta-analyses have shown variable results. Monitoring of liver enzymes may be required.

Acamprosate

Acamprosate works by reducing chronic withdrawal symptoms. Acamprosate increases the proportion of dependent drinkers who maintain abstinence for several weeks to months, a result demonstrated in multiple European studies and confirmed by a meta-analysis of 17 clinical trials. However, this has not been demonstrated in patients who have not undergone detoxification and not achieved alcohol abstinence prior to beginning treatment. Acamprosate should be initiated as soon as possible after detoxification and the recommended duration of treatment is 1 year. There is currently insufficient evidence to suggest that acamprosate has a therapeutic advantage over naltrexone.

Disulfiram

Disulfiram is an adversive agent that causes nausea, vomiting, and dysphoria with alcohol use. Abstinence and counselling are required before initiation of treatment with disulfiram. Data on the effectiveness of disulfiram in alcohol use disorders is mixed. Disulfiram has been shown to have modest effects on maintaining abstinence from alcohol, particularly if it is administered under supervision. It is most effective when given in a monitored fashion, such as in a clinic or by a spouse. Thus the utility and effectiveness of disulfiram may be considered limited because compliance is generally poor when patients are given it to take at their own discretion. Disulfiram may be considered for those patients that can achieve initial abstinence, are committed to maintaining abstinence, can understand the consequences of drinking alcohol while on disulfiram, and can receive adequate ongoing supervision. It may also be used episodically for high-risk situations, such as social occasions where alcohol is present. Daily uninterrupted disulfiram therapy should be continued until full patient recovery, which may require months to years.

How Long Should Medications Be Maintained?

The risk for relapse to alcohol dependence is very high in the first 6-12 months after initiating abstinence and gradually diminishes over several years. Therefore, a minimum initial period of 6 months of pharmacotherapy is recommended. Although an optimal treatment duration hasn't been established, treatment can continue for 1-2 years if the patient responds to medication during this time when the risk of relapse is highest. After patients discontinue medications, they may need to be followed more closely and have pharmacotherapy reinstated if relapse occurs.

If 1 Medication Does Not Work, Should Another Be Prescribed?

If there is no response to the first medication selected, you may wish to consider a second. This sequential approach appears to be common clinical practice, but currently there are no published studies examining its effectiveness. There is not enough evidence to recommend a specific ordering of medications.

Is There Any Benefit to Combining Medications?

There is no evidence that combining any of the medications to treat alcohol dependence improves outcomes over using any 1 medication alone.

Should Patients Receiving Medications Also Receive Specialized Alcohol Counselling or a Referral to Mutual-Help Groups?

Offering the full range of effective treatments will maximize patient choice and outcomes, since no single approach is universally successful or appealing to patients. Medications for alcohol dependence, professional counselling, and mutual-help groups are part of a comprehensive approach. These approaches share the same goal while addressing different aspects of alcohol dependence: neurobiological, psychological, and social. The medications are not prone to abuse, so they do not pose a conflict with other support strategies that emphasize abstinence. Using medications to treat patients does not interfere with counselling or other abstinence-based programs such as AA.

Almost all studies of medications for alcohol dependence have included some type of counselling, and it is recommended that all patients taking these medications receive at least brief medical counselling. In a recent large trial, the combination of oral naltrexone and brief medical counselling sessions delivered by a nurse or physician was effective without additional behavioral treatment by a specialist. Patients were also encouraged to attend mutual support groups to increase social encouragement for abstinence.

  1. Full guideline can be found at http://www.guideline.gov/content.aspx?id=38894&search=(%22naltrexone%22+OR+%22buprenorphine%22+OR+%22methadone%22). Many of these guidelines were based upon a consensus process informed by the literature reviews.

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