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Alcoholism Management

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Alcoholism Management, Problem Drinking Management, Alcohol Dependence Management, Alcohol Abuse Management

  • See Also
  1. Alcohol Dependence
  2. Alcohol Toxicity
  3. Alcohol Withdrawal
  4. Alcohol Detoxification in Ambulatory Setting
  5. Chemical Dependency
  6. Drug Withdrawal
  7. Substance Abuse Evaluation
  8. Substance Addiction Aftercare
  1. See Chemical Dependency Brief Counseling
  2. Track patient progress
    1. Metrics for the last month
      1. Number of Alcohol free days
      2. Number of heavy drinking days
      3. Maximum number of drinks in one day
    2. Lab markers
      1. Biomarkers of Alcohol Use
        1. Urine Ethyl Glucuronide (C1987551)
        2. Urine Ethyl Sulfate
        3. Phospatidylethanol
      2. Other markers
        1. Serum Gamma glutamyl transferase (GGT)
        2. Carbohydrate deficient Transferrin
  1. Initial Management
    1. Alcohol Detoxification
    2. Alcohol Withdrawal Protocol
  2. Long-Term Abstinence Programs (12 step programs appear most effective)
    1. Alcoholics Anonymous
    2. Sponsor
    3. Treatment Program
    4. Halfway House
  3. Adjunctive Medications for abstinence
    1. General
      1. High relapse rate after 3 months
      2. Best evidence is for Naltrexone and Topiramate
      3. Consider Naltrexone with either Campral or Topiramate (generics for all are available)
    2. First line
      1. Naltrexone (Vivitrol, Revia)
        1. Mechanism
          1. Blocks Opioid receptors
          2. Decreases pleasure from Alcohol (which would normally stimulate endogenous Opioids)
        2. Dosing
          1. Oral: 50 mg orally daily ($50/month in 2019)
          2. IM: Vivitrol once monthly IM ($1500/month in 2019)
        3. Efficacy
          1. Effective in reducing Alcohol use in non-abstaining patients
          2. Prevents relapse in one in 20 patients with 3 months of use
          3. Effective in short-term, but not in long-term
        4. Contraindications
          1. Avoid in daily Opioid use (precipitates withdrawal)
          2. Avoid in significant hepatic Impairment
            1. However hepatic panel is NOT required prior to starting medication
            2. Avoid when liver transaminases >5 fold higher than the upper limit of normal
      2. Campral (Acamprosate)
        1. Mechanism
          1. Calcium channel modulator
          2. Balances GABA and glutamate Neurotransmitters
          3. Reduces anxiety from abstinence (with better efficacy in abstinence than Naltrexone)
        2. Efficacy
          1. May prevent relapse in one in 12 patients with 3-6 months of use
        3. Dosing
          1. Two 333 mg tabs orally three times daily ($200/month in 2019)
        4. Adverse Effects
          1. Risk of lower complicance due to a very large tablet taken 3 times daily
          2. Safe in severe liver disease
    3. Second line agents to consider
      1. Selective Serotonin Reuptake Inhibitors (SSRI)
        1. Consider especially if comorbid depression
        2. Prozac often used, but other SSRIs effective
        3. Naranjo (2001) J Clin Psychiatry 62:18-25 [PubMed]
      2. Topiramate (Topamax)
        1. Decreases Alcohol use severity and heavy, binge drinking
        2. Improves abstinence, well being, quality of life in Alcoholics
        3. Requires dose titration
        4. Johnson (2004) Arch Gen Psychiatry 61:905-12 [PubMed]
    4. Other medications that may be effective
      1. Gabapentin (Neurontin) or Pregabalin (Lyrica)
        1. May be combined with other agents (e.g. Naltrexone)
        2. Risk of misuse, especially with Opioids
        3. Dosing
          1. Alone: 600 to 1200 mg orally three times daily
          2. With Topiramate: 600 mg orally three times daily
      2. Ondanestron
    5. Agents to avoid
      1. Baclofen (insufficient evidence)
      2. Disulfiram (Antabuse)
        1. Taken 250 to 500 mg orally daily
        2. Not recommended due to risk and uncertain benefit
  • Resources
  1. See Chemical Dependency Resources
  2. See Alcoholism for Alcohol specific resources
  • Precautions
  1. Vitamin Deficiency is common (Vitamins A, C, B1, B3, B6, B9, B12)
    1. See Alcohol Dependence
  2. Major Depression is common in recovering Alcoholics
    1. Treating Depression may lower risk of relapse
    2. Hasin (2002) Arch Gen Psychiatry 59:794-800 [PubMed]
  • References
  1. (2019) Presc Lett 26(2): 11
  2. Sarmiento (Oct 2000) Federal Practitioner, p.45-50
  3. Strayer in Swadron (2023) EM:Rap 23(6): 9-11
  4. Enoch (2002) Am Fam Physician 65(3):441-50 [PubMed]
  5. Fleming (1997) JAMA 277:1039-45 [PubMed]
  6. Willenbring (2009) Am Fam Physician 80(1): 44-50 [PubMed]
  7. Winslow (2016) Am Fam Physician 93(6): 457-65 [PubMed]