Background
Epidemiology
- In 2018, 14.4 million adults ages 18 and older had an AUD, including 9.2 million men and 5.3 million women.
Neurobiology
- People who are chronically exposed to alcohol experience changes in neural circuits involved with arousal, reward, and stress responses, utilizing dopamine, GABA, glutamate, and serotonin, leading to changes in sensitivity to alcohol’s long term effects.
Diagnosis
Screening:
- Single question screener: “how many times in the past year have you had 5 (for men) or 4 (for women) or more drinks in a day?”
- ≥ 1 binge-drinking day in past year -> sensitivity 82-87%, specificity 61-79%.
- AUDIT-C: 1st 3 questions of AUDIT, score 0-12.
- ≥ 4 -> sensitivity 74-76%, specificity 80-83%.
- ≥ 3 -> sensitivity 74-88%, specificity 64-83%.
- AUDIT: 10-item self-report instrument, score 0-40.
- ≥ 4 -> sensitivity 84-85%, specificity 77-84%.
Assessment for AUD via DSM 5: AUD is a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the following occurring within a 12-month period:
- 6Cs (lost control, unable to cut back, cravings, health consequences, physical consequences, relationship consequences).
- Spent a lot of time drinking or recovering.
- Interfered with home/school/work role.
- Give up other important activities.
- Increased tolerance.
- Withdrawal symptoms.
- 2-3=mild, 4-5=moderate, and 6 or more severe AUD
Treatment
For those with moderate to severe AUD.
- Assess if pregnant: no AUD medication for pregnant patients, use psychosocial treatment.
- 1st line: naltrexone, NNT 12 for reduced use, 20 for stopping.
- Extended-release naltrexone.
- 2nd line: acamprosate (only for patient interested in maintaining sobriety, if not, see 3rd line).
- 3rd line: gabapentin.
- Can be used as adjuvant to naltrexone.
- 4th line: topiramate and others.
- Psychosocial treatment (groups such as AA, SMART Recovery, individual therapy, intensive outpatient, and residential treatment).
|
Medication |
Dosage |
Mechanism |
Adverse Effect |
Contra-indications |
Use in liver or renal disease |
Considerations |
|---|---|---|---|---|---|---|
|
Disulfiram |
250-500 mg daily |
Aldehyde dehydrogenase inhibitor à negative physical effects of EtOH intake |
Drowsiness, diarrhea, headache, dermatitis, hepatitis (rare) |
LFT > 5x ULN Alcohol use in past 24 hours Severe CV disease |
Liver: no Renal: yes |
Good for highly motivated patients or patients already on methadone DOT |
|
Naltrexone |
25 mg on day 1, followed by 50 mg daily; available as long acting injection |
µ-opioid antagonist à reduces cravings, blocks pleasurable effect of EtOH, reduces binges |
GI upset, transaminitis, somnolence, insomnia, dizziness |
LFT > 5x ULN Decompensated cirrhosis Short-acting opioids in past 24 hours Long-acting opioids in past 7 days |
Liver: no Renal: yes |
Can’t be used with opioids |
|
Acamprosate |
666 mg TID (6 pills!) |
Modulates glutamate hyperactivity à improves dysphoria, promotes abstinence |
Diarrhea, fatigue |
Dose reduce in CKD |
Liver: yes Renal: reduce in CKD to 333 mg TID |
Only useful in maintaining sobriety. If patient wants to cut down but not stop drinking, try another option
|
|
Gabapentin (not FDA approved) |
Day 1-3: 300 mg TID, followed by 600 mg TID |
Facilitates GABA à improves anxiety, sleep, dysphoria |
Somnolence, dizziness |
Dose reduce in CKD |
Liver: yes Renal: dose reduce |
Can use with naltrexone |
|
Topiramate (not FDA approved) |
Week 1: 25 mg qHS, week 2: 25 mg BID, increase dose by 25 mg BID per week to reach 150 mg BID |
Facilitates GABA, decreases glutamate à improves dysphoria, cravings, impulsivity |
Cognitive slowing, paresthesia, somnolence, metabolic acidosis (rare), kidney stones, glaucoma |
Dose reduce in CKD Hx of kidney stones Hx of narrow-angle glaucoma Pregnancy planning Using OCP |
Liver: yes Renal: dose reduce |
Not for use in pregnancy |
Kranzler H R, Soyka M. Diagnosis and Pharmacotherapy of Alcohol Use Disorder
Addiction Care Team (ACT) AUD power point slides