Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
brief interventions
People with unhealthy alcohol use that do not meet alcohol-use disorder criteria can often be treated with a brief intervention. These interventions are typically 5-15 minutes long, follow a structured outline, provide education, and may or may not include follow-up treatment. In patients with at-risk drinking, these interventions reduce total alcohol consumed.[63][64]
Brief interventions can consist of one or more sessions in the clinic or hospital setting (e.g., emergency department or inpatient unit), during which education and feedback about the patient's alcohol use and its consequences are provided in a supportive and empathic fashion.
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Brief interventions may be improved by follow-up; for instance, one multi-site randomised controlled trial in the trauma setting showed improvement in several drinking measures at up to 12 months for patients who received an individualised follow-up phone call in addition to brief motivational interviewing, compared with those who just received the interview.[65] A formal means of assessing the effectiveness of the plan and follow-up visits with the clinician should be part of the plan.[66] Though brief interventions are easy to administer, they go beyond simply telling patients to reduce their alcohol use: in studies of their effectiveness, clinicians were trained to provide structured feedback based on an individual’s risk and desire to change their behaviour. One commonly used structure is the FRAMES method: Feedback, Responsibility, Advice, Menu of options, Empathic style, Self-efficacy.
[Figure caption and citation for the preceding image starts]: FRAMES method for brief interventionAdapted by Best Practice topic authors from: Bien TH et al. Addiction. 1993 Mar;88(3):315-35 [Citation ends].
psychosocial treatment
Non-pharmacological approaches can be useful for many patients with alcohol-use disorder, as they provide strategies to help patients avoid returning to alcohol use, enhance self-efficacy, and reduce the impact of stressors that can precipitate return to use. Interventions may be individual or group-based. There is no strong evidence for any one approach, and therefore the patient’s preference should guide treatment choice.[68]
Outpatient and intensive outpatient addiction treatment programmes typically include treatment sessions scheduled from once- or twice-weekly to several times a week, with treatment extending over several weeks to months (or longer). The interventions provided may include: cognitive behavioural therapy (to assist patients in coping with thoughts of return to alcohol use and negative cognitions), counselling strategies (return-to-use prevention, coping with stressors, forming beneficial relationships), and referral of patients to self-help groups, such as Alcoholics Anonymous (AA).[12][69][70] In a meta-analysis of 6 studies, the addition of manualised cognitive behavioural therapy did not improve return-to-use rates when added to naltrexone therapy.[71]
AA, founded in 1939, is the most common programme. Its primary goal is to help individuals maintain total abstinence from alcohol and other addictive substances.
Alcoholics Anonymous
Opens in new window
[ ]
[Evidence A] Self-help programmes such as AA can provide valuable additional support for many patients and their families. Patients indicating benefit from support group attendance should be encouraged to attend the group meetings over an extended timeframe; some patients may benefit from attending indefinitely. In one large randomised controlled trial (RCT), AA improved drinking outcomes, largely through improvements in adaptive social network changes and social self-efficacy.[72] Each AA group is independent, so patients should be encouraged to try several if one is not a good fit. For those who have negative experiences or views of AA, it is important that clinicians are aware of alternatives, such as Smart Recovery groups.
Reassess every 3 months for worsening use or harms of alcohol.
naltrexone
Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[73] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol-use disorder and in those with significant alcohol cravings.[12][40][55]
Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[74][75][76]
Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[77]
[ ]
In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[78] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[79] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[60] Further treatment is determined through shared decision-making.
Primary options
naltrexone: 50 mg orally once daily; 380 mg intramuscularly every 4 weeks
psychosocial treatment
Non-pharmacological approaches can be useful for many patients with alcohol-use disorder, as they provide strategies to help patients avoid returning to alcohol use, enhance self-efficacy, and reduce the impact of stressors that can precipitate return to use. Interventions may be individual or group-based. There is no strong evidence for any one approach, and therefore the patient’s preference should guide treatment choice.[68]
Outpatient and intensive outpatient addiction treatment programmes typically include treatment sessions scheduled from once- or twice-weekly to several times a week, with treatment extending over several weeks to months (or longer). The interventions provided may include: cognitive behavioural therapy (to assist patients in coping with thoughts of return to alcohol use and negative cognitions), counselling strategies (return-to-use prevention, coping with stressors, forming beneficial relationships), and referral of patients to self-help groups, such as Alcoholics Anonymous (AA).[12][69][70] In a meta-analysis of 6 studies, the addition of manualised cognitive behavioural therapy did not improve return-to-use rates when added to naltrexone therapy.[71]
AA, founded in 1939, is the most common programme. Its primary goal is to help individuals maintain total abstinence from alcohol and other addictive substances.
Alcoholics Anonymous
Opens in new window
[ ]
[Evidence A] Self-help programmes such as AA can provide valuable additional support for many patients and their families. Patients indicating benefit from support group attendance should be encouraged to attend the group meetings over an extended timeframe; some patients may benefit from attending indefinitely. In one large randomised controlled trial (RCT), AA improved drinking outcomes, largely through improvements in adaptive social network changes and social self-efficacy.[72] Each AA group is independent, so patients should be encouraged to try several if one is not a good fit. For those who have negative experiences or views of AA, it is important that clinicians are aware of alternatives, such as Smart Recovery groups.
Reassess every 3 months for worsening use or harms of alcohol.
naltrexone
Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[73] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol-use disorder and in those with significant alcohol cravings.[12][40][55]
Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[74][75][76]
Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[77]
[ ]
In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[78] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[79] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[60] Further treatment is determined through shared decision-making.
Primary options
naltrexone: 50 mg orally once daily; 380 mg intramuscularly every 4 weeks
naltrexone
Naltrexone is the best studied medication to support reduced alcohol intake and abstinence in adolescents, and has been found to reduce cravings in adolescents in a few small trials.[104]
Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[73] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol-use disorder and in those with significant alcohol cravings.[12][40][55]
Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[74][75][76]
Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[77]
[ ]
In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[78] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[79] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[60] Further treatment is determined through shared decision-making.
Primary options
naltrexone: 50 mg orally once daily; 380 mg intramuscularly every 4 weeks
psychosocial treatment
Psychosocial interventions increase abstinence rates, compared with usual care or no intervention, in pregnant women who consume alcohol.[95] There is no strong evidence for any one approach, and therefore the patient’s preference should guide treatment choice.[68]
Outpatient and intensive outpatient addiction treatment programmes typically include treatment sessions scheduled from once- or twice-weekly to several times a week, with treatment extending over several weeks to months (or longer). The interventions provided may include: cognitive behavioural therapy (to assist patients in coping with thoughts of return to alcohol use and negative cognitions), counselling strategies (return-to-use prevention, coping with stressors, forming beneficial relationships), and referral of patients to self-help groups, such as Alcoholics Anonymous (AA).[12][69][70] In a meta-analysis of 6 studies, the addition of manualised cognitive behavioural therapy did not improve return-to-use rates when added to naltrexone therapy.[71]
AA, founded in 1939, is the most common programme. Its primary goal is to help individuals maintain total abstinence from alcohol and other addictive substances.
Alcoholics Anonymous
Opens in new window
[ ]
[Evidence A] Self-help programmes such as AA can provide valuable additional support for many patients and their families. Patients indicating benefit from support group attendance should be encouraged to attend the group meetings over an extended timeframe; some patients may benefit from attending indefinitely. In one large randomised controlled trial (RCT), AA improved drinking outcomes, largely through improvements in adaptive social network changes and social self-efficacy.[72] Each AA group is independent, so patients should be encouraged to try several if one is not a good fit. For those who have negative experiences or views of AA, it is important that clinicians are aware of alternatives, such as Smart Recovery groups.
Reassess every 3 months for worsening use or harms of alcohol.
naltrexone
There are no RCTs evaluating the effectiveness of pharmacological interventions to improve maternal, birth, and infant outcomes in pregnant women enrolled in alcohol treatment programmes.[96] Given the impact of alcohol on pregnancy, however, medications should be considered for women who are pregnant and are unable to stop drinking without pharmacological support.
Naltrexone is the best-studied in pregnant patients, although primarily in opioid use disorder, and is not associated with birth defects.[97] It is generally recommended to switch to the oral formulation at 36 weeks’ gestation to allow for effective pain management at birth.
Naltrexone is an opioid receptor antagonist that decreases alcohol use by attenuating the rewarding and reinforcing effects of alcohol. Specifically, naltrexone blocks stimulation of the opioid receptor by endogenous opioids and decreases dopamine release in the ventral tegmental area.[73] It is available in oral and intramuscular formulations. It is particularly useful in patients with a family history of alcohol-use disorder and in those with significant alcohol cravings.[12][40][55]
Oral naltrexone can be started in patients who are still drinking, and it is usually well tolerated. Naltrexone can precipitate opioid withdrawal in those with opioids in their system. It is not started in patients until they have been opioid-free for several days (7-10 days) and is contraindicated in patients who require opioid agonists for pain or opioid use disorder. Naltrexone can cause stomach discomfort and a mild increase in liver function tests, especially in the oral formulation. As such, the oral formulation is not recommended in patients with alanine aminotransferase (ALT) measurements greater than 5 times the normal limit. Intramuscular naltrexone appears to be safe except in acute liver failure or decompensated cirrhosis. As it does not undergo first pass metabolism in the liver, serum concentration is more predictable and it is considered safer.[74][75][76]
Treatment with naltrexone reduces heavy drinking days, increases abstinence, and reduces the risk of returning to any or heavy drinking at 3 and 12 months post-treatment, compared with placebo.[77]
[ ]
In a meta-analysis of 122 studies, the number needed to treat (NNT) to prevent return to drinking for oral naltrexone was 20, and the NNT to reduce heavy drinking was 12.[78] The intramuscular formulation of naltrexone may be more effective in patients with difficulty taking daily medications.[79] Naltrexone can be used as a monotherapy or in combination with gabapentin, topiramate, or acamprosate.
Medications should be continued for 6 months after abstinence is achieved, if that is the patient's goal.[60] Further treatment is determined through shared decision-making.
Primary options
naltrexone: 50 mg orally once daily; 380 mg intramuscularly every 4 weeks
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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