14th February 2025

Management of alcohol and substance misuse

Psychological interventions are the mainstay of treatment for many substance misuse disorders, with a supportive, non-judgemental doctor-patient relationship as the first step towards this. In alcohol and opioid misuse, pharmacological therapies can be used alongside psychological therapies, particularly for more severe cases.

Psychological interventions

These include patient education, motivational interviewing, psychological therapies (e.g. cognitive behavioural therapy, CBT, behavioural therapy, family therapy, group drug counselling) and psychosocial services (e.g. counselling, employment, housing).

Alcohol: pharmacological interventions

At any opportunity, oral or parenteral thiamine supplementation should be provided to prevent Wernicke-Korsakoff syndrome.

Following successful alcohol withdrawal, the medications below can be continued for 6 months or longer and are used in combination with psychological interventions, not in isolation:

• First-line: acamprosate or naltrexone – reduce craving and relapse
• Second-line: disulfiram – induces unpleasant symptoms such as vomiting if alcohol is consumed. This carries additional risks of arrhythmias and hepatotoxicity

Alcohol: withdrawal management

Long-acting benzodiazepines (e.g. chlordiazepoxide, diazepam) reduce withdrawal symptoms and increase detoxification success. These can be given as a tapering-dose regimen or a variable-dose regimen based on symptoms (assessed using the CIWA-Ar scale, Clinical Institute Withdrawal Assessment of Alcohol Scale, revised).

Doses should be reduced in patients who are very young, very old or have liver impairment. Lorazepam is preferable in liver impairment as it relies less on hepatic metabolism.

Comorbidity

In concurrent alcohol misuse and substance misuse with opioids, stimulants, benzodiazepine or cannabis, both conditions should be actively treated. There is added risk of mortality in combined alcohol and opioid use.

With comorbidity of alcohol misuse and mood disorders, alcohol misuse should be treated first. If the patient has a significant and/or high risk mood disorder, psychiatry referral may be needed. Otherwise, they should be reassessed after 3-4 weeks of abstinence or reduction, as alcohol habits disrupt psychological interventions for mood.

References

• Editorial Team, BMJ Publishing Group. Overview of substance use disorders and overdose [Internet]. BMJ Best Practice. 2022 [cited 2022 Mar 1]. Available from: https://bestpractice.bmj.com/topics/en-gb/986
• Patkar AA, Lee JC, Burgess DM, Bhatia K, Musham S. Opioid use disorder [Internet]. BMJ Best Practice. 2020 [cited 2022 Mar 1]. Available from: https://bestpractice.bmj.com/topics/en-gb/200
• Karch SB, Wolff K. Cocaine use disorder [Internet]. BMJ Best Practice. 2022 [cited 2022 Mar 1]. Available from: https://bestpractice.bmj.com/topics/en-gb/199
• Stolbach A. Cocaine overdose [Internet]. BMJ Best Practice. 2021 [cited 2022 Mar 1]. Available from: https://bestpractice.bmj.com/topics/en-gb/340
• Albertson TE. Amfetamine use disorder [Internet]. BMJ Best Practice. 2020 [cited 2022 Mar 1]. Available from: https://bestpractice.bmj.com/topics/en-gb/201
• NHS. Alcohol Support [Internet]. NHS. 2018 [cited 2022 Mar 1]. Available from: https://www.nhs.uk/live-well/alcohol-support/calculating-alcohol-units/
• National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence [Internet]. NICE. 2011 [cited 2022 Mar 1]. Available from: https://www.nice.org.uk/guidance/cg115/chapter/1-Guidance
• National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis and management of physical complications [Internet]. NICE. 2010 [cited 2022 Mar 1]. Available from: https://www.nice.org.uk/Guidance/CG100
• Wang GS. Cannabis (marijuana): Acute intoxication[Internet]. Burns MM, Traub SJ, Ganetsky M, editors. UpToDate. 2019 [cited 2022 Mar 1]. Available from: https://www.uptodate.com/contents/cannabis-marijuana-acute-intoxication
• Cocaine [Internet]. Talk to Frank. 2019 [cited 2022 Apr 10]. Available from: https://www.talktofrank.com/drug/cocaine
• Heroin [Internet]. Talk to Frank. 2018 [cited 2022 Apr 10]. Available from: https://www.talktofrank.com/drug/heroin