20th February 2024

Treatment of alcohol dependence

The goal for the treatment of alcohol dependence is to reduce the amount of alcohol intake or abstinence, and the patient guides this.

Psychological treatment 

Psychosocial interventions are the 1st line intervention recommended by NICE, and this is often in the form of brief intervention. A brief intervention aims to guide patients through the impact of alcohol use and setting goals to reduce their alcohol intake. This is usually undertaken at a primary care level but can be done while a patient is an inpatient. The critical part of this intervention is allowing the patient to acknowledge the harm of drinking, identifying their barriers to change and setting realistic goals for change. 

Patients should also be directed towards community networks or self-help groups, including Alcoholics Anonymous and SMART Recovery, which can help with the process. Other psychological therapies, including cognitive behavioural therapy, environmental-based therapy and motivational interviewing, have been shown to impact reducing alcohol use positively. 

Pharmacological treatment 

Pharmacological therapies are often used in the management of moderate-severe alcohol dependence along with patients with harmful drinking or mild alcohol dependence who have had limited benefit from psychosocial interventions. 

The mainstay of treatment is with acamprosate, naltrexone and disulfiram. Prior to commencing treatment, it is essential to determine any co-existing substance misuse, medication history, including opioid use and baseline blood tests to assess for liver and renal impairment. Patients should also be under regular review while on treatment. 

Naltrexone is a μ-opioid receptor antagonist and appears to affect the hypothalamus-pituitary-adrenal axis to suppress alcohol consumption. It is used as a first-line treatment alongside acamprosate, as it can be used while patients remain on alcohol. It appears to be helpful against craving symptoms. It is contraindicated in patients with hepatic failure or those on opioids. Common side effects include nausea, headaches, and dizziness. Liver function test monitoring is needed for the initial several weeks. 

Acamprosate is an alternative 1st line treatment for alcohol dependence and is typically used on patients who have a contraindication towards naltrexone. Acamprosate works by modulating the glutamate receptors within the CNS. It effectively maintains abstinence and has increased efficacy in those who have stopped alcohol consumption. It is contraindicated in patients with impaired renal function (eGFR<30). Common side effects include diarrhoea, fatigue and nervousness. 

Disulfiram is the last recommended medication and is usually used as an adjunct medication due to poor compliance. Disulfiram’s mode of action is blocking the metabolism of alcohol, resulting in the build-up of acetaldehyde in the body. This results in systemic symptoms, including flushing, nausea, diarrhoea, tachycardia and hypotension when alcohol is taken in conjunction with disulfiram. Patients should abstain from alcohol for at least 24 hours prior to commencing disulfiram, and this should usually be done under supervision. Patients should be warned of the reaction when taken with alcohol and the small risk of hepatotoxicity. 

References

• National Institute for Health and Care Excellence. (2011 Feb 23). Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. Accessed on 2022 Mar 23. Available from: https://www.nice.org.uk/guidance/cg115/resources/alcoholuse-disorders-diagnosis-assessment-and-management-of-harmful-drinking-highrisk-drinking-and-alcohol-dependence-pdf-35109391116229. 
• Drummond, C. (2018). Alcohol-use disorder. Accessed on 2022 Mar 23. Available from: https://bestpractice.bmj.com/topics/en-gb/198. 
• Holt, S. (2022 Mar 14). Alcohol use disorder: Pharmacologic management. Accessed on 2022 Mar 25. Available from: https://www.uptodate.com/contents/alcohol-use-disorder-pharmacologic-management?topicRef=7810&source=see_link#H3866314010. 
• Saxon, A. (2021 Oct 21). Alcohol use disorder: Psychosocial treatment. Accessed on 2022 Mar 25. Available from: https://www.uptodate.com/contents/alcohol-use-disorder-psychosocial-treatment?topicRef=14832&source=see_link.