What are the current guidelines for pharmacological management of alcohol use disorder in adults?

For the pharmacological management of alcohol use disorder in adults, guidelines differentiate between acute alcohol withdrawal and interventions for maintaining abstinence after successful withdrawal ¹,².

• Acute Alcohol Withdrawal:
  • Pharmacotherapy should be offered to treat the symptoms of acute alcohol withdrawal ².
  • Consider offering a benzodiazepine or carbamazepine ².
  • Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine, but it should be used with caution, in inpatient settings only, and according to the summary of product characteristics ².
  • For individuals with liver impairment, if benzodiazepines are used, consider one requiring limited liver metabolism (e.g., lorazepam); start with a reduced dose and carefully monitor liver function ¹. Avoid using benzodiazepines for people with severe liver impairment ¹.
  • Benzodiazepines should only be used for managing alcohol withdrawal and not as ongoing treatment for alcohol dependence ¹.
• Interventions for Moderate and Severe Alcohol Dependence After Successful Withdrawal:
  • After successful withdrawal, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention (such as cognitive behavioural therapies, behavioural therapies, or social network and environment-based therapies) focused specifically on alcohol misuse ¹.
  • Alternatively, consider offering acamprosate or oral naltrexone in combination with behavioural couples therapy to service users who have a regular partner and whose partner is willing to participate in treatment ¹.
  • Disulfiram:
    • If using disulfiram, treatment should start at least 24 hours after the last alcoholic drink consumed ¹.
    • The usual prescribed dose is 200 mg per day ¹.
    • If a service user continues to drink and a dose of 200 mg (taken regularly for at least 1 week) does not cause a sufficiently unpleasant reaction to deter drinking, consider increasing the dose in consultation with the service user ¹.
    • Before starting disulfiram, liver function, urea, and electrolytes should be tested to assess for liver or renal impairment ¹.
    • Prescribers must check the Summary of Product Characteristics (SPC) for warnings and contraindications, including in pregnancy and conditions such as a history of severe mental illness, stroke, heart disease, or hypertension ¹.
    • Service users taking disulfiram must stay under supervision, at least every 2 weeks for the first 2 months, then monthly for the following 4 months ¹.
    • If possible, a family member or carer, properly informed about disulfiram use, should oversee drug administration ¹.
    • Medical monitoring is required at least every 6 months after the initial 6 months of treatment and monitoring ¹.
    • Service users, their families, and carers must be warned about the interaction between disulfiram and alcohol (which can be found in food, perfume, aerosol sprays, etc.), with symptoms including flushing, nausea, palpitations, and more seriously, arrhythmias, hypotension, and collapse ¹.
    • They should also be warned about the rapid and unpredictable onset of rare hepatotoxicity; advise service users to stop taking disulfiram and seek urgent medical attention if they feel unwell or develop a fever or jaundice ¹.
• Drugs Not Routinely Used for Alcohol Misuse Alone:
  • Antidepressants (including selective serotonin reuptake inhibitors [SSRIs]) should not be used routinely for the treatment of alcohol misuse alone ¹.
  • Gammahydroxybutyrate (GHB) should not be used for the treatment of alcohol misuse ¹.