New Alcohol Use Disorder Guideline Emphasizes Medication

Batya Swift Yasgur, MA, LSW

January 10, 2018

A new practice guideline issued by the American Psychiatric Association (APA) recommends pharmacotherapies to treat alcohol use disorder (AUD). The recommendations reflect a broader approach that includes assessment and treatment planning.

Naltrexone and acamprosate are recommended for patients with moderate to severe AUD. Topiramate and gabapentin are suggested if these first-line approaches are unsuccessful. Disulfiram is not recommended as first-line treatment.

"The topic of AUD came to the top of our list as a topic to pursue in guideline development because it is highly prevalent and its rates are increasing, but despite the FDA-approved pharmacologic interventions in our armamentarium, the disorder is remarkably undertreated," lead author Victor Reus, MD, Distinguished Professor of Psychiatry, University of California, San Francisco, told Medscape Medical News.

"This is an area of practice where, given the statistics, there’s a tremendous upside for psychiatrists to assume responsibility for treatment, and a tremendous upside to the benefits not only for individuals treated but for society at large," he said.

The executive summary was published online January 1 in the American Journal of Psychiatry.

Benefits and Harms

Utilizing the Grading of Recommendations Assessment, Development and Evaluation system, the authors developed the guideline by weighing the potential benefits and harms of each statement and identifying the level of confidence in that determination.

The term "recommendation" was used when the authors had confidence that the benefits of the intervention clearly outweigh the harms. The term "suggestion" indicates uncertainty regarding the balance of benefits and harms (denoted by the numbers 1 and 2, respectively).

The authors also rated each statement as high, moderate, or low (denoted by the letters A, B, and C, respectively), on the basis of the strength of the supporting evidence.

The guideline's recommendations fall under four categories: assessment and determination of treatment goals; selection of a pharmacotherapy; recommendations against use of medications in particular patients; and treatment of AUD and comorbid opioid use disorder.

Treatment Goals

  • During the initial psychiatric evaluation of a patient suspected of having AUD, assess current and past use of tobacco, alcohol, and other substances, including prescription and over-the-counter products. (1C)

  • During the initial psychiatric evaluation, include a quantitative behavioral measure (eg, the CAGE or AUDIT-C) to detect the presence and severity of alcohol misuse. (1C)

  • During the initial evaluation and during ongoing treatment, use physiologic biomarkers to identify persistently elevated levels of alcohol consumption. (2C)

  • Assess patients for co-occurring conditions (eg, substance use, medical, and psychiatric disorders). (1C)

  • Establish the initial goals of AUD treatment (eg, abstinence, reduction, or moderation of alcohol use) with the patient and document the goals in the patient’s medical record. (2C)

  • Include and document discussion of the patient’s legal obligations in the initial setting of treatment goals. (2C)

  • Include in the initial discussion the impact of continued alcohol use on risks to self and others and document the discussion. (2C)

  • Patients with AUD should have a documented comprehensive and person-centered treatment plan that includes evidence-based nonpharmacologic and pharmacologic interventions. (1C)

Pharmacotherapy Selection

Offer naltrexone or acamprosate to patients with moderate to severe AUD who

  • have a goal of reducing alcohol consumption or achieving abstinence;

  • prefer pharmacotherapy or have not responded to nonpharmacologic treatments alone;

  • have no contraindications to the use of these medications. (1B)

Offer disulfiram to patients with moderate to severe AUD who

  • have a goal of achieving abstinence;

  • prefer disulfiram or are intolerant to or have not responded to naltrexone and acamprosate;

  • are capable of understanding the risks of alcohol consumptions while taking disulfiram;

  • have no contraindications to the use of this medication. (2C)

Offer topiramate or gabapentin to patients with moderate to severe AUD who

  • have a goal of reducing alcohol consumption or achieving abstinence;

  • prefer these medications, or are intolerant or non-responsive to naltrexone and acamprosate;

  • have no contraindications to these medications. (2C)

Recommendations Against Use of Specific Medications

  • Do not use antidepressants for AUD unless there is a co-occurring disorder for which antidepressants are indicated. (1B)

  • Do not use benzodiazepines except for treating acute alcohol withdrawal or unless there is a co-occurring disorder for which benzodiazepines are indicated. (1C)

  • Do not use pharmacologic treatments for pregnant or breastfeeding women with AUD unless treating acute alcohol withdrawal with benzodiazepines or unless there is a co-occurring disorder warranting pharmacotherapy. (1C)

  • Do not use acamprosate in patients with severe renal impairment. (1C)

  • Do not use acamprosate as first-line treatment in patients with mild to moderate renal impairment. (1C)

  • Do not use naltrexone in patients with acute hepatitis or hepatic failure. (1C)

  • Do not use naltrexone in individuals who use opioids or in cases in which the need for opioids is anticipated. (1C)

Treatment of AUD and Co-occurring Opioid Use Disorder

Prescribe naltrexone to individuals who

  • wish to abstain from opioid use and either abstain from or reduce alcohol use;

  • are able to abstain from opioid use for a clinically appropriate time prior to naltrexone initiation. (1C)

Pharmacotherapy Underutilized

Commenting on the guideline for Medscape Medical News, Ihsan M. Salloum, MD, MPH, professor of psychiatry and chief, Division of Alcohol and Drug Abuse Treatment and Research, Department of Psychiatry, University of Miami Miller School of Medicine, Florida, called it "a positive statement coming from the APA to increase awareness about the availability of effective and safe medication to help with alcohol use disorder."

He noted that prescription of these medications "by community physicians has been very limited, and as a consequence, many who could benefit from these medications do not use them."

Also commenting on the guideline for Medscape Medical News, Andrew Saxon, MD, chair, Council on Addiction Psychiatry at the APA, and professor in the Department of Psychiatry and Behavioral Science, University of Washington, Seattle, who was not a member of the writing group, agreed.

"Only a very small percentage of people in the United States with AUD actually get pharmacotherapy, despite the availability of FDA-approved mediations that have demonstrated efficacy in randomized controlled trials," he observed.

One reason some psychiatrists undertreat AUD is that they lack training or consider it outside the scope of their practice, according to Dr Reus.

Yet, "there is such a high comorbidity between psychiatric disorders and AUD that psychiatrists encounter it frequently, and one of the purposes of the guideline is to try to persuade psychiatric practitioners that this is indeed within the scope of their practice," he said.

"If we can increase the number of people receiving and benefiting from treatments, the geometric benefits that could accrue to society from that involvement would be significant indeed," he emphasized.

What's Different

"Although the guideline does not discuss medications that have never been discussed before, it does succinctly and with cutting-edge scientific rigor offer the potential positive aspects and contraindications of each agent, so the reader can easily glean all the essential information," said Dr Saxon.

He noted "subtle differences" between the APA guideline and the guideline from the Department of Veterans Affairs/Department of Defense (VA/DoD), which is "probably the most recent comparable guideline."

For example, "The VA/DoD guideline ranks naltrexone, acamprosate, disulfiram, and topiramate as first-line medications, with gabapentin secondary, while APA recommends naltrexone and acamprosate as first line, with disulfiram a suggested treatment, if the goal is total abstinence and disulfiram is preferred by the patient.

"I am a proponent of person-centered medicine, and I find it very positive to see it mentioned in the guideline as a recommendation, also implying that we should use evidence-based treatments tailored to the person seeking care," Dr Salloum said.

Dr Saxon agreed, adding that most patients will likely need "some sort of behavioral intervention to go along with the pharmacologic therapy" and that "mutual help groups" can be useful as well.

"I tell patients that I do not require them to attend Alcoholics Anonymous [AA], but I strongly encourage it," he said.

He cautioned that some AA groups discourage the use of medications and that the experience of AA differs from meeting to meeting.

"I suggest that patients try several meetings in different places until they find one that clicks for them," he said. He noted that Smart Recovery, which is available online, can be an option for patients who find AA "unappealing."

Dr Reus concurred that evidence-based nonpharmacologic therapies, such as cognitive-behavioral therapy and motivational enhancement therapy, tailored to each patient's individual needs and circumstances, are important components of "a comprehensive treatment approach" to address "the psychosocial factors that go along with, contribute to, and perpetuate AUD."

Guideline development was funded and supported by the APA without any involvement of industry or external funding. Full disclosures for the guideline authors are listed on the APA's website, Psychiatry Online.

Am J Psychiatry. Published online January 5, 2018. Abstract

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