Version July 2025
INTRODUCTION —
Alcohol use disorders are the most prevalent of all substance use disorders worldwide. The global single-year prevalence has been estimated to be over 100 million individuals [1]. Additionally, nearly 3 million deaths (5.3 percent of all deaths globally) have been attributed to alcohol-related mortality in a single year [2].
Psychosocial interventions are effective in the treatment of alcohol use disorder; however, as many as 70 percent of individuals return to heavy drinking after psychosocial treatment alone [3-6]. Several medications can be used to treat alcohol use disorder, leading to reduced heavy drinking and increased days of abstinence [7].
This topic describes our approach to selecting treatment for alcohol use disorder. The epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of risky drinking and alcohol use disorder are reviewed elsewhere. The pharmacologic and psychosocial interventions for alcohol use disorder are also reviewed elsewhere.
●(See "Alcohol use disorder: Psychosocial management".)
●(See "Substance use disorders: Contingency management".)
●(See "Alcohol use disorder: Pharmacologic management".)
BEFORE INITIATING TREATMENT
Establish treatment goals — Abstinence remains the primary goal of treatment of alcohol use disorder and is associated with better treatment outcomes. Reduction of heavy drinking (fewer episodes of five or more drinks on any day for men and four or more drinks for women) or of higher to lower risk levels of use may be acceptable alternatives for patients who lack readiness to quit [8,9]. However, even lower levels of consumption can be problematic for some individuals.
Individuals not motivated for change — Some patients may not be ready to change or to begin treatment. The care team should expect this circumstance as normal and address it with ongoing contact and motivational interviewing. (See 'Selecting psychosocial interventions' below and "Substance use disorders: Motivational interviewing".)
Evaluate for and treat alcohol withdrawal — We evaluate all individuals for symptoms of alcohol withdrawal and their potential for withdrawal. In patients with either signs and symptoms of withdrawal or a history that suggests a high risk of withdrawal (eg, history of withdrawal), treatment is necessary prior to addressing the alcohol use disorder. Very few individuals who experience withdrawal symptoms can carry through with treatment of alcohol use disorder. Even mild symptoms of withdrawal, or fear of them, may keep the patient from cutting down or quitting.
Individuals who drink daily are at risk for alcohol withdrawal upon cutting down their use of alcohol. Individuals who have recently stopped alcohol use are also at risk for alcohol withdrawal. A full assessment and, if indicated, subsequent treatment of alcohol withdrawal should be done prior to further treatment of alcohol use disorder. (See "Alcohol withdrawal: Epidemiology, clinical manifestations, course, assessment, and diagnosis", section on 'Assessment' and "Alcohol withdrawal: Ambulatory management".)
Evaluate severity of alcohol use disorder — The treatment of alcohol use disorder is driven by severity of the disorder. In the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, text revision (DSM-5-TR), patients are assigned to a severity subtype (mild, moderate, severe) based on the number of symptoms present (table 1) [10]. Individuals with two to three symptoms are considered to have mild alcohol use disorder, individuals with four or five symptoms are considered to have moderate alcohol use disorder, and in individuals with six or more symptoms, severe alcohol use disorder is diagnosed. (See "Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment", section on 'Diagnosis'.)
Comorbid conditions and specific patient populations — In addition to severity of the alcohol use disorder and treatment goals, patient comorbidity can influence the initial choice of treatment for patients with alcohol use disorder. As an example, in an individual with hepatic disease, elevated liver enzymes affect the initial choice of medication. The use of opioids also influences the initial choice of medication. (See "Alcohol use disorder: Pharmacologic management", section on 'Considerations for specific comorbidities'.)
INITIAL TREATMENT —
Limited research data are available on comparative effectiveness and predictors of response to inform clinicians' selection among treatments for alcohol use disorder. While our suggested initial treatment modality (eg, medication management, psychotherapy, or their combination) is based on several factors including severity of the disorder, prior history, treatment goal, and practice guidelines, all treatment decisions also take into account patient preference and are made based on shared decision making [11]. We do not withhold treatment if the individual prefers one treatment without another.
Mild disorder — For patients with mild alcohol use disorder, we suggest initial treatment with one or more psychosocial interventions, such as brief motivational counseling, and participation in a mutual help group, rather than with medication. (See 'Selecting psychosocial interventions' below.)
Selecting psychosocial interventions — All patients with alcohol use disorder should be encouraged to participate in some type of psychosocial treatment, most commonly brief intervention, and in a mutual help group. For individuals with moderate to severe alcohol use disorder, we favor structured, evidence-based psychosocial interventions over psychoeducation. For individuals with mild alcohol use disorder, brief, less structured (but also evidence-based) interventions may be sufficient. An algorithm describes our approach to the psychosocial treatment of alcohol use disorder (algorithm 1).
In our clinical experience, psychosocial interventions can help many patients maintain abstinence. Existing medical evidence does not confirm the superiority of one type of intervention over others. Studies of psychosocial interventions for alcohol use disorder are limited by heterogeneity of patient populations, interventions, and outcomes. Individual interventions and studies regarding their efficacy are discussed separately. (See "Alcohol use disorder: Psychosocial management".)
In selecting psychosocial interventions, the clinician should make the patient aware of the options and their best clinical advice and allow the patient to choose among them. Typically, individuals will choose among these treatments based on availability and cost.
In our clinical experience, individual patient factors may also favor a certain approach. As examples:
●Motivational interviewing – For patients who lack motivation for treatment and those who are seriously contemplating change, motivational interviewing can be a useful initial intervention [12]. Counseling that addresses motivation to change drinking and to engage in treatment is particularly important for those assessed as having low motivation to change. Brief motivational alcohol counseling can offer a starting point for patients with a mild alcohol use disorder. (See "Alcohol use disorder: Psychosocial management", section on 'Motivational interviewing'.)
●Medical management and combined behavioral intervention – For patients with the capability and motivation, we favor interventions known as medical management, combined behavioral intervention, or a combination of both. These are discussed further elsewhere and in an algorithm (algorithm 1). (See "Alcohol use disorder: Psychosocial management", section on 'Combined behavioral intervention' and "Alcohol use disorder: Psychosocial management", section on 'Medical management' and "Alcohol use disorder: Psychosocial management", section on 'Brief intervention'.)
●Mutual help groups and contingency management – Mutual help groups are an effective, widely available, generally free option for helping patients achieve treatment goals [13]. While less available outside of research settings, contingency management is another evidence-based approach. (See "Alcohol use disorder: Psychosocial management", section on 'Mutual help groups' and "Alcohol use disorder: Psychosocial management", section on 'Contingency management'.)
●Community reinforcement, family therapy– For patients with substantial social needs, a multimodal substance use disorder (SUD) intervention that includes the provision of social services can be helpful [12]. An example is the community reinforcement approach. (See "Alcohol use disorder: Psychosocial management".)
For patients with alcohol use disorder who have an involved partner or family member, couples or family therapy or behavioral couples therapy can address relationship and family problems stemming from the alcohol use disorder. Behavioral couples therapy (with an individual who has an SUD and a significant other without an SUD) has been shown to reduce drinking in multiple clinical trials [14-18]. (See "Substance use disorders: Psychosocial management", section on 'Couples and family therapies'.)
Moderate or severe disorder — For patients with a moderate or severe alcohol use disorder, we favor first-line treatment with a combination of medication and structured, evidence-based psychosocial interventions rather than either treatment individually. In our clinical experience, the combination can improve outcomes beyond those of either intervention alone.
While clinical trials support the efficacy of psychosocial interventions compared with controls [19] and medications compared with placebo [11,20], the evidence from clinical trials is mixed as to whether combining medication with a structured psychosocial intervention leads to better outcomes for alcohol use disorder compared with either modality as monotherapy [21-23].
Medication treatment — Several agents are effective in the treatment of alcohol use disorder (AUD). We consider naltrexone, acamprosate, disulfiram, and topiramate each to be reasonable first choices. As minimal direct evidence supports one treatment over another, our choice is based on prior history, co-occurring conditions, treatment goal, and patient preference [24-35].
The pharmacologic management of alcohol use disorder in individuals with and without opioid use disorder is presented in the associated algorithms (table 2 and algorithm 2 and algorithm 3). (See "Alcohol use disorder: Pharmacologic management", section on 'Who we treat' and "Alcohol use disorder: Pharmacologic management", section on 'Choosing initial agent'.)
MONITORING AND EVALUATING RESPONSE
Monitoring — We monitor individuals who are in treatment for alcohol use disorder at least twice monthly for up to two to three months. We encourage ongoing psychosocial treatment and review adherence to and side effects of medication. After several months, we typically see the patient monthly and adjust frequency as needed (eg, for greater symptoms, increased stressors, return to use).
Toxicology testing is less commonly done in treatment of alcohol use disorder than it is when treating patients with other substance use disorders. However, in some cases, for example in an individual who drinks daily and has a goal of abstinence, it can be done weekly. The testing interval can be lengthened as the treatment progresses if response to treatment is favorable. Testing can be skipped if the patient reports use or heavy drinking. Tests we use to assess treatment progress include:
●Urine ethyl glucuronide testing can identify recent consumption, though there are false positives related to other exposures to alcohol (eg, hand sanitizer) [36,37]. We typically use this test on a weekly basis for individuals who have abstinent goals.
●Phosphatidylethanol testing [38] is a whole blood alcohol biomarker, highly specific for recent alcohol use, purported to measure alcohol consumption over the preceding two to three weeks. While it correlates well with self-reported alcohol use, it is probably best used to confirm abstinence over a period of several weeks, rather than as a measure of changes in alcohol consumption.
●Carbohydrate deficient transferrin and gamma-glutamyl-transferase can be useful for detecting changes in heavy drinking in patients who have elevated values at baseline. In these individuals, levels can be monitored during treatment; a decrease in level represents a decrease in regular heavy drinking. While gamma-glutamyl transferase is nonspecific, carbohydrate deficient transferrin is specific. However, neither test is particularly sensitive, and neither can be used to definitively confirm the absence of drinking. Gamma-glutamyl-transferase is less expensive and more widely available [36].
●Urine toxicology testing can only detect recent use (ie, in the last 72 hours); it cannot distinguish heavy from light use, nor does it provide information about symptoms of alcohol use disorder.
Laboratory tests and devices used to detect alcohol consumption are reviewed separately. (See "Risky drinking and alcohol use disorder: Epidemiology, clinical features, adverse consequences, screening, and assessment", section on 'Laboratory evaluation'.)
Defining response — The assessment of treatment response or failure is, in most cases, a process that requires monitoring over a period of weeks to months. For example, we do not assess response to treatment with medication until the patient has been on the treatment for 12 weeks with at least four weeks at the target dose.
Response to treatment is based on goals initially established. If the goal of treatment is reduction of alcohol frequency, the pattern of reduction may not be seen for several weeks. This is particularly relevant when the baseline pattern of drinking is less than daily. Additionally, if the goal of treatment is sustained abstinence, one would not conclude that a treatment has failed based on one use of alcohol (“lapse”).
However, in an individual whose goal is abstinence, a pattern of repetitive lapses signals that the current treatment is ineffective and needs to be re-evaluated. In another individual whose goal is to lessen the weekly frequency of drinking three drinks per night to two, improvement in the frequency that falls short of the goal (ie, cutting back from six nights per week to four nights per week repetitively instead of two nights per week) is a sign of inadequate response. In this case, reassessment of the treatment and consideration of increasing psychosocial support or changing medication is indicated.
PATIENTS WITH ROBUST RESPONSE OR IN REMISSION —
Individuals with alcohol use disorder who maintain abstinence or experience an adequate reduction in heavy drinking should continue psychosocial treatments for at least six months and ideally for 12 months, as this is a duration of time associated with a lower risk of recurrence. (See "Alcohol use disorder: Pharmacologic management", section on 'Good response to initial agent' and "Substance use disorders: Continuing care treatment".)
Individual factors to consider when deciding on treatment duration include the patient’s risk of recurrence, experience of side effects, and their perceived risk and preferences regarding the decision. Treatments can be made less frequent, or medications removed as per patient preference with monitoring for any craving or return to use.
The longer remission (abstinence or reduction to low-risk use) is maintained, the lower the risk of returning to heavy drinking or recurrence of alcohol use disorder. Studies have found greater stability after one, three, and five years or more.
Just as for any chronic or recurring condition, clinician-patient communication should continue after acute treatment for alcohol use disorder has been completed, even during prolonged periods of abstinence, with its frequency and intensity adjusted in accord with the patient’s clinical status. (See "Substance use disorders: Continuing care treatment".)
STRATEGIES FOR INADEQUATE RESPONSE —
The general strategy for patients who do not maintain abstinence or an adequate reduction in heavy drinking with initial treatment for alcohol use disorder is to combine modalities (eg, add either psychotherapy or pharmacologic management if not yet done). Our next steps would be to increase the intensity of the psychosocial treatment and/or change medication.
Psychosocial strategies — For a patient participating in a 12-step group and psychoeducational alcohol counseling, for example, current psychosocial treatment and 12-step involvement, subject to availability, can be:
●Increased in frequency (eg, the number of groups per week)
●Increased in level of care (eg, from outpatient to day treatment)
●Supplemented with a structured, evidenced based psychosocial intervention (if not already participating) or addition of a different modality (eg, contingency management, couples therapy)
For example, if an individual with alcohol use disorder is initially treated with outpatient weekly group and individual alcohol counseling (with participation in a mutual help group) but continues to drink regularly, the patient can be stepped up to an intensive outpatient program. If the increased counseling and support groups are not effective in reaching the goals, a partial hospital program should be considered. Additionally, other evidence-based interventions such as contingency management, where available, can be added to preexisting group treatment. (See "Substance use disorders: Contingency management".)
As with the selection of initial treatment, there are few efficacy data to guide the choice of subsequent treatment, among specific interventions or general categories of intervention (psychosocial treatments, medication, or combined modalities). The choice among them can be made on the basis of treatment availability and patient preference.
Medication strategies — For patients who have not responded adequately to one of the suggested first-line agents, our preference is to discontinue the agent then try subsequent trials of each of the other suggested first-line agents, as clinically indicated. (See 'Medication treatment' above.)
Trials have not supported using higher doses than recommended or combining medications, though there have been very few studies investigating combinations of medications. In our practice, it is not unreasonable to add a second medication if treatment goals are partially met with a first-line agent (eg, adding disulfiram if patient is partially responding to intramuscular naltrexone).
We use the same factors in choosing subsequent medications as we do for the first medication. (See 'Medication treatment' above and "Alcohol use disorder: Pharmacologic management", section on 'Choosing initial agent'.)
If all initial medications tried do not lead to response (eg, reach treatment goal), we consider second tier agents [21,39,40]. (See "Alcohol use disorder: Pharmacologic management", section on 'Second-line agents'.)
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Alcohol use disorders and withdrawal".)
SUMMARY AND RECOMMENDATIONS
●Before initiating treatment – We typically complete a full assessment and, if indicated, treatment for alcohol withdrawal prior to further treatment of alcohol use disorder. Even mild symptoms of withdrawal, or fear of them, may be a driving force in keeping individuals from cutting down or quitting. (See 'Before initiating treatment' above.)
●Initial treatment
•For all individuals – For all patients with alcohol use disorder, regardless of disorder severity or modality of their primary treatment, we suggest alcohol counseling and participation in a mutual help group (Grade 2C). These interventions may be sufficient treatment for a patient with a mild alcohol use disorder (algorithm 1). (See 'Selecting psychosocial interventions' above.)
•Moderate or severe disorder – For patients with a moderate or severe alcohol use disorder, we suggest first-line treatment with a combination of medication, structured, evidence-based psychosocial interventions, social services when needed, and mutual help groups rather than any of these modalities individually (Grade 2C). Patient access to these interventions can vary and patients differ widely in their preferences (algorithm 2 and algorithm 3). (See 'Moderate or severe disorder' above and 'Medication treatment' above.)
●Evaluating response to treatment – We schedule follow-up visits at regular intervals in order to provide the patient with encouragement and support, to engage family members if helpful, and to monitor the patients for treatment response, side effects, medication adherence, and early signs of relapse, which can lead to serious complications. (See 'Monitoring and evaluating response' above.)
●Management of robust response – We continue psychosocial treatment for at least six months and ideally for 12 months in all individuals with alcohol use disorder who maintain abstinence or experience an adequate reduction in heavy drinking. We continue medication treatment for at least a year as this is a duration of time associated with a lower risk of recurrence. (See 'Strategies for inadequate response' above.)
●Strategies for inadequate response – The general strategy for patients who do not maintain abstinence or an adequate reduction in heavy drinking with initial treatment for alcohol use disorder is to combine modalities (eg, add either psychotherapy or pharmacologic management if not yet done). Our next steps would be to increase the intensity of the psychosocial treatment and/or change medication.
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Richard Saitz, MD, MPH, FACP, DFASAM, who contributed to earlier versions of this topic review.
