Pharmacologic treatment of moderate to severe alcohol use disorder*

LAI: long-acting injectable; IM: intramuscularly; CrCl: creatinine clearance.

* This algorithm assumes management of alcohol withdrawal is not necessary or has already been completed. Pharmacologic recommendations are for nonpregnant adults. In all individuals with moderate to severe alcohol use disorder, we recommend psychosocial treatment in addition to pharmacological treatment.

¶ For individuals who want medication treatment for opioid use disorder concomitant with alcohol use disorder and in individuals who have come off of prescribed or illicit use of opioids, we typically treat with naltrexone after a minimum washout of 7 to 10 days and in some cases up to 14 days depending on the half-life of prior opioid used, the length of time on prior medication and its dosing and frequency.

Δ The decision to treat with oral versus LAI naltrexone is one of shared decision making and takes into account patient preference, prior treatment response, and adherence to medications.

◊ Abstinence remains the primary goal of treatment of alcohol use disorder; however, reduction of heavy drinking or of lower risk use are acceptable alternatives for those who do not quit.

§ Starting dose of acamprosate should be 333 mg orally 3 times daily in individuals with CrCl 30 to 50 mL/min. Acamprosate is contraindicated in individuals with CrCl <30 mL/min. Refer to other UpToDate content.

¥ Refer to UpToDate clinical topic and separate table for recommended topiramate dose escalation schedule.

‡ Gabapentin is an alternative when other agents cannot be used or in individuals with prior response to it. Gabapentin has potential for misuse and addiction. Refer to UpToDate clinical topic, table, and drug monograph for use and dosing.

† Disulfiram may be associated with a disulfiram reaction when taken with alcohol containing products. 48 hours of abstinence from alcohol use is required prior to starting disulfiram. In individuals who cannot achieve this or maintain abstinence throughout treatment with disulfiram, we suggest treatment with topiramate as the next choice. Disulfiram is contraindicated in individuals with significant coronary disease, or in those with known hypersensitivity to the agent. Refer to other UpToDate content for treatment of disulfiram reaction.