Choosing initial pharmacotherapy for moderate or severe alcohol use disorder in individuals with opioid use disorder or clinically indicated opioid use^*

CrCl: creatinine clearance.

* This algorithm assumes that treatment for alcohol withdrawal is not necessary or has already been completed. Additionally, this algorithm assumes that the individual is not pregnant.

¶ For individuals who are agreeable to treatment for opioid use disorder who are not willing to undergo medically supervised withdrawal, we treat opioid use disorder with an opioid agonist such as buprenorphine or methadone. Refer to UpToDate content for further discussion of the treatment of opioid use disorder.

Δ Individuals with opioid use disorder who are agreeable to treatment with naltrexone require medically supervised withdrawal prior to treatment.

◊ We avoid disulfiram in individuals with Child-Pugh Class B or C. Acamprosate is preferred; however, topiramate or naltrexone are acceptable alternatives. Our choice is based on the presence of other co-occurring conditions.

§ We are cautious when prescribing acamprosate to individuals with kidney dysfunction. We do not treat with acamprosate in individuals with CrCl ≤30 mL/min. We reduce the dose of acamprosate (eg, 333 mg orally three times daily) in patients with moderate kidney function impairment (ie, CrCl 30 to 50 mL/min). Refer to UpToDate content on the pharmacologic management of alcohol use disorder for further discussion of the use of acamprosate.

¥ We are cautious in prescribing topiramate to individuals with a cognitive disorder. Topiramate has been associated with cognitive deficits.

‡ While abstinence remains the primary goal of treatment for individuals with alcohol use disorder, reduction of heavy drinking may be acceptable for patients who lack readiness to quit.

† We are extremely cautious in prescribing disulfiram to individuals with a cognitive disorder or who may not fully understand the interactions between disulfiram and use of alcohol (eg, disulfiram reaction).