Therapeutic options
Choice of medication depends on the prescriber’s comfort level, reputation of the medication, potential side-effect profile, medical contraindications, and affordability; the most important consideration, however, should be the overall goals and expectations of the patient.
There are 4 FDA-approved medications for AUD (Table); many others are off-label. It is advisable to start with an FDA-approved medication such as disulfiram for the motivated patient who has a collaborator and desires complete abstinence; naltrexone for a patient who wants to cut down on intake (a long-acting formulation can be used for poorly adherent patients); and acamprosate for a patient with at least some established sobriety who needs help with post-withdrawal sleep disturbances.
With regard to off-label medications, topiramate has the highest evidence for efficacy. Gabapentin can augment naltrexone and also helps with sleep, anxiety, withdrawal, and cravings.4,5
Psychosocial interventions
Medications are just 1 tool in recovery; patients should be engaged in a program of counseling. Encourage attendance at AA meetings. An up-and-coming concept is the use of smartphone applications to prevent relapse (or even induce remission); apps that provide an accurate blood alcohol tracking systems and integrated psychosocial therapies are in the pipeline. The novel Reddit online forum r/StopDrinking is a 24-hour peer-support community that relies on fellowship, accountability, monitoring, and anonymity; the forum can compete with motivational interviewing for efficacy in increasing abstinence and preventing relapse.
The authors would like to thank Thomas M. Penders, MS, MD, Medical Director for Consultation-Liaison Psychiatry at Cape Cod Healthcare, Hyannis, Massachusetts, and Affiliate Professor at East Carolina University, Greenville, North Carolina, for all his guidance, support, and mentorship.
In July 2017, Dr. Stanciu will be entering PGY-5 Addiction Psychiatry Fellowship, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, and Dr. Gnanasegaram has accepted a Clinical Instructor position, Department of Psychiatric Medicine, Dartmouth-Hitchcock, New Hampshire.