Anticraving medication for moderate to severe alcohol use disorder

Jon Mong; Keith Ahamad; Paxton Bach

doi:10.1503/cmaj.200895

Anticraving medications help patients to reduce their alcohol consumption by controlling cravings

Alcohol use disorder is characterized by compulsive use, lack of control and harmful consequences of alcohol. Men who have had more than 5 standard drinks and women who have had more than 4 standard drinks on 1 occasion within the past year should be assessed for alcohol use disorder.1 Anticraving medications can play an effective role in overcoming moderate to severe alcohol use disorder and can be prescribed by primary care physicians.1^,2

Psychosocial interventions should be offered in addition to evidence-based pharmacotherapy

Effective psychosocial interventions for alcohol use disorder can be accessed through professionals or peer support groups. Standardized interventions include motivational interviewing and cognitive-behavioural therapy.1^,2

First-line pharmacotherapy includes naltrexone and acamprosate

Naltrexone can be initiated any time at a dose of 25 mg/d and titrated to 50 mg/d (number needed to treat [NNT] of 12 to reduce heavy drinking; NNT of 20 for abstinence in combination with psychosocial interventions).3 Adverse effects include transient dizziness and nausea (number needed to harm [NNH] of 16 and 9, respectively). 3 Acamprosate can be started at 333 mg 3 times per day (TID) after 3 days of abstinence, then titrated to 666 mg TID (NNT of 12 for abstinence in combination with psychosocial interventions).3 Adverse effects include transient anxiety and diarrhea (NNH of 7 and 11, respectively).3 Naltrexone is contraindicated in patients with severe hepatic dysfunction and concomitant opioid use (including opioid agonist therapy). Acamprosate is contraindicated in those with severe renal dysfunction.2

Second-line agents include topiramate and gabapentin

Topiramate is less well studied but may be noninferior to naltrexone.4 It is started at 25 mg/d and titrated by 25 mg weekly to a dose of 100–300 mg/d, but has significant adverse effects, including paresthesias (NNH of 4) and a perception of cognitive “fogging” (NNH of 12).3 Gabapentin at doses of 300–600 mg TID has been shown to help with harm reduction, reducing the proportion of heavy drinking days,5 although adverse effects include fatigue and dizziness (NNH of 10).5

Anticraving therapies are not a treatment for acute alcohol withdrawal

Benzodiazepines and thiamine remain the cornerstone of treatment for complicated withdrawal.2 Anticraving therapies help patients reduce alcohol use but have no role in treating acute withdrawal.

Footnotes

CMAJ Podcasts: author interview at www.cmaj.ca/lookup/doi/10.1503/cmaj.200895/tab-related-content
Competing interests: Keith Ahamad reports holding a Canadian Institutes of Health Research clinician scholar award through the University of British Columbia, and partnering with the British Columbia BC Centre on Substance Use, which received funding from the province of British Columbia. Paxton Bach reports receiving funds from the Michael Smith Foundation for Health Research. No other competing interests were declared.
This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/

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