Psychiatry Clinical Practice Guidelines: 2018 Midyear Review

John Anello; Brian Feinberg; John Heinegg; Yonah Korngold; Richard Lindsey; Cristina Wojdylo; Olivia Wong, DO

Disclosures

July 10, 2018

In This Article

Alcohol Use Disorder

American Psychiatric Association

Naltrexone and acamprosate are recommended for patients with moderate to severe AUD.

Topiramate and gabapentin are suggested if first-line approaches are unsuccessful.

Disulfiram is not recommended as first-line treatment.

During the initial psychiatric evaluation of a patient suspected of having AUD, assess current and past use of tobacco, alcohol, and other substances, including prescription and over-the-counter products.

During the initial psychiatric evaluation, include a quantitative behavioral measure (eg, the CAGE or AUDIT-C) to detect the presence and severity of alcohol misuse.

During the initial evaluation and during ongoing treatment, use physiologic biomarkers to identify persistently elevated levels of alcohol consumption.

Assess patients for co-occurring conditions (eg, substance use, medical, and psychiatric disorders).

Establish the initial goals of AUD treatment (eg, abstinence, reduction, or moderation of alcohol use) with the patient and document the goals in the patient’s medical record.

Include and document discussion of the patient’s legal obligations in the initial setting of treatment goals.

Include in the initial discussion the impact of continued alcohol use on risks to self and others and document the discussion.

Patients with AUD should have a documented comprehensive and person-centered treatment plan that includes evidence-based nonpharmacologic and pharmacologic interventions.

Offer naltrexone or acamprosate to patients with moderate to severe AUD who have a goal of reducing alcohol consumption or achieving abstinence; who prefer pharmacotherapy or have not responded to nonpharmacologic treatments alone; who have no contraindications to the use of these medications.

Offer disulfiram to patients with moderate to severe AUD who have a goal of achieving abstinence; who prefer disulfiram or are intolerant to or have not responded to naltrexone and acamprosate; who are capable of understanding the risks of alcohol consumptions while taking disulfiram; who have no contraindications to the use of this medication.

Offer topiramate or gabapentin to patients with moderate to severe AUD who have a goal of reducing alcohol consumption or achieving abstinence; who prefer these medications or are intolerant or nonresponsive to naltrexone and acamprosate; who have no contraindications to these medications.

Do not use antidepressants for AUD unless there is a co-occurring disorder for which antidepressants are indicated.

Do not use benzodiazepines except for treating acute alcohol withdrawal or unless there is a co-occurring disorder for which benzodiazepines are indicated.

Do not use pharmacologic treatments for pregnant or breastfeeding women with AUD unless treating acute alcohol withdrawal with benzodiazepines or unless there is a co-occurring disorder warranting pharmacotherapy.

Do not use acamprosate in patients with severe renal impairment or as first-line treatment in patients with mild to moderate renal impairment.

Do not use naltrexone in patients with acute hepatitis or hepatic failure or in individuals who use opioids or in cases in which the need for opioids is anticipated.

References

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