Linking To And Excerpting From "The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder"

The complete 226 p PDF link to The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder, Jan 5, 2018

Today, I link to and excerpt from the summary of The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder [PubMed Abstract] [Full-Text PDF]. Am J Psychiatry. 2018 Jan 1;175(1):86-90. doi: 10.1176/appi.ajp.2017.1750101.

All that follows is from the above resource.

INTRODUCTION

The goal of this guideline1 is to improve the quality of care and
treatment outcomes for patients with alcohol use disorder
(AUD), as defined by DSM-5 (American Psychiatric Association, 2013). The guideline focuses specifically on evidencebased pharmacological treatments for AUD but also includes
statements related to assessment and treatment planning that
are an integral part of using pharmacotherapy to treat AUD.
AUD pharmacotherapy is a topic of increasing interest given
the availability of several medications approved by the U.S.
Food and Drug Administration (FDA) for this disorder and
the burden of AUD in the population.
Worldwide, the estimated 12-month adult prevalence of
AUD is 8.5%, with an estimated lifetime prevalence of 20%
(Slade et al., 2016). In the United States (U.S.), AUD has
estimated values for 12-month and lifetime prevalence of
13.9% and 29.1%, respectively, with approximately half of
individuals with lifetime AUD having a severe disorder
(Grant et al., 2015). AUD places a significant strain on both
the personal and public health of the U.S. population.
According to a 2006 Centers for Disease Control and
Prevention-sponsored study (Bouchery et al., 2011), AUD
and its sequelae cost the U.S. $223.5 billion annually and
account for significant excess mortality (Kendler et al.,
2016). Despite its high prevalence and numerous negative
consequences, AUD remains undertreated. Effective and
evidence-based interventions are available, and treatment is
associated with reductions in the risk of relapse (Dawson
et al, 2006) and AUD-associated mortality (Timko et al.,
2006). Nevertheless, fewer than 1 in 10 individuals in the
U.S. with a 12-month diagnosis of AUD receive any treatment (Substance Abuse and Mental Health Services Administration, 2014; Grant et al., 2015). Receipt of evidence-based care is even less common. For example, one study found that of the 11 million people in the U.S. with AUD, only 674,000 received psychopharmacological treatment (Mark et al., 2009). Accordingly, this practice guideline provides evidence-based statements aimed at increasing knowledge and the appropriate use of medications for AUD. The overall goal of this guideline is to enhance the treatment of AUD for millions of affected individuals, thereby reducing the significant psychosocial and public health consequences of this important psychiatric condition.

Rating the Strength of Research Evidence and
Recommendations

The authors of the guideline determined each final rating,
as described in the section “Rating the Strength of Research
Evidence and Recommendations,” and each statement is
endorsed by the APA Board of Trustees. A recommendation
(denoted by the numeral 1 after the guideline statement)
indicates confidence that the benefits of the intervention
clearly outweigh harms. A suggestion (denoted by the numeral 2 after the guideline statement) indicates greater uncertainty. Although the benefits of the statement are still
viewed as outweighing the harms, the balance of benefits
and harms is more difficult to judge, or either the benefits or
the harms may be less clear. With a suggestion, patient values and preferences may be more variable, and this can
influence the clinical decision that is ultimately made. Each
guideline statement also has an associated rating for the
strength of supporting research evidence. Three ratings are
used: high, moderate, or low (denoted by the letters A, B, and
C, respectively) and reflect the level of confidence that the
evidence for a guideline statement reflects a true effect based
on consistency of findings across studies, directness of the
effect on a specific health outcome, precision of the estimate
of effect, and risk of bias in available studies (AHRQ 2014;
Guyatt et al., 2006; Balshem et al., 2011).

GUIDELINE STATEMENTS
Assessment and Determination of Treatment Goals

1. APA recommends (1C) that the initial psychiatric evaluation of a patient with suspected alcohol use disorder include assessment of current and past use of tobacco and alcohol as well as any misuse of other substances, including prescribed or over-the-counter medications or supplements.
2. APA recommends (1C) that the initial psychiatric evaluation of a patient with suspected alcohol use disorder include a quantitative behavioral measure to detect the presence of alcohol misuse and assess its severity.
3. APA suggests (2C) that physiological biomarkers be used
to identify persistently elevated levels of alcohol consumption* as part of the initial evaluation of patients with alcohol use disorder or in the treatment of individuals who have an indication for ongoing monitoring of their alcohol use.

*Alcohol Use Biomarkers from ARUP Laboratories

4. APA recommends (1C) that patients be assessed for
co-occurring conditions (including substance use disorders, other psychiatric disorders, and other medical disorders) that may influence the selection of pharmacotherapy for alcohol use disorder.
5. APA suggests (2C) that the initial goals of treatment of
alcohol use disorder (e.g. abstinence from alcohol use,
reduction or moderation of alcohol use, other elements
of harm reduction) be agreed on between the patient
and clinician and that this agreement be documented in
the medical record.
6. APA suggests (2C) that the initial goals of treatment of
alcohol use disorder include discussion of the patient’s
legal obligations (e.g. abstinence from alcohol use,
monitoring of abstinence) and that this discussion be
documented in the medical record.
7. APA suggests (2C) that the initial goals of treatment of
alcohol use disorder include discussion of risks to self
(e.g. physical health, occupational functioning, legal involvement) and others (e.g. impaired driving) from
continued use of alcohol and that this discussion be
documented in the medical record.
8. APA recommends (1C) that patients with alcohol use
disorder have a documented comprehensive and person-centered treatment plan that includes evidence-based
nonpharmacological and pharmacological treatments.

Selection of a Pharmacotherapy

9. APA recommends (1B) that naltrexone or acamprosate
be offered to patients with moderate to severe alcohol
use disorder who
• have a goal of reducing alcohol consumption or
achieving abstinence
• prefer pharmacotherapy or have not responded to
nonpharmacological treatments alone
• have no contraindications to the use of these medications
10. APA suggests (2C) that disulfiram be offered to patients
with moderate to severe alcohol use disorder who
• have a goal of achieving abstinence
• prefer disulfiram or are intolerant to or have not
responded to naltrexone and acamprosate
• are capable of understanding the risks of alcohol
consumption while taking disulfiram
• have no contraindications to the use of this medication
11. APA suggests (2C) that topiramate or gabapentin be
offered to patients with moderate to severe alcohol use
disorder who
• have a goal of reducing alcohol consumption or
achieving abstinence
• prefer topiramate or gabapentin or are intolerant to
or have not responded to naltrexone and acamprosate
• have no contraindications to the use of these medications.

Recommendations Against Use of Specific Medications

12. APA recommends (1B) that antidepressant medications
not be used for treatment of alcohol use disorder unless
there is evidence of a co-occurring disorder for which
an antidepressant is an indicated treatment.
13. APA recommends (1C) that in individuals with alcohol
use disorder, benzodiazepines not be used unless treating acute alcohol withdrawal or unless a co-occurring disorder exists for which a benzodiazepine is an indicated treatment.
14. APA recommends (1C) that for pregnant or breastfeeding women with alcohol use disorder, pharmacological treatments not be used unless treating acute alcohol withdrawal with benzodiazepines or unless a co-occurring disorder exists that warrants pharmacological treatment.
15. APA recommends (1C) that acamprosate not be used by
patients who have severe renal impairment.
16. APA recommends (1C) that for individuals with mild to
moderate renal impairment, acamprosate not be used as
a first-line treatment and, if used, the dose of acamprosate be reduced compared with recommended doses in individuals with normal renal function.

17. APA recommends (1C) that naltrexone not be used by
patients who have acute hepatitis or hepatic failure.
18. APA recommends (1C) that naltrexone not be used as
a treatment for alcohol use disorder by individuals
who use opioids or who have an anticipated need for
opioids.

GUIDELINE SCOPE

The Agency for Healthcare Research and Quality (AHRQ)
undertook a systematic review of AUD pharmacotherapy in
outpatients (Jonas et al., 2014), which serves as the foundation of the systematic review for this practice guideline.
The specific medications that are discussed in the guideline
include: acamprosate, naltrexone, disulfiram, gabapentin, and
topiramate. The guideline does not apply to the use of these
same medications for indications other than AUD. It also does
not address the management of individuals who are intoxicated with alcohol, who require pharmacotherapy for the
acute treatment of alcohol withdrawal, or who are experiencing other acute medical problems related to alcohol use.
Evidence-based psychotherapeutic treatments for AUD, including cognitive-behavioral therapy, twelve-step facilitation,
and motivational enhancement therapy (Anton et al., 2006;
Martin and Rehm, 2012, Project MATCH Research Group,
1998), also play a major role in the treatment of AUD, but
specific recommendations related to these modalities are
outside the scope of this guideline.

EVIDENCE OF BENEFITS AND HARMS OF
PHARMACOTHERAPY FOR AUD

Naltrexone and acamprosate have the best available research evidence as pharmacotherapy for patients with AUD.
The potential benefit of each medication was viewed as far
outweighing the harms of treatment or the harms of continued alcohol use, particularly when nonpharmacological
approaches have not produced an effect or when patients
prefer to use one of these medications as an initial treatment
option. Accordingly, APA recommends (Statement 9) that that
these medications be offered to patients with moderate to
severe alcohol use disorder in specific clinical circumstances.
Both naltrexone and acamprosate have positive effects overall although not all studies or outcomes show a statistically
significant benefit from these medications. Acamprosate is