Alcohol Use Disorder – Help From The Curbsiders

In this post I link to and excerpt from #194 Alcohol Use Disorder Treatment with Dr. Marlene Martin [Link is to the podcast and show notes, FEBRUARY 10, 2020 By CAROLYN CHAN MD from the Curbsiders [Link is to the episode list].

The clinical information in this podcast begins at 9:05. The first nine minutes is getting to know the hosts and the guest and other non-medical topics.

Here is the podcast:

And here are excerpts:

Alcohol Use Disorder Pearls

Risky drinking is defined as more than 4 drinks per occasion or more than 14 drinks a week for men.  For women the criteria are defined as more than 3 drinks an occasion, or more than 7 drinks a week.

Screen all adults in the primary care setting for risky drinking with one of the following 3 validated tools: AUDIT, AUDIT-C and the single question screen (How many times in the past year, have you had 4 or more drinks in a day (for women), or 5 or more drinks (for men)?

Motivational Interviewing tip: Use your OARS – Open ended questions, affirmations, reflective statements, and summarizing.

To help remember some of the DSM-V criteria for AUD break them up into their physiologic symptoms, a) withdrawal b) tolerance and c) the 5 C’s: loss of Control, Cravings, health and relationship Consequences, Compulsion to drink, and being unable Cut back.

FDA approved medication treatment for AUD includes naltrexone PO, naltrexone LAI (long acting injectable formulation), acamprosate, and disulfiram.

Keep in mind the patient’s comorbidities when selecting a pharmacologic treatment option.  Naltrexone is contraindicated in severe liver disease and in individuals who use opioids. Acamprosate is contraindicated in CrCl < 30, and a patient must be motivated to have adherence to daily disulfiram.

Initiate naltrexone at either 25mg PO daily on day 1 (expert opinion, to minimize side effects), and 50mg on day 2. Follow-up to assess a patient’s success in cutting back and/or abstinence in 4-6 weeks.

These meds work! For naltrexone the NNT is 12 for return to heavy drinking, 20 for return to any drinking (Jonas, 2014).

There is some evidence to suggest gabapentin, topiramate, and baclofen may help patients cut down on their number of heavy drinking days, but these medications should be considered only if the first line medications are not an option.

Psychosocial interventions may work as well as medication treatment. Any of them can be the right one, tailor the referral based on patient preference. Options include: mutual support groups (AA), harm reduction groups, therapy (individual, family, CBT), and contingency management.

See the show notes for detailed discussion.

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