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🍺 ALCOHOL USE DISORDER (AUD) - COMPLETE TREATMENT GUIDE

Integrated from: IPS Clinical Practice Guidelines (SUD), Maudsley Prescribing Guidelines 15th Ed, Textbook of Family Medicine 9e + Latest Evidence (2023-2026)

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PART 1: FOUNDATIONS - UNDERSTANDING AUD

What is AUD?

1. Drinking more/longer than intended
2. Unsuccessful efforts to cut down
3. Significant time spent obtaining/using/recovering
4. Craving
5. Failure to fulfill major role obligations
6. Continued use despite interpersonal problems
7. Important activities given up
8. Use in physically hazardous situations
9. Continued use despite knowing it causes physical/psychological problems
10. Tolerance
11. Withdrawal

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PART 2: STEP-BY-STEP CLINICAL ASSESSMENT

Step 1 - History Taking

• Detailed alcohol use history: age of onset, current use (units/day), pattern (binge vs. daily)
• Withdrawal history: any prior seizures, delirium tremens, hospital admissions
• Previous treatment attempts and outcomes
• Comorbid psychiatric disorders (depression, anxiety, PTSD, ADHD - present in 60% of adolescent SUD cases)
• Family history of AUD
• Psychosocial functioning: academic/occupational, family, legal problems
• Motivation to change (use Motivational Interviewing approach during history)

Step 2 - Screening & Rating Tools

• Males ≥16 years: 5 drinks; 14-15 years: 4 drinks; 9-13 years: 3 drinks
• Females 9-17 years: 3 drinks

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Step 3 - Laboratory Investigations

• Breathalyzer (Blood Alcohol Concentration - BAC)
• Urine: Ethyl glucuronide, Ethyl succinate (highly sensitive, but false positives possible)

• CDT (Carbohydrate-Deficient Transferrin): Best marker for chronic consumption monitoring (increases with use)
• GGT (Gamma-glutamyltransferase): Elevated with recent heavy use
• AST:ALT ratio >2:1: Suggests alcoholic hepatitis
• MCV (Mean Cell Volume): Raised due to macrocytosis

• CBC - anaemia, macrocytosis, bone marrow suppression
• LFTs: ALT, AST, GGT, ALP, LDH, bilirubin, albumin, PT
• KFTs: electrolytes, BUN, creatinine
• Thiamine, B12, folate, pyridoxine, Vitamin D levels
• Urine toxicology (rule out polysubstance use)

• USG abdomen (hepatorenal status)
• Transient elastography (FibroScan) - early detection of alcoholic cirrhosis
• ECG - before pharmacotherapy, especially if malnourished

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PART 3: TREATMENT - THE BIG PICTURE

Phase 1: ACUTE DETOXIFICATION (Alcohol Withdrawal Management)
         ↓
Phase 2: MAINTENANCE / RELAPSE PREVENTION (Anti-craving pharmacotherapy)
         ↓
Phase 3: PSYCHOSOCIAL REHABILITATION (Long-term recovery)

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PHASE 1: ALCOHOL WITHDRAWAL SYNDROME (AWS) MANAGEMENT

Clinical Stages of Withdrawal

Severity Classification (IPS Guidelines)

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DETOXIFICATION DECISION: COMMUNITY vs. INPATIENT

• Mild-to-moderate dependence
• 24h supervising carer available
• Patient can pick up medication daily and be reviewed regularly
• Agreed treatment plan with contingency plan in place
• SADQ <30, no prior DTs/seizures

• Regular consumption >30 units/day
• SADQ >30 (severe dependence)
• History of withdrawal seizures or delirium tremens
• Patient is a minor or elderly
• Concurrent benzodiazepine use + alcohol
• Polysubstance misuse
• Comorbid mental/physical illness or cognitive impairment
• Pregnant patient
• Homeless / no social support
• Failed community detoxification previously

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PHARMACOTHERAPY FOR ACUTE WITHDRAWAL

A. BENZODIAZEPINES - CORNERSTONE OF DETOX

• Normal liver function: Long-acting BZDs preferred - Chlordiazepoxide (first choice) or Diazepam, Clonazepam
• Impaired liver function (cirrhosis, elderly): Medium-acting BZDs that don't have active metabolites - Lorazepam or Oxazepam ("LOT" - Lorazepam, Oxazepam, Temazepam - safe in liver disease)

• Self-tapering effect due to long half-life
• Smoother withdrawal curve
• Less interdose withdrawal

Chlordiazepoxide Fixed-Dose Regimens (Maudsley):

• Diazepam 0.2-0.5mg/kg/dose IV (max 10mg/dose); or 0.5mg/kg/dose PR
• Chlordiazepoxide 25-50mg 6-hourly × 24h; then 25mg 6-hourly × 48h; taper over next 72h
• For pathological intoxication: Low-dose lorazepam 1-5mg PO PRN or haloperidol 1-5mg q4-8h IM

B. ADJUNCT PHARMACOTHERAPY

• 50-100mg IM/IV first dose (must be given BEFORE glucose to prevent precipitating Wernicke's)
• Then oral supplementation
• Deficiency leads to Wernicke's encephalopathy → Korsakoff syndrome

• Anticonvulsants (for breakthrough seizures - NOT as primary prophylaxis in uncomplicated AWS)
• Antipsychotics (haloperidol) for hallucinations - but LOWERS seizure threshold, only use with adequate BZD cover
• IV fluids + electrolyte correction

C. DELIRIUM TREMENS - MANAGEMENT

• ICU admission + airway protection + ventilatory support if needed
• IV diazepam (loading dose) or phenobarbital for refractory DTs
• Thiamine IV + electrolytes
• Continuous monitoring: BP, pulse, SpO2, temp
• Haloperidol for agitation (with BZD - never alone)
• Lateral decubitus position (aspiration prevention)

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Nutritional Deficiency Management

• Poor dietary intake
• Alcoholic gastritis + GI bleeding
• Reduced pancreatic enzyme secretion → impaired digestion
• Damage to GI wall → reduced absorption
• Reduced fat absorption → fat-soluble vitamin deficiency (A, D, E, K)
• Folate deficiency changes → GI wall lining changes → further malabsorption

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PHASE 2: MAINTENANCE / RELAPSE PREVENTION

Goals of Maintenance Pharmacotherapy:

• Prolong abstinence duration
• Prevent relapse to heavy drinking
• Reduce craving
• Support psychosocial treatment gains

• Long-term (possibly indefinite) use is reasonable - treat like a chronic disease (analogous to insulin for diabetes, antihypertensives for HTN)
• Used for moderate-to-severe dependence post-detox; also for mild dependence if psychosocial alone has failed
• Always combine with psychosocial interventions
• Pre-treatment evaluation required: physical exam, LFTs, KFTs, toxicology screen

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DRUG 1: NALTREXONE (Anti-craving - Opioid Antagonist)

• Start 12.5-25mg/day × 1-2 weeks (to test tolerance)
• Target: 50mg OD
• Start 3-7 days after last drink (ensure opioid-free period first)
• Maintenance: minimum 3 months to 1 year

• Oral 50mg/day
• Extended-release injectable (Vivitrol) 380mg IM once monthly - superior adherence, greater efficacy than oral (Maudsley)
• SC implant (170-340mg) lasting ≥6 months (not yet marketed in India)

• Strong cravings during treatment
• Family history of alcohol dependence
• History of opioid use seeking AUD treatment
• Asp40 variant of OPRM1 (mu-opioid receptor gene) - pharmacogenomics marker
• More somatic complaints
• Good motivation for supervised medication

• Nausea (most common - give with food, rich in complex carbs)
• Vomiting, headache, dizziness, fatigue
• Hepatotoxicity (rare - monitor LFTs at baseline, 1 month, 3 months, 6 months, yearly)
• Avoid if active liver disease (AST/ALT >5x upper limit normal)

• Oral naltrexone 50mg/day: NNT = 18 to prevent return to any drinking; NNT = 11 to prevent return to heavy drinking
• Injectable naltrexone: -4.99 fewer drinking days per 30-day period vs. placebo
• First-line recommendation alongside acamprosate

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DRUG 2: ACAMPROSATE (Anti-craving - Glutamate Modulator)

• No clinically significant drug-drug interactions
• Safe in severe hepatic failure (renally excreted unchanged)
• Safe with opioid maintenance therapy
• No interaction with detox medications
• Extremely safe in overdose (up to 56g studied)
• Adverse effects mild and transient

• NNT = 11 to prevent return to any drinking (better than naltrexone for total abstinence)
• First-line alongside naltrexone

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DRUG 3: DISULFIRAM (Deterrent / Aversive agent)

• ALDH inhibition → accumulation of acetaldehyde → Disulfiram-Ethanol Reaction (DER) within 15-30 minutes of alcohol ingestion

• Loading: 250-500mg/day starting 12-24h after last drink; continue for 1-2 weeks
• Maintenance: 125-250mg/day
• Duration: Until stable long-term abstinence is established

• Mild: Reassurance, oral fluids
• Moderate-Severe: Supportive (BP support, IV Vitamin C 1g, ephedrine sulphate, antihistamines IV, oxygen)
• No response: Fomepizole (4-methylpyrazole) 15mg/kg IV single dose

• Before: LFTs, CBC, KFT, pregnancy test (females), BAC
• After initiation: LFTs (AST, ALT, GGT, bilirubin) at 2 weeks, monthly × 6 months, then every 3 months

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DRUG 4: NALMEFENE (Opioid Antagonist - Newer)

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COMPARISON TABLE: FDA/EMA APPROVED MAINTENANCE DRUGS

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DRUGS UNDER INVESTIGATION (IPS)

• Baclofen (GABA-B agonist) - 2023 Cochrane review suggests benefit for maintaining abstinence post-detox; second-line in some UK centres
• Topiramate (GABA/glutamate modulator) - may be as effective as naltrexone; reduces heavy drinking days
• Gabapentin - some evidence, safety concerns limit use
• Ondansetron (5-HT3 antagonist) - may reduce early-onset AUD drinking
• Varenicline (nAChR partial agonist) - under trial
• Prazosin, Doxazosin (alpha-1 blockers) - targeting stress-induced relapse
• GLP-1 receptor agonists (Semaglutide, etc.) - emerging pre-clinical and early clinical data for alcohol reduction (2024-2025 hot topic)
• Sodium oxybate (GHB) - approved in Italy/Austria; not widely accepted elsewhere
• Oxytocin - preclinical
• ABT-436 (selective vasopressin V1b receptor antagonist)

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PHASE 3: PSYCHOSOCIAL INTERVENTIONS

A. Brief Interventions (BI)

• Time-limited, patient-centred approach
• Based on FRAMES model (Miller & Sanchez):
  • Feedback about personal risk
  • Responsibility for change lies with the patient
  • Advice to change clearly given
  • Menu of options offered
  • Empathy and non-confrontational style
  • Self-efficacy enhanced
• Best for hazardous/harmful drinkers before dependence develops
• Delivered in primary care, emergency settings

B. Motivational Enhancement Therapy (MET)

• Based on Motivational Interviewing (Miller & Rollnick)
• 1-4 sessions of 45-90 minutes
• Techniques: Reflective listening, exploring ambivalence, roll with resistance, develop discrepancy, reinforce change talk, support self-efficacy
• Non-confrontational; moves patient from pre-contemplation → contemplation → preparation
• Often used as "gateway" before comprehensive CBT

C. Cognitive Behavioral Therapy (CBT)

• Based on classical + operant conditioning + cognitive restructuring
• Identifies triggers (internal/external), teaches coping skills
• Teaches drink-refusal skills, emergency coping, relapse prevention
• CBT + MET combination (Marijuana Treatment Project model adapted for AUD) shows best outcomes
• Usually 4-12 sessions individual/group

D. Family Systems Approaches

• Functional Family Therapy (FFT)
• Brief Strategic Family Therapy (BSFT)
• Multisystemic Therapy (MST) - especially effective in adolescents
• Multidimensional Family Therapy (MDFT)
• Goals: Psychoeducation for family, establish boundaries/supervision, improve communication, get other family members into treatment if needed
• High attrition rates but powerful when engaged

E. Group Therapy & 12-Step Programs

• Alcoholics Anonymous (AA) - spiritual fellowship, peer support
• Only requirement: desire to stop drinking
• Step study, open/closed meetings, speaker meetings
• Note for adolescents: Group therapy with deviant peers may have iatrogenic effects (deviancy training) - screen carefully
• Anonymity is foundational

F. Contingency Management (CM)

• Operant conditioning - rewards/vouchers for confirmed abstinence (drug testing)
• Escalating reinforcement schedule for consecutive negative tests
• Effective for engagement; can augment MET/CBT

G. Mindfulness-Based Approaches

• Mindfulness-Based Relapse Prevention (MBRP)
• Teaches urge-surfing, present-moment awareness
• Adjunct to CBT/MET

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TREATMENT ALGORITHM (IPS)

Clinical Assessment + AUDIT Score
         |
    ─────┴──────────────────────────
   |                               |
AUDIT 0-15                    AUDIT 16-40
No intervention /           Full diagnostic evaluation
Brief Intervention            + Treatment intervention
         |
    ─────┴──────────────────────────
   |                               |
No physical                  Physical dependence
dependence                  present (withdrawal risk)
         |                         |
Psychosocial                  ────┴────────────
intervention                 |               |
  ± drug prophylaxis        MILD          MODERATE-SEVERE
(mild dependence)            |               |
                       Outpatient         Inpatient/
                       detox              Hospitalization
                             |               |
                        Community       Inpatient BZD
                        BZD regimen     detox + monitoring
                             |
                         Long-term maintenance
                    (Anti-craving + Psychosocial + 12-Step)

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SPECIAL POPULATIONS

Pregnancy

• No safe level of alcohol in pregnancy
• Alcohol = direct fetal teratogen → Fetal Alcohol Syndrome (FAS) / Fetal Alcohol Spectrum Disorder (FASD)
• FAS features: Pre/postnatal growth retardation, CNS dysfunction, characteristic facies (thin vermillion border, smooth philtrum, small palpebral fissures)
• Management: Primarily psychosocial + nutritional (nutritional needs 10-30% higher in pregnancy)
• Pharmacotherapy: ONLY when benefits clearly outweigh risks, under addiction specialist supervision
• Benzodiazepines: Neonatal withdrawal risk; lorazepam/oxazepam if detox unavoidable
• Naltrexone/Acamprosate/Disulfiram: Generally avoided in pregnancy

Psychiatric Comorbidity (Dual Diagnosis)

• 60% of adolescent SUD patients have a comorbid psychiatric disorder
• Common comorbidities: ADHD, Conduct Disorder, Depression, Anxiety, PTSD, Bipolar Disorder
• Treat both simultaneously - not sequentially
• Better abstinence rates when comorbid psychiatric disorder is treated
• Avoid prescribing psychoactive medications with high abuse potential (e.g., stimulants for ADHD) without careful monitoring

Liver Disease

• Use Acamprosate (renally excreted - safe even in severe hepatic failure)
• Use Lorazepam or Oxazepam for detox (no hepatic metabolism to active metabolites)
• Avoid or use with extreme caution: Naltrexone (hepatotoxic), Disulfiram (hepatotoxic)
• ACG Clinical Guideline 2024: Alcohol-associated liver disease management includes AUD treatment as integral component

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LATEST GUIDELINES & ADVANCES (2023-2026)

1. JAMA Meta-Analysis 2023 (McPheeters et al., PMID 37934220)

• 118 RCTs, 20,976 participants
• First-line pharmacotherapy: Oral naltrexone 50mg/day + Acamprosate (strong evidence, both first-line)
• NNT (naltrexone) = 11 for prevention of return to heavy drinking
• NNT (acamprosate) = 11 for prevention of return to any drinking
• Injectable naltrexone: -5 fewer drinking days/30 days vs. placebo
• Must be combined with psychosocial interventions

2. NICE CG115 (UK) - Core Recommendations

• Community detox possible with 24h carer support + agreed plan
• Inpatient detox if history of seizures/DTs, SADQ >30, severe comorbidity
• Disulfiram: Third-line when naltrexone/acamprosate unsuitable; supervised administration essential
• Monitor every 2 weeks × 2 months, then monthly × 4 months, then 6-monthly

3. GRACE-4 Emergency Department Guidelines 2024 (PMID 38747203)

• ED-specific AUD/AWS management
• Detoxification alone is NOT sufficient - must initiate underlying SUD treatment concurrently
• Systematic monitoring + team communication + reassessment critical

4. ASAM 2025-2026 Updates

• New assessment guide for selecting appropriate level of addiction care (Jan 2025)
• New standards for adolescent SUD care (March 2026)
• Hospital/ED implementation guide for SUD care (March 2026)
• Emphasis on addiction consultation services in acute care settings

5. GLP-1 Agonists (Emerging 2024-2025)

• Semaglutide and other GLP-1 agonists showing preclinical and early clinical signals for reducing alcohol consumption
• Multiple trials underway; not yet approved for AUD
• Mechanism: Reward pathway modulation via limbic/mesolimbic GLP-1 receptors

6. Pharmacogenomics

• OPRM1 Asp40 (A118G) polymorphism: Naltrexone is more effective in carriers of the Asp40 allele (G allele / Asn40Asp variant)
• This is moving towards personalized medicine in AUD treatment

7. Maudsley 15th Ed. 2024 Key Updates

• Baclofen (GABA-B agonist) now recognized as second-line option post-2023 Cochrane evidence
• Topiramate may be as effective as naltrexone for reducing heavy drinking
• Lorazepam/oxazepam preferred over chlordiazepoxide when hepatic impairment present

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LONG-TERM OUTCOMES & PROGNOSIS

• Treatment is superior to no treatment (strong evidence)
• Combined pharmacotherapy + psychosocial treatment > either alone
• Extended-release injectable naltrexone > oral for adherence
• Prognosis improves significantly with:
  • Longer duration of supervised pharmacotherapy
  • Strong family/social support
  • Treatment of comorbid psychiatric disorders
  • No polysubstance use
  • Higher motivation at entry
• Relapse is common (like any chronic disease) - treat relapse as part of the illness, not failure

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🎓 VIVA TIPS

Top Questions & Model Answers

Both naltrexone (50mg OD oral) and acamprosate (666mg TID) are first-line, per JAMA 2023 meta-analysis and NICE CG115. Choice depends on patient factors: naltrexone for those with strong cravings/reward drive; acamprosate for protracted withdrawal/insomnia/anxiety; acamprosate preferred in liver disease.

Glucose infusion increases pyruvate → demands more thiamine (TPP co-factor). In thiamine-deficient AUD patients, this can precipitate or worsen Wernicke's encephalopathy. Always give IM thiamine FIRST.

Cardiac disease (failure, CAD, arrhythmia), hypertension, cerebrovascular disease, pregnancy, breastfeeding, liver disease, peripheral neuropathy, severe mental illness, concurrent alcohol ingestion within 24 hours.

Lorazepam or Oxazepam - they don't have active hepatic metabolites (undergo glucuronidation, not oxidation). Remember "LOT" - Lorazepam, Oxazepam, Temazepam are the liver-safe BZDs.

Clinical Institute Withdrawal Assessment for Alcohol - Revised. 10-item scale, takes 5 minutes. Score >10 indicates need for pharmacologically assisted withdrawal. Used for symptom-triggered dosing.

Blocks mu-opioid receptors → prevents alcohol-induced dopamine release in the mesolimbic reward pathway → reduces the euphoric reinforcement ("high") and craving → less motivation to drink ("extinction" of reward-drinking behavior)

Modulates NMDA glutamate receptors (and GABA) → normalizes the glutamate hyperactivity that develops after chronic alcohol use → reduces symptoms of protracted withdrawal (anxiety, insomnia, dysphoria) that trigger relapse to drinking.

Acetaldehyde accumulation → vasodilation, tachycardia, flushing, nausea, vomiting, hypotension. Mild: reassurance + oral fluids. Severe: IV vitamin C 1g, ephedrine sulphate, antihistamines, oxygen. Refractory: Fomepizole 15mg/kg IV.

Alcoholic hallucinosis: Vivid auditory (sometimes visual) hallucinations with CLEAR SENSORIUM and intact orientation - occurs 12-48h after cessation; DTs: Hallucinations + disorientation + autonomic storm + fluctuating consciousness - occurs 48-96h after cessation; more dangerous (mortality 5-15% untreated).

Wernicke's (acute): Confusion + Ophthalmoplegia + Ataxia (classic triad) - due to thiamine deficiency; reversible if treated promptly with IV thiamine. Korsakoff's (chronic): Anterograde + retrograde amnesia, confabulation, relatively preserved cognitive function - results from untreated/inadequately treated Wernicke's; largely irreversible.

When the patient does NOT wish to achieve complete abstinence (goal is harm reduction/reduced drinking) OR when naltrexone is not tolerated/not suitable. Nalmefene is taken PRN before anticipated drinking session.

CDT (Carbohydrate-Deficient Transferrin) - most sensitive and specific for chronic heavy drinking (>50-60g/day for 2 weeks); also useful for treatment monitoring as levels normalize with abstinence. GGT is also used but less specific.

Superior adherence (monthly injection eliminates daily pill-taking), avoids first-pass metabolism giving higher plasma levels, removes "drinking window" that patients exploit with oral dosing (taking drug only when not planning to drink).

F-Feedback about personal risk, R-Responsibility lies with patient, A-Advice clearly given, M-Menu of options offered, E-Empathy shown, S-Self-efficacy enhanced. Used in Brief Interventions for hazardous/harmful drinkers.

Pre/postnatal growth retardation, CNS dysfunction (intellectual disability, behavioral problems, microcephaly), characteristic facies (smooth philtrum, thin vermillion border of upper lip, short palpebral fissures), no safe level of alcohol in pregnancy.

Starting dose in mg QID ≈ current daily alcohol consumption in units. E.g., 20 units/day → start 20mg QID (80mg/day total), taper over 5 days for moderate dependence.

Three drugs: (1) Disulfiram (Antabuse), (2) Acamprosate (Campral), (3) Naltrexone - oral (ReVia) and injectable extended-release (Vivitrol).

OPRM1 A118G (Asp40) variant: Individuals with the G allele (Asp40) respond better to naltrexone treatment. Also, ADH (alcohol dehydrogenase) and ALDH2 gene variants affect alcohol metabolism - ALDH2*2 allele (common in East Asians) causes an endogenous disulfiram-like reaction.

Baclofen (GABA-B agonist), Topiramate (GABA/glutamate modulator), Gabapentin, Ondansetron, GLP-1 agonists (semaglutide - new frontier), Varenicline, Sodium oxybate, Nalmefene (now approved in EU).

Naltrexone: minimum 3 months, ideally 6-12 months. Acamprosate: until stable abstinence, diminished craving, and sound recovery plan in place. Both: may be used indefinitely in chronic severe AUD - analogous to long-term medication for other chronic diseases.

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📊 QUICK REVISION MNEMONICS

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• IPS Clinical Practice Guidelines on Substance Abuse Disorders in Children & Adolescents (SUD IPS.pdf)
• Maudsley Prescribing Guidelines in Psychiatry, 15th Edition (Textbook Library)
• Textbook of Family Medicine, 9th Edition (Textbook Library)
• McPheeters M et al. Pharmacotherapy for AUD: A Systematic Review and Meta-Analysis. JAMA 2023;330(17):1653-1665. [PMID: 37934220]
• NICE CG115: Alcohol-use disorders: diagnosis, assessment and management (2011, current)
• ACG Clinical Guideline: Alcohol-Associated Liver Disease. Am J Gastroenterol 2024. [PMID: 38174913]
• GRACE-4 Guidelines. Acad Emerg Med 2024. [PMID: 38747203]
• ASAM Standards for SUD Care in Hospitals/EDs (March 2026)> Note: The synopsis_clinical_practice.pdf is a scanned image-based PDF with no extractable text layer - it could not be read by any text extraction method. If you can share what specific content it covers, I can incorporate it. All other sources have been fully integrated.

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🍺 ALCOHOL USE DISORDER (AUD) - COMPLETE TREATMENT GUIDE

Integrated from: IPS Clinical Practice Guidelines (SUD), Maudsley Prescribing Guidelines 15th Ed, Textbook of Family Medicine 9e + Latest Evidence 2023-2026

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PART 1: FOUNDATIONS

What is AUD?

1. Drinking more/longer than intended
2. Unsuccessful efforts to cut down
3. Much time spent obtaining/using/recovering
4. Craving
5. Failure to fulfill role obligations
6. Continued use despite interpersonal problems
7. Important activities given up
8. Use in hazardous situations
9. Continued use despite knowing it causes harm
10. Tolerance
11. Withdrawal

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PART 2: STEP-BY-STEP CLINICAL ASSESSMENT

Step 1 - History

• Alcohol use pattern (units/day, binge vs. daily)
• Prior withdrawal history: seizures, DTs, prior hospital admissions
• Prior treatment attempts
• Psychiatric comorbidity (60% of adolescent SUD patients have one)
• Family history of AUD
• Psychosocial functioning: academic/occupational, family, legal

Step 2 - Screening Tools

Step 3 - Investigations

• BAC/Breath analysis - detect recent intake
• CDT (Carbohydrate-Deficient Transferrin) - best biomarker for chronic use + monitoring treatment
• GGT, AST, ALT - elevated with recent heavy use; AST:ALT >2:1 suggests alcoholic hepatitis
• MCV - raised (macrocytosis)
• Ethyl glucuronide (urine) - sensitive marker; false positives possible
• Thiamine, B12, folate, pyridoxine, Vitamin D - check if poor nutritional status suspected
• LFTs, KFTs - baseline before pharmacotherapy
• Urine toxicology - rule out polysubstance use
• USG abdomen - hepatorenal status
• FibroScan - early cirrhosis detection
• ECG - before initiating pharmacotherapy, if malnourished

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PART 3: TREATMENT PHASES

PHASE 1: ACUTE DETOXIFICATION (Alcohol Withdrawal Management)
                    ↓
PHASE 2: MAINTENANCE / RELAPSE PREVENTION (Anti-craving drugs)
                    ↓
PHASE 3: PSYCHOSOCIAL REHABILITATION (Long-term recovery)

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PHASE 1: ALCOHOL WITHDRAWAL SYNDROME (AWS)

Timeline of Withdrawal Features

AWS Severity (IPS Classification)

Community vs. Inpatient Detox Decision

• Regular consumption >30 units/day OR SADQ >30
• History of withdrawal seizures or DTs
• Concurrent benzodiazepine use + alcohol
• Polysubstance misuse
• Comorbid mental/physical illness, cognitive impairment
• Pregnant, homeless, or no social support
• Minor or elderly
• Failed community detox previously

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PHARMACOTHERAPY - ACUTE DETOX

A. BENZODIAZEPINES - Cornerstone

• Normal liver: Long-acting BZDs - Chlordiazepoxide (1st choice), Diazepam, Clonazepam
• Impaired liver (cirrhosis/elderly): "LOT" drugs - Lorazepam, Oxazepam, Temazepam (no active metabolites via glucuronidation; not oxidized)

Chlordiazepoxide Fixed-Dose Regimens (Maudsley):

• Diazepam 0.2-0.5mg/kg/dose IV (max 10mg) or 0.5mg/kg PR
• Pathological intoxication: Lorazepam 1-5mg PO PRN or Haloperidol 1-5mg q4-8h IM (with BZD cover)

B. MANDATORY ADJUNCTS

• 50-100mg IM (first dose IM/IV - BEFORE giving glucose)
• Reason: Glucose → pyruvate → demands thiamine (TPP). Thiamine deficiency → Wernicke's encephalopathy
• Then oral supplementation

• Wernicke's (acute, reversible) → Korsakoff's (chronic, largely irreversible: amnesia + confabulation)

• Poor dietary intake
• Alcoholic gastritis + GI bleeding
• Reduced pancreatic enzyme secretion
• Damaged GI wall → malabsorption
• Reduced fat absorption → fat-soluble vitamin deficiency
• Folate deficiency → further GI wall changes → vicious cycle

C. DELIRIUM TREMENS - Emergency Management

• ICU admission, airway protection, ventilatory support
• IV diazepam loading (or phenobarbital for refractory DTs)
• IV thiamine + electrolyte correction
• Haloperidol for agitation - only with adequate BZD cover (antipsychotics alone lower seizure threshold)
• Lateral decubitus position (aspiration prevention)
• Continuous monitoring: BP, pulse, SpO2, temperature, glucose

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PHASE 2: MAINTENANCE / RELAPSE PREVENTION

Principles

• Treat like a chronic disease - long-term (even indefinite) medication is reasonable
• Indicated for: moderate-to-severe dependence post-detox; mild dependence failed psychosocial alone
• Always combine with psychosocial interventions
• Pre-treatment baseline: physical exam, LFTs, KFTs, toxicology

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DRUG 1: NALTREXONE

• Strong cravings | Family history of AUD | History of opioid use seeking AUD treatment
• Intense alcohol urges during treatment | More somatic complaints
• OPRM1 Asp40 (G allele) carriers - pharmacogenomics marker for naltrexone response

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DRUG 2: ACAMPROSATE

• Safe in severe hepatic failure - drug of choice for AUD with liver disease
• Safe with opioid maintenance therapy
• No drug-drug interactions
• Extremely safe in overdose (up to 56g studied)
• No abuse potential

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DRUG 3: DISULFIRAM

• Mild (BAC 5-10mg%): Reassurance + oral fluids
• Moderate-Severe (BAC 50-150mg%): IV Vitamin C 1g, ephedrine sulphate, antihistamines IV, oxygen/carbogen
• Refractory: Fomepizole (4-methyl pyrazole) 15mg/kg IV single dose

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DRUG 4: NALMEFENE (Newer)

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DRUG COMPARISON TABLE

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DRUGS UNDER INVESTIGATION (IPS + Maudsley)

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PHASE 3: PSYCHOSOCIAL INTERVENTIONS

A. Brief Interventions (BI) - FRAMES Model

• Feedback about personal risk | Responsibility (patient's) | Advice to change
• Menu of options | Empathy | Self-efficacy enhanced

B. Motivational Enhancement Therapy (MET)

• 1-4 sessions, 45-90 minutes each
• Empathetic, non-confrontational
• Explore ambivalence; develop discrepancy; "roll with resistance"; reinforce change talk
• Moves patient: Pre-contemplation → Contemplation → Preparation → Action
• Used as gateway before CBT

C. Cognitive Behavioral Therapy (CBT)

• Identifies triggers, teaches coping/refusal skills
• Cognitive restructuring for negative beliefs
• Role-playing drink-refusal; relapse management skills
• CBT + MET combination shows best outcomes

D. Family Systems Approaches

• Functional Family Therapy (FFT), Brief Strategic Family Therapy (BSFT)
• Multisystemic Therapy (MST), Multidimensional Family Therapy (MDFT) - esp. effective in adolescents
• Goals: psychoeducation, establish supervision/boundaries, improve communication, engage family in treatment

E. 12-Step Programs (AA)

• Spiritual fellowship (not religious), only requirement is desire to stop drinking
• Open meetings (anyone), closed meetings (alcoholics/those wanting to stop only)
• Anonymity is foundational
• Caution in adolescents - deviancy training effect from deviant peer groups

F. Contingency Management (CM)

• Vouchers/rewards for confirmed abstinence (urinalysis/breathalyzer)
• Escalating reinforcement; effective adjunct to MET/CBT

G. Mindfulness-Based Relapse Prevention (MBRP)

• Urge-surfing techniques; present-moment awareness; adjunct to CBT

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SPECIAL POPULATIONS

Pregnancy

• No safe level of alcohol → Fetal Alcohol Syndrome (FAS): growth retardation, CNS dysfunction, characteristic facies (smooth philtrum, thin vermillion border, short palpebral fissures), intellectual disability
• Management: psychosocial + nutritional (needs 10-30% higher than baseline)
• All medications avoided unless benefit clearly outweighs risk (specialist only)

Psychiatric Comorbidity (Dual Diagnosis)

• 60% of adolescents with SUD have comorbid psychiatric disorder
• Treat both simultaneously; better outcomes than treating either alone
• Common comorbidities: ADHD, Conduct Disorder, Depression, Anxiety, PTSD

Liver Disease

• Use Acamprosate (safest - renally excreted)
• For detox: Lorazepam / Oxazepam (LOT rule)
• Avoid or extreme caution: Naltrexone, Disulfiram (both hepatotoxic)

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LATEST GUIDELINES & ADVANCES (2023-2026)

1. JAMA Meta-Analysis 2023 (PMID: 37934220 - 118 RCTs, 20,976 patients)

• First-line: Oral naltrexone 50mg + Acamprosate - both with strong evidence
• Naltrexone NNT = 11 (heavy drinking prevention) and 18 (any drinking prevention)
• Acamprosate NNT = 11 (prevention of return to any drinking)
• Injectable naltrexone: -4.99 fewer drinking days/30 days vs. placebo
• Must always combine with psychosocial interventions

2. NICE CG115 (UK) - Key Points

• Community detox with 24h carer + agreed plan = standard
• Inpatient if SADQ >30, prior DTs/seizures, severe comorbidity
• Disulfiram: third-line with psychological intervention + supervised administration
• Monitor: 2-weekly × 2 months → monthly × 4 months → 6-monthly thereafter

3. GRACE-4 ED Guidelines 2024 (PMID: 38747203)

• Detox alone is insufficient - initiate underlying SUD treatment concurrently in ED
• Systematic monitoring, team communication, regular reassessment emphasized

4. ASAM 2025-2026

• New assessment guide for level of addiction care (Jan 2025)
• New standards for adolescent SUD care (March 2026)
• Hospital/ED implementation guide for SUD (March 2026)

5. GLP-1 Agonists - Emerging Frontier

• Semaglutide and liraglutide showing signals for reducing alcohol consumption in preclinical models and early trials
• Mechanism: GLP-1 receptors in limbic/mesolimbic system modulate reward
• Multiple trials underway; not yet approved for AUD

6. Pharmacogenomics

• OPRM1 A118G (Asp40 variant): G allele carriers respond significantly better to naltrexone - moving toward personalized AUD treatment

7. Maudsley 15th Ed. Updates (2024)

• Baclofen: officially recognized as second-line option (2023 Cochrane data)
• Topiramate: may equal naltrexone; still off-label
• FibroScan now recommended for early cirrhosis detection in AUD patients

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🎓 VIVA TIPS - 20 MUST-KNOW Q&As

Naltrexone 50mg OD and Acamprosate 666mg TID - both first-line per JAMA 2023 and NICE CG115. Choice depends on: acamprosate preferred in liver disease; naltrexone for those with strong craving/reward component.

Glucose → pyruvate → needs thiamine (TPP cofactor). In deficient AUD patients, glucose without thiamine precipitates Wernicke's encephalopathy. Always IM/IV thiamine first.

Cardiac failure/CAD/arrhythmia, hypertension, cerebrovascular disease, pregnancy, breastfeeding, active liver disease, peripheral/optic neuropathy, severe mental illness, alcohol within 24h.

Lorazepam or Oxazepam - "LOT" rule (Lorazepam, Oxazepam, Temazepam). They undergo glucuronidation (not oxidation) → no active metabolites → safe in hepatic failure.

Clinical Institute Withdrawal Assessment for Alcohol - Revised. 10-item, 5-minute scale (objective). Score >10 = pharmacotherapy needed. Used for symptom-triggered BZD dosing in monitored settings.

Blocks mu-opioid receptors → prevents alcohol-induced dopamine release in nucleus accumbens (mesolimbic reward pathway) → reduces euphoric reinforcement and craving → alcohol becomes less rewarding.

Modulates NMDA glutamate receptors (and GABA) → normalizes the glutamate hyperactivity (excitotoxicity) that develops after chronic alcohol use → reduces protracted withdrawal symptoms (insomnia, anxiety, dysphoria) that trigger relapse.

Mild: reassurance + oral fluids. Moderate-severe: IV Vitamin C 1g, ephedrine sulphate, antihistamines IV, oxygen. Refractory: Fomepizole 15mg/kg IV (ALDH inhibitor reversal agent).

Hallucinosis: vivid hallucinations (usually auditory) with clear sensorium and intact orientation; 12-48h. DTs: hallucinations + disorientation + autonomic storm + fluctuating consciousness; 48-96h; mortality 5-15% untreated.

Wernicke (acute): WOA triad - W ataxia, O phthalmoplegia, A ltered consciousness; due to thiamine deficiency; reversible if treated promptly with IV thiamine. Korsakoff (chronic): anterograde + retrograde amnesia + confabulation; largely irreversible.

Patient does NOT want complete abstinence (goal = harm reduction/reduced drinking), or naltrexone not tolerated. Nalmefene taken PRN (1-2h before anticipated drinking session) - gives patient autonomy.

CDT (Carbohydrate-Deficient Transferrin) - most sensitive/specific for chronic heavy drinking (>50g/day × 2 weeks); normalizes with abstinence. GGT also used but less specific.

Superior adherence (monthly injection), avoids first-pass metabolism (higher plasma levels), eliminates the "drinking window" exploited with oral dosing, and removes daily pill burden.

Feedback-personal risk, Responsibility lies with patient, Advice clearly given, Menu of options, Empathy shown, Self-efficacy enhanced. (Miller & Sanchez model)

Pre/postnatal growth retardation; CNS dysfunction (intellectual disability, microcephaly, ADHD); characteristic facies (smooth philtrum, thin vermillion upper lip border, short palpebral fissures). No safe level of alcohol in pregnancy.

Starting dose QID (mg) ≈ daily units consumed. 20 units/day → 20mg QID. Taper over 5-7 days (moderate) or 7-10 days (severe).

(1) Disulfiram (Antabuse) - aversive; (2) Acamprosate (Campral) - anti-craving; (3) Naltrexone - anti-craving (oral ReVia + injectable Vivitrol).

OPRM1 A118G (Asp40 variant) - G allele carriers show significantly better response to naltrexone. Also: ALDH2*2 allele (East Asians) causes endogenous disulfiram-like reaction (natural DER).

Baclofen, Topiramate, Gabapentin, Ondansetron, GLP-1 agonists (semaglutide - 2024 frontier), Varenicline, Sodium oxybate.

Naltrexone: minimum 3 months, ideally 6-12 months; no withdrawal on stopping. Acamprosate: until stable abstinence + diminished craving + sound recovery plan. Both may be used indefinitely in chronic severe AUD - analogous to long-term medication for hypertension or diabetes.

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Quick Mnemonics

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