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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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