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Diagnosis and Pharmacotherapy of Alcohol Use DisorderA Review

Educational Objective
To review the clinical management of patients with alcohol use disorder
1 Credit CME

Importance  Alcohol consumption is associated with 88 000 US deaths annually. Although routine screening for heavy alcohol use can identify patients with alcohol use disorder (AUD) and has been recommended, only 1 in 6 US adults report ever having been asked by a health professional about their drinking behavior. Alcohol use disorder, a problematic pattern of alcohol use accompanied by clinically significant impairment or distress, is present in up to 14% of US adults during a 1-year period, although only about 8% of affected individuals are treated in an alcohol treatment facility.

Observations  Four medications are approved by the US Food and Drug Administration to treat AUD: disulfiram, naltrexone (oral and long-acting injectable formulations), and acamprosate. However, patients with AUD most commonly receive counseling. Medications are prescribed to less than 9% of patients who are likely to benefit from them, given evidence that they exert clinically meaningful effects and their inclusion in clinical practice guidelines as first-line treatments for moderate to severe AUD. Naltrexone, which can be given once daily, reduces the likelihood of a return to any drinking by 5% and binge-drinking risk by 10%. Randomized clinical trials also show that some medications approved for other indications, including seizure disorder (eg, topiramate), are efficacious in treating AUD. Currently, there is not sufficient evidence to support the use of pharmacogenetics to personalize AUD treatments.

Conclusions and Relevance  Alcohol consumption is associated with a high rate of morbidity and mortality, and heavy alcohol use is the major risk factor for AUD. Simple, valid screening methods can be used to identify patients with heavy alcohol use, who can then be evaluated for the presence of an AUD. Patients receiving a diagnosis of the disorder should be given brief counseling and prescribed a first-line medication (eg, naltrexone) or referred for a more intensive psychosocial intervention.

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Article Information

Corresponding Author: Henry R. Kranzler, MD, University of Pennsylvania, Center for Studies of Addiction, 3535 Market St, Ste 500, Philadelphia, PA 19104 (kranzler@pennmedicine.upenn.edu).

Accepted for Publication: July 18, 2018.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Kranzler reports being an advisory board member, consultant, or continuing medical education speaker for Indivior, Otsuka, and Lundbeck. He is a member of the American Society of Clinical Psychopharmacology’s Alcohol Clinical Trials Initiative, which was sponsored in the past 3 years by AbbVie, Alkermes, Amygdala Neurosciences, Arbor, Ethypharm, Indivior, Lilly, Lundbeck, Otsuka, and Pfizer. Dr Kranzler is named as an inventor on PCT patent application 15/878,640 titled “Genotype-guided dosing of opioid agonists,” filed January 24, 2018. Dr Soyka reports working as a consultant for or receiving research grants from Indivior, Lundbeck, Camurus, Mepha, Mundipharma, and Reckitt Benkiser.

Funding/Support: Dr Kranzler’s work was supported by National Institute on Alcohol Abuse and Alcoholism grants R01 AA023192 and R01 AA021164 and the Mental Illness Research, Education and Clinical Center of the Veterans Integrated Service Network 4, US Department of Veterans Affairs.

Role of the Funder/Sponsor: The funding agencies had no role in the collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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