Review: Identification and Treatment of Alcohol Use Disorder
19 Jan, 2025 | 11:41h | UTCIntroduction: This summary provides key insights from a comprehensive review published in the New England Journal of Medicine about the clinical identification and management of alcohol use disorder (AUD). The document highlights AUD’s chronic, relapsing course, its underdiagnosis in general practice, and its wide-ranging health and social impacts. Emphasis is placed on early recognition, the importance of nonjudgmental communication, and the potential for effective treatment across various medical settings.
Key Recommendations:
• Routine Screening and Assessment: Clinicians should routinely ask about alcohol use, employing validated tools (e.g., AUDIT, AUDIT-C, or CAGE) to gauge risk. When self-reporting is unreliable, biologic markers (e.g., γ-glutamyl transpeptidase or phosphatidylethanol) can help detect recent or chronic use.
• Nonjudgmental, Patient-Centered Approach: Engagement improves when patients feel supported rather than stigmatized. Collaboration in care planning can enhance adherence, especially for individuals who are ambivalent about changing their alcohol consumption patterns.
• Brief Interventions: Time-limited counseling, guided by motivational interviewing principles, is effective in reducing alcohol use. These interventions can be delivered by primary care professionals and may motivate further treatment or pharmacotherapy.
• Psychosocial Therapies: Multiple methods—including cognitive behavioral therapy, motivational enhancement, acceptance and commitment therapy, and peer-supported programs (e.g., Alcoholics Anonymous, SMART Recovery)—offer benefit. Clinicians are encouraged to adapt and integrate these treatments based on availability, patient preference, and severity of dependence.
• Pharmacologic Treatment: Medications such as naltrexone (once daily), acamprosate (three times daily), and supervised disulfiram are approved and effective for AUD. Naltrexone helps reduce craving and heavy drinking; acamprosate supports abstinence; and disulfiram, though aversive if alcohol is consumed, can reinforce abstinence in motivated patients. Other agents (e.g., topiramate, gabapentin) show promise but are not universally approved.
• Management of Withdrawal: Outpatient or inpatient treatment of withdrawal depends on clinical stability and coexisting conditions. Benzodiazepines remain first-line for symptom control, with close monitoring to prevent complications like seizures and delirium tremens. Nutritional support, particularly thiamine replacement, is essential to avert Wernicke–Korsakoff syndrome.
• Addressing Coexisting Conditions: AUD commonly co-occurs with mental health disorders (e.g., depression, anxiety) and other substance use (especially tobacco). Screening for suicidality and referring for specialized care can improve overall outcomes. Medical complications (e.g., alcoholic liver disease, hypertension) may also improve with sustained alcohol reduction or abstinence.
• Ongoing Support and Follow-up: AUD has a relapsing course, so long-term care, repeated assessments, and revisiting treatment goals are crucial. Follow-up visits can reinforce progress, manage relapses, and promote sustained recovery efforts.
Conclusion: Recognizing and treating alcohol use disorder significantly improves patient outcomes in both physical and mental domains. Generalist clinicians play a pivotal role in screening, initiating brief interventions, and coordinating care. Timely, evidence-based interventions and a supportive, empathetic stance can reduce the immense burden of AUD, enhance treatment retention, and improve quality of life for affected individuals.
Reference: Haber PS. Identification and Treatment of Alcohol Use Disorder. New England Journal of Medicine. 2025;392:258-266. DOI: http://doi.org/10.1056/NEJMra2306511