Recommend evidence-based treatment: Know your options (2023)

As with many other medical conditions, there is no single approach to treating alcohol dependence (AUD). Different patients require different options. Fortunately, there are more treatment options for AUD than many people realize. High-quality, evidence-based treatments are offered at varying levels of intensity and in a variety of settings to meet individual needs. Treatment can help patients achieve their goal of stopping drinking or significantly reducing their alcohol consumption. Both can significantly improve your state of health, well-being and performance.¹

Health professionals offer two types of evidence-based treatment for AUD: behavioral medicine and medication. They have proven to be just as effective.²and can be combined and tailored to improve outcomes for each patient. Many patients also benefit from active participation in support groups such as Alcoholics Anonymous (AA) or a number of secular alternatives (see).resources), alone or as a complement to a treatment guided by a professional.²

Support for patients with AUD is not only offered in special addiction programs. GPs can offer medicines for AUD along with a brief consultation (see main article onshort speech). Anti-addiction medicine practitioners, clinical psychologists, and other licensed therapists also provide outpatient care in individual or group offices (see main article onremission). These and other flexible and convenient options, such as professional telemedicine services and online or face-to-face support groups, can reduce stigma and other barriers to recovery. Here we briefly describe the options available to help patients with AUD.

A note about the consumption level term used in this main article:get drunkwas defined as 4 or more drinks in one day or 8 or more drinks per week for women and 5 or more drinks in one day or 15 or more drinks per week for men.

What professionally targeted behavioral health treatments have been shown to be effective in treating AUD?

Patients with less severe AUD can be managed by brief interventions in primary care (see main article onshort speech) and FDA-approved AUD drugs. For people with more severe AUD or comorbid mental illnesses, it is advisable to seek evidence-based behavioral health treatment from a licensed professional therapist to set the stage for lasting change (see main article onmental health problems).

Broadly speaking, AUD-centered behavioral health care aims to help patients set goals, identify triggers that may lead to alcohol consumption, develop skills to stop or reduce alcohol consumption, use emotions, manage stress and build relationships. that support treatment goals. Specific evidence-based approaches that are approximately equally effective²Includes the following:

• Cognitive behavioral therapy (CBT)focuses on identifying and managing thoughts, feelings, situations, behaviors, and stressors (called “triggers” or “cues”) that lead to excessive alcohol consumption. The goal is to change unhelpful thought processes and develop skills to deal with situations and triggers that can trigger the urge to drink.
• Therapy to increase motivation.it is conducted over a short period of time to help people develop their own motivation to change their drinking, create a specific plan to change their drinking, and develop the skills and confidence to follow the plan.
• Interventions based on acceptance and mindfulnessIncrease awareness and acceptance of present moment experiences. Mindfulness-based relapse prevention includes strategies for developing CBT skills to encourage flexible responses, rather than “autopilot” responses, to triggers that can lead to alcohol use.
• Approaches to emergency managementInclude tangible rewards for achieving specific, measurable treatment goals. This approach reinforces positive behaviors such as abstinence or regular attendance at treatment sessions.
• Couple and family counseling.The focus is on promoting positive interactions and activities and improving communication skills. Evidence-based approaches grounded in cognitive-behavioral and family systems theories improve patient support and increase the likelihood of improved outcomes from alcohol use compared with individual counseling alone.^3,4
• Twelve-Step Moderation Therapyis a clinical intervention designed to increase active patient participation in a 12-step group such as AA.⁵Increased participation in group meetings may, in turn, lead to a reduction in alcohol consumption.⁶Similarly, a clinical intervention called Peer Support Group Facilitation encourages AUD patients to explore peer support groups widely, including secular options.⁷(See the next section onmutual self-help groups.)

Addiction therapists can offer individual, couples, family, or group sessions. These specialists can be found in treatment programs as well as individual or group practices. NIAAalcohol treatment navigatorHe can direct you to providers in your area who offer evidence-based behavioral therapy.Telemedicine and online options.

If you are a licensed therapist, take a lookresourcesBelow are therapy manuals from NIAAA-sponsored clinical trials. The guides include modules on alcohol-focused cognitive-behavioral therapy, increasing motivation, training support groups, and other evidence-based approaches that can help you manage clients with AUD.

What evidence-based medications are available to treat AUD?

So far, the FDA has approved three drugs to prevent a return to heavy drinking. You don't need any special training or license to prescribe these non-addictive drugs. Therefore, they are no more complicated to prescribe than drugs for other common ailments. As with the treatment of other mental illnesses such as depression, if a patient does not respond well to one medication, it is often worth trying another.

• acamprosatehelps maintain abstinence by acting on the glutamatergic neurotransmitter system to ease the emotional discomfort of anxiety, agitation, dysphoria, and insomnia that can occur as the brain adjusts to withdrawal (see main article on the subject).neuroscience). Two acamprosate tablets are taken three times a day. Acamprosate should be used as soon as the patient achieves abstinence.
• naltrexone(available in both versionsOralfromextended-release injectable medicationforms) works by blocking opioid receptors in the brain involved in the rewarding effects of drinking (see main article onneuroscience). The pill is taken once a day and the injection once a month. Naltrexone can be started while the patient is still drinking.
• disulfiraminterferes with alcohol metabolism by blocking the enzyme acetaldehyde dehydrogenase, resulting in a buildup of acetaldehyde that causes hot flashes, nausea, and other uncomfortable symptoms when drinking alcohol. It is a pill that is taken once a day and helps the patient to maintain abstinence. Disulfiram should never be given before the patient has abstained from alcohol for at least 12 hours.

These drugs are far from being used adequately in the treatment of AUD. According to a 2021 analysis, only 1.6% of adults with AUD were prescribed in the past year.⁸Providing drugs in primary care can be an effective step and motivate change for patients who may be reluctant to accept specialist care due to stigma or other barriers.⁹Your patients may not be familiar with the newer drugs (acamprosate and naltrexone) and may find them more attractive than the older drugs (disulfiram) that induce nausea with alcohol consumption.¹⁰They can also reassure patients that AUD medications are not addictive and are generally well tolerated. Therefore, people who take these drugs can also join support groups, which advise their members not to substitute one addictive drug for another.

If you are considering prescribing medication for AUD, you may find support in a number of medical guides (seeresources, below).^11-14Some primary care physicians may be able to more easily prescribe medications for AUD if they receive prescribing support from an addiction specialist or pharmacist and behavioral health follow-up.⁹If you would like to work with a prescribing physician or specialist therapist, you can find them atBrowser.

What are the options for mutual support groups?

Support groups can be helpful in instilling a sense of community among those recovering. Group beliefs and demographics vary widely. Therefore, advise patients interested in joining a group to try different options to find a good solution. In addition to widely recognized 12-step programs with spiritual components like AA, several secular groups also promote abstinence, including SMART Recovery, LifeRing, Women for Sobriety, Secular Organizations for Sobriety, and Secular AA (see).resources, below, for links).

Research suggests that three of the largest known secular groups in the US - SMART Recovery, LifeRing and Women for Sobriety - appear to be comparable in effectiveness to 12-step programs for people seeking abstinence.¹⁵People in these self-help groups are more successful in achieving abstinence when they are actively involved in their group, as measured, for example, by attending meetings, having a sponsor or close friend in the group, or volunteering in the group. participation group.¹⁵

Clinical interventions, such as the aforementioned 12-Step Facilitation Treatment, have been developed to help patients become more involved in their groups and thereby achieve optimal outcomes. A systematic review found that at 12 months, the facilitation of 12 steps and AA together can be as effective as cognitive-behavioral or motivational improvement therapy to reduce the intensity of alcohol consumption, promote abstinence and reduce the consequences related to alcohol.^sixteen(Verresourcesfor links to therapist manuals to facilitate participation in secular and 12-level self-help groups).

What are the different intensity levels for AUD treatment?

Evidence-based specialist treatment for AUD is offered at four basic levels of care or intensity. These levels, defined by the American Society of Addiction Medicine, form a treatment continuum on which patients increase and decrease treatment intensity as needed:

• Outpatient:Periodic practice visits for counseling, medication support, or both. (See below for some “lesser intensity” outpatient alternatives.)
• Intensive Outpatient Hospitalization or Partial Hospitalization:Coordinated outpatient treatment of complex needs.
• Reside:Low or high intensity programs in 24-hour treatment settings.
• Intensive care unit:Medical assistance 24 hours a day; can ease withdrawal symptoms.

Most treatment for AUD is done on an outpatient basis.^17,18Approximately half of patients with AUD experience withdrawal symptoms when they stop drinking.^2,19and a small proportion require intensive inpatient or outpatient “detox” to control potentially dangerous withdrawal symptoms.^2,20However, detox by itself is not a treatment. Maintaining abstinence and promoting long-term recovery often requires ongoing care in a hospital or outpatient setting, or both. In all contexts, AUD treatment is likely to be measured in months rather than days or weeks.

If you are unsure about the level of care to recommend for a patient, seek a thorough specialist evaluation. Yeslower intensityIf outpatient care is adequate, you can turn to a traditional program or consider alternatives such as these, which can help maintain your patient's privacy and routines:

• Do it yourself – assemble a personalized service team.By building a team consisting of a family physician, an anti-drug physician, and an anti-drug therapist, the "active ingredients" of a specialist program can be reflected.
• Telemedicine: sessions by phone or video.Telehealth services and related insurance coverage have been greatly expanded, allowing greater access to treatment.
• Electronic health.An example of an eHealth program developed with NIAAA support isCBT4CBT, an effective computer-assisted cognitive-behavioral therapy program that can be prescribed by any licensed physician or therapist.

HeBrowserand you arePortal for health professionals.can guide you and your patients to quality care at all levels of care, from inpatient care to telemedicine services. (See main article atremission.)

Finally,Due to the complexity of the AUD (and each patient), no single treatment approach is universally successful or appealing to all patients. The different treatment approaches (behavioral medicine, medication, and support groups) pursue similar goals while considering the different neurobiological, psychological, and social aspects of AUD. Therefore, these approaches complement each other and can work well together in a comprehensive, flexible and individualized treatment plan.