Guidelines Summary

Substance Abuse and Mental Health Services Administration

In March 2020, the Substance Abuse and Mental Health Services Administration (SAMHSA) released considerations for the care and treatment of mental and substance use disorders in the COVID-19 pandemic.^[48]

SAMHSA advises that outpatient treatment options be used to the greatest extent possible. Inpatient facilities should be reserved for those for whom outpatient measures are not considered an adequate clinical option. SAMHSA strongly recommends the use of telehealth and/or telephonic services to provide evaluation and treatment of patients.

SAMHSA urges providers to consider utilizing benzodiazepines in situations in which they believe that the individual would not benefit from administration of anticonvulsant medications that have been effective in treatment of alcohol withdrawal.

US Preventive Services Task Force

The US Preventive Services Task Force (USPSTF) recommends screening adults 18 and older, including pregnant women, for unhealthy alcohol use in primary care settings. Those patients who engage in risky or hazardous drinking should be offered brief behavioral counseling interventions to reduce unhealthy alcohol use. The USPSTF also concludes the evidence is insufficient regarding screening for alcohol use in adolescents 12 to 17 in primary care settings.^[49]

American Psychiatric Association

The American Psychiatric Association (APA) released the following guidelines in 2018:

Naltrexone and acamprosate are recommended to treat patients with moderate to severe alcohol use disorder in specific circumstances (e.g., when nonpharmacological approaches have not produced an effect or when patients prefer to use one of these medications).
Disulfiram produces physical reactions (e.g., flushing) if alcohol is taken within 12–24 hours of the medication use and is not generally used as a first-line treatment.
Topiramate and gabapentin are also suggested as medications for patients with moderate to severe alcohol use disorder, but typically after trying naltrexone and acamprosate first.

The guideline also includes statements related to assessment and treatment planning. Evidence-based psychotherapeutic treatments for alcohol use disorder, including cognitive-behavioral therapy (CBT), 12-step facilitation, and motivational enhancement therapy, also play a major role in treatment. In addition, community-based peer support groups such as Alcoholics Anonymous (AA) and other programs are helpful for many patients.^[50]

Medication

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Media Gallery

Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

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Table 1. AUDIT Questions and Scoring System

Questions	0 Points	1 Point	2 Points	3 Points	4 Points
1. How often do you have a drink containing alcohol?	Never	Monthly or less	2-4 times a month	2-3 times a week	4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?	1 or 2	3 or 4	5 or 6	7-9	10 or more
3. How often do you have 6 or more drinks on 1 occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
4. How often during the past year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
5. How often during the past year have you failed to do what was normally expected of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
9. Have you or has someone else been injured as a result of your drinking?	No		Yes, but not in the past year		Yes, during the past year
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down?	No		Yes, but not in the past year		Yes, during the past year

Table 2. Sensitivity and Specificity of Alcohol Biomarkers*

Biomarker	Sensitivity (%)	Specificity (%)
AST	15-69	47-68
ALT	18-58	50-57
GGT	34-85	11-95
MCV	34-89	26-95
CDT	39-94	82-100
CDT + GGT	90 †	98
Alcohol	0-100	0-100
EtG	76-91	77-92
*Values vary considerably according to gender, age, drinking pattern, prevalence of alcohol abuse/dependence, and prevalence of comorbidity, among other factors.^{[40, 6, 41, 43, 44]} † The sensitivity comes from one study in Finland, which uses a special formula. This study needs to be replicated.^[45]