Treatment: Pharmacologic and Psychosocial Interventions
Alcohol use disorder
FDA-approved medications are naltrexone (oral and long-acting injectable), acamprosate, and disulfiram. Naltrexone reduces craving and heavy drinking; check liver enzymes, and ensure 7–10 days off opioids. Acamprosate supports abstinence, is renally cleared, and is dosed 666 mg three times daily (two tablets twice daily in the United States). Disulfiram works only with supervised adherence and abstinence. Off-label options include topiramate, gabapentin, and baclofen, each with caveats.
Opioid use disorder
Methadone, buprenorphine, and naltrexone are effective. Methadone and buprenorphine reduce mortality; buprenorphine can be started in office settings and has a ceiling on respiratory depression. Avoid precipitated withdrawal by timing induction to withdrawal. Naloxone reverses overdose. Do not require abstinence before starting medication-this is a common fatal error.
Tobacco and stimulants
Varenicline, bupropion, and nicotine replacement are first-line for tobacco. No FDA medication exists for stimulant use disorder; contingency management has the strongest evidence, alongside CBT and motivational interviewing.
Psychosocial treatments
CBT, motivational enhancement, twelve-step facilitation, family therapies, and contingency management. Match intensity to severity using ASAM criteria.
Traps
Only four FDA-approved alcohol medications exist (naltrexone oral and injectable count as formulations, acamprosate, disulfiram). Disulfiram is not for craving. Naltrexone is not for patients on opioids. Buprenorphine is not a weaker methadone-it is a partial agonist with different safety.
Worked example
A patient with AUD and Child-Pugh B cirrhosis: avoid naltrexone; acamprosate or gabapentin with caution is preferable.