Treatment of Alcoholism

Key Points

• Try the least restrictive treatment first for the alcoholic patient.

• Long-term treatment is favored for alcoholism.

• The presence of other disorders increases acuity needs in the alcoholic.

The treatment options for alcoholism are extensive (Fuller et al., 2003; Kranzler et al., 2009). The medications most widely studied for alcohol use disorders are disulfiram, nal-trexone, and acamprosate. Results from the COMBINE study and trials of depot naltrexone formulations and oral topira-mate have provided important new information on the use of these medications in alcohol rehabilitation.

A family physician is faced with several decisions when evaluating a patient for treatment of alcoholism after successful detoxification, or if medically supervised detoxification is not needed. Should the patient go through a hospital or a nonhospital (residential) inpatient program, a day treatment program, or any outpatient program? Should the patient receive counseling, attend AA, or be involved in a cognitive program? Inpatient programs offer isolation from the drinking environment, intensive treatment, family involvement, in-depth assessment, and convenience for further medical or psychiatric assessment. However, they carry significant expense, typically occur after detoxification, remove the patient from the real-world environment, and have not been consistently shown to improve long-term outcomes. Patients who are suicidal or who have serious concomitant mental disorders that may impair recovery, as well as those unable to maintain abstinence in a less restrictive environment, should be considered for these facilities. Advantages of day treatment and outpatient treatment include reduced expense, ability to maintain work in some cases, and usually a longer period of treatment in a less restrictive environment. In general, as long as it is safe to try outpatient treatment initially, it is the least restrictive and most cost-effective method.

Access to relapse prevention treatments of established efficacy should be facilitated for alcohol-dependent patients. These therapies include outpatient programs, residential and "halfway house" milieu therapies, and partial hospitalization programs (SIGN, 2003).

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