Alcohol dependence (Formulary: CNS)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Acamprosate, disulfiram and naltrexone are licensed for maintenance of abstinence after alcohol withdrawal.  

Alcohol withdrawal: seek specialist advice:

Community:

Secondary Care:

For further information refer to:

ACAMPROSATE

Therapy notes

EMC

  • The safety and efficacy of acamprosate has not been established in patients younger than 18 years or older than 65 years. Use is therefore not recommended.
  • Off-label use for older populations could be considered in agreement with the specialists.
  • The interrelationship between alcohol dependence, depression and suicidality is well-recognised and complex, it is recommended that alcohol-dependent patients, including those treated with acamprosate, be monitored for such symptoms.

Formulation and dosage details

Formulation:

Gastro-resistant tablets 333mg 

Specialist service support:

  • Provide intensive counselling and psychosocial support for a minimum of 6 sessions (frequency between sessions may vary)
  • Prescribe the first 4 weeks prior to asking the GP to continue prescribing.
  • Prompt communication with GP of any changes in treatment, results of monitoring undertaken and assessment of adverse events.
  • Advice to GPs on when to stop treatment.
  • Ensure clear arrangements for back-up advice and support.

Dosage:

Indication: For maintaining abstinence in alcohol dependent adults

Dosage: As per BNF

  • Acamprosate works best in those who are abstinent but may be effective in reducing the risk of a minor lapse becoming a full relapse (return to heavy drinking for 4 to 6 weeks) so it should be continued in these patients until a full relapse becomes obvious. If patient starts drinking again or if drinking persists 4 to 6 weeks after initiating acamprosate, the GP should discuss and seek advice from the specialist service.

Treatment duration: Treatment should be maintained for a duration of 6 to 12 months, with discontinuation recommended after 12 months.

Treatment cessation: Treatment should be discontinued in the event of a full relapse, if there is lack of efficacy, or intolerable side effects occur.

Patient information:

BACLOFEN

Therapy notes

EMC

Formulation and dosage details

Formulation:

Tablets 10mg (Restricted: Specialist initiation only)

  • To be initiated by the Specialist prior to handover to Primary care, usually once the patient is stabilised on treatment
  • The specialist service will provide advice on any dosage adjustments, monitoring, when to refer back, and when and how to stop treatment (if appropriate).

Dosage:

Indication: Off-label: To maintain abstinence in alcohol dependent adults

Dosage:

  • Treatment initiation: 10mg three times a day
  • Titration: Increase by 10mg a day each week to manage the following:
    • suppression of craving,
    • management of alcohol consumption,
    • to support abstinence
    • reduce the anxiety associated with alcohol use.
  • Maximum dose: up to a maximum of 100mg each day (as per BNF)

Maintenance dose: When the desired dose is reached, and it is well tolerated, it is recommended to stay at that dose for 2 to 3 months (sometimes less and sometimes more) and then try to reduce the dose to find the lowest effective dose. The maintenance dose is often between one third and half of the maximum dose reached. 

Treatment duration: guided by individual response, treatment goals, and clinical circumstances. Some patients may continue taking baclofen for months or even years, particularly if it remains effective in managing cravings and supporting emotional regulation.

Discontinuation: must be slow and progressive. Abrupt baclofen withdrawal may induce confusion, hallucinations and seizures. The initiating Consultant will facilitate an agreed gradual reduction schedule with the patient and inform the GP of the gradual tapering plan. 

Guidelines:

Patient information:

DISULFIRAM

Therapy notes

EMC

Important Safety Information: Alcohol must NOT be consumed during treatment with disulfiram and for up to 14 days after discontinuation.

Caution is advised in patients with the following conditions:

  • Renal failure
  • Hepatic or respiratory disease
  • Diabetes mellitus
  • Hypothyroidism
  • Cerebral damage
  • Epilepsy

Alcohol avoidance: Patients must be strictly warned not to ingest alcohol during treatment and for 14 days after stopping disulfiram. The disulfiram–alcohol reaction is unpredictable and potentially severe; in rare cases, fatalities have occurred following alcohol consumption during therapy.

Sources of alcohol: Patients should be informed that certain products may contain sufficient alcohol to trigger a reaction, including:

  • Foods
  • Liquid medicines
  • Remedies and tonics
  • Toiletries
  • Perfumes
  • Aerosol sprays

Caution is also advised with low-alcohol, “non-alcoholic,” or “alcohol-free” beers and wines, which may provoke a reaction if consumed in sufficient quantities.

Formulation and dosage details

Formulation:

Tablets 200mg (Restricted: Specialist initiation only)

  • To be initiated by the Specialist prior to handover to Primary care, usually once the patient is stabilised on treatment

Specialist service will provide:

  • Intensive counselling and psychosocial support for a minimum of 6 sessions (frequency between sessions may vary)
  • Prompt communication with GP of any changes in treatment, results of monitoring undertaken and assessment of adverse events.
  • Advice to GPs on when to stop treatment.
  • Ensure clear arrangements for back-up advice and support.

Dosage:

Indication: Adjunct in the treatment of chronic alcohol dependence (under medical supervision) in adults (18 to 65 years)

Pre-treatment assessment: Before initiating Disulfiram therapy, appropriate examinations should be conducted to determine the patient’s suitability for treatment.

Dosage:

  • Treatment initiation: 200mg daily
  • Titration: Dose increase may be necessary of the patient continues to drink but does not experience adverse effects, up to a maximum dose of 500mg daily
  • Maintenance dose: 200mg to 500mg daily (under expert supervision)
  • Review: The patient will be reviewed at 6 months intervals by the specialist and then decision made to carry on communicated to the GP.
  • Duration: If drug is deemed efficacious then can be continued for up to 12 months. 
  • Cessation: If relapse occurs, disulfiram treatment should be discontinued, however, a disulfiram reaction can occur up to 14 days after discontinuation of the drug. 

Administration guidance:

  • All personnel involved in the administration of disulfiram must be aware that it must not be given during a drinking episode.

Alcohol Reaction: 

  • The disulfiram–alcohol reaction can occur within 15 minutes of alcohol ingestion, typically peaking between 30 minutes to 1 hour, and then gradually subsiding over the following few hours.

Symptoms: may be severe and potentially life-threatening. The reaction is characterised by:

  • Intense flushing
  • Dyspnoea (shortness of breath)
  • Headache
  • Palpitations
  • Tachycardia
  • Hypotension
  • Nausea and vomiting

Management considerations:

  • Supportive therapy should be readily available.
  • Measures may be required to counteract hypotension.
  • Severe vomiting may necessitate the administration of intravenous fluids.

Guidelines:

Patient information:

NALTREXONE HYDROCHLORIDE

Therapy notes

EMC

Formulation and dosage details

Formulation:

Tablets 50mg
Restricted: Specialist initiation only

  • To be initiated by the Specialist prior to handover to Primary care, usually once the patient is stabilised on treatment.
  • The specialist service will advise the GP of any dosage adjustments required, monitoring required, when to refer back, and when and how to stop treatment (if appropriate).
  • Refer back to the specialist in the event of a relapse to drinking which persists for 4 to 6 weeks, or concerns over patient compliance.

Medication to support relapse prevention in abstinence should NOT be used without psychological support.

  • Counselling and psychosocial support needs will be provided by the specialist service for a minimum of 6 sessions (frequency between sessions may vary) 

Note: The ‘Sinclair’ method is not advocated or supported in association with naltrexone by NHS Highland. 

Dosage:

Indication: To assist in maintenance of abstinence in Alcohol Use Disorder as per NICE CG115.  Best utilised in reducing heavy drinking in patients without evidence of physical dependency.

Dosage: As per BNF

Treatment duration: Continued up to 12 months is efficacious. To stop naltrexone if the patient relapses into drinking which persists for 4 to 6 weeks after starting naltrexone.

Guidelines:

Drug Interactions: As per BNF

  • Clinical experience and experimental data on the effect of naltrexone on the pharmacokinetics of other substances are limited. No interaction studies have been performed, thus concomitant treatment with naltrexone and other medicinal products should be conducted with caution and should be followed carefully. Concomitant administration of naltrexone with an opioid-containing medication should be avoided.
  • There are NO known interactions between naltrexone and alcohol.
  • Concomitant administration of naltrexone with an opioid-containing medication should be avoided.
    Patients should be warned that attempts to overcome the blockade may result in acute opioid intoxication which may be life threatening.

Contra-indication: As per BNF

Further information

  • Pregnancy: Naltrexone should ONLY be given to pregnant women when, in the judgement of the attending physician, the potential benefits outweigh the possible risk. Referral back to Specialist services for pregnancy management with prescribing.
  • Breastfeeding: During treatment breast feeding is NOT recommended.
  • Pregnancy and breastfeeding cases are reviewed by Specialist services and retained appropriately.

Patient information:

Editorial Information

Version: V2

Document Id: F104