Recommend Evidence-Based Treatment: Know the Options

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    Takeaways

    • You can maximize patient choice and outcomes by offering a full menu of evidence-based treatment options. Approaches for treating alcohol use disorder (AUD) include behavioral health treatments, FDA-approved AUD medications, and mutual support groups, or a combination of any of these.
    • Behavioral health treatments for AUD can bring lasting positive change. Steer patients in need of referral for behavioral support to licensed therapists who provide evidence-based modalities.
    • Three FDA-approved medications for AUD can help prevent a return to heavy drinking and promote abstinence. They are neither addicting nor complicated to prescribe. Seek a prescribing specialist for assistance if needed.
    • One size does not fit all. If one treatment approach does not work for a particular patient, try another.
    • The NIAAA Alcohol Treatment Navigator can help you and your patients recognize the signs of evidence-based treatment for AUD and locate healthcare professionals who provide quality care.

    As with many other medical conditions, treatment for alcohol use disorder (AUD) is not “one size fits all.” Different patients need different options. Fortunately, there are more AUD treatment choices than many people may expect. Evidence-based, quality treatment is offered at different levels of intensity and in a variety of settings to meet individual needs. Treatment can help patients achieve a goal of quitting drinking or of cutting down significantly, either of which can markedly improve their health status as well as how they feel and function.1

    Two types of evidence-based treatment for AUD are offered by healthcare professionals: behavioral healthcare and medications. They have been shown to be about equally effective2 and can be combined and tailored to improve outcomes for each patient. Many patients also benefit from active participation in mutual support groups such as Alcoholics Anonymous (AA) or a number of secular alternatives (see Resources), either on their own or as a complement to professionally led treatment.2

    Support for patients with AUD is offered in more settings than just specialty addiction programs. Primary care professionals can offer medications for AUD along with brief counseling (see Core article on brief intervention). Addiction physicians, clinical psychologists, and other licensed therapists also provide outpatient care in solo or group practices (see Core article on referral). These and other flexible, convenient options such as telehealth professional services and online or in-person mutual support groups may reduce stigma and other barriers to recovery. Here, we briefly describe options available to help patients with AUD.

    A note on a drinking level term used in this Core article: Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

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

    Patients with less severe AUD may be able to receive treatment in primary care via brief interventions (see Core article on brief intervention) and FDA-approved AUD medications. For people with more severe AUD or with mental health comorbidities, it’s wise to seek evidence-based behavioral health treatment with a licensed professional therapist to set the stage for lasting change (see Core article on mental health issues).

    Broadly, AUD-focused behavioral health treatment aims to help patients set goals, identify triggers that could prompt drinking, develop skills to stop or reduce drinking, manage emotions and stress, and build relationships that will support treatment goals. Specific evidence-backed approaches, which are about equally effective,2 include the following:

    • Cognitive-behavioral therapy (CBT) focuses on identifying and managing the thoughts, feelings, situations, behaviors, and stressors (called “triggers” or “cues”) that lead to heavy drinking. The goal is to change unhelpful thought processes and develop the skills to cope with situations and triggers that might result in an urge to drink.
    • Motivational enhancement therapyis conducted over a short period of time to help people build their own motivation for changing their drinking, form a specific plan for changing drinking behavior, and develop the skills and confidence needed to stick to the plan.
    • Acceptance- and mindfulness-based interventions increase awareness and acceptance of present-moment experiences. Mindfulness-based relapse prevention incorporates CBT skill-building strategies to promote flexible rather than “autopilot” responses to triggers that can prompt drinking.
    • Contingency management approaches incorporate tangible rewards for achieving specific, measurable treatment goals. This approach reinforces positive behaviors such as abstaining or regularly attending treatment sessions.
    • Couples and family counseling focus on promoting positive interactions and activities and improving communication skills. Evidence-based approaches based on cognitive behavioral and family systems theories improve patient support and increase the likelihood of improving drinking outcomes compared with individual counseling alone.3,4
    • Twelve-step facilitation therapy is a clinical intervention developed to increase a patient’s active involvement in a 12-step group such as AA.5 Increased attendance at group meetings can, in turn, facilitate decreases in alcohol consumption.6 Similarly, a clinical intervention called Mutual Support Group Facilitation encourages patients with AUD to sample mutual help groups broadly, including secular options.7 (See the section below on mutual support groups.)

    Therapists who specialize in addiction can offer one-on-one, couples, family, or group sessions. These specialists can be found both in treatment programs and in solo or group practices. NIAAA’s Alcohol Treatment Navigator can guide you to providers who offer evidence-based behavioral health treatment near you, as well as telehealth and online options.

    If you are a licensed therapist, see the Resources, below, for therapy manuals from NIAAA-sponsored clinical trials. The manuals contain modules for alcohol-focused CBT, motivational enhancement, mutual support group facilitation, and other evidence-based approaches that can help you treat clients who have AUD.

    What evidence-based medications are available to treat AUD?

    To date, three medications have been approved by the FDA to help prevent a return to heavy drinking. You don’t need specialized training or licensing to prescribe these non-addicting medications, so they are no more complicated to prescribe than those for other common medical conditions. As with treatment for other mental health conditions, such as depression, if a patient does not respond well to one medication, it is often worthwhile to try another.

    • Acamprosate helps to maintain abstinence by acting on the glutamatergic neurotransmitter system to alleviate the emotional discomfort of anxiety, restlessness, dysphoria, and insomnia that can happen as the brain adjusts to abstinence (see Core article on neuroscience). Two acamprosate pills are taken three times per day. Acamprosate should be used once a patient has achieved abstinence.
    • Naltrexone (available in either oral or injectable extended-release forms) works by blocking the opioid receptors in the brain that are involved in the rewarding effects of drinking (see Core article on neuroscience). The pill is taken once per day whereas the injection is given once per month. Naltrexone can be started while a patient is still drinking.
    • Disulfiram interferes with alcohol metabolism by blocking the enzyme acetaldehyde dehydrogenase, causing a buildup of acetaldehyde that leads to flushing, nausea, and other unpleasant symptoms when alcohol is consumed. It is a pill taken once per day that helps patients maintain abstinence. Disulfiram should never be administered until the patient has abstained from alcohol for at least 12 hours.

    These medications are vastly underused in treating AUD. They are prescribed for only 1.6% of adults with past-year AUD, according to a 2021 analysis.8 Offering medications in primary care can be an effective “foot in the door” and can catalyze change for patients who may be reluctant to accept specialty treatment because of stigma or other barriers.9 Your patients may be unaware of the newer medications (acamprosate and naltrexone) and may consider them more appealing than the older medication (disulfiram) that makes people feel sick if they drink alcohol.10 You can also reassure patients that AUD medications are not addicting and are generally well tolerated. Therefore, people who take these medications can also participate in mutual support groups that advise members not to replace one drug of addiction with another.

    If you are considering prescribing AUD medications, you can find support in several clinician’s guides (see Resources, below).11–14 Some primary care physicians may be more comfortable prescribing AUD medications if they have prescribing support from addiction specialists or pharmacists as well as behavioral health support for follow-up.9 If you would like to partner with a specialist prescriber or therapist, you can find them using the Navigator.

    What mutual support group choices are available?

    Mutual support groups may be beneficial for providing a sense of community for those in recovery. Groups vary widely in beliefs and demographics, so advise patients who are interested in joining a group to try different options to find a good fit. In addition to widely recognized 12-step programs with spiritual components such as AA, a number of secular groups promote abstinence as well, such as 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 U.S.—SMART Recovery, LifeRing, and Women for Sobriety—appear comparable in effectiveness to 12-step programs for people who have a goal of abstinence.15 People in any of these mutual help groups have greater success in achieving abstinence if they become actively involved with their group, as measured by, for example, meeting attendance, having a sponsor or close friend in the group, or volunteering for the group.15

    To help patients engage more deeply in their groups and thus obtain optimal outcomes, clinical interventions have been developed such as the twelve-step facilitation treatment mentioned earlier. A systematic review found that together, clinically-delivered twelve-step facilitation and AA can be as effective as cognitive behavioral or motivational enhancement therapy at reducing drinking intensity, promoting abstinence, and reducing alcohol-related consequences at 12 months.16 (See Resources for links to therapist manuals to facilitate participation in 12-step and secular mutual help groups.) 

    What are the different levels of intensity for AUD treatment?

    Evidence-based specialty treatment for AUD is offered at four basic levels of care or intensity. These levels, as defined by the American Society of Addiction Medicine, form a continuum of care in which patients step up and down in treatment intensity as needed:

    • Outpatient: Regular office visits for counseling, medication support, or both. (See below for some "lower intensity" outpatient alternatives.)
    • Intensive outpatient or partial hospitalization: Coordinated outpatient treatment for complex needs.
    • Residential: Low or high intensity programs in 24-hour treatment settings.
    • Intensive inpatient: Medically directed 24-hour services; may manage withdrawal symptoms.

    Most AUD treatment is provided in outpatient settings.17,18 About half of AUD patients will have some symptoms of withdrawal when they stop drinking,2,19 and a small proportion need intensive inpatient or outpatient “detox” to manage potentially dangerous withdrawal symptoms.2,20 Detox alone does not constitute treatment, however. Continued care in residential or outpatient settings or both is often needed to sustain abstinence and promote long-term recovery. Across settings, a course of AUD treatment is likely to be measured in months, not days or weeks.

    If you are uncertain as to which level of care to recommend for a patient, seek a complete assessment by a specialist. If lower intensity outpatient care is appropriate, you can refer to a traditional program, or consider alternatives such as these, which can help maintain your patient’s privacy and routines:

    • Do-it-yourself – build a custom care team. By building a team consisting of a primary care provider, an addiction physician, and an addiction therapist, you can mirror the "active ingredients" of a specialty program.
    • Telehealth – phone or video sessions. Telehealth services have greatly expanded, along with insurance coverage for them, allowing greater access to treatment.  
    • e-Health. An example of an e-Health program developed with NIAAA support is CBT4CBT, an effective computer-based cognitive behavioral therapy program that can be prescribed by any physician or licensed therapist.  

    The Navigator and its portal for healthcare professionals can steer you and your patients to quality treatment at all levels of care, from residential to telehealth services. (See Core article on referral.)   

    In closing, because of the complexity of AUD (and of individuals), no single treatment approach is universally successful or appealing to all patients. The different treatment approaches—behavioral healthcare, medications, and mutual support groups—share similar goals while addressing the varied neurobiological, psychological, and social aspects of AUD. Thus, these approaches are complementary and can work well together in an individualized, flexible, and comprehensive treatment plan.

    Resources

    Alcohol Use Disorder Medication Guides

    Mutual Support Groups

    Therapy Guides for Mental Health Specialists

    Resources to Share with Patients Related to this Article

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

    1. Witkiewitz K, Falk DE, Litten RZ, et al. Maintenance of World Health Organization Risk Drinking Level Reductions and Posttreatment Functioning Following a Large Alcohol Use Disorder Clinical Trial. Alcohol Clin Exp Res. 2019;43(5):979-987. doi:10.1111/acer.14018
    2. Witkiewitz K, Litten RZ, Leggio L. Advances in the science and treatment of alcohol use disorder. Sci Adv. 2019;5(9):eaax4043. doi:10.1126/sciadv.aax4043
    3. McCrady BS, Wilson AD, Muñoz RE, Fink BC, Fokas K, Borders A. Alcohol-Focused Behavioral Couple Therapy. Fam Process. 2016;55(3):443-459. doi:10.1111/famp.12231
    4. McCrady BS, Flanagan JC. The Role of the Family in Alcohol Use Disorder Recovery for Adults. Alcohol Res Curr Rev. 2021;41(1):06. doi:10.35946/arcr.v41.1.06
    5. Twelve Step Facilitation Therapy Manual: A Clinical Research Guide for Therapists Treating Individuals with Alcohol Abuse and Dependence. National Institute on Alcohol Abuse and Alcoholism Accessed December 10, 2021. https://pubs.niaaa.nih.gov/publications/projectmatch/match01.pdf
    6. Humphreys K, Blodgett JC, Wagner TH. Estimating the efficacy of Alcoholics Anonymous without self-selection bias: an instrumental variables re-analysis of randomized clinical trials. Alcohol Clin Exp Res. 2014;38(11):2688-2694. doi:10.1111/acer.12557
    7. Miller W. COMBINE Monograph Series, Volume 1. Combined Behavioral Intervention Manual: A Clinical Guide for Therapists Treating People With Alcohol Abuse and Dependence. DHHS Publication No. (NIH) 04-5288 Accessed July 1, 2021. https://www.niaaa.nih.gov/sites/default/files/publications/Combine_mono…
    8. Han B, Jones CM, Einstein EB, Powell PA, Compton WM. Use of Medications for Alcohol Use Disorder in the US: Results From the 2019 National Survey on Drug Use and Health. JAMA Psychiatry. 2021;78(8):922-924. doi:10.1001/jamapsychiatry.2021.1271
    9. Williams EC, Achtmeyer CE, Young JP, et al. Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics. J Gen Intern Med. 2018;33(3):258-267. doi:10.1007/s11606-017-4202-z
    10. Wallhed Finn S, Bakshi AS, Andréasson S. Alcohol consumption, dependence, and treatment barriers: perceptions among nontreatment seekers with alcohol dependence. Subst Use Misuse. 2014;49(6):762-769. doi:10.3109/10826084.2014.891616
    11. Substance Abuse and Mental Health Services Administration and National Institute on Alcohol Abuse and Alcoholism. Medication for the Treatment of Alcohol Use Disorder: A Brief Guide. Substance Abuse and Mental Health Services Administration; 2015:39.
    12. Pharmacotherapy for Adults With Alcohol Use Disorder in Outpatient Settings | Effective Health Care Program. Agency for Healthcare Research and Quality. Published 2016. Accessed June 11, 2021. https://effectivehealthcare.ahrq.gov/products/alcohol-misuse-drug-thera…
    13. Center for Substance Abuse Treatment. Incorporating Alcohol Pharmacotherapies Into Medical Practice. Substance Abuse and Mental Health Services Administration (US); 2009. Accessed June 11, 2021. http://www.ncbi.nlm.nih.gov/books/NBK64041/
    14. Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Am J Psychiatry. 2018;175(1):86-90. doi:10.1176/appi.ajp.2017.1750101
    15. Zemore SE, Lui C, Mericle A, Hemberg J, Kaskutas LA. A longitudinal study of the comparative efficacy of Women for Sobriety, LifeRing, SMART Recovery, and 12-step groups for those with AUD. J Subst Abuse Treat. 2018;88:18-26. doi:10.1016/j.jsat.2018.02.004
    16. Kelly JF, Humphreys K, Ferri M. Alcoholics Anonymous and other 12‐step programs for alcohol use disorder. Cochrane Database Syst Rev. 2020;2020(3). doi:10.1002/14651858.CD012880.pub2
    17. Substance Abuse and Mental Health Services Administration. National Survey of Substance Abuse Treatment Services. Published online 2018:179.
    18. Edlund MJ, Booth BM, Han X. Who Seeks Care Where? Utilization of Mental Health and Substance Use Disorder Treatment in Two National Samples of Individuals with Alcohol Use Disorders. J Stud Alcohol Drugs. 2012;73(4):635-646. doi:10.15288/jsad.2012.73.635
    19. Schuckit MA, Danko GP, Smith TL, Hesselbrock V, Kramer J, Bucholz K. A 5-year prospective evaluation of DSM-IV alcohol dependence with and without a physiological component. Alcohol Clin Exp Res. 2003;27(5):818-825. doi:10.1097/01.ALC.0000067980.18461.33
    20. Foy A, Kay J. The incidence of alcohol-related problems and the risk of alcohol withdrawal in a general hospital population. Drug Alcohol Rev. 1995;14(1):49-54. doi:10.1080/09595239500185051

     

     

    Earn CME/CE Credit

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    CME/CE Activity — Recommend Evidence-Based Treatment: Know the Options

    Released on 5/6/2022
    Expires on 5/10/2023

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    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Describe evidence-based treatment options for alcohol use disorder (AUD).
    • Identify potential components of an individualized, flexible, and comprehensive treatment plan for alcohol use disorder (AUD) to maximize patient choice and outcomes.
    • Identify patients who will likely need a referral for behavioral health treatment to licensed therapists for lasting positive change.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writers for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    NIAAA Writers and Content Contributors

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    Sudie Back, PhD
    Professor, Department of Psychiatry and
    Behavioral Sciences, MUSC
    Staff Psychologist, Ralph H. Johnson VA
    Medical Center, Charleston, SC

    Douglas Berger MD, MLitt
    Staff Physician, VA Puget Sound,
    Associate Professor of Medicine,
    University of Washington, Seattle, WA

    Randall Brown MD, PhD
    Professor, School of Medicine
    & Public Health,
    University of Wisconsin, Madison, WI

    H. Westley Clark, MD, JD, MPH
    Dean's Executive Professor of Public Health,
    Santa Clara University, Santa Clara, CA

    Barbara J. Mason, PhD
    Pearson Family Professor,
    The Scripps Research Institute, CA

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Nancy Diazgranados, MD, MS, DFAPA
    Deputy Clinical Director, NIAAA

    Falk W. Lohoff, MD
    Lasker Clinical Research Scholar;
    Chief, Section on Clinical Genomics and Experimental Therapeutics, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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