Recommend Evidence-Based Treatment: Know the Options

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 such as SMART Recovery (see Resources), either on their own or as a complement to professionally led treatment. ²

Treatment for 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 private practices and community clinics. (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.

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 is 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 treatments aim 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 behaviors and develop skills to cope with situations and triggers that might result in an urge to drink.
• Motivational enhancement therapy is 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. These approaches reinforce positive behaviors such as abstaining from drinking or regularly attending treatment sessions.
• Couples counseling 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 individual, couples, family, or group sessions. These specialists can be found in addiction specialty treatment programs, independent private practice, and other clinical settings. 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?

Three medications are approved by the FDA to treat AUD.^8,9 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 helpful to try another.

• 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 alcohol (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.
• 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 initiated as soon as possible after withdrawal, when a patient has achieved abstinence.¹⁰
• 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. ¹¹

Offering medications in primary care can be an effective “foot in the door” and can catalyze change for patients who may be reluctant to seek specialty treatment because of stigma or other barriers.¹² 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.¹³ The American Psychiatric Association also suggests that gabapentin or topiramate be offered as second-line therapy for patients who prefer these medications or haven’t responded to the FDA-approved options.¹⁴

Some patients may hesitate to take AUD medications due to misinformation they’ve heard from peers, some treatment environments, and other sources. You can reassure them that AUD medications are valid treatment options that benefit many people and are non-addictive, well tolerated, and generally not needed indefinitely.

If you are considering prescribing AUD medications, you can find support in several clinician guidelines (see Resources, below).^14–17 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 healthcare for follow-up.¹² 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 and recovery 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.¹⁸ People in any of these mutual support groups have greater success in achieving abstinence if they become actively involved with their group, as measured by, for example, regular meeting attendance, having a sponsor or close friend in the group, or volunteering for the group.¹⁸

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.¹⁹ (See Resources for links to therapist manuals to facilitate participation in 12-step and secular mutual support 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 appointments 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. ^20,21 About half of patients with AUD will have some symptoms of withdrawal when they stop drinking,^2,22 and a small proportion need intensive inpatient or outpatient “detox” to manage potentially dangerous withdrawal symptoms. ^2,23 Detox alone does not constitute treatment for AUD, 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 expanded, along with insurance coverage for them, often allowing greater access to treatment.²⁴ Research shows that telehealth AUD treatment can reduce alcohol consumption^25,26 and may appeal to young adults and others who may be less inclined to seek treatment.²⁷
• 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.