Diagnosis and clinical formulation #
Establish persistent impairment involving control over drinking, prioritisation of alcohol, physiological adaptation and continued use despite harm. Record the diagnostic framework used; AUD severity and dependence are not interchangeable with the AUDIT screening category. Quantify beverage volume, alcohol concentration, drinking days and maximum consumption rather than documenting “social drinking”.
Assessment before selecting treatment #
Clarify last use, previous seizures or delirium during withdrawal, earlier treatment response, opioid-containing medicines, other sedatives, nutrition, injuries and cognitive change. Document the patient’s goal and practical capacity to attend appointments. Assess depression, psychosis and self-harm directly; reassessment after drinking changes should not postpone urgent treatment of an established comorbid disorder.
Distinguishing coexisting presentations #
| Presentation | Clinical distinction |
|---|---|
| Alcohol withdrawal | Symptoms follow reduction; autonomic signs and previous complicated withdrawal affect setting. |
| Independent mood disorder | Episodes predating heavy drinking or persisting during recovery need their own formulation. |
| Alcohol-related cognitive impairment | Collateral functional history and reassessment after medical stabilisation are essential. |
Baseline tests and their purpose #
Investigations identify complications and prescribing constraints, not AUD itself.
| Test / assessment | Purpose |
|---|---|
| Renal function and weight | Establish whether acamprosate is appropriate and which product-specific schedule applies. |
| Liver profile | Identify hepatic disease and assess naltrexone/disulfiram suitability. |
| Medication and opioid-use review | Prevent naltrexone-precipitated withdrawal and plan analgesia. |
| Nutritional assessment | Identify need for thiamine and broader nutritional treatment. |
Selecting continuing treatment #
Combine medication with motivational work, relapse-prevention skills and accessible psychosocial support. Naltrexone can support reduced drinking or abstinence; acamprosate is aimed at maintaining abstinence after withdrawal. Discuss peer support, family involvement with consent, and barriers such as housing or transport. Do not use benzodiazepines as continuing AUD treatment.
Doses & prescribing #
Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.
Acamprosate
Maintenance of alcohol abstinence after withdrawal
Adults · 333 mg delayed-release tablets · Oral · US label regimen; duration from UK NICE. Indian authorization not established here.
- Starting dose
- 666 mg three times daily after abstinence is achieved.
- Titration
- No routine upward titration in this label.
- Treatment range / target
- 666 mg three times daily (1,998 mg/day).
- Maximum / limits
- 1,998 mg/day is the recommended regimen; higher dosing is not supplied here.
- Trial & duration
- Reassess ongoing benefit; NICE generally uses 6 months, longer if beneficial.
- Monitoring
- Renal function, adherence, diarrhoea and emerging depression or suicidality.
- Population & organ-function adjustments
- US label: creatinine clearance 30–50 mL/min: 333 mg three times daily; contraindicated at ≤30 mL/min.
- Important cautions
- Does not treat acute withdrawal. Use with psychosocial care. UK weight-based and renal rules differ.
Naltrexone
Relapse prevention following assisted alcohol withdrawal
Adults · Oral tablets · Oral · UK NICE regimen plus US label opioid precautions; Indian authorization not established here.
- Starting dose
- 25 mg once daily under the NICE initiation approach.
- Titration
- Increase toward 50 mg once daily after assessing tolerability; NICE does not specify a universal day-by-day increment.
- Treatment range / target
- 50 mg once daily.
- Maximum / limits
- 50 mg/day is the routine AUD regimen shown; no higher-dose schedule is inferred.
- Trial & duration
- Usually up to 6 months; extend when benefiting and desired.
- Monitoring
- Baseline hepatic assessment; review symptoms of hepatitis, adherence, drinking and analgesia needs.
- Population & organ-function adjustments
- Significant hepatic or renal impairment requires product-specific assessment; no empirical adjustment formula.
- Important cautions
- Exclude current opioid use/dependence. US label recommends at least 7–10 opioid-free days after short-acting opioids; vulnerability after methadone/buprenorphine may last longer. This interval alone does not establish suitability.
Persistent drinking or poor tolerability #
Review the actual medication taken, treatment goal, triggers, opioid exposure, adverse effects and access to psychological care. NICE advises reviewing discontinuation of acamprosate or naltrexone if drinking persists after 4–6 weeks. This differs from the US acamprosate label, which advises continuing through relapse: choose and document the applicable treatment framework instead of treating one lapse as automatic failure.
Duration and relapse prevention #
NICE generally uses up to 6 months of relapse-prevention medication, with longer treatment when beneficial and desired. Rehearse a plan for craving, lapses and re-entry to care. Repeated unsupported withdrawal attempts are not a substitute for continuing treatment.
Organ impairment and other populations #
Acamprosate renal instructions differ between UK product information and US labeling; do not merge serum-creatinine and creatinine-clearance rules. Pregnancy, advanced liver disease and complex polysubstance use require a coordinated specialist plan. An opioid antagonist is unsuitable when opioid analgesia or opioid agonist treatment is required.
Follow-up measures #
Record drinking days, heavy-drinking episodes, craving, adverse effects, adherence, function and the agreed recovery goal. NICE recommends at least monthly supervision during the first 6 months of acamprosate or naltrexone. Reassess depression and suicidality during care, including after abrupt changes in drinking.
Prescribing pitfalls #
Do not mistake withdrawal completion for remission. Avoid counting tablet strengths as evidence of an appropriate regimen. Before naltrexone, specifically ask about tramadol, codeine, methadone and buprenorphine; a routine medication list can miss intermittent or non-prescribed opioid exposure.
Assessment tools #
Choose the instrument for its intended purpose; interpretation accompanies the linked tool.
Patient discussion #
Open a plain-language explanation
The plan depends on drinking pattern, health and previous withdrawal. Stopping suddenly can require medical support when dependence is present.
References · 6
- NICE CG115: alcohol dependence · United Kingdom · Checked 2026-10-26 · Supports: Persistent drinking or poor tolerability; Duration and relapse prevention; Follow-up measures; Acamprosate — Maintenance of alcohol abstinence after withdrawal (333 mg delayed-release tablets); Naltrexone — Relapse prevention following assisted alcohol withdrawal (Oral tablets)
- British Columbia: high-risk drinking and AUD · Canada · Checked 2026-10-26 · Supports: Assessment before selecting treatment; Selecting continuing treatment; Duration and relapse prevention
- NIAAA: AUD diagnosis and recovery · United States · Checked 2026-10-26 · Supports: Diagnosis and clinical formulation; Assessment before selecting treatment; Distinguishing coexisting presentations
- UK alcohol guidelines: pharmacological interventions · United Kingdom · Checked 2026-10-26 · Supports: Baseline tests and their purpose; Organ impairment and other populations
- Acamprosate delayed-release tablets: US label · United States; DailyMed submitted label · Checked 2026-10-26 · Supports: Persistent drinking or poor tolerability; Acamprosate — Maintenance of alcohol abstinence after withdrawal (333 mg delayed-release tablets)
- Naltrexone tablets: US label · United States; DailyMed submitted label · Checked 2026-10-26 · Supports: Organ impairment and other populations; Prescribing pitfalls; Naltrexone — Relapse prevention following assisted alcohol withdrawal (Oral tablets)