BEST PRACTICE CARE OUTLINE
DIAGNOSIS Patients can be screened for problem drinking and Alcohol Use Disorder (AUD) using the Alcohol Use Disorder Identification Test (AUDIT). You can find a printable version which includes a standard drink guide here. The AUDIT is available on a self-administered electronic form here. A score of 8 or more points to hazardous or harmful alcohol consumption and a score of 15 or more points to likely AUD.
CAUSES Alcohol is a toxic and psychoactive substance with dependence producing properties. In countries where just over 80% of people consume alcohol, dependence occurs at a rate estimated at a minimum of around 6.5% of people over the age of 12. 10% of people who have an abundance of endorphin receptors in their brain and may be predisposed to developing AUD if they consume alcohol. Genetic vulnerability to AUD is likely to be due to numerous genes of small to modest effects in many neurotransmitter systems and signal transduction pathways.
PHARMACOTHERAPY: Targeted opioid receptor antagonist therapy (TORAT) is very effective in reducing harmful drinking to within recommended limits and for achieving abstinence. For those diagnosed with alcohol dependence/ Alcohol Use Disorder (AUD), targeted naltrexone can be a very effective pathway to abstinence and a valuable 'safety net' for those who may 'fall off the wagon' of abstinence. As per the medical guidelines at the bottom of this page, all patients with alcohol dependence should be offered naltrexone 50mg. Nalmefene can also be used for TORAT as an alternative. Naltrexone has been proven safe and non-addictive.
TORAT most commonly utilises naltrexone. Patients are prescribed naltrexone to take one hour before a risk of drinking is anticipated. Naltrexone must be taken beforehand every time a risk of drinking is anticipated. Drinking 'unprotected' may worsen this progressive disorder. The opioid receptor antagonist (ORA) binds to opioid receptors in the brain. Endorphins that are released in response to drinking alcohol are then blocked from binding to these receptors. Over time, the pharmacological extinction of the long term reinforcement effect of endorphin release following alcohol consumption is achieved. Some call this the 'reverse Pavlov's dog effect'. Alcohol cravings are reduced to pre-addiction levels in approximately 3 - 4 months. TORAT is a lifelong treatment. The reinforcement that progresses the addiction is prevented. The nervous system reacts by weakening the neural connections that cause craving and drinking. It is realistic to expect drinking to be controlled to within recommended limits and maintained, after pharmacological extinction has been achieved, as long as the patient remains compliant.
As naltrexone blocks the effects of endorphins, targeted use is preferable to daily use. Patients are encouraged to enjoy endorphin producing activities such as exercise when not taking naltrexone to further boost motivation to reduce drinking.
Naltrexone may be prescribed to be taken as needed/targeted at times of higher risk in the first instance. This approach may be more effective than daily naltrexone/injectable naltrexone in many people and can reduce the exposure to the side effects often experienced on naltrexone which impact compliance. For others, daily naltrexone may be the preferred option if compliance in taking targeted naltrexone when required cannot be achieved over time.
Acamprosate can be useful to help maintain abstinence if abstinence is chosen and achieved.
PSYCHOTHERAPY: Research has shown that 60% of people with AUD have no co-occurring mental health condition/s. While only 40% of people with AUD have a mental health condition, it is recommended that health practitioners offer psychological therapy and/or support such as SMART Recovery, Alcoholics Anonymous (AA) or a combination of these as part of the comprehensive treatment program. Links to some free services can be found on our 'Get Help' page. Trauma may be a component of AUD and psychological therapies can reduce trauma symptoms.
Tx COMPLIANCE: Medication compliance can be a challenge. Side effects of naltrexone can be unpleasant, but reduce in time. Patients may need medical support through this. Patients can reduce their dose to 25mg or less until they adjust. A full 50mg is required to be effective, however. Some patients may require a higher dose but this should be recommended with caution. Doses of 300mg or greater daily have been shown to present a hepatotoxicity risk. Patients may benefit from considering online pharmacies offering home delivery to reduce the impact of stigma deterring them from collecting their medication. Medication should be kept with them at all times.
Tx OUTCOMES: Targeted naltrexone therapy alone has a 78% reported success rate for patients maintaining drinking to within recommended limits. Approximately 25% of TORAT patients will also become completely abstinent. Naltrexone should also be made available to patients attending AA in the event of relapse. Further information about comprehensive treatment programs can be found in the guidelines posted below. AA alone has a reported 5 - 10% long term success rate for maintaining complete abstinence.
Patients with mild alcohol dependence may be able to exercise controlled drinking and reduce their drinking to within recommended limits using TORAT. Around 1 in 4 patients on targeted naltrexone can be expected to become completely abstinent. Scientific evidence supporting the efficacy of targeted naltrexone therapy can be viewed here.
Tx COSTS: Nalrexone is available on PBS streamlined authority for patients; 'The treatment must be part of a comprehensive treatment program with the goal of maintaining abstinence/controlled consumption' for $30.00 for 30 tablets ($1 per tablet) or on private script for around $112 for 30 tablets ($3.75 per tablet).
ASSESSMENT guidelines - click logo below
TREATMENT guidelines - click logo below