Incorporating Alcohol Pharmacotherapies Into Medical Practice A Treatment Improvement Protocol TIP 49 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment www.samhsa.gov PHARMACO­ THERAPIES Incorporating Alcohol Pharmacotherapies Into Medical Practice Treatment Improvement Protocol (TIP) Series 49 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment 1 Choke Cherry Road Rockville, MD 20857 Acknowledgments specific, written authorization of the Office of Communications, SAMHSA, This publication was produced under HHS. the Knowledge Application Program, contract number 270-04-7049, a Joint Venture of The CDM Group, Inc., and Electronic Access and Copies JBS International, Inc., for the Center of Publication for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health This publication may be downloaded Services Administration (SAMHSA), or ordered at http://www.samhsa.gov/ U.S. Department of Health and Human shin. Or, please call SAMHSA’s Health Services (HHS). Christina Currier served Information Network at 1-877-SAMHSA-7 as the CSAT Government Project Officer. (1-877-726-4727) (English and Español). Disclaimer Recommended Citation The views, opinions, and content Center for Substance Abuse Treatment. expressed herein are those of the expert Incorporating Alcohol Pharmacotherapies panel and do not necessarily reflect the Into Medical Practice. Treatment views, opinions, or policies of CSAT, Improvement Protocol (TIP) Series 49. SAMHSA, or HHS. No official support of HHS Publication No. (SMA) 09-4380. or endorsement by CSAT, SAMHSA, or Rockville, MD: Substance Abuse and HHS for these opinions or for particular Mental Health Services Administration, instruments, software, or resources is 2009. intended or should be inferred. Originating Office Public Domain Notice Quality Improvement and Workforce All materials appearing in this Development Branch, Division of Services volume except those taken directly Improvement, Center for Substance from copyrighted sources are in the Abuse Treatment, Substance Abuse and public domain and may be reproduced Mental Health Services Administration, or copied without permission from 1 Choke Cherry Road, Rockville, MD SAMHSA/CSAT or the authors. Citation 20857. of the source is appreciated. However, this publication may not be reproduced HHS Publication No. (SMA) 09-4380 or distributed for a fee without the Printed 2009 Contents Consensus Panel ....................................................................................................................... vii Expert Advisory Board ........................................................................................................... ix What Is a TIP? ............................................................................................................................ xi Foreword ...................................................................................................................................xiii Chapter 1—Introduction ...........................................................................................................1 Alcohol Use Disorders in Medical Settings .............................................................................1 Audience for TIP 49 ..................................................................................................................2 Recognition of Alcohol Dependence as a Chronic Illness .......................................................3 Purpose of TIP 49 ......................................................................................................................3 What TIP 49 Does Not Cover ...................................................................................................4 Specialty Treatment Versus Screening and Brief Intervention ............................................5 Why Use Medications To Treat Alcohol Dependence? ...........................................................5 Format, Approach, and Organization of TIP 49 .....................................................................7 Chapter 2—Acamprosate ...........................................................................................................9 What Is Acamprosate? ..............................................................................................................9 Why Use Acamprosate? ..........................................................................................................10 How Is Acamprosate Used? ....................................................................................................11 Who Is Appropriate for Treatment With Acamprosate? ......................................................13 Treatment Duration and Discontinuing Acamprosate .........................................................14 Final Clinical Thoughts ..........................................................................................................14 Chapter 3—Disulfiram .............................................................................................................15 What Is Disulfiram?................................................................................................................15 Why Use Disulfiram? ..............................................................................................................18 How Is Disulfiram Used? ......................................................................................................19 Who Is Appropriate for Treatment With Disulfiram? ..........................................................25 Treatment Duration and Discontinuing Disulfiram .............................................................25 Final Clinical Thoughts ..........................................................................................................26 iii Chapter 4—Oral Naltrexone ...................................................................................................27 What Is Oral Naltrexone? ......................................................................................................27 Why Use Oral Naltrexone? .....................................................................................................28 How Is Oral Naltrexone Used? ..............................................................................................29 Who Is Appropriate for Treatment With Oral Naltrexone? .................................................34 Treatment Duration and Discontinuing Oral Naltrexone ...................................................35 Final Clinical Thoughts .........................................................................................................35 Chapter 5—Extended-Release Injectable Naltrexone ......................................................37 What Is Extended-Release Injectable Naltrexone? ..............................................................37 Why Use Extended-Release Injectable Naltrexone? .............................................................38 How Is Extended-Release Injectable Naltrexone Used? ......................................................39 Who Is Appropriate for Treatment With Extended-Release Injectable Naltrexone? .........42 Treatment Duration and Discontinuing Extended-Release Injectable Naltrexone............43 Final Clinical Thoughts ..........................................................................................................43 Chapter 6—Patient Management ..........................................................................................45 Integrating Medication for Alcohol Dependence Into Clinical Practice Settings ...............45 Initial Assessment ..................................................................................................................46 Choosing a Medication ............................................................................................................51 Combination Therapy .............................................................................................................51 Choosing a Psychosocial Intervention ...................................................................................54 Developing a Treatment Plan ................................................................................................56 Patient Awareness ..................................................................................................................57 Monitoring Patient Progress ..................................................................................................57 Modifying the Treatment Strategy ........................................................................................60 Discontinuing Pharmacotherapy ...........................................................................................61 Final Clinical Thoughts ..........................................................................................................61 Appendix A—Bibliography .....................................................................................................63 Appendix B—NIAAA’s A Pocket Guide for Alcohol Screening and Brief Intervention ................................................................................................................71 Appendix C—Excerpts From Quick Guide for Clinicians Based on TIP 45 ...............77 Appendix D—Excerpts From Quick Guide for Clinicians Based on TIP