Murphy CE 4th, Montioring Monitoring alcohol intake, Montoy JC, Gut health benefits al. Acamprosate — Acamprosate is imtake effective Monitoring alcohol intake to naltrexone and is our first choice in Monitoring alcohol intake with contraindications alfohol naltrexone, including those who are using opioids or prescribed opioids, or in those with advanced liver disease. University of Twente, Overijssel, Netherlands Side effects of oral naltrexone are nausea, headache, and dizziness, which subside with continued use. Studies of acamprosate have generally enrolled patients who have abstained prior to starting medication. Gharani P, Suffoletto B, Chung T, Karimi HA. IntoxiGait Deep Learning Doctoral dissertation.

Monitoring alcohol intake -

Subsequent medication trials — There are limited empirical data supporting augmenting options for suboptimal response to initial medication in the treatment of alcohol use disorder. Our practice is generally to switch from one medication to another in order to minimize polypharmacy.

See 'Combining medications' below. For patients who do not respond to naltrexone or acamprosate or if they are contraindicated , our next choices are disulfiram or topiramate unless contraindicated. We choose between these based on clinical presentation.

For example, in patients who are motivated towards abstinence, and in cases where significant social support is available, we favor treatment with disulfiram.

In patients with a seizure disorder, we favor topiramate table 1. Disulfiram — Clinical trials suggest that disulfiram is effective principally when taken under supervised conditions. This accumulation causes unpleasant effects such as sweating, headache, dyspnea, lowered blood pressure, flushing, sympathetic overactivity, palpitations, nausea, and vomiting [ 35 ].

Forty-eight hours of total abstinence is needed prior to starting disulfiram. Patient education should address "hidden" forms of ethanol eg, tonics and mouthwashes and also the duration of the drug's activity up to 14 days after stopping.

Supervised dosing is not required for this medication, as highly motivated patients likely do not require this level of oversight. Prior research, however, has suggested that patients who do have the benefit of supervised disulfiram dosing, via strong social support, tend to fare substantially better than controls with regards to sustained abstinence [ 36 ].

However, investigators have argued that the unique deterrent effect of disulfiram necessitates open-labeled studies to investigate its efficacy [ ]. However, the ability to draw conclusions from this analysis is limited by substantial heterogeneity among trials in regard to patient populations, measured outcomes, and co-treatments; in addition, several studies were judged to have possible risk of bias.

However, some individuals taking disulfiram who drink alcohol or alcohol-containing products can have a severe reaction to the combination.

The severity and duration of the reaction depends on the amount of alcohol ingested. The reaction may last for several hours or up to a day. Individuals may present with symptoms such as chest pain, confusion, headache, and vomiting that require further evaluation for myocardial infarction and other etiologies.

Once myocardial infarction is excluded in patients with chest pain, treatment is primarily supportive antiemetics for vomiting; Trendelenburg positioning and intravenous fluids for orthostatic hypotension; diphenhydramine for flushing. Fomepizole has been suggested for life-threatening symptoms of acetaldehyde in patients with severe presentations.

Fomepizole 4-methylpyrazole , administered as a single intravenous 7. Severe adverse reactions are rare but include psychosis and hepatitis. Individuals receiving disulfiram should be monitored for hepatotoxicity several weeks after initiating treatment and then every six months if treatment with disulfiram continues [ 43 ].

Topiramate — Topiramate is our preferred choice of medications in patients who have a seizure disorder that would be appropriately treated with it, and who have failed initial treatment with naltrexone or acamprosate. Topiramate , an anticonvulsant medication with pharmacological properties including blocking of voltage-dependent sodium channels, potentiation of gamma-aminobutyric acid mediated transmission and antagonism of glutamate receptors, has been found to decrease alcohol use in individuals with alcohol use disorder.

A titration schedule is shown in the table table 2. A meta-analysis of seven clinical placebo-controlled trials with a total of individuals with alcohol dependence demonstrated efficacy for topiramate with higher rates of abstinence and lower rates of heavy drinking, but similar measure of alcohol craving [ 44 ].

The specific outcome measures used varied across studies, but overall, the effects were judged to be small to moderate. Many of these are intolerable to a relatively small but significant proportion of individuals. See "Antiseizure medications: Mechanism of action, pharmacology, and adverse effects", section on 'Topiramate'.

Gabapentin — Gabapentin may be a reasonable option for patients who may have previously failed a first-line option, particularly if gabapentin was used during a successful ambulatory detoxification.

Clinical trials testing the efficacy of gabapentin at various doses from to mg have found mixed results in treatment for alcohol use disorder [ ]. In one small trial, the efficacy of gabapentin in reducing heavy drinking appeared more pronounced in those with withdrawal symptoms compared with those without [ 48 ].

One important risk of gabapentin is its addictive potential. Combining medications — Combining medications in the treatment of alcohol use disorder has not been supported by trials.

Theoretically, the combination of medications with different mechanisms of action offers the possibility of more effective treatment for patients who do not respond adequately to an individual agent.

As an example, if some effect is achieved with naltrexone , adding acamprosate could have added effect in an individual. In most cases, our practice is to switch from agent to another rather than adding a second agent. Agents with limited empirical support — Other medications with few data to support their use are discussed briefly below.

Due to limited empirical support in the treatment of alcohol use disorder, we cannot recommend them as first- or second-line agents until further studies support their efficacy.

Nalmefene has several potential advantages over naltrexone , including absence of dose-dependent liver toxicity, longer-acting effects, and more effective binding to central opiate receptors.

Nalmefene is approved for treatment of alcohol use disorder in the European Union. It is available in the United States as treatment for opioid overdose [ 18, ]. Additionally, SSRIs may be useful in treating individuals with depression and substance use disorder, commonly occurring comorbidities [ ].

Ondansetron may be selectively efficacious in individuals with early-onset subtype of alcohol dependence onset of problem drinking prior to age 25 years and in individuals with family history of alcohol use disorder [ ]. Some studies suggest that varenicline treatment may be associated with reduced drinking in patients with alcohol addiction who smoke and in patients with alcohol use disorder and depression [ 67,68 ].

In a trial, 95 subjects with alcohol use disorder were randomly assigned to two day-long medication sessions week 4 and week 8 with psilocybin or diphenhydramine active control , each in addition to 12 weeks of manualized psychotherapy [ 69 ].

Over the week follow-up period, subjects in the psilocybin group reported a lower percentage of heavy drinking days than those in the diphenhydramine group 9. Furthermore, subjects in the psilocybin group had fewer mean drinks per day than the diphenhydramine group 1.

No serious adverse events were reported among either group. Although psilocybin is classified as a Schedule I controlled substance in the United States no accepted medical use and high potential for abuse , these data suggest that further evaluation of psilocybin for alcohol use disorder management may be warranted.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately.

See "Society guideline links: Alcohol use disorders and withdrawal". These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed.

These articles are written at the 10 th to 12 th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. The Basics ". Beyond the Basics ".

However, for individuals with the mild subtype of the disorder, we prefer to begin with psychosocial intervention only algorithm 1. See 'Indication for pharmacotherapy' above.

Naltrexone is preferred because of its once daily dosing and the ability to begin treatment while the individual is still drinking. See 'Naltrexone' above. Acamprosate is an appropriate alternative to naltrexone for initial therapy and is our first-choice treatment for individuals who are using opioids or prescribed opioids as well as in those with advanced liver disease.

See 'Acamprosate' above and 'Patients with co-occurring hepatic disease' above. See 'Specific patient populations' above.

See 'Patients with opioid use disorder' above. See 'Patients with clinically indicated opioid use' above. See 'Pregnancy' above. See 'Patients with nonabstinence goals' above. See 'Subsequent medication trials' above. See 'Disulfiram' above and 'Topiramate' above. Other medication options with limited data supporting their use include gabapentin , selective serotonin reuptake inhibitors, ondansetron , and varenicline.

We reserve their use for refractory cases. See 'Agents with limited empirical support' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in. Learn how UpToDate can help you. Select the option that best describes you.

View Topic. Font Size Small Normal Large. Alcohol use disorder: Pharmacologic management. Formulary drug information for this topic. No drug references linked in this topic.

Find in topic Formulary Print Share. View in. Language Chinese English. Author: Stephen R Holt, MD, MS, FACP Section Editor: Murray B Stein, MD, MPH Deputy Editor: Michael Friedman, MD Contributor Disclosures. All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan This topic last updated: Jan 30, As examples: - In a meta-analysis of 50 randomized trials with subjects with alcohol use disorder, naltrexone , as compared with placebo, reduced the risk of a return to heavy drinking, 51 versus 61 percent relative risk 0.

The global burden of disease attributable to alcohol and drug use in countries and territories, a systematic analysis for the Global Burden of Disease Study Lancet Psychiatry ; World Health Organization WHO : Global status report on health and alcohol; Ernst DB, Pettinati HM, Weiss RD, et al.

An intervention for treating alcohol dependence: relating elements of Medical Management to patient outcomes with implications for primary care. Ann Fam Med ; Lee YK, Park SW, Kim YK, et al. Effects of naltrexone on the ethanol-induced changes in the rat central dopaminergic system.

Alcohol Alcohol ; Hemby SE, Johnson BA, Dworkin SI. Neurobiological basis of drug reinforcement. In: Drug Addiction and Its Treatment: Nexus of Neuroscience and Behavior, Johnson, BA, Roache, JD Eds , Lippincott-Raven, Philadelphia Williams KL, Broadbear JH, Woods JH.

Noncontingent and response-contingent intravenous ethanol attenuates the effect of naltrexone on hypothalamic-pituitary-adrenal activity in rhesus monkeys. Alcohol Clin Exp Res ; Hartung DM, McCarty D, Fu R, et al.

Extended-release naltrexone for alcohol and opioid dependence: a meta-analysis of healthcare utilization studies. J Subst Abuse Treat ; Crits-Christoph P, Markell HM, Gibbons MB, et al.

A Naturalistic Evaluation of Extended-Release Naltrexone in Clinical Practice in Missouri. Beatty A, Stock C.

Efficacy of long-acting, injectable versus oral naltrexone for preventing admissions for alcohol use disorder. Ment Health Clin ; Johnson BA. Naltrexone long-acting formulation in the treatment of alcohol dependence.

Ther Clin Risk Manag ; Garbutt JC, Kranzler HR, O'Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial.

National Health Interview Survey NHIS Multi-purpose health survey that monitors the health of the non-institutionalized adults and children in the United States.

This survey collects information on a broad range of health topics, including current alcohol use and binge drinking among adults.

National Health and Nutrition Examination Survey NHANES Collects health and nutrition data through interviews and health examinations of the civilian, non-institutionalized U. The survey specifically collects information on age of first drink, lifetime alcohol use, current alcohol use, and binge drinking.

Pregnancy Risk Assessment Monitoring System PRAMS Survey collects state-specific, population-based data on maternal attitudes and experiences among women two to six months after having a live birth. This survey collects information on alcohol consumption before, during, and shortly after pregnancy.

Other National Surveys National Survey on Drug Use and Health NSDUH Survey that gathers information on mental health and substance abuse, from non-institutionalized persons aged 12 years and older. Collects data on the use of alcohol and illicit drugs, as well as symptoms of substance use disorders.

Monitoring the Future Survey Ongoing and long-term system that collects data on the behaviors, attitudes, and values regarding substance use of American adolescents, college students, and adults.

Each year a total of approximately 50, students in 8th, 10th, and 12th grade are surveyed about substance use, including alcohol consumption, and a subset are sent follow-up questionnaires through age 45 years.

Unlike the conclusions from Barnett et al. The mixed findings may be attributable to reinforcing abstinence vs. drinking reductions. Another possible contributing factor is the duration or other parameters of CM prior to discontinuation of incentives.

Future research is needed to better understand the mixed results. Two studies have reported on SCRAM ® among AUD treatment patients 41 , In both studies, all participants received standard community-based AUD treatment services including group therapy, Step, and relapse prevention approaches.

Alessi et al. Most participants reported neutral comfort with the bracelet, denied the bracelet interfered with their mood, sleep, work, and normal activities, and believed the bracelet helped them reduce their drinking.

These findings indicate that SCRAM ® may be feasibly incorporated into outpatient treatment of AUD. Additionally, Alessi et al. SCRAM ® was used to objectively and near-continuously characterize individuals' drinking habits while in outpatient treatment for the first time.

Participants also completed self-reports of drinking about twice weekly for research purposes only, and not shared with clinic staff , and device data were compared with self-reports to assess the level of agreement. The SCRAM ® data indicated a higher percentage of patients who drank any alcohol and drank heavily compared with the percentage who drank and drank heavily per self-reports.

These results suggest that wearable biosensors may provide clinically useful information to supplement self-reports, which can be biased by response demands and other contextual factors 42 — Throughout the study, clinicians were not provided access to SCRAM ® data; thus, they were not able to use this information to inform treatment decisions.

In addition to wearable devices explicitly designed for alcohol use, researchers have begun using biosensors originally developed for other purposes to improve treatments of alcohol use disorder.

Abrantes et al. Twenty women were enrolled from a partial hospitalization program and were given FitBit Charges and provided counseling on the benefits of physical activity on managing cravings and difficult emotions. Once discharged from the day partial hospitalization program, they were offered 6, min phone calls from an activity counselor who addressed barriers to engaging in physical activity and tailored step goals to meet their individual needs.

Five women did not complete the intervention, and analyses were conducted using both intention-to-treat and among completers only to address missing data.

Similar results were seen in both analytic approaches. These results show promise for using physical activity monitored by biosensors to increase coping strategies for cravings to drink alcohol and maintain abstinence in those critical months following discharge from a partial hospitalization program.

Similarly, Linke et al. Participants completed a week intervention that provided weekly psychoeducation groups focused on integrating physical activity for a healthy lifestyle while reducing substance use and a YMCA membership with access to group training sessions and a Fit4Me personal training program.

Once a week, participants met with a study clinician to review the FitBit HR data and address any barriers to engaging in physical activity. Participants reported in qualitative interviews that the FitBit HR helped them be accountable to their physical activity plan, and that seeing daily and weekly progress on their physical activity goals helped them stay motivated to remain abstinent of alcohol and other drugs.

Leonard et al. For 3 weeks following this session, participants were instructed to use the Mind the Moment mobile application when they received the stress-related alert. The application guides users through brief cognitive behavioral and mindfulness strategies e. Participants were also encouraged to use the application between E4 stress-related alerts.

Additionally, Rouw 48 developed and tested a treatment protocol integrating Sense-IT biosensor data and associated mobile application into inpatient alcohol treatment to enable awareness of physiological processes elicited by arousal, emotions, and cravings.

Sense-IT is an ambulatory biofeedback mobile application that utilizes heart rate data from a smartwatch to provide haptic and visual feedback on wearer's heart rate. The biosensor plus associated mobile application was originally created for patients with Borderline Personality Disorder to improve emotion awareness and regulation For COVID-related logistical reasons, Rouw tested this technology among addiction treatment inpatients as opposed to ambulatory care patients as initially planned.

For 3 weeks, patient participants completed structured sessions using guided imagery and Sense-IT biofeedback with the goal of increasing user's awareness of physiological arousal that occurs when experiencing cravings to drink.

During the biofeedback sessions, participants were given cognitive behavioral therapeutic interventions to cope with the cravings and see the impact of those interventions on their physiological arousal. Patient participants reported they found added value in using Sense-IT to better understand their cravings and added that it facilitated conversations with the interventionist about strategies for coping with cravings.

They noted that the technology may be more useful in an outpatient setting where access to treatment providers is less constant, and the environment is less controlled. Provider participants also reported that the Sense-IT could be a useful tool in improving patients' awareness of their cravings and cueing them to take therapeutic action rather than use substances.

In treatment studies utilizing wearable biosensors, participants generally report good feasibility and acceptability of the devices, suggesting that integration into treatment may be acceptable among patients. Among the limited number of studies using wearable technology in AUD treatment contexts, the majority used these devices to measure alcohol use or abstinence throughout study periods.

With treatments like contingency management, using wearable devices eliminates the need for participants to undergo invasive blood draws or use a breathalyzer during their sessions, which may be more desirable.

Furthermore, recent studies are beginning to expand biosensor uses to include incorporating physiological data, like heart rate and number of steps, into the treatment modality.

While these approaches represent advancements with potential to improve AUD treatment, applications to date have been narrow in scope. The time is ripe for expansion of novel uses for wearable biosensors in this domain of clinical research. There are several important areas related to using wearable technology to treat individuals with AUD that are yet to be explored.

One is incorporating feedback from transdermal alcohol content biosensors into other treatment modalities besides contingency management.

Biosensor data could replace or supplement self-reported alcohol use in behavioral and cognitive behavioral treatments for AUD and inform more accurate and tailored treatment recommendations. For example, based on harm reduction principles, with real-time feedback on alcohol levels, clinicians and patients in an outpatient setting could collaboratively set a daily transdermal alcohol content goal for 1 week at a time with expectations for reducing those levels to either abstinent or healthy levels over time rather than abrupt cessation or abstinence.

Additionally, clinicians could review the biosensor data with the patient and help them understand specific drinking patterns e. Incorporating feedback on alcohol use could similarly be used with pharmacotherapies that treat AUD. Baseline recordings of transdermal alcohol content could potentially help guide dosing decisions for initiation of medication-assisted therapy.

Furthermore, continuous monitoring of numerous physiological constructs using an additional biosensor like FitBit throughout pharmacotherapy could highlight interaction effects of alcohol and other substances on the effectiveness of the medication-assisted therapy Incorporating wearable alcohol biosensors into Just-In-Time Adaptive Interventions JITAIs to reduce drinking is another area for future investigation.

These interventions aim to monitor dynamic states e. Examples in this growing literature include alcohol research that combined smartphone sensor data and ambulatory self-reports of alcohol use to build machine learning models to predict future high-risk drinking In other work, natural language processing of online recovery forums and machine learning techniques were used to build models to automatically detect potential recovery problems, for potential for intervention A meta-analysis of JITAI studies e.

Thus, research suggests that incorporating alcohol biosensors into the development of effective JITAIs has great potential to advance delivering clinically meaningful support to individuals where and when needed. Potential effectiveness of JITAIs could be further enhanced by using biosensors to better understand and detect craving: a known phenomenon in individuals with moderate to severe alcohol use disorder that lacks consensus on definition, factors influencing it, and assessment 53 , Craving is marked by several physiological e.

Intervening in real-time when an individual is experiencing cravings has important implications for preventing relapse, particularly in the early stages of treatment 54 , While the use of biosensors to detect cravings may have the greatest synergy with JITAIs, they could easily be incorporated in a number of treatment modalities to improve treatment outcomes, including medication-assisted therapies targeting craving.

An additional area of significant potential is in the treatment of alcohol withdrawal syndrome. Though many of the commercially available devices are not specifically designed to measure withdrawal symptoms, they are capable of measuring many physiological symptoms that occur in alcohol withdrawal e.

Combining a transdermal alcohol content device with an additional biosensor that measures these physiological changes could create an automated detection for alcohol withdrawal symptoms that drastically improves upon the existing measurement and treatment of alcohol withdrawal, including protracted withdrawal where symptoms can persist for many months subsequent to the immediate period following abrupt cessation Furthermore, devices that measure withdrawal symptoms could facilitate an outpatient treatment protocol for detoxification, reducing the treatment burden of lengthy inpatient stays.

Following detoxification, the biosensors could then be used in some of the aforementioned potential treatment modalities for monitoring and informing outpatient treatment. In conclusion, wearable biosensors have demonstrated their utility in improving delivery of cost-effective, evidence-based treatments for AUD and are currently being explored in novel ways to further improve AUD treatment options and access.

There are numerous innovative uses of wearable biosensors yet to be explored in AUD treatment, and future research should tap into this potential.

RD-M conducted the literature review, composed majority of the paper, created table, and compiled references. SA contributed unique content in the review and discussion sections and expert revisions on content provided by RD-M.

EB provided guidance on subject matter, revisions on flow of paper, and iterative edits to content written by RD-M. All authors contributed to the article and approved the submitted version. RD-M received funding from NIH on the following grants: R42 DA, R44 MH, R01 MH, R01 MH SA received funding from NIH on the following grants: T32 AA, P50 AA, R01 AA EB received funding from NIH on the following grants: R01 MH, R34 MH, R44 DA, R44 MH, R01 MH, R01 HS The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Substance Abuse and Mental Health Services Administration SAMHSA. National Survey on Drug Use and Health NSDUH. Table 5. NSDUHDS Public-Use File Dataset Barnett NP. Alcohol sensors and their potential for improving clinical care.

doi: PubMed Abstract CrossRef Full Text Google Scholar. Fang H, Zhang Z, Wang CJ, Daneshmand M, Wang C, Wang H. A survey of big data research. IEEE Netw. Manyika J, Chui M, Brown B, Bughin J, Dobbs R, Roxburgh C, et al.

Big Data: The Next Frontier for Innovation, Competition, and Productivity. Washington, DC: McKinsey Global Institute Google Scholar. Carreiro S, Smelson D, Ranney M, Horvath KJ, Picard RW, Boudreaux ED, et al. Real-time mobile detection of drug use with wearable biosensors: a pilot study.

J Med Toxicol. Kennedy AP, Epstein DH, Jobes ML, Agage D, Tyburski M, Phillips KA, et al. Continuous in-the-field measurement of heart rate: correlates of drug use, craving, stress, and mood in polydrug users.

Drug Alcohol Depend. Jin H, Abu-Raya YS, Haick H. Advanced materials for health monitoring with skin-based wearable devices.

Adv Healthc Mater. Baig MM, GholamHosseini H, Moqeem AA, Mirza F, Lindén M. systematic review of wearable patient monitoring systems—current challenges and opportunities for clinical adoption. J Med Syst. Muench F. The promises and pitfalls of digital technology in its application to alcohol treatment.

Alcohol Res. PubMed Abstract Google Scholar. van Egmond K, Wright CJ, Livingston M, Kuntsche E. Wearable transdermal alcohol monitors: a systematic review of detection validity, and relationship between transdermal and breath alcohol concentration and influencing factors.

The project, funded by Detoxification Support for Improved Sleep Canada, alcphol in Monitoring alcohol intake Monitoring alcohol intake intzke have specific Moitoring about this project, please contact the Monitoring alcohol intake coordinator at alcohol intkae. The guidance is based on the principle of autonomy in harm reduction and the fundamental idea behind it that people living in Canada have a right to know that all alcohol use comes with risk. CCSA is creating knowledge mobilization products that will be tailored to meet the needs of our audience. Please check back with us in the coming months as we release these new resources.

Video

Tracking your alcohol intake