Alcohol use disorder is the most common substance use disorder. Lifetime prevalence in the US is around 30%; current SUD prevalence around 14%. AUD drives substantial morbidity and mortality — alcohol-related deaths exceed 95,000/year in the US, and alcohol is a leading risk factor for cardiovascular disease, several cancers, and accidents.
Alcohol withdrawal is the only SUD withdrawal that routinely kills. Timeline: tremor and anxiety at 6-12 hours, alcohol-related hallucinosis at 12-24 hours, withdrawal seizures at 12-48 hours, delirium tremens at 48-96 hours with 5-15% mortality if untreated. Risk factors for severe withdrawal: prior withdrawal seizures or DTs, high blood alcohol level on arrival, prolonged heavy use, comorbid medical illness.
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) is the structured 10-item scale that guides symptom-triggered benzodiazepine protocols. Score <8 mild, 8-15 moderate, >15 severe. Symptom-triggered dosing (rather than fixed schedule) reduces total benzodiazepine use and length of stay.
Acute management: long-acting benzodiazepines (chlordiazepoxide, diazepam) preferred for smoother withdrawal trajectory; lorazepam if hepatic dysfunction. Thiamine 100 mg IV before any glucose to prevent Wernicke's encephalopathy. Folate, multivitamin. Monitor electrolytes (magnesium, potassium often low). Inpatient management for severe withdrawal, seizure history, or significant comorbidities.
FDA-approved medications for AUD maintenance:
Naltrexone — mu-opioid antagonist that reduces reward signaling from alcohol. Available oral (50 mg daily) and long-acting injectable (380 mg monthly). The LAI substantially improves adherence and outcomes.
Acamprosate — modulates glutamate signaling that becomes dysregulated in alcohol withdrawal and craving. Three doses daily. Particularly useful in patients with prominent post-withdrawal anxiety and insomnia.
Disulfiram — aversive agent that inhibits acetaldehyde dehydrogenase; drinking on disulfiram produces acetaldehyde accumulation with severe symptoms. Effective in highly motivated patients with observed administration.
Off-label options with evidence: topiramate, gabapentin (particularly useful when post-acute withdrawal symptoms persist), baclofen for some patients.
Behavioral interventions: motivational interviewing, CBT for AUD, Alcoholics Anonymous and 12-step facilitation therapy, contingency management. Combined pharmacology plus behavioral intervention outperforms either alone.
When you encounter a patient with AUD, treatment is effective and substantially reduces mortality. Many patients have never been offered medication-assisted treatment despite its evidence base. Naltrexone LAI or oral, acamprosate, or disulfiram — combined with counseling — produce meaningful outcomes for many patients.