Psych · Addiction psychiatry
Anti-craving pharmacotherapy (naltrexone, acamprosate, disulfiram)
Also known as Relapse prevention medication alcohol · Naltrexone alcohol · Acamprosate · Disulfiram · COMBINE study · XR-NTX alcohol · Anti-craving drugs AUD
Exam-exhaustive fellowship topic on anti-craving pharmacotherapy for alcohol use disorder — naltrexone (oral and XR-NTX), acamprosate, and disulfiram with named doses, mechanisms, liver and renal constraints, hard contraindications, COMBINE trial interpretation, monitoring, psychosocial pairing, special populations, and multi-board guideline deltas. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Starting naltrexone while opioids (including methadone, buprenorphine, codeine, oxycodone) remain on board — precipitated opioid withdrawal and blocked emergency analgesia
- Disulfiram with unsupervised or impulsive drinking, significant cardiac disease, or uneducated use of alcohol-containing products — severe aversive reaction and cardiovascular risk
- Acamprosate in severe renal impairment without dose adjustment or avoidance — accumulation risk
- Using anti-craving drugs as a substitute for acute withdrawal management (benzodiazepines, thiamine, CIWA-Ar) — wrong phase of care
- Acute hepatitis or decompensated liver failure and careless naltrexone start without LFT review and product-guided caution
- Prescribing without psychosocial follow-up or risk review — medication is adjunctive, not a complete treatment
Meet the patient
A 46-year-old man finishes a five-day inpatient detox on Friday. He is clear-headed, embarrassed, and asks a reasonable question: "Is there a tablet for the craving?"[5][9]
There is. There are three. And the difference between a good registrar and a great one is that the great one asks about his rib fractures before answering — because he is still on PRN oxycodone.[5][7]
Every one of these three drugs has exactly one gate that must be checked before the pen moves. Miss the gate and you precipitate withdrawal, accumulate a renally cleared drug, or hand an aversive agent to someone with no supervision.[5][6][8]
Examiners punish three failures here: mixing detox drugs with relapse-prevention drugs, vague dosing with no agent, dose, route, monitoring and contraindication, and cartoon readings of COMBINE.[1][5][9]
References16ShowHide
- [1]Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial JAMA, 2006.PMID 16670409
- [2]Volpicelli JR, Alterman AI, Hayashida M, et al. Naltrexone in the treatment of alcohol dependence Arch Gen Psychiatry, 1992.PMID 1345133
- [3]Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis JAMA, 2014.PMID 24825644
- [4]Maisel NC, Blodgett JC, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction, 2013.PMID 23075288
- [5]Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder Am J Psychiatry, 2018.PMID 29301420
- [6]Rösner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence Cochrane Database Syst Rev, 2010.PMID 20824837
- [7]Garbutt JC, Kranzler HR, O'Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial JAMA, 2005.PMID 15811981
- [8]Fuller RK, Gordis E Does disulfiram have a role in alcoholism treatment today? Addiction, 2004.PMID 14678055
- [9]Connor JP, Haber PS, Hall WD Alcohol use disorders Lancet, 2016.PMID 26343838
- [10]Knox J, Hasin DS, Larson FRR, et al. Prevention, screening, and treatment for heavy drinking and alcohol use disorder Lancet Psychiatry, 2019.PMID 31630982
- [11]Mayo-Smith MF Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal JAMA, 1997.PMID 9214531
- [12]Saunders JB, Aasland OG, Babor TF, et al. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption--II Addiction, 1993.PMID 8329970
- [13]Sullivan JT, Sykora K, Schneiderman J, et al. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar) Br J Addict, 1989.PMID 2597811
- [14]Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial Arch Intern Med, 2002.PMID 12020181
- [15]Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III JAMA Psychiatry, 2015.PMID 26039070
- [16]Amato L, Minozzi S, Vecchi S, et al. Benzodiazepines for alcohol withdrawal Cochrane Database Syst Rev, 2010.PMID 20238336