American Psychiatric Association - The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder

Guideline Writing Group

Victor I. Reus, M.D., Chair

Laura J. Fochtmann, M.D., M.B.I., Vice-Chair, Methodologist

Oscar Bukstein, M.D., M.P.H.

A. Evan Eyler, M.D., M.P.H.

Donald M. Hilty, M.D.

Marcela Horvitz-Lennon, M.D., M.P.H.

Jane Mahoney, Ph.D., R.N., PMHCNS-BC

Jagoda Pasic, M.D., Ph.D.

Michael Weaver, M.D.

Cheryl D. Wills, M.D.

Jack McIntyre, M.D., Consultant

Systematic Review Group

Laura J. Fochtmann, M.D., M.B.I., Methodologist

Joel Yager, M.D.

Seung-Hee Hong

Steering Committee on Practice Guidelines

Michael J. Vergare, M.D., Chair

Daniel J. Anzia, M.D., Vice-Chair

Thomas J. Craig, M.D.

Deborah Cowley, M.D.

Laura J. Fochtmann, M.D., M.B.I., Consultant, Methodologist

David A. Kahn, M.D.

John M. Oldham, M.D.

Carlos N. Pato, M.D., Ph.D.

Joel Yager, M.D., Consultant

APA Assembly Liaisons

John P. D. Shemo, M.D., Chair of Area Liaisons

John M. de Figueiredo, M.D.

Marvin Koss, M.D.

Annette L. Hanson, M.D.

Bhasker Dave, M.D.

Robert M. McCarron, D.O.

Jason W. Hunziker, M.D.

APA wishes to acknowledge the contributions of APA staff (Jennifer Medicus, Seung-Hee Hong, Samantha Shugarman, Michelle Dirst, Kristin Kroeger Ptakowski). APA and the Guideline Writing Group especially thank Laura J. Fochtmann, M.D., M.B.I.; Jeremy Kidd, M.D.; Seung-Hee Hong; and Jennifer Medicus for their outstanding work and effort in developing this guideline. APA also thanks the APA Steering Committee on Practice Guidelines (Michael Vergare, M.D., Chair), liaisons from the APA Assembly for their input and assistance, and APA Councils and others for providing feedback during the comment period.

AA Alcoholics Anonymous

ACCME Accreditation Council for Continuing Medical Education

AHRQ Agency for Healthcare Research and Quality

ALT Alanine aminotransferase

APA American Psychiatric Association

ASAM American Society of Addiction Medicine

AST Aspartate aminotransferase

AUD Alcohol use disorder

AUDIT Alcohol Use Disorders Identification Test

AUDIT-C Alcohol Use Disorders Identification TestConcise

CAGE Cut down, Annoyed, Guilty, Eye-opener

CBI Combined behavioral intervention

CBT Cognitive-behavioral therapy

CDT Carbohydrate-deficient transferrin

CI Confidence interval

COMBINE Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence

CRAFFT Car, Relax, Alone, Forget, Friends, Trouble

CrCl Creatinine clearance

DSM-III-R Diagnostic and Statistical Manual of Mental Disorders , 3rd Edition, Revised

DSM-IV Diagnostic and Statistical Manual of Mental Disorders , 4th Edition

DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders , 4th Edition, Text Revision

DSM-5 Diagnostic and Statistical Manual of Mental Disorders , 5th Edition

eGF Estimated glomerular filtration rate

FDA U.S. Food and Drug Administration

GGT Gamma-glutamyl transferase

GRADE Grading of Recommendations Assessment, Development and Evaluation

GWG Guideline Writing Group

HIV Human immunodeficiency virus

ICD-10 International Classification of Diseases , 10th Revision

IM Intramuscular

IRR Incidence rate ratio

MBSCT Modified behavioral self-control therapy

MCV Mean corpuscular volume

MDD Major depressive disorder

MET Motivational enhancement therapy

MI Motivational interviewing

MM Medical management

NIAAA National Institute on Alcohol Abuse and Alcoholism

NIMH National Institute of Mental Health

NNT Number needed to treat

NQF National Quality Forum

OPRM1 Genotype Opioid receptor 1 genotype

OR Odds ratio

OTC Over-The-Counter

PCM Primary Care Management

PEth Phosphatidylethanol

Project MATCH Matching Alcoholism Treatments to Client Heterogeneity

PTSD Posttraumatic stress disorder

QTc Corrected QT interval

RCT Randomized controlled trial

RD Risk difference

SNP Single nucleotide polymorphism

SRG Systematic Review Group

TSF Twelve-step facilitation

USPSTF U.S. Preventive Services Task Force

WMD Weighted mean difference

Since the publication of the Institute of Medicine (now known as National Academy of Medicine) report, Clinical Practice Guidelines We Can Trust (.

Development of guideline statements entails weighing the potential benefits and harms of the statement and then identifying the level of confidence in that determination. This concept of balancing benefits and harms to determine guideline recommendations and strength of recommendations is a hallmark of GRADE (Grading of Recommendations Assessment, Development and Evaluation), which is used by multiple professional organizations around the world to develop practice guideline recommendations ().

In weighing the balance of benefits and harms for each statement in this guideline, our level of confidence is informed by available evidence, which includes evidence from clinical trials as well as expert opinion and patient values and preferences. Evidence for the benefit of a particular intervention within a specific clinical context is identified through systematic review and is then balanced against the evidence for harms. In this regard, harms are broadly defined and may include serious adverse events, less serious adverse events that affect tolerability, minor adverse events, negative effects of the intervention on quality of life, barriers and inconveniences associated with treatment, direct and indirect costs of the intervention (including opportunity costs), and other negative aspects of the treatment that may influence decision making by the patient, the clinician, or both.

Many topics covered in this guideline have relied on forms of evidence such as consensus opinions of experienced clinicians or indirect findings from observational studies rather than research from randomized trials. It is well recognized that there are guideline topics and clinical circumstances for which high-quality evidence from clinical trials is not possible or is unethical to obtain (). For each guideline statement, we have described the type and strength of the available evidence as well as the factors, including patient preferences, that were used in determining the balance of benefits and harms.

The authors of the guideline determined each final rating, as described in the section Guideline Development Process, and is endorsed by the APA Board of Trustees. A recommendation (denoted by the numeral 1 after the guideline statement) indicates confidence that the benefits of the intervention clearly outweigh harms. A suggestion (denoted by the numeral 2 after the guideline statement) indicates greater uncertainty. Although the benefits of the statement are still viewed as outweighing the harms, the balance of benefits and harms is more difficult to judge, or either the benefits or the harms may be less clear. With a suggestion, patient values and preferences may be more variable, and this can influence the clinical decision that is ultimately made. Each guideline statement also has an associated rating for the strength of supporting research evidence . Three ratings are used: high , moderate , and low (denoted by the letters A, B, and C, respectively) and reflect the level of confidence that the evidence for a guideline statement reflects a true effect based on consistency of findings across studies, directness of the effect on a specific health outcome, precision of the estimate of effect, and risk of bias in available studies ().