Written by Jacob Altholz and Clay Smith
Spoon Feed
Identifying and managing alcohol use disorder (AUD) is a team effort: treating comorbidities and withdrawal, prescribing medications, and engaging specialty care.
Alcohol use disorder – what does an EM doc need to know?
- Ask/Identify – You won’t know if you don’t take a careful, non-judgmental alcohol-use history. Labs may also indicate chronic heavy alcohol use, such as increased AST/ALT, increased MCV, and – of course – high ethanol concentration.
- Intervene – If identified, a brief intervention, such as FLAGS*, actually helps.
- Treat – Management of psychiatric or other substance use disorders is vital to successful treatment. Use benzodiazepines, barbiturates, and symptomatic adjuncts for acute withdrawal. Consider novel agents, like dexmedetomidine for symptomatic management. Use high-dose thiamine when hospitalized; continue if Wernicke’s is diagnosed.
- Prescribe – Disulfuram, naltrexone, and acamprosate are approved for AUD in the U.S. and moderately effective. Avoid disulfuram and naltrexone in liver disease patients. All patients go home with thiamine orally for 5 days.
- Follow-up – Patients benefit most from an integrated team approach, including GI, psychiatry, addiction medicine, and community programs such as Alcoholics Anonymous (AA).
How does this change my practice?
Given that much of alcohol use disorder care is multidisciplinary and primarily outpatient, the study emphasizes the need for expedient referral and integration of appropriate resources to reach patients visiting the ED. My day-to-day practice will continue to include treatment of acute illness and withdrawal, with increased consideration of novel agents, such as dexmedetomidine for symptomatic care.
Source
Identification and Treatment of Alcohol Use Disorder. N Engl J Med. 2025 Jan 16;392(3):258-266. doi: 10.1056/NEJMra2306511. PMID: 39813644
*FLAGS
- Feedback: Give feedback about the personal risks and consequences associated with drinking.
- Listen: Listen to the patient’s response. Discuss any false beliefs regarding the patient’s alcohol consumption level in relation to guidelines.
- Advice — Provide specific advice about the importance of changing current drinking using a nonjudgemental tone. Describe probable benefits of reduced drinking.
- Goals: Discuss safe drinking limits and assist the patient to set goals for changing drinking patterns. Instill optimism in the patient that the chosen goal can be achieved. Motivation-enhancing techniques can be used to encourage patients to develop, implement, and commit to plans to stop drinking.
- Strategies: Negotiate practical strategies to reach the agreed goal.
Interesting