4.10.4.2 Relapse prevention

ChoiceDrugDosage
1st choices

Acamprosate (Campral EC®) tablets e/c 333mg
AND a psychological intervention, e.g. CBT, behavioural therapies, social network and environment-based therapies, or behavioural couples therapy

Dose: 18-65 years, 60kg and above, 666mg three times daily; under 60kg, 666 at breakfast, 333mg at midday and 333mg in early evening
Or

Naltrexone tablets 50mg AND a psychological intervention [unlicensed indication] On specialist advice

Dose:
25mg initially then 50mg daily if tolerated
2nd choice

Disulfiram tablets 200mg AND a psychological intervention On specialist advice

Dose:
800mg for the first dose, reducing over 5 days to 100-200mg daily; should not be continued for longer than 6 months without review

Prescribing Notes

  • Refer to NICE pathway on alcohol-use disorders.
  • Treatments for maintenance of abstinence are an adjunct to counselling.
  • Choice of treatment will be influenced by patient acceptability.
  • Before prescribing a drug for relapse prevention, conduct a comprehensive medical assessment including baseline urea, electrolytes and liver function tests.
  • Acamprosate is best suited to supporting abstinence in individuals who are concerned that craving will lead to lapse/relapse.
  • Acamprosate should be initiated as soon as possible after alcohol withdrawal and maintained if the patient relapses. Repeated relapsing to heavy drinking indicates non-efficacy. Recommended treatment period is 1 year (it is not licensed for use longer than 12 months).
  • Contraindications to acamprosate are severe renal or hepatic impairment and therefore liver and kidney function tests should be performed before commencing treatment. It should be avoided in individuals who are pregnant or breastfeeding.
  • Naltrexone is not licensed for the treatment of alcohol dependence in the UK. However short-term treatment with naltrexone may be effective at reducing craving for alcohol.
  • Disulfiram inhibits alcohol dehydrogenase, leading to acetaldehyde accumulation after drinking alcohol, which can cause extremely unpleasant physical effects. Continued drinking can lead to arrhythmias, hypotension and collapse.
  • Disulfiram is prescribed for patients who would benefit from a deterrent, particularly if they can nominate a partner who can help them to take it regularly.
  • Before initiating disulfiram, the clinician must ensure that no alcohol has been consumed for 24 hours. Contraindications to use include, cardiac failure, coronary artery disease, history of cerebrovascular disease, hypertension, liver disease, peripheral neuropathy and history of severe mental illness.
  • A medical assessment should be undertaken at least every 6 months.
  • Disulfiram self-administration should be supervised by, for example, a partner or an appropriate nurse, or at a day hospital.

 Do not:

  • Use gammahydroxybutyrate (GHB) for treating alcohol misuse.
  • Routinely use antidepressants for treating alcohol misuse alone.
  • Use clomethiazole (chlormethiazole) for alcohol withdrawal.
  • Use benzodiazepines as ongoing treatment – use for withdrawal only.

Cautions

  • Caution needs to be exercised when any benzodiazepines are prescribed in older patients since accumulation may result in over sedation. Oxazepam or lorazepam, as short-acting benzodiazepines, may be preferred in older patients.
  • Benzodiazepine doses may need to be reduced for young people, older people and those with liver impairment; avoid in severe liver impairment. In mild to moderate liver impairment consider using lorazepam (unlicensed use) – start at a low dose and monitor liver function carefully.
  • Before initiating disulfiram, the clinician must ensure that no alcohol has been consumed for 24 hours. Contraindications to use include, cardiac failure, coronary artery disease, history of cerebrovascular disease, hypertension, liver disease, peripheral neuropathy and history of severe mental illness.