Pharmacotherapy for Alcohol Dependence: The 2015 Recommendations of the French Alcohol Society, Issued in Partnership with the European Federation of Addiction Societies

Summary Background The latest French good practice recommendations ( GPR s) for the screening, prevention, and treatment of alcohol misuse were recently published in partnership with the European Federation of Addiction Societies ( EUFAS ). This article aims to synthesize the GPR s focused on the pharmacotherapy of alcohol dependence. Methods A four‐member European steering committee defined the questions that were addressed to an 18‐member multiprofessional working group ( WG ). The WG developed the GPR s based on a systematic, hierarchical, and structured literature search and submitted the document to two review processes involving 37 French members from multiple disciplines and 5 non‐French EUFAS members. The final GPR s were graded A, B, or C, or expert consensus ( EC ) using a reference recommendation grading system. Results The treatment of alcohol dependence consists of either alcohol detoxification or abstinence maintenance programs or drinking reduction programs. The therapeutic objective is the result of a decision made jointly by the physician and the patient. For alcohol detoxification, benzodiazepines ( BZD s) are recommended in first‐line (grade A). BZD dosing should be guided by regular clinical monitoring (grade B). Residential detoxification is more appropriate for patients with a history of seizures, delirium tremens, unstable psychiatric comorbidity, or another associated substance use disorder (grade B). BZD s are only justified beyond a 1‐week period in the case of persistent withdrawal symptoms, withdrawal events or associated BZD dependence (grade B). BZD s should not be continued for more than 4 weeks (grade C). The dosing and duration of thiamine (vitamin B1) during detoxification should be adapted to nutritional status ( EC ). For relapse prevention, acamprosate and naltrexone are recommended as first‐line medications (grade A). Disulfiram can be proposed as second‐line option in patients with sufficient information and supervision ( EC ). For reducing alcohol consumption, nalmefene is indicated in first line (grade A). The second‐line prescription of baclofen, up to 300 mg/day, to prevent relapse or reduce drinking should be carried out according to the “temporary recommendation for use” measure issued by the French Health Agency ( EC ). During pregnancy, abstinence is recommended ( EC ). If alcohol detoxification is conducted during pregnancy, BZD use is recommended (grade B). No medication other than those for alcohol detoxification should be initiated in pregnant or breastfeeding women ( EC ). In a stabilized pregnant patient taking medication to support abstinence, the continuation of the drug should be considered on a case‐by‐case basis, weighing the benefit/risk ratio. Only disulfiram should be always stopped, given the unknown risks of the antabuse effect on the fetus ( EC ). First‐line treatments to help maintain abstinence or reduce drinking are off‐label for people under 18 years of age and should thus be considered on a case‐by‐case basis after the repeated failure of psychosocial measures alone ( EC ). Short half‐life BZD s should be preferred for the detoxification of elderly patients (grade B). The initial doses of BZD s should be reduced by 30 to 50% in elderly patients ( EC ). In patients with chronic alcohol‐related physical disorders, abstinence is recommended ( EC ). Any antidepressant or anxiolytic medication should be introduced after a psychiatric reassessment after 2–4 weeks of alcohol abstinence or low‐risk use (grade B). A smoking cessation program should be offered to any smokers involved in an alcohol treatment program (grade B).