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Am Fam Physician. 2022;106(4):466-469

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Key Points for Practice

• Screening tools can identify unhealthy alcohol use, which can be treated effectively with brief interventions.

• Benzodiazepines are the primary therapy for alcohol withdrawal; gabapentin, carbamazepine, and valproic acid appear to be effective for less severe withdrawal symptoms.

• Naltrexone and topiramate are effective for preventing relapse in alcohol use disorder.

• Psychological therapies are a primary treatment for cannabis and stimulant use disorders and are effective for alcohol use disorder, but they are not beneficial in opioid use disorder.

From the AFP Editors

More than 20 million people in the United States meet the criteria for substance use disorder, leading to $600 billion in health care expenditures annually. Despite this growing problem, only one in eight people with substance use disorder receives targeted care. The U.S. Department of Veterans Affairs and the U.S. Department of Defense (VA/DoD) published updated clinical practice guidelines for managing substance use disorders, based on a systematic review.

Screening for Unhealthy Substance Use


Many people have risky drinking habits without meeting criteria for alcohol use disorder. Screening for unhealthy alcohol use is recommended based on evidence for patients who do not have alcohol use disorder. Brief interventions for these patients help reduce alcohol consumption and improve health outcomes.

The Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) and the Single-Item Alcohol Screening Questionnaire (SASQ) are the recommended tools for assessing unhealthy alcohol use in primary care (Table 1). The AUDIT-C provides more information on normal and heavy drinking, yet requires more time to administer and score. The SASQ is a single question and easy to use within a patient encounter.

Alcohol Use Disorders Iden tification Test–Consumption (AUDIT-C)
5 points or more is a positive screen
1. How often did you have a drink containing alcohol in the past year?Never0
Monthly or less1
2 to 4 times per month2
2 to 3 times per week3
4 or more times per week4
2. On days in the past year when you drank alcohol, how many drinks did you typically have?0 to 20
3 to 41
5 to 62
7 to 93
10 or more4
3. How often did you have 6 (men)/4 (women) or more drinks on one occasion in the past year?Never0
Less than monthly1
Daily or almost daily4
Single-Item Alcohol Screening Questionnaire (SASQ)
1 point is a positive screen
If you drink alcoholic beverages, how many times in the past year have you had 5 (men)/4 (women) or more drinks in a day?None0
1 or more1

For positive screening results in patients who do not meet criteria for alcohol use disorder based on the Diagnostic and Statistical Manual of Mental Disorders, 5th ed., a brief intervention about alcohol-related risks and advice on abstaining or reducing consumption to daily or weekly recommendations should be considered. Short behavioral interventions decrease the mean number of drinks per week and heavy drinking episodes, while increasing the percentage of patients whose alcohol consumption is within recommended limits. Benefits are similar after interventions lasting five to 20 minutes, given by physicians or psychologists and provided in the clinic, emergency department, or inpatient ward.

When substance use disorders, including alcohol, are diagnosed, there are no evidence-based criteria to guide treatment location. The American Society of Addiction Medicine has proposed assessing six dimensions of substance abuse, but the criteria have not been verified.


The U.S. Preventive Services Task Force recommends screening for unhealthy drug use in adults if resources for diagnosis and treatment are available, although reductions in drug use occur primarily in patients who seek care. Drug use disorder screening does not appear to increase treatment program enrollment. Brief interventions for unhealthy drug use do not appear to reduce drug use.

Alcohol Use Disorder

Alcohol use disorder affects 14.5 million people in the United States, and annually more than 95,000 deaths are related to alcohol use.


Alcohol withdrawal is a risk after cessation of consistent alcohol use. Withdrawal symptoms are often graded by the Clinical Institute Withdrawal Assessment for Alcohol-revised version (CIWA-Ar). Because withdrawal delirium has a mortality rate of up to 4% among hospitalized patients, inpatient treatment should be considered for people with CIWA-Ar scores of 20 or more, a history of delirium tremens or withdrawal seizures, complicating medical conditions, comorbid substance use, lack of success with outpatient care, inability to complete an outpatient program, active psychosis, or cognitive impairment. Benzodiazepines are the preferred therapy for patients with CIWA-Ar scores of 10 or more because they reduce the risk of withdrawal seizures by 84% compared with placebo (risk ratio = 0.16; 95% CI, 0.04 to 0.69).

If withdrawal symptoms are less severe, treatment options (Table 2) include gabapentin (Neurontin), carbamazepine (Tegretol), and valproic acid (Depakene). All appear to have similar effectiveness compared with benzodiazepines. These medications may be useful if there are concerns about inadequate monitoring, a history of sedative abuse, or adverse reactions to benzodiazepines.

SubstancePharmacotherapyPsychosocial interventions
First line (moderate to severe):
Acceptable (mild to moderate):
 Carbamazepine (Tegretol)
 Gabapentin (Neurontin)
 Valproic acid (Depakene)
Relapse prevention (moderate to severe)
Strongly recommend:
 Naltrexone (Revia)
 Topiramate (Topamax)
Weakly recommend:
 Disulfiram (Antabuse)
Second line:
12-step facilitation
Behavioral couples therapy
Cognitive behavior therapy
Motivation enhancement therapy
 Buprenorphine/naloxone (Suboxone)
Lofexidine (Lucemyra)
Relapse prevention
First line:
Second line:
 Extended-release intramuscular naltrexone (Vivitrol)
Insufficient evidence:
Oral naltrexone
CannabisNoneCognitive behavior therapy
Motivation enhancement therapy
Combined cognitive behavior and motivation enhancement therapy
StimulantsNoneCocaine use disorder
 Cognitive behavior therapy
 Recovery-focused behavior therapy
 Contingency management with another behavioral intervention
Amphetamine/methamphetamine use disorder
 Contingency management with another behavioral intervention
Sedative hypnoticWithdrawal
Tapering benzodiazepines; no definitive superior strategy (consider 25% dose reduction each week, and once the patient is at 50% of the original dose, reduce by 12.5% every 4 to 7 days)
Cognitive behavior therapy with extended tapering in structured clinical environment
All disordersGroup mutual help programs
 Peer linkage
 12-step facilitation
Structured telephone-based care as an adjunct to usual care


For maintenance pharmacotherapy in alcohol use disorder, naltrexone (Revia, Vivitrol) and topiramate (Topamax) have the best evidence. Naltrexone, delivered daily as an oral dose or monthly as an intramuscular injection, reduces drinking days, heavy drinking, and return to heavy drinking. Topiramate improves abstinence and reduces heavy drinking. In addition to being off label for alcohol use disorder, topiramate often requires more titration. For patients with comorbid posttraumatic stress disorder, topiramate can reduce symptom severity and alcohol use.

Acamprosate and disulfiram (Antabuse) have less evidence for improving outcomes. Acamprosate reduces return to drinking after abstinence but has limited adherence because of large tablet size and three times daily dosing. Disulfiram is only more effective than placebo in open-label trials, especially those with witnessed medication ingestion. Disulfiram rarely causes hepatotoxicity, which is worsened with alcohol use. The benefit of gabapentin for maintenance in alcohol use disorder is uncertain.

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Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, associate medical editor.

A collection of Practice Guidelines published in AFP is available at

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