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

International audienceBACKGROUND: The latest French good practice recommendations (GPRs) 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 GPRs focused on the pharmacotherapy of alcohol dependence.METHODS: A four-member European steering committee defined the questions that were addressed to an 18-member multi-professional working group (WG). The WG developed the GPRs 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 GPRs 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 1) alcohol detoxification / abstinence maintenance programs or 2) drinking reduction programs. - The therapeutic objective is the result of a decision made jointly by the physician and the patient.- Benzodiazepines (BZDs) are the first-line medication for detoxification (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). - BZDs are only justified beyond a one-week period in the case of persistent withdrawal symptoms, withdrawal events or associated BZD dependence (GRADE B). - BZDs should not be continued for more than four weeks (GRADE C). - The dosing and duration of thiamine (vitamin B1) during detoxification should be adapted to nutritional status (EC). - Medications for relapse prevention should be automatically associated with adapted psychosocial support (GRADE A). - Acamprosate and naltrexone are the first-line options for relapse prevention (GRADE A). - Disulfiram can be proposed as second-line treatment in patients who are correctly informed and adequately supervised (EC).- Medications for reducing alcohol consumption are only indicated in dependent individuals (EC). - Nalmefene is indicated as a first-line treatment for reducing alcohol consumption (GRADE A). - The second-line prescription of baclofen, up to 300 mg/d, to prevent relapse or reduce drinking should be carried out according to the “temporary recommendation for use” (TRU) issued by the French Health Agency (EC).- Abstinence is recommended throughout pregnancy (EC).- If medically‐assisted withdrawal is necessary during pregnancy, BZD use is recommended (GRADE B).- No medication other than those for alcohol withdrawal 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 BZDs should be preferred for the detoxification of elderly patients (GRADE B).- The initial doses of BZDs should be reduced by 30 to 50% in elderly patients (EC).- In patients with chronic alcohol-related physical disorders, the goal of 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)