Relapse Prevention Pharmacotherapies

Prescribing any medication to a patient actively engaged in polydrug use poses particular risk for adverse medication interaction, coupled with the likelihood of poor adherence. Initial detoxification is generally recommended prior to prescribing most relapse prevention medication. There is no relapse prevention medication specific for alcohol use disorder with polydrug use, however, such medication is available for alcohol, nicotine and opioid dependence. Commonly prescribed alcohol use disorder pharmacotherapies, and opioid substitution therapies are briefly covered below.

Medications recommended for alcohol relapse prevention include disulfiram, naltrexone and acamprosate; other medications including baclofen and topiramate are sometimes used “off label” (see Chapter 10). Alcohol dependence complicated by polydrug use may also be treated using these medications. The risk for adverse interaction with these medications is generally low, with the exception of opioids with naltrexone. However, in patients with combined opioid and alcohol use problems, naltrexone started after cessation of opioids may help with relapse prevention for both alcohol and opioid drugs. The use of disulfiram for alcohol use disorder with polydrug use should be considered carefully as it can interact with a range of medications and other substances.  Nonetheless, it may be considered an option when alcohol use disorder is clearly linked to the patients’ use of other drugs, for example, a patient on methadone treatment develops alcohol dependence, so is given disulfiram concurrent with methadone dosing in order to prevent relapse to dependent drinking while allowing safer continuation of methadone treatment. There is also limited evidence that disulfiram might be useful in cocaine relapse prevention. Baclofen is sedating and should be avoided in patients concurrently using prescribed or non-prescribed sedatives. 

Generally, any alcohol use disorder and/or polydrug use is a precaution for opioid agonist therapy (OAT) using methadone or buprenorphine but following a comprehensive assessment, a patient identified to have opioid dependence and alcohol use disorder may be considered appropriate for OAT. In such situations, it is generally recommended that this treatment be commenced in an inpatient setting (e.g. detox unit) to reduce the risk for adverse interaction of alcohol, opioids and other drugs such as benzodiazepines.  Subsequent close monitoring in an outpatient setting for any signs of relapse to alcohol and/or polydrug use is strongly recommended. Daily dispensing of OAT should be preferred in people with alcohol use disorder and suspected intoxication monitored using a breathalyser. Doses can be reduced or withheld if intoxication is confirmed. Brief intervention may be effective to reduce alcohol use (see Chapter 6). Particular caution is advised when considering the buprenorphine depot formulation in patients with active alcohol use disorder. It is also important to be aware that in some OAT patients, alcohol and/or polydrug use may be related to inadequate opioid substitution dosing and if so, a therapeutic trial of higher opioid dose is worth considering, following discontinuation of the alcohol/polydrug or inpatient intervention.