Patients diagnosed with an AUD should be advised to substantially reduce or stop their alcohol use. Although recent guidelines on moderate drinking recommend that men consume no more than 2 drinks/day and women 1 drink/day, with no binge drinking63 a meta-analysis of nearly 600,000 participants showed a minimum all-cause mortality risk at a consumption level of about 1 drink/day, irrespective of sex.64 Together with brief counseling, a first-line medication such as oral naltrexone is well tolerated. It can be initiated at a once-daily dosage of 25 mg and increased to 50 mg after 3 days and 100 mg after 7 days.46 Studies have not directly compared the effects of requiring abstinence prior to initiating a medication to treat AUD. Although there is evidence that a longer period of abstinence may be useful with long-acting naltrexone treatment,66 studies of naltrexone67 and topiramate25 that did not require abstinence prior to treatment have shown superiority of the active medication to placebo treatment.
