Anti-craving pharmacotherapy — agent selection, COMBINE, and safety (MEQ)

(i) Phase of care. Acute detox treats withdrawal hyperexcitability with benzodiazepines, thiamine, electrolytes, and monitoring (CIWA-Ar often guides symptom-triggered dosing). Anti-craving pharmacotherapy is post-detox relapse prevention to reduce heavy drinking or support abstinence — it does not replace withdrawal management.[7][2]

(ii) Preferred first-line here. Goal is reducing binge/heavy-drinking days; opioid-free for two weeks; renal function normal; only mild LFT rise. Offer naltrexone 50 mg orally once daily (optional 25 mg test days if nausea risk), medical alert regarding opioids, baseline/follow-up LFTs, and early review. Hard gates excluded: no current opioids, no decompensated liver failure stated. Pair with CBT as agreed.[2][3][4]

(iii) Alternatives. Acamprosate 666 mg TDS if abstinence maintenance preferred and eGFR allows — start after detox; renal dose-adjust/avoid if impairment develops.[2][5] Disulfiram 200–250 mg daily supervised (partner can supervise) only with informed consent, alcohol-product education, and no significant cardiac disease; not if impulsive drinking through reaction is likely.[2][6]

(iv) COMBINE. Landmark RCT: naltrexone and structured medical management improved outcomes; acamprosate was unexpectedly null in that design — do not over-generalise to erase other acamprosate evidence; combination was not a simple additive win story.[1][4]

(v) Psychosocial and disposition. CBT for alcohol, motivational work, family support, crisis plan, review in 1–2 weeks for adherence/tolerability, consider longer course (often ≥3–6 months if helpful), mutual aid optional not coercive, step-up intensity if heavy drinking resumes despite adherence.[1][2][8]