An analysis of more than 120 studies that examined the effectiveness of medications to treat alcohol use disorders reports that acamprosate and oral naltrexone show the strongest evidence for decreasing alcohol consumption, according to a study in JAMA.
Alcohol use disorders (AUDs) are common, cause substantial illness, and result in 3-fold increased rates of early death. Treating AUDs is difficult, but may be aided by medications, although only a small percentage (
Daniel E. Jonas, M.D., M.P.H., of the University of North Carolina at Chapel Hill, and colleagues conducted a review and meta-analysis to evaluate the benefits and harms of medications for the treatment of adults with AUDs. A search of the medical literature identified 122 randomized clinical trials (RCTs) and 1 cohort study (totaling 22,803 participants) that met criteria for inclusion in the analysis.
Most studies assessed acamprosate (27; n = 7,519), naltrexone (53; n = 9,140), or both. The authors present their results in terms of number needed to treat (NNT), which is the average number of patients who need to be treated to see benefit in one patient. The NNT to prevent return to any drinking for acamprosate was 12 and was 20 for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12 for oral naltrexone (50 mg/d). Head-to-head trials have not established superiority of either medication.
For injectable naltrexone, the authors did not find an association with return to any drinking or heavy drinking but found an association with reduction in heavy drinking days.
Because of its long-standing availability (from the 1950s), clinicians may be more familiar with disulfiram than naltrexone or acamprosate. However, evidence from well-controlled trials of disulfiram does not adequately support an association with preventing return to any drinking or improvement in other alcohol consumption outcomes.
Among medications used off-label (prescribing a drug approved to treat a different condition), moderate evidence supports an association with improvement in some consumption outcomes for nalmefene and topiramate.
"When clinicians decide to use one of the medications, a number of factors may help with choosing which medication to prescribe, including the medication's efficacy, administration frequency, cost, adverse events, and availability," the authors conclude.
Editorial: Bringing Patient-Centered Care to Patients With Alcohol Use Disorders
Katharine A. Bradley, M.D., M.P.H., of the Group Health Research Institute, Seattle, and Daniel R. Kivlahan, Ph.D., of the Veterans Health Administration, Washington, D.C., comment on the findings of this study in an accompanying editorial.
"Treatment of AUD is considered an essential health benefit under health care reform. More patients with AUDs will have insurance, which could increase their access to evidence-based treatments for AUDs. The article by Jonas and colleagues should encourage patients and their clinicians to engage in shared decision making about AUD treatment options. By identifying 4 effective medications for AUD [naltrexone, acamprosate, topiramate, and nalmefene], the authors highlight treatment options for a common medical condition for which patient-centered care is not currently the norm. Patients with AUDs should be offered options, including medications, evidence-based behavioral treatments, and mutual support for recovery. Moreover, patients should expect shared decision making about the best options for them."