AHRQ Research Review Finds Medications Acamprosate and Oral Naltrexone Have Best Evidence for Decreasing Alcohol Use

A new research review from AHRQ finds the use of psychosocial co-interventions, such as counseling and the addition of several medications, can decrease alcohol consumption in patients with alcohol-use disorders. The medications acamprosate and oral naltrexone have the best evidence for decreasing alcohol consumption in patients with alcohol-use disorders. Since research has not consistently recognized the superiority of either medication, other factors may impact the choice of medications, including how often a medication is taken, potential adverse reactions and the availability of treatments. These findings are available in the research review, Pharmacotherapy for Adults With Alcohol-Use Disorders in Outpatient Settings and were published in an abstract and study online in the May 13 issue of the Journal of the American Medical Association (JAMA).

2014 May 14;311(18):1889-900. doi: 10.1001/jama.2014.3628.

Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.

Jonas DE1, Amick HR2, Feltner C1, Bobashev G3, Thomas K2, Wines R2, Kim MM4, Shanahan E2, Gass CE5, Rowe CJ6, Garbutt JC7.

Author information

Abstract

IMPORTANCE:

Alcohol use disorders cause substantial morbidity and early mortality yet remain greatly undertreated. Medications are considerably underused.

OBJECTIVE:

To conduct a systematic review and meta-analysis of the benefits and harms of medications (US FDA-approved and others) for adults with alcohol use disorders.

DATA SOURCES:

PubMed, Cochrane Library, PsycINFO, CINAHL, EMBASE, FDA website, and clinical trials registries (January 1, 1970, to March 1, 2014).

STUDY SELECTION:

Two reviewers selected randomized clinical trials (RCTs) with at least 12 weeks' duration that reported eligible outcomes and head-to-head prospective cohort studies reporting health outcomes or harms.

DATA EXTRACTION AND SYNTHESIS:

We conducted meta-analyses using random-effects models and calculated numbers needed to treat for benefit (NNTs) or harm (NNHs).

MAIN OUTCOMES AND MEASURES:

Alcohol consumption, motor vehicle crashes, injuries, quality of life, function, mortality, and harms.

RESULTS:

We included 122 RCTs and 1 cohort study (total 22,803 participants). Most assessed acamprosate (27 studies, n = 7519), naltrexone (53 studies, n = 9140), or both. The NNT to prevent return to any drinking for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD], -0.09; 95% CI, -0.14 to -0.04) and was 20 (95% CI, 11 to 500; RD, -0.05; 95% CI, -0.10 to -0.002) for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12 (95% CI, 8 to 26; RD -0.09; 95% CI, -0.13 to -0.04) for oral naltrexone (50 mg/d). Meta-analyses of trials comparing acamprosate to naltrexone found no statistically significant difference between them for return to any drinking (RD, 0.02; 95% CI, -0.03 to 0.08) or heavy drinking (RD, 0.01; 95% CI, -0.05 to 0.06). For injectable naltrexone, meta-analyses found no association with return to any drinking (RD, -0.04; 95% CI, -0.10 to 0.03) or heavy drinking (RD, -0.01; 95% CI, -0.14 to 0.13) but found an association with reduction in heavy drinking days (weighted mean difference [WMD], -4.6%; 95% CI, -8.5% to -0.56%). Among medications used off-label, moderate evidence supports an association with improvement in some consumption outcomes for nalmefene (heavy drinking days per month: WMD, -2.0; 95% CI, -3.0 to -1.0; drinks per drinking day: WMD, -1.02; 95% CI, -1.77 to -0.28) and topiramate (% heavy drinking days: WMD, -9.0%; 95% CI, -15.3% to -2.7%; drinks per drinking day: WMD, -1.0; 95% CI, -1.6 to -0.48). For naltrexone and nalmefene, NNHs for withdrawal from trials due to adverse events were 48 (95% CI, 30 to 112) and 12 (95% CI, 7 to 50), respectively; risk was not significantly increased for acamprosate or topiramate.

CONCLUSIONS AND RELEVANCE:

Both acamprosate and oral naltrexone were associated with reduction in return to drinking. When directly compared with one another, no significant differences were found between acamprosate and naltrexone for controlling alcohol consumption. Factors such as dosing frequency, potential adverse events, and availability of treatments may guide medication choice.