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Comparison of Pharmacologic Treatments for Alcoholism
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Am Fam Physician. 1999 Nov 1;60(7):2096-2098.
The American Medical Association and the American Psychiatric Association officially recognize alcoholism as a disease. Approximately 10 percent of Americans are affected at some time in their lives. The cost of alcoholism to society is high, in lives lost and dollars spent. An estimated 100,000 persons die annually as a result of alcohol-related causes, and approximately $166 billion is spent annually in indirect and direct health costs. Garbutt and colleagues reviewed the literature to identify which pharmacologic treatments of alcoholism are most likely to help persons achieve long-term sobriety.
Medications identified as pharmacotherapies for alcoholism were the focus of the review. These pharmacotherapies included the opiate antagonists naltrexone and nalmefene, along with disulfiram, acamprosate, lithium, and various serotonergic drugs, including the selective serotonin reuptake inhibitors (SSRIs). The efficacy of each agent or class of agents in reducing the number of drinks ingested, the number of days on which a drink was consumed, the resumption of drinking and episodes of heavy drinking and craving were evaluated. Information about study design and sample size, as well as other study criteria, was collected. The overall strength of the evidence was based on a comparison of information across all studies abstracted.
A total of 41 studies were abstracted, and the data analyzed. Of these studies, 11 evaluated disulfiram, three naltrexone, nine acamprosate, 12 the SSRIs and six lithium. The data on oral disulfiram (200 to 250 mg per day) provided modest evidence of a reduction in drinking frequency, but no improvement in abstinence rates. The data on disulfiram implants were inconclusive. Oral naltrexone (50 mg per day) appeared to reduce drinking frequency and relapse rates but only when used in combination with supportive psychotherapy. The rate of heavy drinking also diminished, as did the reported “high” associated with alcohol consumption. Nalmefene (10 to 40 mg per day) reduced heavy drinking and relapse rates, but these results were based on a small sample size. Acamprosate (1,300 to 2,000 mg per day) increased the number of reported nondrinking days from 30 to 50 percent. Abstinence rates also increased, an effect that seemed to last after study completion. The SSRIs studied, including fluoxetine, buspirone citalopram and ondansetron, appeared to have no major effect on the outcomes studied. However, in depressed alcohol-dependent patients, fluoxetine was associated with decreases in the amount and frequency of drinking. Studies of patients taking lithium found that this drug was no more effective than placebo in treating alcoholism.
The authors conclude that some of the traditional medications used for treatment of alcoholism appear to be less effective than was previously thought and perhaps should be used less frequently. Evidence about the efficacy of disulfiram is inconclusive; it appears to reduce the number of drinking days but is associated with negative evidence on other outcome measures. The authors also emphasize that preliminary evidence tends to support the use of naltrexone and acamprosate, but these agents require additional study. Many questions about the use of pharmacologic agents for treatment of alcoholism remain. What combination of psychosocial intervention and medication is best? What synergistic effects are possible with the use of more than one medication? What is the optimal duration of therapy with each medication? Future research on optimal pharmacotherapy is needed. One thing is certain: psychosocial factors must be addressed before patients can move from addiction to sobriety.
Garbutt JC, et al. Pharmacological treatment of alcohol dependence. A review of the evidence. JAMA. April 14, 1999;281:1318–25.
Copyright © 1999 by the American Academy of Family Physicians.
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