Medications for Alcohol Use Disorder

 


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Am Fam Physician. 2016 Mar 15;93(6):457-465.

  Patient information: See related handout on medicine for alcohol use disorder, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

The U.S. Preventive Services Task Force recommends that clinicians screen adults for alcohol misuse and provide persons engaged in risky or hazardous drinking behaviors with brief behavioral counseling to reduce alcohol misuse. However, only a minority of American adults with high-risk alcohol use receive treatment. Three medications are approved by the U.S. Food and Drug Administration to treat alcohol use disorder: acamprosate, disulfiram, and naltrexone. Acamprosate and naltrexone reduce alcohol consumption and increase abstinence rates, although the effects appear to be modest. Disulfiram has been used for years, but evidence supporting its effectiveness is inconsistent. Other medications may be beneficial to reduce heavy alcohol use. The anticonvulsants topiramate and gabapentin may reduce alcohol ingestion, although long-term studies are lacking. Antidepressants do not decrease alcohol use in patients without mood disorders, but sertraline and fluoxetine may help depressed patients decrease alcohol ingestion. Ondansetron may reduce alcohol use, particularly in selected subpopulations. Further study is needed for genetically targeted or as-needed medications to reduce alcohol use.

Excessive alcohol use is the third leading cause of preventable death in the United States.1 The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., integrates the previous categories of alcohol abuse and alcohol dependence into the diagnosis of alcohol use disorder (AUD); Table 1 shows the complete criteria.2 The National Institutes of Health estimates that AUD affected 9% of adult men and 5% of adult women in the United States in 2013, and many more adults and adolescents engaged in high-risk alcohol use.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Acamprosate (Campral) increases abstinence rates in patients with alcohol use disorder.

A

9, 12, 16

There is inconsistent evidence supporting the use of disulfiram (Antabuse) to decrease alcohol intake in patients with alcohol use disorder.

B

12, 18, 19

Naltrexone (Revia) decreases alcohol consumption in patients with alcohol use disorder.

A

9, 12, 21

Topiramate (Topamax) may decrease alcohol intake in patients with alcohol use disorder.

B

2731

Ondansetron (Zofran) may decrease alcohol intake in patients with alcohol use disorder.

B

41, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Acamprosate (Campral) increases abstinence rates in patients with alcohol use disorder.

A

9, 12, 16

There is inconsistent evidence supporting the use of disulfiram (Antabuse) to decrease alcohol intake in patients with alcohol use disorder.

B

12, 18, 19

Naltrexone (Revia) decreases alcohol consumption in patients with alcohol use disorder.

A

9, 12, 21

Topiramate (Topamax) may decrease alcohol intake in patients with alcohol use disorder.

B

2731

Ondansetron (Zofran) may decrease alcohol intake in patients with alcohol use disorder.

B

41, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

Table 1.

Criteria for the Diagnosis of Alcohol Use Disorder

A.

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

1. Alcohol is often taken in larger amounts or over a longer period than was intended.

2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

4. Craving, or a strong desire or urge to use alcohol.

5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

8. Recurrent alcohol use in situations in which it is physically hazardous.

9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

10. Tolerance, as defined by either of the following:

a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

b. A markedly diminished effect with continued use of the same

The Authors

show all author info

BRADFORD T. WINSLOW, MD, is program director of the Swedish Family Medicine Residency Program in Littleton, Colo. He is also an associate professor of family medicine at the University of Colorado School of Medicine in Aurora....

MARY ONYSKO, PharmD, BCPS, is an associate professor of pharmacy practice at the University of Wyoming School of Pharmacy in Laramie, and a faculty member at the Swedish Family Medicine Residency Programs.

MELANIE HEBERT, MD, is a physician with Kaiser Permanente in Highlands Ranch, Colo. At the time this article was written, she was a third-year resident at the Swedish Family Medicine Residency Program.

Author disclosure: No relevant financial affiliations.

Address correspondence to Bradford T. Winslow, MD, Swedish Family Medicine Residency, 191 E. Orchard Rd., Ste. 200, Littleton, CO 80121 (e-mail: bradford.winslow@healthonecares.com). Reprints are not available from the authors.

REFERENCES

show all references

1. Centers for Disease Control and Prevention. Alcohol use and your health. http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm. Accessed January 11, 2015....

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association;2013:490–491.

3. National Institute on Alcohol Abuse and Alcoholism. National Institutes of Health. Alcohol facts and statistics. March 2015. http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics. Accessed December 2, 2015.

4. U.S. Preventive Services Task Force. Alcohol misuse: screening and behavioral counseling interventions in primary care. May 2013. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care. Accessed February 9, 2015.

5. Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary care validation of a single-question alcohol screening test [published correction appears in J Gen Intern Med. 2010;25(4):375]. J Gen Intern Med. 2009;24(7):783–788.

6. Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830–842.

7. Muncie HL Jr, Yasinian Y, Oge' L. Outpatient management of alcohol withdrawal syndrome. Am Fam Physician. 2013;88(9):589–595.

8. Substance Abuse and Mental Health Services Administration. National Institute on Alcohol Abuse and Alcoholism. Medication for the treatment of alcohol use disorder: a brief guide. 2015. http://store.samhsa.gov/shin/content/SMA15-4907/SMA15-4907.pdf. Accessed December 4, 2015.

9. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889–1900.

10. VA Pharmacy Benefits Management Services, Medical Advisory Panel, and VISN Pharmacist Executives. Alcohol use disorder pharmacotherapy. Naltrexone, acamprosate, and disulfiram. Recommendations for Use. December 2013. http://www.pbm.va.gov/PBM/clinicalguidance/clinicalrecommendations/Alcohol_Use_Disorder_Pharmacotherapy_Acamprosate_Naltrexone_Disulfiram_Recommendations_for_Use.docx. Accessed February 21, 2015.

11. National Institute for Health and Care Excellence. Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. April 2015. https://www.nice.org.uk/guidance/cg115. Accessed December 4, 2015.

12. Agency for Healthcare Research and Quality. Pharmacotherapy for adults with alcohol-use disorders in outpatient settings. Executive summary. http://effectivehealthcare.ahrq.gov/ehc/products/477/1907/alcohol-misuse-drug-therapy-executive-140513.pdf. Accessed February 21, 2015.

13. Epocrates. http://epocrates.com/. Accessed January 19, 2016.

14. Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275–293.

15. Yahn SL, Watterson LR, Olive MF. Safety and efficacy of acamprosate for the treatment of alcohol dependence. Subst Abuse. 2013;6:1–12.

16. Rösner S, Hackl-Herrwerth A, Leucht S, Lehert P, Vecchi S, Soyka M. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010;(9):CD004332.

17. Berger L, Fisher M, Brondino M, et al. Efficacy of acamprosate for alcohol dependence in a family medicine setting in the United States: a randomized, double-blind, placebo-controlled study. Alcohol Clin Exp Res. 2013;37(4):668–674.

18. Laaksonen E, Koski-Jännes A, Salaspuro M, Ahtinen H, Alho H. A randomized, multicentre, open-label, comparative trial of disulfiram, naltrexone and acamprosate in the treatment of alcohol dependence. Alcohol Alcohol. 2008;43(1):53–61.

19. Skinner MD, Lahmek P, Pham H, Aubin HJ. Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PLoS One. 2014;9(2):e87366.

20. Niciu MJ, Arias AJ. Targeted opioid receptor antagonists in the treatment of alcohol use disorders. CNS Drugs. 2013;27(10):777–787.

21. Rösner S, Hackl-Herrwerth A, Leucht S, Vecchi S, Srisurapanont M, Soyka M. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010;(12):CD001867.

22. Garbutt JC, Kranzler HR, O'Malley SS, et al.; Vivitrex Study Group. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial [published corrections appear in JAMA. 2005;293(16):1978, and JAMA. 2005;293(23):2864]. JAMA. 2005;293(13):1617–1625.

23. Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003–2017.

24. Kiefer F, Jahn H, Tarnaske T, et al. Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind, placebo-controlled study. Arch Gen Psychiatry. 2003;60(1):92–99.

25. van den Brink W, Aubin HJ, Bladström A, Torup L, Gual A, Mann K. Efficacy of as-needed nalmefene in alcohol-dependent patients with at least a high drinking risk level: results from a subgroup analysis of two randomized controlled 6-month studies [published correction appears in Alcohol Alcohol. 2013;48(6):746]. Alcohol Alcohol. 2013;48(5):570–578.

26. Pani PP, Trogu E, Pacini M, Maremmani I. Anticonvulsants for alcohol dependence. Cochrane Database Syst Rev. 2014;(2):CD008544.

27. Johnson BA, Rosenthal N, Capece JA, et al.; Topiramate for Alcoholism Advisory Board; Topiramate for Alcoholism Study Group. Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA. 2007;298(14):1641–1651.

28. Johnson BA, Ait-Daoud N, Bowden CL, et al. Oral topiramate for treatment of alcohol dependence: a randomised controlled trial. Lancet. 2003;361(9370):1677–1685.

29. Paparrigopoulos T, Tzavellas E, Karaiskos D, Kourlaba G, Liappas I. Treatment of alcohol dependence with low-dose topiramate: an open-label controlled study. BMC Psychiatry. 2011;11:41.

30. Likhitsathian S, Uttawichai K, Booncharoen H, Wittayanookulluk A, Angkurawaranon C, Srisurapanont M. Topiramate treatment for alcoholic outpatients recently receiving residential treatment programs: a 12-week, randomized, placebo-controlled trial. Drug Alcohol Depend. 2013;133(2):440–446.

31. Kranzler HR, Covault J, Feinn R, et al. Topiramate treatment for heavy drinkers: moderation by a GRIK1 polymorphism [published correction appears in Am J Psychiatry. 2014;171(5):585]. Am J Psychiatry. 2014;171(4):445–452.

32. Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med. 2014;174(1):70–77.

33. Furieri FA, Nakamura-Palacios EM. Gabapentin reduces alcohol consumption and craving: a randomized, double-blind, placebo-controlled trial. J Clin Psychiatry. 2007;68(11):1691–1700.

34. Leung JG, Hall-Flavin D, Nelson S, Schmidt KA, Schak KM. The role of gabapentin in the management of alcohol withdrawal and dependence. Ann Pharmacother. 2015;49(8):897–906.

35. Martinotti G, Di Nicola M, Tedeschi D, et al. Pregabalin versus naltrexone in alcohol dependence: a randomised, double-blind, comparison trial. J Psychopharmacol. 2010;24(9):1367–1374.

36. Torrens M, Fonseca F, Mateu G, Farré M. Efficacy of antidepressants in substance use disorders with and without comorbid depression. A systematic review and meta-analysis. Drug Alcohol Depend. 2005;78(1):1–22.

37. Pettinati HM, Oslin DW, Kampman KM, et al. A double-blind, placebo-controlled trial combining sertraline and naltrexone for treating co-occurring depression and alcohol dependence. Am J Psychiatry. 2010;167(6):668–675.

38. Cornelius JR, Salloum IM, Ehler JG, et al. Fluoxetine in depressed alcoholics. A double-blind, placebo-controlled trial. Arch Gen Psychiatry. 1997;54(8):700–705.

39. Johnson BA, Roache JD, Javors MA, et al. Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: a randomized controlled trial. JAMA. 2000;284(8):963–971.

40. Johnson BA, Roache JD, Ait-Daoud N, Zanca NA, Velazquez M. Ondansetron reduces the craving of biologically predisposed alcoholics. Psychopharmacology (Berl). 2002;160(4):408–413.

41. Kranzler HR, Pierucci-Lagha A, Feinn R, Hernandez-Avila C. Effects of ondansetron in early- versus late-onset alcoholics: a prospective, open-label study. Alcohol Clin Exp Res. 2003;27(7):1150–1155.

42. Johnson BA, Ait-Daoud N, Ma JZ, Wang Y. Ondansetron reduces mood disturbance among biologically predisposed, alcohol-dependent individuals. Alcohol Clin Exp Res. 2003;27(11):1773–1779.

43. Corrêa Filho JM, Baltieri DA. A pilot study of full-dose ondansetron to treat heavy-drinking men withdrawing from alcohol in Brazil. Addict Behav. 2013;38(4):2044–2051.

44. Leone MA, Vigna-Taglianti F, Avanzi G, Brambilla R, Faggiano F. Gamma-hydroxybutyrate (GHB) for treatment of alcohol withdrawal and prevention of relapses. Cochrane Database Syst Rev. 2010;(2):CD006266.

45. Williams SH. Medications for treating alcohol dependence. Am Fam Physician. 2005;72(9):1775–1780.



 

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