FPIN's Clinical Inquiries

Alcohol Use Disorder: Pharmacologic Treatment Options

 

Am Fam Physician. 2020 Oct 1;102(7):online.

Clinical Question

What are the first-line pharmacologic treatment options for alcohol use disorder?

Evidence-Based Answer

Acamprosate and naltrexone should be used as first-line agents for treatment of alcohol use disorder and are effective for reducing relapse rates. Agent selection should be based on comorbid conditions and adherence to the dosing regimen. (Strength of Recommendation [SOR]: A, based on a meta-analysis.) Combining the two agents may provide additional benefit early in treatment. (SOR: B, based on a single randomized controlled trial [RCT]).

Evidence Summary

A 2014 meta-analysis of 22 RCTs and one cohort study (N = 22,803) evaluated relapse rates in patients who received acamprosate or naltrexone, alone or in combination, for at least 12 weeks.1 The primary outcome was a return to alcohol consumption, classified as any or heavy consumption (at least five drinks per day for men or at least four for women). Rates of return to any consumption improved with either agent. The number needed to treat (NNT) for return to any consumption was 12 for acamprosate (95% CI, 8 to 26; 16 trials; n = 4,847) and 20 for naltrexone (95% CI, 11 to 500; 16 trials; n = 2,347). Naltrexone monotherapy demonstrated benefit for heavy consumption (NNT = 12; 95% CI, 8 to 26; 19 trials; n = 2,875).

A 2004 RCT examined the effectiveness of naltrexone or acamprosate, alone or in combination, in preventing relapse in newly detoxified adults (N = 160).2  Table 1 shows relapse rates at 12 and 24 weeks among the four treatment groups.2 Acamprosate, naltrexone, and combination therapy were significantly more effective than placebo at 12 and 24 weeks (P < .05). At 12 weeks, the relapse rate among patients receiving combination therapy was significantly lower than in the acamprosate group (P < .05), but this significance was not observed at 24 weeks. There was an increase in nausea and diarrhea in the combination therapy group (P < .05).

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TABLE 1.

Relapse Rates in Patients Treated for Alcohol Use Disorder

Treatment group (n = 40 per group)Relapse rate at 12 weeks (%)Relapse rate at 24 weeks (%)

Placebo

75

80

Acamprosate, 1,998 mg per day

50*

54.3*

Naltrexone, 50 mg per day

35.3*

52.9*

Combined acamprosate and naltrexone

27.5*†

34.3*


*—P < .05 compared with placebo.

†—P < .05 compared with

Address correspondence to Cynthia Groves, MD, at cynthia.groves@erlanger.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. 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....

2. Kiefer F, Andersohn F, Otte C, et al. Long-term effects of pharmacotherapy on relapse prevention in alcohol dependence. Acta Neuropsychiatr. 2004;16(5):233–238.

3. Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 2018;175(1):86–90.

4. National Institute for Health and Care Excellence. Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high-risk drinking) and alcohol dependence. February 23, 2011. Accessed May 13, 2020. https://bit.ly/3cwDQzo

Clinical Inquiries provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email: questions@fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN's Clinical Inquiries published in AFP is available at https://www.aafp.org/afp/fpin.

 

 

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