Tools for Practice


#253 Pharmacologic management of alcohol use disorder: worth a shot?


CLINICAL QUESTION
Which Health Canada approved pharmacologic treatments are effective for alcohol use disorder?

BOTTOM LINE
Both acamprosate and naltrexone demonstrate benefit for abstinence from alcohol when compared to placebo. For every 12 patients treated with acamprosate, and every 20 patients treated with naltrexone, one fewer patient will return to drinking compared to placebo after 12-52 weeks. If harm reduction is the goal, naltrexone can reduce return to heavy drinking for one out of every 13 patients.


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EVIDENCE
Results statistically significant unless noted. 
  • Systematic review of randomized, controlled trials (RCTs) of 12-52 week treatments, most included supportive therapy and required detoxification. Results versus placebo:1 
    • Return to any drinking: 
      • Acamprosate (16 RCTs, 4847 patients) most common dose 666mg three times per day: 
        • 76% versus 83% placebo. 
          • Number needed to treat (NNT)=12. 
      • Oral naltrexone (16 RCTs, 2347 patients) 50mg daily: 
        • 63% versus 68% placebo. 
          • NNT=20. 
      • No difference with injectable naltrexone (2 RCTs, 939 patients) or disulfiram (2 RCTs, 492 patients). 
    • Return to heavy drinking: 
      • Oral natrexone (19 RCTS, 2875 patients) 50mg daily: 
        • 46% versus 54% placebo. 
          • NNT=13. 
      • No difference with acamprosate (7 RCTs, 2496 patients). 
    • Earlier systematic reviews of acamprosate2 and naltrexone3 reported similar results. 
    • Evidence insufficient or of no benefit for acamprosate or naltrexone on mortality1,4,5 or quality of life.1 
    • Most common adverse effects: 
      • Naltrexone:3,5 
        • Nausea: 26% versus 16% placebo number needed to harm (NNH)=10. 
        • Sleepiness: 21% versus 16% placebo, NNH=20. 
      • Acamprosate:4 
        • Diarrhea: 16% versus 10% placebo, NNH=17. 
        • Incidence decreases after first four weeks of treatment.
Context:  
  • Guidelines suggest first line pharmacotherapy include acamprosate for abstinence or naltrexone for a goal of reduced drinking or abstinence. They also provide practical tips for their use.6 
  • Limited evidence has evaluated naltrexone on an “as needed” basis.  It may reduce alcohol consumption when used as cravings arise or prior to expected drinking.7 
  • Supportive interventions including brief interventions in primary care may benefit 1 in 10 individuals with excessive alcohol intake.8 
  • If patients do not respond to approved medications, trial of alternative medications (example topiramate, gabapentin) may be reasonable.6 
February 18, 2020

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Author(s):

  • Caitlin R Finley BHSc MSc
  • Carly Rumley MD
  • Christina Korownyk MD CCFP

1. Jonas DE, Amick HR, Feltner C, et al. JAMA. 2014; 311(18):1889-1900.

2. Rösner S, Hackl-Herrwerth A, Leucht S, et al. Cochrane Database System Rev. 2010; 9:CD004332.

3. Rösner S, Hackl-Herrwerth A, Leucht S, et al. Cochrane Database System Rev. 2010; 12:CD001867.

4. Rosenthal RN, Gage A, Perhach JL, et al. J Addict Med. 2008; 2(1):40-50.

5. Bolton M, Hodkinson A, Boda S, et al. BMC Medicine. 2019; 17:10.

6. British Columbia Centre on Substance Use (BCCSU), B.C. Ministry of Health and B.C. Ministry of Mental Health and Addictions. Provincial Guideline for the Clinical Management of High-Risk Drinking and Alcohol Use Disorder. 2019. Vancouver, B.C.: BCCSU. Available at: https://www.bccsu.ca/clinical-care-guidance/. Accessed January 14, 2020.

7. Heinälä P, Alho H, Kiianmaa K, et al. J Clin Psychopharmacol. 2001; 21(3):287-92.

8. Tools for Practice #134 Getting patients to drink less--Are words mightier than drink? Available at https://gomainpro.ca/wp-content/uploads/tools-for-practice/1426518561_tfpalcoholscreeningandinterventionsfv2.pdf January 14, 2020.

Authors do not have any conflicts of interest to declare.