Underused drugs may help with alcohol use disorders

Either acamprosate or oral naltrexone is effective for decreasing consumption by people with alcohol use disorders (AUDs), as is off-label use of nalmefene or topiramate, according to a meta-analysis.

Researchers conducted a review and meta-analysis among 122 randomized trials and 1 cohort study totaling 22,803 patients to evaluate the benefits and harms of medications to reduce alcohol consumption.

Results appeared online May 14 at the Journal of the American Medical Association.

Most studies assessed acamprosate (27 studies; n=7,519 patients), naltrexone (53 studies; n=9,140 patients), or both. The number needed to treat (NNT) to prevent return to any drinking was 12 for acamprosate and 20 for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12 for oral naltrexone (50 mg/d). Head-to-head trials have not established superiority of either medication, the authors noted. For injectable naltrexone, meta-analyses found no association with return to any drinking or heavy drinking, but there was 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: weighted mean difference [WMD], −2.0; 95% CI, −3.0 to −1.0; drinks per drinking day: WMD, −1.02; 95% CI, −1.77 to −0.28). For topiramate there was evidence of an improvement in percentage of heavy drinking days (WMD, −9.0%; 95% CI, −15.3% to −2.7%) and drinks per drinking day (WMD, −1.0; 95% CI, −1.6 to −0.48).

For naltrexone, the number needed to harm (NNH), measured by withdrawal from trials due to adverse events, was 48 (95% CI, 30 to 112). For nalmefene, the NNH was 12 (95% CI, 7 to 50). Risk was not significantly increased for acamprosate or topiramate.

Because disulfiram has been available since the 1950s, clinicians may be more familiar with it than naltrexone or acamprosate, the authors noted. However, well-controlled trials of disulfiram do not adequately support an association with preventing return to any drinking or improvement in other alcohol consumption outcomes.

An editorial noted, “By identifying 4 effective medications for AUD (naltrexone, acamprosate, topiramate, and nalmefene), the authors highlight treatment options for a common medical condition for which patient-centered care is not currently the norm. Patients with AUDs should be offered options, including medications, evidence-based behavioral treatments, and mutual support for recovery.”