Pharmacotherapy for Alcohol Use Disorder

Abstract

ImportanceAlcohol use disorder affects more than 28.3 million people in the United States and is associated with increased rates of morbidity and mortality.ObjectiveTo compare efficacy and comparative efficacy of therapies for alcohol use disorder.Data SourcesPubMed, the Cochrane Library, the Cochrane Central Trials Registry, PsycINFO, CINAHL, and EMBASE were searched from November 2012 to September 9, 2022 Literature was subsequently systematically monitored to identify relevant articles up to August 14, 2023, and the PubMed search was updated on August 14, 2023.Study SelectionFor efficacy outcomes, randomized clinical trials of at least 12 weeks’ duration were included. For adverse effects, randomized clinical trials and prospective cohort studies that compared drug therapies and reported health outcomes or harms were included.Data Extraction and SynthesisTwo reviewers evaluated each study, assessed risk of bias, and graded strength of evidence. Meta-analyses used random-effects models. Numbers needed to treat were calculated for medications with at least moderate strength of evidence for benefit.Main Outcomes and MeasuresThe primary outcome was alcohol consumption. Secondary outcomes were motor vehicle crashes, injuries, quality of life, function, mortality, and harms.ResultsData from 118 clinical trials and 20 976 participants were included. The numbers needed to treat to prevent 1 person from returning to any drinking were 11 (95% CI, 1-32) for acamprosate and 18 (95% CI, 4-32) for oral naltrexone at a dose of 50 mg/d. Compared with placebo, oral naltrexone (50 mg/d) was associated with lower rates of return to heavy drinking, with a number needed to treat of 11 (95% CI, 5-41). Injectable naltrexone was associated with fewer drinking days over the 30-day treatment period (weighted mean difference, −4.99 days; 95% CI, −9.49 to −0.49 days) Adverse effects included higher gastrointestinal distress for acamprosate (diarrhea: risk ratio, 1.58; 95% CI, 1.27-1.97) and naltrexone (nausea: risk ratio, 1.73; 95% CI, 1.51-1.98; vomiting: risk ratio, 1.53; 95% CI, 1.23-1.91) compared with placebo.Conclusions and RelevanceIn conjunction with psychosocial interventions, these findings support the use of oral naltrexone at 50 mg/d and acamprosate as first-line pharmacotherapies for alcohol use disorder.

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“…4,5 Unfortunately, chemotherapy drugs employed in clinical practice invariably bring about a range of debilitating side effects, such as nausea, vomiting, diarrhea, hair loss, bone marrow suppression, and a decrease in white blood cell count. [6][7][8] These side effects significantly diminish the quality of life of patients post-chemotherapy. 9,10 Ginsenoside Rg3 is a natural compound in ginseng with a unique tetracyclic triterpene saponin structure.…”

Outcomes After Initiation of Medications for Alcohol Use Disorder at Hospital Discharge

“…3,5 Evidence supporting MAUD efficacy includes randomized clinical trials predominantly based in the outpatient setting with an end point of reduction in drinking. 6,7 Oral naltrexone has been shown to reduce return to any drinking and heavy drinking, and acamprosate reduced return to any drinking among patients who achieved abstinence. 6,7 Use of naltrexone has also been associated with reduced hospitalizations using observational data.…”

“…6,7 Oral naltrexone has been shown to reduce return to any drinking and heavy drinking, and acamprosate reduced return to any drinking among patients who achieved abstinence. 6,7 Use of naltrexone has also been associated with reduced hospitalizations using observational data. 8 Evidence supporting the efficacy of disulfiram is more limited, although it is recommended to use under specific circumstances, including patient preference or intolerance to naltrexone or acamprosate.…”

Pharmacotherapy for Alcohol Use Disorder—Reply

“…In Reply We appreciate the thoughtful letter by Dr Shi regarding our systematic review and meta-analysis of pharmacotherapies for alcohol use disorder. Regarding the meta-analyses that included multiple doses, the analyses were stratified by dose whenever possible (eg, 50-mg oral naltrexone and 100-mg oral naltrexone) . More details are provided in the full evidence report…”