The misuse of alcohol and other drugs can have a damaging impact on individuals, families and communities. It is important to get support if you or someone you know needs help to manage a substance use issue.
What are the first-line pharmacologic treatment options for alcohol use disorder?
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]).
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).
Recommendations from Others
The American Psychiatric Association (APA) and the National Institute for Health and Care Excellence recommend naltrexone and acamprosate as the preferred pharmacologic options for patients with alcohol use disorder, in combination with cognitive behavioral interventions.3,4 The APA recommends against acamprosate therapy in patients with severe renal impairment, and against naltrexone in those with hepatic failure or acute hepatitis.3 Acamprosate is typically taken three times daily; naltrexone is taken once daily and is also available in a long-acting parenteral formulation.
Copyright © Family Physicians Inquiries Network. Used with permission. 1. Health Canada . Canadian Alcohol and Drug Use Monitoring Survey. Summary of results for 2012. Ottawa, ON: Health Canada; 2012. Available from: www.hc-sc.gc.ca/hc-ps/drugs-drogues/stat/_2012/summary-sommaire-eng.php. Accessed 2017 Apr 10. [Google Scholar] 2. Tjepkema M. Alcohol and illicit drug dependence. Health Rep. 2004;15(Suppl):9–19. [PubMed] [Google Scholar] 3. Shield KD, Rylett M, Gmel G, Gmel G, Kehoe-Chan TA, Rehm J. Global alcohol exposure estimates by country, territory and region for 2005—a contribution to the comparative risk assessment for the 2010 Global Burden of Disease Study. Addiction. 2013;108(5):912–22. Epub 2013 Mar 4. [PubMed] [Google Scholar] 4. Jørgensen CH, Pedersen B, Tønnesen H. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcohol Clin Exp Res. 2011;35(10):1749–58. Epub 2011 May 25. [PubMed] [Google Scholar] 5. Jonas DE, Amick HR, Feltner C, Bobashev G, Thomas K, Wines R, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311(18):1889–900. [PubMed] [Google Scholar] 6. Bouza C, Angeles M, Muñoz A, Amate JM. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review. Addiction. 2004;99(7):811–28. Erratum in: Addiction 2005;100(4):573. [PubMed] [Google Scholar] 7. 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):275–93. Epub 2012 Oct 17. [PMC free article] [PubMed] [Google Scholar] 8. 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. [PubMed] [Google Scholar] 9. Rösner S, Hackl-Herrwerth A, Leucht S, Lehert P, Vecchi S, Soyka M. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010;(9):CD004332. [PubMed] [Google Scholar] 10. Baser O, Chalk M, Rawson R, Gastfriend DR. Alcohol dependence treatments: comprehensive healthcare costs, utilization outcomes, and pharmacotherapy persistence. Am J Manag Care. 2011;17(Suppl 8):S222–34. [PubMed] [Google Scholar] 11. Mark TL, Montejano LB, Kranzler HR, Chalk M, Gastfriend DR. Comparison of healthcare utilization among patients treated with alcoholism medications. Am J Manag Care. 2010;16(12):879–88. [PMC free article] [PubMed] [Google Scholar] 12. Canadian Agency for Drugs and Technologies in Health . Common drug review. Acamprosate calcium (Campral—Prempharm Inc). Indication—maintenance of alcohol abstinence. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2008. Available from: www.cadth.ca/media/cdr/relatedinfo/cdr_trans_campral_overview_Jul-29-08.pdf. Accessed 2017 Apr 6. [Google Scholar] 13. Harris KM, DeVries A, Dimidjian K. Datapoints: trends in naltrexone use among members of a large private health plan. Psychiatr Serv. 2004;55(3):221. [PubMed] [Google Scholar] 14. Petrakis IL, Leslie D, Rosenheck R. Use of naltrexone in the treatment of alcoholism nationally in the Department of Veterans Affairs. Alcohol Clin Exp Res. 2003;27(11):1780–4. [PubMed] [Google Scholar] 15. Iheanacho T, Issa M, Marienfeld C, Rosenheck R. Use of naltrexone for alcohol use disorders in the Veterans’ Health Administration: a national study. Drug Alcohol Depend. 2013;132(1–2):122–6. Epub 2013 Feb 22. [PubMed] [Google Scholar] 16. Mason BJ, Goodman AM, Chabac S, Lehert P. Effect of oral acamprosate on abstinence in patients with alcohol dependence in a double-blind, placebo-controlled trial: the role of patient motivation. J Psychiatr Res. 2006;40(5):383–93. Epub 2006 Mar 20. [PubMed] [Google Scholar] 17. Carter AA, Gomes T, Camacho X, Juurlink DN, Shah BR, Mamdani MM. Risk of incident diabetes among patients treated with statins: population based study. BMJ. 2013;346:f2610. Erratum in: BMJ 2013;347:f4356. [PMC free article] [PubMed] [Google Scholar] 18. Dhalla IA, Gomes T, Yao Z, Yao Z, Nagge J, Persaud N, et al. Chlorthalidone versus hydrochlorothiazide for the treatment of hypertension in older adults: a population-based cohort study. Ann Intern Med. 2013;158(6):447–55. [PubMed] [Google Scholar] 19. Juurlink DN, Gomes T, Guttmann A, Hellings C, Sivilotti ML, Harvey MA, et al. Postpartum maternal codeine therapy and the risk of adverse neonatal outcomes: a retrospective cohort study. Clin Toxicol (Phila) 2012;50(5):390–5. Epub 2012 Apr 27. [PubMed] [Google Scholar] 20. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171(7):686–91. [PubMed] [Google Scholar] 21. Beck CA, Southern DA, Saitz R, Knudtson ML, Ghali WA. Alcohol and drug use disorders among patients with myocardial infarction: associations with disparities in care and mortality. PLoS One. 2013;8(9):e66551. [PMC free article] [PubMed] [Google Scholar] 22. Mason BJ, Lehert P. Acamprosate for alcohol dependence: a sex-specific meta-analysis based on individual patient data. Alcohol Clin Exp Res. 2012;36(3):497–508. Epub 2011 Sep 6. [PMC free article] [PubMed] [Google Scholar] 23. Baros AM, Latham PK, Anton RF. Naltrexone and cognitive behavioral therapy for the treatment of alcohol dependence: do sex differences exist? Alcohol Clin Exp Res. 2008;32(5):771–6. Epub 2008 Mar 11. [PMC free article] [PubMed] [Google Scholar] 24. Greenfield SF, Pettinati HM, O’Malley S, Randall PK, Randall CL. Gender differences in alcohol treatment: an analysis of outcome from the COMBINE study. Alcohol Clin Exp Res. 2010;34(10):1803–12. Epub 2010 Jul 20. [PMC free article] [PubMed] [Google Scholar] 25. Johnson I. Alcohol problems in old age: a review of recent epidemiological research. Int J Geriatr Psychiatry. 2000;15(7):575–81. [PubMed] [Google Scholar] 26. Wang YP, Andrade LH. Epidemiology of alcohol and drug use in the elderly. Curr Opin Psychiatry. 2013;26(4):343–8. [PubMed] [Google Scholar] 27. Nielsen B, Nielsen AS, Lolk A, Andersen K. Elderly alcoholics in outpatient treatment. Dan Med Bull. 2010;57(11):A4209. [PubMed] [Google Scholar] 28. Shahpesandy H, Pristásová J, Janíková Z, Mojzisová R, Kasanická V, Supalová O. Alcoholism in the elderly: a study of elderly alcoholics compared with healthy elderly and young alcoholics. Neuro Endocrinol Lett. 2006;27(5):651–7. [PubMed] [Google Scholar] 29. Wadd S, Papadopoulos C. Drinking behaviour and alcohol-related harm amongst older adults: analysis of existing UK datasets. BMC Res Notes. 2014;7:741. [PMC free article] [PubMed] [Google Scholar] 30. Caputo F, Vignoli T, Leggio L, Addolorato G, Zoli G, Bernardi M. Alcohol use disorders in the elderly: a brief overview from epidemiology to treatment options. Exp Gerontol. 2012;47(6):411–6. Epub 2012 Apr 10. [PMC free article] [PubMed] [Google Scholar] 31. CASAColumbia . Addiction medicine: closing the gap between science and practice. New York, NY: National Center on Addiction and Substance Abuse; 2012. Available from: www.centeronaddiction.org/addiction-research/reports/addiction-medicine-closing-gap-between-science-and-practice. Accessed 2014 Mar 29. [Google Scholar] 32. Schomerus G, Holzinger A, Matschinger H, Lucht M, Angermeyer MC. Public attitudes towards alcohol dependence [article in German] Psychiatr Prax. 2010;37(3):111–8. Epub 2010 Feb 10. [PubMed] [Google Scholar] 33. Midner D, Kahan M, Wilson L, Borsoi D. Medical faculty members’ perspectives on substance use disorders: a survey and focus group study. Ann R Coll Physicians Surg Can. 2002;35(8 Suppl 1):1–6. [Google Scholar] 34. Miller NS, Sheppard LM, Colenda CC, Magen J. Why physicians are unprepared to treat patients who have alcohol-and drug-related disorders. Acad Med. 2001;76(5):410–8. [PubMed] [Google Scholar] 35. Harris AH, Ellerbe L, Reeder RN, Bowe T, Gordon AJ, Hagedorn H, et al. Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers. Psychol Serv. 2013;10(4):410–9. Epub 2013 Jan 28. [PubMed] [Google Scholar] 36. CASAColumbia . Missed opportunity: national survey of primary care physicians and patients on substance abuse. New York, NY: National Center on Addiction and Substance Abuse; 2000. [Google Scholar] 37. Oliva EM, Maisel NC, Gordon AJ, Harris AH. Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Curr Psychiatry Rep. 2011;13(5):374–81. [PMC free article] [PubMed] [Google Scholar] 38. Knudsen HK, Roman PM, Oser CB. Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations. J Addict Med. 2010;4(2):99–107. [PMC free article] [PubMed] [Google Scholar] 39. El-Guebaly N. A Canadian perspective on addiction treatment. Subst Abus. 2014;35(3):298–303. [PubMed] [Google Scholar] 40. Pascoe RV, Rush B, Rotondi NK. Wait times for publicly funded addiction and problem gambling treatment agencies in Ontario, Canada. BMC Health Serv Res. 2013;13:483. [PMC free article] [PubMed] [Google Scholar] 41. Ducharme LJ, Knudsen HK, Roman PM. Trends in the adoption of medications for alcohol dependence. J Clin Psychopharmacol. 2006;26(Suppl 1):S13–9. [PubMed] [Google Scholar] 42. Weber EM. Failure of physicians to prescribe pharmacotherapies for addiction: regulatory restrictions and physician resistance. J Health Care Law Policy. 2010;13(1):49–76. [Google Scholar] 43. Horgan CM, Reif S, Hodgkin D, Garnick DW, Merrick EL. Availability of addiction medications in private health plans. J Subst Abuse Treat. 2008;34(2):147–56. Epub 2007 May 17. [PMC free article] [PubMed] [Google Scholar] 44. Ontario Ministry of Health and Long-Term Care . Ontario public drug programs. Exceptional Access Program. Toronto, ON: Ministry of Health and Long-Term Care; Available from: www.health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx. Accessed 2015 Nov 17. [Google Scholar] 45. Suggs LS, Raina P, Gafni A, Grant S, Skilton K, Fan A, et al. Family physician attitudes about prescribing using a drug formulary. BMC Fam Pract. 2009;10:69. [PMC free article] [PubMed] [Google Scholar] 46. Hoffman KA, Ford JH, Tillotson CJ, Choi D, McCarty D. Days to treatment and early retention among patients in treatment for alcohol and drug disorders. Addict Behav. 2011;36(6):643–7. Epub 2011 Jan 28. [PMC free article] [PubMed] [Google Scholar] 47. Capoccia VA, Cotter F, Gustafson DH, Cassidy EF, Ford JH, 2nd, Madden L, et al. Making “stone soup”: improvements in clinic access and retention in addiction treatment. Jt Comm J Qual Patient Saf. 2007;33(2):95–103. [PubMed] [Google Scholar] 48. Williams EC, Kivlahan DR, Saitz R, Merrill JO, Achtmeyer CE, McCormick KA, et al. Readiness to change in primary care patients who screened positive for alcohol misuse. Ann Fam Med. 2006;4(3):213–20. [PMC free article] [PubMed] [Google Scholar] 49. Molfenter T. Reducing appointment no-shows: going from theory to practice. Subst Use Misuse. 2013;48(9):743–9. Epub 2013 Apr 22. [PMC free article] [PubMed] [Google Scholar] 50. Hearne R, Connolly A, Sheehan J. Alcohol abuse: prevalence and detection in a general hospital. J R Soc Med. 2002;95(2):84–7. [PMC free article] [PubMed] [Google Scholar] 51. Mitchell AJ, Meader N, Bird V, Rizzo M. Clinical recognition and recording of alcohol disorders by clinicians in primary and secondary care: meta-analysis. Br J Psychiatry. 2012;201(2):93–100. [PubMed] [Google Scholar] Page 2Prevalence of prescriptions for AUD medications following an AUD hospital visit among ODB-eligible adult patients, overall and by sex: This output was limited to those aged < 65 y, as there were very few patients aged ≥ 65 y.
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