Alcohol use disorder (AUD) is one of the most prevalent substance use disorders in the US. Effective medications for AUD (MAUD) have been available for over 40 years; however, less than 1 percent of individuals with AUD receive them. A recent systematic review of studies lasting ≥12 weeks described the effects on alcohol consumption of FDA-approved MAUD (i.e., acamprosate, disulfiram, and naltrexone), and those that are prescribed off-label for AUD (i.e., baclofen, gabapentin, varenicline, topiramate, prazosin, and ondansetron).

• Of the 118 clinical trials that were included, 100 combined MAUD and non-medication treatments (e.g., counseling).
• There was moderate strength of evidence for the use of acamprosate and oral naltrexone (50mg/day) for reducing return to any drinking and percentage of drinking days (numbers needed to treat [NNT] to prevent one person from returning to any drinking = 11 for acamprosate and 18 for oral naltrexone).
• Oral naltrexone (50mg/day) had moderate strength of evidence for reduction of return to heavy drinking (NNT = 11, compared with placebo).
• Studies involving disulfiram were limited. Studies of baclofen and gabapentin had low strength of evidence. Topiramate had moderate strength of evidence for reduction in drinking days, but had more adverse effects.
• Health outcomes like motor vehicle crashes, injuries, quality of life, function, and mortality were infrequently reported.
• Overall adverse effects were low across studies.

Comments: In this systematic review and meta-analysis, the evidence was strongest for the benefit of naltrexone and acamprosate, which appear to have approximately equal efficacy for treating AUD. The well-established benefits of MAUD suggest that, in the absence of clinical contraindications, all patients who have AUD should be offered one of these two medications. Given the prevalence of AUD in the US and worldwide, inclusive studies exploring all treatment options in all populations—including minoritized and older populations, and individuals with comorbidities such as liver disease—are greatly needed.

(Source: Boston Medical Centre)

Key Points

Question: Which pharmacotherapies are associated with improved outcomes for people with alcohol use disorder?

Findings: In this systematic review and meta-analysis that included 118 clinical trials and 20 976 participants, 50 mg/d of oral naltrexone and acamprosate were each associated with significantly improved alcohol consumption-related outcomes compared with placebo.

Meaning:  These findings support oral naltrexone at 50 mg/d and acamprosate as first-line therapies for alcohol use disorder.

Abstract

Objective: To compare efficacy and comparative efficacy of therapies for alcohol use disorder.

Study Selection: For 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.

Main Outcomes and Measures: The primary outcome was alcohol consumption. Secondary outcomes were motor vehicle crashes, injuries, quality of life, function, mortality, and harms.

Conclusions and Relevance:  In 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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Oral naltrexone has been shown to reduce alcohol consumption and craving in individuals with alcohol use disorder (AUD), yet evidence regarding the efficacy of the extended-release injectable formulation (XR-naltrexone) is limited. Researchers conducted a systematic review and meta-analysis of 7 randomized controlled trials evaluating 1500 adults with AUD receiving XR-naltrexone (150–400 mg) for 2–6 months or placebo, plus some form of behavioral therapy. The primary outcome was the pooled weighted mean difference

Comments: With a modest reduction in drinking days and heavy drinking days per month compared with psychosocial interventions and placebo alone, the results of this meta-analysis suggest that XR-naltrexone may have some efficacy for AUD treatment, especially with longer treatment duration. Further research is needed to determine the long-term efficacy of XR-naltrexone, its effects among an actively drinking population, and how it compares (e.g., efficacy and cost) with oral naltrexone.

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#overdoseawareness #DemandReduction #preventdontpromote

For More See Overdose Day - Does Nomenclature Matter?  and Naloxone  and Naltrexone

Amphetamines are the second-most commonly used drug in the world and their use is rising in the US. There are currently no FDA-approved medications for treating methamphetamine use disorder (MUD). This multisite randomized controlled trial evaluated the efficacy and safety of extended-release naltrexone (380mg every 3 weeks) plus oral extended-release bupropion (450mg daily), compared with placebo for 6 weeks. The primary outcome was treatment response, defined as at least 3 out of 4 methamphetamine-negative urine drug tests over the last 2 weeks of the study.

• The study enrolled 403 patients with moderate or severe MUD.
• 15% of eligible patients were randomized; 69% of the participants were men.
• Overall, 13.6% of patients in the intervention group had a treatment response, compared with 2.5% in the placebo group; this translates to a number needed to treat of 9.
• The most common adverse effects were gastrointestinal disorders, tremor, malaise, hyperhidrosis, and anorexia.

Comments: Medications that are accessible and effective are urgently needed to treat MUD. Behavioral treatments like cognitive behavioral therapy and contingency management show favorable benefit, although their access remains very limited. This trial demonstrates a possible new treatment for MUD; however, limiting factors may be cost of the treatments and patient preference, both of which were not assessed.

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