1. Oral acamprosate and naltrexone, together with psychosocial interventions, were linked with an improvement in return to any drinking. Naltrexone was linked to reductions in return to heavy drinking.
2. No significant association were found with the health outcomes and adverse effects for either of the drugs.
Evidence Rating Level: 2 (Good)
Study Rundown: Alcohol use disorders (AUDs) are infrequently treated with medications. This is an area of high concern because of the significant morbidity and mortality associated with AUDs. This study found that both acamprosate and oral naltrexone, combined with psychosocial interventions, are effective for reducing consumption outcomes: both drugs are associated with abstinence but only naltrexone was linked to improvement in return to heavy drinking. None of these two or other drugs tested, which included disulfiram and several other off-label medications, showed any significant association with improvement in health outcomes (motor vehicle accidents, injuries, quality of life, function and mortality). Although the U.S. Preventive Services Task Force (USPSTF) recommends primary care screening of alcohol misuse, the study found very little evidence to back this recommendation upon analysis of studies in primary care settings. This systematic review and meta-analysis has significant limitations. The concomitant psychosocial interventions used were not defined or taken into consideration for analysis. No comparisons were made between pharmacological interventions and psychosocial outcomes alone. Moreover, randomized control trials (RCTs) analyzed for acamprosate and naltrexone showed a preponderance of European trials and US-based trials, respectively, with differences in patient recruitment based on location.
In-Depth [systematic review and meta-analysis]: This study included 123 articles that looked at pharmacotherapy combined with psychosocial interventions in outpatient settings for patients with verifiable AUDs. This study found no significant difference between acamprosate and naltrexone in consumption outcomes. For return to heavy drinking, only oral naltrexone (50 mg/d) was associated with improvement with an NNT of 12 (95% CI; 8 to 26; 19 trials; n = 2875). Insufficient evidence for association of injectable naltrexone and disulfiram with improvement in any of the alcohol consumption outcomes was noted. In addition, there was insufficient evidence for improvement in any of the health outcomes including motor vehicle accidents, injuries, quality of life, function and mortality. Finally, post hoc subgroup analysis by risk of bias for acamprosate versus placebo showed a decreasing effect size from high risk of bias (RD, – 0.13, 95% CI, – 0.2 to – 0.06) to low risk (RD, – 0.02, 95% CI, – 0.09 0.05) for improvement in returning to any drinking.
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