Oral Naltrexone and Acamprosate Reduce Alcohol Consumption

By Thomas Schwenk, MD

Four medications have clinical value in treating patients with alcohol-use disorders, according to a systematic review in JAMA.

Researchers examined over 120 studies of medications used for alcohol-use disorders. Some 23,000 patients were enrolled, most after detoxification or a period of sobriety.

Acamprosate (a glutamine antagonist and γ-aminobutyric acid agonist) and oral naltrexone (an opioid antagonist) were about equally effective in preventing resumption of any drinking (number needed to treat, 12–20). Naltrexone was also effective in reducing heavy drinking, but acamprosate was not. Disulfiram (an acetaldehyde dehydrogenase inhibitor) did not reduce alcohol consumption.

Two off-label medications — nalmefene (an opioid antagonist) and topiramate (an anticonvulsant) — were associated with improvements in heavy drinking. There was insufficient evidence for other off-label drugs, including SSRIs, tricyclic antidepressants, atypical antipsychotics, and gabapentin.

Primary care clinicians should realize that, because effective medications exist to supplement psychosocial interventions, they can engage patients more assertively in shared decision-making, take primary responsibility for managing mild-to-moderate alcohol-use disorder, and coordinate effective referrals for complex patients.

Dr. Schwenk is deputy editor of NEJM Journal Watch General Medicine, from which this story was adapted.