Reviewing First-Line Pharmacotherapies for Alcohol Use Disorder

A systematic review and meta-analysis published in JAMA Network found that oral naltrexone and acamprosate are effective first-line pharmacotherapies for individuals with alcohol use disorder (AUD), leading to improved alcohol consumption-related outcomes compared with placebo. 

“This systematic review and meta-analysis evaluated efficacy and comparative efficacy of 9 therapies for alcohol use disorder that are either approved by the US Food and Drug Administration (FDA) or more commonly used in the United States for alcohol use disorder,” stated researchers.  

The methods of the study were registered with PROSPERO and a detailed technical report was provided. Multiple databases were searched for relevant studies from November 2012 to September 2022, with additional searches conducted afterwards. Eligible studies included adults with AUD who were treated with FDA-approved or off-label medications for at least 12 weeks in an outpatient setting. Two investigators independently reviewed and selected studies for inclusion. Data extraction, risk-of-bias assessment, and strength of evidence evaluation were conducted, and data synthesis and analysis were performed using appropriate statistical methods. 

The database search found 2860 citations, with 2543 being excluded during title and abstract review. Of the 317 full-text articles included after review, 267 were excluded, leaving 156 articles describing results of 118 randomized clinical trials (RCTs). Among these RCTs, 81 were included in a 2014 systematic review on the topic, while 37 were new.  

The medications acamprosate and naltrexone were found to significantly improve alcohol consumption outcomes in individuals with AUD. Acamprosate when compared with placebo needed to treat 11 people to prevent 1 person from relapse, while naltrexone needed to treat 18 for the same outcome. Acamprosate did not show a significant difference in return to heavy drinking compared to placebo, but oral naltrexone did. Injectable naltrexone had no significant effect on relapse. Medications without FDA indication for AUD treatment, such as topiramate and baclofen, also showed improvements in drinking habits. However, there was insufficient evidence to determine if these medications led to better health outcomes. 

“In conjunction with psychosocial interventions, these findings support the use of oral naltrexone, 50 mg/d, and acamprosate as first-line pharmacotherapies for alcohol use disorder,” said researchers.  

Reference  

McPheeters M, O’Connor EA, Riley S, et al. Pharmacotherapy for alcohol use disorder: A systematic review and meta-analysis. JAMA. 2023;330(17):1653–1665. doi:10.1001/jama.2023.19761