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Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.

Publication ,  Journal Article
Jonas, DE; Amick, HR; Feltner, C; Bobashev, G; Thomas, K; Wines, R; Kim, MM; Shanahan, E; Gass, CE; Rowe, CJ; Garbutt, JC
Published in: JAMA
May 14, 2014

IMPORTANCE: Alcohol use disorders cause substantial morbidity and early mortality yet remain greatly undertreated. Medications are considerably underused. OBJECTIVE: To conduct a systematic review and meta-analysis of the benefits and harms of medications (US FDA-approved and others) for adults with alcohol use disorders. DATA SOURCES: PubMed, Cochrane Library, PsycINFO, CINAHL, EMBASE, FDA website, and clinical trials registries (January 1, 1970, to March 1, 2014). STUDY SELECTION: Two reviewers selected randomized clinical trials (RCTs) with at least 12 weeks' duration that reported eligible outcomes and head-to-head prospective cohort studies reporting health outcomes or harms. DATA EXTRACTION AND SYNTHESIS: We conducted meta-analyses using random-effects models and calculated numbers needed to treat for benefit (NNTs) or harm (NNHs). MAIN OUTCOMES AND MEASURES: Alcohol consumption, motor vehicle crashes, injuries, quality of life, function, mortality, and harms. RESULTS: We included 122 RCTs and 1 cohort study (total 22,803 participants). Most assessed acamprosate (27 studies, n = 7519), naltrexone (53 studies, n = 9140), or both. The NNT to prevent return to any drinking for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD], -0.09; 95% CI, -0.14 to -0.04) and was 20 (95% CI, 11 to 500; RD, -0.05; 95% CI, -0.10 to -0.002) for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12 (95% CI, 8 to 26; RD -0.09; 95% CI, -0.13 to -0.04) for oral naltrexone (50 mg/d). Meta-analyses of trials comparing acamprosate to naltrexone found no statistically significant difference between them for return to any drinking (RD, 0.02; 95% CI, -0.03 to 0.08) or heavy drinking (RD, 0.01; 95% CI, -0.05 to 0.06). For injectable naltrexone, meta-analyses found no association with return to any drinking (RD, -0.04; 95% CI, -0.10 to 0.03) or heavy drinking (RD, -0.01; 95% CI, -0.14 to 0.13) but found an association with reduction in heavy drinking days (weighted mean difference [WMD], -4.6%; 95% CI, -8.5% to -0.56%). Among medications used off-label, moderate evidence supports an association with improvement in some consumption outcomes for nalmefene (heavy drinking days per month: WMD, -2.0; 95% CI, -3.0 to -1.0; drinks per drinking day: WMD, -1.02; 95% CI, -1.77 to -0.28) and topiramate (% heavy drinking days: WMD, -9.0%; 95% CI, -15.3% to -2.7%; drinks per drinking day: WMD, -1.0; 95% CI, -1.6 to -0.48). For naltrexone and nalmefene, NNHs for withdrawal from trials due to adverse events were 48 (95% CI, 30 to 112) and 12 (95% CI, 7 to 50), respectively; risk was not significantly increased for acamprosate or topiramate. CONCLUSIONS AND RELEVANCE: Both acamprosate and oral naltrexone were associated with reduction in return to drinking. When directly compared with one another, no significant differences were found between acamprosate and naltrexone for controlling alcohol consumption. Factors such as dosing frequency, potential adverse events, and availability of treatments may guide medication choice.

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Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

May 14, 2014

Volume

311

Issue

18

Start / End Page

1889 / 1900

Location

United States

Related Subject Headings

  • Topiramate
  • Taurine
  • Randomized Controlled Trials as Topic
  • Outpatients
  • Naltrexone
  • Humans
  • Harm Reduction
  • General & Internal Medicine
  • Fructose
  • Alcohol-Related Disorders
 

Citation

APA
Chicago
ICMJE
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Jonas, D. E., Amick, H. R., Feltner, C., Bobashev, G., Thomas, K., Wines, R., … Garbutt, J. C. (2014). Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA, 311(18), 1889–1900. https://doi.org/10.1001/jama.2014.3628
Jonas, Daniel E., Halle R. Amick, Cynthia Feltner, Georgiy Bobashev, Kathleen Thomas, Roberta Wines, Mimi M. Kim, et al. “Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.JAMA 311, no. 18 (May 14, 2014): 1889–1900. https://doi.org/10.1001/jama.2014.3628.
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 May 14;311(18):1889–900.
Jonas, Daniel E., et al. “Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis.JAMA, vol. 311, no. 18, May 2014, pp. 1889–900. Pubmed, doi:10.1001/jama.2014.3628.
Jonas DE, Amick HR, Feltner C, Bobashev G, Thomas K, Wines R, Kim MM, Shanahan E, Gass CE, Rowe CJ, Garbutt JC. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014 May 14;311(18):1889–1900.
Journal cover image

Published In

JAMA

DOI

EISSN

1538-3598

Publication Date

May 14, 2014

Volume

311

Issue

18

Start / End Page

1889 / 1900

Location

United States

Related Subject Headings

  • Topiramate
  • Taurine
  • Randomized Controlled Trials as Topic
  • Outpatients
  • Naltrexone
  • Humans
  • Harm Reduction
  • General & Internal Medicine
  • Fructose
  • Alcohol-Related Disorders