Progress Not Perfection: Promising Medications for Alcohol Reduction & Relapse Prevention

Cessation

By Lauren DeSouza- Master of Public Health, Simon Fraser Public Research University – Canada
https://cshmke.com/our-team/

Staff Research and Content Writer

A recent systematic review and meta-analysis identified the most effective medications for the long-term treatment of Alcohol Use Disorder (AUD).

AUD is a medical condition characterized by an inability to control or stop alcohol use despite negative social, work, or health consequences. Commonly known as alcohol abuse, alcohol dependence, alcohol addiction, or alcoholism, AUD affects a significant portion of the population. In the past year, 10.5% of Americans aged 12 and older had AUD, and 30% have been diagnosed with AUD at some point in their lives.

Despite its prevalence, only 7% of individuals with AUD receive treatment. AUD is a chronic, relapsing condition that is challenging to overcome. Most individuals with AUD require extended treatment periods and multiple attempts to achieve long-term abstinence. Given these challenges, some practitioners recognize alcohol reduction as a realistic and beneficial goal. Complete abstinence may be unrealistic for many patients and can demotivate them from addressing their alcohol use. Alcohol reduction can reduce alcohol-related harm and is often more attainable.

However, the efficacy of AUD medications in aiding alcohol reduction is not well understood. This new study aimed to identify medications that help patients reduce their alcohol consumption This new study aimed to identify medications that help patients reduce their alcohol consumption long-term and prevent relapse.

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What is the standard treatment for AUD?

The best treatment for AUD combines psychotherapy and pharmacotherapy. Common psychotherapies include motivational interviewing (MI) and Cognitive Behavioral Therapy (CBT). The U.S. Food and Drug Administration has approved three medications to help individuals stop or reduce drinking and prevent relapse: naltrexone (oral and long-acting injectable), acamprosate, and disulfiram. Although not FDA-approved for AUD, topiramate is used by some doctors to treat the condition. Typical pharmacotherapy for AUD lasts 3-6 months, but longer durations may be necessary depending on the patient’s progress.

Most studies on pharmacotherapy for AUD lack long-term follow-up, leaving the long-term efficacy of these medications unclear.

What did this study do?

The purpose of this study was to evaluate the safety and efficacy of pharmacotherapies for AUD over extended treatment durations, defined as 24 weeks or longer. The study was a systematic review and network meta-analysis, analyzing 55 studies to understand the long-term effectiveness of these medications in helping AUD patients reduce alcohol use.

The researchers focused on studies comparing AUD pharmacotherapies with placebos, particularly looking at reductions in heavy drinking days (HDD) and total alcohol consumption (TAC) in both the short and long term. They also assessed adverse events associated with these medications over longer treatment periods.

What are the results of this study?

Included Studies

The literature on long-term treatment for AUD is limited. Only 10 of the 55 studies included long-term follow-up outcomes. Most longer-term studies were on nalmefene, with few or no long-term studies for other pharmacotherapies. This limited the authors’ ability to assess the long-term efficacy and safety of all available pharmacotherapies.

Best Overall Pharmacotherapies for Long-Term Alcohol Reduction

Among the pharmacotherapies reviewed, only nalmefene was effective in reducing HDD and TAC in the long term (after 24 weeks). However, nalmefene was not effective in the short term and did not increase the number of abstinent days compared to placebo. The study emphasized the need for longer follow-up periods to effectively judge the efficacy and safety of nalmefene and other AUD pharmacotherapies.

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Other Promising Pharmacotherapies

In the short term, baclofen reduced TAC and topiramate reduced both HDD and the number of drinking days. However, there were no long-term studies for either drug, preventing conclusions about their long-term safety and efficacy.

Adverse Events

Common adverse events for these pharmacotherapies include nausea, dizziness, tiredness, decreased appetite, and trouble sleeping. Only nalmefene had enough long-term follow-up studies to comprehensively evaluate its safety. These studies revealed higher adverse events compared to placebo, although these events were typically mild and short-lived. Short-term studies of topiramate indicated some adverse events that led patients to discontinue use before they experienced benefits.

What are the recommendations?

The authors recommend nalmefene, topiramate, and baclofen for alcohol reduction in AUD patients, noting that nalmefene and topiramate have higher adverse event rates compared to placebo. Clinicians should use a patient-centered approach, weighing the benefits and harms for each patient when recommending pharmacotherapy. Pharmacotherapy should be combined with psychotherapy, such as MI and CBT. Additionally, the authors call for more long-term studies on the safety and efficacy of topiramate and baclofen.

Key Findings

AUD is a chronic, relapsing condition, making full abstinence difficult to achieve.
Alcohol reduction is a realistic and beneficial goal for many patients with AUD.
Limited information exists about pharmacotherapies that help reduce alcohol consumption and prevent relapse.
Nalmefene, topiramate, and baclofen show promise for alcohol reduction, but more long-term studies are needed to evaluate their safety and efficacy

Reference

Kotake K, Hosokawa T, Tanaka M, So R, Banno M, Kataoka Y, et al. Efficacy and safety of alcohol reduction pharmacotherapy according to treatment duration in patients with alcohol dependence or alcohol use disorder: A systematic review and network meta-analysis. Addiction. 2024; 119(5): 815–832. https://doi.org/10.1111/add.16421

National Institute on Alcohol Abuse and Alcoholism. Alcohol’s Effects on Health: Understanding Alcohol Use Disorder. Published January 2024. Accessed from https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-alcohol-use-disorder

National Institute on Alcohol Abuse and Alcoholism. Alcohol’s Effects on Health: Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics. Updated 2023. Accessed from https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics