Consider these medications to help patients stay sober
Naltrexone can help prevent relapse in recently detoxified patients with alcohol use disorder. The evidence for acamprosate is not quite as strong.
WHAT'S NEW: Consider prescribing naltrexone to prevent relapse
While previous studies suggested that pharmacotherapy could help patients with AUD remain abstinent, this methodologically rigorous meta-analysis compared the efficacy of several commonly used medications and found clear evidence favoring oral naltrexone. Prescribe oral naltrexone 50 mg/d to help patients with moderate to severe AUD avoid returning to any drinking or heavy drinking after alcohol detoxification. Acamprosate may also decrease return to drinking, although the evidence is not as strong (the studies with low bias showed no effect).
CAVEATS: Medication should be used with psychosocial treatments
Pharmacotherapy for AUD should be reserved for patients who want to quit drinking and used in conjunction with psychosocial intervention.3 Only one of the studies analyzed by Jonas et al1 was conducted in primary care. That said, many of the psychosocial interventions—such as regular follow-up visits to encourage adherence and monitor for adverse effects, in conjunction with attendance at Alcoholics Anonymous meetings—could be done in primary care settings.
Comorbidities may limit therapy options. Naltrexone is contraindicated in acute hepatitis and liver failure, and in combination with opioids.5 Acamprosate is contraindicated in renal disease.5
CHALLENGES TO IMPLEMENTATION: Cost, adherence may be factors for some patients
Perhaps the greatest hurdle in pharmacotherapy for AUD in primary care is a lack of familiarity with these medications. For physicians who are comfortable with prescribing these medications, implementation may be hindered by a lack of available psychosocial resources for successful abstinence.
Additionally, the medications are expensive. The branded version of naltrexone 50 mg costs approximately $118 for a 30-day supply,6 and the branded version of acamprosate costs approximately $284 for a 30-day supply.7
As is the case with any chronic medical condition, medication adherence is a challenge. Naltrexone is taken once daily, while acamprosate is taken 3 times a day. The risk of relapse is high until 6 to 12 months of sobriety and then wanes over several years.5 The NIAAA recommends treatment for a minimum of 3 months.5
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
