McPheeters M, O'Connor EA, Riley S, et al. Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis. JAMA. 2023 Nov 7;330(17):1653-1665. doi: 10.1001/jama.2023.19761. (Systematic review)

IMPORTANCE: Alcohol use disorder affects more than 28.3 million people in the United States and is associated with increased rates of morbidity and mortality.

OBJECTIVE: To compare efficacy and comparative efficacy of therapies for alcohol use disorder.

DATA SOURCES: PubMed, the Cochrane Library, the Cochrane Central Trials Registry, PsycINFO, CINAHL, and EMBASE were searched from November 2012 to September 9, 2022 Literature was subsequently systematically monitored to identify relevant articles up to August 14, 2023, and the PubMed search was updated on August 14, 2023.

STUDY SELECTION: For efficacy outcomes, randomized clinical trials of at least 12 weeks' duration were included. For adverse effects, randomized clinical trials and prospective cohort studies that compared drug therapies and reported health outcomes or harms were included.

DATA EXTRACTION AND SYNTHESIS: Two reviewers evaluated each study, assessed risk of bias, and graded strength of evidence. Meta-analyses used random-effects models. Numbers needed to treat were calculated for medications with at least moderate strength of evidence for benefit.

MAIN OUTCOMES AND MEASURES: The primary outcome was alcohol consumption. Secondary outcomes were motor vehicle crashes, injuries, quality of life, function, mortality, and harms.

RESULTS: Data from 118 clinical trials and 20?976 participants were included. The numbers needed to treat to prevent 1 person from returning to any drinking were 11 (95% CI, 1-32) for acamprosate and 18 (95% CI, 4-32) for oral naltrexone at a dose of 50 mg/d. Compared with placebo, oral naltrexone (50 mg/d) was associated with lower rates of return to heavy drinking, with a number needed to treat of 11 (95% CI, 5-41). Injectable naltrexone was associated with fewer drinking days over the 30-day treatment period (weighted mean difference, -4.99 days; 95% CI, -9.49 to -0.49 days) Adverse effects included higher gastrointestinal distress for acamprosate (diarrhea: risk ratio, 1.58; 95% CI, 1.27-1.97) and naltrexone (nausea: risk ratio, 1.73; 95% CI, 1.51-1.98; vomiting: risk ratio, 1.53; 95% CI, 1.23-1.91) compared with placebo.

CONCLUSIONS AND RELEVANCE: In conjunction with psychosocial interventions, these findings support the use of oral naltrexone at 50 mg/d and acamprosate as first-line pharmacotherapies for alcohol use disorder.

Discipline Area Score
FM/GP/Mental Health 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
Psychiatry 5 / 7
Comments from MORE raters

FM/GP/Mental Health rater

This is a helpful review of what seems to be relevant studies of outpatient medications used for treating alcohol use disorder. It affirms the benefit of naltrexone and acamprosate as first-line therapies, and should encourage providers to use these medications. I’m not sure that the final conclusion, ”along with psychosocial interventions…” can be supported by this review, as they didn’t actually look at psychosocial interventions. I worry that some prescribers may take this to mean they should not offer medications if psychosocial interventions are not available. This study supports prescribing regardless of other factors.
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