EVIDENCE-BASED ANSWER
Naltrexone (ReVia) and nalmefene (Revex) are the most effective agents for treating alcoholism. Acamprosate is effective but not available in the United States. Serotonergic agents, selective serotonin reuptake inhibitors (SSRIs), and lithium work best in patients with alcoholism and comorbid depression, anxiety, or bipolar disorder. Disulfiram (Antabuse) decreases drink frequency, but is no better than placebo for other outcomes. Greater effectiveness is achieved when pharmacologic agents are combined with either counseling or Alcoholics Anonymous programs. (Grade of recommendation: B, based on multiple randomized controlled studies with short and incomplete follow-up of patients.)
Evidence summary
Naltrexone (50 mg qd), nalmefene (10–80 mg qd), and acamprosate (dose based on patient weight) are all superior to placebo and other agents such as the SSRIs, disulfiram, and serotonergic agents in reducing relapse rates and the phenomena of craving and in increasing abstinence rates.1-6 For example, naltrexone reduces relapse rates by one half to two thirds.4,6 However, these outcomes apply only to patients who completed the study protocol; noncompleters accounted for up to more than 50% of study participants. When compared with placebo, nalmefene taken for 3 to 24 months significantly reduced relapse without affecting abstinence rates or cravings.3 When compared with placebo, disulfiram failed to significantly increase abstinence rates or decrease relapse rates or cravings.2
In European studies, acamprosate taken for 3 to 24 months significantly increased abstinence rates, but did not significantly decrease relapse or cravings as compared with placebo.3 Fifteen studies evaluating serotonergic agents, lithium, and SSRIs (including citalopram, viqualine, fluoxetine, and others) taken for 2 to 12 weeks have shown promise for increasing abstinence rates and decreasing cravings in alcoholic patients with coexisting psychiatric conditions such as depression, anxiety, and bipolar disorder.2,7,8 Studies combining pharmacologic intervention with Alcoholics Anonymous’s 12-step program or psychological interventions showed the most significant effects on decreasing cravings and relapse rates and increasing abstinence rates.2,3,6,9-12
TABLE
Grade of recommendation based on the evidence
| Agent | Decreased cravings at 6 & 12 months | Increased abstinence rates 6 & 12 months | Decreased relapse rates at 6 & 12 months | Comorbidities: alcoholism with anxiety, depression, or bipolar disorder |
|---|---|---|---|---|
| Naltrexone | B | B | B | D |
| Nalmefene | C | C | B | D |
| Serotonergics | D | D | D | B |
| SSRIs | D | D | D | B |
| Disulfiram | C | C | C | D |
| Lithium | D | D | D | B |
| Acamprosate | B | B | C | D |
| Based on the Oxford Center for Evidence-based Medicine Levels of Evidence (May 2001). | ||||
Recommendations from others
According to the American Society of Addiction Medicine, patients who comply with a combination of medication, education, and counseling have favorable short-term and long-term benefits.1 Naltraxone and acamprosate effectively reduce cravings and increase abstinence.
Clinical Commentary by William Chavey, MD, at http://www.fpin.org.