alcoholism

Pharmacotherapy for Adults With Alcohol Use Disorder in Outpatient Settings: Systematic Review
Background. Unhealthy alcohol use is the third leading preventable cause of death in the United States, accounting for more than 140,000 deaths annually. Only 0.9 percent of Americans who reported having alcohol use disorder (AUD) in the past year indicated they received medication-assisted AUD treatment.

Methods. We updated a 2014 Agency for Healthcare Research and Quality (AHRQ) report on pharmacotherapy for AUD treatment, following AHRQ Evidence-based Practice Center Guidance. We assessed efficacy and comparative effectiveness of specific medications for improving consumption outcomes (Key Question [KQ] 1) and health outcomes (KQ 2). We assessed harms (KQ 3) and sought to identify evidence for the use of pharmacotherapy to treat AUD in primary care (KQ 4) and among subgroups (KQ 5). When possible, we conducted quantitative analyses using random-effects models to estimate pooled effects. When quantitative analyses could not be conducted, we used qualitative approaches.

Results. We included 118 studies (156 articles) in our review, which included 81 studies (106 articles) from the 2014 review and 37 studies (50 articles) published since then. Studies generally included counseling co-interventions in all study groups, and the benefits observed reflect the added benefit of medications beyond those of counseling and placebo. Oral naltrexone at the 50 mg dosage had moderate strength of evidence (SOE) for reducing return to any drinking, return to heavy drinking, percent drinking days, and percent heavy drinking days. The addition of a new randomized controlled trial of injectable naltrexone conducted in a population experiencing homelessness resulted in positive outcomes for a reduction in drinking days and heavy drinking days with low SOE. Acamprosate had moderate SOE for a significant reduction in return to any drinking and reduction in drinking days. Topiramate had moderate SOE for several outcomes as well, but with greater side effects. Two other medications demonstrated low SOE for benefit in at least one consumption outcome—baclofen (reduced return to any drinking) and gabapentin (reduced return to drinking and to heavy drinking). With no new studies on disulfiram, there remains inadequate evidence for efficacy compared to placebo for preventing return to any drinking or for other alcohol consumption outcomes. No new eligible studies provided head-to-head comparisons.

Conclusions. Oral naltrexone at the 50 mg dose had moderate strength of evidence across multiple outcomes and relative ease of use as a once-daily oral medication. Acamprosate and topiramate also have moderate evidence of benefit with a less desirable side effect profile (topiramate) and a higher pill burden (acamprosate). Clinicians and patients may want to consider which treatment outcomes are most important when choosing among the medications. Current data are largely insufficient for understanding health outcomes. Finally, there is relatively little research to assess the use of medications for AUD among subgroups (9 studies) or in primary care settings (1 study).

This article is part of a Festschrift commemorating the 50th anniversary of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Established in 1970, first as part of the National Institute of Mental Health and later as an independent institute of the National Institutes of Health, NIAAA today is the world's largest funding agency for alcohol research. In addition to its own intramural research program, NIAAA supports the entire spectrum of innovative basic, translational, and clinical research to advance the diagnosis, prevention, and treatment of alcohol use disorder and alcohol-related problems. To celebrate the anniversary, NIAAA hosted a 2-day symposium, "Alcohol Across the Lifespan: 50 Years of Evidence-Based Diagnosis, Prevention, and Treatment Research," devoted to key topics within the field of alcohol research. This article is based on Dr. Mason's presentation at the event. NIAAA Director George F. Koob, Ph.D., serves as editor of the Festschrift.

OBJECTIVE:

Project TrEAT (Trial for Early Alcohol Treatment) was designed to test the efficacy of brief physician advice in reducing alcohol use and health care utilization in problem drinkers.

DESIGN:

Randomized controlled clinical trial with 12-month follow-up.

SETTING:

A total of 17 community-based primary care practices (64 physicians) located in 10 Wisconsin counties.

PARTICIPANTS:

Of the 17695 patients screened for problem drinking, 482 men and 292 women met inclusion criteria and were randomized into a control (n=382) or an experimental (n=392) group. A total of 723 subjects (93%) participated in the 12-month follow-up procedures.

INTERVENTION:

The intervention consisted of two 10- to 15-minute counseling visits delivered by physicians using a scripted workbook that included advice, education, and contracting information.

MAIN OUTCOME MEASURES:

Alcohol use measures, emergency department visits, and hospital days.

RESULTS:

There were no significant differences between groups at baseline on alcohol use, age, socioeconomic status, smoking status, rates of depression or anxiety, frequency of conduct disorders, lifetime drug use, or health care utilization. At the time of the 12-month follow-up, there were significant reductions in 7-day alcohol use (mean number of drinks in previous 7 days decreased from 19.1 at baseline to 11.5 at 12 months for the experimental group vs 18.9 at baseline to 15.5 at 12 months for controls; t=4.33; P<.001), episodes of binge drinking (mean number of binge drinking episodes during previous 30 days decreased from 5.7 at baseline to 3.1 at 12 months for the experimental group vs 5.3 at baseline to 4.2 at 12 months for controls; t=2.81; P<.001), and frequency of excessive drinking (percentage drinking excessively in previous 7 days decreased from 47.5% at baseline to 17.8% at 12 months for the experimental group vs 48.1% at baseline to 32.5% at 12 months for controls; t=4.53; P<.001). The chi2 test of independence revealed a significant relationship between group status and length of hospitalization over the study period for men (P<.01).

CONCLUSIONS:

This study provides the first direct evidence that physician intervention with problem drinkers decreases alcohol use and health resource utilization in the US health care system.

OBJECTIVES:

To review the literature on the screening, brief intervention, and referral to treatment (SBIRT) approach to alcohol and drug use with racial and ethnic subgroups in the United States and to develop recommendations for culturally competent SBIRT practice.

METHODS:

Articles reporting on the use of SBIRT components (screening, brief intervention, referral to treatment) for alcohol and drug use were identified through a comprehensive literature search of PubMed from 1995 to 2015.

RESULTS:

A synthesis of the published literature on racial and ethnic considerations regarding SBIRT components (including motivational interviewing techniques) was created using evidence-based findings. Recommendations on culturally competent use of SBIRT with specific ethnic groups are also described.

CONCLUSIONS:

On the basis of the literature reviewed, SBIRT offers a useful set of tools to help reduce risky or problematic substance use. Special attention to validated screeners, appropriate use of language/literacy, trust building, and incorporation of patient and community health care preferences may enhance SBIRT acceptability and effectiveness.

PRACTICE IMPLICATIONS:

Providers should consider the implications of previous research when adapting SBIRT for diverse populations, and use validated screening and brief intervention methods. The accompanying case illustration provides additional information relevant to clinical practice.