Pharmacologically Controlled Drinking in the Treatment of Alcohol Use Disorder: More Evidence Is Needed

This systematic review and meta-analysis summarized the evidence for 5 medications used to reduce alcohol use in non-abstinent adults with alcohol use disorder. The authors identified 32 randomized trials (published 1994–2015) with a total of 6036 patients. The primary outcome was total alcohol consumption, which was reported in 7 of the 9 nalmefene studies examined, 5 of the 14 naltrexone studies, 2 of the 4 topiramate studies, 1 of the 4 baclofen studies, and the 1 acamprosate study (all were compared with placebo).

• Twenty-six studies were deemed to have unclear or high risk of having incomplete outcome data and 17 to be at risk of selective outcome reporting.
• When total alcohol consumption was reported, nalmefene, baclofen, and topiramate showed superiority over placebo. No efficacy was observed for naltrexone and acamprosate.
• Data on heavy drinking days were more complete and the same results were observed, except for baclofen (not superior to placebo).
• No difference was found for any of the medications regarding mortality and serious adverse events.
• In indirect comparisons, topiramate was superior to nalmefene, naltrexone, and acamprosate.
• For all treatments except topiramate, effect sizes were small or inconsistent.

Comments: There is currently no high-quality evidence supporting pharmacological treatment to control drinking in patients with alcohol use disorder. The risks of incomplete outcome data or selective outcome reporting were identified by this report. In addition, no study demonstrated a benefit on health outcomes. More evidence is needed on this topic.

Nicolas Bertholet, MD, MSc

Reference: Palpacuer C, Duprez R, Huneau A, et al. Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network metaanalyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate. Addiction. 2018;113(2):220–237.