Updated Systematic Review Examines Pharmacotherapy for Adults With Alcohol Use Disorder in Outpatient Settings

New research examines evidence-based practice to improve clinical decision making for patients with alcohol use disorder.

An updated systematic review published today in The Journal of the American Medical Association (JAMA) and funded and carried out by the Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ) builds on a 2014 AHRQ report on medications for Alcohol Use Disorder (AUD) treatment. The new review recommends that decisions about medication-assisted treatment for AUD, including the use of drugs such as naltrexone, should be made collaboratively between the patient and their clinician with considerations for desired outcomes, tolerance of side effects, contraindications, and the potential to adhere to the medication regimen.

“Unhealthy alcohol use is the third leading preventable cause of death in the United States, accounting for more than 140,000 deaths annually. Despite this high rate of incidence, only 0.9 percent of Americans who reported having AUD in the past year indicated they received medication-assisted AUD treatment,” said AHRQ Director Robert Otto Valdez, Ph.D., M.H.S.A. “AHRQ’s updated systematic review examines how pharmacotherapy for patients with AUD can have a significant impact on curbing preventable death, family and social consequences, and help individuals on a pathway to achieve recovery.”

Since the 2014 report, the literature on pharmacotherapy for patients with AUD has grown substantially, and this updated systematic review examines new evidence that may improve estimates of the benefits and harms of medications for AUD, thus optimizing clinical decision making. AHRQ expects that this updated systematic review exploring pharmacotherapy for adults with AUD will be helpful to health plans, care providers, purchasers, government programs, and local healthcare systems.

AHRQ followed the Agency’s established process for assessing strength of evidence, detailed in the Methods Guide for Effectiveness and Comparative Effectiveness Reviews (available at https://effectivehealthcare.ahrq.gov/topics/cer-methods-guide/overview). This approach is based on using grades of high, moderate, low, and insufficient to describe how confident researchers are in estimating the effects of interventions to treat diseases and conditions.

Key findings include:

• Evidence for the use of oral naltrexone at the 50 mg dose compared with placebo had moderate strength of evidence across multiple outcomes, as well as the relative ease of use as a once-daily oral medication. Numbers needed to treat were calculated for medications with at least moderate strength of evidence for benefit. Numbers needed to treat offers a measurement of the impact of a medicine or therapy by estimating the number of patients that need to be treated in order to have an impact on one person. The number needed to treat for oral naltrexone at the 50 mg dose compared with placebo to prevent one person from returning to any drinking was 18 and the number needed to treat for preventing one person from returning to heavy drinking was 11.
• The 2014 report found uncertain benefit for injectable naltrexone, but the addition of a new randomized, placebo-controlled trial conducted in a population experiencing homelessness resulted in positive outcomes for reducing drinking and heavy drinking days. Adding to the body of evidence from the prior report resulted in low strength of evidence.
• Acamprosate and topiramate have evidence for benefit with moderate strength of evidence. Treatment decisions could be affected by ease of use (e.g., the need to take multiple pills over a day), the side effect profile, and the potential for contraindications. The number needed to treat for preventing one person from returning to any drinking for acamprosate was 11.
• Since the last report, the addition of 11 new studies of baclofen has demonstrated low strength of evidence for reducing the return to any drinking, and studies of gabapentin showed low strength of evidence for reducing the return to any drinking and return to heavy drinking.
• No new eligible studies were found for disulfiram. Relatively limited evidence from well-controlled trials does not adequately support the efficacy of disulfiram compared with placebo for preventing a return to drinking or other alcohol consumption outcomes.
• Because there are too few studies, very little evidence exists to evaluate the effectiveness of medication treatment for AUD among specific populations or in primary care settings.

AHRQ, through its Evidence-based Practice Centers (EPCs), sponsors the development of systematic reviews to assist public- and private-sector organizations in improving healthcare quality in the United States. These reviews provide comprehensive, science-based information on common, costly medical conditions and new healthcare technologies and strategies.

Systematic reviews are the building blocks underlying evidence-based practice; they focus on the strengths and limits of evidence from research studies about the effectiveness and safety of a clinical intervention. In the context of developing practice recommendations, systematic reviews can help clarify whether assertions about the value of the intervention are based on solid evidence from clinical studies.

For more information about AHRQ EPC systematic reviews and this report, please visit the website: https://www.effectivehealthcare.ahrq.gov.

AHRQ Office of Communications
Press Contact: media@ahrq.hhs.gov