Tuesday, May 13, 2014

Many Patients with Alcohol Use Disorders Not Offered Medications

An exhaustive and brand new meta-analysis and systematic review, published today in the Journal of the American Medical Association, paints a disappointing picture of medication access for those with alcohol use disorders (AUD) in the US. The authors included 123 studies, involving nearly 23,000 participants, and determined that while acamprosate and naltrexone have been shown to be effective treatments, fewer than 10% of those who might benefit are ever prescribed an AUD medication.

Here's the Abstract, via JAMA:

IMPORTANCE Alcohol use disorders cause substantial morbidity and early mortality yet
remain greatly undertreated. Medications are considerably underused.

OBJECTIVE To conduct a systematic review and meta-analysis of the benefits and harms of
medications (US FDA-approved and others) for adults with alcohol use disorders.

DATA SOURCES PubMed, Cochrane Library, PsycINFO, CINAHL, EMBASE, FDA website, and
clinical trials registries (January 1, 1970, to March 1, 2014).

STUDY SELECTION Two reviewers selected randomized clinical trials (RCTs) with at least 12
weeks’ duration that reported eligible outcomes and head-to-head prospective cohort
studies reporting health outcomes or harms.

DATA EXTRACTION AND SYNTHESIS We conducted meta-analyses using random-effects
models and calculated numbers needed to treat for benefit (NNTs) or harm (NNHs).

MAIN OUTCOMES AND MEASURES Alcohol consumption, motor vehicle crashes, injuries,
quality of life, function, mortality, and harms.

RESULTS We included 122 RCTs and 1 cohort study (total 22 803 participants). Most assessed
acamprosate (27 studies, n = 7519), naltrexone (53 studies, n = 9140), or both. The NNT to
prevent return to any drinking for acamprosate was 12 (95% CI, 8 to 26; risk difference [RD],
−0.09; 95% CI, −0.14 to −0.04) and was 20 (95% CI, 11 to 500; RD, −0.05; 95% CI, −0.10 to
−0.002) for oral naltrexone (50 mg/d). The NNT to prevent return to heavy drinking was 12
(95% CI, 8 to 26; RD −0.09; 95% CI, −0.13 to −0.04) for oral naltrexone (50 mg/d).
Meta-analyses of trials comparing acamprosate to naltrexone found no statistically significant
difference between them for return to any drinking (RD, 0.02; 95% CI, −0.03 to 0.08) or
heavy drinking (RD, 0.01; 95% CI, −0.05 to 0.06). For injectable naltrexone, meta-analyses
found no association with return to any drinking (RD, −0.04; 95% CI, −0.10 to 0.03) or heavy
drinking (RD, −0.01; 95% CI, −0.14 to 0.13) but found an association with reduction in heavy
drinking days (weighted mean difference [WMD], −4.6%; 95% CI, −8.5% to −0.56%). Among
medications used off-label, moderate evidence supports an association with improvement in
some consumption outcomes for nalmefene (heavy drinking days per month: WMD, −2.0;
95% CI, −3.0 to −1.0; drinks per drinking day: WMD, −1.02; 95% CI, −1.77 to −0.28) and
topiramate (% heavy drinking days: WMD, −9.0%; 95% CI, −15.3% to −2.7%; drinks per
drinking day: WMD, −1.0; 95% CI, −1.6 to −0.48). For naltrexone and nalmefene, NNHs for
withdrawal from trials due to adverse events were 48 (95% CI, 30 to 112) and 12 (95% CI, 7 to
50), respectively; risk was not significantly increased for acamprosate or topiramate.

CONCLUSIONS AND RELEVANCE Both acamprosate and oral naltrexone were associated with
reduction in return to drinking. When directly compared with one another, no significant
differences were found between acamprosate and naltrexone for controlling alcohol
consumption. Factors such as dosing frequency, potential adverse events, and availability of
treatments may guide medication choice.

Would love to know what readers think about the results of this large study. What are the main drivers of this gap, and why aren't more patients requesting these medications? What needs to be done to improve access?

No comments:

Post a Comment