Anti-craving medications can play an effective role in overcoming moderate to severe alcohol use disorder and can be prescribed by primary care physicians, write researchers from the University of Ottawa and the University of British Columbia in the Canadian Medical Association Journal.
In the short article, the researchers outline five things doctors need to know about anti-craving medication.
Anti-craving medication for moderate to severe alcohol use disorder
Jon Mong, Keith Ahamad and Paxton Bach
Affiliations: Division of General Internal Medicine, University of Ottawa, and the Departments of Family Practice and Medicine, University of British Columbia; and St Paul’s Hospital in Vancouver.
Published in the Canadian Medical Association Journal on10 May 2021.
1- Anti-craving medications help patients to reduce their alcohol consumption by controlling cravings
Alcohol use disorder is characterised by compulsive use, lack of control and harmful consequences of alcohol. Men who have had more than five standard drinks and women who have had more than four standard drinks on one occasion within the past year should be assessed for alcohol use disorder.
Anti-craving medications can play an effective role in overcoming moderate to severe alcohol use disorder and can be prescribed by primary care physicians.
2- Psychosocial interventions should be offered in addition to evidence-based pharmacotherapy
Effective psychosocial interventions for alcohol use disorder can be accessed through professionals or peer support groups. Standardised interventions include motivational interviewing and cognitive-behavioural therapy.
3- First-line pharmacotherapy includes naltrexone and acamprosate
Naltrexone can be initiated any time at a dose of 25 mg/d and titrated to 50 mg/d (number needed to treat [NNT] of 12 to reduce heavy drinking; NNT of 20 for abstinence in combination with psychosocial interventions).
Adverse effects include transient dizziness and nausea (number needed to harm [NNH] of 16 and 9, respectively). Acamprosate can be started at 333 mg 3 times per day (TID) after 3 days of abstinence, then titrated to 666 mg TID (NNT of 12 for abstinence in combination with psychosocial interventions). Adverse effects include transient anxiety and diarrhea (NNH of 7 and 11, respectively).
Naltrexone is contra-indicated in patients with severe hepatic dysfunction and concomitant opioid use (including opioid agonist therapy). Acamprosate is contraindicated in those with severe renal dysfunction.
4- Second-line agents include topiramate and gabapentin
Topiramate is less well studied but may be non-inferior to naltrexone. It is started at 25 mg/d and titrated by 25 mg weekly to a dose of 100–300 mg/d, but has significant adverse effects, including paresthesias (NNH of 4) and a perception of cognitive “fogging” (NNH of 12).
Gabapentin at doses of 300–600 mg TID has been shown to help with harm reduction, reducing the proportion of heavy drinking days, although adverse effects include fatigue and dizziness (NNH of 10).
5- Anti-craving therapies are not a treatment for acute alcohol withdrawal
Benzodiazepines and thiamine remain the cornerstone of treatment for complicated withdrawal. Anti-craving therapies help patients reduce alcohol use but have no role in treating acute withdrawal.
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