Pharmacotherapy For Alcohol Use Disorder Research Articles

Alcohol Use Disorder: Current and Emerging Therapies

Alcohol use disorder (AUD) is a medical condition characterized by problematic and unhealthy patterns of alcohol use ranging from frequent to heavy alcohol consumption. It is a well-recognized psychiatric syndrome that includes a broad spectrum of symptoms and behaviors associated with alcohol misuse. People with AUD don’t stop drinking alcohol despite emotional distress, social, occupational, or health problems. Pharmacological management of AUD depends on the patient’s condition to reduce the symptoms and improve the patient’s health. The US FDA approved three medications, namely naltrexone, acamprosate, and disulfiram for the treatment of AUD. Apart from these medications, psychological therapy, cognitive behavioral therapy, and encouraging patient participation in support groups have been showing promising results. The present review briefly discusses the epidemiology, symptoms, stages, diagnosis, screening, and emerging psychosocial therapies and pharmacotherapy of AUD including approved and off-label uses of drugs and newer agents. Keywords: Alcohol use disorder, Acamprosate, Baclofen, Disulfiram, Gabapentin, Naltrexone, Nalmefene

Probenecid as a pharmacotherapy for alcohol use disorder: Arandomized placebo-controlled alcohol interaction trial.

This study shows the first evidence for pannexin 1 channels as a new target to develop medications for alcohol use disorder (AUD). Due to its history of long-term safe clinical use and preclinical evidence of reducing excessive alcohol intake in rodents, probenecid has clinical potential for AUD. We conducted a Phase I/IIa randomized, double-blind, placebo-controlled, crossover trial investigating the safety, tolerability, and efficacy of an oral dose of probenecid (2 g) when administered with alcohol (0.08 g/dL) in individuals who regularly consume alcohol to the 0.08 g/dL level (N = 35) and in individuals with mild to severe AUD. Alcohol pharmacokinetics and subjective responses were evaluated to assess potential interactions between probenecid and alcohol. Alcohol craving, inflammatory biomarkers, cognitive assessments, and hemodynamics were assessed as additional alcohol research domains. All outcomes were assessed both in the ascending and descending limb of alcohol intoxication using Generalized Estimating Equation. Probenecid did not exert any significant effect on alcohol pharmacokinetics and did not affect alcohol stimulation or sedation. Probenecid, compared to placebo, significantly decreased alcohol craving during the alcohol ascending limb. Inflammatory biomarkers, cognitive performance following alcohol ingestion, and hemodynamics were likewise not affected by probenecid administration. Analysis of sex as a biological variable revealed no differences of probenecid compared to placebo. Taken together, our data support the potential of probenecid for treatment of AUD and suggest that pannexin 1 channels represent a novel emerging therapeutic target for the development of new pharmacotherapies for treating AUD.

Understanding Indian Doctors’ Attitudes Toward Alcohol Pharmacotherapy and Prescription: A Mediational Analysis

Background: Alcohol use disorder (AUD) causes significant morbidity and mortality. Prescription of AUD pharmacotherapies remains low. Attitudes toward AUD pharmacotherapies influence their prescription rates. We conducted an online survey to assess how attitudes modulate the association between knowledge and prescription rates for four commonly used AUD medications among Indian clinicians. Methods: An online survey was sent nationwide to Indian physicians between February and April 2023 to assess knowledge, attitudes, and practices of various AUD medications. An a priori model was defined to indicate the relationship between study variables. Bootstrapped correlation analysis was conducted to determine confidence intervals of the correlation coefficients between knowledge, attitudes, and prescription practices. Additional subgroup analysis was conducted for faculty and private psychiatrists to assess if they prescribed differently. Results: A total of 387 physicians responded to the survey. Bootstrapped correlation analysis indicated that safety and acceptability played a moderated prescription rates for acamprosate and naltrexone while they mediating role among faculty. For Disulfiram, perceived efficacy had a mediating effect, especially among private psychiatrists. Among faculty, perceived safety negatively mediated Disulfiram prescriptions. There was no indirect effect of attitudes on the association between knowledge and prescription practices for Baclofen. Conclusion: The role of attitudes varied across medications. For acamprosate and naltrexone, perceived safety and acceptability significantly moderated prescription rates. For Disulfiram, perceived efficacy played a significant mediating effect. Attitudes did not influence Baclofen prescriptions as a whole, but acceptability significantly mediated prescriptions for private psychiatrists. This might indicate that physicians prescribe Baclofen as an ineluctable option.

The effects of N-acetyl cysteine on intrinsic functional connectivity and neural alcohol cue reactivity in treatment-seeking individuals with alcohol use disorder: a preliminary study.

N-acetyl cysteine (NAC) is a potential pharmacotherapy for alcohol use disorder (AUD), but it is not known whether it modulates neural activation to alcohol cues or intrinsic functional connectivity. We investigated whether NAC attenuates (i) alcohol cue-elicited activation, and (ii) intrinsic functional connectivity compared to placebo in patients with AUD. In this preliminary study, twenty-three individuals (7 females) with moderate-severe AUD received daily NAC (2400mg/day, n = 9), or a placebo (n = 14) for at least 2 weeks. Participants completed a pre-treatment functional magnetic resonance imaging session (T0) and a post-treatment session (T1) comprising resting-state and visual alcohol cue reactivity task acquisitions. Activation differences between sessions, treatment, and session-by-treatment interaction were assessed. Resting-state functional connectivity examined using 377 node ROI-to-ROIs evaluated whether NAC reduced intrinsic functional connectivity after treatment. There were no differences in alcohol cue reactivity for brain activation or subjective craving between NAC and placebo during treatment or across sessions, or significant interaction. A significant treatment-by-time interaction, with reduced intrinsic connectivity was observed after treatment (T1) for NAC-treated compared to placebo-treated patients in the posterior cingulate node (9, left hemisphere) of the dorsal attentional network and connections to salience, ventral-attentional, somatosensory, and visual-peripheral networks implicated in AUD. NAC reduced intrinsic functional connectivity in patients with moderate-severe AUD after treatment compared to placebo, but did not attenuate alcohol cue-elicited activation. However, the absence of cue reactivity findings may result from low power, rather than the absence of cue reactivity findings associated with NAC. These results provide preliminary evidence that NAC treatment may modulate intrinsic functional connectivity brain activation in patients with alcohol use disorder, but replication in larger studies are required to determine the strength of this effect and any associations with clinical outcomes. Clinical Trials Registration: ClinicalTrials.gov Identifier: NCT03879759.

Endpointsfor Pharmacotherapy Trials for AlcoholUse Disorder.

Alcoholuse disorder (AUD) is a debilitating disorder, yet currently approved pharmacotherapies to treat AUD are under-utilized. The three medications approved by the US Food and Drug Administration (FDA) for the indication of AUD are disulfiram, acamprosate, and naltrexone. The current landscape of pharmacotherapies for AUD suggests opportunities for improvement. Clinical trials investigating novel pharmacotherapies for AUD traditionally use abstinence-based drinking outcomes or no heavy drinking days as trial endpoints to determine the efficacy of pharmacotherapies. These outcomes are typically measured through patient self-report endorsements of their drinking. Apart from these traditional outcomes, there have been recent developments in novel endpoints for AUD pharmacotherapies. These novel endpoints include utilizing the World Health Organization (WHO) riskdrinking level reductions to promote a harm-reduction endpoint rather than an abstinence-based endpoint. Additionally, in contrast to patient self-report measurements, biological markers of alcohol use may serve as objective endpoints in AUD pharmacotherapy trials. Lastly, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from AUD and patient-oriented outcomes offer new frameworks to consider endpoints associated with more than alcohol consumption itself, such as the provider-patient experiences with novel pharmacotherapies. These recent developments in new endpoints for AUD pharmacotherapies offer promising future opportunities for pharmacotherapy development, so long as validity and reliability measures are demonstrated for the endpoints. A greater breadth of endpoint utilization may better capture the complexity of AUD symptomatology.

Racial and ethnic disparities in receipt of specialty treatment across risk profiles of adults with heavy alcohol use.

Variation in specialty treatment utilization for alcohol use disorder (AUD) by patient subgroups is poorly understood. This study examined whether and how patient risk profiles predict receipt of specialty treatment and whether there are disparities by race and ethnicity. This cohort study included 206,956 adults with heavy alcohol use (that which exceeded National Instituteon Alcohol Abuse and Alcoholism guidelines) between June 1, 2013 and December 31, 2014, using electronic health record data from Kaiser Permanente Northern California. Five risk profiles (characterized by daily or weekly heavy drinking and level of health risks) were identified in latent class analysis. Logistic regression models were fit to examine associations between risk profiles, race, ethnicity, and receipt of specialty treatment (including addiction medicine, psychiatry, or integrated behavioral health visits, and AUD pharmacotherapy), adjusting for other patient characteristics. Variation in the association between risk profiles and receipt of specialty treatment by race/ethnicity was also examined. Overall, 4.0% of patients received specialty treatment. Latino/Hispanic and Asian/Pacific Islander patients had lower odds of receiving specialty treatment than White patients (adjusted odds ratio [aOR] [95% CI] = 0.80 [0.75, 0.85], and 0.64 [0.59, 0.70], respectively). The substance use disorder and mental health disorder (SUD/MH) risk profile had the highest odds of receiving specialty treatment (10.46 [9.65, 11.34]). Associations between risk profiles and receipt of specialty treatment significantly differed by race/ethnicity. Black patients in the SUD/MH risk profile, and Hispanic/Latino patients in the risk profile with heavy daily drinking and more health risks, had lower odds of receiving specialty treatment than their White counterparts (adjusted ratio of odds ratios [aROR] [95% CI] = 0.69 [0.50, 0.94], and 0.79 [0.67, 0.92], respectively). This study provides new insights into racial/ethnic disparities in specialty treatment utilization for alcohol problems. Findings may help inform strategies for tailoring interventions to address heavy alcohol use.

Sleep as an Important Target or Modifier in Alcohol Use Disorder Clinical Treatment: Example From a Recent Gabapentin Randomized Clinical Trial.

Alcohol consumption affects sleep both in healthy populations and in patients with alcohol use disorder (AUD). However, sleep has typically not been considered within AUD pharmacotherapy trials. We used data from a completed gabapentin clinical treatment trial to explore the medication's effect on patient-rated insomnia measured by a standard insomnia rating (Insomnia Severity Index [ISI]) and whether this influenced gabapentin's effects on alcohol consumption. This study included 90 individuals with current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition AUD criteria reporting current or past alcohol withdrawal. Participants were assigned to placebo or gabapentin (up to 1200 mg/day) for a 16-week randomized controlled trial with percent heavy drinking days (PHDD) and percent abstinent days (PDA) as outcomes. Utilizing mixed-effects models, this study assessed medication effects on ISI over the trial. We then examined the interaction of baseline ISI and medication on drinking. Finally, given our previous finding of alcohol withdrawal influencing gabapentin efficacy, we added change in ISI as a potential "moderator" of the interaction of medication effects and alcohol withdrawal on drinking. Sleep (ISI) improved more in those treated with gabapentin (60.6% reduction) compared with placebo (37.8% reduction; P = 0.013). Higher baseline ISI predicted drinking in gabapentin-treated individuals (lower PHDD [ P = 0.026] and higher (PDA [ P = 0.047]). ISI was an independent predictor of PHDD decrease and PDA increase ( P < 0.001; P = 0.002), but this did not significantly moderate gabapentin's effectiveness. Although gabapentin positively impacts both alcohol use and sleep, its effect on drinking is not fully dependent on sleep improvement, implying a direct biological mechanism on alcohol use.

Pharmacotherapy for alcohol use disorder among adults with medical disorders in Sweden

BackgroundAlcohol-attributable medical disorders are prevalent among individuals with alcohol use disorder (AUD). However, there is a lack of research on prescriptions of pharmacological treatment for AUD in those with comorbid conditions. This study aims to investigate the utilization of pharmacological treatment (acamprosate, disulfiram and naltrexone) in specialist care among patients with AUD and comorbid medical diagnoses.MethodsThis was a descriptive register-based Swedish national cohort study including 132,728 adults diagnosed with AUD (N = 270,933) between 2007 and 2015. The exposure was alcohol-attributable categories of comorbid medical diagnoses. Odds ratios (OR) were calculated using mixed-effect logistic regression analyses for any filled prescription of acamprosate, disulfiram or oral naltrexone within 12 months post AUD diagnosis.ResultsIndividuals with comorbid alcohol-attributable medical diagnoses had lower odds of filling prescriptions for any type of AUD pharmacotherapy compared to those without such comorbidities. Cardiovascular (OR = 0.41 [95% CI: 0.39–0.43]), neurological (OR = 0.52 [95% CI: 0.48–0.56]) and gastrointestinal (OR = 0.57 [95% CI: 0.54–0.60]) diseases were associated with the lowest rates of prescription receipt. The presence of diagnoses which are contraindications to AUD pharmacotherapy did not fully explain the low prescription rate.ConclusionThere is a substantial underutilization of AUD pharmacotherapy in patients with AUD and comorbid medical disorders in specialist care. Increasing the provision of pharmacotherapy to this group of patients is essential and may prevent morbidity and mortality. There is a need to further understand barriers to medical treatment both from the patient and prescriber perspective.

Topiramate Versus Naltrexone for Alcohol Use Disorder: A Genotype-Stratified Double-Blind Randomized Controlled Trial.

There have been no well-controlled and well-powered comparative trials of topiramate with other pharmacotherapies for alcohol use disorder (AUD), such as naltrexone. Moreover, the literature is mixed on the effects of two polymorphisms-rs2832407 (in GRIK1) and rs1799971 (in OPRM1)-on response to topiramate and naltrexone, respectively. The authors sought to examine the comparative effectiveness of topiramate and naltrexone in improving outcomes in AUD and to examine the role of the rs2832407 and rs1799971 polymorphisms, respectively, on response to these medications. In a 12-week, double-blind, placebo-controlled, randomized, multisite, genotype-stratified (rs2832407 and rs1799971) clinical trial comparing topiramate and naltrexone in treating AUD, 147 patients with AUD were randomly assigned to treatment with topiramate or naltrexone, stratified by genotype (rs2832407*CC and *AC/AA genotypes and rs1799971*AA and *AG/GG genotypes). The predefined primary outcome was number of heavy drinking days per week. Predefined secondary outcomes included standard drinks per drinking day per week, body mass index (BMI), craving, markers of liver injury, mood, and adverse events. For the number of heavy drinking days per week, there was a near-significant time-by-treatment interaction. For the number of standard drinks per drinking day per week, there was a significant time-by-treatment interaction, which favored topiramate. There were significant time-by-treatment effects, with greater reductions observed with topiramate than naltrexone for BMI, craving, and gamma-glutamyltransferase level. Withdrawal due to side effects occurred in 8% and 5% of the topiramate and naltrexone groups, respectively. Neither polymorphism showed an effect on treatment response. Topiramate is at least as effective and safe as the first-line medication, naltrexone, in reducing heavy alcohol consumption, and superior in reducing some clinical outcomes. Neither rs2832407 nor rs1799971 had effects on topiramate and naltrexone treatments, respectively.

Leveraging meta-regression to test if medication effects on cue-induced craving are associated with clinical efficacy.

The alcohol cue exposure paradigm is a common method for evaluating new treatments for alcohol use disorder (AUD); however, it is unclear if medication-related reductions in cue-induced craving in the human laboratory can predict the clinical success of those medications in reducing alcohol consumption during clinical trials. To use a novel meta-analytic approach to test whether medication effect sizes on cue-induced alcohol craving are associated with clinical efficacy in clinical trials. We searched the literature for medications tested for AUD treatment using both the alcohol cue-reactivity paradigm and randomized clinical trials (RCTs). For alcohol cue-reactivity studies, we computed medication effect sizes for cue-induced alcohol craving (k = 36 studies, 15 medications). For RCTs, we calculated medication effect sizes for heavy drinking and abstinence (k = 139 studies, 19 medications). Using medication as the unit of analysis, we applied the Williamson-York bivariate weighted least squares estimation to account for errors in both independent and dependent variables. We also conducted leave-one-out cross validation simulations to examine the predictive utility of cue-craving medication effect sizes on RCT heavy drinking and abstinence endpoints. There was no significant relationship between medication effects on cue-induced alcohol craving in the human laboratory and medication effects on heavy drinking ( = 0.253, SE = 0.189,p = 0.090) and abstinence ( = 0.829, SE = 0.747,p = 0.133) in RCTs. The preliminary results of the current study challenge the assumption that alcohol cue-reactivity alone can be used as an early efficacy indicator for AUD pharmacotherapy development. These findings suggest that a wider range of early efficacy indicators and experimental paradigms be considered for Phase II testing of novel compounds.

Molecular mechanisms involved in alcohol craving, IRF3, and endoplasmic reticulum stress: a multi-omics study

Alcohol use disorder (AUD) is the most prevalent substance use disorder worldwide. Acamprosate and naltrexone are anti-craving drugs used in AUD pharmacotherapy. However, molecular mechanisms underlying their anti-craving effect remain unclear. This study utilized a patient-derived induced pluripotent stem cell (iPSC)-based model system and anti-craving drugs that are used to treat AUD as “molecular probes” to identify possible mechanisms associated with alcohol craving. We examined the pathophysiology of craving and anti-craving drugs by performing functional genomics studies using iPSC-derived astrocytes and next-generation sequencing. Specifically, RNA sequencing performed using peripheral blood mononuclear cells from AUD patients with extreme values for alcohol craving intensity prior to treatment showed that inflammation-related pathways were highly associated with alcohol cravings. We then performed a genome-wide assessment of chromatin accessibility and gene expression profiles of induced iPSC-derived astrocytes in response to ethanol or anti-craving drugs. Those experiments identified drug-dependent epigenomic signatures, with IRF3 as the most significantly enriched motif in chromatin accessible regions. Furthermore, the activation of IRF3 was associated with ethanol-induced endoplasmic reticulum (ER) stress which could be attenuated by anti-craving drugs, suggesting that ER stress attenuation might be a target for anti-craving agents. In conclusion, we found that craving intensity was associated with alcohol consumption and treatment outcomes. Our functional genomic studies suggest possible relationships among craving, ER stress, IRF3 and the actions of anti-craving drugs.

Seasonal Variations in Treatment Seeking for Alcohol Use Disorder in the Total Danish Population.

A minority of all individuals with alcohol use disorder (AUD) seek treatment. Contextual factors associated with treatment seeking are poorly understood. It is known that the level of alcohol consumed varies between seasons of the year. However, it is not known to what extent treatment seeking for AUD also varies between seasons. This study aims to investigate seasonal variations in treatment seeking for AUD. The study design was a time-series analysis. The study population consisted of adults age 18 years and older in Denmark seeking AUD treatment. The outcomes were the following two measures of changes in treatment seeking: (a) treatment entry and (b) filled prescription of AUD pharmacotherapy. Data came from the National Alcohol Treatment Register on treatment entries for specialist addiction care and National Prescription Registry for filled prescriptions on AUD pharmacotherapies from 2013 to 2018. Analysis was a segmented negative binomial regression. Treatment seeking for AUD showed clear seasonal variations, with the lowest numbers in December and from March to April. In January, treatment seeking was highest, with a decline around July and a subsequent slight rise from August to October. The findings emphasize the importance of contextual factors when developing and evaluating interventions to increase treatment seeking for AUD.

Quadruple pharmacotherapy for alcohol use disorder tolerable yet insufficient: a case report

BackgroundCombinations of alcohol use disorder (AUD) medications have been investigated, but few if any reports describe patients maintained on more than two options at the same time.Case presentationWe report a case of a middle-aged man hospitalized with gastrointestinal bleeding and acute kidney injury who had been maintained on four AUD medications (naltrexone, acamprosate, disulfiram, and gabapentin) and multiple psychiatric medications simultaneously as an outpatient. Direct quotations of his experiences with each AUD medication are included, revealing some deviations from what was prescribed as well as nuanced perceptions of effects. Overall, he tolerated the regimen well, but its AUD effects were insufficient to prevent several episodes of returning to alcohol use. He had very high hospital utilization. This prompted the initiation of an involuntary commitment, which began a period of at least six months of sobriety.ConclusionsQuadruple pharmacotherapy for AUD may be well tolerated and supportive of recovery for an extended period of time. However, for our patient the regimen ultimately failed to prevent multiple episodes of returning to alcohol use and serious medical complications. In refractory cases like this, more intensive interventions such as involuntary commitment can be considered.

A Survey of Medication Diffusion and Attitudes Among Indian Clinicians Toward Pharmacotherapies for Alcohol Use Disorder.

Alcohol use disorder (AUD) is a significant cause of morbidity and mortality globally. However, uptake of AUD pharmacotherapies among clinicians has remained low. There exists a research gap regarding clinician attitudes and the diffusion of AUD pharmacotherapies among Indian clinicians. We conducted a survey to assess the same. An online survey was sent to clinicians nationwide from February and April 2023 to assess attitudes and practices regarding various AUD medications. Logistic and ordinal regression models evaluate the clinician and caseload factors determining medication diffusion and attitudes. A total of 387 clinicians responded to our survey. Most of them were males (61.7%) and trained psychiatrists (56.3%). The diffusion for acamprosate, naltrexone, and disulfiram was 69.8%, 81.4%, and 58.2%, respectively. Baclofen had the highest diffusion. Female respondents had significantly lower perceived efficacy, acceptability, and safety for disulfiram. Independent practitioners were more likely to prescribe all pharmacotherapies except baclofen. Diffusion for alcohol pharmacotherapies was incomplete. Baclofen had the highest diffusion, probably reflecting its cost and safety profile. Despite its perceived efficacy, safety concerns impacted the diffusion of disulfiram. Female clinicians had lower perceived attitudes toward disulfiram. Specific training for AUD pharmacotherapies is warranted for female clinicians and nonpsychiatrists.

Gut-Liver-Brain Axis and Alcohol Use Disorder: Treatment Potential of Fecal Microbiota Transplantation.

Chronic alcohol use is a major cause of liver damage and death. In the United States, multiple factors have led to low utilization of pharmacotherapy for alcohol use disorder (AUD), including lack of provider knowledge and comfort in prescribing medications for AUD. Alcohol consumption has direct effects on the gut microbiota, altering the diversity of bacteria and leading to bacterial overgrowth. Growing evidence suggests that alcohol's effects on the gut microbiome may contribute to increased alcohol consumption and progression of alcohol-associated liver disease (ALD). This article reviews human and preclinical studies investigating the role of fecal microbiota transplantation (FMT) in ameliorating alcohol-associated alterations to the liver, gut, and brain resulting in altered behavior; it also discusses the therapeutic potential of FMT. For this narrative review, a literature search was conducted in September 2022 of PubMed, Web of Science Core Collection, and Google Scholar to identify studies published between January 2012 and September 2022. Search terms used included "fecal microbiota transplantation" and "alcohol." Most results of the literature search were review articles or articles on nonalcoholic fatty liver disease; these were excluded. Of the remaining empirical manuscripts, very few described clinical or preclinical studies that were directly investigating the effects of FMT on alcohol drinking or related behaviors. Ultimately, 16 studies were included in the review. The literature search identified only a few studies that were directly investigating the effect of FMT on ALD or alcohol drinking and related behaviors. Largely proof-of-concept studies, these findings demonstrate that alcohol can alter the gut microbiome and that the microbiome can be transferred between humans and rodents to alter affective behaviors frequently associated with increased alcohol use. Other studies have shown promise of FMT or other probiotic supplementation in alleviating some of the symptoms associated with ALD and drinking. These results show that the implementation of FMT as a therapeutic approach is still in the investigatory stages.

Alcohol and the dopamine system.

The mesolimbic dopamine pathway plays a major role in drug reinforcement and is likely involved also in the development of drug addiction. Ethanol, like most addictive drugs, acutely activates the mesolimbic dopamine system and releases dopamine, and ethanol-associated stimuli also appear to trigger dopamine release. In addition, chronic exposure to ethanol reduces the baseline function of the mesolimbic dopamine system. The molecular mechanisms underlying ethanol´s interaction with this system remain, however, to be unveiled. Here research on the actions of ethanol in the mesolimbic dopamine system, focusing on the involvement of cystein-loop ligand-gated ion channels, opiate receptors, gastric peptides and acetaldehyde is briefly reviewed. In summary, a great complexity as regards ethanol´s mechanism(s) of action along the mesolimbic dopamine system has been revealed. Consequently, several new targets and possibilities for pharmacotherapies for alcohol use disorder have emerged.

Pharmacotherapy for Alcohol Use Disorder

Alcohol use disorder affects more than 28.3 million people in the United States and is associated with increased rates of morbidity and mortality. To compare efficacy and comparative efficacy of therapies for alcohol use disorder. PubMed, the Cochrane Library, the Cochrane Central Trials Registry, PsycINFO, CINAHL, and EMBASE were searched from November 2012 to September 9, 2022 Literature was subsequently systematically monitored to identify relevant articles up to August 14, 2023, and the PubMed search was updated on August 14, 2023. For efficacy outcomes, randomized clinical trials of at least 12 weeks' duration were included. For adverse effects, randomized clinical trials and prospective cohort studies that compared drug therapies and reported health outcomes or harms were included. Two reviewers evaluated each study, assessed risk of bias, and graded strength of evidence. Meta-analyses used random-effects models. Numbers needed to treat were calculated for medications with at least moderate strength of evidence for benefit. The primary outcome was alcohol consumption. Secondary outcomes were motor vehicle crashes, injuries, quality of life, function, mortality, and harms. Data from 118 clinical trials and 20 976 participants were included. The numbers needed to treat to prevent 1 person from returning to any drinking were 11 (95% CI, 1-32) for acamprosate and 18 (95% CI, 4-32) for oral naltrexone at a dose of 50 mg/d. Compared with placebo, oral naltrexone (50 mg/d) was associated with lower rates of return to heavy drinking, with a number needed to treat of 11 (95% CI, 5-41). Injectable naltrexone was associated with fewer drinking days over the 30-day treatment period (weighted mean difference, -4.99 days; 95% CI, -9.49 to -0.49 days) Adverse effects included higher gastrointestinal distress for acamprosate (diarrhea: risk ratio, 1.58; 95% CI, 1.27-1.97) and naltrexone (nausea: risk ratio, 1.73; 95% CI, 1.51-1.98; vomiting: risk ratio, 1.53; 95% CI, 1.23-1.91) compared with placebo. In conjunction with psychosocial interventions, these findings support the use of oral naltrexone at 50 mg/d and acamprosate as first-line pharmacotherapies for alcohol use disorder.

Emergency department initiation of pharmacotherapy for alcohol use disorder: A retrospective cohort study.

Emergency department initiation of pharmacotherapy for alcohol use disorder: A retrospective cohort study.

Letter to the Editors regarding 'A Meta-Regression of Trial Features Predicting the Effects of Alcohol Use Disorder Pharmacotherapies on Drinking Outcomes in Randomized Clinical Trials: A Secondary Data Analysis'.

Short Summary: Grodin et al. conducted a meta-regression analysis of studies testing the effect of pretrial abstinence and diagnosis of alcohol use disorder as treatment effect predictors of pharmacotherapies for alcohol use disorder. The lack of contrast in these predictors and the suboptimal statistical method that was used may explain the negative findings.

Opioid receptor antagonism and neural response to monetary rewards: Pilot studies in light and heavy alcohol users.

Alcohol use disorder (AUD) is a prevalent condition associated with high degree of comorbidity and mortality. Among the few approved pharmacotherapies for AUD, two involve opioid receptor antagonism. Naltrexone and nalmefene are thought to act via opioid receptor blockage to reduce neural response to alcohol and drug-associated cues and consumption, but there have been limited efforts to characterize these effects in humans. In these studies, we sought to test the magnitude of opioid antagonism effects on neural response to monetary rewards in two groups: light drinkers (for the naltrexone study) and heavy drinkers (for the nalmefene study). We conducted double-blind, randomized, crossover pilot studies of reward activation in the brain following acute administration of opioid antagonist and placebo in 11 light and 9 heavy alcohol users. We used a monetary incentive delay task during functional MRI. We found a main effect of cue type on BOLD activation in the nucleus accumbens, demonstrating a neural reward response. The effect of opioid antagonism, relative to placebo, was small and nonsignificant for reward activation in the accumbens for both light and heavy alcohol users. Based on the results of two pilot studies, opioid antagonist medications do not appear to decrease neural activation to monetary rewards in the nucleus accumbens relative to placebo.