CAVEATS
Medication should be used with psychosocial treatments
Pharmacotherapy for AUD should be reserved for patients who want to quit drinking and should be used in conjunction with psychosocial intervention.3 Only one of the studies analyzed by Jonas et al1 was conducted in primary care. That said, many of the psychosocial interventions—such as regular follow-up visits to encourage adherence and monitor for adverse effects, in conjunction with attendance at Alcoholics Anonymous meetings—could be done in primary care settings.
Comorbidities may limit therapy options. Naltrexone is contraindicated in acute hepatitis and liver failure and in combination with opioids.5 Acamprosate is contraindicated in renal disease.5
CHALLENGES TO IMPLEMENTATION
Cost, adherence may be factors for some patients
Perhaps the greatest hurdle in pharmacotherapy for AUD in primary care is a lack of familiarity with these medications. For clinicians who are comfortable with prescribing these medications, implementation may be hindered by a lack of available psychosocial resources for successful abstinence.
Additionally, the medications are expensive. The branded version of naltrexone (50 mg) costs approximately $118 for a 30-day supply,6 and the branded version of acamprosate costs approximately $284 for a 30-day supply.7
As is the case with any chronic medical condition, medication adherence is a challenge. Naltrexone is taken once daily, while acamprosate is taken three times a day. The risk for relapse is high until six to 12 months of sobriety is achieved and then wanes over several years.5 The NIAAA recommends treatment for a minimum of three months.5
REFERENCES
1. Jonas DE, Amick HR, Feltner C, et al. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 2014;311:1889-1900.
2. CDC. Fact sheets - Alcohol use and your health. www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm. Accessed April 13, 2015.
3. Johnson BA. Pharmacotherapy for alcohol use disorder. UpToDate. www.uptodate.com/contents/pharmacotherapy-for-alcohol-use-disorder. Accessed April 13, 2015.
4. US Preventive Services Task Force. Final recommendation statement: Alcohol misuse: Screening and behavioral counseling interventions in primary care. www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care. Accessed April 13, 2015.
5. US Department of Health and Human Services; National Institutes of Health; National Institute on Alcohol Abuse and Alcoholism. Excerpt from Helping Patients Who Drink Too Much: A Clinician’s Guide. http://pubs.niaaa.nih.gov/publications/Practitioner/Clinicians Guide2005/PrescribingMeds.pdf. Accessed April 13, 2015.
6. Drugs.com. Revia prices, coupons and patient assistance programs. www.drugs.com/price-guide/revia. Accessed April 13, 2015.
7. Drugs.com. Campral prices, coupons and patient assistance programs. www.drugs.com/price-guide/campral. Accessed April 13, 2015.
ACKNOWLEDGEMENT
The PURLs Surveillance System was supported in part by Grant Number UL1RR024999 from the National Center For Research Resources, a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the National Institutes of Health.
Copyright © 2015. The Family Physicians Inquiries Network. All rights reserved.
Reprinted with permission from the Family Physicians Inquiries Network and The Journal of Family Practice. 2015;64(4):238-240.