Pharmacotherapy for Alcohol Dependence
Report/Technology Assessment: Number 3
Under its Evidence-Based Practice Program, the Agency for Health Care Policy and Research (AHCPR) is developing scientific information for other agencies and organizations on which to base clinical guidelines, performance measures, and other quality improvement tools. Contractor institutions review all relevant scientific literature on assigned clinical care topics and produce evidence reports and technology assessments, conduct research on methodologies and the effectiveness of their implementation, and participate in technical assistance activities.
The pharmacotherapy for alcohol dependence was selected as an evidence report topic by the Agency for Health Care Policy and Research (AHCPR) because of its timeliness, the severity and impact of the disease, and the need for careful evaluation of new therapeutic modalities for its treatment. Alcoholism is a prevalent disease that will affect on the order of 10 percent of the adult population of the United States. An estimated 100,000 Americans die each year from alcohol-related disease or injury. The serious financial and nonfinancial impact of this disease extends to family members and society in general, and its annual dollar cost to the country has been estimated (as of 1995) to exceed $166 billion.
The treatment of alcohol dependence requires a two-step approach that includes withdrawal and detoxification followed by further interventions to maintain abstinence. There is considerable uncertainty about the best treatment strategies for patients in the post-detoxification stage. Some advocate a “drug-free” 12-step approach developed by Alcoholics Anonymous (AA), while others assert that the 12-step approach or other psychosocial approaches combined with appropriate nonaddictive pharmacotherapies may improve treatment outcomes.
This summary is drawn from an evidence report that focuses on the pharmacotherapies used for the treatment of alcohol dependence. The report is organized around a series of major clinical questions on the pharmacotherapy for alcohol dependence. They involve pharmaceutical agents that have been historically or are presently used in the treatment of alcoholism: disulfiram, the opiate antagonists naltrexone and nalmefene, serotonergic
agents such as ondansetron, buspirone, and the selective serotonin reuptake inhibitors (SSRIs, such as citalopram, fluoxetine, paroxetine, sertraline, etc.), and lithium. Disulfiram and naltrexone, in particular, are mainstream agents in use in the United States today. However, it is important to recognize that the field of pharmacotherapy for alcohol dependence has evolved substantially over the past 5 years, especially with the emergence of data on the opiate antagonists.
Concomitantly, there is one promising pharmaceutical agent currently in use in Europe—acamprosate (calcium acetyl homotaurinate)—for preventing alcohol relapse. An investigational new drug (IND) application is on file for this drug at the United States Food and Drug Administration (FDA), and it is in Phase III trials in this country.