Alcohol Relapse Prevention

Though the mainstay of treatment for alcohol dependence is psychosocial intervention, medications to maintain abstinence have an important role to play in improving the efficacy of treatment. Up to 70% of patients relapse after psychosocial treatment alone.

Pharmacotherapy should be used in dependent patients who are motivated to reduce or abstain from alcohol intake and who do not have contraindications to the medications. Now let’s look at the current choices available to physicians in the U.S. Many of these medications can be used in general medical settings. The list below includes selected risks involved with these medications.

Note that only naltrexone, acamprostate and disulfiram have been FDA approved for the treatment  of alcohol dependence. Other medications have shown some promising results and are also included here.

Does it work?

A meta-analysis of 18 clinical trials of oral naltrexone found the medication to reduce the risk of relapse, number of drinking days, and cravings in comparison to placebo.

Parenteral naltrexone has been shown in some to reduce the rate of heavy drinking and increase the number of abstinent days.

Acamprostate has been shown to improve abstinence rates but numerous other studies have shown variable benefit in terms of drink-free days and time to heavy drinking.

Disulfiram was studied in a VA cooperative trial and was found to be no more effective than placebo. However, among the patients compliant with the medication, fewer drinking days were recorded. Non-compliance with self-administered home dosing is very high.

Topiramate has been shown to improve abstinence rates and decrease heavy drinking in several trials. Dropout rates have been higher than placebo. Head-to-head studies with other medications for alcohol dependence have not been published. Topiramate is not FDA-approved for the treatment of alcohol dependence.

Each of these therapies should be combined with psychosocial support (there is no evidence for superiority of any particular form, e.g., cognitive behaviorally therapy, motivational interviewing, 12 step programs). The duration of treatment has not been defined: many treatment specialists used the drugs for 6 months, followed by 6 months of follow-up.

Can I just prescribe it?

Any of the above medications can be prescribed by non-specialist providers.

As with opiods, medications can play an important part in prevention of alcohol craving and relapse. Whether, when and how to use them, and when and how to remove them, is an important decision among the care team and the patient.

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