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Medically Assisted Treatment for Alcohol Use Disorder Unfortunately Has Its Limitations

      I have been catching up on reading, and last year, The Journal for Nurse Practitioners published an important article on pharmacologic management of alcohol use disorder (AUD).
      • Pearson C.
      • Duff E.
      Beyond brief intervention: pharmacological management of alcohol use disorder.
      However, 1 misconception should be clarified, and some additional statistics can add to the therapeutic use and expectation of medically assisted treatment for AUD. For clarification, disulfiram is Food and Drug Administration approved and is not an off-label medication for AUD.
      Center for Substance Abuse Treatment
      Incorporating Alcohol Pharmacotherapies Into Medical Practice. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 09-4380.
      Regarding Food and Drug Administration–approved medications, important measures to consider are drug effect size and the number needed to treat (NNT). These reflect the magnitude of response and the number of people required to take the medication for 1 person to benefit. Meta-analyses reveal the effect size for disulfiram,
      • Skinner M.D.
      • Lahmek P.
      • Pham H.
      • et al.
      Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis.
      naltrexone,
      • Maisel N.C.
      • Blodgett J.C.
      • Wilbourne P.L.
      • et al.
      Meta-analysis of naltrexone and acamprosate for treating alcohol use disorder: when are these medications most helpful?.
      and acamprosate.
      • Maisel N.C.
      • Blodgett J.C.
      • Wilbourne P.L.
      • et al.
      Meta-analysis of naltrexone and acamprosate for treating alcohol use disorder: when are these medications most helpful?.
      All show an effect size of 0.2, which indicates a small effect for each medication. More powerful research has been conducted on naltrexone and acamprosate than disulfiram.
      • Maisel N.C.
      • Blodgett J.C.
      • Wilbourne P.L.
      • et al.
      Meta-analysis of naltrexone and acamprosate for treating alcohol use disorder: when are these medications most helpful?.
      Findings further indicate 9 people need to be treated (NNT = 8.6) with naltrexone to prevent 1 additional person from returning to heavy drinking. For acamprosate, 8 people need to be treated (NNT = 7.5) to achieve an additional instance of abstinence. These statistics do not negate the benefit of these Food and Drug Administration–approved medications; they are essential medications to include on a menu of options that we can offer our patients. Nevertheless, their impact is unfortunately limited.
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      References

        • Pearson C.
        • Duff E.
        Beyond brief intervention: pharmacological management of alcohol use disorder.
        J Nurse Pract. 2019; 15: 627-630https://doi.org/10.1016/j.nurpra.2019.05.015
        • Center for Substance Abuse Treatment
        Incorporating Alcohol Pharmacotherapies Into Medical Practice. Treatment Improvement Protocol (TIP) Series 49. HHS Publication No. (SMA) 09-4380.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2009
        • Skinner M.D.
        • Lahmek P.
        • Pham H.
        • et al.
        Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis.
        PLoS One. 2014; 9e87366https://doi.org/10.1371/journal.pone.0087366
        • Maisel N.C.
        • Blodgett J.C.
        • Wilbourne P.L.
        • et al.
        Meta-analysis of naltrexone and acamprosate for treating alcohol use disorder: when are these medications most helpful?.
        Addiction. 2012; 29: 275-293https://doi.org/10.1111/j.1360-0443.2012.04054.x