Opioid antagonists for alcohol dependence
Abstract
Background
Opioid antagonists can decrease alcohol consumption in animals. Their harms and benefits have been examined in many clinical trials.
Objectives
To determine the effectiveness of opioid antagonists in attenuating or preventing the relapses in alcohol dependents in comparison to placebo, other medications and psychosocial treatments.
Search methods
The specialised register of the Cochrane Group on Drugs and Alcohol (September 2003); Cochrane Controlled Trials Register (Cochrane Library 2001, issue 4), MEDLINE (1966‐October 2001), EMBASE (1980‐December 2001), CINHAL (1982 ‐December 2001). Du Pont Pharmaceutical and Ivax Corporation were contacted for information regarding unpublished trials. The reference lists of the obtained papers were examined.
Selection criteria
All randomised controlled trials were included. Participants: people with alcohol dependence. Naltrexone (NTX), nalmefene (NMF) and other opioid antagonists with/without other biological or psychosocial treatments were examined.
Data collection and analysis
Two reviewers evaluated and extracted the data independently. The dichotomous data were extracted on an intention‐to‐treat basis and assessed using the Relative Risk. A weighted mean difference was used to assess the continuous data.
Main results
The review included 29 RCTs. Except two of nalmefene, all others investigated NTX. In comparison to placebo, a short‐term treatment of NTX significantly decreased the relapse [RR (95% CI) = 0.64 (0.51 to 0.82)] and decrease the return to drinking [RR (95% CI) = 0.87 (0.76 to 1.00). In the respect of acceptability, NTX significantly diminished withdrawal [RR (95% CI) = 0.82 (0.70 to 0.97). While a medium‐term treatment of NTX gave no benefit for relapse prevention, it was found to be beneficial on increasing time to first drink and diminishing craving. A medium‐term treatment of NTX was superior to acamprosate in reducing relapses, standard drinks and craving. NTX plus an intensive psychosocial treatment (PST) was not superior to NTX plus a simple PST on any short‐term outcomes. For a medium‐term treatment, NTX plus an intensive PST was superior to NTX plus a simple PST in increasing time to first drink and decreasing craving.
Authors' conclusions
The review findings support that short‐term treatment of NTX should be accepted as a short‐term treatment for alcoholism. Some major limitations of the available evidence include short study duration, small sample sizes and lack of data on psychosocial benefits. Strategies to improve adherence to NTX treatment, e.g., PSTs and management of adverse effects, should be concomitantly given. Due to too little evidence, NMF should have no role for the treatment of alcohol dependence.
Plain language summary
Opioid antagonists for alcohol dependence
Opioid antagonists can decrease alcohol consumption in animals. The review findings support that short‐term treatment of naltrexone (NTX) decreases the chance of alcohol relapses for 36% and likely to reduce the chance of returning to drinking for 13%. NTX treatment can lower the risk of treatment withdrawal in alcohol‐dependent patients for 28% (NNT = 13). The evidence so far have supported that NTX should be accepted as a short‐term treatment for alcoholism. Strategies to improve adherence to NTX treatment, e.g., psychosocial interventions and management of adverse effects, should be concomitantly given. We have not yet known so far how long alcohol‐dependent patients who respond to NTX treatment should continue their treatment. Nalmefene has too little evidence to support its clinical use.
