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Alcohol and Alcoholism (Oxford,... 2011To conduct a systematic review of pharmacological agents used to treat sleep problems in alcohol recovery. (Review)
Review
AIMS
To conduct a systematic review of pharmacological agents used to treat sleep problems in alcohol recovery.
METHODS
In accordance with the Quorum statement, we searched PubMed, EMBASE, Psych Info and Medline databases using the terms alcohol, insomnia/sleep and treatment/management with no year/language restrictions.
RESULTS
The search revealed 1239 articles and 20 met inclusion criteria. Trazodone was compared against placebo and found to be superior in two trials. Trazodone and gabapentin improved sleep measures with gabapentin performing significantly better in an open-label study. The data regarding gabapentin are equivocal with few studies showing a clear benefit. In one randomized trial, topiramate resulted in improved subjective sleep measures and a reduction in the percentage of heavy drinking days. Two randomized control trials of carbamazepine revealed improvement in subjective sleep measures. A randomized study showed lormetazepam was better than zopiclone on some measures. In a small placebo-controlled trial, acamprosate was found to result in improvements on some sleep measures. In single, small, mostly open-label studies, quetiapine, triazolam, ritanserin, bright light and magnesium have shown efficacy, while chlormethiazole, scopolamine and melperone showed no difference or worsening.
CONCLUSION
Trazodone has the most data suggesting efficacy. This finding is tempered by a study suggesting its association with a return to heavy drinking in some patients. Data regarding the efficacy of gabapentin are unclear at this point.
Topics: Acamprosate; Alcoholism; Amines; Central Nervous System Depressants; Cyclohexanecarboxylic Acids; Ethanol; Gabapentin; Humans; Hypnotics and Sedatives; Magnesium; Randomized Controlled Trials as Topic; Sleep Initiation and Maintenance Disorders; Taurine; Trazodone; gamma-Aminobutyric Acid
PubMed: 21715413
DOI: 10.1093/alcalc/agr073 -
The World Journal of Biological... Mar 2017These practice guidelines for the biological treatment of alcohol use disorders are an update of the first edition, published in 2008, which was developed by an... (Review)
Review
These practice guidelines for the biological treatment of alcohol use disorders are an update of the first edition, published in 2008, which was developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). For this 2016 revision, we performed a systematic review (MEDLINE/PUBMED database, Cochrane Library) of all available publications pertaining to the biological treatment of alcoholism and extracted data from national guidelines. The Task Force evaluated the identified literature with respect to the strength of evidence for the efficacy of each medication and subsequently categorised it into six levels of evidence (A-F) and five levels of recommendation (1-5). Thus, the current guidelines provide a clinically and scientifically relevant, evidence-based update of our earlier recommendations. These guidelines are intended for use by clinicians and practitioners who evaluate and treat people with alcohol use disorders and are primarily concerned with the biological treatment of adults with such disorders.
Topics: Advisory Committees; Alcoholism; Antipsychotic Agents; Biological Psychiatry; Drug Therapy, Combination; Electroconvulsive Therapy; Evidence-Based Medicine; Humans; International Cooperation; Practice Guidelines as Topic; Psychotherapy; Randomized Controlled Trials as Topic
PubMed: 28006997
DOI: 10.1080/15622975.2016.1246752 -
Industrial Psychiatry Journal 2018Alcohol use disorders (AUDs) is an important public health concern as estimates of the prevalence of AUD range at 4%-6% in the Indian population. Currently, there is... (Review)
Review
Alcohol use disorders (AUDs) is an important public health concern as estimates of the prevalence of AUD range at 4%-6% in the Indian population. Currently, there is limited literature on the pharmacotherapeutic interventions for AUD in the Indian setting. It is imperative to identify the possible variations in their effects from Western studies, and hence the current review was attempted to perform a comprehensive evaluation and critical appraisal of the methodology of the evidence on pharmacological strategies of relapse prevention of AUD in the Indian setting. A total of 18 studies were included in the review. Disulfiram was the most common pharmacological agent to be studied. The initial literature before 2000 focused primarily on disulfiram, whereas the studies in the next decade compared it to acamprosate and naltrexone and emerging interest in anticraving agents such as baclofen and topiramate had been noted over the past few years. No studies were available on newer agents such as ondansetron, selective serotonin reuptake inhibitors or formulations such as depot and implants. Deterrent agents were found to be better when compared to anticraving agents in terms of abstinence and relapse, whereas the latter were more effective for control of craving. Among the pharmacological agents studied, the greatest evidence exists for disulfiram for relapse prevention which could be due to affordability of disulfiram and social support in the Indian context. The chief methodological limitations include the lack of randomized trials and objective measures for assessing abstinence.
PubMed: 31359967
DOI: 10.4103/ipj.ipj_79_17 -
The Cochrane Database of Systematic... Jan 2005Opioid antagonists can decrease alcohol consumption in animals. Their harms and benefits have been examined in many clinical trials. (Meta-Analysis)
Meta-Analysis Review
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 recommencement of alcohol consumption in patients with alcohol dependence in comparison to placebo, other medications and psychosocial treatments. In addition, discontinuation rate, death, patient satisfaction, functioning, health-related quality of life and economic outcomes were also evaluated.
SEARCH STRATEGY
The specialised register of the Cochrane Group on Drugs and Alcohol was searched until September 2003. The search was integrated with previous searches of Cochrane Controlled Trials Register (Cochrane Library 2001, issue 4), MEDLINE (1966 - October 2001), EMBASE (1980 - December 2001) and 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 also examined.
SELECTION CRITERIA
All relevant randomised controlled trials (RCTs) were included. Participants were people with alcohol dependence. Naltrexone (NTX), nalmefene (NMF) and other opioid antagonists with/without other biological or psychosocial treatments were examined. Two primary outcomes were number of participants with relapses (including those who return to heavy drinking) and number of participants who return to drinking. Other outcomes of interest were time to first drink, percentage or number of drinking days, number of standard drinks, craving, percentage or number of days or episodes of heavy drinking, amount of alcohol consumed, discontinuation rate, patient satisfaction, impaired function, health-related quality of life, economic and death.
DATA COLLECTION AND ANALYSIS
Two reviewers evaluated and extracted the data independently. The dichotomous data were extracted on an intention-to-treat basis. The Relative Risk with the 95% confidence interval was used to assess the dichotomous data. A weighted (or standardised) mean difference (WMD or SMD) with 95% confidence interval was used to assess the continuous data.
MAIN RESULTS
The review included 29 RCTs presented in 36 articles. Except two RCTs 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 was likely to decrease the return to drinking [RR (95% CI) = 0.87 (0.76 to 1.00). In the respect of acceptability, NTX treatment significantly diminished treatment withdrawal [RR (95% CI) = 0.82 (0.70 to 0.97). While a medium-term treatment of NTX gave no benefit in the respect of relapse prevention, it was found to be beneficial on two of four secondary outcomes by 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 primary and secondary 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 decreases the chance of alcohol relapses for 36% (number-needed-to-treat or NNT = 7) and likely to reduce the chance of returning to drinking for 13% (NNT = 12). In comparison to placebo group, NTX treatment can lower the risk of treatment withdrawal in alcohol-dependent patients for 28% (NNT = 13). Some major limitations of the available evidence include short study duration in many trials, small sample sizes in most trials and lack of data on psychosocial benefits. In conclusion, NTX should be accepted as a short-term treatment for alcoholism. Strategies to improve adherence to NTX treatment, eg, PSTs 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. Due to too little evidence, NMF should have no role for the treatment of alcohol dependence.
Topics: Alcoholism; Controlled Clinical Trials as Topic; Humans; Naltrexone; Narcotic Antagonists; Randomized Controlled Trials as Topic
PubMed: 15674887
DOI: 10.1002/14651858.CD001867.pub2 -
Therapeutic Advances in... Sep 2017Psychotic illnesses, such as schizophrenia, are typically enduring and disabling conditions, impacting individual, family, and societal outcomes. Individuals with these... (Review)
Review
BACKGROUND
Psychotic illnesses, such as schizophrenia, are typically enduring and disabling conditions, impacting individual, family, and societal outcomes. Individuals with these face greater vulnerabilities in developing alcohol-use disorder (AUD). Furthermore, the nature of psychoses, often manifesting with paranoia, cognitive impairment, a lack of insight, sub-optimal treatment adherence, and stigma from others, means that they can pose unique treatment challenges when these two conditions comorbidly occur. These challenges mean that the standard literature on the effectiveness of the opioid antagonist naltrexone in AUD does not necessarily translate to this vulnerable population.
METHODS
Following PRISMA guidelines, we herein systematically reviewed the evidence for naltrexone in individuals with both psychosis and AUD. Overall, there is a paucity of research in this important area, with only nine reports meeting search criteria, only four of which were randomized control trials. Studies compared naltrexone with: placebo, another pharmaceutical agent, or upon changes to baseline drinking behaviour. One study evaluated the long-acting injectable formulation of this drug.
RESULTS
Most studies, including the methodologically more robust ones, supported naltrexone's effectiveness over placebo in terms of reduction in drinking days and numbers of drinks consumed on such days in this cohort. Work comparing naltrexone to other pharmaceutical interventions showed approximate equivalence with disulfiram, and modest superiority over acamprosate.
CONCLUSIONS
On this limited evidence base, this review endorses the use of naltrexone as both safe and effective in those with both psychotic illnesses and AUD. Several key issues remain to be elucidated. Critically, study designs meant that they were limited to individuals with good engagement with services, and levels of adherence were attained that are unlikely to be replicated in this cohort in real-world settings. Finally, effects of specific psychosis symptomatology, not least paranoia and insight, upon naltrexone use, and the reverse directional potential of 'double dysphoria' from an opioid antagonist remain largely unexplored.
PubMed: 28959434
DOI: 10.1177/2045125317709975 -
The Australian and New Zealand Journal... Feb 2024Alcohol use disorders confer a significant burden of disease and economic cost worldwide. However, the utilisation of pharmacotherapies to manage alcohol use disorder is... (Review)
Review
OBJECTIVE
Alcohol use disorders confer a significant burden of disease and economic cost worldwide. However, the utilisation of pharmacotherapies to manage alcohol use disorder is poor. We aimed to conduct a systematic review of economic evaluation studies of alcohol use disorder pharmacotherapies.
METHODS
A search was conducted in Embase, Medline, CINAHL, PsychINFO and EconLit (August 2019, updated September 2022). Full economic evaluations using pharmacotherapy to treat alcohol use disorders were included. Included studies were stratified by medication and summarised descriptively. The Consensus on Health Economic Criteria list was used to assess the methodological quality.
RESULTS
A total of 1139 studies were retrieved, of which 15 met the inclusion criteria. All studies were conducted in high-income countries. Four studies analysed nalmefene, four studies assessed acamprosate, three for naltrexone and four for stand-alone and/or combinations of naltrexone and acamprosate. There were 21 interventions synthesised from 15 studies as some studies evaluated multiple interventions and comparators. More than half of the included studies (73%) reported pharmacotherapy as dominant (less costly and more effective than comparators). From healthcare payer perspectives, five studies found that pharmacotherapy added to psychosocial support was dominant or cost-effective, accruing additional benefits at a higher cost but under accepted willingness to pay thresholds. Three analyses from a societal perspective found pharmacotherapy added to psychosocial support was a dominant or cost-effective strategy. Quality scores ranged from 63% to 95%.
CONCLUSION
Pharmacotherapy added to psychosocial support was cost-effective from both healthcare and societal perspectives, emphasising an increased role for pharmacotherapy to reduce the burden of alcohol use disorders.
Topics: Humans; Alcoholism; Acamprosate; Cost-Benefit Analysis; Naltrexone; Alcohol Drinking; Ethanol
PubMed: 37822267
DOI: 10.1177/00048674231201541 -
Academic Emergency Medicine : Official... May 2024Alcohol-related concerns commonly present to the emergency department (ED), with a subset of individuals experiencing the symptoms of an alcohol use disorder (AUD). As... (Review)
Review
OBJECTIVES
Alcohol-related concerns commonly present to the emergency department (ED), with a subset of individuals experiencing the symptoms of an alcohol use disorder (AUD). As such, examining the efficacy of pharmacological anti-craving treatment for AUD in the ED is of increasing interest. The objective of this systematic review was to evaluate the direct evidence assessing the efficacy of providing anti-craving medications for AUD treatment in the ED.
METHODS
A systematic search was conducted according to the patient-intervention-control-outcome question: (P) adults (≥18 years old) presenting to the ED with an AUD (including suspected AUD); (I) anti-craving medications (i.e., naltrexone, acamprosate, gabapentin); (C) no prescription or placebo; (O) reduction of repeat ED visits, engagement in addiction services, reductions in heavy drinking days, reductions in any drinking and amount consumed (or abstinence), and in relapse. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.
RESULTS
From 143 potentially relevant articles, 6 met inclusion criteria: 3 clinical trials, and 3 case studies. The clinical trials identified evaluated oral versus extended-release naltrexone, monthly extended-release naltrexone injections, and disulfiram. Both oral and extended-release naltrexone resulted in decreased alcohol consumption. Monthly extended-release naltrexone injections resulted in significant improvements in drinking and quality of life. Although out of scope, the disulfiram studies identified did not result in an improvement in drinking in comparison to no medication.
CONCLUSIONS
Overall, there are few studies directly examining the efficacy of anti-craving medications for AUD in the ED, although the limited evidence that exists is supportive of naltrexone pharmacotherapy, particularly extended-release injection formulation. Additional randomized controlled trials are necessary for substantive direct evidence on anti-craving medication initiation in the ED.
Topics: Humans; Emergency Service, Hospital; Alcoholism; Alcohol Deterrents; Naltrexone; Acamprosate; Craving; Adult
PubMed: 37735346
DOI: 10.1111/acem.14806 -
Alcohol and Alcoholism (Oxford,... Aug 2021There are potential clinical, ethical and legal concerns with overdosing benzodiazepines (or barbiturates) for the treatment of moderate to severe alcohol withdrawal...
AIM
There are potential clinical, ethical and legal concerns with overdosing benzodiazepines (or barbiturates) for the treatment of moderate to severe alcohol withdrawal symptoms (AWS) through telemedicine or ambulatory outpatients. A rapid systematic review to (a) qualitatively summarize the non-benzodiazepine treatment alternatives, (b) evaluate the quality of evidence for the same to effectively manage moderate to severe AWS.
METHODS
We conducted searches on PubMed (January 1990 to 31 March 2020), Cochrane Central Register of Controlled Trials, and Google Scholar. We selected the English language randomized controlled trials (RCTs) assessing the efficacy and adverse effects of non-benzodiazepine and non-barbiturate medications among adults with a diagnosis of AWS. Data extraction was done in a predefined format. Risk of bias (RoB) assessment and qualitative synthesis of evidence was done with the RoB2 tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) proGDT.
RESULTS
Thirty-four RCTs were included. Gabapentin (n = 6), carbamazepine (n = 5), baclofen (n = 5), valproate (n = 3), clonidine/lofexidine (n = 3) and acamprosate (n = 2) had more than one trial with a particular comparison group. Four studies were found to have a low ROB. The GRADE evidence summary showed gabapentin had a 'moderate' level of evidence against standard benzodiazepine treatments for reducing the severity of AWS. The level of certainty was 'low' for carbamazepine, baclofen and valproate and 'very low' for acamprosate and clonidine/lofexidine. Reported adverse events between these alternative medications and benzodiazepines or placebo were generally unremarkable.
CONCLUSIONS
Although benzodiazepines remain the treatment of choice for AWS, during particular circumstances, gabapentin could be an alternative although like benzodiazepines is not without risk when used in the community. Future RCTs must aim to improve upon the quality of evidence.
Topics: Alcohol Deterrents; Anti-Anxiety Agents; Anticonvulsants; Barbiturates; Benzodiazepines; Evidence-Based Medicine; Humans; Randomized Controlled Trials as Topic; Substance Withdrawal Syndrome; Sympatholytics
PubMed: 33264386
DOI: 10.1093/alcalc/agaa125 -
Progress in Neuro-psychopharmacology &... Aug 2008Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic... (Review)
Review
Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic pharmacotherapy in schizophrenia are based on studies that excluded patients with this dual diagnosis. In the present comprehensive systematic review, the pharmacological studies performed in this subgroup of patients are summarised and discussed from the standpoint of evidence-based medicine. Unfortunately, randomized controlled studies, providing a high evidence level, in patients with this dual diagnosis are rare. Data, mainly based on open studies or case series, suggest superior efficacy for second generation antipsychotic agents (SGAs) (aripiprazole, clozapine, olanzapine, quetiapine, risperidone) with regard to improvement of distinct psychopathological symptoms, reduced craving and greater reduction of substance use compared with orally administered conventional antipsychotics (FGAs). Tricyclic antidepressants given adjunctive to antipsychotic maintenance therapy showed efficacy in reducing substance use and craving. The administration of anti-craving agents (naltrexone) led to a decrease of drug intake. Unfortunately, there is no clinical experience with acamprosate in schizophrenic patients with comorbid alcoholism. In conclusion, there are more theoretically based arguments for the preferential use of SGAs in schizophrenic patients with comorbid substance use disorder while the empirical evidence is weak. The early initiation of treatment with antidepressants, depending on the patient's psychopathology, as well as add-on medication with anti-craving agents should be considered.
Topics: Alcohol Deterrents; Antidepressive Agents; Antipsychotic Agents; Combined Modality Therapy; Diagnosis, Dual (Psychiatry); Disulfiram; Guidelines as Topic; Humans; Schizophrenia; Schizophrenic Psychology; Substance-Related Disorders
PubMed: 18394768
DOI: 10.1016/j.pnpbp.2008.02.008 -
Current Pharmaceutical Design 2021Alcohol use disorders (AUD) are among the most prevalent mental disorders around the world, yet still remain the most undertreated. Many studies report the low rate of...
BACKGROUND AND AIMS
Alcohol use disorders (AUD) are among the most prevalent mental disorders around the world, yet still remain the most undertreated. Many studies report the low rate of treatment uptake, less than 20%, among people with AUD. Among those accessing care, a large majority only approach their GP for help. Therefore, primary care is a strategic setting for the identification and the management of AUD. International recommendations stress AUD pharmacotherapy for withdrawal and craving management, but very few studies have shown interest in the management of AUDs in primary care. The main objective of this study was to analyse pharmacotherapy in AUD management in primary care by means of a systematic literature review.
METHODS
A systematic literature review (PRISMA) was carried out. 5 databases were screened: PUBMED via MEDLINE, LiSSa, the SUDOC catalogue, PASCAL and EMBASE. Search algorithms were used integrating the concepts of pharmacotherapy management, alcohol use disorders and primary care, only in the English language.
RESULTS
296 studies were selected and 10 were included. One was a follow-up study on the national prescription database, while four were cross-sectional studies with an auto-questionnaire survey. Of the 10 studies included, two were conducted in Europe, five in North America, two in Australia and one in South Africa. These pharmacotherapy studies were concerned with the anti-craving treatment, and 3 types of medications were used: Disulfiram, Acamprosate and Naltrexone. Factors identified as limiting or facilitating prescriptions concerned cost, indications, efficacy, training and adjuncts to pharmacotherapy.
CONCLUSION
Knowledge and prescription of pharmacotherapy for AUD, more specifically, anti-craving treatment, is insufficient in primary care. There is a lack of data and studies on the efficacy of anti-craving treatment in primary care. Guidelines for AUD management, including psychological and medical management and pharmacotherapy, do exist but have not been adapted to primary care practice. Barriers and facilitators of pharmacotherapy prescription in AUD in primary care were identified in this study.
Topics: Alcoholism; Cross-Sectional Studies; Disulfiram; Family Practice; Follow-Up Studies; Humans
PubMed: 33059563
DOI: 10.2174/1381612826666201015154051