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Three Part Question

In [patients who have been detoxified from alcohol on the short stay ward] [does treatment with acamprosate] improve [rate of abstinence at six months]

Clinical Scenario

A 40 year old alcohol dependent male is admitted to the short stay ward from the emergency department. Whilst recovering from his head injury he starts to withdraw from alcohol. You treat this with a chlordiazepoxide regime, and at the end of this he states he wants to stay off the booze. He has failed to do this previously. You recommend he engages with alcohol support services. You also wonder whether he'll benefit from acamprosate treatment.

Search Strategy

Medline 1966-present
([placebo or placebos] and [alcoholism or alcoholic or alcohol dependent or alcoholism or alcohol or drinking or alcohol$.af] and [campral or acamprosate calcium or acamprosate.af. or Acamprosate.ti. or (ca-acetyl-homotaurine or calcium acetyl homotaurinate or calcium bis acetyl homotaurine).af. or (ca-acetyl-homotaurine or calcium acetyl homotaurinate or calcium bis acetyl homotaurine]).ti. and [stop drinking alcohol or stop drinking or abstinence or detox or detoxification]) LIMIT to Human and English

Search Outcome

36 papers were identified, two were relevant to the question. One of these was a meta-analysis of 17 RCTs (12 found by our search strategy). (2) The authors included 5 papers not found by our search strategy, as they hand searched journals and contacted authors. A further paper, including data published after the meta-analysis was performed, was found.(1)
Of the papers rejected, 14 were not relevant to the clinical question, seven were reviews and one paper was discarded following critical appraisal.The remaining 2 papers are shown in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Mann K et al 2004 UK	17 RCTs	metanalysis	Continuous abstinence at 6 months	acamprosate 36.1%, placebo 23.4%.	Not a clear description of the setting of the trials, i.e., whether in-patient or out-patient. Heterogeneitytof additional therapies, e.g. counselling. Otherwise a well conducted review.
			Relative benefit	1.47 (95% CI 1.29-1.69)
			Number needed to treat	7.8 at 6 months, 7.5 at 12 months
Baltieri et al 2004 Brazil	75 males 18-60 years, ICD-10 diagnosis alcohol dependence. 40 received acamprosate (1.998mg/day)vs. 35 placebo for 12 weeks	RCT double blinded	Continuous abstinence at 6 months	Kaplan-Meier curve of relapse P=.02 acamprosate group compared to placebo.	Only 24 week study. Small number of patients in study. No confidence intervalsw Use of Kaplan-Meier survival curve. The use of AA not standardized
			Continuous abstinence at 6 months	17(43%) acamprosate patients vs. 7(20%) placebo. NNT 4.3 p= 0.04
			Continuous abstinence at 6 months	P=.04 (patients not attending AA) p=.75 in patients participating in AA

Comment(s)

Two papers have been reported. The paper by Mann et al is a well written paper that looks at 17 RCTs relating to effectiveness of acamprosate compared to placebo in treating alcohol dependence. Sensitivity analysis was performed, and the improved abstinence rate with acapmprosate was confirmed. Of the 17 studies they include, four reported no effect on treatment with acamprosate, however these were small studies lacking statistical power. The second paper by Baltieri et al, also finds acamprosate to be effective in treatment of alcohol dependence although the study is small and non-standardisation of Alcoholics Anonymous care may affect results. This review highlights evidence that acamprosate is effective in maintaining abstinence in detoxified alcohol dependent patients. However, many studies have been carried out as part of a detoxification program carried out in an outpatient setting. There are limited data on the effectiveness of acamprosate in treating patients on a short stay ward, following admission via the Emergency Department. The effect of psychosocial support has also not been questioned in the above studies, which may have an effect on outcome in a clinical setting. Cost campral 333mg. 168 tab pack = £28.92. >60kg 666 mg/tds.

Clinical Bottom Line

Acamprosate increases abstinence rates at 6 months for detoxified alcohol dependent patients.

References

1. Mann K, Lehert P and Morgan M. The Efficacy of Acamprosate in the Maintenance of Abstinence in Alcohol Dependent Individuals: Results of a Meta- Analysis. Alcohol Clin Exp Res 2004; 28(1):51-63
2. Baltieri D and Guerra A Acamprosate in Alcohol Dependence: A randomized Controlled Efficacy Study in a Standard Clinical Setting. J-stud-alcohol 2004 Jan; 65 (1): 36-9