Saturday, August 15, 2009

Acamprosate really can help alcoholics stay sober

There has been some concern about whether Acamprosate can really help patients stay sober off alcohol. Many of us who work in the field of substance abuse have been using this medicine for quite a few years and have been quite impressed with the results. Acamprosate has been used in Europe for over 20 years and results of studies over there are quite impressive – in a meta-analysis of 20 randomized studies ( a meta-analysis is a process where results from multiple studies are all combined together so we can gain more understanding and confidence in the results), 36% of patients on Acamprosate achieved complete abstinence at 6 months versus only 23% on placebo. It was surprising then that the 2 initial US studies, including a very large study called COMBINE did not show any efficacy.

Now a recent review and meta-analysis of all the Acamprosate trials, published in the Journal of Addiction Medicine, has found that indeed Acamprosate is helpful.

Why should there be such a discrepancy between trials, particularly between European and US studies?

The answer may lie in 2 factors. Firstly the European trials usually had patients start on Acamprosate after about 5 weeks of abstinence and inpatient treatment, whereas the US trials usually had patients start Acamprosate after only a few days – meaning more drop outs form the study. Also the European trials often went on for close to a year while the US trials were often much shorter.

So how do Clinicians make sense of all this? I think the evidence suggests that Acamprosate does have some usefulness. It seems to have its best effects if it is continued for a long period of time. It may be that because of its mechanism of action, which is to help restore the brains chemistry and reduce post acute withdrawal symptoms, it works best after acute withdrawal is over. It may be that if patients relapse and drink, it is best to advise them to continue with the medicine and eventually they will benefit from it.

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