Acamprosate was the only intervention with evidence that it was better than placebo in maintaining alcohol abstinence for up to 12 months, following detoxification, in a network meta-analysis.

The investigators searched for randomised controlled trials that looked at drug, psychological, or combined treatment interventions designed to support the maintenance of abstinence in recently detoxified, alcohol-dependent adults.

Studies, from across the world, were included that focussed on interventions appropriate for primary care settings and used medications available in the UK.

Eligible participants were aged 18 years or older with alcohol dependency diagnosed using standardised diagnostic criteria.

Most participants were men and the average age was around 40.

Studies that provided detoxification to participants, as well as those that recruited participants who had undergone detoxification less than four weeks before randomisation were included, with follow-up periods of at least 12 weeks.

A total of 64 trials covering 43 interventions, published between 1986 and 2020, were included in the meta-analysis. Drug treatment was the most common intervention, used in 51 studies (80%). Six studies investigated seven forms of psychosocial interventions and the other seven studies looked at treatment combinations.

The median probability of abstinence maintenance across placebo arms was 25%. Compared with placebo, the only intervention associated with an increased probability of abstinence and moderately good evidence was acamprosate:

• Acamprosate odds ratio (OR) 1.86 (95% CI: 1.49-2.33), corresponding to an absolute probability of abstinence of 38%.

Dropout rates were used as a surrogate for acceptability.

Of the 62 included trials that reported all cause dropouts up to 12 months, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were:

• Acamprosate OR 0.73

(95% CI: 0.62-0.86), probability 42%

• Naltrexone OR 0.70

(95% CI: 0.50-0.98), probability 41%

• Acamprosate-naltrexone OR 0.30 (95% CI: 0.13-0.67), probability 23%

Morbidity and mortality rates caused by alcohol consumption are high in the UK with approximately 7% of hospital admissions related to alcohol use.¹

Liver disease is the third most common cause of premature death in the UK, with about two thirds of deaths from liver disease related to alcohol.²

In England more than half a million adults are alcohol dependent.³ For those accessing services treatment typically centres on medically managed alcohol detoxification, but relapse rates are high.

The study authors conclude: ‘These findings have important implications for clinical practice, as acamprosate was found to be the only intervention with enough high quality evidence for us to conclude that it is better at maintaining alcohol abstinence than placebo.

‘The finding that there is currently little evidence on other interventions, such as disulfiram, for detoxified, alcohol dependent patients in UK primary care settings should lead to the generation of better evidence from high quality pragmatic randomised trials.’

Dr Jez Thompson