Donoghue K. Addiction. 2021 Read full article.

This study looked at adults who had completed treatment for alcohol dependence using data from the national drug treatment monitoring system (NDTMS) in England. They gathered information on prescription medications to prevent alcohol relapse given during the treatment pathway and then considered these against various characteristics of the service users.

The specific medications they looked at were acamprosate, naltrexone, and disulfiram. They considered data for people who completed their “treatment journey” between April 2013 and March 2016. This meant that they were able to extract data for 188,152 people. In 2013/14 the rate of prescribing medications was 2.1% rising to 6.8% in 2014/5 and finally getting up to 7.8% in 2015/16.

In the multivariate logistic regression the characteristics associated with a greater likelihood of prescription included: older age, female, and white; greater severity of alcohol dependence and treatment as an inpatient, residential or in primary care; previous treatment for alcohol dependence and a higher number of drinking days prior to treatment; and a longer treatment journey length. It was noted that people living in a region of UK with low rates of prevalence of alcohol dependence had a lower chance of being prescribed medications. There was no association with other mental health conditions or complex needs.

Commentary: One of the great challenges of managing alcohol dependence is helping people to avoid relapse. We do have a limited number of medications but this study shows that they are simply not being used in the vast majority of people. We seem to be reluctant to prescribe unless we are being battered with characteristics that suggest tough clinical scenarios — the heaviest drinkers who keep bouncing back.

The three medications that were considered in this study are all regarded as being safe and generally effective. They are all cost-effective and licensed for use in the UK. The opening line of this paper flags that 70% of people treated for dependence relapse back within 12 months. It seems surprising that we are not grasping these drugs with greater enthusiasm. The number needed to treat (NNT) to prevent a return to any drinking with acamprosate is 12 and for naltrexone is 20 — a lot better than many medications we commonly use. (The NNT for aspirin to prevent a cardiovascular event after a stroke is 50.)

There is only limited discussion in this paper about the potential reasons for the low rate of prescribing. There has been, and there may still be, some difficulties with prescribing of acamprosate and naltrexone and getting primary care to pick up prescriptions first issued by specialist treatment services. I wonder if this may remain a factor in the low pickup. It could just be the gap that exists between research and practice; it takes time for change. I would also speculate that the configuration of services may be a factor. The more serious alcohol dependence problems seem to be associated with a greater likelihood of prescription. Could it be that medical assessment by prescribers is missing for many people in protocol-driven systems?

Article taken from our latest Clinical Update, edited by Euan Lawson (Editor of the British Journal of General Practice’). To read the full Clinical Update please become an Premium CPD Member.