I read with interest “Meds to get patients off the bottle” (ACP Hospitalist, June 2017), including the recommendation from Hugh Myrick, MD, that patients receive medication-assisted therapy (MAT) with disulfiram. I agree that we must know our patients very well to decide what medication to use but was surprised to see the recommendation for disulfiram before acamprosate or naltrexone.
A meta-analysis by Jonas and colleagues published in the May 14, 2014, JAMA looked at all drugs studied for MAT used on- or off-label since 1970 (including disulfiram, naltrexone, acamprosate, topiramate, gabapentin, baclofen, and others) for at least 12 weeks in the outpatient setting in 22,803 patients. This paper concluded that acamprosate and oral naltrexone are the most effective in reducing alcohol consumption. Impressively, the numbers needed to treat were 12 to 20 to see these benefits—much lower than for many other interventions we routinely use in in medicine. Furthermore, the authors specifically cited that well-controlled studies did not show these same improvements in reducing alcohol consumption with disulfiram, although they did note that this medication may benefit some patients.
Hospitalists can have an important role in promoting the use of MATs for patients with alcohol use disorders. In a study by Wei and colleagues published in the March 2015 Journal of General Internal Medicine, a program at the University of California, San Francisco, to identify patients who may benefit from naltrexone increased prescription of this medication and also decreased readmissions. ED visits were also decreased after this intervention.
Our interdisciplinary hospital medicine teams have many opportunities to collaborate to improve care of our patients with alcohol use disorders. Hospitalists are uniquely positioned to promote systems-oriented solutions, including using validated tools like SBIRT (screening, brief intervention, and referral for treatment) and promoting MATs that have the best data supporting them.
Eileen Barrett, MD, MPH, FACP