JAMA just published a meta analysis of medications used to treat alcoholism. Here are their findings:
To prevent 1 person from returning to any drinking, the NNTs were 12 (95% CI, 8 to 26; 16 trials, n = 4847) and 20 (95% CI, 11 to 500; 16 trials, n = 2347) for acamprosate and oral naltrexone (50 mg/d), respectively. For return to heavy drinking, acamprosate was not associated with improvement, whereas oral naltrexone (50 mg/d) was associated with improvement with an NNT of 12 (95% CI, 8 to 26; 19 trials, n = 2875). For injectable naltrexone, our meta-analyses found no statistically significant association with return to any drinking or return to heavy drinking but found an association with reduction in heavy drinking days (WMD −4.6%; 95% CI, −8.5% to −0.56%; 2 trials, n = 926). Evidence from well-controlled trials of disulfiram does not adequately support an association with preventing return to any drinking or improvement in other alcohol consumption outcomes (Table 1). The largest disulfiram trial (n = 605) reported fewer drinking days for participants who returned to drinking and had a complete set of assessments.32 Results of sensitivity analyses that included studies rated as high or unclear risk of bias were similar to the results of our main analyses (eFigures 1 and 2 in the Supplement).
So . . .
- 1 patient out of 12 who received acamprosate maintained abstinence over a 12 week period, and
- 1 patient out of 20 who received naltrexone maintained abstinence over a 12 week period, and
- 1 patient out of 12 who received naltrexone did not return to heavy drinking over a 12 week period.
You’d think that success rates of 5% to 8.3% (over the relatively short period of 12 weeks) would be pretty disappointing, right? If you agree, you and I appear to be in a tiny minority.
In the last 24 hours, Time, the NY Times, NPR, Huffington Post, CNN, Fox News, and many others are posting articles under headlines touting their effectiveness, their underuse and the “Best Meds for Alcohol Dependence Revealed”.
These stories seem to be incongruent with the findings. Why? Is it that there’s very little hope for recovery from alcoholism? Is it cultural deference to doctors and medical researchers?
I don’t get it.
Why are they not writing stories about an underutilized treatment model that has outcomes that are 10 to 16 times better than these outcomes?
recoveryreview.blog 
Jason – as I frequently read your blogs, I have come to have an appreciation for not only your thoughtfulness, but your ability to communicate in writing. Why don’t YOU write the article that exposes this dissonance between where the public attention is focused vs where the greater success can be found. I simply don’t have the grasp of the research and literature the way you do, but I would do whatever would be helpful to advance the effort. Jerry
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While I am not endorsing the low efficacy numbers revealed here, I do think they need to be seen in context. Addiction disorders overall have some of the worst treatment outcomes in the DSM. I think that all treatments with any degree of effectiveness have some merit given the outcomes associated with addiction related disorders. Also, these stats do not illustrate the efficacy rates for medication and other recovery or treatment tools. What about those attending treatment and using medications or going to 12 step groups along with taking medication. Meta Analysis studies, while popular and helpful in many ways, tend to lead you wherever you want to go as the boundaries and data sources are generally pretty narrow and may also lack proper context when explaining findings. Many treatment programs, both medical and non-medical, often skew numbers to paint the picture that they want. If treatment providers cream who come into their programs or only count those completing their program in the final statistics used to illustrate efficacy, then of course the numbers will show how successful 12 step programs and/or treatment is in addressing addiction disorders. If providers show the real numbers or put them into better context, what we will likely see is that addiction is hard to treat in general. I prefer to see recovery and treatment as consisting of lots of different possible tools and combinations of tools that individuals with the help of clinicians and other supports should have access and power over choosing from among them the ones that will work best for them. The larger issue from my perspective is the intersection of addiction and social class. Many best practices and promising practices are not accessible or affordable to many. Perhaps some of our recent policy changes federally and in Michigan in regards to AHC and medicaid expansion as well as the mental health changes coming down the pipe will help address this larger issue; however, I will still be a fan of having many tools available to those who need them and promoting the empowerment of people to choose what tools will work best for their recovery.
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I have no interest in taking away options from patients.
My problem here is that we have a treatment model with an NNT of 1.25 over 5 years. (Not 12 weeks like the study above.) It gets no press and it’s limited to certain groups of patients with high SES. It’s expensive and relatively complicated, but, as I demonstrated, it could be done much more cheaply. Would it maintain an NNT of 1.25 as it was expanded to other populations? I don’t know. Probably not. But, it’d have a long way to fall before it got to 12 or 20.
NNT is new to me, but I can think of 2 circumstances where I’d be enthused about an NNT of 12 or 20. First, if it was a pretty hopeless condition. Second, if I believed we’d find a way to target the treatment and could improve the NNT with patient selection based on something like genetics or disease subtype.
Addiction isn’t hopeless. Several treatments compare well to treatments for other chronic diseases in compliance and relapse. We’re trying to do better than that relatively low bar. I see a few big barriers. One, as you identified, is classism. Two, is the assumption that addiction is especially hard to treat. (This assumption is understandable. We’ve been treating it poorly and getting poor outcomes. Similar to treating strep throat with 3 days of penicillin at too low a dose or just aspirin rather than the recommended 10 days at the proper dose. We’d start to assume that this is just a really intractable illness.) Three, a cultural/economic reliance on pills and procedures to treat chronic illnesses that respond strongly to lifestyle medicine. Not only do we get poorer outcomes for the chronic illnesses, but we lose the other benefits of the lifestyle interventions that include the prevention of other chronic illnesses and improved global mental and physical health.
So, if a patient wants one of these meds, that’s fine with me, as long as they’re told that this treatment has an NNT of 12 (or 20) over 12 weeks and that there is a treatment that has an NNT of 1.25, but they aren’t getting it because of funding, practitioner bias, etc.
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There’s a lot to agree with here, but we still need to make some kind of judgement on how effective expensive medications are. There is merit in comparing them to psychosocial interventions and also to measuring whether they have an adjuvant effect to such interventions.
Meta-analyses can have challenges in interpretation, but they are ranked the highest form of evidence by many. Numbers needed to treat is an effective way of presenting how effective an intervention is. Generally we would consider a drug effective if NNT were 1-3. NNTs to achieve abstinence (the goal) of 12 for acamprosate and 20 for acamprosate and naltrexone are poor (even with an eye to your comments on how difficult addiction is to treat).
Treatment programmes that include multiple evidence-based interventions and cover as many bases as possible (therapy, therapeutic community, housing, education, employment, families, active connection to mutual aid, etc) will be associated with long term drinking outcomes much better than this.
I would not argue that these drugs have no merit , but I do worry about how such research is interpreted. We have bewildering faith in medications to solve complex disorders. Driven by big pharma and others with vested interests, such poor results can be trumpeted as success. To me there is something of the Emperor’s New Clothes about it all.
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I love this sentence, “We have bewildering faith in medications to solve complex disorders.”
There’s so much obvious truth in it, but it runs completely against our culture.
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Funnily enough, working on a bit of a blog with that theme, inspired by this…
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Cost for treatment for program you outlined for 5 years = $23,900
The most common crime for the federally incarcerated population is a drug offense (47.3%)
Cost for incarceration for inmate in prison for 5 years = $141,615
These statistics beg the question “Why are we still having to have this discussion?” as it seems totally nonsensical to not offer treatment as the most viable (both for the addict and for fiscal responsibility of taxpayers money) option to ease the burden of a society being torn apart by addiction.
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