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Dr. Salsitz: 
Hello, this is CME on ReachMD. And I'm Dr. Edwin Salsitz. Here with me today is Dr. Ethan Cowan.

Acamprosate, like naltrexone, has often been used as a treatment for patients with alcohol use disorder. Dr. Cowan, let's spend some time looking at this agent, acamprosate. What's been your experience with acamprosate?

Dr. Cowan: 
Yeah, so acamprosate is one of the three FDA approved agents for the treatment for alcohol use disorder. Now in my practice in the emergency department, it's used relatively uncommonly. And in reality, there's actually very few patients that we see that come in who are on acamprosate, and I think part of this is due to, again, a lack of education on the part of providers about which medications are available for the treatment for alcohol use disorder. And then with acamprosate in particular, I think that those people who do know about this agent, feel that maybe it's less effective than some of the others or maybe it's more difficult to use because there are contraindications for patients who have ongoing renal disease. So I think unlike maybe some of the other agents, this one is used less often.

So that being my experience, I'm actually curious to kind of hear how this is used more often in the outpatient setting?

Dr. Salsitz: 
Well Dr. Cowan, I agree with everything you've said. Acamprosate has been a unusual drug in the sense that it did very well in European studies, particularly with abstinence as the goal as opposed to decreased heavy drinking. However, in the United States, the studies were not as robust.

The mechanism of action is very intriguing that it operates by balancing out the glutamatergic and GABA interactions which are disturbed by alcohol. But one of the problems with acamprosate is you have to take two pills three times a day. So that brings in the adherence and compliance, and that's not easy to do three times a day. And it also has a 16 to 20% incidence of diarrhea.

And for those reasons, I agree with you, it's become kind of a second-line drug. There are times when naltrexone cannot be used when somebody is on opioid medication for pain or for addiction. And so acamprosate can be tried. You know, with all these medications, one size does not fit all, and it's often a trial-and-error situation.

Dr. Cowan: 
Yeah, that's great. Again, I think that this is a medication that's useful, more likely in our setting as a second-line agent, and oftentimes probably won’t be started upon referral.

Dr. Salsitz:
Yeah. The data on acamprosate is that it should be started when the patient is abstinent for a week or so. Somehow the results are better that way. The other thing about the acamprosate and the naltrexone is that some people think if you drink while you take those medications, you'll get sick. So they're confusing those medications with disulfiram and you don't get sick. We don't want people to drink excessively on the medications, but if they do, they don't get sick.

Dr. Cowan:
That's a really good point.

Dr. Salsitz: 
So this brief discussion has further added to our understanding of the pharmacologic and the psychosocial management of patients with alcohol use disorder. Unfortunately, our time is up. Thanks for listening.

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