La combinación de farmacoterapia y de psicoterapia conductual son las intervenciones más eficaces para la dependencia al alcohol, según un estudio.
ESTADOS UNIDOS
De acuerdo con los resultados de un estudio publicado en la revista “JAMA” y coordinado por Raymond Anton, de la Universidad de Carolina del Sur, la administración de naltrexona como la psicoterapia conductual en un contexto de manejo médico son eficaces en el alcoholismo.
El ensayo, denominado Combine, se realizó entre enero de 2001 y enero de 2004, con datos de 1.383 personas que habían decidido ser abstemias tras un diagnóstico de dependencia al alcohol. Los participantes se dividieron en nueve grupos: en ocho se administró un fármaco - naltrexona, acamprosato, ambos, y/o dos placebos, con o sin psicoterapia- y en el restante, sólo psicoterapia conductual. Los pacientes fueron evaluados al cabo de un año del tratamiento.
Todos los grupos mostraron una reducción sustancial en la dependencia por la bebida. Durante el tratamiento tres grupos -el que recibió naltrexona, el de la psicoterapia y los placebos, y el de naltrexona más psicoterapia- fueron los que arrojaron mayores porcentajes de días de abstinencia (80,6, 79,2 y 77,1%, respectivamente); el grupo que recibió dos placebos registró el 75,1%.
"Dentro de un contexto de seguimiento médico, la naltrexona logra resultados similares a los del tratamiento psicoterápico. No hemos hallado eficacia en el acamprosato frente a placebo, ni tampoco una mayor efectividad en las combinaciones de los dos fármacos y la psicoterapia", concluyen los autores.
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http://jama.ama-assn.org/
Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence
The COMBINE Study: A Randomized Controlled Trial
Raymond F. Anton, MD; Stephanie S. O''Malley, PhD; Domenic A. Ciraulo, MD; Ron A. Cisler, PhD; David Couper, PhD; Dennis M. Donovan, PhD; David R. Gastfriend, MD; James D. Hosking, PhD; Bankole A. Johnson, MD, PhD; Joseph S. LoCastro, PhD; Richard Longabaugh, EdD; Barbara J. Mason, PhD; Margaret E. Mattson, PhD; William R. Miller, PhD; Helen M. Pettinati, PhD; Carrie L. Randall, PhD; Robert Swift, MD; Roger D. Weiss, MD; Lauren D. Williams, MD; Allen Zweben, DSW; for the COMBINE Study Research Group
JAMA. 2006;295:2003-2017.
Context Alcohol dependence treatment may include medications,
behavioral therapies, or both. It is unknown how combining these
treatments may impact their effectiveness, especially in the
context of primary care and other nonspecialty settings.
Objectives To evaluate the efficacy of medication, behavioral
therapies, and their combinations for treatment of alcohol dependence
and to evaluate placebo effect on overall outcome.
Design, Setting, and Participants Randomized controlled
trial conducted January 2001-January 2004 among 1383 recently
alcohol-abstinent volunteers (median age, 44 years) from 11
US academic sites with
Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, diagnoses of primary alcohol
dependence.
Interventions Eight groups of patients received medical
management with 16 weeks of naltrexone (100 mg/d) or acamprosate
(3 g/d), both, and/or both placebos, with or without a combined
behavioral intervention (CBI). A ninth group received CBI only
(no pills). Patients were also evaluated for up to 1 year after
treatment.
Main Outcome Measures Percent days abstinent from alcohol
and time to first heavy drinking day.
Results All groups showed substantial reduction in drinking.
During treatment, patients receiving naltrexone plus medical
management (n = 302), CBI plus medical management
and placebos (n = 305), or both naltrexone and CBI
plus medical management (n = 309) had higher percent
days abstinent (80.6, 79.2, and 77.1, respectively) than the
75.1 in those receiving placebos and medical management only
(n = 305), a significant naltrexone x behavioral
intervention interaction (
P = .009). Naltrexone also
reduced risk of a heavy drinking day (hazard ratio, 0.72; 97.5%
CI, 0.53-0.98;
P = .02) over time, most evident in
those receiving medical management but not CBI. Acamprosate
showed no significant effect on drinking vs placebo, either
by itself or with any combination of naltrexone, CBI, or both.
During treatment, those receiving CBI without pills or medical
management (n = 157) had lower percent days abstinent
(66.6) than those receiving placebo plus medical management
alone (n = 153) or placebo plus medical management
and CBI (n = 156) (73.8 and 79.8, respectively;
P<.001).
One year after treatment, these between-group effects were similar
but no longer significant.
Conclusions Patients receiving medical management with
naltrexone, CBI, or both fared better on drinking outcomes,
whereas acamprosate showed no evidence of efficacy, with or
without CBI. No combination produced better efficacy than naltrexone
or CBI alone in the presence of medical management. Placebo
pills and meeting with a health care professional had a positive
effect above that of CBI during treatment. Naltrexone with medical
management could be delivered in health care settings, thus
serving alcohol-dependent patients who might otherwise not receive
treatment.
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