This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
This study included 739 people with alcohol dependence. Researchers compared strategies to help people take the medication acamprosate as prescribed, to prevent relapse. All participants received standard support (monthly check-ins with addiction services or a GP). The study found that, compared to standard support alone:
- extra telephone support by a pharmacist, plus financial incentives, increased the numbers who took medication as prescribed
- the same telephone support without financial incentives did not significantly increase the numbers taking medication as prescribed.
Information and support for alcohol dependence is available on the NHS website.
The issue: how to help people with alcohol dependence take acamprosate
In England, alcohol misuse is the biggest risk factor for death, ill-health and disability among 15 - 49 year-olds. As of 2019, more than 600,000 people in England were dependent on alcohol. Some complete alcohol treatment successfully but most have frequent relapses.
The medication acamprosate reduces alcohol cravings and helps prevent relapse in people who have stopped drinking. It is recommended by the National Institute for Health and Care Excellence (NICE) in combination with psychological support. People need to take 2 tablets, 3 times a day, at set times. Some struggle to follow these instructions and fail to take the full course of medication, which makes it less effective. Standard support to help people take acamprosate involves monthly check-ins with addiction services for 3 months, and afterwards with their GP.
Extra support might help more people take acamprosate as prescribed. One novel approach is regular telephone calls from a pharmacist. The pharmacist provides information and emotional support, encourages people to take their medication as prescribed, and discusses strategies that might help. People may be offered financial incentives via shopping vouchers, for example, to reinforce their engagement with these calls.
This study assessed the effectiveness and value for money of telephone support, with or without financial incentives, for people prescribed acamprosate. Telephone support involved 1 – 2 calls every 2 weeks for 3 months, followed by 1 call per month up to month 6.
What’s new?
This randomised controlled trial included people across England who had alcohol dependence and were taking acamprosate. Their average age was 46 and most (61%) were male. They were alcohol-free following detoxification at the start of the study.
All participants received standard support. 372 people received no other help, but 182 received telephone support in addition. A further 185 people received telephone support plus incentives (up to £120 in shopping vouchers over 6 months).
The researchers intended to monitor electronically how closely people followed treatment instructions, but the system was too cumbersome for participants. Therefore, collection of the primary outcome was changed to self-reports by participants 6 months after joining the trial. More than 2 in 3 participants provided data (69%, 67%, 76% in different groups).
The researchers found that:
- with standard support alone, well under half (38%) took their medication as prescribed
- with extra telephone support, numbers rose slightly (41%) but the difference was not meaningful
- with extra telephone support plus financial incentives, more (49%) took their medication as prescribed; this was a meaningful increase over standard support alone.
An economic analysis included costs to alcohol services, supported accommodation, and hospital costs. It suggested that telephone support plus incentives was cost-effective compared to standard support alone over 6 months; economic modelling suggested it was cost-effective over 20 years.
Telephone support without incentives was not cost-effective over 6 months compared to standard support alone, but became cost-effective over 20 years. This was because of the long-term health benefits of stopping drinking, such as fewer alcohol-related deaths and diseases.
Why is this important?
Telephone support plus incentives could be a cost-effective way to encourage more people to take acamprosate as prescribed, compared to standard support. The same telephone support offered without incentives did not encourage more people to take their medication as prescribed, and was not cost-effective during the study. However, both approaches were cost-effective once the full benefits of reduced drinking were modelled over the longer term.
Even with the maximum intervention (standard and telephone support plus incentives), only half (49%) of the group took their medication as prescribed. But the researchers say the increase compared with standard support alone, is enough to make a meaningful difference.
A limitation of this study is that the way the primary outcome was measured had to be changed; this is only done in exceptional circumstances. The self-reported data may contain inaccuracies, and few people provided data after 1 year.
What’s next?
The findings have been incorporated into the new UK guidelines for alcohol treatment, due to be published later this year (2024).
Telephone support offered benefits beyond following treatment more closely. People received encouragement from pharmacists and were advised to seek help when they needed it. The researchers say the results support a greater role for pharmacists in addiction treatment. They suggested that telephone support, delivered by specially trained pharmacists, is practical and cost-effective because it makes use of existing expertise and infrastructure.
During the study, the researchers noted that relatively few people who were eligible for acamprosate received it in addiction treatment services, even though it has been recommended by NICE for more than 10 years. In some areas, NHS commissioners had not made acamprosate available. The researchers call for greater awareness of the value of alcohol dependence medications among clinicians, and for all commissioners to make the treatment available.
You may be interested to read
This is a summary of: Donoghue K, and others. Adjunctive Medication Management and Contingency Management to enhance adherence to acamprosate for alcohol dependence: the ADAM trial RCT. Health Technology Assessment 2023; 27: 1 – 118.
Information on the dangers of drinking too much from the World Health Organisation.
Information on alcohol dependence from Alcohol Change UK.
A study about the difficulty in measuring adherence to acamprosate: Donoghue K, and others. The rates and measurement of adherence to acamprosate in randomised controlled clinical trials: A systematic review. PLoS One 2022; 17. DOI: 10.1371/journal.pone.0263350.
Funding: The study was funded by the NIHR Health and Technology Assessment programme.
Conflicts of Interest: Several of the study authors have received funding from pharmaceutical companies. See paper for full details.
Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
