Medications only work modestly for the treatment of alcohol dependence. In TCPR’s last issue on substance abuse (June 2006) we reviewed the evidence on disulfiram (Antabuse), naltrexone, and acamprosate, and concluded that nal- trexone works modestly, acamprosate works less well, and Antabuse has little high quality data but probably works modestly for highly motivated patients. In this new study, funded by the manu- facturer of Topamax, 371 men and women with moderate alcohol depend- ence (5 drinks/day for men, 4 drinks/day for women – but note that the quantity used to define a “standard” drink was quite low: 4 oz. of wine and 10 oz. of beer) were randomly assigned to receive either Topamax, tapered gradually up to 300 mg/day, or placebo. After 14 weeks, patients in the Topamax group decreased percentage of heavy drinking days (HHDs) from 82% to 44%, vs. patients in the place- bo group, who decreased HHDs from 82% to 52% (Johnson BA, et al., JAMA 2007;298(14): 1641-1651).

TCPR’s Take: This was a very modest effect. To put it in concrete terms, before treatment, these patients had about 5.5 heavy drinking days (HDDs) per week. After 14 weeks, placebo patients decreased to about 3.5 HHDs, while Topamax patients decreased to about 3 HHDs. And there's a price to pay: patients on Topamax had side effects such as paresthesias (51% on Topamax vs. 11% on placebo), taste perversion (23% vs 5%), anorexia (20% vs 7%), and difficulty con- centrating (15% vs 3%).