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 Table of Contents    
LETTERS TO EDITOR  
Year : 2021  |  Volume : 63  |  Issue : 3  |  Page : 297-298
Is there a case for inclusion of medicines used to manage alcohol use disorder in the World Health Organization Model List of Essential Medicines?


Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India

Click here for correspondence address and email

Date of Submission07-Apr-2020
Date of Decision06-Jun-2020
Date of Acceptance17-Feb-2021
Date of Web Publication17-Jun-2021
 

How to cite this article:
Balhara YP, Tarwani J. Is there a case for inclusion of medicines used to manage alcohol use disorder in the World Health Organization Model List of Essential Medicines?. Indian J Psychiatry 2021;63:297-8

How to cite this URL:
Balhara YP, Tarwani J. Is there a case for inclusion of medicines used to manage alcohol use disorder in the World Health Organization Model List of Essential Medicines?. Indian J Psychiatry [serial online] 2021 [cited 2022 Nov 29];63:297-8. Available from: https://www.indianjpsychiatry.org/text.asp?2021/63/3/297/318717




Sir,

The current version (twenty first) of World Health Organization Model List of Essential Medicines (EML) does not include any medicines to treat alcohol use disorders (AUDs). No medicines to treat AUD were included in the previous edition of the list.[1] We argue a case for inclusion of these medicines in the EML by the WHO.

AUDs are responsible for around 14% of the total burden attributable to alcohol use globally. Furthermore, AUD accounts for close to one-tenth of the total burden attributable to mental disorders and substance use disorders worldwide.

Naltrexone, acamprosate, and disulfiram are the most used medicines for the management of AUD with an aim to prevent or delay relapse. Furthermore, benzodiazepines are the main stay of treatment for the management of alcohol withdrawal.

Cochrane reviews have documented the effectiveness of naltrexone and acamprosate for different outcomes when used for the management of AUD. A recent meta-analysis concludes that the aggregated effect size for naltrexone and acamprosate as compared to placebo in treatment of AUDs was small but significant (Hedges' g = 0.209 [95% confidence interval [CI] 0.157–0.262]).[2] A review on disulfiram by Skinner et al.[3] showed effect size of 0.58 (95% CI: 0.53–0.63). Over the past years, other pharmacological options have also been studied to treat AUDs.

An earlier meta-analysis found benzodiazepines were superior to placebo (odds ratio 3.28, 95% CI: 1.30–8.28) for therapeutic success within 2 days in the treatment of acute alcohol withdrawal.[4]

Treatment guidelines by the America Medical Association, Indian Psychiatric Society, and National Institute for Health and Clinical Excellence have recommended the use of long-acting benzodiazepines (for alcohol withdrawals), oral naltrexone, and acamprosate in the management of AUD. Furthermore, while acknowledging the quality of evidence in favor of the acamprosate, naltrexone, and disulfiram as “very low,” the WHO mhGAP resource center makes a “strong” recommendation that “acamprosate, disulfiram, or naltrexone should be offered as a part of treatment to reduce relapse to heavy alcohol use in alcohol-dependent patients.” Furthermore, the WHO strongly recommends benzodiazepines as ”front-line medication for the management of alcohol withdrawal in alleviating withdrawal discomfort and preventing seizures and delirium.”[5] Currently, however, none of these medicines is listed in the EML by the WHO. While diazepam has been included in the EML, it is not indicated for the management of alcohol withdrawal.

Cost-effectiveness, cost minimization, and cost benefit analysis have been done for acamprosate and naltrexone for the treatment of alcohol dependence syndrome in some countries which clearly shows public health benefits.[6]

The WHO has identified “lack of access to essential drugs”despite the potential health impact of essential drugs” as one of the serious global public health problems. As per Global Status Report on Alcohol and Health 2018, most of the persons living with AUD are not receiving appropriate treatment. Of the 23 countries that provided data to WHO, only 14% reported more than 40% treatment coverage for persons with AUD. Around 42% of the countries reported 20% or less treatment coverage.[7]

The WHO Model List of Essential Medicines has important public health implications. The Model List has been developed as a guide for the development of national and institutional essential medicine lists. The public health relevance of the WHO list is reflected in the fact that “national lists of essential medicines usually relate closely to national guidelines for clinical health care practice which are used for the training and supervision of health workers.” The WHO model list also guides the “procurement and supply of medicines in the public sector, schemes that reimburse medicine costs, medicine donations, and local medicine production.” As identified by the WHO “international organizations, including UNICEF, UNHCR, and UNFPA as well as nongovernmental organizations and international non-profit supply agencies, have adopted the essential medicines concept and base their medicine supply system mainly on the Model List.”

The criteria for the selection of essential medicines, as specified by the WHO, include factors such as “disease prevalence and public health relevance, evidence of clinical efficacy and safety, and comparative costs and cost-effectiveness.” Given the significant impact of AUD in terms of global burden of disease, huge treatment gap for AUD, and effectiveness and safety data, there is a strong case for inclusion of medicines used to manage AUD in the World Health Organization EML.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Balhara YP. A curious case of the World Health Organization's (WHO) approach on alcohol use disorders – inferences from the WHO list of essential drugs. Addiction 2013;108:2030.  Back to cited text no. 1
    
2.
Maisel NC, Blodgett JC, Wilbourne PL, Humphreys K, Finney JW. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: When are these medications most helpful? Addiction 2013;108:275-93.  Back to cited text no. 2
    
3.
Skinner MD, Lahmek P, Pham H, Aubin HJ. Disulfiram efficacy in the treatment of alcohol dependence: A meta-analysis. PLoS One 2014;9:e87366.  Back to cited text no. 3
    
4.
Holbrook AM, Crowther R, Lotter A, Cheng C, King D. Meta-analysis of benzodiazepine use in the treatment of acute alcohol withdrawal. CMAJ 1999;160:649-55.  Back to cited text no. 4
    
5.
WHO. Management of Alcohol Withdrawal; 2019. Available from: https://www.who.int/mental_health/mhgap/evidence/alcohol/q2/en. [Last accessed on 2020 Apr 02].  Back to cited text no. 5
    
6.
Schwappach D, Popova S, Mohapatra S, Patra J, Godinho A, Rehm J. Strategies for evaluating the economic value of drugs in alcohol dependence treatment. Drug Alcohol Depend 2012;122:165-73.  Back to cited text no. 6
    
7.
World Health Organization. Global Status Report on Alcohol and Health 2018. Geneva: World Health Organization; 2018.  Back to cited text no. 7
    

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Correspondence Address:
Yatan Pal Singh Balhara
Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_305_20

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