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Meta-Analysis
. 2014 Feb 13;2014(2):CD008544.
doi: 10.1002/14651858.CD008544.pub2.

Anticonvulsants for alcohol dependence

Affiliations
Meta-Analysis

Anticonvulsants for alcohol dependence

Pier Paolo Pani et al. Cochrane Database Syst Rev. .

Abstract

Background: Alcohol dependence is a major public health problem that is characterised by recidivism and a host of medical and psychosocial complications. Besides psychosocial interventions, different pharmacological interventions have been or currently are under investigation through Cochrane systematic reviews.

Objectives: The primary aim of the review is to assess the benefits/risks of anticonvulsants for the treatment of alcohol dependence.

Search methods: We searched the Cochrane Drugs and Alcohol Group Trials Register (October 2013), PubMed (1966 to October 2013), EMBASE (1974 to October 2013) and CINAHL (1982 to October 2013).

Selection criteria: Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) comparing anticonvulsants alone or in association with other drugs and/or psychosocial interventions versus placebo, no treatment and other pharmacological or psychosocial interventions.

Data collection and analysis: We used standard methodological procedures as expected by The Cochrane Collaboration.

Main results: A total of 25 studies were included in the review (2641 participants). Most participants were male, with an average age of 44 years. Anticonvulsants were compared with placebo (17 studies), other medications (seven studies) and no medication (two studies). The mean duration of the trials was 17 weeks (range four to 52 weeks). The studies took place in the USA, Europe, South America, India and Thailand. Variation was reported in the characteristics of the studies, including their design and the rating instruments used. For many key outcomes, the risk of bias associated with unclear or unconcealed allocation and lack of blinding affected the quality of the evidence.Anticonvulsants versus placebo: For dropouts (16 studies, 1675 participants, risk ratio (RR) 0.94, 95% confidence interval (Cl) 0.74 to 1.19, moderate-quality evidence) and continuous abstinence (eight studies, 634 participants, RR 1.21, 95% Cl 95% 0.97 to 1.52, moderate-quality evidence), results showed no evidence of differences. Moderate-quality evidence suggested that anticonvulsants reduced drinks/drinking days (11 studies, 1126 participants, mean difference (MD) -1.49, 95% Cl -2.32 to -0.65) and heavy drinking (12 studies, 1129 participants, standardised mean difference (SMD) -0.35, 95% Cl -0.51 to -0.19). Moreover, withdrawal for medical reasons (12 studies, 1410 participants, RR 1.22, 95% Cl 0.58 to 2.56, moderate-quality evidence) showed no evidence of difference, but for specific adverse effects (nine studies, 1164 participants), two of 18 adverse event outcomes favoured placebo. The direction of results was confirmed by subgroup analyses for topiramate and partially for gabapentin and valproate.Anticonvulsants versus naltrexone: No evidence of difference was shown in dropout rates (five studies, 528 participants, RR 0.74, 95% CI 0.52 to 1.06), severe relapse rates (four studies, 427 participants, RR 0.69, 95% Cl 0.44 to 1.07) and continuous abstinence rates (five studies, 528 participants, RR 1.21, 95% Cl 0.99 to 1.49); anticonvulsants were associated with fewer heavy drinking days (three studies, 308 participants, MD -5.21, 95% Cl -8.58 to -1.83), more days to severe relapse (three studies, 244 participants, MD 11.88, 95% Cl 3.29 to 20.46) and lower withdrawal for medical reasons (three studies, 245 participants, RR 0.13, 95% Cl 0.03 to 0.58).

Authors' conclusions: At the current stage of research, randomised evidence supporting the clinical use of anticonvulsants to treat alcohol dependence is insufficient. Results are conditioned by heterogeneity and by the low number and quality of studies comparing anticonvulsants with other medications. The uncertainty associated with these results leaves to clinicians the need to balance possible benefits/risks of treatment with anticonvulsants versus other medications as supported by evidence of efficacy.

PubMed Disclaimer

Conflict of interest statement

None

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 Anticonvulsants versus placebo, outcome: 1.1 Dropouts.
5
5
Forest plot of comparison: 1 Anticonvulsants versus placebo, outcome: 1.3 Alcohol use, continuous outcome: drinks/drinking day.
6
6
Forest plot of comparison: 1 Anticonvulsants versus placebo, outcome: 1.4 Alcohol use, continuous outcome: heavy drinking.
7
7
Forest plot of comparison: 1 Anticonvulsants versus placebo, outcome: 1.5 Continuous abstinence, dichotomous outcome.
8
8
Forest plot of comparison: 1 Anticonvulsants versus placebo, outcome: 1.6 Abstinence, continuous outcome.
9
9
Forest plot of comparison: 1 Anticonvulsants versus placebo, outcome: 1.7 Adverse events.
10
10
Funnel plot of comparison: 1 Anticonvulsants versus placebo, outcome: 1.1 Dropouts.
1.1
1.1. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 1 Dropouts.
1.2
1.2. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 2 Heavy drinking, dichotomous outcome.
1.3
1.3. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 3 Alcohol use, continuous outcome: drinks/drinking day.
1.4
1.4. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 4 Alcohol use, continuous outcome: heavy drinking.
1.5
1.5. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 5 Continuous abstinence, dichotomous outcome.
1.6
1.6. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 6 Abstinence, continuous outcome.
1.7
1.7. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 7 Adverse events.
1.8
1.8. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 8 Craving (OCDS total score or analogue scale).
1.9
1.9. Analysis
Comparison 1 Anticonvulsants versus placebo, Outcome 9 Liver enzyme levels (GGT).
2.1
2.1. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 1 Dropouts.
2.2
2.2. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 2 Heavy drinking, dichotomous outcome: valproate.
2.3
2.3. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 3 Alcohol use, continuous outcome: drinks/drinking day.
2.4
2.4. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 4 Alcohol use, continuous outcome: heavy drinking.
2.5
2.5. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 5 Abstinence, continuous outcome.
2.6
2.6. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 6 Continuous abstinence, dichotomous outcome.
2.7
2.7. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 7 Adverse events.
2.8
2.8. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 8 Craving (OCDS total score or analogue scale).
2.9
2.9. Analysis
Comparison 2 Specific anticonvulsants versus placebo, Outcome 9 Liver enzyme levels.
3.1
3.1. Analysis
Comparison 3 Anticonvulsants versus placebo according to length of trial, Outcome 1 Dropouts.
3.2
3.2. Analysis
Comparison 3 Anticonvulsants versus placebo according to length of trial, Outcome 2 Heavy drinking, dichotomous outcome: over six weeks.
3.3
3.3. Analysis
Comparison 3 Anticonvulsants versus placebo according to length of trial, Outcome 3 Alcohol use, continuous outcome: drinks/drinking day.
3.4
3.4. Analysis
Comparison 3 Anticonvulsants versus placebo according to length of trial, Outcome 4 Alcohol use, continuous outcome: heavy drinking.
3.5
3.5. Analysis
Comparison 3 Anticonvulsants versus placebo according to length of trial, Outcome 5 Continuous abstinence, dichotomous outcome.
3.6
3.6. Analysis
Comparison 3 Anticonvulsants versus placebo according to length of trial, Outcome 6 Abstinence, continuous outcome.
3.7
3.7. Analysis
Comparison 3 Anticonvulsants versus placebo according to length of trial, Outcome 7 Adverse events.
4.1
4.1. Analysis
Comparison 4 Anticonvulsants versus placebo according to psychosocial interventions, Outcome 1 Dropouts.
4.2
4.2. Analysis
Comparison 4 Anticonvulsants versus placebo according to psychosocial interventions, Outcome 2 Heavy drinking, dichotomous outcome: associated psychotherapy.
4.3
4.3. Analysis
Comparison 4 Anticonvulsants versus placebo according to psychosocial interventions, Outcome 3 Alcohol use, continuous outcome: drinks/drinking day.
4.4
4.4. Analysis
Comparison 4 Anticonvulsants versus placebo according to psychosocial interventions, Outcome 4 Alcohol use, continuous outcome: heavy drinking.
4.5
4.5. Analysis
Comparison 4 Anticonvulsants versus placebo according to psychosocial interventions, Outcome 5 Continuous abstinence, dichotomous outcome.
4.6
4.6. Analysis
Comparison 4 Anticonvulsants versus placebo according to psychosocial interventions, Outcome 6 Abstinence, continuous outcome, days abstinent (%): associated psychotherapy.
4.7
4.7. Analysis
Comparison 4 Anticonvulsants versus placebo according to psychosocial interventions, Outcome 7 Adverse events.
5.1
5.1. Analysis
Comparison 5 Anticonvulsants versus placebo according to psychiatric co‐morbidity, Outcome 1 Dropouts.
5.2
5.2. Analysis
Comparison 5 Anticonvulsants versus placebo according to psychiatric co‐morbidity, Outcome 2 Heavy drinking, dichotomous outcome.
5.3
5.3. Analysis
Comparison 5 Anticonvulsants versus placebo according to psychiatric co‐morbidity, Outcome 3 Alcohol use, continuous outcome: drinks/drinking day.
5.4
5.4. Analysis
Comparison 5 Anticonvulsants versus placebo according to psychiatric co‐morbidity, Outcome 4 Alcohol use, continuous outcome: heavy drinking.
5.5
5.5. Analysis
Comparison 5 Anticonvulsants versus placebo according to psychiatric co‐morbidity, Outcome 5 Continuous abstinence, dichotomous outcome.
5.6
5.6. Analysis
Comparison 5 Anticonvulsants versus placebo according to psychiatric co‐morbidity, Outcome 6 Abstinence, continuous outcome.
5.7
5.7. Analysis
Comparison 5 Anticonvulsants versus placebo according to psychiatric co‐morbidity, Outcome 7 Adverse events.
6.1
6.1. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 1 Dropouts.
6.2
6.2. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 2 Severe relapse, dichotomous outcome.
6.3
6.3. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 3 Number of heavy drinking days.
6.4
6.4. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 4 Continuous abstinence, dichotomous outcome.
6.5
6.5. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 5 Abstinence continuous outcome: days to severe relapse.
6.6
6.6. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 6 Adverse events.
6.7
6.7. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 7 Craving (OCDS total score).
6.8
6.8. Analysis
Comparison 6 Anticonvulsants versus other medications (naltrexone), Outcome 8 Liver enzyme levels (GGT).
7.1
7.1. Analysis
Comparison 7 Specific anticonvulsants (topiramate) versus specific other medications (naltrexone), Outcome 1 Dropouts.
7.2
7.2. Analysis
Comparison 7 Specific anticonvulsants (topiramate) versus specific other medications (naltrexone), Outcome 2 Severe relapse, dichotomous outcome.
7.3
7.3. Analysis
Comparison 7 Specific anticonvulsants (topiramate) versus specific other medications (naltrexone), Outcome 3 Continuous abstinence, dichotomous outcome.
7.4
7.4. Analysis
Comparison 7 Specific anticonvulsants (topiramate) versus specific other medications (naltrexone), Outcome 4 Craving (OCDS total score).
8.1
8.1. Analysis
Comparison 8 Anticonvulsants versus no medication, Outcome 1 Alcohol use dichotomous: relapse.
8.2
8.2. Analysis
Comparison 8 Anticonvulsants versus no medication, Outcome 2 Mood.
8.3
8.3. Analysis
Comparison 8 Anticonvulsants versus no medication, Outcome 3 Craving (OCDS score).

Update of

References

References to studies included in this review

Anton 2009 {published data only}
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Baltieri 2008 {published data only}
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Brady 2002 {published data only}
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Brower 2008 {published data only}
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Croissant 2006 {published data only}
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De Sousa 2008 {published data only}
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Fertig 2012 {published data only}
    1. Fertig JB, Ryan ML, Falk DE, Litten RZ, Mattson ME, Ransom J, et al. NCIG 002 Study Group. A double‐blind, placebo‐controlled trial assessing the efficacy of levetiracetam extended‐release in very heavy drinking alcohol‐dependent patients. Alcoholism: Clinical and Experimental Research 2012;36:1421‐30. - PMC - PubMed
Florez 2008 {published data only}
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Florez 2011 {published data only}
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Furieri 2007 {published data only}
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Johnson 2003 {published data only}
    1. Johnson BA, Ait‐Daoud N, Akhtar FZ, Ma JZ. Oral topiramate reduces the consequences of drinking and improves the quality of life of alcohol‐dependent individuals: a randomized controlled trial. Archives of General Psychiatry 2004;61:905‐12. - PubMed
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Johnson 2007 {published data only}
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Kampman 2013 {published and unpublished data}
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Likhitsathian 2013 {published data only}
    1. Likhitsathian S, Uttawichai K, Booncharoen H, Wittayanookulluk A, Angkurawaranon C, Srisurapanont M. Topiramate treatment for alcoholic outpatients recently receiving residential treatment programs: a 12‐week, randomized, placebo‐controlled trial. Drug and Alcohol Dependence 2013;133:440‐6. - PubMed
Martinotti 2007 {published data only}
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Martinotti 2010 {published data only}
    1. Martinotti G, Nicola M, Tedeschi D, Andreoli S, Reina D, Pomponi M, et al. Pregabalin versus naltrexone in alcohol dependence: a randomised, double‐blind, comparison trial. Journal of Psychopharmacology 2010;24:1367‐74. - PubMed
Mueller 1997 {published data only}
    1. Mueller TI, Stout RL, Rudden S, Brown RA, Gordon A, Solomon DA, et al. A double‐blind, placebo‐controlled pilot study of carbamazepine for the treatment of alcohol dependence. Alcoholism: Clinical and Experimental Research 1997;21:86‐92. - PubMed
Paparrigopoulos 2010 {published data only}
    1. Paparrigopoulos T, Tzavellas E, Karaiskos D, Malitas P, Liappas I. An open pilot study of tiagabine in alcohol dependence: tolerability and clinical effects. Journal of Psychopharmacology 2010;24:1375‐80. - PubMed
Paparrigopoulos 2011 {published data only}
    1. Paparrigopoulos T, Tzavellas E, Karaiskos D, Kourlaba G, Liappas I. Treatment of alcohol dependence with low‐dose topiramate: an open‐label controlled study. BMC Psychiatry 2011;11:41. - PMC - PubMed
Richter 2012 {published data only}
    1. Richter C, Effenberger S, Bschor T, Bonnet U, Haasen C, Preuss UW, et al. Efficacy and safety of levetiracetam for the prevention of alcohol relapse in recently detoxified alcohol‐dependent patients: a randomized trial. Journal of Clinical Psychopharmacology 2012;32:558‐62. - PubMed
Rubio 2009 {published data only}
    1. Rubio G, Martínez‐Gras I, Manzanares J. Modulation of impulsivity by topiramate: implications for the treatment of alcohol dependence. Journal of Clinical Psychopharmacology 2009;29:584‐9. - PubMed
Salloum 2005 {published data only}
    1. Salloum IM, Cornelius JR, Daley DC, Kirisci L, Himmelhoch JM, Thase ME. Efficacy of valproate maintenance in patients with bipolar disorder and alcoholism: a double‐blind placebo‐controlled study. Archives of General Psychiatry 2005;62:37‐45. - PubMed
Trevisan 2008 {published data only}
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References to studies excluded from this review

Karam‐Hage 2003 {published data only}
    1. Karam‐Hage M, Brower KJ. Open pilot study of gabapentin versus trazodone to treat insomnia in alcoholic outpatients. Journal of Psychiatry and Clinical Neuroscience 2003;57:542‐4. - PMC - PubMed
Knapp 2010 {published data only}
    1. Knapp CM, Sarid‐Segal O, Richardson MA, Colaneri LS, Afshar M, Devine E, et al. Open label trial of the tolerability and efficacy of zonisamide in the treatment of alcohol dependence. American Journal of Drug and Alcohol Abuse 2010;36:102‐5. - PMC - PubMed
Le Strat 2012 {published data only}
    1. Strat Y. Levetiracetam in the treatment of alcohol dependence: toward the end of the story?. Alcoholism: Clinical and Experimental Research 2012;36:1309‐10. - PubMed
Miranda 2008 {published data only}
    1. Miranda R Jr, MacKillop J, Monti PM, Rohsenow DJ, Tidey J, Gwaltney C, et al. Effects of topiramate on urge to drink and the subjective effects of alcohol: a preliminary laboratory study. Alcoholism: Clinical and Experimental Research 2008;32:489‐97. - PubMed
Mitchell 2012 {published data only}
    1. Mitchell JM, Grossman LE, Coker AR, Messing RO. The anticonvulsant levetiracetam potentiates alcohol consumption in non‐treatment seeking alcohol abusers. Journal of Clinical Psychopharmacology 2012;32:269‐72. - PubMed
Myrick 2007 {published data only}
    1. Myrick H, Anton R, Voronin K, Wang W, Henderson S. A double‐blind evaluation of gabapentin on alcohol effects and drinking in a clinical laboratory paradigm. Alcoholism: Clinical and Experimental Research 2007;31:221‐7. - PubMed
Narayana 2008 {published data only}
    1. Narayana PL, Gupta AK, Sharma PK. Use of anti‐craving agents in soldiers with alcohol dependence syndrome. Medical Journal of Armed Forces India 2008;64:320‐4. - PMC - PubMed
Schacht 2013 {published data only}
    1. Schacht JP, Anton RF, Randall PK, Li X, Henderson S, Myrick H. Effects of a GABA‐ergic medication combination and initial alcohol withdrawal severity on cue‐elicited brain activation among treatment‐seeking alcoholics. Psychopharmacology 2013;227:627‐37. - PMC - PubMed

References to studies awaiting assessment

Bajovic 2012 {published data only}
    1. Bajovic B, Zivkovic N, Djokic G, Pavicevic D. Oxcarbazepine, topiramate and lamotrigine in the treatment of alcohol craving. European Neuropsychopharmacology 2012;22:S65‐6.
De Vita 2012 {published data only}
    1. Vita O, Martinotti G, Nicola M, Tedeschi D, Hatzigiakoumis DS, Monetta M, et al. Topiramate at low dosage vs. placebo in alcohol dependence. European Psychiatry 2012;27:1.
MacKillop 2012 {published data only}
    1. MacKillop J, Monti PM, Tidey J, Swift RM, Ray LA, Miranda R. Behavioral economic analysis of topirmate's effects on motivation for alcohol. Alcoholism: Clinical and Experimental Research 2012;36:247A.
Mason 2010 {published and unpublished data}
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Miranda 2011 {published data only (unpublished sought but not used)}
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Rubio 2002 {published data only}
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References to ongoing studies

Ait‐Daoud 2010 {unpublished data only}
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Anthenelli 2008 {unpublished data only}
    1. Anthenelli R, Heffner JL, Nolting S. Topiramate to Aid Smoking Cessation in Recovering Alcohol Dependent Men. ClinicalTrials.gov 2008.
Batki 2010 {unpublished data only}
    1. Batki LS. Topiramate Treatment of Alcohol Use Disorders in Veterans With Post Traumatic Stress Disorder (PTSD): A Pilot Controlled Trial of Augmentation Therapy. ClinicalTrials.gov 2010.
Beresford 2011 {unpublished data only}
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Ciraulo 2009 {unpublished data only}
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Del Bello 2007 {unpublished data only}
    1. DelBello M. Quetiapine Plus Topiramate or Placebo for Bipolar Mania and Alcohol Use in Adolescents & Young Adults. ClinicalTrials.gov 2007.
Fischer 2011 {unpublished data only}
    1. Fischer BA. A 14‐week Randomized, Placebo‐controlled Study of Topiramate for Alcohol Use Disorders in Veterans With Posttraumatic Stress Disorder. ClinicalTrials.gov 2011.
Frye 2005 {unpublished data only}
    1. Frye MA. An Evaluation of Divalproex vs. Olanzapine for Alcohol Abuse Relapse Prevention in Patients With Bipolar Disorder. ClinicalTrials.gov 2005.
Johnson 2000 {unpublished data only}
    1. Johnson BA, Ait‐Daoud N. Combining Medications: Treatment for Alcoholism. ClinicalTrials.gov 2000.
Johnson 2007 b {unpublished data only}
    1. Johnson B, Ait‐Daoud N. Novel Pharmacotherapy for Dual Dependence. ClinicalTrials.gov 2007.
Jorge 2011 {unpublished data only}
    1. Jorge RE. Treatment Strategy for Alcohol Use Disorders in Veterans With TBI. ClinicalTrials.gov 2011.
Kampman 2011 {unpublished data only}
    1. Kampman KM. A Phase II, Double‐Blind, Placebo‐Controlled, Pilot Trial of Vigabatrin for the Treatment of Cocaine and Alcohol Dependence. ClinicalTrials.gov 2011.
Kranzler 2008 {unpublished data only}
    1. Kranzler HR, Covault J, Arias A, Oncken C, Tennen H, Gelernter J, Armeli S, Drazinic C, Chamberlain S, Levine E, Jensen K, Lieberman R. Topiramate Treatment of Problem Drinkers. ClinicalTrials.gov 2008.
Mariani 2010 {unpublished data only}
    1. Mariani J. Gabapentin for Abstinence Initiation in Alcohol Dependence. ClinicalTrials.gov 2010.
Mason 2009 {unpublished data only}
    1. Mason BJ. Duloxetine Versus Pregabalin for Alcohol Dependence. ClinicalTrials.gov 2009.
Messing 2008 {unpublished data only}
    1. Messing RO, Mitchell JM. Placebo‐Controlled Crossover Trial of Levetiracetam on Ethanol Intake. ClinicalTrials.gov 2008.
Ostacher 2007 {unpublished data only}
    1. Ostacher MJ. Adjunctive Topiramate for Treatment of Alcohol Dependence in Patients With Bipolar Disorder. ClinicalTrials.gov 2007.
Petrakis 2007 {unpublished data only}
    1. Petrakis IL. The Use of Anticonvulsants for Treatment of Patients With Alcohol Dependence and Post Traumatic Stress Disorder. ClinicalTrials.gov 2007.
Ralevski 2007 {unpublished data only}
    1. Ralevski E. Topiramate for Treatment of Patients With Borderline Personality Disorder and Alcohol Dependence. ClinicalTrials.gov 2007.
Schaefer 2008 {unpublished data only}
    1. Schaefer M. Efficacy and Safety of Levetiracetam in Prevention of Alcohol Relapse in Recently Detoxified Alcohol Dependent Patients. ClinicalTrials.gov 2008. - PubMed
South Carolina 2001 {unpublished data only}
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