Date Published: July 8, 2013
Publisher: BioMed Central
Author(s): A C Del Re, Adam J Gordon, Anna Lembke, Alex HS Harris.
As a quality improvement metric, the US Veterans Health Administration (VHA) monitors the proportion of patients with alcohol use disorders (AUD) who receive FDA approved medications for alcohol dependence (naltrexone, acamprosate, and disulfiram). Evidence supporting the off-label use of the antiepileptic medication topiramate to treat alcohol dependence may be as strong as these approved medications. However, little is known about the extent to which topiramate is used in clinical practice. The goal of this study was to describe and examine the overall use, facility-level variation in use, and patient -level predictors of topiramate prescription for patients with AUD in the VHA.
Using national VHA administrative data in a retrospective cohort study, we examined time trends in topiramate use from fiscal years (FY) 2009–2012, and predictors of topiramate prescription in 375,777 patients identified with AUD (ICD-9-CM codes 303.9x or 305.0x) treated in 141 VHA facilities in FY 2011.
Among VHA patients with AUD, rates of topiramate prescription have increased from 0.99% in FY 2009 to 1.95% in FY 2012, although substantial variation across facilities exists. Predictors of topiramate prescription were female sex, young age, alcohol dependence diagnoses, engagement in both mental health and addiction specialty care, and psychiatric comorbidity.
Veterans Health Administration facilities are monitored regarding the extent to which patients with AUD are receiving FDA-approved pharmacotherapy. Not including topiramate in the metric, which is prescribed more often than acamprosate and disulfiram combined, may underestimate the extent to which VHA patients at specific facilities and overall are receiving pharmacotherapy for AUD.
Four medications have been approved by the US Food and Drug Administration (FDA) for the treatment of alcohol dependence, including naltrexone (both oral and injectable extended release), acamprosate, and disulfiram . Naltrexone is an opioid antagonist that reduces the reward properties of and cravings for alcohol . Acamprosate reduces cravings and has been found to be efficacious in maintaining, but perhaps not producing, abstinence . While disulfiram may be more familiar to clinicians than naltrexone or acamprosate, some clinical practice guidelines do not recommend disulfiram as a first-line pharmacological treatment because of significant toxicity risks and limited evidence of effectiveness .
Table 1 presents data on the percent of patients with AUD who received topiramate from FY 2009 through 2012. Approximately 10% of patients prescribed topiramate also received one of the other FDA-approved medications for AUD during the same fiscal year. In FY 2009, nearly 1% (n = 3736) of the 372,817 patients with an AUD filled a prescription for topiramate. This rate increased to 1.45% (n = 5270) in FY 2010 among 357,467 patients with AUD. In FY 2011, 1.45% (n = 5454) of all veterans with AUD (N = 375,777) filled a VHA pharmacy prescription for topiramate. In FY 2012, 1.95% (n = 7427) of all veterans with AUD (N = 381,815) filled a VHA pharmacy prescription for topiramate. Within the 141 VHA facilities in FY 12, the overall proportion of patients who received topiramate ranged from 0% to 6.5% (mean, 2.03%; median, 1.69%) with seven sites prescribing topiramate to more than 2% of patients with AUD. When restricting the analyses to patients who had contact with VHA addiction specialty care within the year, the facility-level proportions of patients who received topiramate ranged from 0% to 13.4% (mean, 2.97%; median, 2.47%) with 16 sites prescribing topiramate to more than 5% of patients with AUD.
Although evidence supports the efficacy of topiramate for alcohol dependence [7-9,21-23], system monitoring metrics and quality measures of pharmacotherapy for AUD used within VHA  and developed elsewhere  only include FDA-approved medications (naltrexone, acamprosate, and disulfiram). This may not only underestimate actual overall patient utilization of pharmacotherapy for AUD but also unnecessarily penalize those facilities with higher rates of topiramate utilization.
Veterans Health Administration facilities are monitored regarding the extent to which patients with AUD are receiving FDA-approved pharmacotherapy. Approximately 2% of the nearly 400,000 VHA patients with AUD were prescribed topiramate, and there was substantial facility-level variation in use. Several patient characteristics were associated with greater likelihood of topiramate prescription, including being female, younger age, diagnosis of alcohol dependence (versus alcohol abuse), treatment in both mental health and addiction specialty care, and having a psychiatric comorbidity. Not including topiramate in the quality improvement metrics appears to underestimate the extent to which VHA patients, at specific facilities and overall, are being prescribed pharmacotherapy for AUDs. We believe that the evidence is sufficient to consider topiramate an evidenced-based treatment for alcohol dependence. Therefore topiramate should be included in related quality measures and system monitoring metrics in VHA and elsewhere.
The authors declare that they have no competing interests.
AD participated in the study design, performed the statistical analysis, and helped to draft the manuscript. AG participated in its coordination and helped to draft the manuscript. AL participated in its coordination and helped to draft the manuscript. AH conceived of the study, participated in its design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.