Post on 06-Nov-2021
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
PharmacotherapyofAlcoholUseDisorders
in2017:WhatistheFirstLineMedication?
StevenL.Batki,M.D.UCSFDept.ofPsychiatry,SFVAMedicalCenter
AddictionResearchProgramandAddictionRecoveryTreatmentServices
October27,2017
Disclosures/Acknowledgments
• NIH/NIDA:researchgrants• DepartmentofDefense:researchgrants• DepartmentofVeteransAffairs:support
S.Batki,MD10/27/17 2
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Objectives
• Followingthispresentation,participantsshouldbeableto:– Namethe4FDA-approvedmedicationsand1otherefficaciousmedicationforAUD
– Identifyadverseeffects,majorrisks,andcontraindicationsoftheseAUDmedications
– NamewhichAUDmedicationscanbeusedwithwhichspecificAUDpatientpopulations
S.Batki,MD10/27/17 3
CaseExample
• Your57yomalepatienttellsyouheisdrinkingheavilyandwantshelp
• Heisstilldrinking;hasnotyetstopped• Hewantstoreduce,notstop• Heisonopioidanalgesics• HisLFTsareelevatedto3xULN• HisEGFR/CrCl indicatesmoderatelysevererenalfn imapairment
S.Batki,MD10/27/17 4
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
UnderutilizationofAUDPharmacotherapy• Alcoholisoneofonly3substances(othersaretobaccoand
opioids)withFDA-approvedefficaciousmedicationsavailable
• Andtherearealsosomeefficaciousnon-FDA-approvedpharmacotherapies
• YetthereisverylittleuseofAUDmedications• Reasonsunclear,multiple,mayincludeperceptionof
ineffectiveness• only8%ofadultsintheUSwithAUDaretreatedwith
medications(SAMHSA.Resultsfromthe2012NationalSurveyonDrugUseandHealth:://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/Index.aspx.AccessedJuly15,2014.
• InseverallargeVAstudiesoverthepastdecade,veryfewveteranswithAUDwerereceivingAUDmedications– 4%ofVApatientswithAUDreceivedmedsinFY2009
(HarrisAHetal.PharmacotherapyofalcoholusedisordersbytheVeteransHealthAdministration:patternsofreceiptandpersistence.Psychiatr Serv.2012;63(7):679-685).
S.Batki,MD10/27/17 5
AUDPharmacotherapy:SomeKeyIssues
• AUDpatientsareheterogeneous– Somemedicationsarecontraindicated,absolutelyorrelatively
incertainpatientgroups(e.g.thosetakingopioidsorwithsevereliverdz),incertainstagesofAUD(e.g activedrinkingvsremission)
– ResponsetoanyoneAUDmedicationisdifficulttopredict• Geneticfactorsmayplayakeyroleinresponse
• DifferentAUDmedicationspresentdifferent– Effectssizedifferences– adverseeffectprofiles– risk/benefitratios– adherencechallenges– costs
S.Batki,MD10/27/17 6
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Alcohol’sNeuropharmacologic EffectsAntonetal.2014Pharmacologictreatmentofalcoholism.Ch 30inHandbookofClinicalNeurology.125(3rd Ed)
AlcoholandtheNervousSystem,SullivanEV&Pfefferbaum AEds.
• ElevatesDAintheNAccàsalientattention,reinforcement,brainreward
• Opioid (Beta-endorphin)releaseà DAreleaseinNAcc
• GABAergic effectsduringintoxication;downregulation afterchronicuse
• Glutamateupregulation withchronicuse,increaseduringwithdrawal
• Otherneurochemicaleffectsinclude– nicotiniccholinergicreceptors– 5-HT– NA– Cannabinoid– Nociceptin-orphanin/ORL S.Batki,MD10/27/17 7
SomeNeurochemicalTargetsforAUDMedications
(adaptedfromAntonetal.2014Pharmacologictreatmentofalcoholism.Ch 30inHandbookofClinicalNeurology.125(3rd Ed)AlcoholandtheNervousSystem,SullivanEV&Pfefferbaum AEds..)
Phenomenon Neurochemistry Pharmacotherapy
Reward OpioidsGlutamate5-HT3Nicotinic cholinergic
Naltrexone*Acamprosate*,TopiramateOndansetronVarenicline
Protractedwithdrawal/dysphoria/anxiety
GlutamateGABA
Acamprosate*,TopiramateGabapentin, Baclofen
Impulsivity GlutamateOpioidsDA
?Topiramate?Naltrexone
*=FDA-approved;Boldface=moreevidenceexistsforefficacyS.Batki,MD10/27/178
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
EfficaciousAUDPharmacotherapies• FDA-approved
– Disulfiram (Antabuse)– Acamprosate (Campral)– Naltrexone
• Oral• Extended-releaseintramuscular(Vivitrol)
• Non-FDA-approved– Topiramate (Topamax,others)– Gabapentin(?)– Someothers:
• Nalmefene• Ondansetron (?)• Varenicline(?)• Baclofen(?)• Pregabalin• Zonisamide
S.Batki,MD10/27/17 9
SomePatientGroupswithClinicalRelevance
• Abstinentvsnonabstinent• Onopioidsvsnotonopioids• Severeliverdiseasevsnosevereliverdisease• Renalimpairmentvsnot• Goal– abstinencevsusereduction(“controlleduse”)
• Logistical:– Accesstofinancialmeansortoproviderswithspecializedtraining
S.Batki,MD10/27/17 10
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
PossiblePredictors• Gender• Craving• Familyhistory• Sweet-liking• Typology:earlyvslateonset• Abstinencevsstillusingattxonset• Adherencecapacity
• Geneticvariationinvolvingallelesforgenescodingforopioid,glutamate,andotherreceptors
S.Batki,MD10/27/17 11
Disulfiram,1• Oldest:FDAapprovedin1949• Mechanismofactionofdisulfiram(Antabuse)
– Chemical:inhibitsacetaldehydedehydrogenase– Behavioral:anticipationofaversiveconsequenceofdrinking
discouragesuse– altersdecisionalbalance• Pharmacology
– Irreversibleinhibitorofacetaldehydedehydrogenase– PreventsconversionofacetaldehydeàacetateàCO2+H2O– Inhibitioncanlastfordays– occasionallyupto14days– Disulfiram-alcoholreaction:headache,flushing,nausea,
vomiting,chestpain,vertigo,sweating,weakness,hypotension• Evidenceforefficacy
– Blindedstudiesshowno benefitoverplacebo(Jonas2014;Skinner2014)– Open-labelstudiesshowefficacyovercontrolgroups(Skinner2014)– Mosteffectiveinsupervisedadministration
S.Batki,MD10/27/17 12
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Disulfiram,2• Dose:
– 250– 500mgonceperday– Controversyaboutwhetherdoseshouldbeincreasedifpatientsdrinkanddo
nothaveDSF/Alcoholreaction;orwhetherDSFshouldbeDC’ed• Adverseeffects
– Drowsiness,headache,metallic/garlictaste,rash,veryrarelypsychosis– Occasional:transaminitis– Rare:fulminanthepatotoxicity
• Contraindications:– Alcoholuseinpast24hours– Severecardiovasculardisease– Pregnancy/nursing
• Predictorsofefficacy– Commitmenttoabstinence,observedadherence
• Clinicaluse– Can’tbeusedinpatientswhoarestilldrinking– Contraindicatedinpregnant/nursingwomen– LFTsbefore,every3monthsfor6months,thenevery6months– Warnptsabout“hidden”alcohol:food,mouthwash,etc.
S.Batki,MD10/27/17 13
Acamprosate,1• FDA-approvedin2004• Mechanismofactionofacamprosate(Campral)
– Modulationofglutamatergic hyperactivityfollowingcessationofalcoholuse
– Thoughttoreducewithdrawal-associateddysphoria• Pharmacology
– ShorthalfliferequiresTIDdose• Dose:2tablets3x/day(total1998mg/day)• Evidenceforefficacy
– 3EuropeanstudiesledtoUSFDAapproval– Meta-analysisshowsefficacyinreducingreturntoanydrinking
(NNT12)(Jonas2014JAMA)
– However,notasingleUSstudyhasshownseparationfromplaceboinITTanalyses(e.g.ProjectCOMBINEfailedtoshowefficacy)
S.Batki,MD10/27/17 14
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Acamprosate,2• Adverseeffects
– Diarrhea,fatigue,insomnia• Predictorsofefficacy
– Detoxificationandabstinenceinitiationpriortostart– Highmotivationforabstinence(asopposedtousereductionor“controlled”
drinking)– Abilitytoadheretocomplexregimen– Possibly:femalegender,highanxiety,negativefamilyhx,late ageofonset (Franck
&Jayaram-Lindsrom 2013)
• Contraindications– pregnant/nursingwomen– renalfailure
• Clinicaluse– Canbeusedinpatientswhoarestilldrinking– Reducedoseto50%inrenalimpairment(CrCl 30-50);contraindicatedCrCl
<30– Monitoradherence– verydifficult3x/dayregimen
S.Batki,MD10/27/17 15
Naltrexone,1• FDA-approvedforAUD:oralin1994,XR-NTXin2006• 2forms:oral andinjectableextended-releasenaltrexone(XR-NTX)
(Vivitrol)• Mechanismofaction
– Mu-opioidantagonist;thoughttoreduceeffectsofalcohol-mediatedincreaseinbetaendorphinandsubsequentincreaseinDAinNAc
– Reducescravingandreducespleasurableeffectsofalcohol– Mayimprovedecision-making,reducehypersalience ofalcoholcues,reduce
impulsivity• Pharmacology
– Oral:oncedaily– Extended-release- givenmonthly
• Dose– Oral:50mgonceperday– XR-NTX:monthlyIM380mg
• Evidenceforefficacy– Oralreducesreturntoanydrinkingandreturntoheavydrinking– Injectablereducesheavydrinkingdays(Jonas2014)
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PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Naltrexone,2• Adverseeffects
– GIupset:nausea,cramping;dizziness,nervousness,fatigue,– Occasionaltransaminitis– XR-NTX:injectionsitereactions;rare– abscess,necrosis
• Contraindications– Opioidtreatment(withinpast7-10days)– pregnant/nursingwomen– Acutehepatitisorliverfailure
• Predictorsofeffectiveness– Positivefamilyhistory– HavingtheGallelefortheOPRM1gene(AtoG,orAsn40Asp
substitution)doesnot appeartopredictwhorespondsbetterbygreaterNTX-mediatedbluntingofalcoholreward(Oslin JAMAPsychiatry2015)
– EarlyonsetAUD(“TypeB”)– Highcraving– “sweet-liking”
S.Batki,MD10/27/17 17
Naltrexone,3
• Clinicaluse– NTXcanbeusedinpatientswhoarestilldrinking– Monitoring:LFTsbefore,q3monthsfor6months,thenq6months
– Paincontrolmayrequirenon-opioidapproaches• NSAIDS,local,regional,conscioussedation• NOTE:seeCSAMWebinaronperioperativepainandacutepainmanagementinpatientsreceivingopioidagonistsorantagonists
– XR-NTXformgreatlyimprovesadherence• Intragluteal IM
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PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Topiramate,1• NotFDA-approvedforAUD,butapprovedasananticonvulsantandmigraine
prophylaxismedication• Mechanismofactionoftopiramate(Topamaxandothers)
– Chemical:• FacilitatesGABAneurotransmission;inhibitsAMPA-kainate glutamatetransmission
– Behavioral• Mayreducepost-withdrawaldysphoria;reducescraving;mayreduceimpulsivity
• Pharmacology– BIDdosing
• Dose– Precisedoseneededisunknown;moststudieshaveuseddosingupto300
mg/day,titratedupslowlyfrom25mg/dayto300mg/dayover6weeks–increaseby25-50mg/dayeachweek.
– Lowerdoses,eg.100-200mg/daymaybeeffective– moreresearchisneeded.– BIDdosing
• Adverseeffects– Memoryandconcentrationproblems;dizziness;somnolence– Paresthesias,alteredtaste– Appetite/weightloss– Rare:kidneystones,metabolicacidosis,narrow-angleglaucoma
S.Batki,MD10/27/17 19
Topiramate,2:EvidenceforEfficacy(Blodgettetal.2014AMeta-analysisoftopiramate’s effectsforindividualswithalcoholusedisorders.AlcoholismClin Exp Research.)
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PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Topiramate,3• Evidenceforefficacy:meta-analyses
– Blodgett(2014)foundefficacygreaterthanNTXoracamprosate,withlargesteffectforincreasingabstinence,andforreducingheavydrinking
– Jonas(2014)foundefficacyforreducingheavydrinkingdaysanddrinksperdrinkingday
• Predictorofeffectiveness– possiblegeneticpredictor– allelesforGRIK1gene
• Contraindications– Renalfailure– Historyofkidneystonesornarrow-angleglaucoma– pregnant/nursingwomen
• Clinicaluse– Canbeusedinpatientswhoarestilldrinking– IfCrCl <70ml/minàcut doseby50%– Checkbicarbonatelevelifmetabolicacidosisissuspected
(hyperventilation,etc)S.Batki,MD10/27/17 21
Gabapentin,1• NotFDA-approvedforAUD,butapprovedas
anticonvulsant;neuropathicpainmed• Mechanismofactionofgabapentin(Neurontinandothers)
– Chemical:facilitatesGABAtransmission– Behavioral:reduceswithdrawal-relatedanxiety,helpssleep,
• Pharmacology– Blocksalpha-2-deltasubunitofcalciumchannelàmodulates
GABAneurotransmission• Dose
– 1800mg/dayin3divideddoses• Evidenceforefficacy
– Mason(2014)JAMAInt Med:increasedabstinence,reducedcraving
• Adverseeffects– Sedation,dizziness,edema
S.Batki,MD10/27/17 22
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
Gabapentin,2
• Predictorsofeffectiveness– Notclearatthistime
• Clinicaluse– Canbeusedinindividualsstilldrinking– Canbeusedinpatientswithsevereliverdisease– EvidenceexistsforGBPaidingsleepinAUDpatients
– Careneedstobetakenincasesofrenalinsufficiency;doseshouldbereduced
S.Batki,MD10/27/17 23
Baclofen• NotFDA-approvedforAUD;approvedasmusclerelaxantfortreating
spasticity• Mechanismofaction
– Chemical:facilitatesGABAfunction– Behavioral:mayreduceanxiety/dysphoriaofpost-withdrawalstate
• Pharmacology– GABAb receptoragonist
• Dose– 10-20mgTID
• Evidenceforefficacy:mixed–mostlynegative– Jonas2014meta-analysisfailedtofindefficacy;severalEuropeancontrolled
trialssupportuse;2recentlargecontrolledUStrialsfailedtoshowbenefit• Adverseeffects
– Fatigue,sedation,dizziness,abdominalpain;overdosecanbedangerous• Predictorsofeffectiveness
– Noneestablished• Clinicaluse
– Canbeusedinpatientswhoarestilldrinking– Renalclearance,socanbeusedinpatientswithsevereliverdisease
S.Batki,MD10/27/17 24
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
OtherPossibleAUDPharmacotherapies
• Ondansetron• Nalmefene• Varenicline
S.Batki,MD10/27/17 25
CaseExample,1
• Your57yomalepatienttellsyouheisdrinkingheavilyandwantshelp
S.Batki,MD10/27/17 26
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
CaseExample,2
• Your57yomalepatienttellsyouheisdrinkingheavilyandwantshelp
• Heisstilldrinking;hasnotyetstopped
S.Batki,MD10/27/17 27
CaseExample,3
• Your57yomalepatienttellsyouheisdrinkingheavilyandwantshelp
• Heisstilldrinking;hasnotyetstopped• Hisgoalistoreduce,notstop
S.Batki,MD10/27/17 28
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
CaseExample,4
• Your57yomalepatienttellsyouheisdrinkingheavilyandwantshelp
• Heisstilldrinking;hasnotyetstopped• Hewantstoreduce,notstop• Heisprescribedopioidanalgesics
S.Batki,MD10/27/17 29
CaseExample,5
• Your57yo malepatienttellsyouheisdrinkingheavilyandwantshelp
• Heisstilldrinking;hasnotyetstopped• Hewantstoreduce,notstop• Heisonopioidanalgesics• HisLFTsareelevatedto3xULN
S.Batki,MD10/27/17 30
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
CaseExample,6
• Your57yomalepatienttellsyouheisdrinkingheavilyandwantshelp
• Heisstilldrinking;hasnotyetstopped• Hewantstoreduce,notstop• Heisonopioidanalgesics• HisLFTsareelevatedto3xULN• HisEGFR/CrCl indicatesmoderatelysevererenalfn imapairment
S.Batki,MD10/27/17 31
IsThereaFirstLineMedicationforAUD?
Probably:…..oralNaltrexone
- startat25mg/day(1/2tablet)for2days,then50mg,withfood- checktransaminasesbeforeandafter3mos
S.Batki,MD10/27/17 32
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
ButIsThereReally aFirstLineMedicationforAUD?,1
• Itdepends…
S.Batki,MD10/27/17 33
IsThereaFirstLineMedicationforAUD?,2
• Ifabstinent:canusedisulfiram– NaltrexoneoralorXR-NTX– Topiramate– Acamprosate– Disulfiram
S.Batki,MD10/27/17 34
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
IsThereaFirstLineMedicationforAUD?,3
• Ifstilldrinking:– Can’tusedisulfiram– Choices:• NaltrexoneoralorXR-NTX• Acamprosate• Topiramate
S.Batki,MD10/27/17 35
IsThereaFirstLineMedicationforAUD?,4
• Ifusingopioids:– Can’tuseNaltrexoneoralorXR-NTX– Choices:• Acamprosate• Disulfiram• Topiramate
S.Batki,MD10/27/17 36
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
IsThereaFirstLineMedicationforAUD?,5
• Ifsevereliverdisease:– Disulfiramisrisky:occasionaltransaminitis;rarefulminantliverfl
– NaltrexoneoralorXR-NTXmaycausetransaminitis
– Choices:• Acamprosate• Topiramate• Gabapentin
S.Batki,MD10/27/17 37
IsThereaFirstLineMedicationforAUD?,6
• Ifsevererenalimpairment:• Thesearerenally clearedà cutdoseinhalf– Topiramate– Acamprosate– Gabapentin– Baclofen
• Thesearehepatically metabolized– Naltrexone– Disulfiram
S.Batki,MD10/27/17 38
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
IsThereaFirstLineMedicationforAUD?,7
• Iffemalepatientofreproductiveageandnotreliablyusingbirthcontrol,checkforpregnancyandcheckifnursing.– Ifpregnantornursing:• NocurrentAUDpharmacotherapiesareconsideredsafe
S.Batki,MD10/27/17 39
IsThereaFirstLineMedicationforAUD?,7
Itdepends…perhapspharmacogenomic datawillultimatelyinformprescribing
(Batki&Pennington(2014)AmJPsychiatry)
*NOTE: OPRM1predictivevalueforNTXresponsehasbeendisproven(Oslin 2015JAMA)
*
S.Batki,MD10/27/17 40
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
SomeSalientQuestionsaboutAUDPharmacotherapy
• Whatisthebestmeasureofoutcome?– Abstinence?Usereduction?– Qualityoflife?– Cognitiveoutcomes?
• Predictors?• Bestdose?(e.g.topiramate,oralNTX)• Combinationsofmedications?• Bestrouteofadministration,forwhom?• Howlongshouldtreatmentbecontinued?• Howtoincreaseutilization?
S.Batki,MD10/27/17 41
steven.batki@ucsf.edu
S.Batki,MD10/27/17 42
PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
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PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
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PharmacotherapyofAlcoholUseDisordersin2017:WhatistheFirstLineMedication? /StevenBatki,MD
October27,2017CSAM– TreatingAddictioninthePreliminaryCareSafetyNet(TAPC)WebinarSeries
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