Overview of harm reduction treatments for alcohol problems

'Everywhere I call, there's nothing available': Understanding the alcohol treatment landscape and needs among unstably housed people who use alcohol in Rhode Island

INTRODUCTION

Alcohol is a leading cause of morbidity and mortality in the United States and people who are unstably housed are disproportionately impacted by adverse alcohol-related health outcomes. Addressing the needs of unstably housed people with high-intensity alcohol use (i.e., heavy episodic use or binge drinking), including those whose goal is not abstinence, is critical to reducing harms among this population. This study explores the alcohol-related treatment and support needs among unstably housed people who use alcohol.

METHODS

Data collection included participant observation and semi-structured interviews (n = 25) with unstably housed people with high-intensity alcohol use. Data were analysed thematically, with attention to structural vulnerability and social-structural forces at shaping perceptions of and experiences with alcohol treatment.

RESULTS

Participants underscored how housing instability was critical in precipitating and maintaining heavy alcohol use, with alcohol often used to manage the stress and anxiety related to housing instability. While participants regularly engaged with alcohol treatment programs, program design and barriers to access undermined the effectiveness of these services for participants. Participants described the need for a range of program and service options across a continuum of care to be implemented to support participants in meeting their diverse needs and identified goals regarding alcohol use.

DISCUSSION AND CONCLUSIONS

Alcohol treatment and supports need to be modified so that they include a range of harm reduction and abstinence-based models to better meet people's diverse needs. Furthermore, treatment must be paired with permanent and affordable housing to address underlying drivers of alcohol-related harm for unstably housed people.

Novel medications for problematic alcohol use

Alcohol-related harm, a major cause of disease burden globally, affects people along a spectrum of use. When a harmful pattern of drinking is present in the absence of significant behavioral pathology, low-intensity brief interventions that provide information about health consequences of continued use provide large health benefits. At the other end of the spectrum, profound behavioral pathology, including continued use despite knowledge of potentially fatal consequences, warrants a medical diagnosis, and treatment is strongly indicated. Available behavioral and pharmacological treatments are supported by scientific evidence but are vastly underutilized. Discovery of additional medications, with a favorable balance of efficacy versus safety and tolerability can improve clinical uptake of treatment, allow personalized treatment, and improve outcomes. Here, we delineate the clinical conditions when pharmacotherapy should be considered in relation to the main diagnostic systems in use and discuss clinical endpoints that represent meaningful clinical benefits. We then review specific developments in three categories of targets that show promise for expanding the treatment toolkit. GPCRs remain the largest category of successful drug targets across contemporary medicine, and several GPCR targets are currently pursued for alcohol-related indications. Endocrine systems are another established category, and several promising targets have emerged for alcohol indications. Finally, immune modulators have revolutionized treatment of multiple medical conditions, and they may also hold potential to produce benefits in patients with alcohol problems.

Perspectives of clinical stakeholders and patients from four VA liver clinics to tailor practice facilitation for implementing evidence-based alcohol-related care

BACKGROUND

Unhealthy alcohol use (UAU) is particularly dangerous for people with chronic liver disease. Liver clinics may be an important setting in which to provide effective alcohol-related care by integrating evidence-based strategies, such as brief intervention and medications for alcohol use disorder. We conducted qualitative interviews with clinical stakeholders and patients at liver clinics in four Veterans Health Administration (VA) medical centers to understand barriers and facilitators of integrating alcohol-related care and to support tailoring of a practice facilitation implementation intervention.

METHODS

Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process (RAP) guided by the CFIR.

RESULTS

We interviewed 46 clinical stakeholders and 41 patient participants and analyzed findings based on the CFIR. Clinical stakeholders described barriers and facilitators that ranged from operations/clinic resource-based (e.g., time and capacity, desire for additional provider types, referral processes) to individual perspective and preference-based (e.g., supportiveness of leadership, individual experiences/beliefs). Patient participants shared barriers and facilitators that ranged from relationship-based (e.g., trusting the provider and feeling judged) to resource and education-based (e.g., connection to a range of treatment options, education about impact of alcohol). Many barriers and facilitators to integrating alcohol-related care in liver clinics were similar to those identified in other clinical settings (e.g., time, resources, role clarity, stigmatizing beliefs). However, some barriers (e.g., fellow-led care and lack of integration of liver clinics with addictions specialists) and facilitators (e.g., presence of quality improvement staff in clinics and integrated pharmacists and behavioral health specialists) were more unique to liver clinics.

CONCLUSIONS

These findings support the possibility of integrating alcohol-related care into liver clinics but highlight the importance of tailoring efforts to account for variation in provider beliefs and experiences and clinic resources. The barriers and facilitators identified in these interviews were used to tailor a practice facilitation implementation intervention in each clinic setting.

A Mixed-Methods Examination of Language Used by College Students to Describe Alcohol Recovery

Given that approximately 5% of the U.S. population is currently attending college, research is needed to better understand the language that college students use to describe alcohol recovery regardless of their current drinking behavior. College student perceptions of alcohol recovery are important, given that students may experience an alcohol use disorder themselves or may encounter others with an alcohol use disorder. Research on college student perceptions of alcohol recovery in the literature is scarce but is needed to better understand the alcohol recovery process. The current mixed-methods study examines language that college students use to describe alcohol recovery based on findings from two focus group interviews. The focus groups were conducted with college students who reported using alcohol at least once in their lifetime. All participants (N = 18) were asked questions regarding language perceived to be associated with alcohol recovery. Data were examined within a thematic analysis framework. The three central themes related to alcohol recovery that emerged in the study were harm reduction-based recovery, abstinence-based recovery, and social correlates of recovery. College students rated the terms "recovered," "drinking reduction," and "sobriety" as being highly representative of being in recovery, whereas the terms "bars" and "light drinker" were identified as not being representative of recovery. A better understanding of these themes will help the field understand the language that college students use to describe alcohol recovery.

Alcohol use disorder and disability insurance in Switzerland: the attitudes and views of lawyers, insurance medical experts, and addiction-specialist therapists

BACKGROUND

According to a landmark decision by the Swiss Federal Supreme Court, people with a substance use disorder (SUD) are now eligible for disability benefits if their disorder impairs their ability to work. Alcohol use disorder (AUD) is one of the most common SUDs in Switzerland and is associated with high societal and economic costs. This study aimed to gain an in-depth understanding of the views of professional stakeholder groups regarding AUD and their opinions on the new legal precedent.

METHODS

Swiss social insurance lawyers, insurance medical experts, and addiction-specialist therapists (N = 79) answered an online questionnaire. Due to violations of the assumption of normality, non-parametric tests are reported in most cases.

RESULTS

Therapists held significantly higher regard for patients with AUD than both lawyers and insurance medical experts. All three groups strongly supported a disease view of AUD but agreed significantly less that it was a disease like cancer, suggesting that AUDs might be seen as at least partially self-inflicted. Overall, moralist views of AUD received considerably less support than the disease view, with lawyers agreeing with moralist views more than therapists. All groups were well-informed and largely supportive about the new legal precedent. When asked about stipulating participation in medical treatment to mitigate damages associated with a claim, attending therapy was supported the most amongst the groups (80% of participants felt this was somewhat or fully appropriate), followed by a reduction in drinking quantity (58%), and abstinence (18%). In all three groups, we identified associations between certain views and opinions on AUD and support for the new legal precedent.

CONCLUSIONS

Whilst there were differences between the stakeholder groups in their regard for and views of AUD, all three adopted a clear harm-reduction approach with respect to measures to mitigate damages associated with the insurance disability claim. A possible connection of this stance with the Swiss national drug policy in recent years is discussed together with limitations of the study and practical implications of the findings.

Expanding the continuum of substance use disorder treatment: Nonabstinence approaches

Only a small minority of people with substance use disorders (SUDs) receive treatment. A focus on abstinence is pervasive in SUD treatment, defining success in both research and practice, and punitive measures are often imposed on those who do not abstain. Most adults with SUD do not seek treatment because they do not wish to stop using substances, though many also recognize a need for help. This narrative review considers the need for increased research attention on nonabstinence psychosocial treatment of SUD - especially drug use disorders - as a potential way to engage and retain more people in treatment, to engage people in treatment earlier, and to improve treatment effectiveness. We describe the development of nonabstinence approaches within the historical context of SUD treatment in the United States, review theoretical and empirical rationales for nonabstinence SUD treatment, and review existing models of nonabstinence psychosocial treatment for SUD among adults to identify gaps in the literature and directions for future research. Despite significant empirical support for nonabstinence alcohol interventions, there is a clear gap in research examining nonabstinence psychosocial treatment for drug use disorders. Future research must test the effectiveness of nonabstinence treatments for drug use and address barriers to implementation.

Are non-abstinent reductions in World Health Organization drinking risk level a valid treatment target for alcohol use disorders in adolescents with ADHD?

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Changes in WHO alcohol risk level are highly variable in youth treated for ADHD/SUD.

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Achieving > 2-level reduction in WHO risk is linked to improvements in functioning.

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Achieving > 2-level reduction in WHO risk is linked to decreased ADHD symptoms.

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> 2-level reduction in WHO risk may be a valid non-abstinent AUD outcome in youth with ADHD/SUD.

Introduction

Abstinence from drinking represents the primary treatment target for alcohol use disorders (AUD) in youth, but few adolescents who engage in problematic drinking seek treatment. A reduction in World Health Organization (WHO) drinking risk level has been established as valid and reliable non-abstinent treatment target for AUD in adults but remains unstudied in youth.

Methods

The present study used data from the NIDA-CTN-0028 trial to examine associations between reductions in WHO drinking risk level and changes in global functioning and attention-deficit hyperactivity disorder (ADHD) symptoms during treatment in a sample of adolescents (ages 13–18 years) with ADHD and comorbid substance use disorder (SUD) (n = 297, 61% with AUD) receiving a 16-week intervention that combined ADHD pharmacotherapy (OROS-methylphenidate vs. placebo) and drug-focused cognitive-behavioral therapy.

Results

Shifts in drinking risk level during treatment were highly variable in adolescents treated for ADHD/SUD, and influenced by AUD diagnostic status. In the total sample, 15% of participants had a 2-level or greater reduction in WHO drinking risk level, with 59% and 24% showing no change or an increase in risk-level during treatment respectively. Achieving at least a 2-level change in WHO drinking risk level during treatment was associated with greater reduction in ADHD symptoms and better functional outcomes.

Conclusions

These findings parallel the adult AUD literature and provide preliminary support for the use 2-level reductions in WHO risk levels for alcohol use as a clinically valid non-abstinent treatment outcome for youth with ADHD and comorbid AUD.

Online mutual-help intervention for reducing heavy alcohol use

Online interventions have potential to reach a wide range of people, including heavy drinkers unable or unwilling to seek formal treatment or support groups. This study examined a self-guided alcohol Internet intervention that provides access to several different online social networks and is based on principles of harm reduction, cognitive-behavioral therapy (CBT), and relapse prevention. Active participants in the online program (N = 57) completed a survey that retrospectively assessed prior alcohol use, current alcohol use patterns, drinking goals, involvement in online activities, and use of CBT self-help tools. Findings indicated significant reductions in drinks per week (DPW), drinks per day (DPD), and drinking days per week (DDW) from baseline to post-intervention. Longer time in the online program was associated with greater reduction in DDW, rs(57) = .31, p = .02; while use of CBT self-help tools was positively correlated with reduction in DPW, rs(57) = .37, p = .005. Engagement in multiple online activities (i.e., social networking, e-mail groups, chat room, forum discussion) was associated with greater drinking reductions in DPW, (F[1,55]) = 8.55, p < .005; and DDW, (F[1,55]) = 7.12, p < .01). Results suggest that an online program may assist heavy drinkers in decreasing alcohol use through utilization of a cyber community, social networking, and self-help tools. Conversely, 74% of participants were still engaging in high-risk drinking, raising the possibility that an online mutual-help group with personalized goals intended to reduce harm, may inadvertently normalize heavy alcohol use.

"There is a Place": impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness

BACKGROUND

The twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA).

METHODS

We examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of "messy", "ordered" and "social arenas" maps that provide insight into the social worlds of participants and the impact of MAPs.

RESULTS

Prior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing.

CONCLUSIONS

In a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.

On the outside looking in: Finding a place for managed alcohol programs in the harm reduction movement

Alcohol policy in North America is dominated by moderation and abstinence-based modalities that focus on controlling population-level alcohol consumption and modifying individual consumption patterns to prevent and reduce alcohol-related harms. However, conventional alcohol policies and interventions do not adequately address harms associated with high-risk drinking among individuals experiencing severe alcohol use disorder (AUD) and structural vulnerability such as poverty and homelessness. In this commentary we address this gap in alcohol harm reduction, and highlight the lack of, and distinct need for, alcohol-specific harm reduction for people experiencing structural vulnerability and severe AUD. These individuals, doubly impacted by structural oppression and severe AUD, engage in various high-risk drinking practices that contribute to a unique set of harms that conventional abstinence-based treatments and interventions fail to adequately attend to. Managed alcohol programs (MAPs) have been established to address these multiple intersecting harms, and though gaining momentum across Canada, have had a hard time finding their place within the harm reduction movement. We illustrate how MAPs play a crucial role in the harm reduction movement in their ability to not only address high-risk drinking practices among structurally marginalized individuals, but to respond to harms associated with broader structural inequities such as poverty and homelessness.

Effect of repeated abstinence on chronic ethanol self-administration in the rhesus monkey

RATIONALE

Abstinence-based approaches to treating alcohol use disorder (AUD) are highly prevalent, but abstinence from chronic drinking may exacerbate subsequent levels of alcohol intake in relapse.

OBJECTIVE

Use a non-human primate model that encompasses a range of chronic voluntary ethanol drinking to isolate biological responses to repeated cycles of imposed abstinence as a function of baseline voluntary alcohol drinking levels.

METHODS

Over a 26-month protocol, young adult male rhesus macaques were first induced to drink alcohol and then given continuous access to 4% (w/v) ethanol (n = 8) or water (n = 4) for approximately 14 months, followed by three 28- to 35-day abstinence phases, with 3 months of ethanol access in between. Ethanol intake and blood ethanol concentration (BEC) were the primary dependent variables. Observational signs of physical dependence and circulating ACTH and cortisol were monitored.

RESULTS

Prior to abstinence, stable, categorical, individual differences in voluntary ethanol intake under chronic access conditions were found. Following abstinence, categorical "non-heavy" drinking subjects increased drinking transiently (increased between 0.7 and 1.4 g/kg/day in first month after abstinence) but returned to baseline after 3 months. Categorical "heavy" drinkers, however, maintained drinking 1.0-2.6 g/kg above baseline for over 3 months following abstinence. Signs of physical dependence were rare, although huddling and social withdrawal increased in ethanol and control subjects. The most prominent effect on hormonal measures was heightened cortisol during abstinence that increased to a greater extent in ethanol subjects.

CONCLUSION

Involuntary abstinence increases drinking in the absence of overt physical withdrawal symptoms, and heavy drinkers are more robustly affected compared to non-heavy drinkers.

Clinical Validation of Reduced Alcohol Consumption After Treatment for Alcohol Dependence Using the World Health Organization Risk Drinking Levels

Background

Alcohol use disorder (AUD) is a highly prevalent public health problem associated with considerable individual and societal costs. Abstinence from alcohol is the most widely accepted target of treatment for AUD, but it severely limits treatment options and could deter individuals who prefer to reduce their drinking from seeking treatment. Clinical validation of reduced alcohol consumption as the primary outcome of alcohol clinical trials is critical for expanding treatment options. One potentially useful measure of alcohol treatment outcome is a reduction in the World Health Organization (WHO, International Guide for Monitoring Alcohol Consumption and Related Harm. Geneva, Switzerland, 2000) risk levels of alcohol use (very high risk, high risk, moderate risk, and low risk). For example, a 2‐shift reduction in WHO risk levels (e.g., high risk to low risk) has been used by the European Medicines Agency (2010, Guideline on the Development of Medicinal Products for the Treatment of Alcohol Dependence. UK) to evaluate nalmefene as a treatment for alcohol dependence (AD; Mann et al. 2013, Biol Psychiatry 73, 706–13).

Methods

The current study was a secondary data analysis of the COMBINE study (n = 1,383; Anton et al., 2006) to examine the association between reductions in WHO risk levels and reductions in alcohol‐related consequences and mental health symptoms during and following treatment in patients with AD.

Results

Any reduction in WHO risk drinking level during treatment was associated with significantly fewer alcohol‐related consequences and improved mental health at the end of treatment and for up to 1 year posttreatment. A greater reduction in WHO risk drinking level predicted a greater reduction in consequences and greater improvements in mental health.

Conclusions

Changes in WHO risk levels appear to be a valid end point for alcohol clinical trials. Based on the current findings, reductions in WHO risk drinking levels during treatment reflect meaningful reductions in alcohol‐related consequences and improved functioning.

Adolescents from affluent city districts drink more alcohol than others

AIMS

To estimate the level of alcohol consumption and problems among adolescents in city districts in Oslo, Norway with different socio-economic composition; to test whether differences in alcohol consumption are related to district differences in socio-demographic characteristics; and to analyse whether such associations remain significant after controlling for individual-level variables.

DESIGN

Cross-sectional survey using multi-level linear regression analyses with individual responses at the lowest level and city-district data at the highest level.

SETTING

Oslo, Norway.

PARTICIPANTS

A total of 6635 secondary school students, in 62 schools, living in 15 different city districts.

MEASUREMENTS

Frequency of alcohol consumption and alcohol intoxication; alcohol problems; and individual characteristics such as immigrant status, religious involvement and parental norms with regard to alcohol. Socio-economic indicators in city districts, such as education, income and unemployment, were combined into a district-level socio-economic index (DLSI).

FINDINGS

DLSI scores were related positively to alcohol use (r = 0.31, P < 0.01) and alcohol intoxication (r = 0.25, P < 0.01) but negatively to alcohol problems among alcohol users (r = -0.18, P < 0.01). DLSI scores remained significant for alcohol consumption and alcohol intoxication, after controlling for individual-level variables (P < 0.01), but this was not the case for alcohol problems.

CONCLUSION

Adolescents in affluent areas of Oslo, Norway report the highest levels of alcohol consumption and alcohol intoxication of all areas; neighbourhood characteristics such as education, income and unemployment levels seem to play a role in such drinking behaviour. Alcohol users in poorer districts reported more alcohol problems than those in other districts; however, here neighbourhood effects do not seem to play a role.

Alcohol abstinence or harm-reduction? Parental messages for college-bound light drinkers

Parental communications about alcohol can have a significant impact on college students' alcohol use; however, it is unclear what types of communication may be most beneficial for reducing alcohol risk, particularly among students who have already initiated alcohol use. The present research examines differences in alcohol use and employment of drinking protective behavioral strategies between pre-college matriculation high school seniors receiving predominantly abstinence parent messaging and students primarily receiving harm-reduction parent messaging. Students who identified as light drinkers were recruited during their last month in high school and completed an online assessment of alcohol use and parent alcohol communication. Analyses revealed that, in comparison to light drinkers who primarily received harm-reduction messaging from parents, light drinkers who received more abstinence messaging reported less frequent alcohol use, lower peak alcohol consumption, and greater use of protective drinking strategies aimed at changing the way they drank and avoiding serious hazards associated with drinking. Findings from this study underscore the utility of messages related to abstinence even for parents who are aware that their children have had previous experiences with alcohol and highlight the need for longitudinal research assessing additional mechanisms associated with message efficacy among light, moderate and heavy drinking students transitioning to college.

Protective behavioral strategies for reducing alcohol involvement: a review of the methodological issues

Alcohol use among college students remains a major public health concern with many students experiencing negative alcohol-related consequences as a result of their drinking. Protective behavioral strategies (PBS) have been conceptualized as skills used by drinkers to moderate their drinking and/or resulting consequences. The correlational evidence for the relationships among PBS, alcohol use, and related problems has been mixed. Experimental research reveals inconsistent relationships among intervention condition, PBS use, and alcohol outcomes. There is currently insufficient evidence to support the claim that PBS function as a mechanism of behavior change for college drinkers. We propose that the inconsistencies found in the correlational and experimental research are explained in part by psychometric and methodological issues. This review summarizes measurement and methodological issues in studies that have directly assessed the relationship between PBS and alcohol use and/or alcohol-related consequences in college drinking samples. Additionally, we provide some suggestions and future directions to overcome methodological and conceptual limitations and to advance understanding of the role of protective behavioral strategy use in reducing alcohol involvement among college drinkers.

Beyond drug use: a systematic consideration of other outcomes in evaluations of treatments for substance use disorders

Across the addictions field, the primary outcome in treatment research has been reduction in drug consumption. A comprehensive view of the impact of substance use disorders on human functioning suggests that effective treatments should address the many consequences and features of addiction beyond drug use, a recommendation forwarded by multiple expert panels and review papers. Despite recurring proposals, and a compelling general rationale for moving beyond drug use as the sole standard for evaluating addiction treatment, the field has yet to adopt any core set of 'other' measures that are routinely incorporated into treatment research. Among the many reasons for the limited impact of previous proposals has been the absence of a clear set of guidelines for selecting candidate outcomes. This paper is the result of the deliberations of a panel of substance abuse treatment and research experts convened by the National Institute on Drug Abuse to discuss appropriate outcome measures for clinical trials of substance abuse treatments. This paper provides an overview of previous recommendations and outlines specific guidelines for consideration of candidate outcomes. A list of outcomes meeting those guidelines is described and illustrated in detail with two outcomes: craving and quality of life. The paper concludes with specific recommendations for moving beyond the outcome listing offered in this paper to promote the programmatic incorporation of these outcomes into treatment research.

Investigation of the relationship between in vitro and in vivo release behaviors of acamprosate from enteric-coated tablets

Acamprosate calcium is a highly soluble drug with low permeability that is used to maintain abstinence in alcohol-dependent patients. The aim of this study was to investigate the relationship between in vitro and in vivo behaviors of acamprosate from enteric-coated tablets. The in vitro release behavior of acamprosate tablets in pH 6.8 buffer solution was determined in three dissolution conditions, 50 and 150 rpm (paddle method) and 180 rpm (basket method). The results of this in vitro experiment indicated that acamprosate tablets hardly disintegrated, and drug dissolution was retarded despite the extremely hydrophilic nature of the drug. A single dose (333 mgx2 tablets) of each formulation was orally administered to four beagle dogs under fasting conditions, and the pharmacokinetic parameters were calculated. The mean AUC0-48, Cmax, Tlag and Tmax for the two types of tablets ranged from 41.5-53.6 microg.h/mL, 4.3-4.5 microg/mL, 2.0-2.5 h and 3.8-4.0 h, respectively. In conclusion, it is suggested that retarded drug release from the tablets and the low drug permeability may result in poor absorption and erratic bioavailability of this drug in humans.