Treatment for Alcohol Dependence in Primary Care Compared to Outpatient Specialist Treatment-A Randomized Controlled Trial

A smartphone app-based intervention combined with face-to-face sessions for alcohol dependence at internal medicine clinics: A randomized controlled trial

BACKGROUND

Addressing the limited access to treatments for alcohol dependence, we developed ALM-002, a therapeutic application to be "prescribed" for non-abstinence-oriented treatment in internal medicine settings. Our objective was to preliminarily assess the efficacy and safety of ALM-002.

METHODS

In a multicenter, open-label randomized controlled trial, participants aged ≥20 with alcohol dependence and daily alcohol consumption exceeding 60 g for men and 40 g for women, without severe complications, were randomly assigned to either the intervention group using ALM-002 or the treatment-as-usual control group. Participant in both groups received individual face-to-face sessions by physicians at weeks 0, 4, 8, and 12. The primary endpoint was the change in heavy drinking days (HDDs) from week 0 to week 12. A mixed model for repeated measures was employed.

RESULTS

We enrolled 43 participants: 22 in the intervention group and 21 in the control group. A significant reduction in HDDs every 4 weeks from week 0 to week 12 was observed, with a between-group difference of -6.99 days (95% CI: -12.4 to -1.6 days, standardized mean difference: -0.80).

CONCLUSIONS

These results indicate the potential of ALM-002 as a viable treatment for alcohol dependence. Further studies are needed to evaluate the clinical potential of ALM-002.

Adjusting the 15-method to Danish general practice: identification of barriers, facilitators, and user needs

BACKGROUND

The 15-method is an opportunistic screening and brief intervention tool for alcohol-related problems in primary healthcare. A Danish feasibility study of the 15-method indicated that adjustments were needed to improve its contextual fit to Danish general practice. This adjustment process was conducted in two parts. The first part focused on identifying barriers, facilitators, and user needs for addressing alcohol using the 15-method. The second part will address the identified barriers and user needs to finalize a Danish version of the method. This study reports on part one of the adjustment process.

METHODS

Semi-structured individual interviews and focus group interviews with healthcare professionals (n = 8) and patients (n = 5) from general practice in Denmark. Data analysis was conducted using thematic content analysis. The results were condensed into two focus areas that will form the basis for user workshops in part two of the adjustment process.

RESULTS

The main barriers for addressing alcohol using the 15-method were patients and healthcare professionals not having the same agenda, having difficulty opening a conversation on alcohol, and workflow in the practices. Main facilitators included high interpersonal skills, taking the patient's perspective, and good routines and interdisciplinary work. Suggested adjustments and additions to the method included digitalization, visual icebreakers, quotes and examples, and development of a quick guide. The identified focus areas for user workshops were Communication and Material, and Integration to Workflows.

CONCLUSION

Healthcare professionals found the opportunistic screening approach exemplified by the 15-method to be beneficial in identifying and addressing alcohol-related problems. They appreciate the method's structured framework that assists in presenting treatment options. Identified adjustment areas to the 15-method will lay the groundwork for future efforts to develop a finalized Danish version of the 15-method.

The identification and treatment of alcohol problems in primary care (iTAPP) study: protocol for a stepped wedge cluster randomized control trial testing the 15-method in a primary care setting

BACKGROUND

The 15-method is a targeted screening and treatment approach for alcohol problems in primary care. The 15-method used in primary care has proven as effective as specialized treatment for mild to moderate alcohol dependence in Sweden. A feasibility study of the 15-method in Danish primary care found the method acceptable and feasible.

AIMS

To evaluate the effectiveness of the 15-method in a Danish primary care setting in (1) lowering the proportion of patients exceeding the Danish low-risk alcohol consumption limit of ten standard units per week and a maximum of four standard units on a single day for men and women, and (2) increasing the likelihood of alcohol use being addressed during a consultation in general practice. Further, the rate of prescribed pharmacological treatment for alcohol problems (Disulfiram, Naltrexone, Acamprosate, and Nalmefene) will be measured along with the use of the biomarkers Alanine Transaminase and Gamma-Glutamyl Transferase.

METHODS

Stepped wedge cluster randomized controlled trial in sixteen general practices in the Region of Southern Denmark. Following a three-month baseline, the practices are randomly assigned to launch dates in one of four clusters. General practitioners and nurses receive three hours of training in the 15-method before launch. Patient questionnaires will collect data on alcohol consumption levels among patients affiliated with the practices. The healthcare professionals will register consultations in which alcohol is addressed in their patient filing system. Pharmacological treatment rates and the use of biomarkers will be collected through Danish national registries. The study follows the Medical Research Council's guidelines for developing and evaluating complex interventions.

DISCUSSION

From the patient's perspective, the 15-method may help identify alcohol-related problems at an earlier stage with flexible treatment offers in a familiar setting. For healthcare professionals, it addresses a traditionally challenging topic by equipping them with concrete tools, communication training, and clear treatment directives. From a societal perspective, primary care holds a unique position to identify hazardous and harmful alcohol use across different age groups, with potential public health and economic benefits through early identification and intervention.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05916027. Retrospectively registered 22 June 2023.

Behavioural self-control training versus motivational enhancement therapy for individuals with alcohol use disorder with a goal of controlled drinking: A randomized controlled trial

BACKGROUND AND AIMS

Controlled drinking (CD) is an attractive treatment goal for a large proportion of individuals with alcohol use disorder (AUD), but the availability of treatment methods supporting a goal of CD is scarce. We tested if behavioural self-control training (BSCT) was superior to motivational enhancement therapy (MET) for individuals with AUD with a treatment goal of CD.

DESIGN

Randomized controlled two-group trial. Follow-ups were conducted at 12 and 26 weeks (primary end-point) after inclusion.

SETTING

Three specialized dependency care clinics in Stockholm, Sweden.

PARTICIPANTS

Two hundred and fifty self-referred adults (52% men) fulfilling criteria of AUD (DSM-5) and a stated treatment goal of CD.

INTERVENTION AND COMPARATOR

BSCT (n = 125), a five-session treatment based on cognitive behavioural therapy versus the active comparator, MET (n = 125), containing four sessions based on Motivational Interviewing.

MEASUREMENTS

Primary outcome measure was mean weekly alcohol consumption at the 26-week follow-up, adjusted for baseline consumption.

CONCLUSIONS

A randomized controlled trial found no evidence of a difference between behavioural self-control training and motivational enhancement therapy in reducing weekly alcohol consumption. Both groups substantially reduced consumption and behavioural self-control training was superior in reducing hazardous drinking.

Improving access to treatment for alcohol dependence in primary care: A qualitative investigation of factors that facilitate and impede treatment access and completion

BACKGROUND

Timely intervention for people with alcohol dependence in primary care is needed. Primary care services have a key role in supporting adults with alcohol dependence and require appropriate provision of services.

OBJECTIVE

To examine the perceptions of both primary care practitioners and adults with alcohol dependence regarding service provision and to describe help seeking behaviours for adults with alcohol dependence.

DESIGN AND SETTING

Qualitative study consisting of semi-structured interviews with adults with alcohol dependence, healthcare professionals and staff members of specialist alcohol services who had previous or current experience in the management, treatment, or referral of adults with alcohol dependence in Northwest England.

METHOD

Interviews were conducted with ten adults with alcohol dependence and 15 staff. Data were analysed thematically, applying principles of constant comparison.

RESULTS

Three themes were identified following inductive thematic analysis. The first theme, point of access relates to current service provision being reactive rather than preventative, the stigma associated with alcohol dependence and a person's preparedness to change. The second theme identified was treatment process and pathways that highlights difficulties of engagement, mental health support, direct access and person-centred support. The third theme was follow-up care and discusses the opportunities and threats of transitional support or aftercare for alcohol dependence, signposting and peer support.

CONCLUSION

There are clear opportunities to support adults with alcohol dependence in primary care and the need to increase provision for timely intervention for alcohol related issues in primary care.

The efficacy of an internet-based cognitive behavioral program added to treatment-as-usual for alcohol-dependent patients in primary care: a randomized controlled trial

BACKGROUND AND AIMS

Most alcohol-dependent people have a moderate level of dependence. General practitioners (GPs) hesitate to engage in this area, and need to have access to treatment they find applicable and feasible to use. The aim of this present study was to test if an open-ended internet-based cognitive-behavioral therapy (iCBT) program added to treatment-as-usual (TAU) is more effective than TAU-only for alcohol-dependent patients in primary care.

DESIGN, SETTING AND PARTICIPANTS

The present study was a two-group, parallel, randomized controlled superiority trial comparing iCBT+TAU versus TAU-only at 3- and 12-month follow-ups. TAU was delivered at 14 primary care centers in Stockholm, Sweden. A total of 264 patients (mean age 51 years, of whom 148 were female and 116 were male) with alcohol dependence and hazardous alcohol consumption were enrolled between September 2017 and November 2019.

MEASUREMENTS

Participants were randomized at a ratio of 1:1 to iCBT, as a self-help intervention added to TAU (n = 132) or to TAU-only (n = 132). The GPs gave participants in both treatment arms feedback on the assessments and biomarkers and offered TAU at the primary care center. Primary outcome was weekly alcohol consumption in g/week at 12-month follow-up, analyzed according to intention-to-treat (n = 132 + 132). The per-protocol analysis included participants who completed at least one module of iCBT (n = 102 + 132).

FINDINGS

There was no significant difference in weekly alcohol consumption between iCBT+TAU and TAU in the intention-to-treat (ITT) analysis at 12-month follow-up [iCBT+TAU = 133.56 (95% confidence interval, CI = 100.94-166.19) and TAU = 176.20 (95% CI = 144.04-208.35), P = 0.068, d = 0.23]. In the per-protocol analysis, including only those who initiated iCBT, the iCBT+TAU group showed lower mean weekly alcohol consumption compared with TAU [iCBT+TAU = 107.46 (95% CI = 71.17-143.74), TAU = 176.00 (95% CI = 144.21-207.80), P = 0.010, d = 0.42].

CONCLUSIONS

In Sweden, an internet-based cognitive-behavioral program added to treatment-as-usual to reduce alcohol consumption showed weak evidence of a benefit at 12 months in the intention-to-treat analysis and good evidence of a benefit in the per-protocol analysis.

Group cognitive behavioral therapy as an effective approach for patients with alcohol dependence: A perspective study

Alcohol dependence (AD) syndrome refers to a strong addiction to alcohol and high tolerance physiologically or psychologically, due to the repeated consumption of alcohol-based substances. This study aimed to examine the efficacy of group cognitive behavioral therapy (GCBT) on patients with AD. A total of 128 patients with AD were randomly assigned to the GCBT or control group. Patients in the GCBT group underwent an 8-week GCBT in addition to conventional treatment, and patients in the control group only received conventional treatment. The insight and treatment attitude questionnaire (ITAQ) score, chronic disease self-cognition evaluation score (CDSCES), treatment adherence, and relapse rate at 6 and 12 months were compared among the 2 groups. The ITAQ scores of the GCBT group, after treatment, increased significantly compared to those of the control group (19.69% vs 13.26%, P < .001). The CDSCES in the GCBT group increased significantly compared to those in the control group after treatment (3.98 vs 2.18, P = .001 for problem-solving ability; 8.08 vs 5.08, P = .001 for self-management efficacy; 4.29 vs 3.30, P = .005 for a positive response, and 4.84 vs 3.44, P = .008 for a social function, respectively). After treatment, the percentage of patients with AD with full compliance in the GCBT group was much higher than in the control group (93.8% vs 65.6%, P < .001). Contrastingly, the percentage of patients with AD with partial compliance in the GCBT group was much lower than that in the control group (3.2% vs 34.4%, P < .001). The relapse rate (%) of drinking in patients with AD in the GCBT group was much lower than that in the control group (1.56% vs 21.8%, P = .001 for 6 months and 4.7% vs 51.6%, P < .001 for 12 months). The results suggest that GCBT for 8 weeks is an effective approach for patients with AD, improving problem-solving ability, self-management efficacy, positive response, and social function, leading to increase in treatment compliance, and reducing relapse rate.

Danish feasibility study of a new innovation for treating alcohol disorders in primary care: the 15-method

BACKGROUND

The 15-method: a new brief intervention tool for alcohol problems in primary care has shown promising results in Sweden for mild to moderate alcohol use disorders. The present study evaluated the 15-method's usability, organizational integration, and overall implementation feasibility in Danish general practice in preparation for a large-scale evaluation of the method's effectiveness in identifying and treating alcohol problems in general practice.

METHODS

Five general practices in the Central and Southern Region of Denmark participated: seven general practitioners (GPs), eight nurses. Participants received a half day of training in the 15-method. Testing of implementation strategies and overall applicability ran for 2 months. A focus group interview and two individual interviews with participating GPs along with five individual patient interviews concluded the study period.

RESULTS

Results indicate that implementation of the 15-method is feasible in Danish general practice. The healthcare professionals and patients were positive about the method and its possibilities. The method was considered a new patient centered treatment offer and provided structure to a challenging topic. An interdisciplinary approach was much welcomed. Results indicate that the method is ready for large scale evaluation.

CONCLUSIONS

Implementation of the 15-method is considered feasible in Danish general practice and large-scale evaluation is currently being planned.

Effects of Alcohol Reduction Interventions on Blood Pressure

PURPOSE OF REVIEW

Much of alcohol's purported negative impact on a population's health can be attributed to its association with increased blood pressure, rates of hypertension, and incidence of cardiovascular disease (CVD). Less attention, however, has been placed on the association of the positive impact of alcohol reduction interventions on physical health.

RECENT FINDINGS

This review delineates the evidence of blood pressure reductions as a function of alcohol reduction interventions based on current care models. The findings of this review suggest two things: (1) sufficient evidence exists for a relationship between alcohol reductions and blood pressure generally, and (2) little evidence exists for the relationship between alcohol reductions and blood pressure for any one care model currently employed in the health system. The evidence base would benefit from more studies using established alcohol reduction interventions examining the impact of these interventions on blood pressure.

Effects of Internet-Based Cognitive Behavioral Therapy for Harmful Alcohol Use and Alcohol Dependence as Self-help or With Therapist Guidance: Three-Armed Randomized Trial

Background

Alcohol use is a major contributor to health loss. Many persons with harmful use or alcohol dependence do not obtain treatment because of limited availability or stigma. They may use internet-based interventions as an alternative way of obtaining support. Internet-based interventions have previously been shown to be effective in reducing alcohol consumption in studies that included hazardous use; however, few studies have been conducted with a specific focus on harmful use or alcohol dependence. The importance of therapist guidance in internet-based cognitive behavioral therapy (ICBT) programs is still unclear.

Objective

This trial aims to investigate the effects of a web-based alcohol program with or without therapist guidance among anonymous adult help-seekers.

Methods

A three-armed randomized controlled trial was conducted to compare therapist-guided ICBT and self-help ICBT with an information-only control condition. Swedish-speaking adult internet users with alcohol dependence (3 or more International Classification of Diseases, Tenth Revision criteria) or harmful alcohol use (alcohol use disorder identification test>15) were included in the study. Participants in the therapist-guided ICBT and self-help ICBT groups had 12-week access to a program consisting of 5 main modules, as well as a drinking calendar with automatic feedback. Guidance was given by experienced therapists trained in motivational interviewing. The primary outcome measure was weekly alcohol consumption in standard drinks (12 g of ethanol). Secondary outcomes were alcohol-related problems measured using the total alcohol use disorder identification test-score, diagnostic criteria for alcohol dependence and alcohol use disorder, depression, anxiety, health, readiness to change, and access to other treatments or support. Follow-up was conducted 3 (posttreatment) and 6 months after recruitment.

Results

During the recruitment period, from March 2015 to March 2017, 1169 participants were included. Participants had a mean age of 45 (SD 13) years, and 56.72% (663/1169) were women. At the 3-month follow-up, the therapist-guided ICBT and control groups differed significantly in weekly alcohol consumption (−3.84, 95% Cl −6.53 to −1.16; t₄₁₇=2.81; P=.005; Cohen d=0.27). No significant differences were found in weekly alcohol consumption between the self-help ICBT group and the therapist-guided ICBT at 3 months, between the self-help ICBT and the control group at 3 months, or between any of the groups at the 6-month follow-up. A limitation of the study was the large number of participants who were completely lost to follow-up (477/1169, 40.8%).

Conclusions

In this study, a therapist-guided ICBT program was not found to be more effective than the same program in a self-help ICBT version for reducing alcohol consumption or other alcohol-related outcomes. In the short run, therapist-guided ICBT was more effective than information. Only some internet help-seekers may need a multisession program and therapist guidance to change their drinking when they use internet-based interventions.

Trial Registration

ClinicalTrials.gov NCT02377726; https://clinicaltrials.gov/ct2/show/NCT02377726

New Australian guidelines for the treatment of alcohol problems: an overview of recommendations

OF RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity-frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient's needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the "teach-back" technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A).

SUMMARY OF KEY RECOMMENDATIONS AND LEVELS OF EVIDENCE

Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

Treatment of alcohol dependence in Swedish primary care: perceptions among general practitioners

OBJECTIVE

To describe general practitioners' (GPs) attitudes to the management of patients with alcohol dependence in primary care and current treatment routines and their view on a new treatment approach; internet-based Cognitive Behavioral Therapy (iCBT).

DESIGN

A qualitative interview study with ten GPs participating in a randomized controlled trial. The interviews were analyzed using qualitative content analysis.

SETTING

The participating GPs were recruited via purposeful sampling from primary care clinics in Stockholm.

SUBJECTS

The GPs were participants in an RCT investigating if iCBT when added to treatment as usual (TAU) was more effective than TAU only when treating alcohol dependence in primary care.

RESULTS

The GPs found alcohol important to discuss in many consultations and perceived most patients open to discuss their alcohol habits. Lack of training and treatment options were expressed as limiting factors when working with alcohol dependence. According to the respondents, routines for treating alcohol dependence were rare.

CONCLUSION

GPs believed that iCBT might facilitate raising questions about alcohol use and thought iCBT may serve as an attractive treatment option to some patients. The iCBT program did not require GPs to acquire skills in behavioral treatment, which could make implementation more feasible.KEY POINTSAlcohol dependence is highly prevalent, has a large treatment gap and is relevant to discuss with patients in many consultations in primary care.This study is based on interviews with 10 GPs participating in a randomized controlled trial comparing internet-based Cognitive Behavioral Therapy (iCBT) for alcohol-dependent patients to treatment as usual.GPs viewed alcohol habits as important to discuss and they perceived most patients are open to discuss this.The access to iCBT seemed to increase GPs' willingness to ask questions about alcohol and was viewed as an attractive treatment for some patients.The iCBT program did not require GPs to acquire skills in behavioral treatment, which might be timesaving and make implementation more feasible.

Internet-based therapy versus face-to-face therapy for alcohol use disorder, a randomized controlled non-inferiority trial

BACKGROUND AND AIMS

Most people with alcohol use disorder (AUD) are never treated. Internet-based interventions are effective in reducing alcohol consumption and could help to overcome some of the barriers to people not seeking or receiving treatment. The aim of the current study was to compare internet-delivered and face-to-face treatment among adult users with AUD.

DESIGN

Randomized controlled non-inferiority trial with a parallel design, comparing internet-delivered cognitive-behavioural therapy (ICBT) (n = 150) with face-to-face CBT (n = 151), at 3- and 6-month follow-ups.

SETTING

A specialized clinic for people with AUD in Stockholm, Sweden. Participants were recruited between 8 December 2015 and 5 January 2018.

PARTICIPANTS

A total of 301 patients [mean age 50 years, standard deviation (SD) = 12.3] with AUD, of whom 115 (38%) were female and 186 (62%) were male.

INTERVENTION AND COMPARATOR

Participants were randomized in blocks of 20 at a ratio of 1 : 1 to five modules of therapist-guided ICBT or to five modules of face-to-face CBT, delivered over a 3-month period. The same treatment material and the same therapists were used in both groups.

MEASUREMENTS

The primary outcome was standard drinks of alcohol consumed during the previous week at 6-month follow-up, analysed according to intention-to-treat. The pre-specified non-inferiority limit was five standard drinks of alcohol and d = 0.32 for secondary outcomes.

RESULTS

The difference in alcohol consumption between the internet and the face-to-face group was non-inferior in the intention-to-treat analysis of data from the 6-month follow-up [internet = 12.33 and face-to-face = 11.43, difference = 0.89, 95% confidence interval (CI) = -1.10 to 2.88]. The secondary outcome, Alcohol Use Disorder Identification Test score, failed to show non-inferiority of internet compared with face-to-face in the intention-to-treat analysis at 6-month follow-up (internet = 12.26 and face-to-face = 11.57, d = 0.11, 95% CI = -0.11 to 0.34).

CONCLUSIONS

Internet-delivered treatment was non-inferior to face-to-face treatment in reducing alcohol consumption among help-seeking patients with alcohol use disorder but failed to show non-inferiority on some secondary outcomes.

"I Felt I Was Reaching a Point with My Health": Understanding Reasons for Engagement and Acceptability of Treatment Services for Unhealthy Alcohol Use in Primary Care

INTRODUCTION/OBJECTIVES

Despite increasing need, there are large gaps in provision of care for unhealthy alcohol use. Primary care practices have become increasingly important in providing services for unhealthy alcohol use, yet little is known about the reasons patients engage in these services and their views on acceptability of such programs. The purpose of this study was to examine primary care patients' reasons for engagement, experiences with, and acceptability of a primary care practice-based program for treating unhealthy alcohol use.

METHODS

This qualitative study was conducted in a primary care practice that was developing a collaborative care model for treating unhealthy alcohol use in primary care. Semi-structured interviews were conducted with 24 primary care patients. Data were analyzed using conventional qualitative content analysis.

RESULTS

Findings suggest that patients engaged for both internal (concerns about drinking and health) and external reasons (family or provider concern). Patient experiences in the program were shaped by their affective responses (enjoyable, enlightening), as well as therapeutic benefits (gaining new insights about drinking; staff/provider support). Acceptability was driven by core program elements (medication, therapy, integration) as well as positive impacts on drinking cognition and behavior and flexible, patient-centered approaches.

CONCLUSIONS

Offering flexible and comprehensive programs with mutiple elements and both abstinence and moderation goals could also improve patient engagement and views on acceptability. Primary care practices will need to be thoughtful about the resources needed to implement these programs in terms of staffing, training, and program support.

Treating alcohol use disorders in primary care - a qualitative evaluation of a new innovation: the 15-method

OBJECTIVE

This study aims to explore how the characteristics of an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.

METHODS/DESIGN/SETTING/SUBJECT

General practitioners and heads of primary care units (n = 10) that delivered the 15-method in a randomized controlled trial participated in individual interviews at two occasions in Stockholm, Sweden. Data were analyzed with theoretical thematic analysis, using Diffusion of Innovation Theory.

RESULTS

The participants described that offering the 15-method met a need among their patients. Participants were positive towards the training and the manual for the method. They mentioned a previous lack of routines to work with alcohol use disorders. The 15-method was described as easy to use. It would however be more feasible to implement in a team of different professions, rather than among general practitioners only. Priorities made by regional health care managers were described as important for the implementation, as well as financial incentives. A barrier to implementation was that alcohol screening was perceived as difficult. While the 15-method was perceived as effective in reducing the patients' alcohol use and cost effective, participants expressed uncertainty about the long-term effects.

CONCLUSIONS

The 15-method provides structure for treatment of alcohol use disorders and is described by general practitioners and heads as a promising approach. Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.KEY POINTSLittle attention has been given to develop treatment models for alcohol use disorders that are adapted to primary care settings.This study describes how an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.The 15-method provides structure for treatment of alcohol use disorders in primary care and is described by general practitioners and heads as a promising approach.Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.

Evidence based models of care for the treatment of alcohol use disorder in primary health care settings: a systematic review

Background

Pharmacological and behavioural treatments for alcohol use disorders (AUDs) are effective but the uptake is limited. Primary care could be a key setting for identification and continuous care for AUD due to accessibility, low cost and acceptability to patients.

We aimed to synthesise the literature regarding differential models of care for the management of AUD in primary health care settings.

Methods

We conducted a systematic review of articles published worldwide (1998-present) using the following databases; Medline, PsycINFO, Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials and Embase. The Grey Matters Tool guided the grey literature search. We selected randomised controlled trials evaluating the effectiveness of a primary care model in the management of AUD. Two researchers independently assessed and then reached agreement on the included studies. We used the Cochrane risk of bias tool 2.0 for the critical appraisal.

Results

Eleven studies (4186 participants) were included. We categorised the studies into ‘lower’ versus ‘higher’ intensity given the varying intensity of clinical care evaluated across the studies. Significant differences in treatment uptake were reported by most studies. The uptake of AUD medication was reported in 5 out of 6 studies that offered AUD medication. Three studies reported a significantly higher uptake of AUD medication in the intervention group. A significant reduction in alcohol use was reported in two out of the five studies with lower intensity of care, and three out of six studies with higher intensity of care.

Conclusion

Our results suggest that models of care in primary care settings can increase treatment uptake (e.g. psychosocial and/or pharmacotherapy) although results for alcohol-related outcomes were mixed. More research is required to determine which specific patient groups are suitable for AUD treatment in primary health care settings and to identify which models and components are most effective.

Trial Registration

PROSPERO: CRD42019120293.

Brief motivational therapy versus enhanced usual care for alcohol use disorders in primary care in Chile: study protocol for an exploratory randomized trial

BACKGROUND

Harmful alcohol use is a leading cause of global disability and death. However, increased detection and brief intervention capacity of more severe alcohol use disorders has not been accompanied by increased availability of treatment services. Incorporating treatment for such disorders into primary care is of paramount importance for improving access and health outcomes. This study aims to estimate the effectiveness of a Brief Motivational Treatment (BMT) applied in primary care for treatment of these disorders.

METHODS

A parallel-group, single-blinded, severity-stratified, randomized clinical trial will test the superiority of BMT over enhanced usual care. Eligible participants will be those seeking treatment and who fulfill DSM-V criteria for alcohol use disorder and criteria for harmful alcohol use. With an estimated a loss to follow-up of 20%, a total of 182 participants will be recruited and equally randomized to each treatment group. The intervention group will receive an adaptation of the motivational enhancement therapy, as manualized in Project MATCH. This treatment consists of four 45-min sessions provided by a general psychologist with at least 3 years of primary care experience. The primary outcome is the change from baseline in the drinks per drinking day during the last 90 days, which will be captured using the Timeline Follow Back method. Secondary outcomes will describe the changes in alcohol use pattern, motivational status, and severity of the disorder. All participants will be analyzed according to the group they were allocated, regardless of the treatment actually received. Mean differences (MD) will be computed for continuous outcomes and relative risks (RR) and RR reductions (RRR) for dichotomous results. Linear models will deliver the subgroup analyses. Missingness is assumed to be associated with the baseline alcohol use pattern and severity, so a multiple imputation method will be used to handle missing data.

DISCUSSION

This trial aims to test the superiority of BMT over enhanced usual care with a reasonable superiority margin, over which the BMT could be further considered for incorporation into PC in Chile. Its pragmatic approach ultimately aims to inform policymakers about the benefit of including a brief psychosocial treatment into PC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04345302 . Registered on 28 April 2020.

Choosing internet-based treatment for problematic alcohol use-why, when and how? Users' experiences of treatment online

Background

Internet-based treatment has emerged as a cost-effective option for reaching people who for different reasons are not reached by traditional treatment. Internet-based treatment for problematic alcohol use, specifically, has been found to show results on par with other forms of treatment. However, in-depth knowledge of users’ experiences is required to understand what works, and what needs further development. The aim of this study is to investigate the help-seeking motives among users of an internet-based service for problematic alcohol use, as well as the users’ experiences of the support available through the service.

Method

The study consists of a thematic analysis of interviews with 38 former users of the internet-based intervention Alkoholhjälpen.

Results

The analysis shows that health and relationship factors, as well as feelings of shame, were important motives for the users’ decisions to reduce their drinking. Availability and anonymity seem to have been important reasons for choosing internet-based support. The different treatment components, i.e. ICBT program, therapist support and discussion forum, were each perceived as helpful by some users but not by others. Treatment components were described as more useful when users were able to personally identify with the content, and when it helped them reflect on their own alcohol consumption.

Conclusions

There are several aspects that are relevant, beyond the comparison between components, if we want to understand what works and for whom in internet-based treatment. Internet-based treatment services should be generous in terms of options for the users.

Abstinence or controlled drinking – a five-year follow-up on Swedish clients reporting positive change after treatment for substance use disorders

Purpose

The purpose of this paper is to investigate how clients – five years after completing treatment interventions endorsing abstinence – view abstinence and the role of Alcoholics Anonymous (AA) in their recovery process.

Design/methodology/approach

Interviews with 40 clients were conducted shortly after them finishing treatment and five years later. All the interviewees had attended treatment programmes based on the 12-step philosophy, and they all described abstinence as crucial to their recovery process in an initial interview.

Findings

At follow-up, the majority remained abstinent. For many, attending AA meetings was still important – some described attending as a routine, whereas others stressed that the meetings were crucial for remaining abstinent. For those who reported controlled drinking (CD), this was described either as a natural step in their recovery process or as associated with worries and self-doubts.

Research limitations/implications

The results suggest the importance of offering interventions with various treatment goals and that clients choosing CD as part of their sustained recovery would benefit from support in this process, both from peers and professionals.

Originality/value

There are heterogeneous views on the possibilities of CD after recovery from substance use disorder both in research and in treatment systems. This study on client views on abstinence versus CD after treatment advocating total abstinence can contribute with perspectives on this ongoing discussion.

The efficacy of iCBT added to treatment as usual for alcohol-dependent patients in primary care: study protocol for a randomized controlled trial

BACKGROUND

Alcohol dependence is a common disorder with a continuum regarding severity. Most alcohol-dependent persons have a moderate level of dependence and live under socially orderly conditions. Treatment-seeking in this group is low, mainly due to stigma and because treatment options are seen as unappealing. Alcohol is a relevant topic to discuss in many primary care (PC) consultations and PC is less stigmatizing to visit compared to addiction care units for people with alcohol problems. However, general practitioners (GPs) hesitate to engage in treating alcohol problems due to time constraints and lack of knowledge. Screening and brief interventions are effective for high consumers but there are few studies on dependence.

METHODS

This is a two-group, parallel, randomized controlled trial (RCT). The aim is to study whether an Internet-based Cognitive Behavioral Treatment (iCBT) when added to treatment as usual (TAU) is more effective than TAU only for alcohol dependence in PC. Two hundred and sixty adults with alcohol dependence will be included. Participants are randomized to iCBT and TAU or TAU only. The primary study outcome is alcohol consumption in grams per week and heavy-drinking days. Secondary outcomes include alcohol-related problem severity, number of diagnostic criteria for alcohol dependence, depression and anxiety symptoms, health-related quality of life and biochemical markers for high consumption and liver pathology. Data will be analyzed using mixed-effect models.

DISCUSSION

Internet-based interventions are attractive to, and have been shown to reach, people with alcohol problems. Yet there are no studies investigating the efficacy of Internet treatment of alcohol dependence in PC. In this study we hypothesize that iCBT when added to TAU will improve treatment outcome for alcohol dependence in PC, compared to TAU only. If effective, iCBT can be distributed to the public to a low cost for a stakeholder and has the opportunity to reduce both short-term and long-term public health costs.

TRIAL REGISTRATION

ISRCTN69957414. Retrospectively registered on 7 June 2018.

Study protocol: a cluster-randomized trial implementing Sustained Patient-centered Alcohol-related Care (SPARC trial)

Background

Experts recommend that alcohol-related care be integrated into primary care (PC) to improve prevention and treatment of unhealthy alcohol use. However, few healthcare systems offer such integrated care. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington (KPWA) partnered to design a high-quality program of evidence-based care for unhealthy alcohol use: the Sustained Patient-centered Alcohol-related Care (SPARC) program. SPARC implements systems of clinical care designed to increase both prevention and treatment of unhealthy alcohol use. This clinical care for unhealthy alcohol use was implemented using three strategies: electronic health record (EHR) decision support, performance monitoring and feedback, and front-line support from external practice coaches with expertise in alcohol-related care (“SPARC implementation intervention” hereafter).

The purpose of this report is to describe the protocol of the SPARC trial, a pragmatic, cluster-randomized, stepped-wedge implementation trial to evaluate whether the SPARC implementation intervention increased alcohol screening and brief alcohol counseling (so-called brief interventions), and diagnosis and treatment of alcohol use disorders (AUDs) in 22 KPWA PC clinics.

Methods/Design

The SPARC trial sample includes all adult patients who had a visit to any of the 22 primary care sites in the trial during the study period (January 1, 2015–July 31, 2018). The 22 sites were randomized to implement the SPARC program on different dates (in seven waves, approximately every 4 months). Primary outcomes are the proportion of patients with PC visits who (1) screen positive for unhealthy alcohol use and have documented brief interventions and (2) have a newly recognized AUD and subsequently initiate and engage in alcohol-related care. Main analyses compare the rates of these primary outcomes in the pre- and post-implementation periods, following recommended approaches for analyzing stepped-wedge trials. Qualitative analyses assess barriers and facilitators to implementation and required adaptations of implementation strategies.

Discussion

The SPARC trial is the first study to our knowledge to use an experimental design to test whether practice coaches with expertise in alcohol-related care, along with EHR clinical decision support and performance monitoring and feedback to sites, increase both preventive care—alcohol screening and brief intervention—as well as diagnosis and treatment of AUDs.

Trial registration

The trial is registered at ClinicalTrials.Gov: NCT02675777. Registered February 5, 2016, https://clinicaltrials.gov/ct2/show/NCT02675777.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0795-9) contains supplementary material, which is available to authorized users.