Do manualized psychosocial interventions help reduce relapse among alcohol-dependent adults treated with naltrexone or placebo? A meta-analysis

Combined pharmacological and psychosocial interventions for alcohol use disorder

BACKGROUND

Alcohol use disorder (AUD) is a mental disorder characterised by a strong desire to consume alcohol and impaired control of alcohol use, with devastating consequences. Many people with AUD do not respond to psychosocial or pharmacological interventions when these are provided alone. Combining these interventions may improve the response to treatment, though evidence remains limited.

OBJECTIVES

To assess the effects of combined pharmacological and psychosocial interventions for the treatment of AUD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in November 2023, without language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing combined pharmacological and psychosocial interventions versus pharmacological or psychosocial interventions alone, or no intervention/treatment as usual (TAU), in adults with AUD. Our primary outcomes were continuous abstinent participants, frequency of use (measured as heavy drinkers, percentages of abstinent days, heavy-drinking days), amount of use (number of drinks per drinking day), adverse events, serious adverse events, dropouts from treatment, and dropouts due to adverse events.

DATA COLLECTION AND ANALYSIS

We assessed risk of bias using Cochrane's RoB 1 tool, performed random-effects meta-analyses, and evaluated the certainty of evidence according to the GRADE approach.

MAIN RESULTS

We included 21 RCTs (4746 participants). The most studied pharmacological and psychosocial interventions were naltrexone (81.0%) and cognitive behavioural therapy (66.7%), respectively. Most participants were men (74%), aged about 44 years, with AUD, without comorbid mental disorders or other substance use disorders; 15 RCTs detoxified participants before treatment. We judged 28.5% of the studies as at low risk of bias for random sequence generation, allocation concealment, performance bias for objective and subjective outcomes, and detection bias for subjective outcomes; all studies were at low risk of detection bias for objective outcomes; 85.7% of studies were at low risk of attrition bias; 14.2% of studies were at low risk of reporting bias. 1) Compared to psychosocial intervention alone, combined pharmacological and psychosocial interventions probably reduce the number of heavy drinkers (above the clinically meaningful threshold (MID) of 2%; absolute difference (AD) -10%, 95% confidence interval (CI) -18% to -2%; risk ratio (RR) 0.86, 95% CI 0.76 to 0.97; 8 studies, 1609 participants; moderate-certainty evidence). They may increase continuous abstinent participants (MID 5%; AD 5%, 95% CI 1% to 11%; RR 1.17, 95% CI 1.02 to 1.34; 6 studies, 1184 participants; low-certainty evidence). They probably have little to no effect on: • the rate of abstinent days (MID 8%; mean difference (MD) 4.16, 95% CI 1.24 to 7.08; 10 studies, 2227 participants); • serious adverse events (MID 1%; AD -2%, 95% CI -3% to 0%; RR 0.20, 95% CI 0.03 to 1.12; 4 studies; 524 participants); • dropouts from treatment (MID 10%; AD -3%, 95% CI -5% to 0%; RR 0.89, 95% CI 0.79 to 1.01; 15 studies, 3021 participants); and • dropouts due to adverse events (MID 5%; AD 2%, 95% CI 0% to 5%; RR 1.91, 95% CI 1.04 to 3.52; 8 studies, 1572 participants) (all moderate-certainty evidence). They may have little to no effect on: • heavy-drinking days (MID 5%; MD -3.49, 95% CI -8.68 to 1.70; 4 studies, 470 participants); • number of drinks per drinking day (MID 1 drink; MD -0.57, 95% CI -1.16 to 0.01; 7 studies, 805 participants); and • adverse events (MID 30%; AD 17%, 95% CI -5% to 46%; RR 1.25, 95% CI 0.93 to 1.68; 4 studies, 508 participants) (all low-certainty evidence). 2) Compared to pharmacological intervention alone, combined pharmacological and psychosocial interventions may have little to no effect on: • the rate of abstinent days (MID 8%; MD -1.18, 95% CI -4.42 to 2.07; 2 studies, 1158 participants); and • dropouts from treatment (MID 10%; AD 1%, 95% CI -10 to 14%; RR 0.98, 95% CI 0.65 to 1.47; 3 studies, 1246 participants) (all low-certainty evidence). We are uncertain about their effect on: • continuous abstinent participants (MID 5%; AD 3%, 95% CI -5% to 18%; RR 1.22, 95% CI 0.62 to 2.40; 1 study, 241 participants); • the number of heavy drinkers (MID 2%; AD 2%, 95% CI -4% to 8%; RR 1.03, 95% CI 0.94 to 1.12; 1 study, 917 participants); • the number of drinks per drinking day (MID 1 drink; MD -2.40, 95% CI -3.98 to -0.82; 1 study, 241 participants); and • dropouts due to adverse events (MID 5%; AD -1%, 95% CI -3% to 6%; RR 0.61, 95% CI 0.14 to 2.72; 2 studies, 1165 participants) (all very low-certainty evidence). 3) We are uncertain about the effect of combined pharmacological and psychosocial interventions, when compared to TAU, on: • the number of heavy drinkers (MID 2%; AD -5%, 95% CI -13% to 2%; RR 0.93, 95% CI 0.83 to 1.03; 1 study, 616 participants); • the rate of abstinent days (MID 8%; MD 3.43, 95% CI -1.32 to 8.18; 1 study, 616 participants); • dropouts from treatment (MID 10%; AD 0%, 95% CI -10% to 15%; RR 0.98, 95% CI 0.58 to 1.65; 2 studies, 696 participants); and • dropouts due to adverse events (MID 5%; AD 3%, 95% CI 0% to 15%; RR 2.97, 95% CI 0.70 to 12.67; 1 study, 616 participants) (all very low-certainty evidence). The certainty of evidence ranged from moderate to very low, downgraded mainly due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

As implications for practice, our findings indicate that adding pharmacological to psychosocial interventions is safe and helps people with AUD recover. These conclusions are based on low- to moderate-certainty evidence. Given the few studies and very low-certainty evidence, any benefits of adding psychosocial to pharmacological interventions or comparing the combined intervention to TAU are less clear. As implications for research, further studies should investigate the effects of the combined intervention compared to pharmacotherapy or TAU.

Evidence of subgroup differences in meta-analyses evaluating medications for alcohol use disorder: An umbrella review

Randomized controlled trials (RCTs) evaluating medications for alcohol use disorder (AUD) often examine heterogeneity of treatment effects through subgroup analyses that contrast effect estimates in groups of patients across individual demographic, clinical, and study design-related characteristics. However, these analyses are often not prespecified or adequately powered, highlighting the potential role of subgroup analyses in meta-analysis. Here, we conducted an umbrella review (i.e., a systematic review of meta-analyses) to determine the range and characteristics of reported subgroup analyses in meta-analyses of AUD medications. We searched PubMed to identify meta-analyses of RCTs evaluating medications for the management of AUD, alcohol abuse, or alcohol dependence in adults. We sought studies that measured drinking-related outcomes; quality of life, function, and rates of mortality; adverse events; and dropout. We considered meta-analyses that reported the results from formal subgroup analyses (comparing the summary effects across subgroup levels); summary effect estimates stratified across subgroup levels; and meta-regression, regression, or correlation-based subgroup analyses. We analyzed nine meta-analyses that included 61 formal subgroup analyses (median = 6 per meta-analysis), of which 33 (54%) were based on baseline participant-level and 28 (46%) were based on trial-level characteristics. Of the 58 subgroup analyses with either a p-value from a subgroup test or a statement by the authors that the subgroup analyses were not statistically significant, eight (14%) were statistically significant at the p < 0.05 level. Twelve meta-analyses reported the results of 102 meta-regression analyses, of which 25 (25%) identified statistically significant predictors of the relevant outcome of interest; nine (9%) were based on baseline participant-level and 93 (91%) were based on trial characteristics. Subgroup analyses across meta-analyses of AUD medications often focus on study-level characteristics, which may not be as clinically informative as subgroup analyses based on participant-level characteristics. Opportunities exist for future meta-analyses to standardize their subgroup methodology, focus on more clinically informative participant-level characteristics, and use predictive approaches to account for multiple relevant variables.

Common strategies in empirically supported psychological interventions for alcohol use disorders: A meta-review

ISSUES

Despite the large number of effective psychological interventions for alcohol use disorders (AUD), there is still a lack of clarity concerning the strategies that make these interventions effective.

APPROACH

The overall goal of this review was to identify, examine and synthesise the information about common strategies from evidence-based psychological interventions for AUDs by conducting a review of systematic reviews, that is, a meta-review. We isolated the relevant primary studies from eligible systematic reviews and extracted information about the interventions from these studies to understand the strategies used. Analysis was restricted to narrative summaries.

KEY FINDINGS

Thirteen reviews were eligible for inclusion in our meta-review. Of these, eight demonstrated the effectiveness of a range of psychological interventions-behavioural couples therapy, cognitive behaviour therapy combined with motivational interviewing, brief interventions, contingency management, psychotherapy plus brief interventions, Alcoholics Anonymous and 12-step treatment programs, family-therapy or family-involved treatment, and community reinforcement approach. The most commonly used component strategies in effective interventions for AUDs included assessment, personalised feedback, motivational interviewing, goal setting, setting and review of homework, problem solving skills and relapse prevention/management.

IMPLICATIONS

Evidence about commonly used strategies in evidence-based psychological interventions for AUDs offer the possibility of creating menu-driven interventions that can be tailored to respond to individual client needs and preferences in different contexts.

The Added Value of Pharmacotherapy to Cognitive Behavior Therapy And Vice Versa in the Treatment of Alcohol Use Disorders: A Systematic Review

AIM

To explore whether combined interventions i.e. psychotherapeutic plus psychosocial interventions are more effective than monotherapies in the treatment of alcohol use disorders.

METHODS

Systematic review of the results of randomized controlled trials that compared combined therapies with monotherapies (either pharmacotherapy or psychotherapy).

RESULTS

The search resulted in 28 eligible studies. Data from these RCTs showed that 10 out of 19 RCTs (53%) demonstrated an added value of combined therapy (psychotherapy + pharmacotherapy) compared to psychotherapy only, whereas only three out of nine RCTs (33%) comparing combined therapy with pharmacotherapy showed a possible added value for combined therapy.

CONCLUSIONS

Pharmacotherapy is effective to treat AUD with or without psychotherapy and that psychotherapy can best be offered in combination with pharmacotherapy.

rTMS Reduces Craving and Alcohol Use in Patients with Alcohol Use Disorder: Results of a Randomized, Sham-Controlled Clinical Trial

(1) Background: Current evidence-based treatments for alcohol use disorder (AUD) are moderately effective. Studies testing repetitive transcranial magnetic stimulation (rTMS) in AUD commonly apply a limited number of rTMS sessions with different rTMS settings, showing inconsistent effects on craving for alcohol. This study tested the efficacy of a robust rTMS protocol on craving and alcohol use. (2) Methods: In a single-blind randomized controlled trial in recently detoxified patients with AUD, ten days of high-frequency rTMS over the right dorsolateral prefrontal cortex on top of treatment as usual (n = 14) was compared with sham rTMS (n = 16). Outcome measures were alcohol craving and use over a follow-up period of one year. Analysis was performed by means of repeated measures multivariate analysis of variance. (3) Results: The results showed a main group-by-time interaction effect on craving (Wilks’ Λ = 0.348, F (12, 17) = 2.654, p = 0.032) and an effect of group on alcohol use (Wilk’s Λ = 0.44, F (6, 23) = 4.9, p = 0.002), with lower alcohol craving and use in the group with active rTMS compared to the control group. Differences in craving between groups were most prominent three months after treatment. At 12 months follow-up, there was no effect of rTMS on craving or abstinence. (4) Conclusions: This small-scale randomized controlled trial showed the efficacy of high-frequency rTMS over the right dlPFC diminished alcohol craving and use in recently detoxified patients with AUD during the first months after detoxification. These findings suggest that rTMS might be an effective add-on in treating patients with AUD and warrant replication in future large-scale studies.

Medication-enhanced behavior therapy for alcohol use disorder: Naltrexone, Alcoholics Anonymous Facilitation, and OPRM1 genetic variation

Medication-assisted behavior treatment for alcohol use disorder (AUD) holds promise to enhance the efficacy of medication and of behavior therapy when administered individually. The present study examines the treatment benefit of combined outpatient naltrexone (NTX) treatment with Alcoholics Anonymous Facilitation (AAF) behavior therapy, in the context of OPRM1 genotype. The minor OPRM1 Asp40 G-allele has been associated with greater positive reinforcing effects of alcohol consumption and greater alcohol craving, suggesting that individuals carrying the OPRM1 G allele may have an improved naltrexone response. Twenty patients, including 7 G-allele carriers, received 90 days of naltrexone with medication support and dispensing sessions, and ten AAF behavior therapy sessions. During treatment and the eight-week posttreatment follow-up, an overall increase in percent days abstinent was observed for the sample as a whole, but G-allele carriers reported relatively heavier drinking relative to other subjects. These findings suggest that this enhanced medication-assisted behavior treatment is a promising therapeutic combination, and mirror other recent findings that G-allele carriers may require more intensive treatment.

Novel approaches to alcohol rehabilitation: Modification of stress-responsive brain regions through environmental enrichment

Relapse remains the most prominent hurdle to successful rehabilitation from alcoholism. The neural mechanisms underlying relapse are complex, but our understanding of the brain regions involved, the anatomical circuitry and the modulation of specific nuclei in the context of stress and cue-induced relapse have improved significantly in recent years. In particular, stress is now recognised as a significant trigger for relapse, adding to the well-established impact of chronic stress to escalate alcohol consumption. It is therefore unsurprising that the stress-responsive regions of the brain have also been implicated in alcohol relapse, such as the nucleus accumbens, amygdala and the hypothalamus. Environmental enrichment is a robust experimental paradigm which provides a non-pharmacological tool to alter stress response and, separately, alcohol-seeking behaviour and symptoms of withdrawal. In this review, we examine and consolidate the preclinical evidence that alcohol seeking behaviour and stress-induced relapse are modulated by environmental enrichment, and these are primarily mediated by modification of neural activity within the key nodes of the addiction circuitry. Finally, we discuss the limited clinical evidence that stress-reducing approaches such as mindfulness could potentially serve as adjunctive therapy in the treatment of alcoholism. This article is part of the Special Issue entitled "Neurobiology of Environmental Enrichment".

The Effect of the Cognitive-behavioral Model-based Psychoeducation and Exercise Intervention on Quality of Life in Alcohol Use Disorder

PURPOSE

The aim of the study was to assess the effect of the cognitive behavior model (CBM)-based psychoeducation and exercise intervention on quality of life (QoL) in alcohol use disorder (AUD).

DESIGN

This study was a non-randomized controlled trial.

METHODS

CBM-based psychoeducation and exercise intervention was applied to the experimental group four times a week for 6weeks; no intervention was applied to the control group.

FINDINGS

No difference was seen between the points of pretest QoL of the experimental and control groups (p>0.05). However, according to the posttest, the experimental group's mean score of QoL was higher than the control groups (p<0.05).

CONCLUSION

It was found that CBM-based psychoeducation and exercise intervention applied to individuals with AUD affected the QoL positively.

CLINICAL RELEVANCE

CBM-based psychoeducation and exercise intervention can be used by nurses to improve AUD individuals' quality of life.

Exercise as an Adjunctive Treatment for Substance Use Disorders: Rationale and Intervention Description

Substance use disorders (SUDs) are maladaptive patterns of substance use that are associated with psychiatric comorbidity, unhealthy lifestyle choices, and high rates of relapse. Exercise is associated with a wide range of acute and long-term benefits for both mental and physical health and is presently being investigated as a promising adjunctive treatment for SUD. Despite positive effects of regular physical activity on treatment outcomes and risk factors for relapse, low adherence and high attrition rates limit the benefits derived from exercise interventions. Lack of motivation is one of many perceived barriers to initiating exercise that contributes to poor adherence to interventions. In the present article, we describe the protocol for a novel, integrated exercise intervention that combines motivational interviewing (MI), a client-centered approach designed to enhance intrinsic motivation and resolve ambivalence toward change, and contingency management (CM), a behavioral treatment that provides monetary incentives for the completion of target behaviors. The protocol seeks to address the challenges surrounding initiation and maintenance of an exercise program at a level consistent with public health guidelines, particularly for sedentary patients. We conclude with considerations for the implementation of the intervention in SUD specific clinics.

Is the Construct of Relapse Heuristic, and Does It Advance Alcohol Use Disorder Clinical Practice?

OBJECTIVE

Alcohol use disorder (AUD) relapse is a construct that has been of major clinical and research interest but has been inconsistently defined. The purpose of this study was to review the definitions of AUD relapse that have been used in clinical research as a basis for drawing conclusions about its heuristic value.

METHOD

A systematic review of the literature was conducted on empirical studies that (a) were published in peer-reviewed journals, (b) were published between 2010 and 2015, (c) were written in English, and (d) provided a definition of alcohol relapse (or lapse) that was used in the study.

RESULTS

The review yielded 139 individual studies that met inclusion criteria. The studies showed wide variability in how relapse was defined and interpreted in the literature, and there was little direct empirical or theoretical rationale provided for the definitions of relapse that were chosen. Furthermore, the concept of AUD relapse as a discrete state is not consistent with the empirical literature on the clinical course of alcohol consumption.

CONCLUSIONS

We conclude that the heuristic value of AUD relapse as currently studied is low. An alternative approach that embeds the construct in theory and data on the clinical course of alcohol consumption and aligns with current trends in healthcare would seem to have a better chance of improving AUD clinical decision-making and knowledge about AUD in general.

Neurofeedback training for alcohol dependence versus treatment as usual: study protocol for a randomized controlled trial

Background

Real-time functional magnetic resonance imaging (rtfMRI) is used for neurofeedback training (NFT). Preliminary results suggest that it can help patients to control their symptoms. This study uses rtfMRI NFT for relapse prevention in alcohol dependence.

Methods/design

Participants are alcohol-dependent patients who have completed a detoxification programme within the past 6 months and have remained abstinent. Potential participants are screened for eligibility, and those who are eligible are randomly assigned to the treatment group (receiving rtfMRI NFT in addition to treatment as usual) or the control group (receiving only treatment as usual). Participants in both groups are administered baseline assessments to measure their alcohol consumption and severity of dependence and a variety of psychological and behavioural characteristics that are hypothesised to predict success with rtfMRI NFT. During the following 4 months, experimental participants are given six NFT sessions, and before and after each session various alcohol-related measures are taken. Participants in the control group are given the same measures to coincide with their timing in the experimental group. Eight and 12 months after the baseline assessment, both groups are followed up with a battery of measures. The primary research questions are whether NFT can be used to teach participants to down-regulate their brain activation in the presence of alcohol stimuli or to up-regulate their brain activation in response to pictures related to healthy goal pursuits, and, if so, whether this translates into reductions in alcohol consumption. The primary outcome measures will be those derived from the functional brain imaging data. We are interested in improvements (i.e., reductions) in participants’ alcohol consumption from pretreatment levels, as indicated by three continuous variables, not simply whether or not the person has remained abstinent. The indices of interest are percentage of days abstinent, drinks per drinking day, and percentage of days of heavy drinking. General linear models will be used to compare the NFT group and the control group on these measures.

Discussion

Relapse in alcohol dependence is a recurring problem, and the present evaluation of the role of rtfMRI in its treatment holds promise for identifying a way to prevent relapse.

Trial registration

ClinicalTrials.gov Identifier: NCT02486900, registered on 26 June 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1607-7) contains supplementary material, which is available to authorized users.