Reductions in WHO risk drinking levels correlate with alcohol craving among individuals with alcohol use disorder

BACKGROUND

Abstinence has historically been considered the preferred goal of alcohol use disorder (AUD) treatment. However, most individuals with AUD do not want to abstain and many are able to reduce their drinking successfully. Craving is often a target of pharmacological and behavioral interventions for AUD, and reductions in craving may signal recovery. Whether reductions in drinking during AUD treatment are associated with reductions in craving has not been well examined.

METHODS

We conducted secondary analyses of data from three AUD clinical trials (N's= 1327, 346, and 200). Drinking reductions from baseline to the end of treatment were measured as changes in World Health Organization (WHO) risk drinking levels; alcohol craving was measured using validated self-report measures. Regression analyses tested whether drinking reductions were associated with end-of-treatment craving reductions; moderation analyses tested whether associations between drinking reduction and end-of-treatment craving differed across AUD severity.

RESULTS

Reductions of at least 1 or at least 2 WHO risk drinking levels were associated with lower craving (all p's < 0.05). Results were substantively similar after removing abstainers at the end-of-treatment. Associations between drinking reductions and craving were generally not moderated by AUD severity.

CONCLUSIONS

Individuals with WHO risk drinking level reductions reported significantly lower craving, as compared to those who did not achieve meaningful reductions in drinking. The results demonstrate the utility of WHO risk drinking levels as AUD clinical trial endpoints and provide evidence that drinking reductions mitigate craving.

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.

Alcohol dependence severity determines the course of treatment-seeking patients

BACKGROUND

While accumulating evidence suggests a relation between the severity of alcohol dependence and the risk of its recurrence, the impact of dependence severity on the course of the disorder has not been carefully evaluated. The present study examined the impact of several severity indices of alcohol dependence on the drinking course after inpatient treatment.

METHODS

This prospective study was conducted over a 12-month period following alcohol treatment at a specialized hospital. A total of 712 consecutively admitted alcohol-dependent patients were targeted for enrollment at the time of their hospitalization, with 637 patients registered and followed. The characteristics and severity of the subjects were assessed using multiple methods at admission, with their course after discharge followed continuously using mailed questionnaires that queried them regarding their drinking behavior.

RESULTS

Greater severity of dependence, assessed using the number of ICD-10 diagnostic criteria met, was associated with a lower rate of abstinence during the study period (p = 0.035). The rate of abstinence also decreased significantly as the baseline blood gamma-glutamyl transferase value and Alcohol Dependence Scale (ADS) score increased (p = 0.031 and p = 0.0002, respectively). In multivariate Cox proportional hazards analyses, the group with the most severe ADS scores had a significantly greater risk of relapse to drinking than the group with the least severe scores (HR = 2.67, p = 0.001). Dependence severity also associated with the drinking pattern; participants in both the controlled drinking group and the abstinence group had lower ADS scores at admission and a later age at first drinking (p = 0.001 and p < 0.001, respectively) than those with poorer drinking outcomes.

CONCLUSIONS

The present study showed that more severe alcohol dependence predicts a poorer course after alcohol treatment, as reflected by findings on multiple measures. These results suggest that assessing the dependence severity at the outset of treatment could be useful both in predicting treatment outcome and targeting interventions to alcohol-dependent individuals who need additional support in their recovery.

Controlled drinking-non-abstinent versus abstinent treatment goals in alcohol use disorder: a systematic review, meta-analysis and meta-regression

BACKGROUND AND AIMS

The proportion of untreated patients with alcohol use disorder (AUD) exceeds that of any other mental health disorder, and treatment alternatives are needed. A widely discussed strategy is to depart from the abstinence paradigm as part of controlled drinking approaches. This first systematic review with meta-analysis aims to assess the efficacy of non-abstinent treatment strategies compared with abstinence-based strategies.

METHODS

CENTRAL, PubMed, PsycINFO and Embase databases were searched until February 2019 for controlled (randomized and non-randomized) clinical trials (RCTs and non-RCTs) among adult AUD populations, including an intervention group aiming at controlled drinking and a control group aiming for abstinence. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Cochrane Collaboration guidelines, literature search, data collection and risk of bias assessment were carried out independently by two reviewers [International Prospective Register of Systematic Reviews (PROSPERO), registration no. CRD42019128716]. The primary outcome was the proportion of participants consuming alcohol at or below the recommended threshold. Secondary outcomes were social functioning, drinking reductions, abstinence rates and dropouts. Using random-effects models, RCTs and non-RCTs were analyzed separately. Sensitivity and subgroup analyses accounted for methodological rigor, inclusion of goal-specific treatment, length of follow-up and AUD severity.

RESULTS

Twenty-two studies (including five RCTs) with 4204 patients were selected. There was no statistically significant difference between both treatment paradigms in RCTs [odds ratio (OR) = 1.32, 95% confidence interval (CI) = 0.51-3.39]. Non-randomized studies of free goal choice favored abstinence-orientation (OR = 0.60, 95% CI = 0.40-0.90), unless goal-specific treatment was provided (OR = 0.79, 95% CI = 0.40-1.56), or in studies of low risk of bias (OR = 0.73, 95% CI = 0.49-1.09) or with long follow-up (OR = 1.49, 95% CI = 0.78-2.85). Effect sizes were not clearly dependent upon AUD severity. Abstinence- and controlled drinking interventions did not clearly differ in their effect on social functioning and drinking reductions.

CONCLUSIONS

Available evidence does not support abstinence as the only approach in the treatment of alcohol use disorder. Controlled drinking, particularly if supported by specific psychotherapy, appears to be a viable option where an abstinence-oriented approach is not applicable.

GRATITUDE WHILE DRINKING, GRATITUDE WHILE RECOVERING: A STUDY OF ALCOHOL USE DISORDERS

Background

For decades researchers have debated whether those diagnosed with alcohol use disorders can return to non-problematic drinking. Now, recovery researchers are measuring aspects of wellbeing in addition to aspects of pathology, producing surprising findings that have added to the debate. Recent studies show that some with alcohol use disorders who continue to drink endorse high levels of positive psychosocial functioning.

Objectives

Employ trait gratitude as a marker of wellness to answer the following questions: how do individuals who continue to drink but endorse high gratitude at follow-up differ from peers at baseline? Does trait gratitude correlate differently with demographic, psychosocial, and clinical factors for abstinent members of Alcoholics Anonymous (AA) versus actively drinking non-AAs?

Methods

275 individuals with alcohol dependence were assessed for trait gratitude at 2.5-3-year follow-up in a naturalistic, longitudinal study. The sample was assessed on psychosocial and clinical indicators at baseline and follow-up.

Results

Drinkers who endorsed high gratitude had higher socioeconomic status, greater levels of positive spirituality, more stable personality indicators, less addiction severity, fewer negative life events, and fewer psychiatric symptoms than their peers at baseline. For actively drinking non-AAs, trait gratitude correlated differently, and positively, with years of education, income, and purpose in life compared with sober AA members. For AA members, gratitude correlated with AA involvement and length of sobriety.

Discussion

Across multiple domains, a subset of drinkers report doing relatively well despite meeting criteria for alcohol dependence. Trait gratitude correlates differently with other constructs for AAs versus non-AAs, indicating that gratitude for recovery might be contextually sensitive, operating differently within and without the structure of AA.

Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network meta-analyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate

BACKGROUND AND AIMS

Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders (AUDs) is an emerging concept. Our objective was to explore the comparative effectiveness of drugs used in this indication.

DESIGN

Systematic review with direct and network meta-analysis of double-blind randomized controlled trials (RCTs) assessing the efficacy of nalmefene, naltrexone, acamprosate, baclofen or topiramate in non-abstinent adults diagnosed with alcohol dependence or AUDs. Two independent reviewers selected published and unpublished studies on Medline, the Cochrane Library, Embase, ClinicalTrials.gov, contacted pharmaceutical companies, the European Medicines Agency and the Food and Drug Administration, and extracted data.

SETTING

Thirty-two RCTs.

PARTICIPANTS

A total of 6036 patients.

MEASUREMENTS

The primary outcome was total alcohol consumption (TAC). Other consumption outcomes and health outcomes were considered as secondary outcomes.

FINDINGS

No study provided direct comparisons between drugs. A risk of incomplete outcome data was identified in 26 studies (81%) and risk of selective outcome reporting in 17 (53%). Nalmefene [standardized mean difference (SMD) = -0.19, 95% confidence interval (CI) = -0.29, -0.10; I²  = 0%], baclofen (SMD = -1.00, 95% CI = -1.80, -0.19; one study) and topiramate (SMD = -0.77, 95% CI = -1.12, -0.42; I²  = 0%) showed superiority over placebo on TAC. No efficacy was observed for naltrexone or acamprosate. Similar results were observed for other consumption outcomes, except for baclofen (the favourable outcome on TAC was not reproduced). The number of withdrawals for safety reasons increased under nalmefene and naltrexone. No treatment demonstrated any harm reduction (no study was powered to explore health outcomes). Indirect comparisons suggested that topiramate was superior to nalmefene, naltrexone and acamprosate on consumption outcomes, but its safety profile is known to be poor.

CONCLUSIONS

There is currently no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes.

Alcohol treatment goal choice predicts longitudinal drinking outcomes in adolescent substance users

Social cognitive theory suggests that when individuals select their own goals, they work harder to achieve them as compared to clinician-imposed goals. Moreover, achieving goals during the course of treatment may increase self-efficacy, which could positively predict outcome. Research in clinical samples of adults with alcohol use disorder supports the utility of treatment goal choice in predicting longitudinal outcomes; a total abstinence (TA) goal choice has been associated with better clinical outcomes (e.g. greater percentage of days abstinent, more days to relapse to heavy drinking) compared to a controlled use (CU) goal choice. Treatment of adolescents presents unique challenges, because adolescents tend to be resistant to treatment and often enter treatment in response to external pressures (e.g. parent, school system). Data from 110 adolescents aged 14 to 18 were collected upon admission to outpatient substance use disorder treatment. A series of hierarchical linear regressions was used to test the utility of the alcohol treatment goal choice variable in predicting drinking outcomes at 6-, 12-, and 24-month follow-ups. Separate models were run to examine binge drinking days, percentage of days abstinent, and drinks per drinking day at each time point. Goal choice significantly predicted drinking outcomes at the 12-month follow-up, but not at the 6- or 24-month time points, such that TA goal choice was associated with better clinical outcomes. These findings are relevant to treatment planning, as they suggest that goal choice may have clinical utility as a predictor of alcohol use disorder clinical course in adolescents.

Who achieves low risk drinking during alcohol treatment? An analysis of patients in three alcohol clinical trials

BACKGROUND AND AIMS

There is evidence that low-risk drinking is possible during the course of alcohol treatment and can be maintained following treatment. Our aim was to identify characteristics associated with low-risk drinking during treatment in a large sample of individuals as they received treatment for alcohol dependence.

DESIGN

Integrated analysis of data from the Combined Pharmacotherapies and Behavioral Intervention (COMBINE) study, Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) and the United Kingdom Alcohol Treatment Trial (UKATT) using repeated-measures latent class analysis to identify patterns of drinking and predictors of low-risk drinking patterns during treatment.

SETTING

United States and United Kingdom.

PARTICIPANTS

Patients (n = 3589) with alcohol dependence receiving treatment in an alcohol clinical trial were primarily male (73.0%), white (82.0%) and non-married (41.7%), with an average age of 42.0 (standard deviation = 10.7).

MEASUREMENTS

Self-reported weekly alcohol consumption during treatment was assessed using the Form-90 and validated with biological verification or collateral informants.

FINDINGS

Seven patterns of drinking during treatment were identified: persistent heavy drinking (18.7% of the sample), increasing heavy drinking (9.6%), heavy and low-risk drinking (6.7%), heavy drinking alternating with abstinence (7.9%), low-risk drinking (6.8%), increasing low-risk drinking (10.5%) and abstinence (39.8%). Lower alcohol dependence severity and fewer drinks per day at baseline significantly predicted low-risk drinking patterns [e.g. each additional drink prior to baseline predicted a 27% increase in the odds of expected classification in heavy drinking versus low-risk drinking patterns; odds ratio = 1.27 (95% confidence interval (CI) = 1.10, 1.47, P = 0.002]. Greater negative mood and more heavy drinkers in the social network were significant predictors of expected membership in heavier drinking patterns.

CONCLUSIONS

Low-risk drinking is achievable for some individuals as they undergo treatment for alcohol dependence. Individuals with lower dependence severity, less baseline drinking, fewer negative mood symptoms and fewer heavy drinkers in their social networks have a higher probability of achieving low-risk drinking during treatment.

The alcohol dependence syndrome: a legacy of continuing clinical and scientific importance

This paper offers some reflections on Griffith Edwards' continuing legacy with particular reference to his and Milton Gross's formulation of alcohol dependence as a 'provisional' clinical syndrome. The ideas and language from this seminal paper have heavily influenced international diagnostic classification systems. However, it is observed that there has also been significant (and increasing) divergence-in particular around the original proposal that dependence and negative alcohol-related consequences are independent, if inevitably inter-related dimensions. This is most apparent in the conflation of alcohol-related problems and dependence phenomena implicit in DSM-V. It is also argued that the alcohol dependence syndrome (ADS) has substantial continuing influence and relevance to current clinical practice. The hypothesis that degree of alcohol dependence is a useful indicator of the possibility of a return to controlled drinking continues to receive support, and underpins the widespread implementation of brief interventions for 'early stage' problem drinkers. It is suggested that the kind of careful clinical observations that underpinned the original concept of alcohol dependence have continuing relevance to the formulation of improved understanding, measurement instruments, diagnostic systems and clinical responses.

The early history of ideas on brief interventions for alcohol

AIMS

This study explores the early development of brief interventions for alcohol using a history of ideas approach with a particular focus on intervention content.

METHODS

The source publications of the key primary studies published from approximately 1962 to 1992 were examined, followed by a brief review of the earliest reviews in this field. These studies were placed in the context of developments in alcohol research and in public health.

RESULTS

After early pioneering work on brief interventions, further advances were not made until thinking about alcohol problems and their treatment, most notably on controlled drinking, along with wider changes in public health, created new conditions for progress. There was then a golden era of rapid advance in the late 1980s and early 1990s, when preventing the development of problem drinking became important for public health reasons, in addition to helping already problematic drinkers. Many research challenges identified at that time remain to be met. The content of brief interventions changed over the period of study, although not in ways well informed by research advances, and there were also obvious continuities, with a renewed emphasis on the facilitation of self-change being one important consequence of the development of internet applications.

CONCLUSIONS

Ideas about brief interventions have changed in important ways. Brief interventions have been studied with different populations of drinkers, with aims embracing both individual and population-level perspectives, and without well-specified contents. The brief intervention field is an appropriate target for further historical investigations, which may help thinking about addressing alcohol and other problems.

Motivation and self-efficacy in the context of moderated drinking: global self-report and ecological momentary assessment

Despite ample research demonstrating the role of motivation and self-efficacy in predicting drinking in the context of abstinence, little research explicitly explores their role in the context of moderation, and none have utilized daily diary methods. The purpose of this study was to (a) explore the concordance between global self-report and daily diary composite measures of motivation and self-efficacy and (b) compare the ability of each in predicting drinking outcomes in the context of a study of brief AUD treatments focused on controlled drinking. Problem drinkers (N = 89) were assessed, provided feedback about their drinking, and randomly assigned to one of three conditions: two brief AUD treatments or a third group asked to change on their own. Global self-report (GSR) measures were administered at baseline and Week 8 (end of treatment). Daily diary composites (DDC) were created from data collected via an Interactive Voice Recording system during the week prior to baseline and the week prior to Week 8. Findings revealed some concordance between GSR and DDC at both baseline and Week 8, indicating the two methods capture some of the same construct; however, their respective relationships to drinking differed. DDC for both baseline and Week 8 significantly predicted Week 8 drinking outcomes, whereas only change in GSR significantly predicted drinking outcomes. Findings suggest that motivation and self-efficacy are important to moderated drinking, and that both GSR and daily diary methods are useful in understanding mechanisms of change in the context of moderation. Daily diary methods may provide significant advantages. Limitations and arenas for future research are discussed.

Reduced-risk drinking as a viable treatment goal in problematic alcohol use and alcohol dependence

This review describes and discusses studies related to reduced-risk drinking as an additional treatment option for patients with problematic alcohol use and alcohol dependence. The review provides some empirical support for the following statements: (a) reduced-risk drinking is a viable option for at least some problem and dependent drinkers; (b) abstinence and non-abstinence-based treatments appear to be equally effective; (c) allowing patients to choose their treatment goal increases the success rate. The relatively short follow-up period (1-2 years) of the studies hampers a proper evaluation of the added value of the reduced-risk drinking approach.

Accounting for self-selected drinking goals in the assessment of treatment outcome

Many treatment outcome studies are abstinence-based and rely on achieved abstinence as an indicator of success, making the implicit assumption that participants have an abstinence goal. However, it is often the case that participants self-select controlled drinking goals, even in the context of an abstinence-based treatment. The current study explored the use of an outcome variable, percent weeks meeting goal (PWMG), which takes into account individual goal choice at baseline. The sample consisted of 57 women who participated in a cognitive-behavioral therapy treatment for alcohol dependence and were followed for 18 months after baseline. Twenty-two (39%) women self-selected controlled drinking goals, and 35 (61%) self-selected an abstinence goal at baseline. A repeated measures analysis of variance with PWMG as the dependent variable revealed that both goal groups were equally successful in meeting their goals during the 6-month treatment period. After treatment, participants with a goal of abstinence had more PWMG than did participants with a self-selected controlled drinking goal, but the difference was significant at a trend level. The two goal groups did not differ in outcome when the authors compared them using more traditional measures of outcome, percent days abstinent and percent heavy drinking days.