Alcohol Dependence In Primary Care Research Articles

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

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

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 POINTS Alcohol 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.

Treatment of Alcohol Dependence in Primary Care Compared With Outpatient Specialist Treatment: Twelve-Month Follow-Up of a Randomized Controlled Trial, With Trajectories of Change

The purpose of this study was to investigate if brief treatment for alcohol dependence in primary care with the 15-method was as effective as specialist addiction care. In addition, we sought to investigate trajectories for change of alcohol consumption. This study was a randomized controlled noninferiority trial, between-groups parallel design, with a noninferiority limit of 50 g of alcohol per week. A total of 288 adults fulfilling ICD-10 criteria for alcohol dependence were randomized to treatment in primary care or specialist outpatient care at a university addiction clinic. The primary outcome was change in weekly alcohol consumption at the 12-month follow-up. Secondary outcomes were heavy drinking days, severity of dependence, consequences of drinking, psychological health, quality of life, satisfaction with treatment, and biomarkers. Trajectories were investigated using change in World Health Organization drinking risk levels. The intention-to-treat analysis (n = 231) showed that the estimated weekly alcohol consumption in primary care was 18.2 g (95% CI [14.9, 51.3]) higher compared with specialist care (p = .28). Noninferiority was not demonstrated as the confidence interval exceeded the noninferiority limit. The secondary outcomes showed no differences between primary care and specialist care except that patients randomized to specialist care were more satisfied with treatment. The analyses of trajectories showed the main part of change in consumption occurred from baseline to the 6-month follow-up and was maintained to the 12-month follow-up. Although noninferiority could not be demonstrated, based on similar trajectories and sustained reduction of alcohol use, this study indicates brief treatment of alcohol dependence in primary care with the 15-method is a feasible and promising approach.

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

BackgroundAlcohol 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.MethodsThis 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.DiscussionInternet-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 registrationISRCTN69957414. Retrospectively registered on 7 June 2018.

Feasibility, acceptability and cost-effectiveness of a brief, lay counsellor-delivered psychological treatment for men with alcohol dependence in primary care: an exploratory randomized controlled trial.

AimsTo examine the feasibility, acceptability and preliminary cost‐effectiveness of a lay counsellor delivered psychological treatment for men with alcohol dependence in primary care.DesignSingle‐blind individually randomized trial comparing counselling for alcohol problems (CAP) plus enhanced usual care (EUC) versus EUC only.SettingTen primary health centres in Goa, India.ParticipantsMen (n = 135) scoring ≥ 20 on the Alcohol Use Disorder Identification Test (AUDIT). Sixty‐six participants were randomized to EUC and 69 to CAP + EUC.InterventionsCAP, a lay counsellor‐delivered psychological treatment for harmful drinking, with referral to de‐addiction centre for medically assisted detoxification. EUC comprised consultation with physician, providing screening results and referral to a de‐addiction centre.MeasurementsBaseline socio‐demographic data, readiness to change and perceived usefulness of counselling. Acceptability and feasibility process indicators such as data on screening and therapy. Outcomes were measured at 3 and 12 months post‐randomization and included remission, mean daily alcohol consumed, percentage of days abstinent (PDA), percentage of days of heavy drinking (PDHD), recovery, uptake of detoxification services, impacts of alcohol dependence, resource use and costs.FindingsParticipants in the CAP + EUC arm had more numerically but not statistically significantly favourable outcomes compared with those in the EUC arm for (a) remission at 3 months [adjusted odds ratio (aOR) = 1.95, 95% confidence interval (CI) = 0.74–5.15] and 12 months (aOR = 1.90, 95% CI = 0.72–5.00), (b) proportion of non‐drinkers at 3 months (aOR = 1.26; 95% CI = 0.58–2.75) and 12 months (aOR = 1.25; 95% CI = 0.58–2.64) and (c) ethanol consumption among drinkers at 3 months (count ratio = 0.91; 95% CI = 0.58–1.45) and 12 months (count ratio = 1.06; 95% CI = 0.73–1.54). There was no statistically significant evidence of a difference in the occurrence of serious adverse events between the two arms. From a societal perspective, there was a 53% chance of CAP + EUC being cost‐effective in achieving remission at 12 months at the willingness‐to‐pay threshold of $415.ConclusionsLay counsellor‐delivered psychological treatment for men with alcohol dependence (AD) in primary care may be effective in managing AD in low‐ and middle‐income countries. A definitive trial of the intervention is warranted.

Drug therapy for alcohol dependence in primary care in the UK: A Clinical Practice Research Datalink study.

AimTo evaluate drug therapy for alcohol dependence in the 12 months after first diagnosis in UK primary care.DesignOpen cohort study.SettingGeneral practices contributing data to the UK Clinical Practice Research Database.Participants39,980 people with an incident diagnosis of alcohol dependence aged 16 years or older between 1 January 1990 and 31 December 2013.Main outcome measureUse of pharmacotherapy (acamprosate, disulfiram, naltrexone, baclofen and topiramate) to promote abstinence from alcohol or reduce drinking to safe levels in the first 12 months after a recorded diagnosis of alcohol dependence.FindingsOnly 4,677 (11.7%) of the cohort received relevant pharmacotherapy in the 12 months following diagnosis. Of the 35,303 that did not receive pharmacotherapy, 3,255 (9.2%) received psychosocial support. The remaining 32,048 (80.2%) did not receive either mode of treatment in the first 12 months. Factors that independently reduced the likelihood of receiving pharmacotherapy included: being male (Odds Ratio [OR] 0.74; 95% CI 0.69 to 0.78); older (65-74 years: OR 0.61; 95% CI 0.49 to 0.77); being from a practice based in the most deprived quintile (OR 0.58; 95% CI 0.53 to 0.64); and being located in Northern Ireland (OR 0.78; 95% CI 0.67 to 0.91). The median duration to initiation of pharmacotherapy was 0.80 months (95% CI 0.70 to 1.00) for acamprosate and 0.60 months (95% CI 0.43 to 0.73) for disulfiram. Persistence analysis for those receiving acamprosate and disulfiram revealed that many patients never received a repeat prescription; persistence at 6 months was 27.7% for acomprosate and 33.2% for disulfiram. The median duration of therapy was 2.10 months (95% CI 1.87 to 2.53) for acamprosate and 3.13 months (95% CI 2.77 to 3.36) for disulfiram.ConclusionDrug therapy to promote abstinence in alcohol dependent patients was low, with the majority of patients receiving no therapy, either psychological or pharmacological. When drug therapy was prescribed, persistence was low with most patients receiving only one prescription. Our data show that treatment for alcohol dependence is haphazard, and there is an urgent need to explore strategies for improving clinical management of this patient group.

Gabapentin

Gabapentin

Gabapentin Treatment for Alcohol Dependence

Approved medications for alcohol dependence are prescribed for less than 9% of US alcoholics. To determine if gabapentin, a widely prescribed generic calcium channel/γ-aminobutyric acid-modulating medication, increases rates of sustained abstinence and no heavy drinking and decreases alcohol-related insomnia, dysphoria, and craving, in a dose-dependent manner. A 12-week, double-blind, placebo-controlled, randomized dose-ranging trial of 150 men and women older than 18 years with current alcohol dependence, conducted from 2004 through 2010 at a single-site, outpatient clinical research facility adjoining a general medical hospital. Oral gabapentin (dosages of 0 [placebo], 900 mg, or 1800 mg/d) and concomitant manual-guided counseling. Rates of complete abstinence and no heavy drinking (coprimary) and changes in mood, sleep, and craving (secondary) over the 12-week study. RESULTS Gabapentin significantly improved the rates of abstinence and no heavy drinking. The abstinence rate was 4.1% (95% CI, 1.1%-13.7%) in the placebo group, 11.1% (95% CI, 5.2%-22.2%) in the 900-mg group, and 17.0% (95% CI, 8.9%-30.1%) in the 1800-mg group (P = .04 for linear dose effect; number needed to treat [NNT] = 8 for 1800 mg). The no heavy drinking rate was 22.5% (95% CI, 13.6%-37.2%) in the placebo group, 29.6% (95% CI, 19.1%-42.8%) in the 900-mg group, and 44.7% (95% CI, 31.4%-58.8%) in the 1800-mg group (P = .02 for linear dose effect; NNT = 5 for 1800 mg). Similar linear dose effects were obtained with measures of mood (F2 = 7.37; P = .001), sleep (F2 = 136; P < .001), and craving (F2 = 3.56; P = .03). There were no serious drug-related adverse events, and terminations owing to adverse events (9 of 150 participants), time in the study (mean [SD], 9.1 [3.8] weeks), and rate of study completion (85 of 150 participants) did not differ among groups. Gabapentin (particularly the 1800-mg dosage) was effective in treating alcohol dependence and relapse-related symptoms of insomnia, dysphoria, and craving, with a favorable safety profile. Increased implementation of pharmacological treatment of alcohol dependence in primary care may be a major benefit of gabapentin as a treatment option for alcohol dependence. clinicaltrials.gov Identifier: NCT00391716.

Use of AUDIT‐Based Measures to Identify Unhealthy Alcohol Use and Alcohol Dependence in Primary Care: A Validation Study

As programs for screening, brief intervention, and referral to treatment (SBIRT) for unhealthy alcohol use disseminate, evidence-based approaches for identifying patients with unhealthy alcohol use and alcohol dependence (AD) are needed. While the National Institute on Alcohol Abuse and Alcoholism Clinician Guide suggests use of a single alcohol screening question (SASQ) for screening and Diagnostic and Statistical Manual checklists for assessment, many SBIRT programs use alcohol use disorders identification test (AUDIT) "zones" for screening and assessment. Validation data for these zones are limited. This study used primary care data from a bi-ethnic southern U.S. population to examine the ability of the AUDIT zones and other AUDIT-based approaches to identify unhealthy alcohol use and dependence. Existing data were analyzed from interviews with 625 female and male adult drinkers presenting to 5 southeastern primary care practices. Timeline follow-back was used to identify at-risk drinking, and diagnostic interview schedule was used to identify alcohol abuse and dependence. Validity measures compared performance of AUDIT, AUDIT-C, and AUDIT dependence domains scores, with and without a 30-day binge drinking measure, for detecting unhealthy alcohol use and dependence. Optimal AUDIT scores for detecting unhealthy alcohol use were lower than current commonly used cutoffs (5 for men, 3 for women). Improved performance was obtained by combining AUDIT cutoffs of 6 for men and 4 for women with a 30-day binge drinking measure. AUDIT scores of 15 for men and 13 for women detected AD with 100% specificity but low sensitivity (20 and 18%, respectively). AUDIT dependence subscale scores of 2 or more showed similar specificity (99%) and slightly higher sensitivity (31% for men, 24% for women). Combining lower AUDIT cutoff scores and binge drinking measures may increase the detection of unhealthy alcohol use in primary care. Use of lower cutoff scores and dependence subscale scores may increase diagnosis of AD; however, better measures for detecting dependence are needed.

GP-led services for alcohol misuse: the Fresh Start Clinic.

Background A growing number of patients are presenting to health services with alcohol misuse disorders. The challenge to the NHS is to deliver the most cost-effective treatment solutions for all forms of alcohol misuse disorders. Setting NHS Wandsworth undertook a 12-month pilot to identify the most effective model for delivering treatment for alcohol dependency within the primary care setting. Question What are the most effective models to treat patients with alcohol dependency in primary care? Methods Model A: This was a locally enhanced services agreement (LES) agreement for screening, brief interventions and treatment. Practices were required to attend training in the management of alcohol withdrawal and had access to specialist nurse support. Model B: A GP-led clinic supported by a full-time specialist nurse prescriber. The clinic was promoted as the Fresh Start Clinic. It offers planned alcohol withdrawal within a pre-agreed structured treatment plan, and sign posts to after care. Results There were 76 treatment episodes in the fresh start clinic compared with 6 recorded treatment episodes under the LES. Fresh Start ClinicWaiting time to treatment is 7 days.We achieved a 100% completion rate.Patient satisfaction questionnaires confirmed positive patient experience.Twenty percent of patients completed questionnaires.Fifty seven percent abstinence at 3-6 months follow-up.Fifty percent improvement in mental well being as measured by Beck's Depression Inventory.Improvement in markers of dependency (GGT and MCV).The cost per treatment episode in the Fresh Start Clinic was significantly less. Conclusions The Fresh Start Clinic offers clinically safe and cost-effective treatment to patients suffering from mild to moderate alcohol dependency in a primary care setting and offers choice to both GP's and patients.

Brief alcohol questionnaires for identifying hazardous, harmful and dependent alcohol use in primary care

This is the protocol for a review and there is no abstract. The objectives are as follows: To compare the diagnostic accuracy of one brief alcohol questionnaires with another for identifying risk, harmful or hazardous drinking, or alcohol dependence in primary care.

Extended-release naltrexone for treatment of alcohol dependence in primary care

The feasibility of using extended-release injectable naltrexone (XR-NTX) to treat alcohol dependence in routine primary care settings is unknown. An open-label, observational cohort study evaluated 3-month treatment retention, patient satisfaction, and alcohol use among alcohol-dependent patients in two urban public hospital medical clinics. Adults seeking treatment were offered monthly medical management (MM) and three XR-NTX injections (380 mg, intramuscular). Physician-delivered MM emphasized alcohol abstinence, medication effects, and accessing mutual help and counseling resources. Seventy-two alcohol-dependent patients were enrolled; 90% (65 of 72) of eligible subjects received the first XR-NTX injection; 75% (49 of 65) initiating treatment received the second XR-NTX injection; 62% (40 of 65), the third. Among the 56% ( n = 40) receiving three injections, median drinks per day decreased from 4.1 (95% confidence interval = 2.9–6) at baseline to 0.5 (0–1.7) during Month 3. Extended-release naltrexone delivered in a primary care MM model appears a feasible and acceptable treatment for alcohol dependence.