Controlled drinking-non-abstinent versus abstinent treatment goals in alcohol use disorder: a systematic review, meta-analysis and meta-regression.
Abstinence
alcohol use disorder
controlled drinking
drinking goal
meta-analysis
meta-regression
Journal
Addiction (Abingdon, England)
ISSN: 1360-0443
Titre abrégé: Addiction
Pays: England
ID NLM: 9304118
Informations de publication
Date de publication:
08 2021
08 2021
Historique:
revised:
20
07
2020
received:
27
05
2020
accepted:
06
11
2020
pubmed:
15
11
2020
medline:
30
9
2021
entrez:
14
11
2020
Statut:
ppublish
Résumé
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. 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. 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. 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.
Sections du résumé
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.
Types de publication
Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
1973-1987Commentaires et corrections
Type : CommentIn
Type : CommentIn
Informations de copyright
© 2020 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.
Références
World Health Organization (WHO). Global status report on alcohol and health 2018. Geneva: WHO; 2018. Available at: https://apps.who.int/iris/handle/10665/274603 (accessed 11 September 2019).
Grant B. F., Goldstein R. B., Saha T. D., Chou S. P., Jung J., Zhang H., et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on alcohol and related conditions III. JAMA Psychiatry 2015; 72: 757-766.
Kohn R., Saxena S., Levav I., Saraceno B. The treatment gap in mental health care. Bull World Health Organ 2004; 82: 858-866.
Carvalho A. F., Heilig M., Perez A., Probst C., Rehm J. Alcohol use disorders. Lancet 2019; 394: 781-792.
Mann K, Batra A, Hoch E, the Leitliniengruppe. S3-Leitlinie. Screening, diagnose und Behandlung alkoholbezogener Störungen [S3 Guideline for Screening, Diagnosis and Treatment of Alcohol-related Disorders]. AWMF-register no. 076-001. Berlin/Heidelberg: Springer-Verlag; 2016.
National Institute for Health and Care Excellence (NICE). Alcohol-use Disorders: Diagnosis, Assessment and Management of Harmful Drinking (High-Risk Drinking) and Alcohol Dependence. Available at: https://www.nice.org.uk/guidance/cg115 (accessed 13 September 2019).
American Psychiatric Association (APA) The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients with Alcohol Use Disorder. Washington, DC: APA Publishing; 2018.
Finn S. W., Bakshi A.-S., Andréasson S. Alcohol consumption, dependence, and treatment barriers: perceptions among nontreatment seekers with alcohol dependence. Subst Use Misuse 2014; 49: 762-769.
Falk D. E., O'Malley S. S., Witkiewitz K., Anton R. F., Litten R. Z., Slater M., et al. evaluation of drinking risk levels as outcomes in alcohol pharmacotherapy trials: a secondary analysis of 3 randomized clinical trials. JAMA Psychiatry 2019; 76: 374-381.
European Medicines Agency (EMA) Annual Report 2010 (adopted by the management board June 28, 2011). EMA/306870/2011. Amsterdam, the Netherlands: EMA; 2011.
Bschor T., Henssler J., Müller M., Baethge C. Baclofen for alcohol use disorder-a systematic meta-analysis. Acta Psychiatr Scand 2018; 138: 232-242.
Center for Drug Evaluation and Research. Alcoholism: Developing Drugs for Treatment. U.S. Food and Drug Administration Available at: http://www.fda.gov/regulatory-information/search-fda-guidance-documents/alcoholism-developing-drugs-treatment (accessed 9 January 2020).
Marlatt G. A., Larimer M. E., Baer J. S., Quigley L. A. Harm reduction for alcohol problems: moving beyond the controlled drinking controversy. Behav Ther 1993; 24: 461-503.
Davis A. K., Rosenberg H. Acceptance of non-abstinence goals by addiction professionals in the United States. Psychol Addict Behav 2013; 27: 1102-1109.
Luquiens A., Reynaud M., Aubin H. J. Is controlled drinking an acceptable goal in the treatment of alcohol dependence? A survey of French alcohol specialists. Alcohol Alcohol 2011; 46: 586-591.
Rosenberg H., Davis A. K. Differences in the acceptability of non-abstinence goals by type of drug among American substance abuse clinicians. J Subst Abuse Treat 2014; 46: 214-218.
Roerecke M., Gual A., Rehm J. Reduction of alcohol consumption and subsequent mortality in alcohol use disorders: systematic review and meta-analyses. J Clin Psychiatry 2013; 74: e1181-e1189.
Batra A., Müller C. A., Mann K., Heinz A. Alcohol dependence and harmful use of alcohol. Dtsch Arztebl Int 2016; 113: 301-310.
Enggasser J. L., Hermos J. A., Rubin A., Lachowicz M., Rybin D., Brief D. J., et al. Drinking goal choice and outcomes in a web-based alcohol intervention: results from VetChange. Addict Behav 2015; 42: 63-68.
Sanchez-Craig M., Annis H. M., Bornet A. R., MacDonald K. R. Random assignment to abstinence and controlled drinking: evaluation of a cognitive-behavioral program for problem drinkers. J Consult Clin Psychol 1984; 52: 390-403.
Graber R. A., Miller W. R. Abstinence or controlled drinking goals for problem drinkers: a randomized clinical trial. Psychol Addict Behav 1988; 2: 20-33.
Hasin D. S., Wall M., Witkiewitz K., Kranzler H. R., Falk D., Litten R., et al. Change in non-abstinent WHO drinking risk levels and alcohol dependence: a 3 year follow-up study in the US general population. Lancet Psychiatry 2017; 4: 469-476.
Witkiewitz K., Kranzler H. R., Hallgren K. A., O'Malley S. S., Falk D. E., Litten R. Z., et al. Drinking risk level reductions associated with improvements in physical health and quality of life among individuals with alcohol use disorder. Alcohol Clin Exp Res 2018; 42: 2453-2465.
Nutt D. J., Gual A., Anderson P., Rehm J. Why less is always more in the treatment of alcohol use disorders. JAMA Psychiatry 2019; 76: 359-360.
Kline-Simon A. H., Litten R. Z., Weisner C. M., Falk D. E. Posttreatment low-risk drinking as a predictor of future drinking and problem outcomes among individuals with alcohol use disorders: a 9-year follow-up. Alcohol Clin Exp Res 2017; 41: 653-658.
Charlet K., Heinz A. Harm reduction-a systematic review on effects of alcohol reduction on physical and mental symptoms. Addict Biol 2017; 22: 1119-1159.
Caddy G. R., Addington H. J., Perkins D. Individualized behavior therapy for alcoholics: a third year independent double-blind follow-up. Behav Res Ther 1978; 16: 345-362.
Higgins JPT, Green S editors. Cochrane Handbook for Systematic Reviews of Interventions, version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available at: http://handbook-5-1.cochrane.org/ (accessed 12 September 2019).
Moher D., Liberati A., Tetzlaff J., Altman D. G., the PRISMA Group Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Med 2009; 6: e1000097.
National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2011. Available at: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/moderate-binge-drinking (accessed 10 January 2020).
World Health Organization. International Guide for Monitoring Alcohol Consumption and Related Harm (WHO/MSD/MSB/00.4) 2000. Available at: https://apps.who.int/iris/handle/10665/66529
Miller W. R., Wilbourne P. L. Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002; 97: 265-277.
Miller W. R., Walters S. T., Bennett M. E. How effective is alcoholism treatment in the United States? J Stud Alcohol 2001; 62: 211-220.
Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ et al. editors. Cochrane Handbook for Systematic Reviews of Interventions, version 6.0 (updated July 2019). Cochrane Collaboration; 2019. Available at: www.training.cochrane.org/handbook/https://training.cochrane.org/handbook/current (accessed 21 October 2019).
Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M et al. The Newcastle-Ottawa scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-analyses. Available at: http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed 12 September 2019).
Booth P. G., Dale B., Ansari J. Problem drinkers' goal choice and treatment outcome: a preliminary study. Addict Behav 1984; 9: 357-364.
Pomerleau O., Pertschuk M., Adkins D., Brady J. P. A comparison of behavioral and traditional treatment for middle-income problem drinkers. J Behav Med 1978; 1: 187-200.
Sanchez-Craig M., Lei H. Disadvantages to imposing the goal of abstinence on problem drinkers: an empirical study. Br J Addict 1986; 81: 505-512.
Lee H. S., Mericle A. A., Ayalon L., Areán P. A. Harm reduction among at-risk elderly drinkers: a site-specific analysis from the multi-site primary care research in substance abuse and mental health for elderly (PRISM-E) study. Int J Geriatr Psychiatry 2009; 24: 54-60.
Stimmel B., Cohen M., Sturiano V., Hanbury R., Korts D., Jackson G. Is treatment for alcoholism effective in persons on methadone maintenance? Am J Psychiatry 1983; 140: 862-866.
Orford J., Keddie A. Abstinence or controlled drinking in clinical practice: a test of the dependence and persuasion hypotheses. Br J Addict 1986; 81: 495-504.
Adamson S. J., Heather N., Morton V., Raistrick D. Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes. Alcohol Alcohol 2010; 45: 136-142.
Mowbray O., Krentzman A. R., Bradley J. C., Cranford J. A., Robinson E. A. R., Grogan-Kaylor A. The effect of drinking goals at treatment entry on longitudinal alcohol use patterns among adults with alcohol dependence. Drug Alcohol Depend 2013; 132: 182-188.
Berger L., Brondino M., Fisher M., Gwyther R., Garbutt J. C. Alcohol use disorder treatment: the association of pretreatment use and the role of drinking goal. J Am Board Fam Med 2016; 29: 37-49.
Bujarski S., O'Malley S. S., Lunny K., Ray L. A. The effects of drinking goal on treatment outcome for alcoholism. J Consult Clin Psychol 2013; 81: 13-22.
Dunn K. E., Strain E. C. Pretreatment alcohol drinking goals are associated with treatment outcomes. Alcohol Clin Exp Res 2013; 37: 1745-1752.
Mann K., Lemenager T., Hoffmann S., Reinhard I., Hermann D., Batra A., et al. Results of a double-blind, placebo-controlled pharmacotherapy trial in alcoholism conducted in Germany and comparison with the US COMBINE study. Addict Biol 2013; 18: 937-946.
Al-Otaiba Z., Worden B. L., McCrady B. S., Epstein E. E. Accounting for self-selected drinking goals in the assessment of treatment outcome. Psychol Addict Behav 2008; 22: 439-443.
Simon J., Adamson J. D. S. Drinking goal selection and treatment outcome in out-patients with mild-moderate alcohol dependence. Drug Alcohol Rev 2001; 20: 351-359.
Booth P. G., Dale B., Slade P. D., Dewey M. E. A follow-up study of problem drinkers offered a goal choice option. J Stud Alcohol 1992; 53: 594-600.
Haug S., Eggli P., Schaub M. P. Drinking goals and their association with treatment retention and treatment outcomes among clients in outpatient alcohol treatment. Subst Use Misuse 2017; 52: 313-321.
Hodgins D. C., Leigh G., Milne R., Gerrish R. Drinking goal selection in behavioral self-management treatment of chronic alcoholics. Addict Behav 1997; 22: 247-255.
Meyer A., Wapp M., Strik W., Moggi F. Association between drinking goal and alcohol use one year after residential treatment: a multicenter study. J Addict Dis 2014; 33: 234-242.
Öjehagen A., Berglund M. Changes of drinking goals in a two-year out-patient alcoholic treatment program. Addict Behav 1989; 14: 1-9.
Vollmer H., Krämer S., Schneider R., Feldhege F. J., Schulze B., Krauthan G. Ein verhaltenstherapeutisches Programm zur Behandlung junger Alkoholabhängiger unter besonderer Berücksichtigung der Therapiemotivation [A behaviorally-oriented therapeutic program for the treatment of young alcohol-dependent patients with particular consideration of the motivation for therapy]. Suchtgefahren 1982; 28: 1-15.
Lozano B. E., Stephens R. S. Comparison of participatively set and assigned goals in the reduction of alcohol use. Psychol Addict Behav 2010; 24: 581-591.
Heather N, Raistrick D, Godfrey C. A summary of the review of the effectiveness of treatment for alcohol problems. Available at: https://scholar.googleusercontent.com/scholar?q=cache:1y1muVyp5pUJ:scholar.google.com/&hl=en&as_sdt=0,5 (accessed 3 November 2019).
Hulse G. K., Tait R. J. Five-year outcomes of a brief alcohol intervention for adult in-patients with psychiatric disorders. Addiction 2003; 98: 1061-1068.
Shaw G. K., Waller S., Latham C. J., Dunn G., Thomson A. D. The detoxification experience of alcoholic in-patients and predictors of outcome. Alcohol Alcohol 1998; 33: 291-303.
Gual A., Bravo F., Lligoña A., Colom J. Treatment for alcohol dependence in Catalonia: health outcomes and stability of drinking patterns over 20 years in 850 patients. Alcohol Alcohol 2009; 44: 409-415.
Kraemer K. L., Maisto S. A., Conigliaro J., McNeil M., Gordon A. J., Kelley M. E. Decreased alcohol consumption in outpatient drinkers is associated with improved quality of life and fewer alcohol-related consequences. J Gen Intern Med 2002; 17: 382-386.
Higuchi S., Maesato H., Yoshimura A., Matsushita S. Acceptance of controlled drinking among treatment specialists of alcohol dependence in Japan. Alcohol Alcohol 2014; 49: 447-452.
Davis A. K., Nickelsen T., Zucker R. A., Bonar E. E., Walton M. A. Acceptability of nonabstinent treatment outcome goals among addiction treatment providers in Ukraine. Psychol Addict Behav 2018; 32: 485-495.