Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis

AbstractObjectiveTo determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Org...

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Published in:	BMJ (Online) Vol. 371; p. m3934
Main Authors:	Cheng, Hung-Yuan, McGuinness, Luke A, Elbers, Roy G, MacArthur, Georgina J, Taylor, Abigail, McAleenan, Alexandra, Dawson, Sarah, López-López, José A, Higgins, Julian P T, Cowlishaw, Sean, Lingford-Hughes, Anne, Hickman, Matthew, Kessler, David
Format:	Journal Article
Language:	English
Published:	England British Medical Journal Publishing Group 25.11.2020 BMJ Publishing Group LTD BMJ Publishing Group Ltd
Subjects:	Abstinence Adult Alcohol Alcohol Abstinence - psychology Alcoholism - psychology Alcoholism - therapy Behavior Therapy - methods Bias Clinical medicine Clinical trials Drug withdrawal Drugs Female Humans Intervention Liver diseases Male Meta-analysis Middle Aged Naltrexone Patients Primary care Primary Health Care - methods Randomized Controlled Trials as Topic Systematic review Treatment Outcome United Kingdom > UK
ISSN:	1756-1833, 0959-8138, 1756-1833
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Abstract	AbstractObjectiveTo determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization’s International Clinical Trials Registry Platform.Study selectionRandomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks.Data extractionOutcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention.Results64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence.ConclusionsEvidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.Systematic review registrationPROSPERO CRD42016049779.
AbstractList	To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care. Systematic review and network meta-analysis. Medline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform. Randomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks. Outcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention. 64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence. Evidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care. PROSPERO CRD42016049779. ObjectiveTo determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization’s International Clinical Trials Registry Platform.Study selectionRandomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks.Data extractionOutcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention.Results64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence.ConclusionsEvidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.Systematic review registrationPROSPERO CRD42016049779. AbstractObjectiveTo determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.DesignSystematic review and network meta-analysis.Data sourcesMedline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization’s International Clinical Trials Registry Platform.Study selectionRandomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks.Data extractionOutcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention.Results64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence.ConclusionsEvidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.Systematic review registrationPROSPERO CRD42016049779. To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.OBJECTIVETo determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.Systematic review and network meta-analysis.DESIGNSystematic review and network meta-analysis.Medline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform.DATA SOURCESMedline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform.Randomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks.STUDY SELECTIONRandomised controlled trials comparing two or more interventions that could be used in primary care. The population was patients with alcohol dependency diagnosed by standardised clinical tools and who became detoxified within four weeks.Outcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention.DATA EXTRACTIONOutcomes of interest were continuous abstinence from alcohol (effectiveness) and all cause dropouts (as a proxy for acceptability) at least 12 weeks after start of intervention.64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence.RESULTS64 trials (43 interventions) were included. The median probability of abstinence across placebo arms was 25%. Compared with placebo, the only intervention associated with increased probability of abstinence and moderate certainty evidence was acamprosate (odds ratio 1.86, 95% confidence interval 1.49 to 2.33, corresponding to an absolute probability of 38%). Of the 62 included trials that reported all cause dropouts, interventions associated with a reduced number of dropouts compared with placebo (probability 50%) and moderate certainty of evidence were acamprosate (0.73, 0.62 to 0.86; 42%), naltrexone (0.70, 0.50 to 0.98; 41%), and acamprosate-naltrexone (0.30, 0.13 to 0.67; 17%). Acamprosate was the only intervention associated with moderate confidence in the evidence of effectiveness and acceptability up to 12 months. It is uncertain whether other interventions can help maintain abstinence and reduce dropouts because of low confidence in the evidence.Evidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.CONCLUSIONSEvidence is lacking for benefit from interventions that could be implemented in primary care settings for alcohol abstinence, other than for acamprosate. More evidence from high quality randomised controlled trials is needed, as are strategies using combined interventions (combinations of drug interventions or drug and psychosocial interventions) to improve treatment of alcohol dependency in primary care.PROSPERO CRD42016049779.SYSTEMATIC REVIEW REGISTRATIONPROSPERO CRD42016049779.
Author	Lingford-Hughes, Anne López-López, José A Cowlishaw, Sean Elbers, Roy G Hickman, Matthew McAleenan, Alexandra Kessler, David Cheng, Hung-Yuan McGuinness, Luke A Taylor, Abigail Higgins, Julian P T MacArthur, Georgina J Dawson, Sarah
Author_xml	– sequence: 1 givenname: Hung-Yuan surname: Cheng fullname: Cheng, Hung-Yuan organization: Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK – sequence: 2 givenname: Luke A surname: McGuinness fullname: McGuinness, Luke A organization: Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK – sequence: 3 givenname: Roy G surname: Elbers fullname: Elbers, Roy G organization: Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK – sequence: 4 givenname: Georgina J surname: MacArthur fullname: MacArthur, Georgina J organization: Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK – sequence: 5 givenname: Abigail surname: Taylor fullname: Taylor, Abigail organization: Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK – sequence: 6 givenname: Alexandra surname: McAleenan fullname: McAleenan, Alexandra organization: Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK – sequence: 7 givenname: Sarah surname: Dawson fullname: Dawson, Sarah organization: Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK – sequence: 8 givenname: José A surname: López-López fullname: López-López, José A organization: Department of Basic Psychology and Methodology, University of Murcia, Spain – sequence: 9 givenname: Julian P T surname: Higgins fullname: Higgins, Julian P T organization: National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK – sequence: 10 givenname: Sean surname: Cowlishaw fullname: Cowlishaw, Sean organization: Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia – sequence: 11 givenname: Anne surname: Lingford-Hughes fullname: Lingford-Hughes, Anne organization: Faculty of Medicine, Department of Brain Sciences, Imperial College London, London, UK – sequence: 12 givenname: Matthew surname: Hickman fullname: Hickman, Matthew organization: National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK – sequence: 13 givenname: David orcidid: 0000-0001-5333-132X surname: Kessler fullname: Kessler, David email: david.kessler@bristol.ac.uk organization: National Institute for Health Research School for Primary Care Research, University of Bristol, Bristol, UK
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Snippet	AbstractObjectiveTo determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary... To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care. Systematic review and... ObjectiveTo determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.DesignSystematic... To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.OBJECTIVETo determine the...
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SubjectTerms	Abstinence Adult Alcohol Alcohol Abstinence - psychology Alcoholism - psychology Alcoholism - therapy Behavior Therapy - methods Bias Clinical medicine Clinical trials Drug withdrawal Drugs Female Humans Intervention Liver diseases Male Meta-analysis Middle Aged Naltrexone Patients Primary care Primary Health Care - methods Randomized Controlled Trials as Topic Systematic review Treatment Outcome
Title	Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis
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