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.
Bibliographical noteFunding Information:
4National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK 5Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia 6Faculty of Medicine, Department of Brain Sciences, Imperial College London, London, UK 7National Institute for Health Research School for Primary Care Research, University of Bristol, Bristol, UK We thank the study authors who provided data and extra information for this review, including the Project MATCH executive committee for providing the Project MATCH public dataset for the secondary analysis. The authors acknowledge that the reported results are, in whole or in part, based on analyses of the Project MATCH Public Data Set. These data were collected as part of a multisite clinical trial of alcoholism treatments supported by a series of grants from the National Institute on Alcohol Abuse and Alcoholism and made available to the authors by the Project MATCH Research Group. This article has not been reviewed or endorsed by the Project MATCH Research Group and does not necessarily represent the opinions of its members, who are not responsible for the contents.
Funding: This review was funded primarily by the School for Primary Care Research, National Institute for Health Research (NIHR SPCR; ref 286). JPTH and MH are NIHR senior investigators. JPTH, MH, and DK are supported by NIHR Bristol Biomedical Research Centre at University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol. JPTH is supported by the NIHR Applied Research Collaboration West (ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust. JPTH and MH are supported by the NIHR Health Research Health Protection Research Unit (HPRU) HPRU in Evaluation of Interventions at University of Bristol. LAM is supported by a NIHR doctoral research fellowship (DRF-2018-11-ST2-048). GJM was supported by an NIHR postdoctoral fellowship award (PDF-2013-06-026). This report is independent research supported by the NIHR (postdoctoral fellowship, PDF-2013-06-026). The views expressed in this article are those of the authors and do not necessarily represent those of the UK National Health Service or NIHR. The conduct of the review, writing of the paper, and decision to submit for publication were independent of all research funders. The funders had no role in considering the study design or in the collection, analysis, and interpretation of data, writing of the report, or decision to submit the article for publication. Competing interests: All authors have completed the ICMJE uniform disclosure from at www.icmje.org/coi_disclosure.pdf and declare: support from the School for Primary Care Research, National Institute for Health Research for the submitted work; HC, AM, JPTH, and LAM report grants from the National Institute for Health Research (NIHR) School for Primary Care Research during the conduct of the study, LAM reports grants from NIHR doctoral research fellowship during the conduct of the study, ALH reports grants from GSK and Lundbeck and personal fees from Silence Therapeutics during the conduct of the study, JLL reports grants from Economic and Social Research Council outside the submitted work, MH reports personal fess and others from MSD, Gilead, and Abbvie outside the submitted work, ALH reports personal fees from Janssen-Cilag, Pfizer, Sanofi-Aventis, Lundbeck, and others from Opiant and Lightlak (unpaid consultancy) outside the submitted work; ALH led the British Association for Psychopharmacology’s guidelines: Evidence based guidelines for the pharmacological management of substance misuse, addiction, and co-morbidity: recommendations from the British Association for Psychopharmacology. J Psychopharmacol 18(3):293-335; and updated in 2012: Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from BAP. J Psychopharmacol 26(7):899-952. The original guidelines received support from Archimedes Pharma, Lundbeck, Pfizer, Schering. ALH was a member of the National Institute for Health and Care Excellence clinical guideline group: Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence. A NICE Clinical guideline (CG115) 2011.
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