Primary care interventions for alcohol misuse: US Preventative Services Task Force recommendations

This post was written by Paul Christiansen for the Mental Elf blog, you can find the original here

Alcohol misuse is recognised as one of the major health care issues in the US. Specifically, alcohol misuse is ranked third in causes of preventable deaths (after tobacco and obesity) affecting 30% of the population. Alcohol dependence has 4% prevalence in the US, but hazardous drinking patterns are believed to be evident in 21% of adults, contributing to a range of health concerns including gastritis, liver disease, pancreatitis and anxiety. In addition, 23% of 17 year olds reported at least one episode of heavy drinking in the previous fortnight. Significantly, heavy drinking is the major contributing factor to traffic accidents, the leading cause of death in US teenagers (Miniño, 2010).

Heavy drinking contributes to traffic accidents, which are the leading cause of death in US teenagers

The US Preventative Services Task Force (USPSTF) is an independent group of experts who make evidence-based recommendations about preventative services and interventions with the goal of improving the health of Americans. The current paper largely focuses on hazardous alcohol use which they define as drinking more than three (females) or four drinks (males) in a single session.

Their latest recommendations published here are specifically concerned with the efficacy of brief behavioural counselling interventions in primary care settings, and assessing which screening tests for alcohol misuse are most sensitive. Clear recommendations for adults are made although the authors conclude there is not sufficient evidence to recommend any primary care interventions for adolescents.

Methods

The USPSTF have based their recommendations on a review of treatment trials published between 1985 and 2011, and reviews and meta-analyses published between 2006 and 2011, which investigated behavioural counselling and screening procedures in adults, pregnant women and adolescents. Although this is largely a review article, there are also some statistics reported based upon meta-analysis of selected studies. The USPSTF specifically examined:

• Direct evidence for the effectiveness and accuracy of screening instruments
• The effectiveness of various brief behavioural counselling interventions for improving intermediate and long-term outcomes (23 trials)
• Possible harms of these procedures

Among the screening instruments were many that readers will be familiar with, for example the Alcohol Use Disorders Identification Test (AUDIT), the AUDIT-Consumption (AUDIT-C; essentially the first three questions from the standard AUDIT). Other screening instruments investigated include single question methods e.g. “how many times in the previous year have you consumed over 5 drinks in one day?”, the Rapid Alcohol Problems Screen and Alcohol-Related Problems Survey.

Brief behavioural counselling strategies reviewed included face to face, telephone contact, online resources and self help manuals that include a range of cognitive-behavioural strategies such as action plans, stress management and problem solving. Counselling durations ranged from brief single contact (less than five minutes) up to extended multi contact (more than one session of over 15 minutes). Unfortunately the impact of different forms and durations of counselling were not specifically analysed, although an earlier systematic review (Jonas et al, 2012) in the same journal reported that the efficacy of counselling interventions improves with increased contact time.

Results

This is what they found:

Brief behavioural counselling can reduce multiple indices of alcohol misuse, although the long term advantages are not clear

• The AUDIT was the most sensitive screening tool with a 4+ cut off having the greatest sensitivity to alcohol misuse
• AUDIT-C and single question screens were also found to be sensitive screening instruments
• Meta-analysis of relevant studies revealed brief behavioural counselling significantly reduces binge drinking, total number of drinks per week, risky drinking patterns and incidents of exceeding recommended limits. Furthermore, there were no reported harms of the interventions
• Significantly, meta-analysis of the nine trials that assessed long term outcomes found no evidence of significant improvement following brief behavioural counselling
• Although found to be effective in both young and older adults, there was limited evidence for the efficacy of brief behavioural counselling in pregnant women and no evidence (due to a lack of research) on the efficacy of brief behavioural counselling in adolescents

 Conclusions

• The AUDIT is the most sensitive screening measure of alcohol misuse
• Overall, brief behavioural counselling can reduce multiple indices of alcohol misuse, although the long term advantages are not clear
• There is a severe lack of research investigating the impact of these interventions on adolescents

The authors concluded with these key recommendations:

The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioural counselling interventions to reduce alcohol

BUT

…the current evidence is insufficient to assess the balance of benefits and harms of screening and behavioural counselling interventions in primary care settings to reduce alcohol misuse in adolescents

This guidance highlights a lack of research investigating the impact of these interventions on young people

To summarise, this review indicates that any brief behavioural counselling interventions in primary care settings can improve short term alcohol outcomes in adults. Although it is notable that no recommendations were made in relation to adolescents due to the paucity of research.

Overall, this review offers some clarity to practitioners regarding the efficacy of brief behavioural counselling, although it does not make clear which forms of intervention (manual, telephone face-to-face) are most effective. The recommendation of the AUDIT as a screening tool adds to the large evidence base demonstrating this to be a reliable and sensitive instrument. Finally, the lack of recommendations for adolescents highlights the need for investigations into brief behavioural counselling in this population, if they are relatively cheap and effective in adults this indicates that they could be a useful clinical tool in adolescents.

The Elf would like to add a note of caution to experimental psychologists; the use of the 4+ cut off to define risky drinkers in a sample of UK undergraduates would probably lead to great difficulty in finding non-risk participants 

Links

Virginia A. Moyer, on behalf of the U.S. Preventive Services Task Force; Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2013 Aug;159(3):210-218.

Jonas DE et al Behavioral Counseling After Screening for Alcohol Misuse in Primary Care: A Systematic Review and Meta-analysis for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2012 Nov;157(9):645-654.

Miniño AM. Mortality Among Teenagers Aged 12–19 Years: United States, 1999–2006 (PDF). National Center for Health Statistics Data Brief, No. 37, May 2010.

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Using adaptive treatments for smoking cessation may prove effective!

 This post was written by Andrew Jones for the Mental Elf blog, you can find the original here

Around 20% of adults in the UK smoke cigarettes regularly. Smoking was the primary cause of approximately 462,900 hospital admissions and 79,100 (18%) deaths in adults over the age of 35 last year. Therefore, smoking cessation represents a serious (and costly!) clinical challenge on an individual and global level.

Many smoking cessation aids are available, including over the counter treatments such as nicotine patches, gums and inhalers, known as Nicotine Replacement Therapy (NRT). Prescription drugs such as bupropion and varenicline are also widely used. These treatments have differing degrees of efficacy as well as potential side-effects (which we have discussed in a previous elf blog). Despite the treatment options available, quitting rates are low and there is little available guidance to inform health care providers as to which treatment should be provided for any given smoker.

A recent study published in the American Journal of Psychiatry set out to examine the optimal treatment strategies for individual smokers who did not respond well to initial treatment with NRT.

Methods and Results 

The authors performed a double-blind, parallel-arm adaptive treatment trial, consisting of two separate phases. Smokers who expressed a desire to quit were recruited using various media advertisements. To be eligible, participants had to smoke more than 10 cigarettes per day for 3 years and have an expired breath carbon monoxide (CO) reading of at least 10 ppm (parts per million). Following screening of 1,256 smokers, 606 were eligible and enrolled into the study.

The volunteers attended a research center weekly for two weeks prior to a target quit date, during each visit brief support was given and various measures including smoking diaries, expired CO and withdrawal symptoms were recorded. The first line treatment was open-label NRT which everybody received, chosen for its safety and tolerability.

There were two phases to the research, each with a different hypothesis.

Phase 1 

This phase examined whether individuals who did not respond adequately to first line NRT could be ‘rescued’ by switching to a different treatment strategy. Individuals were classed as ‘non responders’ if their expired CO did not reduce by more than 50% in the first week of NRT.

 These non responders were then randomly assigned to one of three treatment strategies:

1.  Switch from NRT to varenicline

2.  NRT augmented with bupropion

3. Continuation of NRT only

NRT was not augmented with varenicline due to increased risk of adverse effects. The primary measure of interest was continuous abstinence 8-11 weeks after the target quit date.

313 smokers were categorized as non responders and were randomly assigned to one of the three strategies. Individuals who remained on NRT alone following initial poor response had low abstinence success rates of 16% after 8-11 weeks, which reduced further to 5.8% after 6 months.

NRT augmented with bupropion significantly improved continuous abstinence rates compared to NRT only after 8–11 weeks  (28.3%; p=.04; odds ratio = 2.06, 95% CI=1.05 – 4.07). Significant improvements in both continuous and point abstinence were demonstrated up to 6 months later.

The switch from NRT to varenicline did not significantly improve continuous abstinence at 8-11 weeks. However, there was a significant improvement in 6 month point abstinence (16.5%; p=.03; odds ratio = 2.80, 95% CI 1.11 – 7.06).

Phase 2 

This phase set out to examine whether a change in treatment strategy could ‘rescue’ individuals who had lapsed one week after their quit date. Lapsers were identified as individuals who self reported taking even one puff of a cigarette, or who provided a CO reading over 10 ppm. 95 lapsers were randomly assigned to one of the three strategies used in phase 1 and given a second quit date exactly one week later. If individuals did not lapse they remained on NRT.

Individuals who lapsed after one week showed no significant improvements in continuous or point abstinence if NRT was augmented with bupropion, or if they were switched to varenicline, compared to those who continued with NRT only.

Discussion

The results of the study support an adaptive smoking cessation strategy and suggest that individuals who do not respond to NRT as a first line treatment before their quit date may benefit from a switch to an alternative therapy. Specifically, augmenting NRT with Bupropion led to an abstinence rate 2-3 times higher than continuation of NRT alone at later follow-ups. There were also some improvements among smokers who switched to varenicline. However, using the same adaptive treatment strategies to rescue smokers who relapsed after one week of the quit date had no significant beneficial effects on abstinence.

The authors correctly point out that the results of phase 2 should be interpreted with caution due to relatively small group sizes. Furthermore, whilst the adaptive treatment led to a significant improvement in ‘non-responders’ the actual abstinence rates after 6 months were still relatively low (13.1% for NRT augmented with bupropion). Future research should investigate which smokers will respond best to adaptive treatment by examining predictive markers of smoking and treatment efficacy such as genes.

The principle finding from this research is that individuals who did not respond to NRT by reducing their smoking were identified before their target quit date, therefore no participants actually relapsed before receiving adaptive treatment. By doing this the authors suggest that:

 "we could minimize the deleterious effects of relapse on motivation and retention in treatment".

To conclude, it may be possible to ‘rescue’ smokers who do not respond well to NRT before their quit date, by offering alternative pharmacotherapies instead.

Links

Rose, J.E. & Behm, F.M. (2013). Adapting smoking cessation treatment according to initial response to precessation nicotine patch. American Journal of Psychiatry; 170, 860-867. [PubMed abstract]

The target study is also discussed in a podcast (August 2013) from the American Journal of Psychiatry.

Statistics on Smoking: England, 2013 (PDF). Health and Social Care Information Centre, 15 Aug 2013.

Concurrent treatments may be effective in treating comorbid alcohol dependence and PTSD

This post was written by Abi Rose for the Mental Elf, you can find the original here.

In those with post-traumatic stress disorder (PTSD), alcohol abuse or dependence is the most common co-morbid disorder. Unfortunately, although individuals with PTSD and alcohol dependence (AD) often have complex needs, the treatments available usually only target one issue. This is often due to specialist treatment services not having access to treatments for comorbid disorders, and the belief that treatment for PTSD can increase drinking behaviour, while AD may interfere with PTSD treatment.

Following treatment, those with comorbid PTSD and AD are more likely to relapse, and relapse quickly, than patients with AD alone or AD with other comorbidities. These increased risks combined with the complex needs of this patient group make the development of effective concurrent treatments a priority.

Effective concurrent treatments combine two or more therapies for two or more conditions

Foa and colleagues conducted a trial (recently published in JAMA) which primarily assessed the effectiveness of combining an evidence-based pharmacotherapy for AD (naltrexone) with an evidence-based psychosocial treatment for PTSD (prolonged exposure therapy).

Overall they found that:

1. Naltrexone decreased percentage of drinking days
2. Prolonged exposure therapy did not decrease PTSD symptoms compared with other groups during treatment
3. Prolonged exposure therapy did not worsen percentage drinking behaviour

Methods

165 patients were recruited from two clinical sites in Pennsylvania and required a diagnosis of AD (defined by: DSM-IV, >12 drinks per week, >4 drinks in one day over past 30 days) and PTSD (DSM-IV, ≥15 score on the PTSD symptom severity scale). Patients did not have any other substance dependence (except nicotine), psychiatric condition, or physical condition which could interfere with the treatments provided.

Patients were randomised to 1 of 4 conditions:

1. Prolonged exposure therapy & naltrexone (100 mg/d)
2. Prolonged exposure therapy & placebo
3. Naltrexone (100 mg/d)
4. Placebo

Treatments were started after outpatient detoxification, and lasted 6 months. Prolonged exposure therapy was administered once a week for 12 weeks and then once a fortnight for 12 weeks, and involved: imagining, processing, and discussing traumatic memories; listening to these sessions at home; in vivo exposure to safe situations.

In addition, all participants received 18 supportive counselling sessions with a nurse (administered on the same time frame as the exposure therapy).

Outcome measures were PTSD symptom severity, percentage of days drinking and alcohol craving.

Outcome measures were taken at baseline, during treatment, and up to 52 weeks follow-up.

Results

Of the 165 patients, 11-15 patients in each treatment group did not receive the intervention as randomised; 20-26 completed the 3 month follow-up, 19-30 completed the 6 month follow-up.

Alcohol dependence outcomes:

Naltrexone decreased the percentage of drinking days

• All patients reported a decrease in drinking during treatment, irrespective of which group they were in
• Following treatment, those on naltrexone reported fewer drinking days than those on placebo
• Craving was lower in those receiving naltrexone, supporting the suggestion that naltrexone’s therapeutic effect may be to reduce craving
• There was no effect of prolonged exposure therapy on drinking outcomes

PTSD outcomes:

• PTSD symptoms decreased during treatment, irrespective of treatment group
• Following treatment, there were no differences in PTSD symptoms across the different groups
• Further analysis found that 70% of patients in the Exposure + Naltrexone group had a low PTSD severity score (≤10) 6 months following treatment. This compared favourably with those in the Exposure + Placebo (55%), naltrexone (43.9%) and placebo (37.2%) groups

Conclusions

Patients receiving the prolonged exposure treatment only attended a third of the available sessions on average

The finding that prolonged exposure therapy was no better than supportive counselling as a treatment for PTSD is inconsistent with other evidence. The authors suggest that supportive counselling (which all patients received) may have masked specific effects of prolonged exposure, and this is something that needs to be controlled for in future research. However, the lack of a significant finding may also be due to poor adherence rates; patients only attended an average of 6/18 exposure sessions.

Importantly, the PTSD treatment did not exacerbate AD symptoms and, at 6 month follow-up, there was a lower alcohol relapse rate in those from the Exposure + Naltrexone group.

Sum-up

Given the low adherence rates to the prolonged exposure treatment, this study is unable to comment on the long-term effectiveness of the PTSD therapy. The complex needs of this patient group make it possible that those with comorbid disorders have difficulties in engaging and sticking with treatment regimes. Therefore, future research needs to focus on ways to improve treatment adherence.

The now somewhat out of date NICE guidance (NICE, 2005) suggests treating alcohol dependence before PTSD treatment starts (although in severe cases collaborative care may be appropriate). However, the current study found that treatments did not exacerbate comorbid symptoms. It is important that research continues to investigate the effectiveness of concurrent treatments in complex patient groups, and for health services to look at ways to deliver such treatments packages.

Links

Foa EB., et al. (2013) Concurrent naltrexone and prolonged exposure therapy for patients with comorbid alcohol dependence and PTSD: a randomized clinical trial. Journal of the American Medical Association 310(5): 488-495. [Abstract]

Jacobsen LK., et al (2001) Substance use disorders in patients with posttraumatic stress disorder: A review of the literature. American Journal of Psychiatry 158(8): 1184-1190

Post-traumatic stress disorder (PTSD). The management of PTSD in adults and children in primary and secondary care (PDF). NICE clinical guideline 26, March 2005.

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Do people stop smoking if their doctor advises them to? Cochrane review says sometimes and it IS worth the effort

This post was originally written by Matt Field for the Mental Elf website, you can find the original here. 

As previously discussed on the Mental Elf, the rates of tobacco smoking in most developed countries are falling, helped in part by high levels of taxation and bans on smoking in public places.

However, over 20% of adults in the UK continue to smoke, and this means that smoking is the greatest single cause of premature illness and death.  Therefore, anything that can be done to persuade smokers to quit is likely to have a major impact on public health.

General Practitioners and other health professionals could play an important role if they simply advised their patients to stop smoking as a precursor to prescribing medication, or referring them to local Stop Smoking services. In this Cochrane review, Stead et al. (2013) looked at whether advice from doctors could help their patients to quit smoking.

Methods

This paper is an update of previous Cochrane reviews on this topic. The authors identified randomised controlled trials that examined the influence of smoking cessation advice from a medical practitioner on abstinence from smoking at least 6 months later.

Having identified relevant papers, the authors pooled the data and asked:

• - Is advice from a doctor to give up smoking more effective than no advice, in terms of the number of patients who manage to quit?
• 
  
• - Are there any benefits of offering more intensive advice (as opposed to just giving brief advice), and of following patients up afterwards?
• 
  

Results

Brief advice and intensive advice both improve quit rates, but only everso slightly

The total sample size was over 31,000, from 42 randomised trials that were published between 1972 and 2012.

The majority of the individual trials randomly assigned people to receive brief advice to give up smoking, or they got no advice at all (not even a wagging of the finger). There was enormous variation in what constituted ‘brief advice’, but this didn’t seem to affect the overall results too much.

There were 17 trials in which the intervention was classed as minimally intensive ‘brief advice’, and 11 trials in which the intervention was classed as more intensive.

• Comparison of minimally intensive brief advice with no advice demonstrated that brief advice led to a small but significant increase in quit rates (Relative Risk (RR) = 1.66, 95% CI 1.42 to 1.94).
• 
  
• Comparisons of more intensive advice with no advice also demonstrated an increase in quit rates (RR = 1.84; 95% CI 1.60 to 2.13).
• 
  
• However, this indirect comparison between different studies revealed no statistically significant difference between brief advice and more intensive advice (note the overlapping confidence intervals).
• 
  

There were fifteen additional trials that made a direct comparison between intensive advice and brief advice. This revealed significantly higher quit rates among people who received intensive advice compared to those who received only brief advice (RR = 1.37, 95% CI 1.20 to 1.56).

Other findings included a small incremental effect on quit rates if follow-ups were provided after the initial advice. However, provision of additional aids (such as self-help manuals) did not make much difference, and there were minimal differences between different types of intervention.

Discussion

Giving smokers brief advice to help them quit is better than nothing, but only just! However, it’s cheap and easy so definitely something that GPs should be doing.

Overall, patients who receive brief advice to quit smoking from their doctor are more likely to actually do so, compared to patients who receive no advice. The effect size is small, although it is slightly larger if the advice is more intensive, or if patients are followed up a bit later.

Can brief advice make a difference in the real world? The ‘unassisted quit rate’ (the percentage of smokers who will quit if given no help or advice whatsoever) is difficult to estimate, and it varied enormously between studies in this analysis. But a plausible estimate is 3%, and this gives us a ‘number needed to treat for an additional beneficial outcome’ (NNTB) ranging between 33 and 80. In other words, doctors would need to offer brief advice to between 33 and 80 of their patients in order to get one of them to stop smoking! While this may seem rather pitiful, we have to remember that most smokers do not manage to quit by themselves and anything that nudges smokers towards quitting, particularly something very quick and easy like brief advice from a doctor, should be put into practice whenever possible.  

The authors conclude their paper by stating that:

"Every smoker who does not receive advice represents a missed opportunity".

And the Mental Elf agrees with that!

Links

Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD000165. DOI: 10.1002/14651858.CD000165.pub4.

Cochrane summary of this review

Research roundup summer 2013

This is the Summer 2013 research roundup from the Addiction Research Group based in the Department of Psychological Sciences, University of Liverpool. We have been hard at work throughout the ‘heatwave’ and (more typical) downpours of our British summer.  The fruits of our labours can be seen below...

Top spot goes to Gordon Fernie (a former post-doc) and colleagues who published a study in Addiction (Open Access) which looked at bidirectional relationships between three measures of behavioural impulsivity (delay discounting, risk-taking, and disinhibition) and alcohol involvement among adolescents. They measured impulsivity and alcohol involvement in 287 adolescents at five time points over the course of two years. The results show that individual differences in performance on three measures of behavioural impulsivity each predicted alcohol involvement six months later. However, alcohol involvement did not predict subsequent impulsivity. This study is the first to show that those three measures of impulsivity predict alcohol involvement after fairly short follow-up periods of six months. This press release generated a bit of media coverage, some of which can be seen here.

Andy Jones worked with Andrej Stancak on a study that was published in the Journal of Psychopharmacology, examining electrophysiological markers of response conflict during disinhibition and their relationship with alcohol consumption.  They demonstrated that when individuals performed a stop signal task (a measure of inhibitory control), the magnitude of the P300 component of the event-related potential during inhibition was inversely correlated with increased alcohol consumption during a subsequent laboratory taste test. This suggests that better inhibition (as inferred from brain activity during a task that requires inhibitory control) is associated with reduced consumption of alcohol.  This was the first study to directly examine the relationship between electrophysiological markers of inhibitory control, and alcohol-seeking.

Matt Field organised and edited a special issue on Addiction for The Journal of Experimental Psychopathology. The issue covered some of the current 'hot topics' in addictive behaviours including social influences, negative affect, motivated attention, implicit cognitive processes and disinhibition. Our research group contributed two papers for the special issue. We collaborated with colleagues from the Netherlands on a paper examining motivated attention (again using electrophysiological measures) in alcohol-dependent patients seeking treatment. Andy Jones and other colleagues at Liverpool also published a research paper that explored the effects of alcohol-related cues and contexts on disinhibited behaviour, a study that was conducted in our Bar Lab.

We contributed two review papers for a forthcoming special issue of CNS Spectrums. The first discusses the clinical relevance of attentional bias in substance use disorders and the second discusses pharmacological modulation of these biases. Staying on the topic of attentional bias, Matt Field wrote a critical commentary of a paper published in the journal European Addiction Research. You can find this, and other commentaries here. 

In other news…

We are delighted to welcome Dr Charlotte Hardman to our research group. An appetite and obesity researcher by trade, Charlotte has been working closely with the addiction group on projects related to food addiction and attentional bias to rewarding cues.

The addiction research group has expanded... for the summer at least! We are pleased to welcome a group of summer students who are working on research projects in addiction and motivated behaviour:

Marianne Erskine-Shaw, under the supervision of Abi Rose is working on a project examining alcohol intoxication and attentional bias. Her studentship was funded by the British Psychological Society. Jade Scott is working with Charlotte Hardman on attentional bias to food and alcohol cues, and Rebecca Dallas is working with Eric Robinson on a project examining the effects of peer influences on drinking behaviours in our Bar Lab. Both Jade and Rebecca are funded by the School of Psychology, University of Liverpool. 

Our research group played a (small) part in a successful application for funding from the National Institute for Health Research, details here. The broad aim of the funding is to investigate how to improve mental health care, and our group will be looking at interventions to reduce problem drinking. 

Paul Christiansen also received a grant from Alcohol Research UK to investigate beliefs about the acute effects of alcohol on impaired control over drinking, both in the laboratory and normal day-to day life. More on this later....

Finally, we have been getting out and about to disseminate our research! Matt Field, Pawel Jedras, Andy Jones and Paul Christiansen all attended the British Association for Psychopharmacology summer meeting in Harrogate. Pawel, Andy and Paul all gave a poster presentation on some of their current projects. Pawel also gave a short oral presentation in a symposium on reward and choice.  You can spot us talking shop in some pictures from the conference at the BAP’s facebook page. Some of Abi Rose's data was presented at the World Congress of World Congress of Behavioural and Cognitive Therapies (WCBCT) meeting in Lima, Peru in July. Slightly more exotic than Harrogate. 

That's it! If you are based in Liverpool and are interested in taking part in some of our research, you can email Andy Jones for information about studies that are running at the moment.