Primary care and the maintenance of abstinence in alcohol dependence: what might work?





by Dr Vincent Cheng, Senior Research Associate in Research Synthesis, Bristol Medical School and Professor David Kessler, Professor of Primary Care, Centre for Academic Primary Care and Centre for Academic Mental Health,  University of Bristol

The problem

Specialist alcohol treatment services cannot cope with the growing problem of alcohol use disorder. Even before the recent COVID-19 lockdown, it was estimated that more than 80% of those in need of treatment were not receiving it. The predicted economic downturn is not likely to improve this figure. Given that primary care is universally accessible in the UK, we were interested in bringing together the evidence on what interventions could be delivered in primary care.

We conducted a systematic review and network meta-analysis of treatments (psychological, pharmacological, or both) for maintaining abstinence in recently detoxified, alcohol dependent adults that could be delivered in a community setting. The review was recently published in the British Medical Journal.

What we found

Our review asked a deceptively simple question: ‘what interventions to maintain abstinence from alcohol might be effective in primary care?, which appears to have given a straightforward answer. We conducted a comprehensive systematic review to look at trials investigating the effect of treatments on alcohol dependent patients. We looked at how many people remained abstinent and how many people ended trials without dropping out. Considering these two outcomes, including the quality of evidence, the drug acamprosate came up as the only treatment with reasonable evidence in the analysis.

We visualised the results using an innovative coordinate map to illustrate the relation between treatment effects and evidence (figure 4 in the published paper).

Another interesting finding is that the evidence for the use of naltrexone and disulfiram in the review is not as strong as suggested in NICE guidance. We were a little surprised about this. Then we noticed that NICE had a slightly different approach. They did not take account of the number of studies in their appraisal.

What does this mean for patients and GPs?

So, does this mean we should now encourage GPs to prescribe acamprosate to patients who are alcohol dependent and want to be abstinent? That is one possible interpretation of the findings, but it would be wise to look a little more closely before we start writing prescriptions in primary care.

We have to start with the limitations of the study. Many of the trials we looked at were conducted in the US, where the system is different to the UK setting. Most of them were drug trials and there is far too little work on psychological interventions on their own or combined with medication. This does not invalidate our conclusions, but does mean that we need to think carefully about generalisability and whether there are additional non-pharmaceutical things we can do to support abstinence.

There are also questions about which group of people with alcohol use disorders are most likely to benefit from an intervention delivered in primary care. In the review, study participants had already stopped drinking, often after detoxification. We took this approach because we thought it had a chance of capturing a group who were sufficiently ‘severe’ to need to be detoxified and who were also motivated to be abstinent. We did not have a direct measure of either severity or wish for abstinence. This means our population may have been biased towards the more severely dependent.

There is also an important ‘real-world’ question that still needs to be addressed. Is there capacity and willingness to take on the long-term management of alcohol dependence in UK primary care? In one respect, this question answers itself; we are already doing it. There is specialist support, but it is not always easily accessible. Alcohol dependent patients who become severely unwell often end up in secondary care. There are non-NHS agencies who offer help and support, but a substantial proportion of the burden of day-to-day care for the physical and mental wellbeing of those who misuse alcohol falls on primary care.

The only way to address at least some of these questions is a pragmatic trial of an intervention to support abstinence, delivered in primary care. Clearly a feasibility phase is important, and it seems prudent to develop an intervention that includes some level of psychological support and access to expert opinion when required.

Review citation: Cheng Hung-Yuan, McGuinness Luke A, Elbers Roy G, MacArthur Georgina J, Taylor Abigail, McAleenan Alexandra et al. Treatment interventions to maintain abstinence from alcohol in primary care: systematic review and network meta-analysis BMJ 2020; 371 :m3934

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