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. 2020 Nov 25:371:m3934.
doi: 10.1136/bmj.m3934.

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

Hung-Yuan Cheng  1 , Luke A McGuinness  1 , Roy G Elbers  1 , Georgina J MacArthur  1 , Abigail Taylor  1 , Alexandra McAleenan  1 , Sarah Dawson  1 , José A López-López  1   2 , Julian P T Higgins  1   3   4 , Sean Cowlishaw  1   5 , Anne Lingford-Hughes  6 , Matthew Hickman  1   3   4 , David Kessler  7   4   8
Affiliations

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

Hung-Yuan Cheng et al. BMJ. .

Abstract

Objective: To determine the most effective interventions in recently detoxified, alcohol dependent patients for implementation in primary care.

Design: Systematic review and network meta-analysis.

Data sources: Medline, Embase, PsycINFO, Cochrane CENTRAL, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform.

Study selection: 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.

Data extraction: 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.

Results: 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.

Conclusions: 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.

Systematic review registration: PROSPERO CRD42016049779.

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Conflict of interest statement

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.

Figures

Fig 1
Fig 1
Study selection flowchart
Fig 2
Fig 2
Network plots for alcohol abstinence in relation to treatment for alcohol dependency. Size of circles is proportional to number of randomised patients and width of lines is proportional to number of studies in each direct comparison. A-CHESS=Addiction-Comprehensive Health Enhancement Support System; ACP=acamprosate; CBT=cognitive behavioural therapy; CIT=citalopram; CST=coping skill training; GHB=sodium salt of gamma hydroxybutyric acid (sodium oxybate); MET=motivational enhancement therapy; NTX=naltrexone; TAU=treatment as usual
Fig 3
Fig 3
Network plots for all cause dropouts in relation to treatment for alcohol dependency. Size of circles is proportional to number of randomised patients and width of lines is proportional to number of studies in each direct comparison. A-CHESS=Addiction-Comprehensive Health Enhancement Support System; ACP=acamprosate; CBT=cognitive behavioural therapy; CIT=citalopram; CST=coping skill training; GHB=sodium salt of gamma hydroxybutyric acid (sodium oxybate); MET=motivational enhancement therapy; NTX=naltrexone; TAU=treatment as usual
Fig 4
Fig 4
Clustered ranking plot by mean rank values from results of network meta-analyses of abstinence and all cause dropouts. Interventions are coloured according to the confidence of evidence by outline (abstinence) and fill (all cause dropout). The interventions in the white zone were ranked better than placebo based on both outcomes. A-CHESS=Addiction-Comprehensive Health Enhancement Support System; ACP=acamprosate; CBT=cognitive behavioural therapy; CIT=citalopram; EST=escitalopram; CST=coping skill training; GHB=sodium salt of gamma hydroxybutyric acid (sodium oxybate); MET=motivational enhancement therapy; NTX=naltrexone; TAU=treatment as usual
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