Several treatments for alcohol problems are proven to be effective.16/10/2018 Läkartidningen, Sweden.
Claudia Fahlke, professor, psychologist, psychological department, University of Gothenburg; Dependence Clinic, Sahlgrenska University Hospital, Gothenburg
claudia.fahlke@psy.gu.se
Sven Andréasson, Professor, Chief Physician, Department of Public Health, Karolinska Institutet, StockholmKEY MESSAGES
There are today several evidence-based psychological, psychosocial and pharmacological treatments for alcohol dependence.
The vast majority of people with alcohol dependence have mild to moderate dependence. By offering them evidence-based efforts, the possibility of preventing continued negative development increases.
The challenge we are now faced with is that these efforts are rarely offered in the health care sector or in primary care, which has the largest contact area for people with alcohol dependence.
We need, therefore, greater dissemination of evidence-based efforts and support their implementation.Several treatments for alcohol problems are proven to be effective
The challenge is to realize the treatments in care so that people with mildly moderate dependence can get help.
Addiction to alcohol is known to give rise to a variety of biological, psychological and social consequences for the individual. Nevertheless, it has been surprisingly slow to get alcohol dependence, often associated with high social costs, accepted as a condition to be addressed with scientifically. This applies to both healthcare, decision-makers and society as a whole [1].
Alcohol problems are strongly stigmatizing, which in many cases prevents the patient from seeking healthcare. Contributing to this is the division of responsibility in Sweden between healthcare and the municipality concerning addiction problems., Social services have the main responsibility in Sweden for people having addiction problems, and many in the Swedish health care refer these patients to the social services.
Just over 10 years ago, the Swedish National Board of Health (Socialstyrelsen) published the first national guidelines [2] containing more than 50 recommendations regarding effective methods and efforts to combat alcohol dependence. The guidelines were revised in 2015 and contain more than 150 evidence-based methods and efforts to address alcohol dependence, ie recommendations for screening, sampling, support and treatment [3].
Psychological and psychosocial efforts with evidence
With regard to psychological and psychosocial treatments, motivational enhancement therapy (MET, currently, MET) currently has the strongest scientific support in the National Board of Health's guidelines from 2015 [3]. Actions such as cognitive behavioral therapy (KBT), relapse prevention, twelve-step treatment and community reinforcement approach (CRA) also have strong scientific support.
For all efforts there are structured manuals to follow. However, the duration and duration of each treatment vary greatly: ranging from 5 sessions of MET for 12 weeks to CRA treatment that can last for 1 year. MET is an individual treatment, such as CRA, while KBT and relapse prevention can also be given in a group. Twelve-step treatment is given in particular by group.
For all efforts, the therapist should have a good knowledge of dependent and relevant education in the method to be given. In order to exercise KBT, the therapist should also have basic psychotherapy education [3].
Motivational treatment has the strongest support
Studies show that MET has an equally good effect on alcohol dependence like CBS and twelve-step treatment. The reason that MET is given a higher priority in the National Board of Health and Welfare's guidelines [3] is that treatment is more cost-effective than KBT and twelve-step treatment. MET is a treatment aimed at developing motivation for changing alcohol consumption in people with alcohol dependence. In MET, therapists are working to support the patient's ability to make an informed decision on change.
The MET treatment briefly means using motivational conversations (MI) to initiate an examination of the role of alcohol for the individual, medical, psychological and social. Motivational calls are also used to feedback and evaluate the survey results. The mapping of the possible effects of alcohol is done by means of an interview and a number of questionnaires as well as alcohol-related biomarkers. Following the feedback call, three follow-up motivational calls follow. A relative is recommended to be involved in the feedback call.
As soon as the patient's motivation is clarified and discussed, it can also be concretized in a written plan for changing alcohol consumption, followed up in subsequent conversations.
The MET manual is intended for use in adult work and can be downloaded free of charge at Δεν είναι ορατοί οι σύνδεσμοι (links).
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Είσοδος [4]. Manual adapted for young people exists, but not yet in Swedish translation.
Three pharmacological treatments are recommended
Among the pharmacological treatments, disulfiram, naltrexone and acamprosate receive the highest recommendations in the National Board of Health and Welfare's guidelines [3].
Disulfiram has a rapid onset effect if alcohol is consumed; The normal breakdown of the alcohol is blocked, with a consequence of acetaldehyde accumulation. This leads to a series of poisoning symptoms: nausea, headache, palpitation and anxiety. Disulfiram is used if the target is full-blown. However, the effect of the drug has been questioned, which is due to the motivation to take the tablets. However, in the case of monitored intake, the effect is good [5].
Traditionally, therefore, treatment with disulfiram has resulted in frequent visits to healthcare services for supervised intake. However, in the long run it has been difficult to maintain such treatments. Instead, one tries to engage someone related to attend the tablet intake.
In modern treatment of motivated patients, disulfiram today is used to break a long-term problem for a few months and to prevent relapses. The motivation to take the tablets on their own is judged to be the same as for other treatment of chronic diseases, such as high blood pressure or asthma. Already 20 years ago, it was found that the compliance was the same for alcohol dependence as for chronic diseases such as asthma and diabetes [6].
Naltrexone results in decreased dopamine release in alcohol consumption, which results in limited rewarding after alcohol consumption. This has been shown to lead to fewer days of intensive consumption. Genetic variation at the receptor level causes that about 30 percent of patients to describe a good effect of the tablets [7]. About the same number describes no effect.
Since the effect of naltrexone starts after an hour, tablets can be taken as needed. This applies mainly to those patients who have a clear drinking pattern and who can predict risk situations where they can lose control of their drinking. Side effects, especially in the form of nausea, are common and require careful escalation of the drug upon insertion.
Acamprosate has a primary effect on alcohol cravings, and is mainly used to achieve or maintain complete sobriety [8]. Again, there is a significant genetic variation, where about 30 percent of patients have a good effect with reduced consumption and fewer relapses.
For all drugs, the best effect is achieved when the medicine is given in the context of regular follow-up of laboratory tests[7]. Although the above-described drugs have a low cost per effect, with an NNT (number needed to treat) of 8-9 [9], there is still a subversion of those with major regional differences.
The severity of the dependence determines the choice of treatment
However, the type of intervention that should be given depends on the severity of the dependency and on the patient's informed choices. For example, in the risk of alcohol, limited advice is effective [10]. This means that costly and time-consuming efforts should not be prioritized in risk-taking. In terms of alcohol dependency, the severity varies considerably [11].
In the case of mild or moderately pronounced alcohol dependence, which accounts for approximately 75 percent of all alcohol dependents, fewer of the diagnostic criteria meet, patients receive lower values for dependency estimates, describe lower alcohol consumption and lower values of the biological markers (low-fat transferrin [CDT] and phosphatidyl ethanol [PEth]).
People with mild to moderate alcohol dependence are helped by MET, but also by KBT and relapse prevention. They are also assisted by pharmacological treatment or a combination of pharmacological treatment with the aforementioned psychological or psychosocial treatments. Particularly MET, short forms of CBS and pharmacological treatment may be advantageously performed in primary care.
For this, educational efforts are required, which, however, can generally be kept short. In the TAP (Treatment for Alcohol Dependence in Primary Care) study, where general physicians at 12 health centers in Stockholm conducted a short treatment program for alcohol dependence, with good results, the training was completed in 1 day [12].
Vid svårare beroende krävs vanligtvis mer omfattande insatser av den specialiserade beroendevården, inklusive farmakologisk behandling. Ibland behövs också tillägg av socialtjänstens stödinsatser, främst vad gäller stöd att komma i arbete och boende, men också nätverksarbete och samverkan (vård- och stödsamordning) [3].
Vid behandling av samsjuklighet är det dessutom nödvändigt att såväl beroendet som den psykiska sjukdomen behandlas samtidigt [2, 3].
Behandling som sällan erbjuds inom hälso- och sjukvård
De flesta med alkoholberoende har lindrigt till måttligt beroende [1, 3]. Genom att erbjuda dem evidensbaserade psykologiska och psykosociala behandlingar (t ex MET, KBT och återfallsprevention) eller farmakologiska behandlingar kan en fortsatt negativ beroendeutveckling förhindras.
Den utmaning vi nu står inför är att dessa insatser sällan erbjuds inom hälso- och sjukvården, och inte heller inom primärvården, som har den största kontaktytan mot personer med alkoholberoende. En möjlig väg är att stärka behandlingspersonalens kompetens i dessa evidensbaserade insatser och verka för att dessa insatser för alkoholberoende alltid kan erbjudas, såväl inom primärvård som inom specialistvård.
Mot bakgrund av de omfattande hälsoproblem som hög alkoholkonsumtion och alkoholberoende ger upphov till finns mycket att vinna på att i högre grad uppmärksamma och behandla dessa tillstånd – för såväl patient som samhälle.
Potentiella bindningar eller jävsförhållanden: Inga uppgivna.
References:
1) SOU 2011:35. Bättre insatser vid missbruk och beroende. Individen, kunskapen och ansvaret. Slutbetänkande av Missbruksutredningen. Stockholm: Socialdepartementet; 2011.
2) Nationella riktlinjer för missbruks- och beroendevård. Vägledning för socialtjänstens och hälso- och sjukvårdens verksamhet för personer med missbruks- och beroendeproblem. Stockholm: Socialstyrelsen; 2007. Artikelnr 2007-102-1.
3) Nationella riktlinjer för vård och stöd vid missbruk och beroende. Stöd för styrning och ledning. Stockholm: Socialstyrelsen; 2015. Artikelnr 2015-4-2.
4) Hammarberg A, Andréasson S, Fahlke C, et al. Manual för motivationshöjande behandling (MET). Svensk reviderad version. 2016. Δεν είναι ορατοί οι σύνδεσμοι (links).
Εγγραφή ή Είσοδος
5) Jørgensen CH, Pedersen B, Tønnesen H. The efficacy of disulfiram for the treatment of alcohol use disorder. Alcohol Clin Exp Res. 2011;35(10):1749-58.
6) O’Brien C, McLellan AT. Myths about the treatment of addiction. Lancet. 1996;347(8996):237-40.
7) Anton RF, Oroszi G, O’Malley S, et al. An evaluation of mu-opioid receptor (OPRM1) as a predictor of naltrexone response in the treatment of alcohol dependence: results from the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) study. Arch Gen Psychiatry. 2008;65(2):135-44.
8 ) Rösner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010;(9):CD004332.
9) Maisel NC, Blodgett JC, Paula L, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275-93.
10) Nationella riktlinjer för prevention och behandling vid ohälsosamma levnadsvanor. Stöd för styrning och ledning. Stockholm: Socialstyrelsen; 2018.
11) Andréasson S, Danielsson AK, Hallgren M. Severity of alcohol dependence in the Swedish adult population: association with consumption and social factors. Alcohol. 2013;47(1):21-5.
12) Wallhed Finn S, Hammarberg A, Andréasson S. Treatment for alcohol dependence in primary care compared to outpatient specialist treatment – a randomized controlled trial. Alcohol Alcohol. 2018;53(4):376-85.Δεν είναι ορατοί οι σύνδεσμοι (links).
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24 Οκτωβρίου 2013, 08:47:14