Clinical Question: 35 y/o male with alcohol use disorder determined to quit wants to know if cognitive behavioral therapy is most effective for achieving sobriety.
Is Cognitive behavioral therapy most effective in achieving sobriety in patients with alcohol use disorder?
PICO Question:
Problem/patient population: Alcohol use dependence, adult male (18-65)
Intervention: Cognitive behavioral therapy
Comparator: Pharmacological therapy, combined CBT and pharmacological therapy.
Outcome: Long term sobriety
Search Strategy:
Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on:
PICO Search Terms
| Problem/ population | Intervention/indications | Comparisons | Outcome |
| AUD | Cognitive behavioral therapy | Pharmacological intervention | Long term sobriety |
| AUD in adult males | Combined CBT and pharmacological therapy | ||
| Psychological intervention |
Filters/limit – Gender – Male, Age – Adults (18-65), Date of publication: After 2015
Results found:
Number of articles returned once relevant limits are added
| DATABASE | TERMS | FILTERS | RESULT |
| PubMed | Cognitive behavioral therapy, AUD, pharmacological interventions | 5 years, Male, | 9561 |
| Science Direct | Treatment of AUD, long term sobriety | 5 Years, Male | 60 |
Articles Chosen for Inclusion (please copy and paste the abstract with link):
| ARTICLE Network Support II: Randomized Controlled Trial of Network Support Treatment and Cognitive Behavioral Therapy for Alcohol Use Disorder [science direct]10.1016/j.drugalcdep.2016.06.010 |
| AbstractBackgroundThe social network of those treated for alcohol use disorder can play a significant role in subsequent drinking behavior, both for better and worse. Network Support treatment was devised to teach ways to reconstruct social networks so that they are more supportive of abstinence and less supportive of drinking. For many patients this may involve engagement with AA, but other strategies are also used.
Purpose The current trial of Network Support treatment, building on our previous work, was intended to further enhance the ability of patients to construct abstinence-supportive social networks, and to test this approach against a strong control treatment. Methods Patients were 193 men and women with alcohol use disorder recruited from the community and assigned to either 12 weeks of Network Support (NS) or Packaged Cognitive-Behavioral Treatment (PCBT) and followed for 27 months. Results Results of multilevel analyses indicated that NS yielded better posttreatment results in terms of both proportion of days abstinent and drinking consequences, and equivalent improvements in 90-day abstinence, heavy drinking days and drinks per drinking day. Mediation analyses revealed that NS treatment effects were mediated by pre-post changes in abstinence self-efficacy and in social network variables, especially proportion of non-drinkers in the social network and attendance at Alcoholics Anonymous.ConclusionIt was concluded that helping patients enhance their abstinent social network can be effective and may provide a useful alternative or adjunctive approach to treatment. |
| ARTICLE: Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network meta‐analyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate. https://doi-org.york.ezproxy.cuny.edu/10.1111/add.13974 |
| ABSTRACT
BACKGROUND AND AIMS Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders (auds) is an emerging concept. Our objective was to explore the comparative effectiveness of drugs used in this indication. DESIGN Systematic review with direct and network meta‐analysis of double‐blind randomized controlled trials (rcts) assessing the efficacy of nalmefene, naltrexone, acamprosate, baclofen or topiramate in non‐abstinent adults diagnosed with alcohol dependence or auds. Two independent reviewers selected published and unpublished studies on medline, the cochrane library, embase, clinicaltrials.gov, contacted pharmaceutical companies, the european medicines agency and the food and drug administration, and extracted data. SETTING: Thirty‐two rcts. PARTICIPANTS: A total of 6036 patients. MEASUREMENTS The primary outcome was total alcohol consumption (tac). Other consumption outcomes and health outcomes were considered as secondary outcomes. FINDINGS No study provided direct comparisons between drugs. A risk of incomplete outcome data was identified in 26 studies (81%) and risk of selective outcome reporting in 17 (53%). Nalmefene [standardized mean difference (smd) = −0.19, 95% confidence interval (ci) = −0.29, –0.10; i2 = 0%], baclofen (smd = −1.00, 95% ci = −1.80, −0.19; one study) and topiramate (smd = −0.77, 95% ci = −1.12, –0.42; i2 = 0%) showed superiority over placebo on tac. No efficacy was observed for naltrexone or acamprosate. Similar results were observed for other consumption outcomes, except for baclofen (the favourable outcome on tac was not reproduced). The number of withdrawals for safety reasons increased under nalmefene and naltrexone. No treatment demonstrated any harm reduction (no study was powered to explore health outcomes). Indirect comparisons suggested that topiramate was superior to nalmefene, naltrexone and acamprosate on consumption outcomes, but its safety profile is known to be poor. CONCLUSIONS There is currently no high‐grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes. |
| ARTICLE: A Randomized Trial of Personalized Cognitive-Behavior Therapy for Alcohol Use Disorder in a Public Health Clinic https://doi.org/10.3389/fpsyt.2018.00297 |
| ABSTRACTBackground: Tailored psychological interventions based on individual risk factors are likely to improve treatment for Alcohol Use Disorders (AUDs). Key risk factors for poor treatment outcome include alcohol craving, positive expectations of alcohol consumption, and impulsivity.Design: Pragmatic randomized Cognitive-Behavioral Treatment (CBT) trial.Setting: Public hospital alcohol and drug clinic.Participants: Three-hundred seventy-nine patients (65% male; Age years M = 44.32, SD = 10.75) seeking treatment for AUD.Procedure: Patients were randomly allocated into treatment as usual (TAU) or targeted treatment. Patients in targeted treatment were allocated one of three treatment modules focusing on craving, positive expectancy, or impulsivity based on assessment results. Treatment included eight, 1 h sessions of CBT over 12 weeks delivered by clinical psychologists.Hypotheses: Targeted treatment was expected to have fewer drinking days and consume less alcohol during the treatment period than TAU. Improvement in targeted mechanisms was predicted to be greatest for patients within matched conditions.Results: Patients attended an average of 4.4 sessions with 93 (25%) completing the whole 12-week treatment episode. The mean proportion of drinking days between sessions was 5% with an average consumption of 64 grams of ethanol. No significant effect of targeted treatment was identified on drinking days or consumption. The craving (b = −18.97, 95% CI = −31.44, −6.51) and impulsivity (b = −26.65, 95% CI = −42.09, −11.22) modules demonstrated significant reductions in their targeted constructs over treatment, above TAU. Only reduction in craving was associated with reduced drinking days [exp(b) = 0.958, p = 0.003] and alcohol consumption [exp(b) = 0.962, p= 0.02]. Significant indirect effects for the targeted craving module through craving reduction were identified for reduction in drinking days (β = −0.72, 95% CI = −1.50, −0.158) and alcohol consumption (β = −0.78, 95% CI = −1.72, −0.11).Conclusions: In the context of a public health service, the effectiveness of individualized treatment targeting risk mechanisms identified during pre-treatment assessment was not confirmed. Some evidence was found for improved treatment response to the implementation of a manualized craving module when pre-treatment craving was high. |
| ARTICLE: Adding Psychotherapy to the Naltrexone Treatment of Alcohol Use Disorder: Meta-analytic Review
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6175267/ |
| ABSTRACTBackgroundIt remains unclear if naltrexone combined with psychotherapy is superior to naltrexone alone in treating alcohol use disorders (AUD). The current meta-analysis examined the hypothesis that psychotherapy is a significant moderator that influences AUD-related outcomes and that naltrexone combined with psychotherapy is associated with significantly better AUD-related outcomes than naltrexone alone.MethodsA total of 30 studies (Nnaltrexone = 2317; Nplacebo = 2056) were included. Random effects model meta-analyses were carried out for each of the studied outcomes. Subsequently, the random effects model pooled estimates from studies with and without psychotherapy were compared using a Wald test. A mixed-effect model, incorporating psychotherapy as a moderator, was used to examine the impact of psychotherapy on treatment outcomes.ResultsNaltrexone had a significant treatment effect on abstinence relapse and Gamma-Glutamyl Transferase levels, but not cravings. The pooled estimates for studies with and without psychotherapy were not significantly different for any of the studied outcomes. Psychotherapy was not a significant moderator in the mixed effects models for any of the studied outcomes. ConclusionsNaltrexone treatment is efficacious in reducing alcohol consumption, but not reducing cravings. Adding psychotherapy on top naltrexone did not result in any significant additional benefit for AUD patients.for alcohol use disorders may be maintained in part by alcohol consumption. Initiating abstinence is associated with reductions in drinking urges immediately and then more gradually over time. |
| ARTICLE: State-of-the-Art Behavioral and Pharmacological Treatments for Alcohol Use Disorder |
| ABSTRACT
Background:Alcohol use disorder (AUD) and its associated consequences remain significant public health concerns. Given that AUD represents a spectrum of severity, treatment options represent a continuum of care, ranging from single-session brief interventions to more intensive, prolonged, and specialized treatment modalities. Objective: This qualitative literature review seeks to describe the best practices for AUD by placing a particular emphasis on identifying those practices which have received the most empirical support. Method: This review summarizes psychological and pharmacological intervention options for AUD treatment, with a focus on the relapse prevention phase of recovery. Psychological and pharmacological treatments are summarized in terms of the empirical evidence favoring each approach and the level of AUD severity for which they are most indicated. Scientific Significance: One of the broad assertions from this review is that while AUD is highly prevalent, seeking treatment for AUD is not. There are a myriad of behavioral and pharmacological treatments that have shown compelling evidence of efficacy for the treatment of AUD. In the behavioral treatment literature, Cognitive Behavioral Therapy (CBT) has received the most consistent support. Opioid antagonism (via naltrexone) has been the most widely studied pharmacotherapy and has produced moderate effect sizes. While none of the treatments reviewed herein represents a so called “silver bullet” for AUD, they each have the potential to significantly improve the odds of recovery. Precision medicine, or the identification of best treatment matches for individual patients, looms as an important overarching goal for the field; although specific matches are not yet sufficiently reliable in their empirical evidence to warrant clinical dissemination. |
SUMMARY OF THE EVIDENCE:
| Author (Date) | Level of Evidence | Sample/Setting(# of subjects/ studies, cohort definition etc.) | Outcome(s) studied | Key Findings | Limitations and Biases |
| Litt et al. 2016
Network Support II: Randomized Controlled Trial of Network Support Treatment and Cognitive Behavioral Therapy for Alcohol Use Disorder |
Randomized Controlled Trial | 193 men and women with alcohol use disorder were recruited and assigned to either 12 weeks of Network Support (NS) or Packaged Cognitive-Behavioral Treatment (PCBT) and followed for 27 months.
[Alcoholics Anonymous (AA) was used for the Network support treatment] |
Specific significance of social network building compared to general relapse prevention skills training, and how Network support affects long-term outcomes of abstinence. | Social network (of non-drinking friends) can be effective in helping patients enhance their abstinent and may provide a useful alternative or adjunctive approach to AUD treatment.- Social networks are influential in both the initiation and maintenance of drinking so having an enhanced sober social network is useful in maintain long term sobriety. | Some limitations include – Low number of minority patients.The small number of therapists used might have reduced generalizability. |
| Palpacuer C et al. 2017
Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network meta-analyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate. |
Systematic review | 32 RCTs
Total of 6036 patients |
Primary outcome: Total alcohol consumption (TAC)Secondary outcomes: Consumption outcomes and health outcomes | No high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. | No treatment demonstrated any harm reduction (no study explored health outcomes).[While there was no comparison with CBT it identifies the efficacy of pharmacological treatment of AUD] |
| Coates et al. 2018
A Randomized Trial of Personalized Cognitive-Behavior Therapy for Alcohol Use Disorder in a Public Health Clinic. |
Randomized Cognitive-Behavioral Treatment (CBT) trial. | Three-hundred seventy-nine patients (65% male; Age years M = 44.32, SD = 10.75) seeking treatment for AUD. | Number of Drinking days and amount alcohol consumed during the treatment period.Compared the effectiveness of standard CBT for AUD to a tailored CBT treatment program based on the psychometric profiles of three mechanisms—craving, positive expectancy, and impulsivity–in a public health clinic. | Although Comprehensive reviews of AUD treatment and rehabilitative services conclude that individual differences are likely to determine differential treatment response no evidence was found to show improved effectiveness of a tailored CBT treatment over standard CBT. | Treatment provided to the patient’s was not randomly allocated.Long term follow ups were not performed so the effect of the efficacy of individualized CBT in the long run is not known. |
| Ahmed et al. 2018
Adding Psychotherapy to the Naltrexone Treatment of Alcohol Use Disorder: Meta-analytic Review |
Metanalysis | 30 studies comparing the use of naltrexone with or without psychotherapy. | AUD related outcomes (abstinence, relapse, cravings, Gamma-Glutamyl Transferase levels) with concurrent use of psychotherapy and naltrexone vs naltrexone alone. | Naltrexone was efficacious in improving outcomes such as abstinence and relapse but did not reduce cravings.There is no significant difference in treatment outcomes with concurrent use of psychotherapy and naltrexone. | Different psychotherapy treatments were said to have varying degree of outcomes when combined with naltrexone, but no further data was provided on that.Selection of English language only studies caused a selection bias. |
| Ray et al. 2019
State-of-the-Art Behavioral and Pharmacological Treatments for Alcohol Use Disorder |
Review | Study does not mention the number of studies but 178 articles are listed as reference in order to provide treatment options with the most empirical support. | Relapse prevention phase of recovery after psychological and/or pharmacological treat is provided for AUD. | CBT remains one of the most widely studied and empirically supported treatments for AUD.Psychosocial treatments may be optimally effective when combined with another psychosocial modality and/or with pharmacotherapy in the form of medication assisted treatment. Support of naltrexone is not uniform as effect sizes are modest and some show no significant difference between outcomes of patients treated by naltrexone or placebo. |
The statement that CBT is the most empirically supported psychosocial treatment and naltrexone the most supported pharmacological treatment is a subjective evaluation of scientific literature however; it provides an extensive list of various treatment modalities of AUD and its efficacy. |
Conclusion:
Since treatment with CBT, motivational interviewing, mindfulness-based approaches show most efficacy in psychological treatment of AUD and since no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder was found I would tell the patient that CBT is one of the most effective in improving abstinence in patients with AUD.
Clinical bottom line:
Although there are various behavioral and pharmacological treatments that show compelling evidence of efficacy for the treatment of AUD, treatment with CBT, motivational interviewing, mindfulness-based approaches show most efficacy in psychological treatment of AUD and naltrexone is seen to produced moderate effect sizes in improving abstinence and relapse in patients with AUD. Combined behavioral intervention and pharmacological management with naltrexone did not seem to enhance the effects of the medication in improving abstinence and relapse. To identify medications or combination of medication and psychotherapy with high efficacy and to know the optimal duration/sequence for the treatment of AUD requires additional research.
REFERENCES:
Ahmed R, Kotapati VP, Khan AM, et al. Adding Psychotherapy to the Naltrexone Treatment of Alcohol Use Disorder: Meta-analytic Review. Cureus. 2018;10(8):e3107. Published 2018 Aug 6. doi:10.7759/cureus.3107
Coates JM, Gullo MJ, Feeney GFX, Young RM and Connor JP (2018) A Randomized Trial of Personalized Cognitive-Behavior Therapy for Alcohol Use Disorder in a Public Health Clinic. Front. Psychiatry 9:297. doi: 10.3389/fpsyt.2018.00297
Litt, M. D., Kadden, R. M., Tennen, H., & Kabela-Cormier, E. (2016). Network Support II: Randomized controlled trial of Network Support treatment and cognitive behavioral therapy for alcohol use disorder. Drug and Alcohol Dependence, 165, 203–212. https://doi.org/10.1016/j.drugalcdep.2016.06.010
Palpacuer C, Duprez R, Huneau A, et al. Pharmacologically controlled drinking in the treatment of alcohol dependence or alcohol use disorders: a systematic review with direct and network meta-analyses on nalmefene, naltrexone, acamprosate, baclofen and topiramate. Addiction. 2018;113:220–237.
Ray LA Ph.D, Bujarski S Ph.D, Grodin E Ph.D, et al. State-of-the-art behavioral and pharmacological treatments for alcohol use disorder. Am J Drug Alcohol Abuse. 2019;45(2):124‐140. doi:10.1080/00952990.2018.1528265
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