Treatment of alcohol dependence in primary care

Abstract: Alcohol dependence is a common disorder and contributes to substantial morbidity and mortality globally. Only 10-20 percent engage in treatment, which makes alcohol dependence the mental disorder with the largest treatment gap. Most individuals with alcohol dependence have a dependence of low to moderate severity. These individuals are concerned about their drinking but are not interested in seeking treatment in specialized care. Primary care, however, is viewed as an appealing treatment option for these individuals. In Swedish primary care few routines are in place for the treatment of alcohol use disorders (AUD). General practitioners (GP) are hesitant to engage in this field. Time concerns and perceived limited competence constitutes barriers for the identification and treatment of alcohol dependence in primary care. The overall aim with this thesis was to study new approaches aimed at enhancing the identification and treatment of alcohol dependence in primary care. Study I was a randomized controlled superiority trial including 264 participants with alcohol dependence in primary care in Stockholm. The objective was to test the efficacy of an internet-delivered cognitive behavioral therapy (iCBT) program for alcohol dependent patients in primary care. Our hypothesis was that iCBT, a five-module self-help program, when added to treatment as usual (TAU) was more efficacious than TAU only. As clear routines for treating alcohol dependence are lacking, TAU will vary. Therefore, the involved GPs were offered a one-hour training in giving feedback on assessments and biomarkers and providing pharmacotherapy for AUD. Linear mixed effects models were used to analyze primary and secondary outcomes. No significant differences between the groups were seen for the primary outcome of mean weekly alcohol consumption at 12 months in the intention-to-treat analysis. The per-protocol analysis showed that when including only patients who actually initiated the iCBT program, the combination of iCBT and TAU resulted in lower mean weekly alcohol consumption compared to TAU at 12-months. Study II was a secondary analysis based on data from Study I with the aim to investigate the role of socio-demographic and clinical predictors for outcome in Study I, using linear mixed effects models. Primary outcome was mean number of standard drinks the last 30 days. Severity of dependence was the only variable that was found to moderate treatment outcome. Patients with severe dependence showed a significantly larger reduction in alcohol consumption between baseline and 3 months compared to moderately dependent patients in TAU. The moderately dependent patients continued to reduce their consumption between 3- and 12 months, while the severely dependent patients increased their consumption during this period. To conclude, reduced alcohol consumption over time was found for moderately dependent patients treated in primary care with both iCBT+TAU and TAU, while the effect for severely dependent patients was more limited, suggesting a possible need for more care. Study III was a qualitative interview study with the aim to investigate how GPs experience the management of patients with alcohol dependence in primary care, current treatment routines and their view on iCBT. Ten GPs from primary care clinics in Stockholm (5/5 women/male) with prior experience as care providers in Study I were recruited via purposeful sampling and interviewed. Interview data was analyzed using qualitative content analysis. The GPs found alcohol important to discuss due to its impact on patients’ health. They found most patients open to discuss their alcohol consumption. Routines for treating alcohol dependence were rare. Limited time, treatment options and perceived limited expertise were expressed as hampering factors when working with alcohol dependence. GPs believed that iCBT as a treatment option might facilitate discussions about alcohol with patients. The iCBT program was viewed as an attractive treatment option to some patients and did not require GPs to acquire behavioral treatment skills, potentially enhancing its implementation. Study IV was a prospective longitudinal register-based study including 128 of all 223 publicly funded primary care clinics in Region Stockholm. The aim was to investigate the extent to which the combination of two implementation strategies impacted on alcohol-related clinical activity in primary care in Region Stockholm. The two strategies were a) a new policy making prevention and interventions of AUD mandatory in primary care and b) training in the 15-Method. The new policy was introduced on February 2021 and training in targeted screening and treatment of AUD for primary care professions was launched ten months after implementation of the new policy. Data from registers were collected at six time periods; at three months before the new policy was launched; at three and nine months after the new policy was launched, but before training was available; at six, 12 and 18 months after training was available. Seven measures that reflect alcohol-related clinical activities were obtained from the primary care electronic case files and were analyzed with Generalized Estimating Equations. From low levels of alcohol-related clinical activities at baseline, a modest increase in some of the alcohol-related clinical activities was found 9 months after the new policy. The training in the 15-Method was not associated with further increases. Few professionals appear to have participated in the training. While a policy making alcohol interventions mandatory, combined with a training program, has strong support from implementation science, more implementation strategies seem necessary to impact on how clinicians in primary care can handle AUD. The main conclusions of the thesis were that treatment of alcohol dependence in primary care is efficacious both for patients receiving TAU and for patients treated with iCBT plus TAU. For patients that utilized the iCBT program in combination with TAU, additive efficacy was found on mean weekly alcohol consumption. Severity of dependence predicted treatment outcome for alcohol dependent patients in primary care. Moderately dependent patients reduced their weekly alcohol consumption during treatment and continued to reduce their consumption at 12 months follow-up. Severely dependent patients reduced their weekly alcohol consumption during treatment, but increased their consumption after end of treatment, suggesting a need for more care. The GPs involved in the studies viewed iCBT as a convenient treatment option for some patients and having access to iCBT might facilitate discussions about alcohol. Regarding implementation strategies, the new policy making alcohol interventions mandatory in primary care was associated with a modest increase in some alcohol-related activities, whereas no additional benefit was found for a brief digital training course in prevention and treatment of alcohol dependence.