Prevalence and long-term change in alcohol consumption: results from a population-based cohort in Southern India.

BACKGROUND: Alcohol consumption in India is below the global average, with limited data on long-term effects. The current study aims to examine changes over time among alcohol consumers, the pattern of drinking and help-seeking for alcohol problems among South Indian men. METHOD: Data on the intake of various alcohol types were collected through standard questionnaires in two adult follow-ups [Baseline: 1998-2002, Follow-up: 2016-2019] from male participants in the Vellore birth cohort (VBC). Alcohol intake was converted to weekly standard drink units for analysis. Data on drinking patterns using the Alcohol Use Disorder Identification Test (AUDIT) and information on help-seeking among problem drinkers were collected during follow-up. Socio-demographic associations with alcohol consumption were determined using logistic regression. RESULTS: The prevalence of alcohol consumption was 54.5% and 47.7% at the baseline and follow-up, respectively. Over two decades, 12% of men reported to have newly started drinking and 18% quit drinking. Lower education and lower socio-economic status (SES) were the strongest predictors of alcohol consumption. The AUDIT assessment among drinkers reported hazardous drinking of 38.4%, harmful drinking of 4.7% and 3.7% probable alcohol dependence. Among the persons with high AUDIT scores, 25% were concerned about high consumption, and 9% sought help to stop their alcohol consumption. CONCLUSION: Our results showed a decline in alcohol consumption in this cohort over two decades. Among drinkers, a high proportion report hazardous and harmful consumption. Low levels of education and SES are significant predictors of alcohol consumption. A low proportion of help-seeking reflects alcohol-related stigma in the community.

Long-term effects of an alcohol prevention program at licensed premises: a Swedish 20-year follow-up study.

Background: In 1996, a multicomponent community-based alcohol prevention program in Responsible Beverage Service (RBS) targeting licensed premises was developed by STAD (Stockholm Prevents Alcohol and Drug Problems) and implemented in Stockholm, Sweden. The program consists of community mobilization and collaboration, training, and enforcement. Early evaluations have shown a significant increase in the refusal rates of alcohol service to intoxicated patrons, from 5% in 1996 to 70% in 2001, and a 29% decrease in the frequency of police-reported violence. A cost-effectiveness analysis showed a cost-saving ratio of 1:39. The program was institutionalized by a collaborative steering group consisting of community stakeholders. This study aimed to evaluate the long-term effects over 20 years of the RBS program. The indicator chosen was the rate of alcohol overserving to obviously intoxicated patrons at licensed premises in Stockholm. Methods: A 20-year follow-up study was conducted using the same procedure as the baseline and previous follow-ups. Professional male actors (pseudopatrons) were trained by an expert panel to enact a standardized scene of obvious alcohol-intoxication. In 2016, 146 licensed premises located in the central part of Stockholm were randomly selected and visited. A review of program implementation from its initiation 1996 was conducted, examining critical events, including commitment from key actors in the community, training of bar staff, and enforcement. Results: At the 20-year follow-up, pseudopatrons were refused alcohol service in 76.7% of the attempts, which was at the same level (70%) as in the follow-up in 2001, thus indicating sustained effects of the RBS program. Compared with previous follow-ups, serving staff used more active intervention techniques in 2016 toward intoxicated patrons, such as refusing to take the order (56.9% in 2016 vs. 42.0% in 2001), and fewer passive techniques, such as ignoring patrons (6.5% in 2016 vs. 15.5% in 1999) or contacting a colleague (4.1% in 2016 vs. 25% in 2001). Conclusion: The sustained long-term effects of the RBS program are unique and can be explained by the high level of institutionalization of the multicomponent program, which is still ongoing in Stockholm. These findings can inform the dissemination of the program to other countries and settings.

The identification and treatment of alcohol problems in primary care (iTAPP) study: protocol for a stepped wedge cluster randomized control trial testing the 15-method in a primary care setting.

BACKGROUND: The 15-method is a targeted screening and treatment approach for alcohol problems in primary care. The 15-method used in primary care has proven as effective as specialized treatment for mild to moderate alcohol dependence in Sweden. A feasibility study of the 15-method in Danish primary care found the method acceptable and feasible. AIMS: To evaluate the effectiveness of the 15-method in a Danish primary care setting in (1) lowering the proportion of patients exceeding the Danish low-risk alcohol consumption limit of ten standard units per week and a maximum of four standard units on a single day for men and women, and (2) increasing the likelihood of alcohol use being addressed during a consultation in general practice. Further, the rate of prescribed pharmacological treatment for alcohol problems (Disulfiram, Naltrexone, Acamprosate, and Nalmefene) will be measured along with the use of the biomarkers Alanine Transaminase and Gamma-Glutamyl Transferase. METHODS: Stepped wedge cluster randomized controlled trial in sixteen general practices in the Region of Southern Denmark. Following a three-month baseline, the practices are randomly assigned to launch dates in one of four clusters. General practitioners and nurses receive three hours of training in the 15-method before launch. Patient questionnaires will collect data on alcohol consumption levels among patients affiliated with the practices. The healthcare professionals will register consultations in which alcohol is addressed in their patient filing system. Pharmacological treatment rates and the use of biomarkers will be collected through Danish national registries. The study follows the Medical Research Council's guidelines for developing and evaluating complex interventions. DISCUSSION: From the patient's perspective, the 15-method may help identify alcohol-related problems at an earlier stage with flexible treatment offers in a familiar setting. For healthcare professionals, it addresses a traditionally challenging topic by equipping them with concrete tools, communication training, and clear treatment directives. From a societal perspective, primary care holds a unique position to identify hazardous and harmful alcohol use across different age groups, with potential public health and economic benefits through early identification and intervention. TRIAL REGISTRATION: Clinicaltrials.gov NCT05916027. Retrospectively registered 22 June 2023.

Associations of device-measured and self-reported physical activity with alcohol consumption: Secondary analyses of a randomized controlled trial (FitForChange).

BACKGROUND: Physical activity (PA) is increasingly used as an adjunct treatment for alcohol use disorder (AUD). Previous studies have relied on self-report measures of PA, which are prone to measurement error. In the context of a randomized controlled trial of PA for AUD, we examined: (1) associations between device-measured and self-reported PA, (2) associations between PA measurements and alcohol use, and (3) the feasibility of obtaining device-measured PA data in this population. METHOD: One-hundred and forty individuals with clinician-diagnosed AUD participated in a 12-week intervention comparing usual care (phone counselling) to yoga-based exercise and aerobic exercise. Device-measured PA (Actigraph GT3x), self-reported PA (International Physical Activity Questionnaire) and alcohol consumption (Timeline Follow Back Method) were assessed before and after the trial. Effects of the interventions on PA levels were assessed using linear mixed models. RESULTS: In total, 42% (n=59) of participants returned usable device-measured PA data (mean age= 56±10 years, 73% male). Device-measured and self-reported vigorous-intensity PA were correlated (ß= -0.02, 95%CI= -0.03, -0.00). No associations were found for moderate-intensity PA. Compared to usual care, time spent in device-measured light-intensity PA increased in the aerobic exercise group (∆= 357, 95%CI= 709, 5.24). Increases in device-measured light-intensity PA were associated with fewer standard drinks (∆= -0.24, 95%CI= -0.03, -0.44), and fewer heavy drinking days (∆= -0.06, 95%CI=-0.01, -0.10). CONCLUSION: Increases in light-intensity/habitual PA were associated with less alcohol consumption in adults with AUD. Self-reported PA data should be interpreted with caution. Incentives are needed to obtain device-measured PA data in AUD populations.

Alcohol Dependence, Treatment Seeking, and Treatment Preferences Among Elderly: A Qualitative Study.

INTRODUCTION: In Sweden, alcohol consumption has increased among people aged 65 years and older. Among older adults, 2.7% of men and 1.6% of women fulfill criteria for alcohol dependence. The large majority do not seek treatment. Little is known about treatment seeking among older adults with alcohol dependence. AIM: The aim of this study was to describe elderly's views on alcohol dependence, treatment seeking, and treatment preferences. Possible gender differences will also be explored. METHODS: Between December 2017 and March 2018, two focus group interviews and 10 individual interviews were conducted, using semistructured interviews. In total, 13 elderly participated. Data were analyzed using the framework approach. RESULTS: Two themes and five subthemes were identified: (a) "regret and feelings of shame when losing control" consisting of two subthemes, namely, (1) loss of control over your alcohol consumption and (2) regret and feelings of shame, and (b) "taking back control over your life" consisting of three subthemes, namely, (1) becoming aware that you have problematic alcohol use, (2) to seek help for alcohol dependence, and (3) views on treatment options and treatment settings. CONCLUSIONS: Increased alcohol use was attributed to a decrease in responsibility and belonging. Alcohol dependence was associated with shame and stigma, which was especially strong for women. Preferred treatments were tailored for the individual, rather than to general factors such as age or gender. Moreover, important components of treatment were to be met with respect, continuity, and controlled drinking as a treatment goal. Future research should focus on interventions to reduce stigma and the development of patient-centered treatments.

Do changes in mood and anxiety mediate exercise-induced reductions in alcohol cravings? An exploratory study.

OBJECTIVE: Exercise is increasingly used as adjunct treatment for alcohol use disorder (AUD). Evidence suggests that moderate-to-high-intensity exercise can ameliorate cravings. We explored the potential mediating effects of changes in mood states in the relationship between exercise intensity and alcohol cravings. METHOD: Secondary analyses of a nested single-arm trial within a randomized controlled trial (FitForChange). In total, 117 sedentary adults (68.4% female, M = 52 ± 12 years) with clinician diagnosed (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) AUD and indications of craving (Desire for Alcohol Questionnaire) completed a 12-min submaximal cardiorespiratory fitness test on a cycle ergometer. Assessments of craving, mood states (POMS), and state anxiety (STAI-Y1) were taken immediately before, after, and 30 min after exercise. Ratings of perceived exertion (RPE) were included as indirect measures of exercise intensity. The med4way command in Stata was used to explore mediating and interaction effects of improvements in total mood disturbance (TMD) and state anxiety. RESULTS: Improvements in mood and anxiety did not mediate the effect of higher exercise intensity on reductions in alcohol craving. A significant reference interaction was found between "hard" (or greater) exertion and anxiety improvements (ß = -1.06, 95% CI [-1.50, -0.61]). Participants whose anxiety reduced during exercise had two times higher odds of reduced cravings when exercising at a higher intensity than participants whose anxiety worsened (OR = 2.04, 95% CI [1.12, 3.72]). CONCLUSIONS: Reductions in anxiety may partly explain the positive effect of higher exercise intensity on alcohol cravings. The findings are preliminary and require replication in future studies. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Behavioural self-control training versus motivational enhancement therapy for individuals with alcohol use disorder with a goal of controlled drinking: A randomized controlled trial.

BACKGROUND AND AIMS: Controlled drinking (CD) is an attractive treatment goal for a large proportion of individuals with alcohol use disorder (AUD), but the availability of treatment methods supporting a goal of CD is scarce. We tested if behavioural self-control training (BSCT) was superior to motivational enhancement therapy (MET) for individuals with AUD with a treatment goal of CD. DESIGN: Randomized controlled two-group trial. Follow-ups were conducted at 12 and 26 weeks (primary end-point) after inclusion. SETTING: Three specialized dependency care clinics in Stockholm, Sweden. PARTICIPANTS: Two hundred and fifty self-referred adults (52% men) fulfilling criteria of AUD (DSM-5) and a stated treatment goal of CD. INTERVENTION AND COMPARATOR: BSCT (n = 125), a five-session treatment based on cognitive behavioural therapy versus the active comparator, MET (n = 125), containing four sessions based on Motivational Interviewing. MEASUREMENTS: Primary outcome measure was mean weekly alcohol consumption at the 26-week follow-up, adjusted for baseline consumption. CONCLUSIONS: A randomized controlled trial found no evidence of a difference between behavioural self-control training and motivational enhancement therapy in reducing weekly alcohol consumption. Both groups substantially reduced consumption and behavioural self-control training was superior in reducing hazardous drinking.

Sticking with it? Factors associated with exercise adherence in people with alcohol use disorder.

BACKGROUND: Emerging evidence suggests that exercise may be an efficacious treatment for alcohol use disorder (AUD), but adherence is suboptimal. We examined factors associated with adherence to an exercise intervention for non-treatment seeking adults with AUD. METHODS: This secondary analysis of a randomized controlled trial included 95 physically inactive adults aged 18-75 years with clinician-diagnosed AUD. Study participants were randomly assigned to 12-weeks fitness centre-based, supervised aerobic exercise or yoga classes and asked to attend at least three times/week. Adherence was assessed both objectively (based on use of a keycard at entry) and subjectively using an activity calendar. The association between AUD and other predictor variables with adherence was assessed using logistic and Poisson regression models. RESULTS: Just under half of participants (47/95, 49%) completed ≥ 12 supervised exercise sessions. When both supervised classes and self-reported sessions were included, 32/95 (34%) participants completed ≤ 11 sessions, 28/95 (29%) did 12-23 sessions and 35/95 (37%) completed ≥ 24 sessions. In univariate logistic regression analyses, lower education was associated with non-adherence (<12 sessions) (OR = 3.02, 95%CI = 1.19-7.61). In models adjusted for demographic and clinical variables, moderate AUD (OR = 0.11, 95%CI = 0.02-0.49) and severe AUD (OR = 0.12, 95%CI = 0.02-0.69) were associated with non-adherence, when compared to low severity AUD. Higher body mass index (OR = 0.80, 95%CI = 0.68-0.93) was also associated with non-adherence. Results were materially the same when objective and subjective adherence data were combined. CONCLUSION: Adults with AUD can be supported to engage in yoga and aerobic exercise. Additional support may be required for those with moderate or severe AUD, higher BMI, and lower education.

The efficacy of an internet-based cognitive behavioral program added to treatment-as-usual for alcohol-dependent patients in primary care: a randomized controlled trial.

BACKGROUND AND AIMS: Most alcohol-dependent people have a moderate level of dependence. General practitioners (GPs) hesitate to engage in this area, and need to have access to treatment they find applicable and feasible to use. The aim of this present study was to test if an open-ended internet-based cognitive-behavioral therapy (iCBT) program added to treatment-as-usual (TAU) is more effective than TAU-only for alcohol-dependent patients in primary care. DESIGN, SETTING AND PARTICIPANTS: The present study was a two-group, parallel, randomized controlled superiority trial comparing iCBT+TAU versus TAU-only at 3- and 12-month follow-ups. TAU was delivered at 14 primary care centers in Stockholm, Sweden. A total of 264 patients (mean age 51 years, of whom 148 were female and 116 were male) with alcohol dependence and hazardous alcohol consumption were enrolled between September 2017 and November 2019. MEASUREMENTS: Participants were randomized at a ratio of 1:1 to iCBT, as a self-help intervention added to TAU (n = 132) or to TAU-only (n = 132). The GPs gave participants in both treatment arms feedback on the assessments and biomarkers and offered TAU at the primary care center. Primary outcome was weekly alcohol consumption in g/week at 12-month follow-up, analyzed according to intention-to-treat (n = 132 + 132). The per-protocol analysis included participants who completed at least one module of iCBT (n = 102 + 132). FINDINGS: There was no significant difference in weekly alcohol consumption between iCBT+TAU and TAU in the intention-to-treat (ITT) analysis at 12-month follow-up [iCBT+TAU = 133.56 (95% confidence interval, CI = 100.94-166.19) and TAU = 176.20 (95% CI = 144.04-208.35), P = 0.068, d = 0.23]. In the per-protocol analysis, including only those who initiated iCBT, the iCBT+TAU group showed lower mean weekly alcohol consumption compared with TAU [iCBT+TAU = 107.46 (95% CI = 71.17-143.74), TAU = 176.00 (95% CI = 144.21-207.80), P = 0.010, d = 0.42]. CONCLUSIONS: In Sweden, an internet-based cognitive-behavioral program added to treatment-as-usual to reduce alcohol consumption showed weak evidence of a benefit at 12 months in the intention-to-treat analysis and good evidence of a benefit in the per-protocol analysis.

Exercise as treatment for alcohol use disorder: A qualitative study.

INTRODUCTION: Exercise is a promising treatment option for individuals with alcohol use disorder, but qualitative studies are lacking. Our aim was to explore experiences of yoga and aerobic exercise among non-treatment-seeking adults with alcohol use disorder. METHODS: Semi-structured qualitative interviews (face-to-face or telephone) with 12 participants from a randomised controlled trial. Qualitative content analysis was used to analyse data. RESULTS: One main category was identified, motivating and maintaining a lifestyle change, including four generic categories: (i) Initiating factors for lifestyle change, which describes how the concept of a lifestyle change initiated participants change; (ii) Influencing lifestyle change, explains how mood-enhancing effects from exercise influence exercise behaviours; (iii) Influencing physical and mental health, which describes how improvements in physical and mental health influence self-confidence and self-esteem; and (iv) Influencing alcohol consumption, which describes how exercise reduced alcohol cravings and that success in changing exercise behaviours made participants take healthier decisions regarding their alcohol intake. DISCUSSION AND CONCLUSIONS: Exercise may help reduce alcohol intake, especially when presented in the context of a lifestyle change. Being able to self-select the type of exercise may increase compliance and optimise these benefits. Intentional planning and positive results from exercise may strengthen the individual's self-efficacy and increase the motivation to change behaviours associated with alcohol consumption.

Effects of physical activity on symptoms of depression and anxiety in adults with alcohol use disorder (FitForChange): Secondary outcomes of a randomised controlled trial.

PURPOSE: To compare the effects of yoga, aerobic exercise, and usual care on anxiety and depressive symptoms in non-treatment seeking adults with AUD. METHOD: Parallel, three-group, open-label randomised (1:1:1) controlled trial with blinded follow-up assessment. Non-treatment seeking adults (aged 18-75 years) were recruited via advertisements in a free newspaper in Stockholm, Sweden. All participants had clinician-diagnosed AUD prior to randomisation. This trial excluded those who were physically active, or for whom supervised physical activity was contraindicated. Participants were randomly assigned to 12-weeks of aerobic exercise, yoga, or usual care (telephone counselling). The secondary outcome of interest was the Hospital Anxiety and Depression Scale (HADS), assessed at baseline and 12-week follow-up. Primary analyses consisted of linear regression models and followed intention-to-treat (ITT) principals. RESULTS: In total, 140 participants (mean age 53.7 years, SD=11.8) were recruited. Follow-up was completed for 42/45 participants randomised to TAU, 42/49 to aerobic exercise and 43/46 to yoga. ITT analyses included 126 trial participants. There were statistically significant within-group improvements in total HADS in all three intervention groups. Effect sizes for usual care and aerobic exercise were small (Hedges' g=0.48, 95% CI=0.16, 0.80 and g=0.41, 95% CI=0.09, 0.72, respectively), while yoga was associated with a large treatment effect (g=1.06, 95% CI=0.69, 1.43). There were significant between-group differences in these improvements favouring yoga (B=-2.15, 95% CI=-4.16, -0.15, p = .035) relative to usual care, but no significant differences between yoga and aerobic exercise. No injuries were reported. CONCLUSIONS: Findings support the recommendation of yoga for non-treatment seeking adults with AUD.

Brief interventions for alcohol use disorders in low- and middle-income countries: barriers and potential solutions.

Global alcohol consumption and harmful use of alcohol is projected to increase in the coming decades, and most of the increase will occur in low- and middle-income countries (LMICs); which calls for cost-effective measures to reduce alcohol exposure in these countries. One such evidence based measure is screening and brief intervention (BI) for alcohol problems. Some of the characteristics of BI make them a particularly appealing choice of interventions in low-resource settings. However, despite evidence of effectiveness, implementation of BI in LMICs is rare. In this paper we discuss barriers to implementation of BI in LMICs, with examples from Latin America and India. Key barriers to implementation of BI in LMICs are the lack of financial and structural resources. Specialized services for alcohol use disorders are limited or non-existent. Hence primary care is often the only possible alternative to implement BI. However, health professionals in such settings generally lack training to deal with these disorders. In our review of BI research in these countries, we find some promising results, primarily in countries from Latin America, but so far there is limited research on effectiveness. Appropriate evaluation of efficacy and effectiveness of BI is undermined by lack of generalisability and methodological limitations. No systematic and scientific efforts to explore the implementation and evaluation of BI in primary and community platforms of care have been published in India. Innovative strategies need to be deployed to overcome supply side barriers related to specialist manpower shortages in LMICs. There is a growing evidence on the effectiveness of non-specialist health workers, including lay counsellors, in delivering frontline psychological interventions for a range of disorders including alcohol use disorders in LMICs. This paper is intended to stimulate discussion among researchers, practitioners and policy-makers in LMICs because increasing access to evidence based care for alcohol use disorders in LMICs would need a concerted effort from all these stakeholders.

Effects of exercise in non-treatment seeking adults with alcohol use disorder: A three-armed randomized controlled trial (FitForChange).

BACKGROUND: Most individuals with alcohol use disorder (AUD) do not seek treatment. Stigma and the desire to self-manage the problem are likely explanations. Exercise is an emerging treatment option but studies in non-treatment seeking individuals are lacking. We compared the effects of aerobic exercise, yoga, and treatment as usual (phone-based support) on alcohol consumption in non-treatment seeking adults with AUD. METHODS: Three-group parallel, single blind, randomized controlled trial. 140 physically inactive adults aged 18-75 diagnosed with AUD were included in this community-based trial. Participants were randomized to either aerobic exercise (n = 49), yoga (n = 46) or treatment as usual (n = 45) for 12-weeks. The primary study outcome was weekly alcohol consumption at week 13 (Timeline Follow-back). RESULTS: A significant decrease in weekly alcohol consumption was seen in all three groups: aerobic exercise (mean ∆ = - 5.0, 95% C = - 10.3, - 3.5), yoga group (mean ∆ = - 6.9, 95% CI = - 10.3, - 3.5) and TAU (mean ∆ = - 6.6, 95% CI = - 8.8, - 4.4). The between group changes were not statistically significant at follow-up. Per-protocol analyzes showed that the mean number of drinks per week reduced more in both TAU (mean ∆ = - 7.1, 95% CI = - 10.6, - 3.7) and yoga (mean ∆ = - 8.7, 95% CI = - 13.2, - 4.1) compared to aerobic exercise (mean ∆ = - 1.7, 95% CI = - 4.4, 1. 0), [F(2, 55) = 4.9, p = 0.011]. CONCLUSIONS: Participation in a 12-week stand-alone exercise program was associated with clinically meaningful reductions in alcohol consumption comparable to usual care (phone counseling) by an alcohol treatment specialist.

Effects of Internet-Based Cognitive Behavioral Therapy for Harmful Alcohol Use and Alcohol Dependence as Self-help or With Therapist Guidance: Three-Armed Randomized Trial.

BACKGROUND: Alcohol use is a major contributor to health loss. Many persons with harmful use or alcohol dependence do not obtain treatment because of limited availability or stigma. They may use internet-based interventions as an alternative way of obtaining support. Internet-based interventions have previously been shown to be effective in reducing alcohol consumption in studies that included hazardous use; however, few studies have been conducted with a specific focus on harmful use or alcohol dependence. The importance of therapist guidance in internet-based cognitive behavioral therapy (ICBT) programs is still unclear. OBJECTIVE: This trial aims to investigate the effects of a web-based alcohol program with or without therapist guidance among anonymous adult help-seekers. METHODS: A three-armed randomized controlled trial was conducted to compare therapist-guided ICBT and self-help ICBT with an information-only control condition. Swedish-speaking adult internet users with alcohol dependence (3 or more International Classification of Diseases, Tenth Revision criteria) or harmful alcohol use (alcohol use disorder identification test>15) were included in the study. Participants in the therapist-guided ICBT and self-help ICBT groups had 12-week access to a program consisting of 5 main modules, as well as a drinking calendar with automatic feedback. Guidance was given by experienced therapists trained in motivational interviewing. The primary outcome measure was weekly alcohol consumption in standard drinks (12 g of ethanol). Secondary outcomes were alcohol-related problems measured using the total alcohol use disorder identification test-score, diagnostic criteria for alcohol dependence and alcohol use disorder, depression, anxiety, health, readiness to change, and access to other treatments or support. Follow-up was conducted 3 (posttreatment) and 6 months after recruitment. RESULTS: During the recruitment period, from March 2015 to March 2017, 1169 participants were included. Participants had a mean age of 45 (SD 13) years, and 56.72% (663/1169) were women. At the 3-month follow-up, the therapist-guided ICBT and control groups differed significantly in weekly alcohol consumption (-3.84, 95% Cl -6.53 to -1.16; t417=2.81; P=.005; Cohen d=0.27). No significant differences were found in weekly alcohol consumption between the self-help ICBT group and the therapist-guided ICBT at 3 months, between the self-help ICBT and the control group at 3 months, or between any of the groups at the 6-month follow-up. A limitation of the study was the large number of participants who were completely lost to follow-up (477/1169, 40.8%). CONCLUSIONS: In this study, a therapist-guided ICBT program was not found to be more effective than the same program in a self-help ICBT version for reducing alcohol consumption or other alcohol-related outcomes. In the short run, therapist-guided ICBT was more effective than information. Only some internet help-seekers may need a multisession program and therapist guidance to change their drinking when they use internet-based interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT02377726; https://clinicaltrials.gov/ct2/show/NCT02377726.

Changes in craving following acute aerobic exercise in adults with alcohol use disorder.

AIMS: Exercise is increasingly being studied as treatment for alcohol use disorder (AUD). We examined the effects of an acute bout of exercise on alcohol craving, heterogeneity of response, and factors associated with reductions in craving. METHODS: Within the context of a randomized controlled trial, we conducted an exploratory, single-arm study. In total, 117 adults with AUD (52.7 years; SD = 12.3; 68.4% female) and indications of alcohol craving (Desire for Alcohol Questionnaire, DAQ-short version total score >8) were included. The intervention was a 12-min sub-maximal fitness test performed on a cycle ergometer. We examined changes in participant's self-rated desire for alcohol immediately before and after exercise. Personal, clinical, and exercise-related factors associated with reductions (≥0.5 SD) in craving were identified using hierarchical logistic regression. RESULTS: In the total sample craving reduced from pre-to post-exercise (p < 0.001, g = 0.60 [0.40-0.79]). Three groups were observed: those whose craving decreased (70.1%; p < 0.001, g = 1.12 [0.85-1.40]), increased (16.2%; p < 0.001, g = 1.08 [0.51-1.64]), or did not change (13.7%). Forty percent experienced clinically meaningful reductions in craving (≥0.5 SD). In fully adjusted models, two factors were associated with these reductions: higher pre-exercise cravings (OR = 1.15 [1.07-1.23], p < 0.001) and lower cardiorespiratory fitness (OR = 0.88 [0.79-1.00], p = 0.043). CONCLUSIONS: In most adults with AUD, short bouts of moderately intense aerobic exercise helps reduce cravings for alcohol. Those with higher cravings and lower cardiorespiratory fitness are most likely to benefit.

Treatment of alcohol dependence in Swedish primary care: perceptions among general practitioners.

OBJECTIVE: To describe general practitioners' (GPs) attitudes to the management of patients with alcohol dependence in primary care and current treatment routines and their view on a new treatment approach; internet-based Cognitive Behavioral Therapy (iCBT). DESIGN: A qualitative interview study with ten GPs participating in a randomized controlled trial. The interviews were analyzed using qualitative content analysis. SETTING: The participating GPs were recruited via purposeful sampling from primary care clinics in Stockholm. SUBJECTS: The GPs were participants in an RCT investigating if iCBT when added to treatment as usual (TAU) was more effective than TAU only when treating alcohol dependence in primary care. RESULTS: The GPs found alcohol important to discuss in many consultations and perceived most patients open to discuss their alcohol habits. Lack of training and treatment options were expressed as limiting factors when working with alcohol dependence. According to the respondents, routines for treating alcohol dependence were rare. CONCLUSION: GPs believed that iCBT might facilitate raising questions about alcohol use and thought iCBT may serve as an attractive treatment option to some patients. The iCBT program did not require GPs to acquire skills in behavioral treatment, which could make implementation more feasible.KEY POINTSAlcohol dependence is highly prevalent, has a large treatment gap and is relevant to discuss with patients in many consultations in primary care.This study is based on interviews with 10 GPs participating in a randomized controlled trial comparing internet-based Cognitive Behavioral Therapy (iCBT) for alcohol-dependent patients to treatment as usual.GPs viewed alcohol habits as important to discuss and they perceived most patients are open to discuss this.The access to iCBT seemed to increase GPs' willingness to ask questions about alcohol and was viewed as an attractive treatment for some patients.The iCBT program did not require GPs to acquire skills in behavioral treatment, which might be timesaving and make implementation more feasible.

Treating alcohol use disorders in primary care - a qualitative evaluation of a new innovation: the 15-method.

OBJECTIVE: This study aims to explore how the characteristics of an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived. METHODS/DESIGN/SETTING/SUBJECT: General practitioners and heads of primary care units (n = 10) that delivered the 15-method in a randomized controlled trial participated in individual interviews at two occasions in Stockholm, Sweden. Data were analyzed with theoretical thematic analysis, using Diffusion of Innovation Theory. RESULTS: The participants described that offering the 15-method met a need among their patients. Participants were positive towards the training and the manual for the method. They mentioned a previous lack of routines to work with alcohol use disorders. The 15-method was described as easy to use. It would however be more feasible to implement in a team of different professions, rather than among general practitioners only. Priorities made by regional health care managers were described as important for the implementation, as well as financial incentives. A barrier to implementation was that alcohol screening was perceived as difficult. While the 15-method was perceived as effective in reducing the patients' alcohol use and cost effective, participants expressed uncertainty about the long-term effects. CONCLUSIONS: The 15-method provides structure for treatment of alcohol use disorders and is described by general practitioners and heads as a promising approach. Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.KEY POINTSLittle attention has been given to develop treatment models for alcohol use disorders that are adapted to primary care settings.This study describes how an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.The 15-method provides structure for treatment of alcohol use disorders in primary care and is described by general practitioners and heads as a promising approach.Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.

Effects of acute exercise on craving, mood and anxiety in non-treatment seeking adults with alcohol use disorder: An exploratory study.

BACKGROUND: Exercise is increasingly being used in the treatment of alcohol use disorder (AUD). We examined the short-term effects of acute exercise on alcohol craving, mood states and state anxiety in physically inactive, non-treatment seeking adults with AUD. METHODS: Exploratory, single-arm study. In total, 140 adults with AUD (53.7 ± 11.8 years; 70 % female) were included in a randomized controlled trial (RCT) to study effects of physical activity on alcohol consumption. This acute exercise study was nested within the larger RCT. The intervention was a 12-minute sub-maximal fitness test performed on a cycle ergometer. Participants self-rated their desire for alcohol (DAQ) and completed mood (POMS-Brief) and state anxiety (STAI-Y1) questionnaires 30-minutes before exercise, immediately before, immediately after, and 30-minutes post. Ratings of perceived exertion (RPE) were collected. Effects of exercise were assessed using RM-ANOVA and dependent sample t-tests with effect sizes (Hedges g). RESULTS: In total, 70.6 % had mild or moderate AUD (DSM-5 criteria = 4.9 ± 2). The intervention was generally perceived as 'strenuous' (RPE = 16.1 ± 1.6). In the total sample, there was a main effect of time with reductions in alcohol craving [F(3,411) = 27.33, p < 0.001], mood disturbance [F(3,411) = 53.44, p < 0.001], and state anxiety [F(3,411) = 3.83, p = 0.013]. Between-group analyses indicated larger magnitude effects in those with severe compared to mild AUD, however, AUD severity did not significantly moderate the within-group improvements: group x time interaction for alcohol craving [F(6,411) = 1.21, p = 0.305]. Positive effects of exercise were maintained 30-minutes post-exercise. CONCLUSION: A short bout of aerobic exercise reduced alcohol craving and improved mood states in adults with AUD.