Changes in processing speed during early abstinence from alcohol dependence.

BACKGROUND: Processing speed is a task-independent construct underpinning more complex goal-related abilities. Processing speed is impaired in alcohol dependence (AD) and is linked to relapse, as are the functions it underpins. Reliable measurement of processing speed may allow tracking of AD recovery trajectories and identify patients requiring additional support. AIMS: To assess changes in reaction time (RT) from baseline (at the start of a detoxification programme) across early abstinence. METHODS: Vibrotactile RT was assessed in early recovery between days 3 and 7 of treatment in 66 individuals with AD (25 females; aged 19-74, 44.60 ± 10.60 years) and against 35 controls tested on one occasion (19 females; 41.00 ± 13.60), using two multivariate multiple regressions. A mixed multivariate analysis of covariance (MANCOVA) of available AD data (n = 45) assessed change in RT between timepoints and between treatment settings (outpatient vs inpatient). RESULTS: The group (AD vs control) significantly predicted choice RT at baseline and follow-up but did not significantly predict simple RT or RT variability, which is inconsistent with previous findings. At follow-up, mental fatigue was also predicted by the group, and MANCOVA indicated that this had worsened in inpatients but improved in outpatients. CONCLUSIONS: Recovery of RT measures so early in the treatment journey was not in line with previous research which indicates persisting deficits. The interaction between setting and timepoint indicates that despite being typically less medically complex, outpatients require ongoing support and monitoring during their recovery.

Improving access to treatment for alcohol dependence in primary care: A qualitative investigation of factors that facilitate and impede treatment access and completion.

BACKGROUND: Timely intervention for people with alcohol dependence in primary care is needed. Primary care services have a key role in supporting adults with alcohol dependence and require appropriate provision of services. OBJECTIVE: To examine the perceptions of both primary care practitioners and adults with alcohol dependence regarding service provision and to describe help seeking behaviours for adults with alcohol dependence. DESIGN AND SETTING: Qualitative study consisting of semi-structured interviews with adults with alcohol dependence, healthcare professionals and staff members of specialist alcohol services who had previous or current experience in the management, treatment, or referral of adults with alcohol dependence in Northwest England. METHOD: Interviews were conducted with ten adults with alcohol dependence and 15 staff. Data were analysed thematically, applying principles of constant comparison. RESULTS: Three themes were identified following inductive thematic analysis. The first theme, point of access relates to current service provision being reactive rather than preventative, the stigma associated with alcohol dependence and a person's preparedness to change. The second theme identified was treatment process and pathways that highlights difficulties of engagement, mental health support, direct access and person-centred support. The third theme was follow-up care and discusses the opportunities and threats of transitional support or aftercare for alcohol dependence, signposting and peer support. CONCLUSION: There are clear opportunities to support adults with alcohol dependence in primary care and the need to increase provision for timely intervention for alcohol related issues in primary care.

Prevalence and incidence of alcohol dependence: cross-sectional primary care analysis in Liverpool, UK.

OBJECTIVES: Liverpool has high prevalence of alcohol use disorders (AUDs) compared with the rest of the UK. Early identification and referral in primary care would improve treatment for people with AUD. This study aimed to identify changes in prevalence and incidence of AUD in primary care in Liverpool, to identify local need for specialist services. DESIGN: Cross-sectional retrospective analysis of electronic health records. SETTING: National Health Service (NHS) Liverpool Clinical Commissioning Group (CCG) primary care. In total, 62 of the 86 general practitioner (GP) practices agreed to share their anonymised Egton Medical Information Systems (EMIS) data from 1 January 2017 to 31 December 2021. PARTICIPANTS: Patients aged over 18 years with a SNOMED code for alcohol dependence (AD) or hazardous drinking (N=4936). Patients were excluded if they had requested that their data was not to be shared, and practices were excluded if they opted out (N=2) or did not respond to the data sharing request (N=22). PRIMARY AND SECONDARY OUTCOMES: Prevalence and incidence of AUD diagnoses in primary care over the 5-year period; demographic profile of patients (sex, age, ethnicity, occupation); GP postcode; alcohol-related medications; and psychiatric and physical comorbidities. RESULTS: There were significant decreases in incidence of AD and hazardous drinking diagnoses over the 5 years (p<0.001 in all cases). Prevalence showed less change over time. Diagnoses were significantly higher in more deprived areas (Indices of Multiple Deprivation decile 1 vs 2-10). Overall pharmacotherapy prescriptions were lower than national estimates. CONCLUSIONS: There are low levels of identification of AUDs in primary care in Liverpool, and this is decreasing year on year. There was weak evidence to suggest patients in the most deprived areas are less likely to receive pharmacotherapy once diagnosed. Future research should seek to investigate practitioner and patient perspectives on barriers and facilitators to management of AUDs in primary care.

Informing the development of diagnostic criteria for differential diagnosis of alcohol-related cognitive impairment (ARCI) among heavy drinkers: A systematic scoping review.

BACKGROUND: Early detection and diagnosis of alcohol-related cognitive impairment (ARCI) among heavy drinkers is crucial to facilitating appropriate referral and treatment. However, there is lack of consensus in defining diagnostic criteria for ARCI. Uncertainty in attributing a diagnosis of suspected ARCI commonly arises in clinical practice and opportunities to intervene are missed. A systematic scoping review approach was taken to (i) summarise evidence relating to screening or diagnostic criteria used in clinical studies to detect ARCI; and (ii) to determine the extent of the research available about cognitive assessment tools used in 'point-of-care' screening or assessment of patients with suspected non-Korsakoff Syndrome forms of ARCI. METHODS: We searched Medline, PsycINFO, Cinahl and the Web of Science, screened reference lists and carried out forward and backwards citation searching to identify clinical studies about screening, diagnosis or assessment of patients with suspected ARCI. RESULTS: In total, only 7 studies met our primary objective and reported on modifications to existing definitions or diagnostic criteria for ARCI. These studies revealed a lack of coordinated research and progress towards the development and standardisation of diagnostic criteria for ARCI. Cognitive screening tools are commonly used in practice to support a diagnosis of ARCI, and as a secondary objective we included an additional 12 studies, which covered a range of settings and patient populations relevant to screening, diagnosis or assessment in acute, secondary or community 'point-of-care' settings. Across two studies with a defined ARCI patient sample and a further four studies with an alcohol use disorder patient sample, the accuracy, validity and/or reliability of seven different cognitive assessment tools were examined. The remaining seven studies reported descriptive findings, demonstrating the lack of evidence available to draw conclusions about which tools are most appropriate for screening patients with suspected ARCI. CONCLUSION: This review confirms the scarcity of evidence available on the screening, diagnosis or assessment of patients with suspected ARCI. The lack of evidence is an important barrier to the development of clear guidelines for diagnosing ARCI, which would ultimately improve the real-world management and treatment of patients with ARCI.

Subjective executive function deficits in hazardous alcohol drinkers.

BACKGROUND: Dependent alcohol drinkers exhibit differences in the structure and function of the brain, and impairments in cognitive function, including executive functions (EFs). Less is known about the impact of non-dependent but hazardous use (that which raises the risk of harm), and it is also unclear to what extent executive impairments in this cohort affect real-world function. The current study examines the relationship between alcohol use, EF and alcohol-related problems, in the general population. METHODS: A between-groups cross-sectional design assessed EF across two levels of drinking; hazardous (Alcohol Use Disorders Identification Test (AUDIT) score of ⩾8) and non-hazardous. Alcohol drinkers (n = 666; 136 male; 524 female; six not disclosed; aged 28.02 ± 10.40 years) completed validated questionnaires online assessing subjective EF, alcohol use and alcohol-related problems. RESULTS: Organisation, Strategic Planning, Impulse Control and overall function were significantly impaired in hazardous drinkers. Furthermore, the effect of alcohol on EF, partially mediated the relationship between alcohol use and alcohol-related problems. CONCLUSION: Hazardous drinking was associated with lower subjective EF, and this mediated the effect of alcohol on alcohol-related problems. This may be due to changes in prefrontal brain regions, which could indicate greater risk for the development of alcohol dependence (AD). Future research should use additional means to assess EF in hazardous drinkers, including recovery of function, development of AD and the relationship between cognition and alcohol-related daily problems.

Alcohol-related brain injury: An unrecognized problem in acute medicine.

Alcohol-related brain injury (ARBI) is an unrecognized and therefore untreated consequence of alcohol use disorder. Here, we explore a 12-month period prevalence of alcohol-related brain injury (ARBI) in alcohol use disorder patients. Inpatients aged ≥18 years reviewed by the Alcohol Care Team's Specialist Nurses between April 1, 2017 and March 31, 2018 were eligible for the study (n = 1276). Screening identified a high-risk subset of patients who matched at least one of the following: 1) more than three alcohol-related admissions in one year; 2) two alcohol-related admissions in any given 30-day period; 3) patient or their significant other had concerns regarding cognition. The high-risk patients were assessed for evidence of ARBI using the Montreal Cognitive Assessment Tool (MoCA). The primary measure of interest was MoCA ≤23. Analysis was conducted between subgroups of the study population to identify prevalence rate ratios for matching the high-risk screening criteria, and MoCA ≤23 in high-risk patients. Two hundred and five patients were identified as high risk for ARBI. The period prevalence rates in this high-risk group for patients with a MoCA ≤23 was 36.1%. Those under the age of 35 years were significantly less likely to match the high-risk criteria. Patients that were homeless or staying in hostels were more likely to match the high-risk criteria and were also at increased risk of MoCA ≤23, compared with those living with family members. In summary, ARBI is common in patients with AUD attending acute hospitals. ARBI is often not diagnosed, and thus further work is required to improve screening for, and identification of, these patients to develop evidence-based clinical pathways that optimize care.

Benefits of temporary alcohol restriction: a feasibility randomized trial.

BACKGROUND: Participation in temporary alcohol abstinence campaigns such as 'Dry January' may prompt enduring reductions in alcohol consumption. A randomized controlled trial (RCT) is required to establish any long-term benefits or negative consequences of temporary abstinence. In the present study, we randomized heavy drinkers to complete or intermittent alcohol abstinence for 4 weeks, in order to evaluate the feasibility of conducting a large-scale RCT. METHODS: This was a mixed methods feasibility study in which we explored recruitment and retention to a randomized trial, compliance with alcohol abstinence instructions and barriers to compliance, and acceptability of study procedures (primary feasibility outcomes). A community sample of women aged between 40 and 60 who drank in excess of 28 alcohol units per week were randomized to abstain from alcohol for 4 weeks either completely or intermittently (at least four abstinent days per week). To monitor compliance, both groups provided regular breath samples on a cellular breathalyser. A subsample completed a semi-structured interview that probed barriers to compliance with abstinence instructions and acceptability of study procedures. RESULTS: Within 5 months, we recruited, screened and randomized 25 participants (20% of participants who responded to advertisements: 14 in the complete abstinence group, 11 in the intermittent abstinence group), 24 of whom were retained throughout the 28-day intervention period. Participants in both groups tended to comply with the instructions: the median number of breathalyser-verified abstinent days was 24 (IQR = 15.5-25.0; 86% of target) in the complete abstinence group versus 12 (IQR = 10-15; 75% of target) in the intermittent abstinence group. Semi-structured interviews identified some barriers to compliance and methodological issues that should be considered in future research. No adverse events were reported. CONCLUSIONS: It is feasible to recruit heavy drinking women from community settings and randomize them to either complete or intermittent abstinence from alcohol for 4 weeks. The majority of participants were retained in the study and compliance with the abstinence instructions was good, albeit imperfect. A comprehensive RCT to compare temporary alcohol abstinence with other alcohol reduction strategies on long-term alcohol consumption is feasible. Findings from such a trial would inform implementation of alcohol campaigns and interventions.

Health-related quality of life in alcohol dependence: Similar cross-cultural impact beyond specific drinking habits.

This study explores sociocultural differences in alcohol-related impact on quality of life between France and United Kingdom. We included 38 alcohol-dependent patients in France and United Kingdom in 10 focus groups. We used a text-mining approach. Three classes of each corpus regarded identical themes across the countries: (a) core impact on quality of life, (b) drinking habits, (c) sources of help. Core impact was similar between the two countries. Main differences were in drinking habits and referral to sources of help. Despite differences in drinking habits, the domains of life impacted by alcohol were non-country specific.

Accuracy of alcohol and breast cancer risk information on Drinkaware's website.

A recent paper in Drug and Alcohol Review analysed the information on cancer disseminated by 27 alcohol industry funded organisations. The independent UK alcohol education charity Drinkaware was among the organisations whose information was studied, and based on the analysis claims were made of misrepresentation of evidence about the alcohol-related risk of cancer and alcohol industry influence. This commentary challenges the validity of these findings in respect to the evidence relating to the Drinkaware information, as the analysis is found to be misrepresenting the information by both disregarding the wider information content provided and the order and prominence with which alcohol-related cancer risk is presented. Furthermore, it is argued that the public has a right to be provided with relevant evidence-based information about cancer risk. It is critical that Drinkaware's important public health function is not compromised by unjustified allegations of inaccuracy and by unwarranted attacks on its independence and integrity.

The Use of Baclofen as a Treatment for Alcohol Use Disorder: A Clinical Practice Perspective.

Alcohol use disorder (AUD) is a brain disorder associated with high rates of mortality and morbidity worldwide. Baclofen, a selective gamma-aminobutyric acid-B (GABA-B) receptor agonist, has emerged as a promising drug for AUD. The use of this drug remains controversial, in part due to uncertainty regarding dosing and efficacy, alongside concerns about safety. To date there have been 15 randomized controlled trials (RCTs) investigating the use of baclofen in AUD; three using doses over 100 mg/day. Two additional RCTs have been completed but have not yet been published. Most trials used fixed dosing of 30-80 mg/day. The other approach involved titration until the desired clinical effect was achieved, or unwanted effects emerged. The maintenance dose varies widely from 30 to more than 300 mg/day. Baclofen may be particularly advantageous in those with liver disease, due to its limited hepatic metabolism and safe profile in this population. Patients should be informed that the use of baclofen for AUD is as an "off-label" prescription, that no optimal fixed dose has been established, and that existing clinical evidence on efficacy is inconsistent. Baclofen therapy requires careful medical monitoring due to safety considerations, particularly at higher doses and in those with comorbid physical and/or psychiatric conditions. Baclofen is mostly used in some European countries and Australia, and in particular, for patients who have not benefitted from the currently used and approved medications for AUD.

Systematic review: Baclofen dosing protocols for alcohol use disorders used in observational studies.

The popularity of baclofen as an anti-craving agent in the treatment of alcohol use disorders (AUDs) has increased, especially in patients with established liver disease. However, evidence-based guidelines to inform practice are lacking. The aim of this systematic review is explore the prescribing practices of baclofen in AUD treatment. Electronic databases were searched for relevant articles from 2002. Assessment of eligibility criteria for inclusion was performed independently by two investigators. The main outcomes of interest were maximum dose, starting dose, titration regimen, effectiveness, and tolerability. Twenty-five studies reporting outcomes in 613 patients treated with baclofen for an AUD were identified. Starting doses ranged between 5 and 50mg/d. Titration was study-dependent, and doses were increased until either therapeutic target (abstinence or study-defined low risk drinking) was achieved or adverse events resulted in a dose reduction or discontinuation. The maximum dose for individual patients ranged between 20 and 630mg/d. Seven studies reported at least one patient using >300mg/d. In studies with 10 or more patients, we found a negative correlation between dose and proportion of patients achieving the therapeutic goal. However, this was skewed by one study. A range of serious adverse events were reported. Most were reported at doses over 100mg/d, but others presented at lower doses. Baclofen is a promising therapeutic in this area. Evidence is required, however, to support practitioners in prescribing doses that optimise outcomes and reduce adverse events.

A prospective cohort study examining the effectiveness of baclofen in the maintenance of abstinence in alcohol use disorder patients attending a joint liver and alcohol treatment clinic.

OBJECTIVE: Alcohol-related liver disease (ARLD) is the leading cause of alcohol-related mortality in the UK. Helping patients with ARLD to stop drinking is an important treatment goal. The aim of this study is to explore baclofen's utility in maintaining abstinence. METHODS - A PROSPECTIVE COHORT STUDY: Patients with ARLD were commenced on baclofen; the dose was titrated according to tolerability and response up to 30 mg three times daily. Severity of physical dependence and biochemical markers of liver injury were assessed at baseline, 3 months, and 12 months. RESULTS: Length of follow-up differed. Of 219 patients in the original cohort, 186 and 113 were evaluated at 3 months and 12 months, respectively. Loss to follow-up was due to death, baclofen non-adherence, and failure to attend appointments. Comparison of baseline and 1-year biochemical markers showed significant reductions in GGT (median change = 82.0; 95% CI = -149.0 to -40.0; p < 0.0005), ALT (-10.5; 95% CI = -16.5 to -5.0; p = 0.001), and bilirubin (-4.5; 95% CI = -7.0 to -2.0; p < 0.001). The proportion of eligible patients reporting complete abstinence at 3 and 12 months was 55% and 53%, respectively. A significant reduction in alcohol consumption and Severity of Alcohol Dependence Questionnaire score was observed at both follow-up time points. CONCLUSION: Adherence to the baclofen was good, and it had a positive impact on measures of alcohol consumption. A limitation of our study is its observational nature. Further randomized studies alongside investigation of dosing strategies are required.

Drug therapy for alcohol dependence in primary care in the UK: A Clinical Practice Research Datalink study.

AIM: To evaluate drug therapy for alcohol dependence in the 12 months after first diagnosis in UK primary care. DESIGN: Open cohort study. SETTING: General practices contributing data to the UK Clinical Practice Research Database. PARTICIPANTS: 39,980 people with an incident diagnosis of alcohol dependence aged 16 years or older between 1 January 1990 and 31 December 2013. MAIN OUTCOME MEASURE: Use of pharmacotherapy (acamprosate, disulfiram, naltrexone, baclofen and topiramate) to promote abstinence from alcohol or reduce drinking to safe levels in the first 12 months after a recorded diagnosis of alcohol dependence. FINDINGS: Only 4,677 (11.7%) of the cohort received relevant pharmacotherapy in the 12 months following diagnosis. Of the 35,303 that did not receive pharmacotherapy, 3,255 (9.2%) received psychosocial support. The remaining 32,048 (80.2%) did not receive either mode of treatment in the first 12 months. Factors that independently reduced the likelihood of receiving pharmacotherapy included: being male (Odds Ratio [OR] 0.74; 95% CI 0.69 to 0.78); older (65-74 years: OR 0.61; 95% CI 0.49 to 0.77); being from a practice based in the most deprived quintile (OR 0.58; 95% CI 0.53 to 0.64); and being located in Northern Ireland (OR 0.78; 95% CI 0.67 to 0.91). The median duration to initiation of pharmacotherapy was 0.80 months (95% CI 0.70 to 1.00) for acamprosate and 0.60 months (95% CI 0.43 to 0.73) for disulfiram. Persistence analysis for those receiving acamprosate and disulfiram revealed that many patients never received a repeat prescription; persistence at 6 months was 27.7% for acomprosate and 33.2% for disulfiram. The median duration of therapy was 2.10 months (95% CI 1.87 to 2.53) for acamprosate and 3.13 months (95% CI 2.77 to 3.36) for disulfiram. CONCLUSION: Drug therapy to promote abstinence in alcohol dependent patients was low, with the majority of patients receiving no therapy, either psychological or pharmacological. When drug therapy was prescribed, persistence was low with most patients receiving only one prescription. Our data show that treatment for alcohol dependence is haphazard, and there is an urgent need to explore strategies for improving clinical management of this patient group.

A Randomized Controlled Trial of Extended Brief Intervention for Alcohol-Dependent Patients in an Acute Hospital Setting.

AIMS: To determine whether alcohol-dependent patients in a hospital setting benefit from extended brief interventions (EBI) delivered by an Alcohol Specialist Nurse. METHODS: Alcohol-dependent patients recruited via screening at the emergency department (ED) (n = 267), whether or not admitted to hospital, were randomized to EBI (up to six counselling sessions offered) or control. At 6 months, 84.2% of patients were assessed by a researcher blinded to the intervention. The primary outcome was a fall in Severity of Alcohol Dependence Questionnaire. RESULTS: There was no difference between groups in the primary outcome [odds ratio (OR) 1.02; 95% confidence interval (CI): 0.38, 2.75, P = 0.97]. Secondary outcomes including alcohol consumption and readiness to change did not show a significant difference between groups. However, all secondary outcome measures improved, on average, in both arms. CONCLUSIONS: Although EBI can be delivered in an ED or inpatient setting, it was not shown to be an advantage over screening and usual management (which included advice on alternative services), with patients in both groups showing an average improvement. TRIAL REGISTRATION: ISRCTN78062794.

A randomised controlled trial of extended brief intervention for alcohol dependent patients in an acute hospital setting (ADPAC).

BACKGROUND: Alcohol dependence affects approximately 3% of the English population, and accounts for significant medical and psychiatric morbidity. Only 5.6% of alcohol-dependent individuals ever access specialist treatment and only a small percentage ever seek treatment. As people who are alcohol dependent are more likely to have experienced health problems leading to frequent attendance at acute hospitals it would seem both sensible and practical to ensure that this setting is utilised as a major access point for treatment, and to test the effectiveness of these treatments. METHODS/DESIGN: This is a randomised controlled trial with a primary hypothesis that extended brief interventions (EBI) delivered to alcohol-dependent patients in a hospital setting by an Alcohol Specialist Nurse (ASN) will be effective when compared to usual care in reducing overall alcohol consumption and improving on the standard measures of alcohol dependence. Consecutive patients will be screened for alcohol misuse in the Emergency Department (ED) of a district general hospital. On identification of an alcohol-related problem, following informed written consent, we aim to randomize 130 patients per group. The ASN will discharge to usual clinical care all control group patients, and plan a programme of EBI for treatment group patients. Follow-up interview will be undertaken by a researcher blinded to the intervention at 12 and 24 weeks. The primary outcome measure is level of alcohol dependence as determined by the Severity of Alcohol Dependence Questionnaire (SADQ) score. Secondary outcome measures include; Alcohol Use Disorders Identification Test (AUDIT) score, quantity and frequency of alcohol consumption, health-related quality of life measures, service utilisation, and patient experience. The trial will also allow an assessment of the cost-effectiveness of EBI in an acute hospital setting. In addition, patient experience will be assessed using qualitative methods. DISCUSSION: This paper presents a protocol for a RCT of EBI delivered to alcohol dependent patients by an ASN within an ED. Importantly; the trial will also seek to understand patients' perceptions and experiences of being part of a RCT and of receiving this form of intervention. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN78062794.

Brief interventions in dependent drinkers: a comparative prospective analysis in two hospitals.

AIMS: To investigate whether brief interventions (BIs) delivered by a dedicated Alcohol Specialist Nurse (ASN) to non-treatment-seeking alcohol-dependent patients in an acute hospital setting are effective in reducing alcohol consumption and dependence. METHODS: A prospective cohort control study in two acute NHS Hospital Trusts in the North West England, one of which provided BI (university teaching hospital-test site) while the other did not (district general hospital-control site), including follow-up BIs. Subjects were alcohol-dependent patients aged ≥18 years. RESULTS: A total of 100 patients were recruited at each site. No differences were found between the groups in the baseline demographic parameters or medical co-morbidities. At the test site, further sessions were sometimes offered, and 46 patients received more than one intervention (median 4, mean 6.3 and maximum 20). At 6 months, alcohol consumption (P < 0.0001), Alcohol Use Disorders Identification Tool (AUDIT) score (P < 0.0001) and Severity of Alcohol Dependence Questionnaire score (P = 0.0001) were significantly lower at the test site than the control site. Outcomes were found to be independent of both the baseline level of dependence and medical co-morbidity. CONCLUSION: BI delivered by a dedicated ASN for non-treatment-seeking alcohol-dependent individuals, who often have significant medical co-morbidities, seem to be effective in an acute hospital setting. This study provides a framework to inform the design of a future randomized controlled trial.