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.

Impact of Users' Attitudes Toward Anonymous Internet Interventions for Cannabis vs. Alcohol Use: A Secondary Analysis of Data From Two Clinical Trials.

Background: Numerous trials have demonstrated the efficacy of internet interventions targeting alcohol or cannabis use, yet a substantial proportion of users do not benefit from the format, warranting further research to identify moderators of treatment effects. Users' initial attitudes toward treatment is a potential moderator, yet no previous study has investigated users' attitudes in the context of internet interventions for addictive disorders. Method: In this secondary analysis on two internet-based trials targeting harmful alcohol use (n = 1,169) and regular cannabis use (n = 303), respectively, we compared user groups' attitudes at the item level; explored within-group heterogeneity by submitting attitude scores to a k-means cluster analysis; and investigated whether latent subgroups in each user group moderated the treatment effects. Outcome models were run using generalized linear models with 10,000 bias-corrected bootstraps accounting for subject-level clustering. Results: While substance groups and latent subgroups converged in enjoying the anonymity provided by the format, their interest toward treatment differed. Outcome analyses revealed a significant and negative time by subgroup effect on grams of cannabis consumed and screening test score (CAST), favoring the subgroup with positive treatment attitudes. There were not any significant effects of subgroup on alcohol consumption. Despite initial treatment reluctance, participants in the neutral subgroup decreased their cannabis use (gram) significantly when receiving the intervention vs. control. Conclusions: This first, exploratory study revealed key differences between substance groups' attitudes, but more importantly that within-group heterogeneity appear to affect cannabis outcomes. Assessing attitudes could be key in patient-treatment matching, yet more research is needed.

Internet-based therapy versus face-to-face therapy for alcohol use disorder, a randomized controlled non-inferiority trial.

BACKGROUND AND AIMS: Most people with alcohol use disorder (AUD) are never treated. Internet-based interventions are effective in reducing alcohol consumption and could help to overcome some of the barriers to people not seeking or receiving treatment. The aim of the current study was to compare internet-delivered and face-to-face treatment among adult users with AUD. DESIGN: Randomized controlled non-inferiority trial with a parallel design, comparing internet-delivered cognitive-behavioural therapy (ICBT) (n = 150) with face-to-face CBT (n = 151), at 3- and 6-month follow-ups. SETTING: A specialized clinic for people with AUD in Stockholm, Sweden. Participants were recruited between 8 December 2015 and 5 January 2018. PARTICIPANTS: A total of 301 patients [mean age 50 years, standard deviation (SD) = 12.3] with AUD, of whom 115 (38%) were female and 186 (62%) were male. INTERVENTION AND COMPARATOR: Participants were randomized in blocks of 20 at a ratio of 1 : 1 to five modules of therapist-guided ICBT or to five modules of face-to-face CBT, delivered over a 3-month period. The same treatment material and the same therapists were used in both groups. MEASUREMENTS: The primary outcome was standard drinks of alcohol consumed during the previous week at 6-month follow-up, analysed according to intention-to-treat. The pre-specified non-inferiority limit was five standard drinks of alcohol and d = 0.32 for secondary outcomes. RESULTS: The difference in alcohol consumption between the internet and the face-to-face group was non-inferior in the intention-to-treat analysis of data from the 6-month follow-up [internet = 12.33 and face-to-face = 11.43, difference = 0.89, 95% confidence interval (CI) = -1.10 to 2.88]. The secondary outcome, Alcohol Use Disorder Identification Test score, failed to show non-inferiority of internet compared with face-to-face in the intention-to-treat analysis at 6-month follow-up (internet = 12.26 and face-to-face = 11.57, d = 0.11, 95% CI = -0.11 to 0.34). CONCLUSIONS: Internet-delivered treatment was non-inferior to face-to-face treatment in reducing alcohol consumption among help-seeking patients with alcohol use disorder but failed to show non-inferiority on some secondary outcomes.

Promoting Evidence-Based Practice for Improved Occupational Safety and Health at Workplaces in Sweden. Report on a Practice-Based Research Network Approach.

Despite the rapid growth in research and R&D expenditures, the translation of research into practice is limited. One approach to increase the translation and utilization of research is practice based research networks. With the aim of strengthening evidence-based practice (EBP) within occupational health services in Sweden (OH-Services), a practice-based research network (PBRN-OSH) was developed. The PBRN-OSH includes researchers and representatives from end-users. This paper reports on the development, outputs and lessons learned in the PBRN-OSH. The PBRN-OSH resulted in several practice-based research projects as well as different measures to ensure EBP in OSH such as the governmentally sanctioned national guidelines for the OH-services. Moreover, results show that the competence in EBP increased among practitioners at the OH-services. Conducting research in a PBRN is more resource demanding; however, this does not imply that it is less cost effective. To succeed in increasing the utility of research findings via PBRN, resources must be invested into an infrastructure that supports collaboration in the PBRN, including costs for a variety of means of dissemination. Further, translation activities need to be included in academic career paths and reward systems if a major improvement in the impact and return of investments from research is to be expected.

Guided web-based treatment program for reducing cannabis use: a randomized controlled trial.

BACKGROUND: The aim of this study was to investigate the effects of a web-based treatment program with therapist guidance for adults and adolescents with regular cannabis use from the general population. METHODS: A double blinded randomized controlled trial with a parallel group design was conducted (intervention group n = 151, wait-list control group n = 152). Follow-up 12 weeks from treatment commencement of a 13-module intervention. The primary outcome was frequency of cannabis use. Time by group interaction effects were modeled using generalized estimated equations and the instrumental variable approach was used to estimate the effect of intervention adherence. RESULTS: At follow-up, the intention to treat (ITT) analyses did not show any significant time by group effects. A significant association between intervention adherence and scores on the cannabis abuse screening test (CAST) was found. Secondary analysis excluding participants who had received other professional help revealed time by group effects for secondary outcomes gram cannabis consumed past week, number of dependency criteria and CAST score. Due to methodological limitations, these latter results should be interpreted with caution. CONCLUSIONS: In this study we did not find a web-based treatment program with therapist guidance to be more effective than a waiting-list in reducing frequency of cannabis use. Trial registration The trial was pre-registered at ClinicalTrials.gov (NCT02408640) April 3, 2015.

Dose-Response Characteristics of the Alcohol Biomarker Phosphatidylethanol (PEth)-A Study of Outpatients in Treatment for Reduced Drinking.

AIM: Measurement of whole-blood phosphatidylethanol (PEth) offers high sensitivity and specificity as alcohol biomarker. A remaining issue of importance for the routine application is to better establish the relationship between PEth concentration and amount and duration of drinking. METHODS: The study included 36 subjects (32-83 years) voluntarily attending outpatient treatment for reduced drinking. At ~ 3- to 4-week intervals, they provided a diary on their daily alcohol intake and gave blood samples for measurement of PEth and carbohydrate-deficient transferrin (CDT). Whole-blood PEth 16:0/18:1 was measured by liquid chromatography-tandem mass spectrometry and serum CDT (%disialotransferrin) by high-performance liquid chromatography. RESULTS: At start, the self-reported past 2-week alcohol intake ranged 0-1260 (median 330) g ethanol, the PEth 16:0/18:1 concentration ranged 0.05-1.20 (median 0.23) µmol/L, and the CDT value ranged 0.7-13.0% (median 1.5%). At the final sampling after 5-20 (median 12) weeks, neither reported alcohol intake nor PEth and CDT levels differed significantly from the starting values. The PEth concentration showed best association with past 2-week drinking, followed by for intake in the next last week. The changes in PEth concentration vs past 2-week alcohol intake between two successive tests revealed that an increased ethanol intake by ~ 20 g/day elevated the PEth concentration by on average ~ 0.10 µmol/L, and vice versa for decreased drinking. CONCLUSIONS: The PEth concentration correlated well with past weeks alcohol intake, albeit with a large inter-individual scatter. This indicates that it is possible to make only approximate estimates of drinking based on a single PEth value, implying risk for misclassification between moderate and heavy drinking.

Development of evidence-based practice in occupational health services in Sweden: a 3-year follow-up of attitudes, barriers and facilitators.

PURPOSE: The Swedish government initiated an investigation of how to secure and develop the competence of the occupational health services. The primary aim of the present study was to investigate whether the development of evidence-based practice (EBP) in the Swedish occupational health services in relation to attitudes, knowledge and use improved during the first 3 years of the government's initiative. METHODS: The study has a mixed methods design combining questionnaires and interviews with data collection at baseline and at 3-year follow-up. RESULTS: The response rate was 66% at baseline and 63% at follow-up. The results show that practitioners' knowledge of EBP was moderate at baseline and improved at follow-up (p = 0.002; 95% CI 0.01; 0.21). Practitioners experienced lower levels of organizational and managerial support for EBP at follow-up (p < 0.001; 95% CI 0.18; 0.38). The results revealed that managers viewed responsibility for implementing EBP as a matter for individual practitioners rather than as an organizational issue. CONCLUSIONS: Occupational health service managers and practitioners are generally positive to EBP. However, the findings emphasize the need to educate managers in how to support EBP at the organizational level by creating an infrastructure for EBP in the OHS.

Web-Based Self-Help for Problematic Alcohol Use: a Large Naturalistic Study.

PURPOSE: This observational study examined user characteristics, intervention use patterns, and variables associated with reductions in alcohol consumption for anonymous Internet help-seekers using a Web-based self-help program. METHOD: A Web-based cognitive behavioral therapy (CBT) program with eight modules delivered over 10 weeks was offered to participants with at least hazardous use of alcohol according to the Alcohol Use Disorders Identification Test (AUDIT) (n = 4165). At baseline and 10-week follow-up, participants completed the Timeline-followback (TLFB), AUDIT, Drug Use Disorders Identification Test (DUDIT), Hospital Anxiety and Depression Scale (HADS), EuroQol-5 dimension (EQ-5D), World Health Organization Quality of Life Scale-abbreviated version (WHOQOL-BREF), Readiness to Change Questionnaire (RCQ), and Readiness Ruler. Follow-up completers and non-completers were compared at baseline, and follow-up completer outcomes were reported. Predictors of change in drinking behavior were evaluated at follow-up. RESULTS: Registered users were 41.88 years old on average (SD = 12.36), and 52 % were women; the mean baseline number of drinks during the past week was 27.27 (SD = 17.92) with 62 % in the AUDIT category of probable dependence and only 7 % having low-risk consumption according to public health guidelines. At follow-up (n = 1043), 53 % showed a clinically significant change to a lower level of alcohol use (χ2 = 254.403, p < 0.001); the mean alcohol consumption fell (t = 22.841, p < 0.001) and the proportion with low-risk consumption rose to 40 %. Being male, scoring higher on baseline readiness, completing the program, and accessing other support predicted low-risk drinking and clinically significant change to a lower level of alcohol use at follow-up. CONCLUSION: A publicly available Web-based program for managing problematic alcohol use attracted users with considerable alcohol- and health-related problems, which were changed to lower severity for follow-up completers.

Clinical trial of a new technique for drugs of abuse testing: a new possible sampling technique.

Exhaled breath has recently been proposed as a matrix for drug testing. This study aims to further explore, develop and validate exhaled breath as a safe and effective non-invasive method for drug testing in a clinical setting. Self-reported drug use was recorded and drug testing was performed by mass spectrometry and immunochemical methods using breath, plasma and urine samples from 45 individuals voluntarily seeking treatment for recreational drug use. Cannabis was the most prevalent drug detected by any method. Urine sampling detected most cases. The exhaled breath technique was less sensitive (73%) than plasma analysis for detection of cannabis uses but captures a more recent drug intake than both plasma and urine. Exhaled breath was the preferred specimen to donate according to interview data of the participants. Testing illicit drugs with the exhaled breath sampling technique is a sufficient, non-invasive and safe alternative and complement to plasma and/or urine sampling.

Screening and brief intervention for risky alcohol consumption in the workplace: results of a 1-year randomized controlled study.

AIMS: To assess the effectiveness of brief alcohol intervention on hazardous and harmful drinking in the 12-month period after a voluntary alcohol screening. METHODS: At a large transport company, employees presenting to the occupational health services for a routine health and lifestyle check-up were offered to undertake an alcohol screening by means of self-report (the Alcohol Use Disorders Identification Test-AUDIT) and a biomarker (carbohydrate-deficient transferrin in serum-CDT). Those screening positive for the AUDIT and/or CDT were randomized to a brief or comprehensive intervention group or to a control group. An identical follow-up session was performed 12 months later. RESULTS: Of 990 employees (68% men) that volunteered for the alcohol screening, 194 (20%) tested positive for the AUDIT and/or CDT. Among the 158 (81%) subjects who also attended the follow-up session, the frequency of positive screening results at baseline/follow-up were 51%/23% for the AUDIT (P < 0.0001) and 58%/34% (P < 0.0001) for CDT. However, there were no significant differences between the brief and comprehensive intervention groups or between the intervention groups and the control group. CONCLUSION: The results suggested that alcohol screening and brief intervention performed in connection with routine health and lifestyle examinations in the workplace may be effective in reducing alcohol consumption. Given the lack of difference in outcome between the intervention groups and the control group, alcohol screening may in itself cause reduction in drinking. In addition, at least some of the positive effect may be explained by regression towards the mean.

Single-session motivational interviewing for drug detoxification inpatients: effects on self-efficacy, stages of change and substance use.

Thirty-five inpatients at a Stockholm hospital drug user detoxification unit received single-session Motivational Interviewing (MI) between 2006 and 2008. At baseline and after 3 months, they were compared to a semi-randomized control group of 52 patients with treatment as usual. In the MI group, self-efficacy increased regarding abstention in connection with positive feelings, appreciation of positive drug effects increased, and participants tended to transition toward preparation/action stages of change. Despite implementation challenges, the study demonstrates the feasibility and effectiveness of single-session MI delivery in the inpatient drug detoxification setting and suggests paths for future research on delivery of single-session MI.

A comprehensive workplace intervention and its outcome with regard to lifestyle, health and sick leave: the AHA study.

This study is a prospective multicentre cohort study entitled Work and Health in the Processing and Engineering Industries, the AHA Study (AHA is the Swedish abbreviation for the study). Four large workplaces in Sweden participated during the years from 2000 to 2003. The present report has two objectives: (1) to present a comprehensive occupational health intervention programme and (2) to evaluate this programme with a focus on lifestyle (smoking and exercise), health related quality of life (HRQoL) and sick leave. Interventions were provided on an individual and group level, including evidence-based methods for four health/focus areas (individual level) and a group intervention based on a survey-feedback methodology. The analyses in this report were exclusively employed at an organizational level. The proportion of smokers decreased at three companies and the course of the HRQoL was advantageous at two of the companies as compared to a gainfully employed reference group. A significant decrease in sick leave was revealed at one company, whereas a break in an ascending sick-leave trend appeared at a second company as compared to their respective corporate groups. This comprehensive workplace intervention programme appears to have had positive effects on smoking habits, HRQoL and sick leave.

Towards increased alcohol intervention activity in Swedish occupational health services.

OBJECTIVES: To investigate the extent to which Swedish occupational physicians and nurses discuss alcohol issues with their patients, their reasons for and against addressing these issues, their amount of education in handling risky drinking, and factors that they believe could facilitate increased alcohol intervention activity in OHS. METHODS: All Swedish physicians and nurses in OHS were surveyed with a postal questionnaire. The questionnaire was returned by 313 physicians (response rate 54%) and 759 nurses (response rate 69%). RESULTS: As much as 70% of the physicians and 85% of the nurses reported that they "frequently" discussed alcohol problems with their patients. The majority of both physicians (81%) and nurses (69%) admitted participating in a maximum of a half-day training in handling risky drinking. Among the physicians, the most common reason for asking patients about their alcohol consumption was the clinical relevance (57%). Seventy-three per cent of the nurses initiated discussions about alcohol on the basis of questionnaire responses. Both the physicians (72%) and nurses (90%) said that the knowledge about counselling techniques to use when alcohol-related symptoms are evident was the most important facilitator to increased intervention activity. CONCLUSIONS: OHS professionals usually discuss alcohol-related issues with their patients. Nonetheless, they are interested in gaining further education and knowledge in this respect. The study results indicate that OHS is an important setting for alcohol prevention.

A test of the validity of the motivational interviewing treatment integrity code.

To evaluate the Swedish version of the Motivational Interviewing Treatment Code (MITI), MITI coding was applied to tape-recorded counseling sessions. Construct validity was assessed using factor analysis on 120 MITI-coded sessions. Discriminant validity was assessed by comparing MITI coding of motivational interviewing (MI) sessions with information- and advice-giving sessions as well as by comparing MI-trained practitioners with untrained practitioners. A principal-axis factoring analysis yielded some evidence for MITI construct validity. MITI differentiated between practitioners with different levels of MI training as well as between MI practitioners and advice-giving counselors, thus supporting discriminant validity. MITI may be used as a training tool together with supervision to confirm and enhance MI practice in clinical settings. MITI can also serve as a tool for evaluating MI integrity in clinical research.

Coding counsellor behaviour in motivational interviewing sessions: inter-rater reliability for the Swedish Motivational Interviewing Treatment Integrity Code (MITI).

The aim of this study was to evaluate inter-rater reliability when using the Swedish version of the Motivational Interviewing Treatment Code (MITI) as an adjunct to MI training, clinical practice and research. Coders were trained to use the MITI for scoring taped sessions. The 4-month basic training had a duration of 39 hours. Following training, 60 audio-taped live interviews were randomly assigned for MITI coding. Mean intra-class correlation (ICC) coefficients were calculated for 7 coders across all pairs of coders. Cronbach's alpha was calculated to estimate the covariance between each pair across their common interviews. Six months later, a second inter-rater reliability test was performed, when 5 coders coded the same 15 randomly selected tapes. At the second reliability testing the mean ICC was 0.81 and the mean Cronbach's alpha was 0.96. However, the ICC varied for different sub-variables of the MITI, ranging from 0.42 empathy to 0.79 for number of Closed questions. In conclusion, MITI shows promising potential to be a reliable tool to confirm and enhance MI training as well as practice in clinical settings and in evaluating MI integrity in clinical MI research. However, coder assessment of empathy and MI-spirit, "global" variables, requires further refinement.

Screening for high-risk and elevated alcohol consumption in day and shift workers by use of the AUDIT and CDT.

BACKGROUND: Alcohol consumption levels and drinking patterns have been reported to vary between day and shift workers, although the results have been conflicting. Previous results indicate that questions about alcohol habits may be asked in the workplace. However, no studies have evaluated the Alcohol Use Disorders Identification Test (AUDIT) or the alcohol biomarker carbohydrate-deficient transferrin (CDT) in serum for this purpose. AIM: To investigate, in conjunction with routine health examinations, whether there is any difference between permanent day and shift workers in high-risk alcohol consumption, according to the AUDIT and CDT. Gamma-glutamyl transferase (GGT) in serum was included mainly as a comparison test. METHODS: The employees who attended for a regular health examination during the study period were offered voluntary alcohol screening with the AUDIT and CDT. RESULTS: Altogether, 990 employees (day, two-shift, and three-shift workers) participated in the study, 194 (20%) of whom screened positive with the AUDIT and/or CDT. There were no significant differences in the screening results between day and shift workers, whereas significantly fewer of the two-shift workers (odds ratio=0.5, 95% confidence interval=0.3-0.9) screened positive with CDT. CONCLUSIONS: The present findings on employees who attended for regular health examinations suggest that shift workers did not show a higher level of risky alcohol consumption than day workers, according to the results with the AUDIT, CDT and GGT. On the contrary, the two-shift workers appeared to drink significantly less.

The Alcohol Use Disorders Identification Test and carbohydrate-deficient transferrin in alcohol-related sickness absence.

BACKGROUND: Previous studies have shown that elevated, risky levels of alcohol consumption may lead to higher rates of sickness absence. However, no studies have examined the Alcohol Use Disorders Identification Test (AUDIT) or serum carbohydrate-deficient transferrin (CDT) in relation to sickness absence in the workplace. The purpose of this study was to examine the relationship between sick-days, 12 months before screening, and the AUDIT and CDT (CDTect kit). Serum gamma-glutamyltransferase also was used for comparison. METHOD: The study was carried out over 36 months in a large workplace and formed part of an ongoing controlled study. In conjunction with a routine health examination, employees were offered the opportunity to undergo an alcohol screening. Absence data were obtained from the company payroll system, and sickness absence was analyzed by using a three-ordinal level cumulative logistic model on the number of sick-days. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Of the 989 subjects who participated in the study, 193 (19.5%) screened positive in relation to either the AUDIT (>or=8 points) or CDT (<20 units/liter for men, and <27 units/liter for women), or both. Employees who screened positive with the AUDIT had a significantly higher proportion of sick-days (p = 0.047) compared with those who screened negative (OR = 1.4, CI 1.0-1.9). Neither long, continuous periods of sickness absence nor absence on Mondays or Fridays gave a clear indication of individuals who screened positive on the AUDIT or CDT test. CONCLUSION: Our data indicate that individuals with moderately elevated or risky levels of alcohol consumption show an increase in sick-days. Accordingly, workplaces have a good reason for using a more systematic approach to alcohol screening in routine workplace health examinations.