Sequential Combined Treatment in Preventing Relapse in Alcohol Dependence
Sequential Combined Treatment in Preventing Relapse in Alcohol Dependence
Aim: The aim of this study was to compare the effectiveness of the sequential combined treatment (SCT) and treatment as usual (TU) in relapse prevention in a sample of alcohol-dependent patients, during 180 days of outpatient treatment.
Method: 209 alcohol-dependent patients who could attend with an informant adult were randomized to either TU or SCT. The primary outcome measure was time to first relapse, defined as the consumption of any amount of alcohol during the 180 days of follow-up. Secondary outcome measures included maximum duration of continuous abstinence (MDCA), cumulative abstinence duration (CAD), quality of life (ARPQ) and blood test markers of alcohol consumption.
Results: The SCT approach was more effective than TU. The Kaplan-Meier abstinent proportion at the end of the 180 days was 78% for the SCT group and 59% for the TU group (P < 0.01). The mean time to first relapse was 150 days for SCT and 123 days for TU (P < 0.01). The relative risk reduction of relapse was 62% for SCT after adjustment in multiple Cox regression (P < 0.01). SCT had more MDCA (P < 0.05) and more CAD (P < 0.05). Therapy sessions lasted slightly longer for SCT than TU (mean 13 min versus 10 min).
Conclusions: SCT can result in better outcomes than TU in the outpatient treatment of alcohol dependence.
Portugal is among the world's largest consumers of alcoholic beverages. In 2003, according to World Drink Trends (2005), it held 8th place, with a consumption of 9.6 l of ethanol per capita, behind countries such as Luxembourg, Czech Republic, Republic of Ireland, Germany, Spain and the United Kingdom.
The diseases caused by the excessive consumption of alcoholic beverages include the syndrome of dependence of alcohol (SDA), with an estimated prevalence in Portugal of 580,000 persons and the syndrome of abuse of alcohol (SAA), estimated at 746,000 persons (Gameiro, 1998).
The ambulatory treatment of SDA (defined following the American Psychiatric Association, 1994) in the Portuguese health service tends to follow a medical model based predominantly on an individual approach. The phase of detoxification is based mostly on the patient himself and is followed by medication for the maintenance of abstinence. This is the practice of usual treatment. Previous research into the treatment of SDA in Portugal was based on this approach and has shown very modest results (Barrias et al., 1997). In that randomized controlled study, the percentage of abstinent people at the end of 6 months of treatment was 45% of those who took acamprosate and 37% of those who took placebo, but this difference failed to achieve statistical significance. At the end of 1-year follow-up, acamprosate gave 39% of abstinence compared with 26% on the placebo group (P = 0.01). The mean time to the first relapse was 111 days for the acamprosate group and 55 days for the placebo group (P < 0.001).
Treatments with disulfiram exist in Portugal, but often without systematic supervision to assure adherence to the medication. Without this supervision, the treatment has not been shown to be effective (Fuller et al., 1986; Chick et al., 1992, 1999; Brewer et al., 2000). The only randomized and controlled studies that demonstrated that disulfiram was effective used it under supervision (Chick et al., 1992; Hughes and Cook, 1997; Brewer et al., 2000; Buri et al., 2007; Slattery et al., 2003; De Sousa and De Sousa, 2004, 2005; Laaksonen et al., 2007). De Sousa and De Sousa (2004) reported a time to first relapse of 103 days for the disulfiram group against 44 for the naltrexone group. In Laaksonen et al. (2007), these figures were 30 days for the disulfiram group, 16 for naltrexone and 11 for acamprosate.
In recent years, specialists in addictions' treatment in Portugal have advanced some innovative developments. Independent of the community reinforcement approach (Azrin 1976, 1982; Smith et al., 2001), but with some similarities, they developed the sequential combined treatment (David and Neto, 1997; Neto et al., 1997; David et al., 1998), first for heroin addicts' treatment with naltrexone, and then for alcoholics. With this method it has been possible to achieve encouraging rates of abstinence at the end of a year of SCT treatment of heroin addicts: 61% at the end of 6 months and 57% at the end of 1 year (Neto et al., 1997).
Expecting that the SCT approach works in a similar way as in other substance-addicted patients, the main hypothesis of this study is that the SCT approach can give better results than TU in the relapse prevention of alcoholic-dependent patients.
Abstract and Introduction
Abstract
Aim: The aim of this study was to compare the effectiveness of the sequential combined treatment (SCT) and treatment as usual (TU) in relapse prevention in a sample of alcohol-dependent patients, during 180 days of outpatient treatment.
Method: 209 alcohol-dependent patients who could attend with an informant adult were randomized to either TU or SCT. The primary outcome measure was time to first relapse, defined as the consumption of any amount of alcohol during the 180 days of follow-up. Secondary outcome measures included maximum duration of continuous abstinence (MDCA), cumulative abstinence duration (CAD), quality of life (ARPQ) and blood test markers of alcohol consumption.
Results: The SCT approach was more effective than TU. The Kaplan-Meier abstinent proportion at the end of the 180 days was 78% for the SCT group and 59% for the TU group (P < 0.01). The mean time to first relapse was 150 days for SCT and 123 days for TU (P < 0.01). The relative risk reduction of relapse was 62% for SCT after adjustment in multiple Cox regression (P < 0.01). SCT had more MDCA (P < 0.05) and more CAD (P < 0.05). Therapy sessions lasted slightly longer for SCT than TU (mean 13 min versus 10 min).
Conclusions: SCT can result in better outcomes than TU in the outpatient treatment of alcohol dependence.
Introduction
Portugal is among the world's largest consumers of alcoholic beverages. In 2003, according to World Drink Trends (2005), it held 8th place, with a consumption of 9.6 l of ethanol per capita, behind countries such as Luxembourg, Czech Republic, Republic of Ireland, Germany, Spain and the United Kingdom.
The diseases caused by the excessive consumption of alcoholic beverages include the syndrome of dependence of alcohol (SDA), with an estimated prevalence in Portugal of 580,000 persons and the syndrome of abuse of alcohol (SAA), estimated at 746,000 persons (Gameiro, 1998).
The ambulatory treatment of SDA (defined following the American Psychiatric Association, 1994) in the Portuguese health service tends to follow a medical model based predominantly on an individual approach. The phase of detoxification is based mostly on the patient himself and is followed by medication for the maintenance of abstinence. This is the practice of usual treatment. Previous research into the treatment of SDA in Portugal was based on this approach and has shown very modest results (Barrias et al., 1997). In that randomized controlled study, the percentage of abstinent people at the end of 6 months of treatment was 45% of those who took acamprosate and 37% of those who took placebo, but this difference failed to achieve statistical significance. At the end of 1-year follow-up, acamprosate gave 39% of abstinence compared with 26% on the placebo group (P = 0.01). The mean time to the first relapse was 111 days for the acamprosate group and 55 days for the placebo group (P < 0.001).
Treatments with disulfiram exist in Portugal, but often without systematic supervision to assure adherence to the medication. Without this supervision, the treatment has not been shown to be effective (Fuller et al., 1986; Chick et al., 1992, 1999; Brewer et al., 2000). The only randomized and controlled studies that demonstrated that disulfiram was effective used it under supervision (Chick et al., 1992; Hughes and Cook, 1997; Brewer et al., 2000; Buri et al., 2007; Slattery et al., 2003; De Sousa and De Sousa, 2004, 2005; Laaksonen et al., 2007). De Sousa and De Sousa (2004) reported a time to first relapse of 103 days for the disulfiram group against 44 for the naltrexone group. In Laaksonen et al. (2007), these figures were 30 days for the disulfiram group, 16 for naltrexone and 11 for acamprosate.
In recent years, specialists in addictions' treatment in Portugal have advanced some innovative developments. Independent of the community reinforcement approach (Azrin 1976, 1982; Smith et al., 2001), but with some similarities, they developed the sequential combined treatment (David and Neto, 1997; Neto et al., 1997; David et al., 1998), first for heroin addicts' treatment with naltrexone, and then for alcoholics. With this method it has been possible to achieve encouraging rates of abstinence at the end of a year of SCT treatment of heroin addicts: 61% at the end of 6 months and 57% at the end of 1 year (Neto et al., 1997).
Expecting that the SCT approach works in a similar way as in other substance-addicted patients, the main hypothesis of this study is that the SCT approach can give better results than TU in the relapse prevention of alcoholic-dependent patients.
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