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).
A qualitative interview study with ten GPs participating in a randomized controlled trial. The interviews were analyzed using qualitative content analysis.
The participating GPs were recruited via purposeful sampling from primary care clinics in Stockholm.
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.
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.
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 POINTS
Alcohol 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.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, OILJ, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Alcohol dependence is a common disorder with a continuum regarding severity. Most alcohol-dependent persons have a moderate level of dependence and live under socially orderly conditions. ...Treatment-seeking in this group is low, mainly due to stigma and because treatment options are seen as unappealing. Alcohol is a relevant topic to discuss in many primary care (PC) consultations and PC is less stigmatizing to visit compared to addiction care units for people with alcohol problems. However, general practitioners (GPs) hesitate to engage in treating alcohol problems due to time constraints and lack of knowledge. Screening and brief interventions are effective for high consumers but there are few studies on dependence.
This is a two-group, parallel, randomized controlled trial (RCT). The aim is to study whether an Internet-based Cognitive Behavioral Treatment (iCBT) when added to treatment as usual (TAU) is more effective than TAU only for alcohol dependence in PC. Two hundred and sixty adults with alcohol dependence will be included. Participants are randomized to iCBT and TAU or TAU only. The primary study outcome is alcohol consumption in grams per week and heavy-drinking days. Secondary outcomes include alcohol-related problem severity, number of diagnostic criteria for alcohol dependence, depression and anxiety symptoms, health-related quality of life and biochemical markers for high consumption and liver pathology. Data will be analyzed using mixed-effect models.
Internet-based interventions are attractive to, and have been shown to reach, people with alcohol problems. Yet there are no studies investigating the efficacy of Internet treatment of alcohol dependence in PC. In this study we hypothesize that iCBT when added to TAU will improve treatment outcome for alcohol dependence in PC, compared to TAU only. If effective, iCBT can be distributed to the public to a low cost for a stakeholder and has the opportunity to reduce both short-term and long-term public health costs.
ISRCTN69957414. Retrospectively registered on 7 June 2018.
Alcohol dependence is a common disorder and contributes to substantial morbidity and mortality globally. Only 10-20 percent engage in treatment, which makes alcohol dependence the mental disorder ...with the largest treatment gap. Most individuals with alcohol dependence have a dependence of low to moderate severity. These individuals are concerned about their drinking but are not interested in seeking treatment in specialized care. Primary care, however, is viewed as an appealing treatment option for these individuals. In Swedish primary care few routines are in place for the treatment of alcohol use disorders (AUD). General practitioners (GP) are hesitant to engage in this field. Time concerns and perceived limited competence constitutes barriers for the identification and treatment of alcohol dependence in primary care.The overall aim with this thesis was to study new approaches aimed at enhancing the identification and treatment of alcohol dependence in primary care.Study I was a randomized controlled superiority trial including 264 participants with alcohol dependence in primary care in Stockholm. The objective was to test the efficacy of an internet-delivered cognitive behavioral therapy (iCBT) program for alcohol dependent patients in primary care. Our hypothesis was that iCBT, a five-module self-help program, when added to treatment as usual (TAU) was more efficacious than TAU only. As clear routines for treating alcohol dependence are lacking, TAU will vary. Therefore, the involved GPs were offered a one-hour training in giving feedback on assessments and biomarkers and providing pharmacotherapy for AUD. Linear mixed effects models were used to analyze primary and secondary outcomes. No significant differences between the groups were seen for the primary outcome of mean weekly alcohol consumption at 12 months in the intention-to-treat analysis. The per-protocol analysis showed that when including only patients who actually initiated the iCBT program, the combination of iCBT and TAU resulted in lower mean weekly alcohol consumption compared to TAU at 12-months.Study II was a secondary analysis based on data from Study I with the aim to investigate the role of socio-demographic and clinical predictors for outcome in Study I, using linear mixed effects models. Primary outcome was mean number of standard drinks the last 30 days. Severity of dependence was the only variable that was found to moderate treatment outcome. Patients with severe dependence showed a significantly larger reduction in alcohol consumption between baseline and 3 months compared to moderately dependent patients in TAU. The moderately dependent patients continued to reduce their consumption between 3- and 12 months, while the severely dependent patients increased their consumption during this period. To conclude, reduced alcohol consumption over time was found for moderately dependent patients treated in primary care with both iCBT+TAU and TAU, while the effect for severely dependent patients was more limited, suggesting a possible need for more care.Study III was a qualitative interview study with the aim to investigate how GPs experience the management of patients with alcohol dependence in primary care, current treatment routines and their view on iCBT. Ten GPs from primary care clinics in Stockholm (5/5 women/male) with prior experience as care providers in Study I were recruited via purposeful sampling and interviewed. Interview data was analyzed using qualitative content analysis. The GPs found alcohol important to discuss due to its impact on patients’ health. They found most patients open to discuss their alcohol consumption. Routines for treating alcohol dependence were rare. Limited time, treatment options and perceived limited expertise were expressed as hampering factors when working with alcohol dependence. GPs believed that iCBT as a treatment option might facilitate discussions about alcohol with patients. The iCBT program was viewed as an attractive treatment option to some patients and did not require GPs to acquire behavioral treatment skills, potentially enhancing its implementation.Study IV was a prospective longitudinal register-based study including 128 of all 223 publicly funded primary care clinics in Region Stockholm. The aim was to investigate the extent to which the combination of two implementation strategies impacted on alcohol-related clinical activity in primary care in Region Stockholm. The two strategies were a) a new policy making prevention and interventions of AUD mandatory in primary care and b) training in the 15-Method. The new policy was introduced on February 2021 and training in targeted screening and treatment of AUD for primary care professions was launched ten months after implementation of the new policy. Data from registers were collected at six time periods; at three months before the new policy was launched; at three and nine months after the new policy was launched, but before training was available; at six, 12 and 18 months after training was available. Seven measures that reflect alcohol-related clinical activities were obtained from the primary care electronic case files and were analyzed with Generalized Estimating Equations. From low levels of alcohol-related clinical activities at baseline, a modest increase in some of the alcohol-related clinical activities was found 9 months after the new policy. The training in the 15-Method was not associated with further increases. Few professionals appear to have participated in the training. While a policy making alcohol interventions mandatory, combined with a training program, has strong support from implementation science, more implementation strategies seem necessary to impact on how clinicians in primary care can handle AUD.The main conclusions of the thesis were that treatment of alcohol dependence in primary care is efficacious both for patients receiving TAU and for patients treated with iCBT plus TAU. For patients that utilized the iCBT program in combination with TAU, additive efficacy was found on mean weekly alcohol consumption. Severity of dependence predicted treatment outcome for alcohol dependent patients in primary care. Moderately dependent patients reduced their weekly alcohol consumption during treatment and continued to reduce their consumption at 12 months follow-up. Severely dependent patients reduced their weekly alcohol consumption during treatment, but increased their consumption after end of treatment, suggesting a need for more care. The GPs involved in the studies viewed iCBT as a convenient treatment option for some patients and having access to iCBT might facilitate discussions about alcohol. Regarding implementation strategies, the new policy making alcohol interventions mandatory in primary care was associated with a modest increase in some alcohol-related activities, whereas no additional benefit was found for a brief digital training course in prevention and treatment of alcohol dependence.
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.
According to a 2013–2014 survey of nearly 46,000 U.S. adults and youths, 28% of adults were current users of tobacco and 9% of youths had used tobacco in the previous 30 days. Approximately 40% of ...users used multiple products, with cigarettes plus e-cigarettes the most common combination.
Smoking is responsible for more U.S. deaths annually than the acquired immunodeficiency syndrome, use of alcohol and illegal drugs, motor vehicle accidents, murders, and suicides combined.
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With recent data suggesting higher smoking-attributable mortality than previously estimated,
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the medical community is urged to make tobacco control a high priority.
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The prevalence of current use of cigarettes has declined during the past 50 years, from 42% of adults in 1965 to less than 20% in 2014,
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,
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but disparities in cigarette smoking across demographic subgroups (particularly according to race or ethnic group, educational attainment, and socioeconomic status) have widened during the past . . .
IntroductionThis study assessed patterns of e-cigarette and cigarette use from Wave 1 to Wave 2 among adult e-cigarette users at Wave 1 of the Population Assessment of Tobacco and Health (PATH) ...Study.MethodsWe examined changes in e-cigarette use frequency at Wave 2 among adult e-cigarette users at Wave 1 (unweighted n=2835). Adjusted prevalence ratios (aPR) were calculated using a predicted marginal probability approach to assess correlates of e-cigarette discontinuance and smoking abstinence at Wave 2.ResultsHalf (48.8%) of adult e-cigarette users at Wave 1 discontinued their use of e-cigarettes at Wave 2. Among dual users of e-cigarettes and cigarettes at Wave 1, 44.3% maintained dual use, 43.5% discontinued e-cigarette use and maintained cigarette smoking and 12.1% discontinued cigarette use at Wave 2, either by abstaining from cigarette smoking only (5.1%) or discontinuing both products (7.0%). Among dual users at Wave 1, daily e-cigarette users were more likely than non-daily users to report smoking abstinence at Wave 2 (aPR=1.40, 95% CI 1.02 to 1.91). Using a customisable device (rather than a non-customisable one) was not significantly related to smoking abstinence at Wave 2 (aPR=1.14, 95% CI 0.81 to 1.60).ConclusionsThis study suggests that e-cigarette use patterns are highly variable over a 1-year period. This analysis provides the first nationally representative estimates of transitions among US adult e-cigarette users. Future research, including additional waves of the PATH Study, can provide further insight into long-term patterns of e-cigarette use critical to understanding the net population health impact of e-cigarettes in USA.
There is conflicting evidence for gender differences in smoking cessation, and there has been little research on gender differences in smoking cessation medication (SCM) use and effectiveness. Using ...longitudinal data from the International Tobacco Control Four Country Surveys (ITC-4) conducted in the United Kingdom, the United States, Canada, and Australia, we examined gender differences in the incidence of quit attempts, reasons for quitting, use of SCMs, reasons for discontinuing use of SCMs, and rates of smoking cessation.
Data were analyzed from adult smokers participating in the ITC-4, annual waves 2006-2011 (n = 7,825), as well as a subsample of smokers (n = 1,079) who made quit attempts within 2 months of survey. Adjusted modeling utilized generalized estimating equations.
There were no gender differences in the likelihood of desire to quit, plans to quit, or quit attempts between survey waves. Among quit attempters, women had 31% lower odds of successfully quitting (OR = 0.69; 95% CI = 0.51, 0.94). Stratified by medication use, quit success was lower among women who did not use any SCMs (OR = 0.59; 95% CI = 0.39, 0.90), and it was no different from men when medications were used (OR = 0.73; 95% CI = 0.46, 1.16). In particular, self-selected use of nicotine patch and varenicline contributed to successful quitting among women.
Women may have more difficulty quitting than men, and SCMs use may help attenuate this difference.
ObjectiveCigarettes are the most harmful and most prevalent tobacco product in the USA. This study examines cross-sectional prevalence and longitudinal pathways of cigarette use among US youth (12–17 ...years), young adults (18–24 years) and adults 25+ (25 years and older).DesignData were drawn from the first three waves (2013–2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US adults and youth. Respondents with data at all three waves (youth, N=11 046; young adults, N=6478; adults 25+, N=17 188) were included in longitudinal analyses.ResultsAmong Wave 1 (W1) any past 30-day (P30D) cigarette users, more than 60%, persistently used cigarettes across three waves in all age groups. Exclusive cigarette use was more common among adult 25+ W1 P30D cigarette users (62.6%), while cigarette polytobacco use was more common among youth (57.1%) and young adults (65.2%). Persistent exclusive cigarette use was the most common pathway among adults 25+ and young adults; transitioning from exclusive cigarette use to cigarette polytobacco use was most common among youth W1 exclusive cigarette users. For W1 youth and young adult cigarette polytobacco users, the most common pattern of use was persistent cigarette polytobacco use.ConclusionsCigarette use remains persistent across time, regardless of age, with most W1 P30D smokers continuing to smoke at all three waves. Policy efforts need to continue focusing on cigarettes, in addition to products such as electronic nicotine delivery systems that are becoming more prevalent.
Highlights • Compared to non-users, tobacco users are more likely to use alcohol or any drug. • Female non-cigarette tobacco users are more likely to use drugs. • Tobacco users are more likely to ...have substance use and mental health problems. • Female tobacco users are more likely to have substance and mental health problems.
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