Controlled drinking—non‐abstinent versus abstinent treatment goals in alcohol use disorder: a systematic review, meta‐analysis and meta‐regression

Abstract

Background and Aims The proportion of untreated patients with alcohol use disorder (AUD) exceeds that of any other mental health disorder, and treatment alternatives are needed. A widely discussed strategy is to depart from the abstinence paradigm as part of controlled drinking approaches. This first systematic review with meta‐analysis aims to assess the efficacy of non‐abstinent treatment strategies compared with abstinence‐based strategies. Methods CENTRAL, PubMed, PsycINFO and Embase databases were searched until February 2019 for controlled (randomized and non‐randomized) clinical trials (RCTs and non‐RCTs) among adult AUD populations, including an intervention group aiming at controlled drinking and a control group aiming for abstinence. Following Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) and Cochrane Collaboration guidelines, literature search, data collection and risk of bias assessment were carried out independently by two reviewers [International Prospective Register of Systematic Reviews (PROSPERO), registration no. CRD42019128716]. The primary outcome was the proportion of participants consuming alcohol at or below the recommended threshold. Secondary outcomes were social functioning, drinking reductions, abstinence rates and dropouts. Using random‐effects models, RCTs and non‐RCTs were analyzed separately. Sensitivity and subgroup analyses accounted for methodological rigor, inclusion of goal‐specific treatment, length of follow‐up and AUD severity. Results Twenty‐two studies (including five RCTs) with 4204 patients were selected. There was no statistically significant difference between both treatment paradigms in RCTs [odds ratio (OR) = 1.32, 95% confidence interval (CI) = 0.51–3.39]. Non‐randomized studies of free goal choice favored abstinence‐orientation (OR = 0.60, 95% CI = 0.40–0.90), unless goal‐specific treatment was provided (OR = 0.79, 95% CI = 0.40–1.56), or in studies of low risk of bias (OR = 0.73, 95% CI = 0.49–1.09) or with long follow‐up (OR = 1.49, 95% CI = 0.78–2.85). Effect sizes were not clearly dependent upon AUD severity. Abstinence‐ and controlled drinking interventions did not clearly differ in their effect on social functioning and drinking reductions. Conclusions Available evidence does not support abstinence as the only approach in the treatment of alcohol use disorder. Controlled drinking, particularly if supported by specific psychotherapy, appears to be a viable option where an abstinence‐oriented approach is not applicable.

Commentary on Henssler et al.: The public health case for promoting and valuing drinking reductions in the treatment of alcohol use disorder

“…This body of work comprises a limited number of randomized clinical trials and a larger number of non‐randomized treatment evaluations that compared non‐abstinent and abstinence‐based treatment strategies, including a subset of studies that allowed patients to choose their drinking goals and provided goal‐specific interventions. The recent systematic review and meta‐analysis by Henssler and colleagues [2] examined this research using modern review methods and replicated earlier reviews [3] that provided compelling evidence that controlled drinking is possible, even among some individuals with severe AUD. Moreover, for the first time, Henssler and colleagues [2] rigorously showed that treatments focused on abstinence goals did not significantly differ from treatments that allowed controlled drinking with respect to patient psychosocial functioning and successful maintenance of drinking reductions.…”

“…The recent systematic review and meta‐analysis by Henssler and colleagues [2] examined this research using modern review methods and replicated earlier reviews [3] that provided compelling evidence that controlled drinking is possible, even among some individuals with severe AUD. Moreover, for the first time, Henssler and colleagues [2] rigorously showed that treatments focused on abstinence goals did not significantly differ from treatments that allowed controlled drinking with respect to patient psychosocial functioning and successful maintenance of drinking reductions.…”

“…These meta‐analysis and meta‐regression [2] findings are aligned with other recent empirical research showing that drinking reductions, short of complete abstinence from alcohol, are achievable, sustainable and associated with improvements in how individuals with AUD feel and function for several years or more after treatment [4–6]. These results provide further support for considering non‐abstinent recovery from AUD as a potential treatment target that could expand the scope and reach of AUD treatment in the population with problems [7,8].…”

Reward Deficiency Syndrome (RDS): A Cytoarchitectural Common Neurobiological Trait of All Addictions

“…This enormous amount of work (over five decades) points to a biogenetic disease characterized by genetic anomalies, leading to biochemical deficiencies or imbalances and receptor malfunctions. On the other side are a number of psychologists who seem to ignore a vast body of research findings spanning the past five decades [13][14][15][16]. They reject or are unaware of important clinical data, the concept of SUDs as a disease, and in our opinion, have advanced three misleading hypotheses.…”

Treating patients with multiple substance use in accordance with their personal treatment goals: a new paradigm for addiction treatment

“…Reduction treatment targets people who are ready for change but who are either not able or not willing to adopt a totally abstinent lifestyle. In the case of alcohol use disorders, several reviews and meta-analyses show that abstinence-oriented treatment approaches are not superior to treatment aiming at CD (Henssler et al, 2020;Kö rkel, 2015;van Amsterdam and van den Brink, 2013) and furthermore the "results do not confirm the conventional wisdom that CD is only acceptable in non-dependent patients" (Henssler et al, 2020).…”