Harm-reduction treatment may benefit those experiencing homelessness, alcohol use disorder
Pharmacological/behavioral harm-reduction treatment improved alcohol-related outcomes and physical health-related quality of life in those experiencing homelessness and alcohol use disorder, researchers reported in The Lancet Psychiatry.
“Currently available treatments are not highly engaging or effective for this population, and the typical requirements of high-intensity, often inpatient, treatment, combined with the expectation of achieving alcohol abstinence, pose the most formidable barriers,” Susan E. Collins, PhD, of the department of psychiatry and behavioral sciences at the University of Washington School of Medicine, and colleagues wrote. “Our previous studies in this population showed that few participants (5% to 11%) experiencing homelessness and alcohol use disorder in community-based service settings (ie, shelters, supportive housing, neighborhood clinics and drop-in centers) aspired to achieve abstinence. Instead, participants preferred lower intensity approaches that do not require abstinence, with patient-driven goal-setting and a focus on health-related quality of life.”
The researchers conducted the current randomized clinical trial to assess the efficacy of combined pharmacological and behavioral harm-reduction treatment for alcohol use disorder (HaRT-A) among individuals who experienced homelessness and alcohol use disorder. They conducted the trial at three community-based service sites in Seattle and included 308 adults aged 21 to 65 years who met DSMIV-TR criteria for alcohol use disorder and who experienced past-year homelessness. Participants received either HaRT-A plus intramuscular injections of 380 mg extended-release naltrexone (HaRT-A plus XR-NTX group); HaRT-A plus placebo injection; HaRT-A alone; or community-based supportive services as usual. Self-reported alcohol use, measured via the Alcohol Quantity Use Assessment questionnaire, and frequency, measured via the Addiction Severity Index, as well as alcohol-related harm, measured via the Short Inventory of Problems-2R questionnaire, and physical and mental health-related quality of life, measured via the Short Form-12 survey, served as primary outcomes. Collins and colleagues compared the effects of the three active treatments groups with the services-as-usual control group, and the HaRT-A plus XR-NTX group with the HaRT-A plus placebo group, using piecewise growth modelling and an intention-to-treat model that included data from the 12-week treatment course and during the 24 weeks after treatment withdrawal.
Results showed significant improvement from baseline to 12 weeks after treatment in the HaRT-A plus XR-NTX group vs. the services-as-usual control group in peak alcohol quantity, alcohol frequency, alcohol-related harm and physical health-related quality of life. The
HaRT-A plus placebo group exhibited significant improvements in peak alcohol quantity, alcohol frequency and physical health-related quality of life compared with the services-as-usual control group. The HaRT-A alone group showed significant improvements in alcohol-related harm and physical health-related quality of life compared with the services-as-usual control group. The active treatment groups plateaued, but the services-as-usual group showed improvements, after treatment discontinuation at 12 weeks, meaning the services-as-control group showed greater reductions in alcohol-related harm compared with both the HaRT-A plus XR-NTX group and the HaRT-A alone group during the post-treatment period. During this period, the services-as-usual control group showed significant improvement in mental-health related quality of life vs. the HaRT-A alone group, as well as on physical health-related quality of life vs. the HaRT-A plus XR-NTX group, the HaRT-A plus placebo group and the HaRT-A alone group.
The researchers observed no significant linear differences for all other primary outcomes between the services-as-usual and active treatment groups. Further, they did not observe significant differences for any of the primary outcomes upon comparing the HaRT-A plus placebo group with the HaRT-A plus XR-NTX group. Participants appeared more likely to drop out in the services-as-usual control group than in the active treatment groups according to missing data analysis; however, the researchers found primary outcome findings were robust to attrition. Adverse events were not more common among the HaRT-A plus XR-NTX, HaRT-A plus placebo and HaRT-A alone groups vs. the service-as-usual control group.
“Further research is needed to investigate whether this approach could help to reduce health-care service utilization and the associated costs, and to establish the optimal length of harm-reduction treatment for alcohol use disorder,” Collins and colleagues wrote.
In a related editorial, Stefan G Kertesz, MD, MSc, of the department of medicine at the University of Alabama at Birmingham School of Medicine, highlighted the implications of these findings for clinicians.
“For clinicians eager to strengthen the role of still underused medications for addiction, this study delivers a measure of support,” Kertesz wrote. “However, the data also suggest that the key ingredient might have been the offer of a structured, behavioral harm reduction-focused therapy, based on client-centered, collaborative feedback, that draws on motivational interviewing and humanistic psychotherapy. The manual for such care includes structured feedback, elicitation of the patient’s preferred goals, and if chosen by the patient, guidance on safer drinking strategies. Crucially for this therapy, participants were not required to affirm a specific goal of alcohol reduction or abstinence.”