Department of Psychiatry and Psychotherapy, University of Cologne Medical School, Cologne, Germany.
Department of Psychiatry and Psychotherapy, Charité Campus Mitte, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin and Berlin Institute of Health, Berlin, Germany.
Addiction. 2021 Aug;116(8):1973-1987. doi: 10.1111/add.15329. Epub 2020 Dec 14.
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.
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.
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.
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.
未接受治疗的酒精使用障碍（AUD）患者比例超过任何其他精神健康障碍，因此需要替代治疗方法。一种广泛讨论的策略是摆脱戒酒模式，采用控制饮酒的方法。本项系统评价与荟萃分析旨在评估与基于戒酒的策略相比，非戒酒治疗策略的疗效。
在 2019 年 2 月之前，通过 CENTRAL、PubMed、PsycINFO 和 Embase 数据库，对成年 AUD 人群的对照（随机和非随机）临床试验（RCT 和非 RCT）进行了检索，包括旨在控制饮酒的干预组和旨在戒酒的对照组。根据系统评价和荟萃分析的首选报告项目（PRISMA）和 Cochrane 协作组指南，由两名审查员独立进行文献检索、数据收集和偏倚风险评估[国际前瞻性注册系统评价（PROSPERO），注册号 CRD42019128716]。主要结局指标为达到推荐阈值以下饮酒的参与者比例。次要结局指标为社会功能、饮酒减少、戒酒率和脱落率。使用随机效应模型，分别对 RCT 和非 RCT 进行分析。敏感性和亚组分析考虑了方法学严谨性、包含特定目标的治疗、随访时间和 AUD 严重程度。
共纳入 22 项研究（包括 5 项 RCT），共纳入 4204 名患者。在 RCT 中，两种治疗方案之间无统计学差异[比值比（OR）=1.32，95%置信区间（CI）=0.51-3.39]。非随机自由目标选择研究倾向于戒酒（OR=0.60，95%CI=0.40-0.90），除非提供特定的治疗（OR=0.79，95%CI=0.40-1.56），或研究偏倚风险较低（OR=0.73，95%CI=0.49-1.09）或随访时间较长（OR=1.49，95%CI=0.78-2.85）。效应大小似乎不依赖于 AUD 严重程度。戒酒和控制饮酒干预在社会功能和饮酒减少方面的效果没有明显差异。
现有证据不支持将戒酒作为治疗酒精使用障碍的唯一方法。在不适用戒酒方法的情况下，控制饮酒，特别是如果得到特定心理治疗的支持，似乎是一种可行的选择。
