NEW YORK (Reuters Health) – Adding extended-release naltrexone to a behavioral harm-reduction strategy did not appear to improve alcohol-related outcomes and physical health-related quality of life in homeless people who drink too much, new research indicates.
But the behavioral harm-reduction strategy, with or without naltrexone, did produce benefits compared with services as usual, researchers report in The Lancet Psychiatry.
People who are homeless are much more likely to be diagnosed with alcohol-use disorder and are at greater risk of dying of alcohol-attributable causes than the general population, the team notes.
Currently available treatments are not highly engaging or effective in the homeless population, and the typical requirements of high-intensity, often inpatient, treatment, combined with the expectation of achieving alcohol abstinence, pose “formidable barriers,” write Dr. Susan Collins of the University of Washington School of Medicine, in Seattle, and colleagues.
In earlier studies, they found that only a minority of people experiencing homelessness and alcohol-use disorder in community-based service settings (shelters, supportive housing, neighborhood clinics and drop-in centers) aspired to achieve alcohol abstinence. Instead, they preferred lower-intensity approaches that did not require abstinence, with patient-driven goal-setting and a focus on health-related quality of life.
In their current study, Dr. Collins and colleagues tested the efficacy of combined pharmacological and behavioral harm-reduction treatment for alcohol-use disorder (HaRT-A) in 308 adults experiencing homelessness in Seattle.
Over 12 weeks, participants received either HaRT-A plus intramuscular injections of extended-release naltrexone (HaRT-A plus XR-NTX); HaRT-A plus placebo injection; HaRT-A alone; or community-based supportive services as usual. Patients assigned to HaRT-A attended sessions at baseline and weeks one, four, eight and 12; XR-NTX and placebo injections were given at baseline and weeks four and eight.
There were significant improvements from baseline to 12 weeks after treatment in the group receiving HaRT-A plus XR-NTX compared with the services-as-usual control group in peak alcohol intake, alcohol frequency, alcohol-related harm and physical health-related quality of life.
The group receiving HaRT-A plus placebo also showed significant improvement in peak alcohol quantity, 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.
After treatment was discontinued at 12 weeks, the active-treatment groups plateaued, but the services-as-usual group showed improvements. Thus, the services-as-usual 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 post-treatment weeks 12 to 36.
During this post-treatment period, the services-as-usual control group also showed significant improvement on mental-health-related quality of life, compared with the HaRT-A alone group, as well as on physical health-related quality of life compared with the HaRT-A plus XR-NTX group, the HaRT-A plus placebo group and the HaRT-A alone group.
“When comparing the HaRT-A plus placebo group with the HaRT-A plus XR-NTX group, there were no significant differences for any of the primary outcomes,” Dr. Collins and colleagues report.
“Missing data analysis indicated that participants were more likely to drop out in the services-as-usual control group than in the active treatment groups; however, primary outcome findings were found to be robust to attrition,” they add.
They say further research is needed to test whether this combined behavioral harm-reduction and drug therapy could help lower use of healthcare services and associated costs, and to determine the optimal length of harm-reduction treatment for alcohol-use disorder.
In a linked editorial, Dr. Stefan Kertesz of the University of Alabama at Birmingham School of Medicine, writes, “For clinicians eager to strengthen the role of still underused medications for addiction, this study delivers a measure of support.”
“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,” Dr. Kertesz concludes.
“This trial, to its enormous credit, models a structured form of treatment that can be offered to people with alcohol use disorder both when they experience homelessness and after they return to housing,” Dr. Kertesz adds.
The study was funded by the National Institute on Alcohol Abuse and Alcoholism.
SOURCE: https://bit.ly/3rUJ1RB and https://bit.ly/30OgnWh Lancet Psychiatry, online March 10, 2021.
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