Alcohol Treatment Outcome Studies Research Articles

Development of the alcohol use discrepancy instrument (AUDI): An instrument for measuring a purported mechanism of behavior change underlying self-regulation theory

Self-regulation theory (SRT) posits that individuals make decisions regarding behavior change based on a comparison of their actual (e.g., excessive alcohol use) and desired (e.g., abstinence) behaviors. This comparison must result in a discrepancy of sufficient magnitude to motivate an individual toward behavior change. It appears that this purported mechanism of behavior change (MOBC) has not been tested with regards to alcohol use disorder (AUD) treatment. Furthermore, there seems to be no psychometrically sound instrument for assessing such discrepancies in a clinical sample. The purpose of this study was to establish the psychometric properties of an instrument developed to assess actual versus desired alcohol use discrepancies that could be used to test this purported MOBC underlying SRT. The Alcohol Use Discrepancy Instrument (AUDI) was administered to 235 individuals participating in the Clifford et al. (2007) alcohol treatment outcome study that centered on research assessment exposure reactivity effects. Principal axis factor analysis yielded a unidimensional construct (Cronbach’s α = 0.80). Baseline and six-month AUDI scores were correlated with concurrent alcohol use (proportion days abstinent, drinks per drinking day, and proportion heavy days, p < .01) in expected directions. Parallel process models provided further evidence of the AUDI’s construct validity, as well as its potential as a measure of discrepancy as a MOBC.The AUDI has good psychometric properties and is likely to prove useful for assessing discrepancies between actual and desired alcohol use behavior, which, according to the principles of SRT, is essential for behavior change and maintenance.

Do Co-morbid Anxiety Disorders Predict Drinking Outcomes in Women with Alcohol Use Disorders?

It is unclear whether co-morbid anxiety disorders predict worse drinking outcomes during attempts to change drinking behavior. Studies have yielded mixed results, and have rarely examined drinking outcomes based on a specific type of anxiety disorder. Women with alcohol use disorders (AUDs) are of particular interest as they are at risk for co-morbid anxiety [Kessler et al. (1997) Lifetime co-occurrence of DSM-III-R alcohol abuse and dependence with other psychiatric disorders in the national co-morbidity survey. Arch Gen Psychiat 54:313-21]. Participants were 260 women with AUDs participating in an alcohol-treatment outcome studies. The Timeline Follow-Back was used to assess drinking frequency (percent days drinking) prior, within and 6 months post-treatment. The current study tested the hypothesis that having at least one lifetime anxiety disorder diagnosed at baseline using the Structured Clinical Interview for DSM Disorders would be associated with more drinking at all study time points. Exploratory analyses examined patterns of drinking outcomes by specific anxiety diagnoses. Lifetime anxiety diagnosis was linked to poorer drinking outcomes post-treatment (β = 0.15, P = 0.020), despite less frequent drinking prior to treatment. Analyses by specific anxiety diagnosis indicated that generalized anxiety disorder predicted poorer drinking outcomes within treatment (β = 0.14, P = 0.018) and during follow-up (β = 0.16, P = 0.014). Co-morbid anxiety problems complicate treatment for AUDs among women. Further, specific anxiety disorders should be evaluated as distinct constructs as evidenced by the differential outcomes related to generalized anxiety disorder. Implications for treatment development for women with AUDs are discussed.

Effects of Adrenal Sensitivity, Stress- and Cue-Induced Craving, and Anxiety on Subsequent Alcohol Relapse and Treatment Outcomes

Alcoholism is a chronic, relapsing illness in which stress and alcohol cues contribute significantly to relapse risk. Dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, increased anxiety, and high alcohol craving have been documented during early alcohol recovery, but their influence on relapse risk has not been well studied. To investigate these responses in treatment-engaged, 1-month-abstinent, recovering alcohol-dependent patients relative to matched controls (study 1) and to assess whether HPA axis function, anxiety, and craving responses are predictive of subsequent alcohol relapse and treatment outcome (study 2). Experimental exposure to stress, alcohol cues, and neutral, relaxing context to provoke alcohol craving, anxiety, and HPA axis responses (corticotropin and cortisol levels and cortisol to corticotropin ratio) and a prospective 90-day follow-up outcome design to assess alcohol relapse and aftercare treatment outcomes. Inpatient treatment in a community mental health center and hospital-based research unit. Treatment-engaged alcohol-dependent individuals and healthy controls. Time to alcohol relapse and to heavy drinking relapse. Significant HPA axis dysregulation, marked by higher basal corticotropin level and lack of stress- and cue-induced corticotropin and cortisol responses, higher anxiety, and greater stress- and cue-induced alcohol craving, was seen in the alcohol-dependent patients vs the control group. Stress- and cue-induced anxiety and stress-induced alcohol craving were associated with fewer days in aftercare alcohol treatment. High provoked alcohol craving to both stress and to cues and greater neutral, relaxed-state cortisol to corticotropin ratio (adrenal sensitivity) were each predictive of shorter time to alcohol relapse. These results identify a significant effect of high adrenal sensitivity, anxiety, and increased stress- and cue-induced alcohol craving on subsequent alcohol relapse and treatment outcomes. Findings suggest that new treatments that decrease adrenal sensitivity, stress- and cue-induced alcohol craving, and anxiety could be beneficial in improving alcohol relapse outcomes.

Improving the quality of reporting alcohol outcome studies: Effects of the CONSORT statement

It is critical that the reporting of randomized controlled trials (RCTs) be transparent and comprehensive. The aim of this study was to examine if adopting standards of reporting, the Consolidated Standards of Reporting Trials (CONSORT), improved the quality of reporting of alcohol treatment outcome studies. RCTs were identified from eight journals publishing a substantial number of alcohol treatment outcome studies ( n = 127 RCTs) and coded for the quality of reporting according to the CONSORT guidelines. Both CONSORT adopter and non-adopter journals showed significant improvements in the quality of reporting of alcohol treatment outcome studies over time. While overall results suggested a non-significant trend for more improvement over time in the quality of reporting for adopter compared to non-adopter journals, comparison of effects sizes suggested that specific areas of reporting did significantly improve for the adopter journals. Results suggest that efforts to improve reporting such as the CONSORT guidelines can be useful and influential.

What is Relapse? A Contemporary Exploration of Treatment of Alcoholism

In clinical settings, clients treated for alcohol abuse or dependency often engage with multiple service providers. Nonstandardized definitions for treatment outcome obscure treatment success. Using content analysis and preestablished selection criteria on a set of alcohol treatment outcome studies conducted between 1990 and 2006, we evaluated the definition of relapse using a typology derived from an interrater agreement analysis. The interrater agreement was good and the modal category indicated that a multifaceted operationalization was most often used to indicate success. Key to standardizing treatment success might be inclusion of multiple domains of life function in defining relapse.

Influence of Subject Eligibility Criteria on Compliance With National Institutes of Health Guidelines for Inclusion of Women, Minorities, and Children in Treatment Research

Many alcohol treatment outcome studies exclude some patients with particular problems, such as psychiatric disorders, noncompliance, and homelessness. Such criteria may increase the likelihood of a study being successfully conducted, but may also have the unintended consequence of reducing a study's ability to comply with National Institutes of Health guidelines for inclusion of racial minorities, women, and children in treatment research. This paper examined this issue empirically using 5 prior studies of treatment systems enrolling over 100,000 alcohol patients. Widely used eligibility criteria in the alcohol treatment field typically exclude between one-fifth to one-third of patients from enrolling in research. Under several eligibility criteria, most notably those for drug use and social/residential instability, women and African-American patients are substantially more likely to be excluded than are men and non-African-American patients, respectively. In designing treatment studies with many eligibility criteria, researchers may therefore inadvertently be thwarting their own good faith efforts to ensure that a range of vulnerable populations are able to participate in research. We analyze the implications of this dilemma for the generalizability of treatment results and for research design, and provide data that may help researchers working in different treatment systems estimate the impact of various eligibility criteria.

Prevalence and predictors of research participant eligibility criteria in alcohol treatment outcome studies, 1970–98

To describe the eligibility criteria (i.e. study participant inclusion and exclusion rules) employed in alcohol treatment outcome research and to identify predictors of their use. The eligibility criteria of 683 alcohol treatment outcome studies conducted between 1970 and 1998 were coded reliably into 14 general categories. Predictors of the use of eligibility criteria were then examined. Patients were most often ruled ineligible for research studies because of their level of alcohol problems (39.1% of studies), comorbid psychiatric problems (37.8%), past or concurrent utilization of alcohol treatment (31.8%), co-occurring medical conditions (31.6%), and because they were deemed non-compliant and unmotivated (31.5%). The number of eligibility criteria employed in studies increased from the 1970s through the 1990s, and was positively associated with funding from the US National Institute of Alcohol Abuse and Alcoholism (NIAAA) and from the private sector, lack of an inpatient/residential treatment condition, presence of a pharmacotherapy, and use of a randomized, multiple-condition design. Principal investigators with doctoral degrees used more eligibility criteria than those with lower degrees. Participant eligibility criteria are extensively employed in alcohol treatment outcome research, and vary significantly across historical periods, funders and research designs. Researchers should report the details of subject eligibility criteria and excluded patients more fully, and, evaluate how eligibility criteria affect the cost, feasibility, and generalizability of treatment outcome research.

Is alcohol assessment therapeutic? Pretreatment change in drinking among alcohol-dependent women.

Participants in alcohol treatment outcome studies typically undergo extensive assessment protocols to determine eligibility and provide descriptive and predictive data before beginning therapy. Changes in alcohol consumption as a result of reactivity to assessment have generally not been studied; most researchers collapse data across the pretreatment period and compare them with within-treatment and posttreatment periods. Previously we found a reduction in drinking days from 90 days prebaseline to 3 months postbaseline, with no significant additional reduction during the second 3 months of treatment, in a clinical trial of cognitive-behavioral therapy (CBT) for alcohol-dependent women. The current study examined the points at which these participants stopped or reduced their drinking during the pretreatment assessment period. As part of a randomized clinical trial of 6 months of individual or couples CBT for 102 alcoholic women, study participants were assessed briefly via a telephone screen, a 90-minute clinical intake session with their spouses, and then a 3- to 4-hour baseline research interview. Changes in drinking frequency occurred at all four points in the pretreatment assessment process, resulting in 44% of the participants becoming abstinent before the first session of treatment. A decrease in drinking quantity across the assessment period also was found. Participants who significantly reduced drinking prior to Session 1 demonstrated better drinking outcomes during and 12 months after treatment. Changes in alcohol consumption during the assessment process in treatment outcome studies should be examined in future studies, as implications abound for interpretation of results from clinical trials. Also, implications regarding the active ingredients in brief interventions and mechanisms of the therapeutic impact of alcohol assessment should be further addressed.

Measuring youth outcomes from alcohol and drug treatment.

This report examines adolescent alcohol and drug treatment outcome research from a process-oriented, developmental perspective. A dynamic developmental model is proposed in which adolescent treatment outcome research incorporate considerations relevant to changes occurring typically during this stage of life as well as developmental distinctions pertinent to the early onset of abuse and dependence. Findings from our developmentally focused longitudinal research of adolescent treatment participants and the extant literature on adolescent treatment outcome are reviewed. Conceptual, research design and measurement recommendations are presented from this double developmental perspective of addiction. Techniques for engaging youth in the research process, managing confidentiality and facilitating self-disclosure are described. Developmental considerations in the type and timing of outcome assessments, measurement content, predictor domains and data analytical approaches are discussed. Predictors and process measures for adolescent alcohol treatment outcome study are suggested based on current findings. Inclusion of developmental considerations may enhance the utility of adolescent treatment outcome research.

Datapoints: do participants in alcoholism treatment outcome studies resemble patients seen in everyday practice?

Datapoints: do participants in alcoholism treatment outcome studies resemble patients seen in everyday practice?

Alcoholism treatment outcome studies, 1970–1998: An expanded look at the nature of the research

We reviewed 701 alcohol treatment outcome studies reported between 1970 and 1998. Examining the nature of the research allows us to characterize this field of study, analyze trends over time, and improve upon this work in the future. For multiple-group studies, the majority of both investigators and participants were male, and participant characteristics were generally inconsistently surveyed and reported. Between the 1970s and the 1990s, research on pharmacological treatments and research conducted in outpatient settings became more common. Additionally, the types of outcome measures assessed varied more widely and were more likely to be continuous and quantifiable.

Drug treatment outcome methodology (1993–1997): Strengths, weaknesses, and a comparison to the alcohol field

Although several critiques of the methodology of alcohol treatment outcome studies have been published, similar reviews of the methodology of drug treatment outcome studies are lacking. This paper reviews the methodology of drug treatment outcome studies published from 1993 through 1997 and draws comparisons with the most recent methodological review of alcohol treatment outcome studies. Each drug study was evaluated as to whether the following types of data were reported: (1) demographic, (2) drug use, (3) study characteristics, and (4) outcome and follow-up information. Although results for drug studies showed some areas of strength compared to alcohol studies, in general, the weaknesses were similar to or worse than in the alcohol field, including inadequate reporting of demographic and drug use variables. Weaknesses in follow-up procedures were particularly notable. Suggestions for improving the reporting of methodological and outcome variables for drug treatment outcome studies are discussed.

Methodological characteristics and quality of alcohol treatment outcome studies, 1970-98: an expanded evaluation.

To examine the methodological quality of the research literature examining treatment for alcohol use disorders. In total, 701 studies first reported between 1970 and 1998 were evaluated with a scoring system covering 19 areas of research quality. Methodological quality improved from a score of 8.2 out of a possible 28.5 in the 1970s, to 10.6 in the 1990s. Strengths included reporting the initial number of participants and conducting follow-ups of 12 months or longer. Although the percentage of studies with adequate power also increased overall, the average statistical power of comparative studies to detect a medium-sized treatment effect was low (0.54). Areas with room for improvement include: ensuring that follow-up data are collected when respondents are not under the influence of alcohol, testing for differential dropout among treatment groups with respect to participant background characteristics, reporting the number of individuals being treated in the programs from which samples are drawn, noting the reliability and validity of measures used and conducting process analyses to examine potential mechanisms underlying treatment effects.

Subject reactivity effects and alcohol treatment outcome research.

Attributions regarding alcohol treatment research protocols influencing clinical outcomes have persisted for more than 25 years. Although well-designed alcohol treatment outcome studies typically involve frequent, and often comprehensive, research assessment protocols, procedures are seldom in place to control or account for possible subject reactivity to the research protocol. This article presents a theoretical basis for a relationship between research protocols and treatment outcomes. The article reviews the relevant alcohol treatment outcome literature and presents a "weight of evidence" regarding subject reactivity effects and alcohol treatment outcome research assessment protocols. Also, the FRAMES (feedback, responsibility, advice, menu, empathy and self-efficacy) model was coupled with self-regulation theory to provide a theoretical explanation of how research assessment protocols might contribute to clinically relevant behavioral change. Researcher attributions, empirical investigations and theoretical considerations all provide evidence that is consistent with the existence of subject reactivity to research assessment protocols. Recommendations are made regarding interpretation of data collected as part of an alcohol treatment outcome study, control of potential subject reactivity confounding variables and directions for future research.

Use of exclusion criteria in selecting research subjects and its effect on the generalizability of alcohol treatment outcome studies.

Researchers have not systematically examined how exclusion criteria used in selection of research subjects affect the generalizability of treatment outcome research. This study evaluated the use of exclusion criteria in alcohol treatment outcome research and its effects on the comparability of research subjects with real-world individuals seeking alcohol treatment. Eight of the most common exclusion criteria described in the alcohol treatment research literature were operationalized and applied to large, representative clinical patient samples from the public and private sectors to determine whether the hypothetical research samples differed substantially from real-world samples. Five hundred ninety-three consecutive individuals seeking alcohol treatment at one of eight treatment programs participated. A trained research technician gathered information from participants on demographic variables and on alcohol, drug, and psychiatric problems as measured by the Addiction Severity Index. Large proportions of potential research subjects were excluded under most of the criteria tested. The overall pattern of results showed that African Americans, low-income individuals, and individuals who had more severe alcohol, drug, and psychiatric problems were disproportionately excluded under most criteria. Exclusion criteria can result in alcohol treatment outcome research samples that are more heavily composed of white, economically stable, and higher-functioning individuals than are real-world samples of substance abuse patients seen in clinical practice, potentially compromising the generalizability of results. For both scientific and ethical reasons, in addition to studies that use exclusion criteria, outcome research that uses no or minimal exclusion criteria should be conducted so that alcohol treatment outcome research can be better generalized to vulnerable populations.

Interpersonal factors and post‐treatment drinking and subjective wellbeing

A conceptual clarification of the domain of social relationships defines three aspects of social relationships (structure, function and quality), which have both alcohol-specific and general components. We analyse the correlations among post-treatment indicators of social relationships and the association between these interpersonal variables and post-treatment drinking and subjective wellbeing. This is a secondary analysis of data from an alcohol treatment outcome study, in which subjects were randomly assigned to one of three treatment conditions and followed for 18 months. The outpatient treatment program is located within a private psychiatric hospital in the north-eastern United States. We analyzed the 140 subjects who completed a social network instrument 12 months following treatment assignment. This secondary analysis combined clients from three treatment conditions, all of which were based upon social learning theory. Interview and questionnaire self-report data were collected by trained interviewers. Indicators of social relationships are found to be relatively independent of one another. Only alcohol-specific social relationship indicators are significantly associated with drinking outcomes, and only general indicators are significantly associated with subjective wellbeing. Functional indicators, addressing social interaction content, have stronger effects on outcomes than structural or quality indicators. General and alcohol-specific support from friends have more influence than support from family; both surpass the influence of co-workers. A better understanding of the roles of social relationships during the course of treatment and recovery or relapse may help clarify how treatment personnel can utilize clients' interpersonal relationships more effectively to maximize treatment effectiveness.

Alcohol treatment outcome methodology: State of the art 1989–1993

This article reviews the 61 alcohol treatment outcome studies published from 1989–1993 with respect to methodology. Although better assessment of subjects' pretreatment characteristics was noted, a minority of studies met even the basic requirements of experimental studies. Further, some reversals of methodological progress were observed in several areas, particularly in collecting outcome data from multiple sources. It is suggested that funding agencies and journal editors require that submissions meet minimum standards for adequate outcome evaluation.

Aftercare telephone contacts with problem drinkers can serve a clinical and research function.

Research staff typically gather treatment outcome data, whereas clinicians perform aftercare contacts. To date no alcohol treatment outcome study has examined the utility of therapists collecting outcome data through aftercare contacts. Using the Alcohol Timeline Followback (TLFB) method modified for clinical aftercare contacts, 154 problem drinkers who were part of a cognitive-behavioral intervention completed the modified TLFB with their primary therapist during aftercare telephone contacts conducted 1 and 3 months after their last treatment session. Clients reported their daily alcohol use over the past 30 days using four consumption categories (i.e. 0 drinks, 1-4 drinks, 5-9 drinks and 10+ drinks). At a 6-month follow-up research interview, a trained research assistant gathered standard TLFB data from the clients that included the time period for aftercare contacts. Correlations between the two TLFB formats showed good alternate form reliability, especially for frequency of alcohol use. Discrepancies between reports were positively associated with heavier pre-treatment and post-treatment drinking, suggesting possible memory biases among heavier drinkers. Subject reports also closely paralleled collateral reports of the subjects' drinking. These results support the utility of a brief TLFB instrument for use by therapists in assessing clients' outcomes by telephone during aftercare contacts.

Alcoholism treatment outcome studies, 1980–1992: The nature of the research

We reviewed 339 alcoholism treatment outcome studies reported between 1980 and 1992. After comparing single and multiple treatment group studies, we focus on multiplegroup studies, examining and comparing principal investigator and study characteristics, patient characteristics, treatment modalities and characteristics, and follow-up points and outcome variables in published and unpublished studies. This article provides an overview of the nature of the alcoholism treatment outcome research reported in the English language over the 13-year review period.

Alcoholism treatment outcome studies, 1980–1992: Methodological characteristics and quality

We examine the methodological characteristics and provision of study information in 339 alcoholism treatment outcome studies reported between 1980 and 1992. We consider factors in four methodological domains: sampling and description of patients, specification of treatments, outcome variable assessment and follow-up, and treatment effect estimates; we also consider the methodological quality of the studies. Although methodological quality has improved over time, there remains room for improvement. Of special concern is the low statistical power of many studies. Multiple treatment group studies had an average .54 probability of detecting a treatment effect of medium size.