Treatment For Alcohol Problems Research Articles

A randomized study of cellphone technology to reinforce alcohol abstinence in the natural environment

Contingency management (CM) uses tangible incentives to systematically reinforce abstinence and is among the most efficacious psychosocial substance abuse treatments. This study assessed the feasibility and initial efficacy of a portable CM procedure designed to address technical limitations for detecting drinking that have prevented using CM for alcohol problems. Participants received a cellphone, breathalyzer and training on video-recording alcohol breath tests (BrACs) and texting results. For 4 weeks, staff texted participants one to three times daily indicating that a breath alcohol concentration test (BrAC) was due within the hour. Participants were randomized to (1) modest compensation for submitting dated time-stamped BrAC videos regardless of results or (2) the same plus CM with escalating vouchers for on-time alcohol-negative tests (n-BrAC; <02 g/dl). 'Thank-you' texts were sent, with CM patients also informed of results-based earnings. Participants' natural environment. Adults (n = 30; ≥ 21 years) who drank frequently but were not physiologically dependent. Drinking and related problems were assessed at intake and week 4. BrACs and self-reports of drinking were collected throughout. The primary outcome was the percentage of n-BrACs. Other outcomes were the longest duration of consecutive n-BrACs (longest duration of abstinence) and self-reports of drinking. On average, 88.6% (10.4%) of BrACs were submitted on time, without group differences (P = 0.18). The percentage of n-BrACs and LDA were greater with CM, and there was an interaction effect on drinking frequency and negative consequences, with decreases over time with CM (P = 0.00; effect sizes d = 0.52-0.62). Cellphone technology may be useful for extending contingency management to treatment for alcohol problems.

Brief Intervention for Risk‐Drinking Women: A Mixed Methods Analysis of Content and Process

Although brief interventions (BIs) are among the most highly promoted treatments for alcohol problems, their effective components are unknown. This may be particularly important when considering women since some reviews have suggested that BIs are more efficacious among men. The purpose of this pilot study is to utilize a mixed methods and gender analysis approach to generate hypotheses about the effective components of BIs given to women with medical problems exacerbated by problem drinking. Random sample of 20 BIs given to women with diabetes, hypertension, infertility, or osteoporosis. Quantitative and qualitative analytic methods were undertaken in a stepwise progression, followed by a gender analysis using the Worldview Assessment Framework. Main findings include that a worldview encompassing drinking as an entitlement may be a moderator limiting the effectiveness of a BI, that understanding the impact of alcohol on infertility problems as distinct from prenatal alcohol use may be a mediator for BI effectiveness, and that providing information about sensible drinking limits in the context of a specific medical problem was feasible. Content and process areas are important to consider when offering BI for risk-drinking women with medical problems and may help to improve treatment efficacy in this group.

Efficacy of IVR-Based Brief Intervention for Alcohol Problems

Efficacy of IVR-Based Brief Intervention for Alcohol Problems

The Role of Military and Veterans Affairs Chaplains in the Treatment of Alcohol Problems

Chaplains can play a unique and valuable role in the treatment of alcohol dependence, a condition that has physical, psychological, and spiritual dimensions. To best fulfill this role, chaplains need to have a broad understanding of the nature of alcohol problems and current strategies for effectively interacting with individuals who have these problems, especially those with severe problems, and with their families. This article is designed to expand the chaplain’s knowledge about alcohol use disorders as well as evidence-based treatments and to offer recommendations on how chaplains can promote recovery of individuals with alcohol-related problems.

Evidence from regression‐discontinuity analyses for beneficial effects of a criterion‐based increase in alcohol treatment

Brief interventions effectively reduce alcohol problems; however, it is controversial whether longer interventions result in greater improvement. This study aims to determine whether an increase in treatment for people with more severe problems resulted in better outcome. We employed regression-discontinuity analyses to determine if drinking driver clients (n = 22,277) in Ontario benefited when they were assigned to a longer treatment program (8-hour versus 16-hour) based on assessed addiction severity criteria. Assignment to the longer16-hour program was based on two addiction severity measures derived from the Research Institute on Addictions Self-inventory (RIASI) (meeting criteria for assignment based on either the total RIASI score or the score on the recidivism subscale). The main outcome measure was self-reported number of days of alcohol use during the 90 days preceding the six month follow-up interview. We found significant reductions of one or two self-reported drinking days at the point of assignment, depending on the severity criterion used. These data suggest that more intensive treatment for alcohol problems may improve results for individuals with more severe problems.

Can screening and brief intervention lead to population-level reductions in alcohol-related harm?

A distinction is made between the clinical and public health justifications for screening and brief intervention (SBI) against hazardous and harmful alcohol consumption. Early claims for a public health benefit of SBI derived from research on general medical practitioners’ (GPs’) advice on smoking cessation, but these claims have not been realized, mainly because GPs have not incorporated SBI into their routine practice. A recent modeling exercise estimated that, if all GPs in England screened every patient at their next consultation, 96% of the general population would be screened over 10 years, with 70-79% of excessive drinkers receiving brief interventions (BI); assuming a 10% success rate, this would probably amount to a population-level effect of SBI. Thus, a public health benefit for SBI presupposes widespread screening; but recent government policy in England favors targeted versus universal screening, and in Scotland screening is based on new registrations and clinical presentation. A recent proposal for a national screening program was rejected by the UK National Health Service’s National Screening Committee because 1) there was no good evidence that SBI led to reductions in mortality or morbidity, and 2) a safe, simple, precise, and validated screening test was not available. Even in countries like Sweden and Finland, where expensive national programs to disseminate SBI have been implemented, only a minority of the population has been asked about drinking during health-care visits, and a minority of excessive drinkers has been advised to cut down. Although there has been research on the relationship between treatment for alcohol problems and population-level effects, there has been no such research for SBI, nor have there been experimental investigations of its relationship with population-level measures of alcohol-related harm. These are strongly recommended. In this article, conditions that would allow a population-level effect of SBI to occur are reviewed, including their political acceptability. It is tentatively concluded that widespread dissemination of SBI, without the implementation of alcohol control measures, might have indirect influences on levels of consumption and harm but would be unlikely on its own to result in public health benefits. However, if and when alcohol control measures were introduced, SBI would still have an important role in the battle against alcohol-related harm.

Gender differences in the correlates of hazardous drinking among Iraq and Afghanistan veterans

BackgroundDespite increasing numbers of women veterans from the Iraq and Afghanistan conflicts, few studies have examined hazardous drinking in this group. The present study examined the prevalence of and risk and protective factors for hazardous drinking in a community-based sample of men and women veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND). MethodsVeterans completed a structured survey that assessed hazardous drinking using the Alcohol Use Disorders Identification Test (AUDIT), and a broad range of demographic, life history, and psychopathology variables. Correlations and multivariate logistic regression analyses were conducted to examine risk and protective factors associated with hazardous drinking. ResultsA total 30.2% of male veterans and 16.3% of female veterans screened positive for hazardous drinking. In a multivariate analysis in male veterans, younger age, lifetime exposure to assaultive trauma, and conflict in interpersonal relationships were independently associated with hazardous drinking (p<.05). Among women veterans, younger age and posttraumatic stress disorder (PTSD) symptoms were independently associated with hazardous drinking in a multivariate analysis (p<.05). Secondary analyses of PTSD symptom clusters revealed that emotional numbing symptoms were independently related to hazardous drinking in women veterans (p<.05). ConclusionsResults of this study suggest that hazardous drinking is prevalent in both men and women OEF/OIF/OND veterans and is more likely to occur at younger ages. In addition, results indicate gender differences in the association between hazardous drinking and lifetime trauma history, PTSD symptoms, and interpersonal conflict, which may have important implications for the treatment of alcohol problems in men and women veterans.

The Effectiveness of Psychosocial Modalities in the Treatment of Alcohol Problems in Adults: A Review of the Evidence

Our objectives were to review the effectiveness of psychosocial modalities in the treatment of alcohol use disorders and problems, and to examine the impact of therapists on treatment outcome, the evidence on best practices for comorbid conditions, and the evidence on treatment matching. We based our review on published systematic reviews of this topic after 2000. There is strong evidence that some, but not all, psychosocial treatments are effective in treating alcohol problems. Those with the strongest empirical support are motivational enhancement therapy, various cognitive-behavioural interventions, and brief interventions. Meta-analyses for several of these modalities suggest typical effect sizes in the low-to-moderate range. When these modalities have been compared with one another in well-designed clinical trials, they have been shown to be of comparable effectiveness. There is little basis on which to recommend one of these modalities over another but good reason to select from among them.

Could an advance practice nurse improve detection of alcohol misuse in the emergency department?

Alcohol misuse is a prevalent problem in New Zealand society, and one that exacts a considerable cost in terms of health, social cohesion, and economic productivity. Despite the burden of alcohol misuse, screening, brief assessment, and interventions for alcohol problems are frequently poorly performed within general health services. In this paper we explore the response to alcohol problems in a New Zealand emergency department and discuss difficulties encountered in improving rates of detection by emergency department personnel. We report the results of a clinical audit of alcohol screening and brief assessment and a staff education programme designed to improve practice in this area, but which met with limited success. The potential role for an advanced practice nurse providing a clinical consultation and liaison service to the emergency department staff is explored. We argue that such a role has potential to reduce the health and social costs of alcohol misuse, and to meet the national policy objective of providing a treatment response to people with alcohol-related problems in contact with health services.

Treating Alcohol Problems With Couple Therapy

Couple therapy for treating alcohol use disorders (AUDs) results in less drinking and greater relationship stability and satisfaction in both men and women with AUDs. The theoretical tenets, treatment methods, and research evidence for Alcohol Behavioral Couple Therapy (ABCT) are summarized. The application of ABCT is illustrated through the treatment of a 42-year-old woman with an AUD and her 56-year-old husband. During 12 sessions over a 6-month period, the woman attained abstinence from alcohol and learned cognitive and behavioral coping skills to deal with drinking antecedents. Her husband learned to support her abstinence by stopping drinking himself, helping her cope with drinking urges, and reinforcing her successes. The couple increased positive pleasurable activities that did not involve alcohol and improved their communication skills. Challenges in the treatment included her ambivalence about abstaining, their complicated work and travel schedules, and other life stressors.

Screening and brief intervention for alcohol problems in Dr George Mukhari Hospital out-patients in Gauteng, South Africa: a single-blinded randomized controlled trial protocol

BackgroundFor alcohol drinkers in South Africa it has been found that annual consumption per drinker is among the highest in the world. High prevalence rates of hazardous and harmful alcohol use have also been found in a hospital out-patient setting in South Africa. Hospital settings are a particularly valuable point of contact for the delivery of brief interventions because of the large access to patient populations each year. With this in mind, the primary purpose of this randomized controlled trial is to provide screening for alcohol misuse and to test the efficacy of brief interventions in reducing alcohol intake among hospital out-patients in South Africa.Methods/DesignThe study design for this efficacy study is a randomised controlled trial with 6- and 12-month follow-ups to examine the effects of a brief alcohol intervention to reduce alcohol use by problem drinkers in a hospital setting. The unit of randomisation is the individual out-patient identified as a medium risk drinker attending Dr George Mukhari Hospital. Out-patients will be screened for alcohol problems, and those identified as medium risk drinkers will be randomized into an experimental or control group. The experimental group will receive one brief counselling session on alcohol risk reduction, while the control group will receive a health education leaflet.DiscussionThe trial will evaluate the impact of alcohol screening and brief interventions for patients with alcohol problems in a hospital out-patient setting in South Africa. The findings will impact public health and will enable the health ministry to formulate policy related to brief alcohol interventions, which will result in reduction in alcohol use.Trial registrationPACTR201110000319392

Alcohol problems in a remand Scottish prisoner population.

Alcohol misuse is internationally recognised as a major public health problem. The link between alcohol and crime is strong and offenders have a higher prevalence of alcohol problems when compared with the general population. Alcohol-related crime is estimated to cost the Scottish economy over £700 m per annum. The purpose of this paper is to measure the nature and prevalence of Alcohol Use Disorders (AUDs) in adult male prisoners on remand in a prison in Scotland. Using the Alcohol Use Disorders Identification Test (AUDIT) screening tool, all new remand prisoners were screened over a two week period. Prevalence of alcohol problems within the sample was high: 73 per cent of the sample was identified with an AUD, with 43 per cent with scores indicating possible alcohol dependence. This is the first study to focus solely on a remand prisoner population and the results show high levels of need. The criminal justice setting is ideally placed to identify and treat alcohol problems in this hard to reach population.

Mental health experts' perspectives on barriers to dissemination of couples treatment for alcohol use disorders.

Despite evidence supporting the efficacy of couples-based approaches to treating alcohol problems, provision of such treatments has been limited. To better understand the limited use of this treatment, the current study explored barriers to the adoption of couples treatment for alcohol use disorders. Experts in alcohol treatment, couples treatment, and behavioral couples treatment for alcohol problems (n = 12) were interviewed on this topic; interview transcripts were analyzed using grounded theory qualitative procedures. All mental health experts endorsed the perspective that implementation and acceptance of couples treatment posed difficulties for providers. Four themes (logistical barriers at the provider level, logistical barriers at the system levels, provider treatment preferences, and lack of appropriate training) were identified. Results from the current study provide guidance in addressing barriers to the adoption of couples-based treatments.

Meeting in the middle: motivational interviewing and self-determination theory.

Motivational interviewing (MI) is indeed a bottom-up model that emerged from practical experience in the field of alcohol treatment. The original description of MI [1] suggested some links to social psychological theories, but focused on an intuitive approach in treating alcohol problems for which there was at the time no empirical support. Our subsequent volumes [2,3] have similarly focused on clinical applications without proposing an underlying theory of treatment or change. In part this reflects our own temperaments, preferring intuitive to rational-deductive ways of knowing [4,5], with a focus on the real world of clinical practice. We are bottom-up people. Much of what we have done in our careers has sprung from efforts to deal with practical problems that clinicians encounter in their daily work [6]. The world of academia, in contrast, tends to place a high premium on starting from coherent theory and rationally deriving hypotheses that will be tested to either confirm or revise the theory. This has simply never been a forte or primary scientific interest for either of us, to the dismay of some of our mentors and colleagues. We have preferred instead to move between the context of discovery and the context of justification [7] - deriving intuitive hypotheses from clinical experience, submitting them to the verification of scientific method, and then going back to the drawing board to try again. Over time, this approach may lead to the development of a higher-order theory as a byproduct [8]. The rigor of scientific method is equally important in both approaches. They differ in the source of hypotheses: intuitive experience versus rational deduction from a pre-existing theory. Both approaches have value and a long tradition in the history of science. Whether either one is in some sense superior to the other is a value judgment that we do not wish to make. The history of MI, however, does suggest potential value in beginning from clinical intuition. A large evidence base comprising more than 200 randomized clinical trials has emerged, showing positive effects (albeit inconsistent) across many health problem areas. Well before this evidence base accumulated, however, MI disseminated readily and rapidly by word of mouth among clinicians, who are drawn to it not just from the clinical trials but because, for the lack of a better term, they seem to recognize it. It feels intuitively sound based on their own experience. This kind of practice-based evidence is also important, and needs to be compared, tested and refined with clinical trials. Hall [9] suggested a similar two-way street in psychotherapy research with cultural minorities. Evidence-based treatments are worth trying in populations where they have not yet been tested [10], and there is also a need for scientific study of the intuitive interventions that have arisen from an indigenous culture's own wisdom and experience. So what about Self-Determination Theory (SDT) that grew up independently from MI, but bears a certain family resemblance? There may be a natural fit [11]. MI has lacked a well-developed theory to rationalize its efficacy. SDT has focused less on refining specific clinical procedures for putting it into practice. A marriage may be premature, but the flirtation is not. The three human hungers emphasized in SDT - autonomy, relatedness, and competence - are all directly addressed in MI. More than most psychotherapies, MI assumes, respects, and implicitly relies on volition to instigate self-regulation [12]. The emerging psycholinguistic mechanisms of MI [8,13,14] can be linked to the more general development of volition and self-regulation through language [15]. The relational component of MI also appears to be important [8], consistent with SDT. Supporting autonomy is a key element in the underlying spirit of MI. SDT and MI, it would seem, have much to learn from each other. SDT also holds promise for improving our understanding of MI. A puzzling aspect in MI clinical research is the inconsistency of its outcomes. There are many positive trials, but also an impressive number of negative trials, including some of our own [16]. SDT may help to clarify the conditions that contribute to the effectiveness of MI in practice. MI has been faulted for underemphasizing social context [17], a factor that is clearly integrated in SDT, and a well-supported theory never hurts the academic credibility of any psychotherapy. Is SDT more than just another pair of theoretical glasses through which to view the phenomena of MI? Will SDT lead to unique testable hypotheses that teach us important things about MI that we didn't already know? It remains to be seen. We do not propose to develop such a systematic integration ourselves, but we gladly offer our support to those whose aptitudes and inclinations lie in this direction.

MISLEADING CONCLUSIONS FROM CLINICAL RESEARCH

Alcohol dependence is a chronic remitting disorder—for some; but clearly not for all, as Cunningham & McCambridge observe in their thought-provoking paper 1. Several epidemiological studies around the world, at least the western world, confirm that the majority of people who at one point in time fulfil the criteria for alcohol dependence no longer do so a few years later on. It is also evident that this disorder, like most other disorders, varies in severity. Most people seem to develop it in a mild form, typically in young adulthood, and then appear to mature out of their drinking problems. In a recent Swedish study 2, approximately 75% of all subjects with dependence had a mild or moderate form of dependence, with three or four DSM-IV dependence criteria, and a minority, approximately 25%, had a more severe form, with five to seven criteria. How these epidemiological observations connect with neurobiological research is still unclear. In spite of impressive advances in this field we still do not understand why some people do not develop dependence at all, in spite of considerable exposure to alcohol, and how clinical severity and neurobiological measures of impairment correlate 3. Cunningham & McCambridge make an important point where they observe that most clinical and biological addiction research has been based on clinically selected samples. This limits generalizability, as the vast majority of people with alcohol dependence do not seek or receive treatment 4. Those who do tend to have more severe forms of addiction and/or more psychiatric comorbidity and other psychosocial trouble. Perhaps it is only in this group that significant structural changes in the brain or changes in biochemistry will be found—and perhaps it is mainly in this group that the chronic remitting form of alcohol dependence is found. More studies are required on the less severe end of the alcohol problems continuum to clarify this. One serious consequence of present popular conceptions about dependence and its treatment is that they leave the majority of alcohol-dependent people without help from the treatment system. This is troublesome for the individuals concerned and their families, as well as for the wider community. As Cunningham & McCambridge rightly observe, the epidemiological paradox applies to the alcohol field as much as to other health fields, where most of the suffering and costs are generated in the majority with lower severity. There has been general agreement for at least 20–30 years that treatment for alcohol problems needs a broader base in the community 5. However, so far little progress has been made in this regard. Despite impressive evidence of effectiveness, screening and brief intervention for alcohol problems has not yet been integrated into routine practice. One reason for this failure is probably the concern that screening will reveal not only hazardous or harmful drinking, but alcohol dependence as well, and that this disorder is considered too complicated to manage in primary care. This view of alcohol dependence is largely a result of clinical research based on the most severe cases. Clinical research, experiences among practitioners, popular perceptions of addiction, all contribute to a vicious circle. Drinking problems are managed mainly without treatment because treatment is unattractive. The barriers to treatment are overcome only when the trouble becomes very severe, reinforcing the perception that alcohol dependence is a very severe disorder. As this view is shared by general practitioners, other non-specialists and the general population alike, only people with the chronic remitting form of the disorder will be found in treatment—and will form the basis for further studies of the disorder. What is needed now is, on one hand, neurobiological research on the majority of alcohol-dependent people who do not seek treatment and, on the other hand, research on how people in this group view their condition and what kind of help—if any—they want. A reasonable hypothesis is that many people with alcohol dependence realize that they are drinking too much, but reject help from the formal addiction treatment system because they do not identify with the majority of severely dependent, socially marginalized people who are being treated today. For practitioners, the major challenge is to make treatment for alcohol dependence more attractive to the large majority. Researchers have the responsibility to convey to practitioners a correct picture of alcohol dependence as a mainly time-limited disorder of mild or moderate severity and equip them with adequate tools to manage this disorder. None.

Fifty years of brief intervention effectiveness trials for heavy drinkers

Fifty years of brief intervention effectiveness trials for heavy drinkers

An evaluation of an alcohol awareness group for learning disabled offenders in a secure setting

PurposeIndividuals with learning disabilities (LD) who offend are more likely to be dependent on alcohol than those who do not. There is strong evidence to suggest that interventions for alcohol problems can be effective; this paper aims to address this issue.Design/methodology/approachThe pre and post assessment scores from an alcohol awareness group (AAG) were collected from 34 service users with LD or a dual diagnosis of LD and mental health problems. The programme was manual led and included 12 sessions. The data collected were used to evaluate the programme.FindingsClients' level of knowledge and self efficacy increased after programme completion. Post group, those with a lower IQ had gained a greater level of alcohol‐related knowledge compared to those with a higher IQ. Clients with a learning disability alone scored slightly higher than those with a dual diagnosis.Originality/valueThe AAG has been successful in increasing motivation to change drinking behaviour, knowledge of problems related to alcohol, and “safe drinking” practice. These outcomes have been achieved across a wide range of cognitive abilities suggesting that those with an IQ below 60 can also benefit from this type of intervention.

Alcohol Treatment in Native North America: Gender in Cultural Context

Using ethnographic findings from two community-based substance abuse programs for indigenous peoples in the United States and Canada, this article examines how greater attention to cultural context can help to inform the treatment of alcohol problems among Native North American women. Cultural context shapes not only therapeutic activities and interactions within substance abuse programs, but also how such programs develop within different communities. These findings add to the growing evidence that gender can powerfully shape how Native American clients engage spiritual resources and respond to conventional styles of psychotherapeutic talk, supporting emergent efforts to rethink “cultural competency” in mental health services for Native North Americans.

Marital Status and Treatment Utilization for Alcohol Use Disorders

Objectives Marital status influences observed rates of alcohol use disorders (AUDs), and married and cohabiting (ie, partnered) individuals may be less likely than separated, divorced, or widowed (previously married) individuals to seek treatment for alcohol problems. To guide dissemination of treatment for partnered individuals, this study examined the representation of AUDs among individuals from different marital status groups, and examined the interaction between AUD status and marital status on prior-year alcohol treatment utilization. Methods Respondents included individuals who met criteria for a past-year AUD (N=3327) from the National Epidemiologic Survey on Alcohol and Related Conditions. Analyses were conducted that examined the association between marital and AUD status, and the interaction between marital and AUD status on past-year alcohol treatment utilization. Results Results confirmed that partnered individuals were overrepresented among individuals with an alcohol abuse diagnosis. Low rates of alcohol treatment utilization were present across marital groups. Among those with an alcohol abuse diagnosis, partnered individuals were less likely to seek treatment than previously married individuals. Conclusions Few individuals meeting criteria for an AUD used alcohol treatment, indicating a great need for dissemination of alcohol treatments. Partnered individuals with an alcohol abuse diagnosis are a group that may benefit particularly from efforts to disseminate efficacious treatments tailored to the needs of individuals in a committed romantic relationship.

Factors Related to Recent Alcohol Abstinence among Individuals Who Received Previous Treatment

Background: Alcohol problems are widespread throughout the United States. While treatment can be successful, many individuals continue to drink. One method to assess treatment results over time is by investigating abstinence as a measure of success. Objectives: The main aim of this study is to investigate factors that may be associated with past-year (PY) abstinence among individuals who received prior-to-past-year (PPY) treatment for alcohol problems, while also assessing abstinence by treatment subtype. Method: This study uses data from 1742 individuals who received PPY treatment for alcohol problems in the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Logistic regression models were used to assess the strength of association between alcohol abstinence and key demographic and clinical factors. Results: The level of PY abstinence was 36.5% among those who previously sought treatment for alcohol problems. Younger age groups and those who were nicotine dependent or had a cannabis use disorder were less likely to be abstinent. There were no differences based on sex or PY major depression or generalized anxiety disorder. Conclusion: While causal inferences cannot be made, these results suggest that the majority of people continue to drink, even after being treated for alcohol problems. Nonetheless, variation may exist depending on the form of treatment a person receives. More research is needed regarding long-term levels of abstinence after individuals receive treatment.