Mediational Analyses of the Effects of Social Behaviour and Network Therapy on Alcohol Use.

INTRODUCTION: Social behaviour and network therapy involves an active participation of the practitioner in recruiting a supportive network to change the client's alcohol use. Despite achieving beneficial effects on alcohol consumption, its possible mechanisms of change are a relatively under-studied topic compared to those of other alcohol treatment interventions. This study aimed to explore therapist skills through which social behaviour and network therapy may achieve effects on alcohol consumption in comparison with motivational enhancement therapy. METHODS: This study was secondary analysis of data from the UK Alcohol Treatment Trial, a multicentre, pragmatic, randomized controlled trial. The sample comprised 376 participants randomized to motivational enhancement therapy or social behaviour and network therapy. We used the UK Alcohol Treatment Trial Process Rating Scale to assess therapist skills. Outcomes drinks per drinking day and percentage of days abstinent were assessed 12 months after treatment initiation. Analyses were conducted in a simple mediation framework. RESULTS: Therapist skills score (combining frequency and quality) for involving others in behaviour change mediated social behaviour and network therapy effects on percentage of days abstinent (b = 0.06, 95% CI: 0.02; 0.10, p = 0.01). The frequency with which therapists acted as an active agent for change also mediated the effects of social behaviour and network therapy on percentage of days abstinent (b = 0.03, 95% CI: 0.003; 0.05, p = 0.03). The frequency with which the therapist stressed social support as a key factor in achieving change unexpectedly mediated an increase in drinks per drinking day (b = 0.10, 95% CI: 0.01; 0.18, p = 0.02). The two latter mediation effects were not sustained when quality was considered. All other indirect effects tested were non-significant. DISCUSSION/CONCLUSIONS: How social behaviour and network therapy exerts effects on alcohol outcomes is not yet well understood and in this study was not attributable to observed ratings of therapist treatment-specific skills. Therapist skill in planning the involvement of others during treatment, however, warrants further study. We suggest that the present findings should be regarded as hypothesis generating as it identifies specific targets for further investigation in alcohol treatment process studies.

Serial mediation analysis of treatment-specific processes in two contrasting alcohol treatments.

INTRODUCTION: This study explored whether treatment-specific processes linking therapist behaviors, post-session client ratings, and 3-month proximal outcomes (i.e., end of treatment) can explain 12-month outcomes for two contrasting alcohol treatment conditions with equivalent overall outcomes. METHODS: This study is a secondary analysis of the UK Alcohol Treatment Trial (UKATT), a multi-center randomized controlled trial of treatment for alcohol problems comparing 3-session motivational enhancement therapy (MET) to 8-session social behaviour and network therapy (SBNT). Among 742 adult clients included in UKATT, 351 had one treatment session recorded and coded and were followed-up 3 and 12 months after baseline. The study team conducted serial mediation analyses to test whether the frequency and quality of MET and SBNT skills were related to 12-month alcohol outcomes (drinks per drinking day) through postsession client ratings of treatment progress (Processes of Change Questionnaire, PCQ), readiness to change (RTC) and social support for drinking after 3-months. RESULTS: Higher quality of MET skills was related to higher PCQ scores, which were in turn related to greater post-treatment RTC, and subsequently to better alcohol outcomes. Total indirect effect was consistently significant. In contrast, only PCQ was predictive of treatment outcome in the SBNT portion of the model. CONCLUSIONS: This study provides evidence from a large pragmatic trial that the quality of MET skills positively influences alcohol outcomes in part through improvements in motivation during treatment and actively trying to change when treatment ends. Research should explore the ways in which SBNT secured outcomes that were equivalent to MET.

¿Un cambio de paradigma para la ciencia de la adicción? / A paradigm shift for addiction science?

Este artículo parte de la base de que en la actualidad se está produciendo una transformaciónradical en la ciencia de las adicciones y se pregunta si puede considerarse útil como un “cambiode paradigma” kuhniano. El rompecabezas de la adicción es que las personas etiquetadas comoadictas persisten en comportarse de manera que saben que se dañan a sí mismas y a los demás. Enla “ciencia oficial” actualmente dominante, la respuesta a este enigma es que el comportamientoadictivo representa una especie de compulsión causada por una enfermedad del cerebro. Sinembargo, esto se contradice con los hallazgos anómalos de varios tipos de pruebas que indicanque el comportamiento adictivo no es automático y obligado, sino voluntario e intencionado. Portanto, el paradigma emergente se basa en la suposición de que el comportamiento adictivo esun trastorno de elección. Cómo se puede resolver el rompecabezas de la adicción es la primeratarea que debe abordarse bajo este nuevo paradigma, pero se sugieren algunas posibilidades. Sise cree que la evidencia de la neuroimagen es prueba suficiente de que la adicción debe ser unaenfermedad cerebral, se ofrecen razones de por qué tal creencia es infundada. Se exploran lasimplicaciones para el tratamiento y la prevención de la adicción derivadas del nuevo paradigma. Elartículo concluye señalando que la existencia de la Red de Teoría de la Adicción (Addiction TheoryNetwork) demuestra que el autor no es el único que cree que es posible un cambio de paradigmaen la ciencia de la adicción y alertando al lector sobre un próximo libro de varios autores en el quese examina exhaustivamente la validez del modelo de enfermedad cerebral de la adicción. (AU)

This article assumes that a radical transformation is currently occurring in addiction science andasks whether this can usefully be seen as a Kuhnian ‘paradigm shift’. The puzzle of addiction isthat people labelled as addicts persist in behaving in ways they know cause harm to themselvesand others. In the currently dominant ‘normal science’, the answer to this puzzle is that addictive behaviour represents a kind of compulsion caused by a disease of the brain. However, thisis contradicted by anomalous findings from several types of evidence that addictive behaviouris not automatic and compelled but is voluntary and intentional. The emerging paradigm istherefore based on the assumption that addictive behaviour is a disorder of choice. How thepuzzle addiction can be solved is the first task to be addressed under this new paradigm butsome possibilities are suggested. If it is believed that evidence from neuroimaging is sufficientproof that addiction must be a brain disease, reasons are provided for why such a belief isunfounded. Implications for the treatment and prevention of addiction arising from the newparadigm are explored. The article concludes by pointing out that the existence of the Addiction Theory Network shows that the author is not alone is believing that a paradigm shift inaddiction science is possible and by alerting the reader to a forthcoming multi-authored bookin which the validity of the brain disease model of addiction is comprehensively examined. (AU)

A paradigm shift for addiction science? / ¿Un cambio de paradigma para la ciencia de la adicción?

This article assumes that a radical transformation is currently occurring in addiction science andasks whether this can usefully be seen as a Kuhnian ‘paradigm shift’. The puzzle of addiction isthat people labelled as addicts persist in behaving in ways they know cause harm to themselvesand others. In the currently dominant ‘normal science’, the answer to this puzzle is that addictive behaviour represents a kind of compulsion caused by a disease of the brain. However, thisis contradicted by anomalous findings from several types of evidence that addictive behaviouris not automatic and compelled but is voluntary and intentional. The emerging paradigm istherefore based on the assumption that addictive behaviour is a disorder of choice. How thepuzzle addiction can be solved is the first task to be addressed under this new paradigm butsome possibilities are suggested. If it is believed that evidence from neuroimaging is sufficientproof that addiction must be a brain disease, reasons are provided for why such a belief isunfounded. Implications for the treatment and prevention of addiction arising from the newparadigm are explored. The article concludes by pointing out that the existence of the Addiction Theory Network shows that the author is not alone is believing that a paradigm shift inaddiction science is possible and by alerting the reader to a forthcoming multi-authored bookin which the validity of the brain disease model of addiction is comprehensively examined. (AU)

Este artículo parte de la base de que en la actualidad se está produciendo una transformaciónradical en la ciencia de las adicciones y se pregunta si puede considerarse útil como un “cambiode paradigma” kuhniano. El rompecabezas de la adicción es que las personas etiquetadas comoadictas persisten en comportarse de manera que saben que se dañan a sí mismas y a los demás. Enla “ciencia oficial” actualmente dominante, la respuesta a este enigma es que el comportamientoadictivo representa una especie de compulsión causada por una enfermedad del cerebro. Sinembargo, esto se contradice con los hallazgos anómalos de varios tipos de pruebas que indicanque el comportamiento adictivo no es automático y obligado, sino voluntario e intencionado. Portanto, el paradigma emergente se basa en la suposición de que el comportamiento adictivo esun trastorno de elección. Cómo se puede resolver el rompecabezas de la adicción es la primeratarea que debe abordarse bajo este nuevo paradigma, pero se sugieren algunas posibilidades. Sise cree que la evidencia de la neuroimagen es prueba suficiente de que la adicción debe ser unaenfermedad cerebral, se ofrecen razones de por qué tal creencia es infundada. Se exploran lasimplicaciones para el tratamiento y la prevención de la adicción derivadas del nuevo paradigma. Elartículo concluye señalando que la existencia de la Red de Teoría de la Adicción (Addiction TheoryNetwork) demuestra que el autor no es el único que cree que es posible un cambio de paradigmaen la ciencia de la adicción y alertando al lector sobre un próximo libro de varios autores en el quese examina exhaustivamente la validez del modelo de enfermedad cerebral de la adicción (AU)

An application of moderated nonlinear factor analysis to develop a commensurate measure of alcohol problems across four alcohol treatment studies.

BACKGROUND: Self-report measures of alcohol problems are commonly included in studies evaluating treatment and recovery from alcohol use disorder (AUD), but no prior study has examined the replicability of the measurement of alcohol problems across studies with various measures and diverse samples. Further, it is unclear which items may be better indicators of alcohol problems for patient subgroups. In the present study, we integrated data from four large alcohol treatment studies to develop a commensurate measure of alcohol problems using moderated nonlinear factor analysis (MNLFA). METHODS: Data were from the COMBINE study, Project MATCH, the Relapse Replication and Extension Project (RREP), and the United Kingdom Alcohol Treatment Trial (UKATT), yielding a total sample size of 4414. MNLFA was carried out on the Drinker Inventory of Consequences (COMBINE, MATCH, RREP) and Alcohol Problems Questionnaire (UKATT). RESULTS: We successfully created a 78-item commensurate measure of alcohol problems and examined differential item functioning (DIF) by study membership, time, and socio-demographic characteristics. Sixty-two items demonstrated intercept DIF, suggesting differences in rates of item endorsement for clients with the same underlying levels of alcohol problems across patient subgroups. Six items demonstrated loading DIF, suggesting differences in the extent to which the items were indicative of alcohol problems across patient subgroups. CONCLUSIONS: The self-reported measurement of alcohol problems replicates across measures and diverse samples. Items with DIF have clinical implications for the treatment of AUD. Finally, MNLFA scores can be used to test substantive research questions across these studies.

The "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) Core Outcome Set: International Consensus on Outcomes to Measure in Efficacy and Effectiveness Trials of Alcohol Brief Interventions.

OBJECTIVE: The purpose of this study was to report the "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) recommended core outcome set (COS) to improve efficacy and effectiveness trials/evaluations for alcohol brief interventions (ABIs). METHOD: A systematic review identified 2,641 outcomes in 401 ABI articles measured by 1,560 different approaches. These outcomes were classified into outcome categories, and 150 participants from 19 countries participated in a two-round e-Delphi outcome prioritization exercise. This process prioritized 15 of 93 outcome categories for discussion at a consensus meeting of key stakeholders to decide the COS. A psychometric evaluation determined how to measure the outcomes. RESULTS: Ten outcomes were voted into the COS at the consensus meeting: (a) typical frequency, (b) typical quantity, (c) frequency of heavy episodic drinking, (d) combined consumption measure summarizing alcohol use, (e) hazardous or harmful drinking (average consumption), (f) standard drinks consumed in the past week (recent, current consumption), (g) alcohol-related consequences, (h) alcohol-related injury, (i) use of emergency health care services (impact of alcohol use), and (j) quality of life. CONCLUSIONS: The ORBITAL COS is an international consensus standard for future ABI trials and evaluations. It can improve the synthesis of new findings, reduce redundant/selective reporting (i.e., reporting only some, usually significant outcomes), improve between-study comparisons, and enhance the relevance of trial and evaluation findings to decision makers. The COS is the recommended minimum and does not exclude other, additional outcomes.

The concept of akrasia as the foundation for a dual systems theory of addiction.

The aim of this article is to argue that the ancient concept of akrasia can serve as the conceptual foundation and theoretical justification for a dual systems theory of addiction. Akrasia refers to acting against one's better judgement and thus to behaviour that agents know is bad for them and have previously resolved to abjure, addiction being seen as an extreme form of akrasia. In this way akrasia can provide the basis for accounts of addictive behaviour that stress its inconsistency over time and the great difficulty addicts experience in changing it. A definition of addiction consistent with this view is offered and defended, and some of its general advantages for understanding and responding to addiction described. A consequence of defining addiction in this way is that it should be seen as a disorder of choice or, alternatively, of self-regulation, and reasons are given why the latter term should be preferred. It is then proposed that the concept of akrasia and the perspective on addiction that follows from it lead logically to the need for a dual systems theory of addiction. Although no such theory is presented here, terminological issues are clarified, criticisms of dual systems theories are noted, and a rudimentary description of what an integrated dual systems theory of addiction might look like is provided.

World Health Organization risk drinking level reductions are associated with improved functioning and are sustained among patients with mild, moderate and severe alcohol dependence in clinical trials in the United States and United Kingdom.

AIMS: To examine whether World Health Organization (WHO) risk-level reductions in drinking were achievable, associated with improved functioning and maintained over time among patients at varying initial alcohol dependence severity levels. Design and setting Secondary data analysis of multi-site randomized clinical trials: the US Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) study and the UK Alcohol Treatment Trial (UKATT). PARTICIPANTS: Individuals with alcohol dependence enrolled in COMBINE (n = 1383; 68.8% male) and seeking treatment for alcohol problems in UKATT (n = 742; 74.1% male). Interventions Naltrexone, acamprosate or placebo, and combined behavioral intervention or medication management in COMBINE. Social behavior network therapy or motivational enhancement therapy in UKATT. MEASUREMENTS: WHO risk-level reductions were assessed via the calendar method. Alcohol dependence was measured by the Alcohol Dependence Scale, the Leeds Dependence Questionnaire and the Diagnostic and Statistical Manual of Mental Disorders. Measures of functioning included alcohol-related consequences (Drinker Inventory of Consequences and Alcohol Problems Questionnaire), mental health (Short Form Health Survey) and liver enzyme tests. FINDINGS: One- and two-level reductions in WHO risk levels in the last month of treatment were maintained at the 1-year follow-up [adjusted odds ratio (OR), 95% confidence interval (CI) = one-level reduction in COMBINE: 3.51 (2.73, 4.29) and UKATT: 2.65 (2.32, 2.98)] and associated with fewer alcohol-related consequences [e.g. B, 95% CI = one-level reduction COMBINE: -26.22 (-30.62, -21.82)], better mental health [e.g. B, 95% CI = one-level reduction UKATT: 9.53 (7.36, 11.73)] and improvements in γ-glutamyltransferase [e.g. B, 95% CI = one-level reduction UKATT: -89.77 (-122.50, -57.04)] at the end of treatment, even among patients with severe alcohol dependence. Results were similar when abstainers were excluded. Conclusions Reductions in World Health Organization risk levels for alcohol consumption appear to be achievable, associated with better functioning and maintained over time in both the United States and the United Kingdom.

Recovery from addiction: Behavioral economics and value-based decision making.

Behavioral economics provides a general framework to explain the shift in behavioral allocation from substance use to substance-free activities that characterizes recovery from addiction, but it does not attempt to explain the internal processes that prompt those behavioral changes. In this article we outline a novel analysis of addiction recovery based on computational work on value-based decision making (VBDM), which can explain how people with addiction are able to overcome the reinforcement pathologies and decision-making vulnerabilities that characterize the disorder. The central tenet of this account is that shifts in molar reinforcer preferences over time from substance use to substance-free activities can be attributed to changes in evidence accumulation rates and response thresholds in the context of choices involving substance use and substance-free alternatives. We discuss how this account can be reconciled with the established mechanisms of action of psychosocial interventions for addiction and demonstrate how it has the potential to empirically address longstanding debates regarding the nature of impairments to self-control in addiction. We also highlight conceptual and methodological issues that require careful consideration in translating VBDM to addiction and recovery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

The Variability of Outcomes Used in Efficacy and Effectiveness Trials of Alcohol Brief Interventions: A Systematic Review.

OBJECTIVE: The purpose of this study was to characterize recent alcohol brief intervention (ABI) efficacy and effectiveness trials, summarize outcomes, and show how variability in outcomes and reporting compromises the evidence base. METHOD: A systematic review and narrative synthesis of articles from 10 databases were undertaken (January 2000-November 2017); study selection represented recent, readily available publications. The National Institute of Care Excellence (NICE) Public Health Guideline 24 (Alcohol use disorders: prevention) informed ABI definitions. The review was conducted using Centre for Reviews and Dissemination (CRD) guidance and pre-registered on PROSPERO (CRD42016047185). Seven a priori specified domains were used to classify outcomes: biomarkers, alcohol-related outcomes, economic factors/resource use, health measures, life impact, intervention factors, and psychological/behavioral factors. RESULTS: The search identified 405 trials from 401 eligible papers. In 405 trials, 2,641 separate outcomes were measured in approximately 1,560 different ways. The most common outcomes used were the number of drinks consumed in a week and frequency of heavy episodic drinking. Biomarkers were least frequently used. The most common primary outcome was weekly drinks. By trial type, the most frequent outcome in efficacy and effectiveness trials was frequency of heavy drinking. CONCLUSIONS: Consumption outcomes predominated; however, no single outcome was found in all trials. This comprehensive outcome map and methodological detail on ABI effectiveness and efficacy trials can aid decision making in future trials. There was a diversity of instruments, time points, and outcome descriptions in methods and results sections. Compliance with reporting guidance would support data synthesis and improve trial quality. This review establishes the need for a core outcome set (COS)/minimum data standard and supports the Outcome Reporting in Brief Interventions: Alcohol initiative (ORBITAL) to improve standards in the ABI field through a COS for effectiveness and efficacy randomized trials.

Prioritization of Outcomes in Efficacy and Effectiveness of Alcohol Brief Intervention Trials: International Multi-Stakeholder e-Delphi Consensus Study to Inform a Core Outcome Set.

OBJECTIVE: Outcomes used in alcohol brief intervention trials vary considerably. Achieving consensus about key outcomes can enhance evidence synthesis and improve healthcare guidelines. This international, e-Delphi study sought to prioritize outcomes for alcohol brief intervention trials as part of a larger program of work develop an alcohol brief intervention core outcome set. METHOD: In total, 150 registrants from 19 countries, representing researchers, policymakers, and patients, participated in a two-round e-Delphi study. In Round 1, participants (n = 137) rated 86 outcomes, derived from a review of the literature and a patient and public involvement panel, by importance. In Round 2, participants (n = 114) received feedback on importance ratings for each outcome, and a reminder of their personal rating, before rating the outcomes for importance a second time. Seven additional outcomes suggested in Round 1 were added to the Round 2 questionnaire. We defined consensus a priori as 70% agreement across all stakeholder groups. RESULTS: Seven consumption outcomes met inclusion criteria: typical frequency, typical quantity, frequency of heavy drinking, alcohol-related problems, weekly drinks, at-risk drinking, and combined consumption measures. Others meeting the threshold were alcohol-related injury, quality of life, readiness to change, and intervention fidelity. CONCLUSIONS: This is the first international e-Delphi study to identify and prioritize outcomes for use in alcohol brief intervention trials. The use and reporting of outcomes in future alcohol brief intervention trials should improve evidence synthesis in systematic reviews and meta-analyses. Further work is required to refine these outcomes into a core outcome set that includes guidance for measurement of outcomes.

Indeed, not really a brain disorder: Implications for reductionist accounts of addiction.

Borsboom et al.'s formulation provides an opportunity for a fundamental rethink about the "brain disease model" of addiction that dominates research, treatment, policy, and lay understanding of addiction. We also demonstrate how the American opioid crisis provides a contemporary example of how "brain disease" is not moderated by the environmental context but is instead crucially dependent upon it.

A mediation analysis of treatment processes in the UK Alcohol Treatment Trial.

OBJECTIVE: To determine whether treatment outcomes are mediated by therapist behaviors consistent with the theoretical postulates on which two contrasting treatments are based. METHOD: We used data from the U.K. Alcohol Treatment Trial (UKATT), a pragmatic, multicenter, randomized controlled trial comparing the effectiveness of Motivational Enhancement Therapy (MET) and Social Behavior and Network Therapy (SBNT) in the treatment of alcohol problems. N = 376 clients (mean age 42.5, 74.5% male) had 12-month follow-up data and one treatment session recorded and coded using the UKATT Process Rating Scale, a reliable manual-based assessment of treatment fidelity including frequency and quality ratings of treatment-specific therapist tasks and therapist styles. Analyses were conducted using a mediation framework. RESULTS: Analysis of individual paths from treatment condition to treatment process indices (a path) and from treatment process indices to alcohol outcomes (b path) showed that (a) SBNT therapists more often used SBNT-specific behaviors, and did so with overall higher quality; (b) MET therapists more often used MET-specific behaviors, but there was no evidence that they performed these behaviors with higher quality than SBNT therapists; (c) only the quality of MET behaviors significantly predicted 12-month alcohol outcomes, irrespective of treatment condition. Consistently, there were no significant indirect effects. Multiple component analysis indicated that therapist quality of specific tasks influenced outcomes. CONCLUSIONS: The quality of delivery of the same treatment tasks in both treatments studied transcended the impact of delivering treatments according to different theoretical underpinnings in UKATT. (PsycINFO Database Record

Using Bayes factors to evaluate evidence for no effect: examples from the SIPS project.

AIMS: To illustrate how Bayes factors are important for determining the effectiveness of interventions. METHOD: We consider a case where inappropriate conclusions were drawn publicly based on significance testing, namely the SIPS project (Screening and Intervention Programme for Sensible drinking), a pragmatic, cluster-randomized controlled trial in each of two health-care settings and in the criminal justice system. We show how Bayes factors can disambiguate the non-significant findings from the SIPS project and thus determine whether the findings represent evidence of absence or absence of evidence. We show how to model the sort of effects that could be expected, and how to check the robustness of the Bayes factors. RESULTS: The findings from the three SIPS trials taken individually are largely uninformative but, when data from these trials are combined, there is moderate evidence for a null hypothesis (H0) and thus for a lack of effect of brief intervention compared with simple clinical feedback and an alcohol information leaflet (B = 0.24, P = 0.43). CONCLUSION: Scientists who find non-significant results should suspend judgement-unless they calculate a Bayes factor to indicate either that there is evidence for a null hypothesis (H0) over a (well-justified) alternative hypothesis (H1), or that more data are needed.

Q: Is Addiction a Brain Disease or a Moral Failing? A: Neither.

This article uses Marc Lewis' work as a springboard to discuss the socio-political context of the brain disease model of addiction (BDMA). The claim that promotion of the BDMA is the only way the general public can be persuaded to withhold blame and punishment from addicts is critically examined. After a discussion of public understandings of the disease concept of addiction, it is pointed out that it is possible to develop a scientific account of addiction which is neither a disease nor a moral model but which the public could understand. Evidence is reviewed to suggest that public acceptance of the disease concept is largely lip-service and that the claim the BDMA removes stigma among the public and professionals is unsupported by evidence. Further, there is good evidence that biogenetic explanations of mental/behavioural disorders in general have been counterproductive in the attempt to ally stigma. A model of addiction as a disorder of choice may attract special problems in public-facing communications and risks being misunderstood. However, ways of presenting this model to the public are suggested that may avoid such risks. Lastly, the claim that the BDMA is the only way of ensuring access to treatment and of maintaining research funding for addiction is disputed and a way in which these benefits can be retained under a disorder-of-choice model proposed. The article concludes by enthusiastically endorsing Lewis' call for a third stage in the governing image of addiction.

Rethinking alcohol interventions in health care: a thematic meeting of the International Network on Brief Interventions for Alcohol & Other Drugs (INEBRIA).

In 2016, the International Network on Brief Interventions for Alcohol & Other Drugs convened a meeting titled "Rethinking alcohol interventions in health care". The aims of the meeting were to synthesize recent evidence about screening and brief intervention and to set directions for research, practice, and policy in light of this evidence. Screening and brief intervention is efficacious in reducing self-reported alcohol consumption for some with unhealthy alcohol use, but there are gaps in evidence for its effectiveness. Because screening and brief intervention is not known to be efficacious for individuals with more severe unhealthy alcohol use, recent data showing the lack of evidence for referral to treatment as part of screening and brief intervention are alarming. While screening and brief intervention was designed to be a population-based approach, its reach is limited. Implementation in real world care also remains a challenge. This report summarizes practice, research, and policy recommendations and key research developments from our meeting. In order to move the field forward, a research agenda was proposed to (1) address evidence gaps in screening, brief intervention, and referral to treatment, (2) develop innovations to address severe unhealthy alcohol use within primary care, (3) describe the stigma of unhealthy alcohol use, which obstructs progress in prevention and treatment, (4) reconsider existing conceptualizations of unhealthy alcohol use that may influence health care, and (5) identify efforts needed to improve the capacity for addressing unhealthy alcohol consumption in all world regions.

Who achieves low risk drinking during alcohol treatment? An analysis of patients in three alcohol clinical trials.

BACKGROUND AND AIMS: There is evidence that low-risk drinking is possible during the course of alcohol treatment and can be maintained following treatment. Our aim was to identify characteristics associated with low-risk drinking during treatment in a large sample of individuals as they received treatment for alcohol dependence. DESIGN: Integrated analysis of data from the Combined Pharmacotherapies and Behavioral Intervention (COMBINE) study, Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) and the United Kingdom Alcohol Treatment Trial (UKATT) using repeated-measures latent class analysis to identify patterns of drinking and predictors of low-risk drinking patterns during treatment. SETTING: United States and United Kingdom. PARTICIPANTS: Patients (n = 3589) with alcohol dependence receiving treatment in an alcohol clinical trial were primarily male (73.0%), white (82.0%) and non-married (41.7%), with an average age of 42.0 (standard deviation = 10.7). MEASUREMENTS: Self-reported weekly alcohol consumption during treatment was assessed using the Form-90 and validated with biological verification or collateral informants. FINDINGS: Seven patterns of drinking during treatment were identified: persistent heavy drinking (18.7% of the sample), increasing heavy drinking (9.6%), heavy and low-risk drinking (6.7%), heavy drinking alternating with abstinence (7.9%), low-risk drinking (6.8%), increasing low-risk drinking (10.5%) and abstinence (39.8%). Lower alcohol dependence severity and fewer drinks per day at baseline significantly predicted low-risk drinking patterns [e.g. each additional drink prior to baseline predicted a 27% increase in the odds of expected classification in heavy drinking versus low-risk drinking patterns; odds ratio = 1.27 (95% confidence interval (CI) = 1.10, 1.47, P = 0.002]. Greater negative mood and more heavy drinkers in the social network were significant predictors of expected membership in heavier drinking patterns. CONCLUSIONS: Low-risk drinking is achievable for some individuals as they undergo treatment for alcohol dependence. Individuals with lower dependence severity, less baseline drinking, fewer negative mood symptoms and fewer heavy drinkers in their social networks have a higher probability of achieving low-risk drinking during treatment.