Effectiveness and treatment moderators of internet interventions for adult problem drinking: An individual patient data meta-analysis of 19 randomised controlled trials.

BACKGROUND: Face-to-face brief interventions for problem drinking are effective, but they have found limited implementation in routine care and the community. Internet-based interventions could overcome this treatment gap. We investigated effectiveness and moderators of treatment outcomes in internet-based interventions for adult problem drinking (iAIs). METHODS AND FINDINGS: Systematic searches were performed in medical and psychological databases to 31 December 2016. A one-stage individual patient data meta-analysis (IPDMA) was conducted with a linear mixed model complete-case approach, using baseline and first follow-up data. The primary outcome measure was mean weekly alcohol consumption in standard units (SUs, 10 grams of ethanol). Secondary outcome was treatment response (TR), defined as less than 14/21 SUs for women/men weekly. Putative participant, intervention, and study moderators were included. Robustness was verified in three sensitivity analyses: a two-stage IPDMA, a one-stage IPDMA using multiple imputation, and a missing-not-at-random (MNAR) analysis. We obtained baseline data for 14,198 adult participants (19 randomised controlled trials [RCTs], mean age 40.7 [SD = 13.2], 47.6% women). Their baseline mean weekly alcohol consumption was 38.1 SUs (SD = 26.9). Most were regular problem drinkers (80.1%, SUs 44.7, SD = 26.4) and 19.9% (SUs 11.9, SD = 4.1) were binge-only drinkers. About one third were heavy drinkers, meaning that women/men consumed, respectively, more than 35/50 SUs of alcohol at baseline (34.2%, SUs 65.9, SD = 27.1). Post-intervention data were available for 8,095 participants. Compared with controls, iAI participants showed a greater mean weekly decrease at follow-up of 5.02 SUs (95% CI -7.57 to -2.48, p < 0.001) and a higher rate of TR (odds ratio [OR] 2.20, 95% CI 1.63-2.95, p < 0.001, number needed to treat [NNT] = 4.15, 95% CI 3.06-6.62). Persons above age 55 showed higher TR than their younger counterparts (OR = 1.66, 95% CI 1.21-2.27, p = 0.002). Drinking profiles were not significantly associated with treatment outcomes. Human-supported interventions were superior to fully automated ones on both outcome measures (comparative reduction: -6.78 SUs, 95% CI -12.11 to -1.45, p = 0.013; TR: OR = 2.23, 95% CI 1.22-4.08, p = 0.009). Participants treated in iAIs based on personalised normative feedback (PNF) alone were significantly less likely to sustain low-risk drinking at follow-up than those in iAIs based on integrated therapeutic principles (OR = 0.52, 95% CI 0.29-0.93, p = 0.029). The use of waitlist control in RCTs was associated with significantly better treatment outcomes than the use of other types of control (comparative reduction: -9.27 SUs, 95% CI -13.97 to -4.57, p < 0.001; TR: OR = 3.74, 95% CI 2.13-6.53, p < 0.001). The overall quality of the RCTs was high; a major limitation included high study dropout (43%). Sensitivity analyses confirmed the robustness of our primary analyses. CONCLUSION: To our knowledge, this is the first IPDMA on internet-based interventions that has shown them to be effective in curbing various patterns of adult problem drinking in both community and healthcare settings. Waitlist control may be conducive to inflation of treatment outcomes.

Overcoming Addictions, a Web-Based Application, and SMART Recovery, an Online and In-Person Mutual Help Group for Problem Drinkers, Part 2: Six-Month Outcomes of a Randomized Controlled Trial and Qualitative Feedback From Participants.

BACKGROUND: Despite empirical evidence supporting the use of Web-based interventions for problem drinking, much remains unknown about factors that influence their effectiveness. OBJECTIVE: We evaluated the performance of 2 resources for people who want to achieve and maintain abstinence: SMART Recovery (SR) and Overcoming Addictions (OA). OA is a Web application based on SR. We also examined participant and intervention-related factors hypothesized to impact clinical outcomes of Web-based interventions. METHODS: We recruited 189 heavy drinkers through SR's website and in-person meetings throughout the United States. We began by randomly assigning participants to (1) SR meetings alone, (2) OA alone, and (3) OA and SR (OA+SR). Recruitment challenges compelled us to assign participants only to SR (n=86) or OA+SR (n=102). The experimental hypotheses were as follows: (1) Both groups will reduce their drinking and alcohol-related consequences at follow-up compared with their baseline levels, and (2) The OA+SR condition will reduce their drinking and alcohol or drug-related consequences more than the SR only condition. Additionally, we derived 3 groups empirically (SR, OA, and OA+SR) based on the participants' actual use of each intervention and conducted analyses by comparing them. Primary outcome measures included percent days abstinent (PDA), mean drinks per drinking day (DDD), and alcohol or drug-related consequences. Postbaseline assessments were conducted by phone at 3 and 6 months. Secondary analyses explored whether clinical issues (eg, severity of alcohol problems, level of distress, readiness to change) or intervention-related factors (eg, Internet fluency, satisfaction with site) affected outcomes. RESULTS: Both intent-to-treat analyses and the actual-use analyses showed highly significant improvement from baseline to follow-ups for all 3 groups. Mean within-subject effect sizes were large (d>0.8) overall. There was no significant difference between groups in the amount of improvement from baseline to the average of the follow-ups. We found that participants who stopped drinking before joining the clinical trial had significantly better outcomes than participants who were still drinking when they joined the study. Neither Internet fluency nor participants' reported ease of navigating the site had an impact on outcomes. CONCLUSIONS: These results support our first experimental hypothesis but not the second. On average, participants improved on all dependent measures. Both SR and OA helped participants recover from their problem drinking. Web-based interventions can help even those individuals with lengthy histories of heavy drinking to make clinically significant reductions in their consumption and related problems. These interventions work well for individuals in the action stage of change. TRIAL REGISTRATION: Clinicaltrials.gov NCT01389297; https://clinicaltrials.gov/ct2/show/NCT01389297 (Archived by WebCite at http://www.webcitation.org/6kLNUNDcc).

Overcoming Addictions, a Web-based application, and SMART Recovery, an online and in-person mutual help group for problem drinkers, part 1: three-month outcomes of a randomized controlled trial.

BACKGROUND: Overcoming Addictions (OA) is an abstinence-oriented, cognitive behavioral, Web application based on the program of SMART Recovery. SMART Recovery is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum, and other resources. OBJECTIVE: To evaluate the effectiveness of OA and SMART Recovery (SR) with problem drinkers who were new to SMART Recovery. Our experimental hypotheses were: (1) all groups will reduce their drinking and alcohol/drug-related consequences at follow-up compared to their baseline levels, (2) the OA condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR), and (3) the OA+SR condition will reduce their drinking and alcohol/drug-related consequences more than the control group (SR only). METHODS: We recruited 189 heavy problem drinkers primarily through SMART Recovery's website and in-person meetings throughout the United States. We randomly assigned participants to (1) OA alone, (2) OA+attend SMART Recovery (SR) meetings (OA+SR), or (3) attend SR only. Baseline and follow-ups were conducted via GoToMeeting sessions with a Research Assistant (RA) and the study participant. We interviewed significant others to corroborate the participant's self-report. Primary outcome measures included percent days abstinent (PDA), mean drinks per drinking day (DDD), and alcohol/drug-related consequences. RESULTS: The intent-to-treat analysis of the 3-month outcomes supported the first hypothesis but not the others. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001). Actual use relationships were found for the OA groups, between SR online meetings and improvement in PDA (r=.261, P=.033). In addition in the OA groups, the number of total sessions of support (including SR & other meetings, counselor visits) was significantly related to PDA (r=.306, P=012) and amount of improvement in alcohol-related problems (r=.305, P=.012). In the SR only group, the number of face-to-face meetings was significantly related to all three dependent variables, and predicted increased PDA (r=.358, P=.003), fewer mean DDD (r=-.250, P=.039), and fewer alcohol-related problems (r=-.244, P=.045), as well as to the amount of improvement in all three of these variables. Six-month follow-ups have been completed, and the results are currently being analyzed. CONCLUSIONS: These results support our first experimental hypothesis but not the second or third. All groups significantly increased their PDA and decreased both their mean DDD and their alcohol-related problems, which indicates that both interventions being investigated were equally effective in helping people recover from their problem drinking.

The college drinker's check-up: outcomes of two randomized clinical trials of a computer-delivered intervention.

The objective of the study was to evaluate the effectiveness of a computer-delivered intervention (CDI) to reduce heavy drinking and alcohol-related problems in college students in two randomized clinical trials. In Experiment 1, we randomized 144 students to either the CDI or an assessment-only control group with follow-ups at 1 and 12 months. In Experiment 2, we randomized 82 students to either the CDI or a delayed-assessment control group with follow-up at 1 month. In Experiment 1, participants in both groups significantly reduced their drinking at both follow-ups. Compared to the control group, the CDI group reduced their drinking significantly more at 1 and 12 months on three drinking measures at α < .05. Using a more conservative, Bonferroni-adjusted criterion yielded one significant difference in a measure of heavier drinking at the 1 month follow-up. The mean between-groups effect sizes were d = .34 and .36 at 1 and 12 months, respectively. Experiment 2. Compared to the delayed assessment control group, the CDI group significantly reduced (by the Bonferroni-adjusted criterion) their drinking on all consumption measures. These results support the effectiveness of the CDI with heavy drinking college students when used in a clinical setting. In addition, the significant reductions in typical drinking in the control group in Experiment 1 and not in Experiment 2 combined with comparable baseline characteristics suggests that the control group in Experiment 1 demonstrated assessment reactivity.

Evaluation of two web-based alcohol interventions in the U.S. military.

OBJECTIVE: The U.S. military has traditionally had high rates of alcohol misuse and alcohol-related problems, necessitating effective treatment programs that minimize participant burden. Web-based interventions have shown promise as efficient treatment options for college students and adults but have not been widely evaluated in the military. This study evaluated the efficacy of two web-based alcohol interventions originally created for civilians and then adapted for U.S. military personnel. METHOD: Two web-based alcohol interventions, Alcohol Savvy and Drinker's Check-Up, were adapted for use among military populations. The interventions were evaluated using a convenience sample of 3,070 active-duty military personnel at eight installations. Following a baseline survey, participants were assigned to one of three treatment conditions: (a) Alcohol Savvy, (b) Drinker's Check-Up, or (c) control (no program participation). Follow-up surveys were completed by 1,072 participants 1 month following baseline and by 532 participants 6 months following baseline. RESULTS: At 1-month follow-up, participants who completed the Drinker's Check-Up intervention had significant reductions in multiple measures of alcohol use relative to controls. Positive outcomes were found for average number of drinks consumed per occasion, frequent heavy episodic drinker status, and estimated peak blood alcohol concentration. These reductions in alcohol use at the 1-month follow-up were maintained at the 6-month follow-up. There were no statistically significant changes in alcohol use for participants who completed Alcohol Savvy. CONCLUSIONS: This study expands the literature on the effectiveness of web-based treatment for alcohol misuse. Findings indicate that web-based programs (Drinker's Check-Up in particular) can significantly decrease several indicators of alcohol use in U.S. military personnel.

ModerateDrinking.Com and moderation management: outcomes of a randomized clinical trial with non-dependent problem drinkers.

OBJECTIVE: To evaluate the effectiveness of a web-based protocol, ModerateDrinking.com (MD; www.moderatedrinking.com) combined with use of the online resources of Moderation Management (MM; www.moderation.org) as opposed to the use of the online resources of MM alone. METHOD: We randomly assigned 80 problem drinkers to either the experimental or control group with follow-ups at 3, 6, and 12 months. RESULTS: Seventy-five participants (94%) had outcome data at 1 or more follow-up points, and 59 participants (73%) were assessed at all 3 follow-ups. Comparing baseline measures to the average outcomes at follow-ups indicated a significant overall reduction in both groups in alcohol-related problems and consumption variables. Compared with the control group, the experimental group had better outcomes on percent days abstinent. There was an interaction between intensity of drinking at baseline and treatment in determining outcomes assessing drinking. Less heavy drinkers in the experimental group had better outcomes on log mean blood alcohol content (BAC) per drinking day compared with the control group. Heavier drinkers did not differentially benefit from the MD program on this measure. Mixed model analyses in general corroborated these outcomes. CONCLUSION: The outcome data provide partial evidence for the effectiveness of the MD web application combined with MM, compared with the effectiveness of the resources available online at MM by themselves.

A web application for moderation training: initial results of a randomized clinical trial.

Eighty-four heavy drinkers who responded to a newspaper recruitment advertisement were randomly assigned to receive either (a) training in a Moderate Drinking protocol via an Internet-based program (www.moderatedrinking.com) and use of the online resources of Moderation Management (MM; www.moderation.org) or (b) use of the online resources of MM alone. Follow-ups are being conducted at 3, 6, and 12 months. Results of the recently completed 3-month follow-up (86% follow-up) indicated both groups significantly reduced their drinking based on these variables: standard drinks per week, percent days abstinent, and mean estimated blood alcohol concentration (BAC) per drinking day. Both groups also significantly reduced their alcohol-related problems. Relative to the control group, the experimental group had better outcomes on percent days abstinent and log drinks per drinking day. These short-term outcome data provide evidence for the effectiveness of both the Moderate Drinking Web application and of the resources available online at MM in helping heavy drinkers reduce their drinking and alcohol-related problems.

Web-based norms for the Drinker Inventory of Consequences from the Drinker's Checkup.

To date, the only published norms for the Drinker Inventory of Consequences (DrInC) have come from a sample of heavy drinkers in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) who were enrolling in a treatment program. We have generated an additional set of norms for the DrInC based on a large sample (N = 1,564) of heavy drinkers who have completed the DrInC as part of a Web-based brief motivational intervention, the Drinker's Checkup (DCU; www.drinkerscheckup.com). Although these drinkers were not seeking formal treatment, they were concerned enough about their drinking to pay $25 to use the DCU. Comparing the means and decile scores for lifetime and recent total scores and subscale scores between the DCU and MATCH samples revealed that DrInC scores for the DCU sample were significantly lower than the MATCH sample. These findings have implications for giving normative feedback using the DrInC with non-treatment-seeking populations. The use and limitations of these findings are discussed.

Computer-based tools for diagnosis and treatment of alcohol problems.

Diagnosis and treatment of alcohol-related problems are time-intensive procedures that often are difficult to implement in busy clinical settings. Computer-based tools are one approach that may enhance the availability and cost-effectiveness of assessment and intervention and also may offer other advantages over face-to-face interventions. Several PC- and Internet-based programs have been developed that can be used for assessing alcohol problems, some of which are based on existing screening instruments. Other programs have demonstrated effectiveness as interventions, serving to increase patient motivation and reduce alcohol-associated harm through skill building. Investigators also have begun to analyze the mechanisms through which computer-based programs can induce these effects. Future efforts should be aimed at developing and evaluating additional computer-based interventions, particularly for specific patient subgroups, and at removing barriers to the incorporation of such programs into clinical practice.

The Drinker's Check-up: 12-month outcomes of a controlled clinical trial of a stand-alone software program for problem drinkers.

Sixty-one problem drinkers were randomly assigned to either immediate treatment or a 4-week wait-list control group. Treatment consisted of a computer-based brief motivational intervention, the Drinker's Check-up (DCU). Outcomes strongly support the experimental hypotheses and long-term effectiveness of the treatment. Overall, participants reduced the quantity and frequency of drinking by 50%, and had similar reductions in alcohol-related problems that were sustained through 12-month follow-up. The DCU seems to be effective in enhancing problem drinkers' motivation for change.

Demon rum: high-tech solutions to an age-old problem.

This article summarizes the proceedings of a symposium at the 2004 Research Society on Alcoholism Meeting in Vancouver, British Columbia, Canada, organized and chaired by Scott T. Walters. The purpose of the symposium was to describe several brief motivational interventions offered via the Internet, including the evidence for web-based interventions, applications and contexts in which such approaches are being used, and directions for future research. Walters provided an overview and introduction to the topic and discussed the e-CHUG (www.e-chug.com) and e-TOKE (www.e-toke.com) feedback interventions for college alcohol and marijuana prevention, including the contexts in which they are being used and ways they are being integrated with other campus prevention efforts. Dr. Hester presented 12-month results from a controlled trial of the Drinker's Check-up (www.drinkerscheckup.com), an intervention for adult problem drinkers that is available both as a Windows and as an Internet application. Dr. Chiauzzi described the development and testing of My Student Body (www.mystudentbody.com), a tailored drinking prevention web site for college students. Finally, Dr. Miller addressed the use of online assessment and feedback to reduce drinking, including the history of web-based interventions and their likely future and the potential limitations of such approaches.

Using technical innovations in clinical practice: the Drinker's Check-Up software program.

Interest in assessing and treating a variety of psychological conditions with software programs is increasing rapidly. This article reviews a software program for problem drinkers entitled the Drinker's Check-Up (DCU) and illustrates its use with three patients. The DCU is based on the principles of brief motivational interventions and can be used as a stand-alone intervention by therapists without expertise in substance abuse or as a prelude to alcohol treatment services. It is the first software program to provide integrated assessment, feedback, and assistance with decision making for individuals experiencing problems with alcohol. Preliminary data from an ongoing clinical trial of the DCU as a stand-alone intervention indicate that it is an effective intervention for a wide range of problem drinkers.