In selecting treatment, recent drinking behavior may guide the way

People who reduce their drinking in the two weeks before they enter formal treatment have better treatment outcomes than those who don’t, researchers at the University at Buffalo’s Research Institute on Addictions (RIA) found in a pilot study. So now the researchers are going to look at whether those people could do as well in a briefer and more tailored intervention, with more intense interventions for those patients who did not reduce their drinking before treatment.

For the current study, which is now in the recruitment phase, researchers at the New York-based institute received $3 million for the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to examine a tailored treatment approach for people who reduce drinking before treatment. The study will be conducted by Paul Stasiewicz, PhD, senior research scientist and director of RIA’s Clinical Research Center.

The question is whether people who make a substantial pre-treatment change could benefit from a different treatment content from those who don’t. Instead of focusing on how to stop drinking, their treatment could be better tailored to relapse prevention.

The pilot study

About half of the sample in the RIA's pilot study changed substantially in the one-month period prior to entering the first treatment session. The other group didn’t make any changes. The treatment offered in that study was 12 weekly sessions of individual cognitive-behavioral therapy (CBT) for alcohol dependence.

“When we looked at the people who changed pre-treatment, we noticed that they did much better compared to the group that didn’t make these pretreatment changes,” says Stasiewicz. In the interest of being more “cost-effective,” treatment for these patients could be a six-week course of relapse prevention, rather than the 12 weeks of standard CBT.

The researchers recruited participants for the study by advertising in the community that there was treatment available at no cost for people having problems with alcohol. This is different from screening and referral done in a healthcare setting. “People hear the ad, but they have to make the phone call,” says Stasiewicz.

The researchers looked at the drinking behavior of participants six months before they made the call and then two weeks before, followed by what happened between the phone call and the baseline assessment, and then what happened between the assessment and session one. They found that during the two-week period before they made the phone call, some people did make changes in their drinking. These people, the “rapid changers,” didn’t change as much during actual treatment as the people who did not reduce their drinking prior to treatment, for the simple reason that they had already made changes. “There was a floor effect—there was nowhere else for them to go,” says Stasiewicz.

So the researchers wanted to see if rapid changers can do just as well with fewer sessions, and of a different kind.

For the current study, the researchers are proposing two groups—one for those who didn’t reduce drinking pre-treatment, and one for those rapid changers who did change pre-treatment. The non-changers will be randomized into one of two arms: either 12 weeks of standard CBT, or combined Motivational Interviewing (MI) and CBT.

Stasiewicz’s hypothesis is that the rapid changers will do as well with six sessions of relapse prevention as minimal changers who get 12 sessions of CBT or 12 sessions of CBT pus MI.

In the current study, the researchers will look at other individual characteristics that might help identify what makes people more likely to change pre-treatment, and therefore be better suited to the shorter intervention.

“One trait we’ll be looking at is task persistence,” says Stasiewicz. “Is it that they set their mind to something?”

In addition to reduced drinking, there are two other components of change that accompanied treatment: decreases in negative emotion, and increases in self-efficacy for abstinence. In the pilot study, these changes lagged behind the drinking changes in general, but occurred faster in the rapid change group, which experienced them about four sessions into treatment. For the gradual change group, these changes occurred a month later, around session 8 or 9.

It makes sense for the emotional and self-efficacy improvements to lag behind reducing alcohol consumption, says Stasiewicz. “After 28 days of sobriety, you start to think more clearly, other problems in life have cleared up, people aren’t as angry at you, and you start to believe more in your ability to stay that way,” he says. “It’s similar to people who lose weight—they feel better.”

Two weeks before the call

Something happened in the minds of the rapid changers two weeks before they made the phone call to be screened for the study. For the five-and-a-half months before the call, they had been drinking at consistently high levels.

“Maybe they started thinking about change, maybe because of our advertisement [for the study], maybe because of a life event,” says Stasiewicz. The researchers want to know how these individuals managed to start reducing their drinking before treatment, and how this could be connected to better outcomes. “Do they have more social support? Are they more self-determined? Are they better at changing their behavior?”

One of the compelling variables in this study is the promise of free treatment. If free sessions—whether six of relapse prevention or 12 of CBT or CBT/MI—weren’t available, would the results be the same? Noting that access and cost are cited as the main barriers to treatment, Stasiewicz says it is important to reduce such barriers.

For the current study, recruitment will take place this summer and fall, with a total of 200 participants.

Alison Knopf is a freelance writer based in New York.

NIAAA director on abstinence prior to acamprosate

George Koob, PhD, director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), says there is overwhelming data showing that the drug acamprosate works well only in people who have become abstinent first. In Japan, patients were treated inpatient for two months first, and these patients had the best response to acamprosate, a medication that interests Koob because he was part of the team that went before the Food and Drug Administration (FDA) for approval of the drug.

Achieving abstinence through two months of inpatient treatment first is not feasible in this country. As Koob puts it, “I’m not sure we have a healthcare system that would support that.” But what Paul Stasiewicz, PhD, is doing in his study at the University at Buffalo is relevant to the acamprosate story, says Koob.

“He’s looking at who is going to respond best, and what are the conditions that set up for this response,” Koob says. If patients who are on their way to abstinence on their own can be identified, they could receive a treatment that would help them sustain that abstinence, rather than one that is focused on helping them achieve it in the first place.