Measurement of substance-free reinforcement in addiction: A systematic review

Can Alcohol Use Disorder Recovery Include Some Heavy Drinking? A Replication and Extension up to 9 Years Following Treatment

BACKGROUND

Recent research indicates some individuals who engage in heavy drinking following treatment for alcohol use disorder fare as well as those who abstain with respect to psychosocial functioning, employment, life satisfaction, and mental health. The current study evaluated whether these findings replicated in an independent sample and examined associations between recovery profiles and functioning up to 6 years later.

METHODS

Data were from the 3-year and 7- to 9-year follow-ups of subsamples initially recruited for the COMBINE study (3-year follow-up: n = 694; 30.1% female, 21.0% non-White; 7- to 9-year follow-up: n = 127; 38.9% female, 27.8% non-White). Recovery at 3 years was defined by latent profile analyses including measures of health functioning, quality of life, employment, alcohol consumption, and cannabis and other drug use. Functioning at the 7- to 9-year follow-up was assessed using single items of self-rated general health, hospitalizations, and alcohol consumption.

RESULTS

We identified 4 profiles at the 3-year follow-up: (i) low-functioning frequent heavy drinkers (13.9%), (ii) low-functioning infrequent heavy drinkers (15.8%), (iii) high-functioning heavy drinkers (19.4%), and (iv) high-functioning infrequent drinkers (50.9%). At the 7- to 9-year follow-up, the 2 high-functioning profiles had the best self-rated health, and the high-functioning heavy drinking profile had significantly fewer hospitalizations than the low-functioning frequent heavy drinking profile.

CONCLUSIONS

Previous findings showing heterogeneity in recovery outcomes were replicated. Most treatment recipients functioned well for years after treatment, and a subset who achieved stable recovery engaged in heavy drinking and reported good health outcomes up to 9 years after treatment. Results question the long-standing emphasis on drinking practices as a primary outcome, as well as abstinence as a recovery criterion in epidemiologic and treatment outcome research and among stakeholder groups and funding/regulatory agencies. Findings support an expanded recovery research agenda that considers drinking patterns, health, life satisfaction, and functioning.

Relative expected value of drugs versus competing rewards underpins vulnerability to and recovery from addiction

Behavioural economic theories of addiction contend that greater expected value of drug relative to alternative non-drug rewards is the core mechanism underpinning vulnerability to and recovery from addiction. To evaluate this claim, we exhaustively review studies with human drug users that have measured concurrent choice between drugs vs. alternative rewards, and explored individual differences. These studies show that drug choice can be modulated by drug cues, drug devaluation, imposition of costs/punishment and negative mood induction. Regarding individual differences, dependence severity was reliably associated with overall drug preference, and self-reported drug use to cope with negative affect was reliably associated with greater sensitivity to mood induced increases in drug choice. By contrast, there were no reliable individual differences in sensitivity to the effect of drug cues, drug devaluation or punishment on drug choice. These findings provide insight into the mechanisms that underpin vulnerability to dependence: vulnerability is conferred by greater relative value ascribed to drugs, and relative drug value is further augmented by negative affective states in those who report drug use coping motives. However, dependence does not appear to be characterised by abnormal cue-reactivity, habit learning or compulsion. We then briefly review emerging literature which demonstrates that therapeutic interventions and recovery from addiction might be attributed to changes in the expected relative value of drug versus alternative rewards. Finally, we outline a speculative computational account of the distortions in decision-making that precede action selection in addiction, and we explain how this account provides a blueprint for future research on the determinants of drug choice, and mechanisms of treatment and recovery from addiction. We conclude that a unified economic decision-making account of addiction has great promise in reconciling diverse addiction theories, and neuropsychological evaluation of the underlying decision mechanisms is a fruitful area for future research and treatment.

Behavioral economics and coping-related drinking motives in trauma exposed drinkers: Implications for the self-medication hypothesis

Behavioral economic theory can help researchers understand complex behavior by considering the availability and economic value associated with an individual's choices. This study explored how behavioral economic constructs relate to alcohol consumption and alcohol problems in a sample of trauma-exposed young adults. We further explored whether these behavioral economic constructs explained unique variance in alcohol outcomes beyond coping-related drinking motives. Participants were 91 trauma-exposed young adults who reported recent alcohol consumption (M_age = 26.53, female = 36.26%, non-White = 41.75%). Participants were recruited through Amazon Mechanical Turk. Questionnaires measured alcohol consumption, problems, and motives for use, as well as alcohol demand, delay discounting, future orientation, and access to environmental reward. Future orientation (ΔR2 = .05, p = .03) and delay discounting (ΔR2 = .04, p = .05) explained unique variance in alcohol problems after controlling for coping-related drinking motives. Further, alcohol demand indices (ΔR2s = .04-.10, ps = .00-.05) explained unique variance in alcohol consumption after controlling for coping-related drinking. Both coping motives and behavioral economic variables contribute to alcohol consumption and alcohol-related consequences among trauma-exposed young adults. Findings suggest that, beyond coping motives, behavioral economics may play a meaningful role in understanding alcohol misuse. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City

Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.

A Reinforcer Pathology perspective on relapse

The Reinforcer Pathology theory proposes conditions under which drugs emerge as excessively preferred reinforcers compared to other available reinforcers among drug users. The theory highlights 2 key variables as important determinants of drug preference: (a) excessive preference for immediate rewards (high discounting of future rewards); and (b) excessive valuation for addictive reinforcers (e.g., drugs). Two iterations of the Reinforcer Pathology theory exist with the latest iteration (i.e., Reinforcer Pathology 2.0) specifying that the temporal window of reinforcer integration (measured by delay discounting) is a determinant of reinforcer value. The 2 iterations of the Reinforcer Pathology theory are described. A novel insight and understanding of abstinence and relapse from a Reinforcer Pathology perspective, limitations, and future directions are discussed. The Reinforcer Pathology theory continues the long-standing efforts to scientifically understand and better define novel concepts and methods to further translational research and improve treatment outcomes. Exploring the complementary relation between the Reinforcer Pathology perspective and other current approaches could have a valuable effect.

Temporal precedence of self-regulation over depression and alcohol problems: Support for a model of self-regulatory failure

Alcohol use is highly comorbid with depression, especially among college students, whose rates of both phenomena are higher than in the general population. The self-medication hypothesis (i.e., alcohol use is negatively reinforced via the alleviation of negative affect) has dominated explanatory models of comorbidity. However, self-regulation has also demonstrated cross-sectional relationships with both depression and alcohol problems and may contribute to the development of alternative comorbidity models. Self-regulation introduces three alternative models that can be tested empirically: (a) a depressed regulation model, (b) a central nervous system depressant model, and (c) a self-regulatory failure model. The purpose of this study was to test the utility of these models (in addition to the self-medication hypothesis) by examining the temporal precedence in the relations between self-regulation, depressive symptoms, and alcohol problems among heavy-drinking college students (N = 393) over 5 assessment points (baseline, 1 month, 6 months, 12 months, and 16 months) using an autoregressive cross-lagged model. Lower self-regulation, and higher alcohol problems and depressive symptoms, prospectively predicted higher depressive symptoms. Higher alcohol problems and lower self-regulation prospectively predicted higher alcohol problems. Only self-regulation prospectively predicted self-regulation. These results were consistent across multiple time points. Findings are consistent with a self-regulatory failure model of depressive symptoms and alcohol problems. Therefore, self-regulation may be an important etiological variable and potential intervention target to reduce both alcohol problems and depressive symptoms among college students. (PsycINFO Database Record (c) 2019 APA, all rights reserved).