Reductions in Craving and Negative Affect Predict 3-Month Post-Discharge Alcohol Use Following Residential Treatment

The effect of approach bias modification during alcohol withdrawal treatment on craving, and its relationship to post-treatment alcohol use in a randomised controlled trial

BACKGROUND

Approach bias modification (ApBM) for alcohol use disorder helps prevent relapse, yet the psychological mechanisms underlying its efficacy remain unclear. Alcohol craving predicts relapse and appears to be related to the biased processing of alcohol stimuli which is reduced by ApBM. However, there is little research examining whether ApBM reduces alcohol craving.

METHODS

In a randomised controlled trial testing the effect of 4 ApBM sessions (vs. sham training) on post-treatment alcohol use in 300 alcohol withdrawal inpatients, we administered the Alcohol Craving Questionnaire - Short Form - Revised (ACQ-SF-R) pre and post-training and at 2-week, 3, 6 and 12-month follow ups; and a cue-induced craving measure pre and post training.

RESULTS

Groups did not significantly differ in terms of declines in ACQ-SF-R total scores (p = .712) or cue-induced craving (p = .841) between the first and last training session, nor in terms of ACQ-SF-R scores at follow-ups (p = .509). However, the ACQ-SF-R Expectancy subscale, which assesses craving based on anticipated positive reinforcement from alcohol, was significantly lower in the ApBM group than in controls following training (p = .030), although the group x time interaction for this subscale was non-significant (p = .062). Post-intervention Expectancy scores mediated only a small portion of ApBM's effect on post-discharge alcohol use (14% in intention-to-treat analysis, p = .046; 15% in per-protocol analysis, p = .020).

CONCLUSIONS

ApBM does not appear to have robust, sustained effects on alcohol craving. Reduced craving is unlikely to account for ApBM's relapse prevention effects. However, further research on whether ApBM's effects are related to devaluation of alcohol reward expectancy is warranted.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry Identifier: ACTRN12617001241325.

Suicidal ideation predicted by changes experienced from pre-treatment to 3-month postdischarge from residential substance use disorder treatment

PURPOSE

Individuals with substance use disorders (SUD) are at an elevated risk for suicide. Abstinence and drug-related treatment outcomes remain integral to SUD treatment, but recovery incorporates more than just the absence of substance use or mental illness and including positive mental health indices in assessment and treatment of suicidality is needed.

AIMS

The current study investigates the role of traditional indicators of recovery, as well as positive psychology constructs, in predicting suicidal ideation following residential SUD treatment.

METHOD

The study utilized a longitudinal design with baseline and 3-month postdischarge follow-up assessments of 791 individuals who attended residential SUD treatment in Australia.

RESULTS

Rates of suicidal ideation decreased from baseline to follow-up, and the magnitude of change in most indices was associated with suicidal ideation at follow-up assessment. In a hierarchical logistic regression, baseline suicidal ideation, as well as a reduction in psychological distress, increase in refusal self-efficacy, and increase in self-forgiveness, emerged as significant predictors of follow-up suicidal ideation. The final model correctly classified 98.8% of participants as not experiencing SI, and 8.7% of participants as experiencing SI at follow-up, resulting in a total predictive accuracy of 86.9%.

CONCLUSIONS

The results suggested that changes in traditional recovery indices may facilitate reductions in suicidality. As a whole, changes in positive psychology indices did not add to the ability to predict suicidal ideation once traditional indices had been accounted for, but this does not preclude the importance of these indices to SUD treatment and suicide prevention efforts.

Is craving a risk factor for substance use among treatment-seeking individuals with alcohol and other drugs use disorders? A meta-analytic review

BACKGROUND

It is still unclear whether craving should be considered a key risk factor for substance-use behaviors (SUB) among treatment-seeking individuals with alcohol (AUD) and other drugs use disorders. Therefore, this study aims at clarifying this topic using a meta-analytic approach.

METHODS

Cohen's d was computed as effect size (ES) measure. Heterogeneity of ESs was computed using the Q statistic and I² index. The analyses also evaluated the impact assessment length on ESs. Furthermore, proximal effects of craving on SUB were compared to distal ones. The diagnoses of specific substance use disorders (SUDs), together with assessment instruments and research design were considered as additional moderators.

RESULTS

Thirty-six independent studies were included for a total of 4868 treatment-seeking individuals with SUDs. Patients who used substances showed slightly higher levels of craving than abstinent ones. The heterogeneity of results was large and significant. The length of period of assessment was positively related to ESs. The analyses highlighted no differences between pooled ESs of proximal and distal impacts of craving on SUB. The diagnoses of SUDs were significant moderators. Considering AUD, assessment instruments and research design were additional moderators.

CONCLUSIONS

Craving is a modest time-dependent proximal and distal risk factor for SUB among individuals with SUDs. Both the frequency of craving episodes and a heightened reactivity to craving cues are largely associated to SUB among individuals with AUD. Future studies should evaluate the mediating and moderating roles of self-regulatory mechanisms on the relationship between craving and SUB.

PTSD Symptom Clusters and Craving Differs by Primary Drug of Choice

Objective: Research has demonstrated a cyclical relationship between posttraumatic stress disorder (PTSD) and substance use disorder. Identifying factors that link PTSD symptom clusters and substance use disorder may illuminate mechanisms underlying the PTSD-substance use disorder relationship, better informing interventions that target this comorbidity. The current study of individuals enrolled in an outpatient aftercare chemical dependency program in King County, Washington, assessed whether overall PTSD symptoms and specific PTSD symptom clusters predicted craving depending on individuals identified primary drug of choice (DOC). Methods: Participants eligible for the parent study were at least 18 years of age, fluent in English, medically cleared from substance withdrawal, and able to participate in treatment sessions and agreed to random assignment. Random assignment to either a mindfulness-based relapse prevention group, a standard relapse prevention group, or a treatment as usual group was conducted on a computer randomization program. A secondary analysis of baseline data was employed in the current study to determine which of the PTSD symptom clusters (avoidance, hyperarousal, and intrusion) predicted substance craving. Results: Covarying for severity of dependence, results suggest that overall PTSD scores predicted craving in participants who identified alcohol, stimulants, and opiates as their primary DOC. Further, avoidance-related PTSD symptoms alone predicted a significant proportion of the variability in craving in stimulant users, and hyperarousal symptoms alone predicted a significant proportion of the variability in craving in alcohol users. No specific PTSD cluster significantly predicted a proportion of the variability in craving in marijuana or opiates users. Conclusions: Findings suggest that craving may play a role in maintaining the relationship between specific PTSD symptom clusters and substance use disorder, and the nature of this relationship may differ by primary DOC. The clinical trial on which this secondary analysis of data was conducted is registered as NCT01159535 at www.clinicaltrials.gov.The original trial from which data for this study was drawn was supported by the National Institutes of Health [NIH/NIDA 5 R01 DA025764-02].

Alcohol use disorder relapse factors: A systematic review

A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.

The relationship between executive functions and emotion regulation in females attending therapeutic community treatment for substance use disorder

BACKGROUND

Difficulties in emotion regulation influence the development of substance use disorder (SUD), its severity, course, treatment outcomes, and relapse. Impaired executive functions (EFs) are common in SUD populations and may relate to emotion dysregulation. The current study tested whether performance on three basic EF tasks ('working memory', 'inhibition', and 'task-switching') and/or inventory-based assessment of EF were related to difficulties in emotion regulation in females attending residential SUD therapeutic community treatment.

METHODS

Cross-sectional design in which participants (N=50, all female) completed a questionnaire battery including the Difficulties in Emotion Regulation Scale (DERS) and Behavior Rating Inventory of Executive Function - Adult Version (BRIEF-A) was used. Participants also completed neuropsychological assessment of EF including the Working Memory Index (WMI; Wechsler Adult Intelligence Scale), and measures of inhibition and task-switching (Color-Word Interference Test; Delis-Kaplan Executive Function System).

RESULTS

Executive dysfunction, as assessed by the Global Executive Composite (GEC; BRIEF-A), and personality disorder indicators (Standardised Assessment of Personality - Abbreviated Scale; SAPAS) were positively correlated with DERS scores. Sequential hierarchical regression indicated that task-switching, GEC, and SAPAS scores statistically predicted DERS scores, while working memory and inhibition did not. Mediation analysis indicated that there was a significant indirect effect of GEC scores and task-switching performance on DERS scores, through SAPAS scores.

CONCLUSIONS

Impairment of EF, particularly task-switching, is related to difficulties in emotion regulation in a female sample attending residential SUD treatment. Cognitive training interventions that improve task-switching performance may be beneficial in promoting effective emotion regulation and improved SUD treatment outcomes.

Gender Differences in Affects and Craving in Alcohol-Dependence: A Study During Alcohol Detoxification

BACKGROUND

Alcohol craving is a major cause of relapse in alcohol-dependent (AD) patients. It is closely related to the high depression and anxiety symptoms that are frequently observed at the early stages of abstinence, and these comorbid symptoms might thus constitute a relapse factor when they persist after detoxification. As these negative affects are known to evolve during the detoxification process, the aim of this study was to investigate the course of the relation between affects and craving during detoxification, with a particular attention given to gender in light of the known differences in affects between AD men and women.

METHODS

AD patients (n = 256) undergoing a detoxification program were evaluated for positive (PA) and negative affectivity (NA), depression and anxiety symptoms, and craving, twice within a 3-week interval (on the first [T1] and the eighteenth day [T2] of abstinence).

RESULTS

Detoxification course was associated with improvements regarding NA, depression and anxiety symptoms, and craving. Moreover, these negative affects were related to craving intensity. However, for men, the relation was only present at the beginning of detoxification, while, for women, it persisted at the end of detoxification as did high levels of depression. Furthermore, only with women was the level of craving at T2 proportional to negative affects reported at T1, and depression symptoms experienced at T1 were reliable predictors of craving at T2.

CONCLUSIONS

Given the importance of craving in relapse, special care should be given to improve depressive symptoms in AD women to promote long-term abstinence. Also, the remaining portion of AD women who still exhibit substantial symptoms of anxiety and depression at the end of detoxification could benefit from an integrated treatment simultaneously tackling mood and alcohol-dependence disorders.