Revisiting the Drinker Inventory of Consequences: An extensive evaluation of psychometric properties in two alcohol clinical trials

A clinical science guide for reviewing the cross-cultural rigor of assessments in an alcohol training clinic

A standard component of service delivery in alcohol treatment clinics is evidence-based assessment (EBA). Although EBA is essential for selecting appropriate treatment modalities for alcohol use and associated problems, there are limitations in existing EBAs concerning evidence of cultural equivalence and utility among individuals seeking alcohol treatment. However, training in EBA, addictions, and clinical applications with diverse populations all are gaps in clinical training in doctoral programs in clinical psychology. The present work used the clinical science model to review the psychometric properties, cross-cultural utility, and measurement invariance of measures in an assessment battery used in an alcohol treatment training clinic. This article describes the results of that review, recommendations for retaining or replacing common assessment measures used in alcohol treatment clinics, and recommendations for alcohol treatment clinics interested in engaging in similar processes. Findings suggested that more research is needed to evaluate the psychometric properties of EBAs utilized in an alcohol treatment assessment battery, particularly among American Indian and Alaska Native people, and to test measurement invariance across race/ethnicity and other identity groups in alcohol treatment-seeking populations. Overall, routine reviews of cultural relevance are needed in clinical settings to stay current with the emerging literature. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Evidence-Based Assessment of Substance Use Disorder

The current review describes updated information on the evidence-based assessment of substance use disorder. We offer an overview of the state of the science for substance-related assessment targets, instruments (screening, diagnosis, outcome and treatment monitoring, and psychosocial functioning and wellbeing) and processes (relational and technical) as well as recommendations for each of these three components. We encourage assessors to reflect on their own biases, beliefs, and values, including how those relate to people that use substances, and to view the individual as a whole person. It is important to consider a person's profile of symptoms and functioning inclusive of strengths, comorbidities, and social and cultural determinants. Collaborating with the patient to select the assessment target that best fits their goals and integration of assessment information in a holistic manner is critical. We conclude by providing recommendations for assessment targets, instruments, and processes as well as recommendations for comprehensive substance use disorder assessment, and describe future directions for research.

Effect of Cognitive Behavioral Therapy for Insomnia on Alcohol Treatment Outcomes Among US Veterans: A Randomized Clinical Trial

Importance

Three of 4 adults in treatment for alcohol use disorder (AUD) report symptoms of insomnia. Yet the first-line treatment for insomnia (cognitive behavioral therapy for insomnia, CBT-I) is often delayed until abstinence is established.

Objective

To test the feasibility, acceptability, and preliminary efficacy of CBT-I among veterans early in their AUD treatment and to examine improvement in insomnia as a mechanism for improvement in alcohol use outcomes.

Design, Setting, and Participants

For this randomized clinical trial, participants were recruited through the Addictions Treatment Program at a Veterans Health Administration hospital between 2019 and 2022. Patients in treatment for AUD were eligible if they met criteria for insomnia disorder and reported alcohol use in the past 2 months at baseline. Follow-up visits occurred posttreatment and at 6 weeks.

Interventions

Participants were randomly assigned to receive 5 weekly sessions of CBT-I or a single session about sleep hygiene (control). Participants were asked to complete sleep diaries for 7 days at each assessment.

Main Outcomes and Measures

Primary outcomes included posttreatment insomnia severity (assessed using the Insomnia Severity Index) and follow-up frequency of any drinking and heavy drinking (4 drinks for women, ≥5 drinks for men; number of days via Timeline Followback) and alcohol-related problems (Short Inventory of Problems). Posttreatment insomnia severity was tested as a mediator of CBT-I effects on alcohol use outcomes at the 6-week follow-up.

Results

The study cohort included 67 veterans with a mean (SD) age of 46.3 years (11.8); 61 (91%) were male and 6 (9%) female. The CBT-I group included 32 participants, and the sleep hygiene control group 35 participants. Of those randomized, 59 (88%) provided posttreatment or follow-up data (31 CBT-I, 28 sleep hygiene). Relative to sleep hygiene, CBT-I participants reported greater decreases in insomnia severity at posttreatment (group × time interaction: -3.70; 95% CI, -6.79 to -0.61) and follow-up (-3.34; 95% CI, -6.46 to -0.23) and greater improvements in sleep efficiency (posttreatment, 8.31; 95% CI, 1.35 to 15.26; follow-up, 18.03; 95% CI, 10.46 to 25.60). They also reported greater decreases in alcohol problems at follow-up (group × time interaction: -0.84; 95% CI, -1.66 to -0.02), and this effect was mediated by posttreatment change in insomnia severity. No group differences emerged for abstinence or heavy-drinking frequency.

Conclusions and Relevance

In this randomized clinical trial, CBT-I outperformed sleep hygiene in reducing insomnia symptoms and alcohol-related problems over time but had no effect on frequency of heavy drinking. CBT-I should be considered a first-line treatment for insomnia, regardless of abstinence.

Trial Registration

ClinicalTrials.gov Identifier: NCT03806491.

Hazardous drinking and alcohol use disorders

Alcohol is one of the most widely consumed psychoactive drugs globally. Hazardous drinking, defined by quantity and frequency of consumption, is associated with acute and chronic morbidity. Alcohol use disorders (AUDs) are psychiatric syndromes characterized by impaired control over drinking and other symptoms. Contemporary aetiological perspectives on AUDs apply a biopsychosocial framework that emphasizes the interplay of genetics, neurobiology, psychology, and an individual's social and societal context. There is strong evidence that AUDs are genetically influenced, but with a complex polygenic architecture. Likewise, there is robust evidence for environmental influences, such as adverse childhood exposures and maladaptive developmental trajectories. Well-established biological and psychological determinants of AUDs include neuroadaptive changes following persistent use, differences in brain structure and function, and motivational determinants including overvaluation of alcohol reinforcement, acute effects of environmental triggers and stress, elevations in multiple facets of impulsivity, and lack of alternative reinforcers. Social factors include bidirectional roles of social networks and sociocultural influences, such as public health control strategies and social determinants of health. An array of evidence-based approaches for reducing alcohol harms are available, including screening, pharmacotherapies, psychological interventions and policy strategies, but are substantially underused. Priorities for the field include translating advances in basic biobehavioural research into novel clinical applications and, in turn, promoting widespread implementation of evidence-based clinical approaches in practice and health-care systems.

Negative Consequences of Alcohol Use among People Living with HIV

Introduction: Among people living with HIV (PLWH), alcohol use can have negative impacts beyond HIV-related outcomes. The objectives of this study are to identify the most common alcohol-related consequences among PLWH in Florida and describe factors associated with experiencing more alcohol-related consequences. Methods: Data were collected from PLWH in the Florida Cohort study who drank at least monthly in the past year (n=397). Self-reported consequences were assessed by the 15-item Short Inventory of Problems Revised (SIP-2R). Nonparametric tests and a generalized estimating equation model with inverse probability of exposure weighting were used to evaluate associations between the total SIP-2R score and socio-demographics, mental health, and substance use while controlling for alcohol use. Results: Over half (56%) endorsed at least one consequence and 29% endorsed 5 or more consequences. The most common consequences were doing something they regretted and taking foolish risks (both endorsed by 37% of participants), both in the impulse control domain. After controlling for alcohol use and other covariates, homelessness and injection drug use remained significantly associated with greater SIP-2R scores. Conclusion: PLWH who are experiencing homelessness or injecting drugs could benefit from receiving additional screening for alcohol-related consequences if they report any alcohol use.

Psychometric Properties of the "Alcohol Consumption Consequences Evaluation" (ACCE) Scale for Young Spanish University Students

Instruments that evaluate alcohol use consequences among young people do not consider the intensive alcohol consumption pattern that is so characteristic during these ages. Some of these instruments are even ineffective in the Spanish population. Hence the interest in developing an instrument more adapted to the reality of our young people. A total of 601 university students (35.9% male and 64.1% female) from 18 to 20 years old were recruited. All of them answered a total of 77 items obtained from the review of both the scientific literature and the different scales used to measure consequences derived from alcohol consumption. In addition, they completed the AUDIT and the Timeline Followback for self-reported consumption. The data were analyzed using factor analysis and a two-parameter logistic model. ROC curve analysis was used to establish cut-off points for different risk levels of alcohol consumption distinguishing between genders. The final 43-item scale Alcohol Consumption Consequences Evaluation (ACCE) (Evaluación de Consecuencias derivadas del Consumo de Alcohol [ECCA]) shows adequate psychometric properties: α = 0.94; unidimensionality through exploratory factor analysis (EFA) (26.25% of explained variance) and confirmatory factor analysis (CFA) (RMSEA = 0.39; TLI and CFI > 0.90). In addition, ROC analyses, both at a global scale and distinguishing between genders, were able to characterize consumers with different levels of risk, obtaining areas under the curve between 0.82 and 0.88. A scale has been obtained that enables the establishment of cut-off points to distinguish between the consequences of low, moderate and high risk alcohol consumption. The clinical utility of the ACCE is highlighted by using one single instrument to perform the screening of a possible alcohol risk consumption as well as identifying the consequences that need to be worked on in the evaluated person’s or group’s intervention.

Predictive value of non-consumption outcome measures in alcohol use disorder treatment

BACKGROUND AND AIMS

For decades, researchers have called for the systematic inclusion of non-consumption outcomes, such as alcohol-related consequences and temptation/craving, in addition to consumption outcomes (e.g. percentage of days abstinent) to evaluate alcohol use disorder (AUD) treatment efficacy. However, Food and Drug Administration (FDA) guidelines for alcohol medications development suggest that non-consumption outcomes may be insensitive to changes that occur within AUD treatment trial assessment windows, although this has never been directly tested. We aimed to measure the predictive value of diagnostically related, non-consumption measures of AUD treatment effects.

METHODS

Pre- to post-treatment effect sizes were examined. Logistic regression analyses were used to test the predictive value of non-consumption outcome measures that were administered in the COMBINE (Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence) Study and Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity) in detecting 12-month outcomes following treatment.

RESULTS

Pre- to post-treatment effect sizes suggested that non-consumption measures changed during the course of treatment; effect sizes for temptation/craving, self-efficacy, consequences and consumption variables were mostly medium to large (medium effect sizes were 0.2 < dz < 0.8, large effect sizes were dz > 0.8). The regression results indicated temptation/craving and self-efficacy predicted 12-month drinking outcomes in COMBINE and MATCH, and drinking consequences predicted 12-month drinking outcomes in COMBINE.

CONCLUSIONS

Self-report measures of temptation and alcohol craving can change as a result of alcohol dependence treatment and can predict drinking outcomes.

Consumption outcomes in clinical trials of alcohol use disorder treatment: Consideration of standard drink misestimation

Background. The Food and Drug Administration recently added a new clinical endpoint for evaluating the efficacy of alcohol use disorder (AUD) treatment that is more inclusive of treatment goals besides abstinence: no heavy drinking days (NHDD). However, numerous critiques have been noted for such binary models of treatment outcome. Further, there is mounting evidence that participants inaccurately estimate the quantities of alcohol they consume during drinking episodes (i.e., drink size misestimation), which may be particularly problematic when using a binary criterion (NHDD) compared to a similar, continuous alternative outcome variable: percent heavy drinking days (PHDD). Yet, the impact of drinking misestimation on binary (e.g., NHDD) versus continuous outcome variables (e.g., PHDD) has not been studied. Objectives. Using simulation methods, the present study examined the potential impact of drink size misestimation on NHDD and PHDD. Methods. Data simulations were based on previously published findings of the amount of error in how much alcohol is actually poured when estimating standard drinks. We started with self-reported daily drinking data from COMBINE study participants with complete data (N = 888; 68.1% male), then simulated inaccuracy in those estimations based on literature on standard drink size misestimation. Results. Clinical trial effect sizes were consistently lower for NHDD than for PHDD. Drink size misestimation further lowered effect sizes for NHDD and PHDD. Conclusions. Drink size misestimation may lead to inaccurate conclusions about drinking outcomes and the comparative effectiveness of AUD treatments, including inflated type-II error rates, particularly when treatment "success" is defined by binary outcomes such as NHDD.