Shifts in behavioral allocation patterns as a natural recovery mechanism: Postresolution expenditure patterns

Role of relative-reinforcement value of alcohol-free activities during recovery from alcohol use disorder in an adult clinical sample

Behavioral economic theory has been extensively applied to understand alcohol use disorder (AUD). Applications of behavioral economic theory conceptualize AUD as a pattern of harmful alcohol use over extended periods of time in which choices between drinking or engaging in alcohol-free activities favor drinking. Recovery, in contrast, entails a sustained shift toward a pattern of selecting rewarding alcohol-free activities. The present study examined whether alcohol-free activity engagement and the relative-reinforcement value (RRV) of engaging in those activities predicted AUD treatment outcomes via secondary analysis of data from Project MATCH, a multisite randomized clinical trial examining behavioral treatments for AUD (N = 1,279, 75.8% male, 81.0% non-Hispanic White, 9.5% Black, 7.7% Hispanic/Latino, 1.5% American Indian/Alaska Native, < 1% Asian American, and other race/ethnicity). Regression analyses indicated that every additional alcohol-free activity reported at 6 months posttreatment was associated with 7% fewer drinking days, 5% fewer heavy drinking days, and approximately one less drink per drinking day, as well as with significant improvements in depression, purpose in life, and psychosocial functioning at 12 months following treatment. Consistent with behavioral economic theory, higher RRV of alcohol-free activities also predicted significant reductions in drinking and improvements in functioning, and these associations were stronger compared to results for alcohol-free activity frequency only. The findings highlight the importance of understanding environmental contexts conducive to recovery and support the value of increasing alcohol-free activity engagement and the RRV of engaging in such activities to facilitate reductions in drinking and improved functioning among individuals with AUD. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Applying behavioral economics to understand changes in alcohol outcomes during the transition to adulthood: Longitudinal relations and differences by sex and race

OBJECTIVE

Population drinking trends show clear developmental periodicity, with steep increases in harmful alcohol use from ages 18 to 22 followed by a gradual decline across the 20s, albeit with persistent problematic use in a subgroup of individuals. Cross-sectional studies implicate behavioral economic indicators of alcohol overvaluation (high alcohol demand) and lack of alternative substance-free reinforcers (high proportionate alcohol-related reinforcement) as potential predictors of change during this developmental window, but longitudinal evidence is sparse.

METHOD

Using a sample of emerging adults (N = 497, Mage = 22.61 years, 62% female, 48.69% White, 40.44% Black), this study examined prospective, bidirectional relations between both past-week heavy drinking days (HDD) and alcohol problems and proportionate alcohol-related reinforcement (reinforcement ratio), alcohol demand intensity (consumption at zero price), alcohol demand Omax (maximum expenditure), and change in demand elasticity (rate of change in consumption across escalating price) over five assessments (every 4 months) using random intercept cross-lagged panel models.

RESULTS

Alcohol problems and HDD decreased across assessments. Significant between-person effects indicated that each behavioral economic variable was associated with increased drinking risk. Change in reinforcement ratio was positively associated with decreases in alcohol problems. Multigroup invariance modeling revealed distinct risk pathways in that change in demand intensity and Omax predicted change in alcohol problems for male participants and change in intensity predicted change in alcohol problems for non-White participants.

CONCLUSION

The study provides consistent support for proportionate alcohol-related reinforcement and mixed support for demand as within-person predictors of reductions in drinking. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Self-change from problems with alcohol and drugs: A scoping review of the literature since 2010

ISSUES

Self-change from alcohol and drug use problems is increasingly acknowledged in research. Despite the growing number of published studies, the most recent broad review of this dispersed field dates back to 2010. The present review narratively synthesises key findings from empirical studies and critically identifies research gaps and directions for further research.

APPROACH

Following the PRISMA guidelines for scoping reviews, a systematic search was conducted in multiple scientific databases, resulting in the identification of 56 relevant articles with explicit empirical results on self-change.

KEY FINDINGS

The scoping review presents findings related to: (i) methods and definitions used; (ii) the prevalence of self-change; (iii) indicators of self-change; (iv) the process of self-change; and (v) population views on self-change.

CONCLUSION

The review highlights the significant growth in research on self-change considering key themes as well as the need for a relational and time-bound approach to self-change in research and practice.

A brief measure of non-drug reinforcement: Association with treatment outcomes during initial substance use recovery

BACKGROUND

Translational research demonstrates that drug use is inversely associated with availability and engagement with meaningful non-drug reinforcers. Evaluation of non-drug reinforcement in treatment-receiving clinical populations is limited, likely owing to the time intensive nature of existing measures. This study explores the association of non-drug reinforcers with treatment outcomes using a novel, brief measure of past month non-drug reinforcement quantifying three elements: relative frequency, access, and enjoyability.

METHODS

Respondents enrolled in substance use treatment (residential, intensive outpatient, and medically managed withdrawal) in clinics across the United States (N = 5481) completed standardized assessments of non-drug reinforcement and treatment outcomes (i.e., return to use and life satisfaction) one-month after treatment discharge. Non-drug reinforcement measures (availability, engagement, enjoyability) were used as predictors of return to use and life satisfaction using generalized linear models.

RESULTS

Non-drug reinforcement indices were associated with return to use and life satisfaction in unadjusted models (e.g., 12.4 % versus 58.3 % return to use for those with the highest and lowest availability, respectively). Consistent results were observed in models adjusted for sociodemographic variables and risk factors (i.e., sleep disturbance, anhedonia, stress). Comparisons by drug class generally showed lower non-drug reinforcement among patients reporting heroin or methamphetamine as their primary drug.

CONCLUSIONS

Results highlight the importance of non-drug reinforcement during the first month following treatment. Rapid measurement of non-drug reinforcement in stepped care settings may illuminate critical deficits in early stages of behavior change, identify those at greatest risk for return to use, and provide targets for treatment to improve recovery trajectories.

Pretreatment changes in drinking: Theoretical and methodological implications for alcohol use disorder treatment outcome research

BACKGROUND

There is a growing recognition of the importance of changes in drinking prior to the first treatment session (i.e., pretreatment change). A major limitation of past studies of pretreatment change is the reliance on retrospective reporting on drinking rates between the baseline assessment and the first treatment session collected at the end of treatment. The present study sought to extend previous findings by examining 12-month treatment outcomes and correlates of pretreatment changes in drinking measured weekly during treatment.

METHODS

Data from a randomized behavioral clinical trial examining the effect of therapeutic alliance feedback on drinking outcomes were analyzed (n = 165). All participants received cognitive behavioral therapy for alcohol dependence, completed pre and posttreatment assessments, and provided weekly measures of drinking during treatment.

RESULTS

Results indicated that approximately half of the sample reduced their heavy drinking days by 70% or more and number of drinking days by 50% or more prior to beginning treatment. Further, individuals who reported greater consideration of how their problematic drinking affected their social environment displayed greater changes in drinking days prior to treatment. Changes in heavy drinking days were also related to relationship status, such that individuals who were single/never married were less likely to change prior to treatment than those who were married/cohabitating or separated/divorced.

CONCLUSION

These confirm the importance of pretreatment change in the study of treatment outcomes, and suggest that interpersonal processes, including the appraisal of drinking behavior in a social context, may play an important role in pretreatment changes in drinking.

Contextual decision-making and alcohol use disorder criteria: Delayed reward, delayed loss, and probabilistic reward discounting

OBJECTIVE

Alcohol use disorder (AUD) is an etiologically heterogeneous psychiatric disorder defined by a collection of commonly observed co-occurring symptoms. It is useful to contextualize AUD within theoretical frameworks to identify potential prevention, intervention, and treatment approaches that target personalized mechanisms of behavior change. One theoretical framework, behavioral economics, suggests that AUD is a temporally extended pattern of cost/benefit analyses favoring drinking decisions. The distribution of costs and benefits across choice outcomes is often unequally distributed over time and has different probabilities of receipt, such that delay and probability become critical variables. The present study examines the relations between different forms of economic discounting (delayed reward, delayed cost, and probabilistic reward) and individual symptoms of AUD to inform etiological models.

METHOD

Participants (N = 732; 41% female, 4.2% Black, 88.1% White, 8% Hispanic) completed an online survey with measures of AUD symptoms and economic discounting. We examined relations between economic discounting and AUD symptoms with zero-order correlations, in separate models (factor models), and in models controlling for an AUD factor (factor-controlled models).

RESULTS

Delayed reward discounting was positively associated with the give up AUD criteria across all three levels of analysis. Probability discounting was associated with social/interpersonal problems across two out of three sets of analyses. Consistent with the broad discounting literature, effect sizes were small (range = -.15 to .13).

CONCLUSIONS

These results support the idea that AUD criteria are etiologically distinct, resulting in varying AUD profiles between persons that are differentially associated with behavioral economic discounting. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Addictive behavior as molar behavioral allocation: Distinguishing efficient and final causes in translational research and practice

OBJECTIVE

Translational research on addictive behaviors viewed as molar behavioral allocation is critically reviewed. This work relates rates of behavior to rates of reinforcement over time and has been fruitfully applied to addictive behaviors, which involve excessive allocation to short-term rewards with longer term costs.

METHOD

Narrative critical review.

RESULTS

This approach distinguishes between final and efficient causes of discrete behaviors. The former refers to temporally extended behavior patterns into which the act fits. The latter refers to environmental stimuli or internal psychological mechanisms immediately preceding the act. Final causes are most clear when addictive behaviors are studied over time as a function of changing environmental circumstances. Discrete acts of addictive behavior are part of an extended/molar behavior pattern when immediate constraints on engagement are low and few rewarding alternatives are available. Research framed by efficient causes often use behavioral economic simulation tasks as individual difference variables that precede discrete acts. Such measures show higher demand for addictive commodities and steeper discounting in various risk groups, but whether they predict molar addictive behavior patterning is understudied.

CONCLUSIONS

Although efficient cause analysis has dominated translational research, research supports viewing addictive behavior as molar behavioral allocation. Increasing concern with rate variables underpinning final cause analysis and considering how study methods and temporal units of analysis inform an efficient or final cause analysis may advance understanding of addictive behaviors that occur over time in dynamic environmental contexts. This approach provides linkages between behavioral science and disciplines that study social determinants of health. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Bidirectional prospective associations between behavioral economic indicators and drinking patterns during alcohol use disorder natural recovery attempts

OBJECTIVES

Behavioral economic (BE) theory posits that harmful alcohol use is a joint product of elevated alcohol demand and preference for immediate over delayed rewards. Despite cross-sectional research support, whether expected bidirectional relations exist between BE indicators and drinking during recovery attempts is unknown. Therefore, this prospective research investigated quarter-by-quarter cross-lagged associations between BE simulation tasks and drinking following a natural recovery attempt. Higher demand and discounting in a given quarter should predict subsequent drinking. Conversely, drinking in a given quarter should predict subsequent higher demand and discounting.

METHOD

Community-dwelling problem drinkers were enrolled shortly after stopping heavy drinking without treatment (N = 191). Drinking practices, problems, delay discounting, and alcohol demand (intensity, Omax, Pmax, elasticity) were assessed at baseline and 3-, 6-, 9-, and 12-month follow-ups. Longitudinal cross-lagged models related each BE indicator in the previous quarter to drinking status in the next quarter, and vice versa.

RESULTS

Higher demand intensity (consumption when drinks are free) at Quarter 1 distinguished participants who drank heavily in Quarter 2 from those who abstained. In turn, heavy drinking participants in Quarter 2 had higher intensity at Quarter 3 than abstainers and moderate drinkers in Quarter 2, and higher intensity at Quarter 3 distinguished heavy drinkers in Quarter 4 from moderate drinkers (ps < .05). Hypothesized associations for other BE indices were inconsistent or partially supported.

CONCLUSIONS

Alcohol purchase task metrics showed some hypothesized prospective associations with drinking during a natural recovery attempt, which supports their ecological validity as relapse risk indicators. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Matching, behavioral economics, and teleological behaviorism: Final cause analysis of substance use and health behavior

Howard Rachlin and his contemporaries pioneered basic behavioral science innovations that have been usefully applied to advance understanding of human substance use disorder and related health behaviors. We briefly summarize the innovations of molar behaviorism (the matching law), behavioral economics, and teleological behaviorism. Behavioral economics and teleological behaviorism's focus on final causes are especially illuminating for these applied fields. Translational and applied research are summarized for laboratory studies of temporal discounting and economic demand, cohort studies of alcohol and other drug use in the natural environment, and experimental behavioral economic modeling of health behavior-related public health policies. We argue that the teleological behavioral perspective on health behavior is conducive to and merges seamlessly with the contemporary socioecological model of health behavior, which broadens the contextual influences (e.g., community, economic, infrastructure, health care access and policy) of individuals' substance use and other health risk behaviors. Basic-to-applied translations to date have been successful and bode well for continued applications of basic science areas pioneered by Howard Rachlin and his contemporaries.

Mechanisms of Behavior Change in Substance Use Disorder With and Without Formal Treatment

This article provides a narrative review of studies that examined mechanisms of behavior change in substance use disorder. Several mechanisms have some support, including self-efficacy, craving, protective behavioral strategies, and increasing substance-free rewards, whereas others have minimal support (e.g., motivation, identity). The review provides recommendations for expanding the research agenda for studying mechanisms of change, including designs to manipulate putative change mechanisms, measurement approaches that expand the temporal units of analysis during change efforts, more studies of change outside of treatment, and analytic approaches that move beyond mediation tests. The dominant causal inference approach that focuses on treatment and individuals as change agents could be expanded to include a molar behavioral approach that focuses on patterns of behavior in temporally extended environmental contexts. Molar behavioral approaches may advance understanding of how recovery from substance use disorder is influenced by broader contextual features, community-level variables, and social determinants of health. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.