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Residual alcohol use disorder symptoms after treatment predict long-term drinking outcomes in seniors with DSM-5 alcohol use disorder

BACKGROUND

Risk of relapse within the first months after alcohol use disorder (AUD) interventions is substantial among older adults. For this vulnerable group, little information exists on how this risk is associated with residual DSM-5 AUD symptoms after treatment.

AIMS

To investigate among older adults who received short-term treatment for DSM-5 AUD (1) the prediction of drinking behaviors and quality of life 12 months after treatment initiation by 6-month DSM-5 AUD symptoms, AUD severity, and AUD remission, and (2) whether these DSM-5 AUD indicators provide prognostic information beyond that gained from 6-month alcohol use (AU) status.

METHODS

The international multicenter RCT "ELDERLY-Study" enrolled adults aged 60+ with DSM-5 AUD. We used data from the subsample of 323 German and Danish participants with complete DSM-5 AUD criterion information 6 months after treatment initiation (61% male; mean age = 65.5 years). AU was assessed with Form 90, DSM-5 AUD with the M.I.N.I., and quality of life with the WHOQOL-BREF. Generalized linear models were applied to investigate the associations between 6-month AUD indicators and 12-month AU and quality of life.

RESULTS

Independent of AU at 6 months, having 1 (vs. no) residual AUD symptom at 6 months predicted a 12-month "slip," defined as exceeding a blood alcohol concentration of 0.05% at least once during that time (OR: 3.7, 95% CI: 1.5 to 9.0), heavy episodic drinking, and hazardous use (p < 0.05). AUD remission was associated with a lower risk of a "slip" at 12 months (p < 0.05). Failed reduction/cessation was associated with poorer physical health (Coef.: -0.4, 95% CI -0.7 to -0.1).

CONCLUSION

For older adults, residual AUD symptoms in the first months after short-term treatment predict problematic AU outcomes during the first 12 months after treatment entry. Thus, residual symptoms should be addressed in this patient population during posttreatment screenings.

Changes in DSM criteria following a culturally-adapted computerized CBT for Spanish-speaking individuals with substance use disorders

This study sought to replicate and extend findings regarding change in the number of endorsed Diagnostic and Statistical Manual (DSM) criteria for substance use disorders as a meaningful outcome for clinical trials with Spanish-speakers. A secondary analysis was conducted of data from 83 treatment-seeking individuals with current DSM-IV substance dependence participating in a randomized controlled trial evaluating a culturally-adapted version of a computer-based cognitive behavioral therapy program (CBT4CBT) for Spanish-speakers. Participants were randomized to either weekly standard outpatient counseling (treatment as usual - TAU), or TAU plus access to CBT4CBT (TAU+CBT4CBT). The Structured Clinical Interview for DSM-IV (SCID-IV) was administered at baseline and at the end of the 8-week treatment period to measure change in diagnostic status and total criteria count. Frequency of substance use during treatment and throughout a 6-month follow-up period was measured by self-report using a calendar-based Timeline FollowBack method, with abstinence verified through instant urine toxicology, and problem severity was measured with the Addiction Severity Index (ASI). Results of a generalized linear model with Poisson's distribution indicated significant reduction in the total count of DSM-IV dependence criteria during treatment (Wald X² = 136.20; p < .001), and a significant interaction with treatment assignment (Wald X² = 19.92, p < .001), indicating a greater reduction in endorsed criteria for those assigned to TAU+CBT4CBT compared to TAU only. Total criteria count and diagnostic status at end-of-treatment was significantly correlated with substance use outcomes during the follow-up period, such that fewer criteria endorsed were associated with greater rates of abstinence and lower problem severity. These findings paralleled the primary outcomes from the main trial, and replicated prior findings in English-speakers regarding the utility of DSM criteria count as a potential clinically meaningful outcome.

Response to commentaries: The quest(ion) remains in the search for a meaningful reduction-based end-point

There are multiple challenges toward the identification and acceptance of a meaningful reduction-based endpoint for use in drug use disorder medication efficacy clinical trials. Evaluation of change in diagnostic criteria, and severity metrics based on criterion counts, may be a promising approach for future research.