Predicting relapse in patients with severe alcohol use disorder: The role of alcohol insight and implicit alcohol associations

Effectiveness of the Korean-Patient Placement Criteria for Alcohol Use Disorders: A Prospective Exploratory Study

OBJECTIVE

Various patient placement criteria (PPC) have been developed to address alcohol use disorder (AUD), which has a high relapse rate and imposes substantial socioeconomic costs. Although research has shown PPC to be an effective tool, evidence supporting the Korean-PPC (K-PPC) is insufficient. This paper investigated whether treatment matching with the K-PPC was effective, based on variables related to AUD.

METHODS

In total, 524 participants were evaluated using the 6 dimensions of the K-PPC and levels of care (LoC) were recommended based on the results. Participants whose treatment matched with the recommended LoC were classified into the matched group, and those whose treatment did not match were classified into the mismatched group. Subsequently, treatment was planned according to the determined LoC, and a total of 3 follow-up evaluations were conducted at 1 month, 3 months, and 6 months.

RESULTS

There was no significant difference in the follow-up rate between the K-PPC matched group and the mismatched group. Of the variables measured by the 6 dimensions of the K-PPC, alcohol-related variables, depression, insight, and biomedical outcomes showed the most significant results (especially alcohol-related variables) from the baseline evaluation to the 6-month follow-up. In addition, the average adherence to the treatment program in the 6-month period was found to be higher in the matched group than in the mismatched group.

CONCLUSION

The K-PPC could be effective for placing patients and providing treatment by matching patient characteristics. Enhancing treatment program retention can also have a positive effect on clinical outcomes.

Exploring the Self-Care Factors for Recovery in Alcohol Use Disorder and the Role of Peer Recovery Coaches: A Qualitative Study

Self-care is important in addiction recovery, and peer recovery coaches (PRCs) play key roles in recovery. This qualitative study explored self-care factors for individuals recovering from alcohol use disorder and the role of PRCs in supporting these individuals' self-care. Individual interviews with five PRCs and five workers in community addiction management centers in South Korea were performed. Data were analyzed using content analysis. Two categories and six subcategories were derived. The two categories were "elements of self-care: preparation and practice for a new way of life" and "the roles of PRCs: recovery facilitators with differentiated competencies." The factors identified as being involved self-care were summarized as "changing one's thought process and attitude" and "practical enactment considering the situation." The effective roles of PRCs were "sharing specific and realistic information," "providing motivation," "building empathy," and "presenting role models as mentors." This study identified self-care factors that should be included in addiction recovery programs with the participation of PRCs and also identified the roles of the PRCs. Developing and applying nursing interventions with PRCs in clinical and community nursing settings is necessary.

Definition and measurement of alcohol-associated insight in early liver transplantation for acute alcohol-associated hepatitis: A systematic review

BACKGROUND

Alcohol accounts for a large disease burden in hepatology and liver transplantation (LT) and across the globe. Clinical evaluations and decisions about LT candidacy are challenging because they rely on detailed psychosocial assessments and interpretations of psychiatric and substance use disorder data, which often must occur rapidly according to the acuity of end-stage liver disease. Such difficulties commonly occur during the process of candidate selection and liver allocation, particularly during early LT (eLT) in patients with acute alcohol-associated hepatitis (AAH). Patients with AAH commonly have very recent or active substance use, high short-term mortality, psychiatric comorbidities, and compressed evaluation and treatment timetables. LT clinicians report that patients' alcohol-associated insight (AAI) is among the most relevant psychosocial data in this population, yet no studies exist examining how LT teams define and use AAI in eLT or its effect on clinical outcomes. In April 2022, we searched Ovid MEDLINE, Elsevier Embase, EBSCOhost PsycInfo and CINAHL, and Wiley Cochrane Central Register of Controlled Trials for reports describing AAH populations who underwent eLT, which also described psychosocial evaluation parameters. The searches retrieved 1603 unique reports. After eligibility screening, 8 were included in the qualitative analysis. This systematic review reveals that AAI is a poorly defined construct that is not measured in a standardized way. Yet it is a commonly cited parameter in articles that describe the psychosocial evaluation and decision-making of patients undergoing eLT for AAH. This article also discusses the general challenges of assessing AAI during eLT for AAH, existing AAI definitions and rating scales, how AAI has been used to date in the broader hepatology and LT literature, and future areas for clinical and research progress.

Effect of environmental enrichment on relapse rates in patients with severe alcohol use disorder: protocol for a randomised controlled trial

INTRODUCTION

Alcohol use disorder (AUD) ranks among the most prevalent psychiatric disorders worldwide. Despite current treatments, more than half of patients relapse within weeks after treatment. In animal models, exposure to environmental enrichment (EE) has been shown to be a promising approach to reduce relapse. However, controlled, multimodal EE is difficult to transpose to humans. To address this gap, this study aims at assessing the effectiveness of exposure to a newly designed EE protocol during AUD treatment in reducing relapse to alcohol use. Our EE will allow an enhancement of the standard intervention, and will combine several promising enrichment factors identified in the literature-physical activity, cognitive stimulation, mindfulness and virtual reality (VR).

METHODS AND ANALYSIS

A randomised controlled trial involving 135 participants receiving treatment for severe AUD will be conducted. Patients will be randomised to an intervention enhancement group or a control group. The enhanced intervention will consist of six 40-min sessions of EE spread over 9 days. During the first 20 min of these sessions, patients will practise mindfulness in multisensory VR, in virtual environments designed to practise mindfulness and use it to regulate craving induced by virtual cues or stress. Then, participants will practise indoor cycling combined with cognitive training exercises. The control group will undergo standard management for AUD. The primary outcome is relapse assessed at 2 weeks after treatment, using a questionnaire and biological indicators. Relapse will be defined as drinking at least five drinks per occasion or drinking at least five times a week. It is predicted that the group receiving the EE intervention will have a lower relapse rate than the control group. The secondary outcomes are relapse at 1 month and 3 months after treatment, craving and drug-seeking behaviour, mindfulness skills acquisition and the effect of the intervention enhancement on the perceived richness of the daily environment, assessed by questionnaires and neuropsychological tasks.

ETHICS AND DISSEMINATION

All participants have to give written informed consent to the investigator. This study is approved by the Ethics Committee Nord Ouest IV of Lille (reference number 2022-A01156-37). Results will be disseminated through presentations, peer-reviewed journals and seminar conferences. All information on ethical considerations and open science practices can be accessed at https://osf.io/b57uj/ TRIAL REGISTRATION NUMBER: NCT05577741.

Development and validation of the Schedule for the Assessment of Insight in Alcohol Dependence (SAI-AD): Dimensions and correlates of insight in alcohol use disorder

INTRODUCTION

The objectives of this study were to develop a multidimensional, clinician-rated scale that assess impaired insight into illness in patients with alcohol use disorder (AUD) and to examine its reliability, validity and internal structure. Moreover, we investigated the relationships of overall insight and its dimensions with demographic and clinical characteristics in AUD.

METHODS

We developed the Schedule for the Assessment of Insight in Alcohol Dependence (SAI-AD), based on scales that has already been used in psychosis and other mental disorders. Sixty-four patients with AUD were assessed with SAI-AD. Hierarchical cluster analysis and multidimensional scaling were used to identify insight components and assess their inter-relationships.

RESULTS

The SAI-AD demonstrated good convergent validity (r = -0.73, p < 0.001) and internal consistency (Cronbach's alpha = 0.72). Inter-rater and test-retest reliabilities were high (intra-class correlations 0.90 and 0.88, respectively). Three subscales of SAI-AD were identified which measure major insight components: awareness of illness, recognition of symptoms and need for treatment, and treatment engagement. Higher levels of depression, anxiety and AUD symptom severity were associated with overall insight impairment but not with recognition of symptoms and need for treatment, or with treatment engagement. Illness duration was specifically and positively associated with the treatment engagement component of insight.

CONCLUSIONS

Insight is a multidimensional construct in AUD and its major components appear to be associated with different clinical aspects of the disorder. The SAI-AD is a valid and reliable tool for the assessment of insight in AUD patients.

Black patients and women have reduced access to liver transplantation for alcohol-associated liver disease

Although sex and racial disparities for liver transplantation (LT) are known, it is unclear if disparities exist for patients with alcohol-associated liver disease (ALD). We aimed to compare sex and racial/ethnic differences in mortality, LT listing, and LT rates in patients with and without ALD. We analyzed patients who were listed for LT and/or died of end-stage liver disease (ESLD) between 2014 and 2018 using the United Network for Organ Sharing Standard Transplant Analysis and Research and Centers for Disease Control and Prevention Wide-ranging OnLine Data for Epidemiologic Research databases, respectively. Patients with ALD were compared with non-ALD patients. Our primary outcome was the ratio of listings for LT to deaths from ESLD-listing-to-death ratio (LDR)-a previously derived metric to assess access to the waiting list. Differences between sex and race/ethnicity were analyzed with chi-square tests and multivariable linear regression. There were 65,588 deaths and 16,133 listings for ALD compared with 75,020 deaths and 40,194 listings for non-ALD. LDR was lower for ALD (0.25 vs. 0.54; p < 0.001). Black patients had the lowest LDR in both ALD and non-ALD (0.13 and 0.39 for Black patients vs. 0.26 and 0.54 for White patients; p < 0.001). Women with ALD had a lower LDR (0.21 vs. 0.26; p < 0.001), whereas women without ALD had higher LDR than men (0.69 vs. 0.47; p < 0.001). There were significant negative interactions between women and ALD in LDR and the transplant-to-death ratio. Multivariable analysis and a sensitivity analysis, with more liberal definitions of ALD and non-ALD, confirmed these findings. Patients with ALD have lower access to LT. Among those with ALD, female and Black patients have the lowest access. New initiatives are needed to eliminate these inequities.

Acamprosate may be safer than baclofen for the treatment of alcohol use disorder in patients with cirrhosis: a first description of use in real-world clinical practice

OBJECTIVES

Patients with alcohol use disorder (AUD) and liver cirrhosis benefit from stopping alcohol intake. Baclofen has been trialled for AUD in cirrhosis and appears to be effective. However, in patients without cirrhosis acamprosate is safer and more efficacious. Acamprosate is rarely used in cirrhosis due to safety concerns: the only published report was for 24 h in a controlled setting. Our centre uses both medications off-label in cirrhotic patients. We performed an audit to pragmatically compare the safety of acamprosate to baclofen in these patients.

METHODS

The electronic records of patients prescribed acamprosate or baclofen between 01/04/17 and 31/03/20 were retrospectively reviewed. Adverse events and abstinence at last follow-up were compared by Student's t-test, Mann-Whitney U or chi-square test. Confounding variables were evaluated by logistic regression.

RESULTS

In total 48 cirrhotic patients taking acamprosate (median 84 days, range 2-524); 44 baclofen (247 days, 8-910) met inclusion criteria. At baseline, 41% had Childs-Pugh B or C cirrhosis. More patients taking baclofen had an unplanned hospital admission or attendance (23 vs 13; P = 0.013) and the mean number per patient was higher (1.6 vs 0.6; P = 0.032). Sub-group analysis revealed increased admissions in actively drinking patients prescribed baclofen to achieve abstinence (mean 2.4 vs 0.6; P = 0.020); acamprosate use was associated with a reduced chance of admission or attendance (OR, 0.284; 0.095-0.854; P = 0.025) independent of treatment length. No difference in efficacy was observed.

CONCLUSIONS

In patients with cirrhosis, acamprosate was associated with fewer unplanned admissions than baclofen, hence may be safer despite historical concerns.

Clinical insight level predicts successful quit or control attempts during the first three months of outpatient addiction treatment

INTRODUCTION

Low clinical insight in psychiatry is defined as poor recognition of one's mental illness, including disability to self-evaluate symptom severity. It has been reported as common in addiction and is associated with lower treatment compliance. Longitudinal studies suggest that low clinical insight could be linked to more relapse. However, association with successful quit attempts remains unknown.

OBJECTIVE

Our objective was to examine the prospective link between baseline clinical insight level and self-reports of successful attempts to quit / control use during the first 3 months of outpatient addiction treatment.

METHODS

Participants were recruited from the ADDICTAQUI cohort at outpatient treatment intake for substance or behavioral addictions. They completed a baseline evaluation using the Addiction Severity Index (ASI), the Mini International Neuropsychiatric Interview (MINI), and the modified Hanil Alcohol Insight Scale (m-HAIS) with a follow-up ASI 3 months later. Data were analyzed using multiple logistic regression and non-parametric tests.

RESULTS

Lower clinical insight level at baseline was associated with less successful quit / control attempts during the first 3 months of outpatient treatment compared to a higher clinical insight level, controlling for sociodemographic factors, baseline addiction severity, and comorbidities (n = 54; exp(B) = 0.76; p (FDRcor) = 0.033).

CONCLUSION

Poor clinical insight may be a barrier to treatment success, and future studies should examine underlying mechanisms.

Machine learning prediction of dropping out of outpatients with alcohol use disorders

BACKGROUND

Alcohol use disorder (AUD) is a chronic disease with a higher recurrence rate than that of other mental illnesses. Moreover, it requires continuous outpatient treatment for the patient to maintain abstinence. However, with a low probability of these patients to continue outpatient treatment, predicting and managing patients who might discontinue treatment becomes necessary. Accordingly, we developed a machine learning (ML) algorithm to predict which the risk of patients dropping out of outpatient treatment schemes.

METHODS

A total of 839 patients were selected out of 2,206 patients admitted for AUD in three hospitals under the Catholic Central Medical Center in Korea. We implemented six ML models-logistic regression, support vector machine, k-nearest neighbor, random forest, neural network, and AdaBoost-and compared the prediction performances thereof.

RESULTS

Among the six models, AdaBoost was selected as the final model for recommended use owing to its area under the receiver operating characteristic curve (AUROC) of 0.72. The four variables affecting the prediction based on feature importance were the length of hospitalization, age, residential area, and diabetes.

CONCLUSION

An ML algorithm was developed herein to predict the risk of patients with AUD in Korea discontinuing outpatient treatment. By testing and validating various machine learning models, we determined the best performing model, AdaBoost, as the final model for recommended use. Using this model, clinicians can manage patients with high risks of discontinuing treatment and establish patient-specific treatment strategies. Therefore, our model can potentially enable patients with AUD to successfully complete their treatments by identifying them before they can drop out.

Instrumental and Pavlovian Mechanisms in Alcohol Use Disorder

Purpose of Review

Current theories of alcohol use disorders (AUD) highlight the importance of Pavlovian and instrumental learning processes mainly based on preclinical animal studies. Here, we summarize available evidence for alterations of those processes in human participants with AUD with a focus on habitual versus goal-directed instrumental learning, Pavlovian conditioning, and Pavlovian-to-instrumental transfer (PIT) paradigms.

Recent Findings

The balance between habitual and goal-directed control in AUD participants has been studied using outcome devaluation or sequential decision-making procedures, which have found some evidence of reduced goal-directed/model-based control, but little evidence for stronger habitual responding. The employed Pavlovian learning and PIT paradigms have shown considerable differences regarding experimental procedures, e.g., alcohol-related or conventional reinforcers or stimuli.

Summary

While studies of basic learning processes in human participants with AUD support a role of Pavlovian and instrumental learning mechanisms in the development and maintenance of drug addiction, current studies are characterized by large variability regarding methodology, sample characteristics, and results, and translation from animal paradigms to human research remains challenging. Longitudinal approaches with reliable and ecologically valid paradigms of Pavlovian and instrumental processes, including alcohol-related cues and outcomes, are warranted and should be combined with state-of-the-art imaging techniques, computational approaches, and ecological momentary assessment methods.

Distinct Whole-Body Movements in Response to Alcohol and Sexual Content in Alcohol Use Disorder

BACKGROUND

Spontaneous motor responses of approach and avoidance toward stimuli are important in characterizing psychopathological conditions, including alcohol use disorder (AUD). However, divergent results have been reported, possibly due to confounded parameters (e.g., using a symbolic vs. a sensorimotor task, implementation of approach-avoidance as a measure vs. a manipulation).

METHODS

We studied whole-body/posturometric changes by using a sensorimotor measure relying on embodied cognition principles to assess forward (approach) and backward (avoidance) spontaneous leaning movements. Over a 12-second period, 51 male patients with AUD and 29 male control participants were instructed to stand still in response to both alcohol and sexual visual content. Patients with AUD were then divided into "abstainers" and "relapsers," depending on their continuous abstinence at 2 weeks postdischarge (obtained via a telephone follow-up interview). The effects of the group, the stimulus type, the experimental period, and their interactions on the posturometric changes were tested using mixed Analyses of variance (ANOVAs), with a significance threshold set at 0.05.

RESULTS

Contrary to our expectations, patients and controls did not show significant difference in their forward/backward micromovements while passively viewing alcohol or sexual content (p > 0.1). However, in line with our hypothesis, patients who relapsed several weeks following discharge from the rehabilitation program were significantly more reactive and more likely to lean back during the first seconds of viewing alcohol cues (p = 0.002). Further, "relapsers" were more likely to lean forward during exposure to sexual content than participants who remained abstinent (p < 0.001).

CONCLUSIONS

Among individuals with AUD, there are distinct pattern of spontaneous movements that differentiate "abstainers" and "relapsers," findings that can be understood in light of existing data and theories on action tendencies.

Link Between Perception of Treatment Need and Craving Reports in Addiction

BACKGROUND

Perception of treatment need (PTN), a component of clinical insight, is associated to negative addiction treatment outcomes when low. Our hypothesis was that lower PTN was associated with less craving when reported retrospectively, the most common measure of craving in clinical settings.

OBJECTIVE

To explore the association between PTN and craving among a dataset of subjects with severe substance use disorders.

METHODS

Participants were recruited from outpatient addiction clinic admissions or harm reduction program services. Good and low PTN were based on consistency between severe addiction (at least six DSM-5 criteria) and self-report need for addiction treatment from the Addiction Severity Index. Craving was retrospectively characterized over the past 30 days. Multiple regression analyses were conducted.

RESULTS

Participants with low PTN (n = 97) retrospectively reported less frequent and intense episodes of craving, compared with participants with good PTN (n = 566) after controlling for sociodemographic factors, addiction type, and severity (p < 0.0001).

CONCLUSION

Low perception of treatment need among subjects with severe addictions is associated to less retrospective report of craving, which may contribute to reduced efficiency of treatment. Further studies are needed to explore the mechanisms of the association.