Short of Complete Abstinence: An Analysis Exploration of Multiple Drinking Episodes in Alcoholism Treatment Trials

A Randomized Controlled Trial of an Integrated Alcohol Reduction Intervention in Patients With Hepatitis C Infection

BACKGROUND AND AIMS

Hepatitis C virus (HCV) and alcohol use are patient risk factors for accelerated fibrosis progression, yet few randomized controlled trials have tested clinic-based alcohol interventions.

APPROACH AND RESULTS

A total of 181 patients with HCV and qualifying alcohol screener scores at three liver center settings were randomly assigned to the following: (1) medical provider-delivered Screening, Brief Intervention, and Referral to Treatment (SBIRT), including motivational interviewing counseling and referral out for alcohol treatment (SBIRT-only), or (2) SBIRT plus 6 months of integrated colocated alcohol therapy (SBIRT + Alcohol Treatment). The timeline followback method was used to assess alcohol use at baseline and 3, 6, and 12 months. Coprimary outcomes were alcohol abstinence at 6 months and heavy drinking days between 6 and 12 months. Secondary outcomes included grams of alcohol consumed per week at 6 months. Mean therapy hours across 6 months were 8.8 for SBIRT-only and 10.1 for SBIRT + Alcohol Treatment participants. The proportion of participants exhibiting full alcohol abstinence increased from baseline to 3, 6, and 12 months in both treatment arms, but no significant differences were found between arms (baseline to 6 months, 7.1% to 20.5% for SBIRT-only; 4.2% to 23.3% for SBIRT + Alcohol Treatment; P = 0.70). Proportions of participants with any heavy drinking days decreased in both groups at 6 months but did not significantly differ between the SBIRT-only (87.5% to 26.7%) and SBIRT + Alcohol Treatment (85.7% to 42.1%) arms (P = 0.30). Although both arms reduced average grams of alcohol consumed per week from baseline to 6 and 12 months, between-treatment effects were not significant.

CONCLUSIONS

Patients with current or prior HCV infection will engage in alcohol treatment when encouraged by liver medical providers. Liver clinics should consider implementing provider-delivered SBIRT and tailored alcohol treatment referrals as part of the standard of care.

Examining measurement reactivity in daily diary data on substance use: Results from a randomized experiment

The debate about whether measurement reactivity exists in daily diary research on substance use is still unsettled due to the issues of study design and statistical methodology. This study proposes a time-varying effect model (TVEM) that characterizes the trajectory of substance use behaviors with nonparametric functions determined by the data rather than imposes presumed parametric functions. It also allows researchers to investigate the effect of measurement reactivity on not only the likelihood of using substances but also the amount of substance use. The TVEM was applied to analyze diary data on alcohol and marijuana use collected from an experiment, which randomized 307 participants in Michigan into daily and weekly assessment schedules during 2014-2016. This study found short-term measurement reactivity on alcohol use, but did not find a significant reactivity effect on marijuana use. The daily group had smaller odds of abstinence from drinking but lower expected drinking quantity in the first week of assessment, which dissipated by the second week. The results indicate that although daily self-monitoring could have short-term reactivity on substance use behaviors that tend to fluctuate across days, such as alcohol use, it does not affect substance use behaviors that are quite consistent, such as marijuana use. Our findings imply that although daily monitoring of drinking may motivate people to reduce the quantity consumed once they start to drink, it may also arouse their desire to start drinking. Yet, both effects tend to last only one week, as participants accommodate to the monitoring by the second week.

Statistical methods for evaluating the correlation between timeline follow-back data and daily process data with applications to research on alcohol and marijuana use

BACKGROUND

Retrospective timeline follow-back (TLFB) data and prospective daily process data have been frequently collected in addiction research to characterize behavioral patterns. Although previous validity studies have demonstrated high correlations between these two types of data, the conventional method adopted in those studies was based on summary measures that may lose critical information and the Pearson's correlation coefficient that has an undesirable property. This study proposes the functional concordance correlation coefficient to address these issues.

METHODS

We use real data collected from a randomized experiment to demonstrate the applications of the proposed method and compare its analytical results with those of the conventional method. We also conduct a simulation study based on the real data to evaluate the level of overestimation associated with the conventional method.

RESULTS

The results of the real data example indicate that the correlation between these two types of data varies across substances (alcohol vs. marijuana) and assessment schedules (daily vs. weekly). Additionally, the correlations estimated by the conventional method tend to be higher than those estimated by the proposed method. The simulation results further show that the magnitude of overestimation associated with the conventional method is greatest when the true correlation is medium.

CONCLUSIONS

The findings of the real data example imply that daily assessments are particularly beneficial for characterizing more variable behaviors like alcohol use, whereas weekly assessments may be sufficient for low variation events such as marijuana use. The proposed method is a better approach for evaluating the validity of TLFB data.

The Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention: Study protocol of a multi-center randomized controlled trial

INTRODUCTION

Among patients with hepatitis C virus (HCV) infection, alcohol synergistically increases the risk of cirrhosis, hepatocellular carcinoma, and death. Randomized controlled trials of integrated models of HCV-alcohol treatment have been recommended but only performed in patients with severe alcohol use disorders.

OBJECTIVES

This pragmatic randomized controlled trial seeks to compare clinical effectiveness and cost-effectiveness of integrated alcohol treatment compared to enhanced treatment as usual (TAU) on alcohol consumption and economic outcomes among patients ever infected with HCV.

METHODS

Patients recruited from three liver centers who had current or prior chronic HCV and qualifying alcohol screener scores were randomly assigned to enhanced TAU or the Hepatitis C-Alcohol Reduction Treatment (Hep ART) intervention. All patients received enhanced TAU, consisting of a patient-administered alcohol screener and care from medical providers who were trained in Screening, Brief Intervention and Referral to Treatment (SBIRT), including brief motivational interviewing counseling. The Hep ART intervention combined enhanced TAU with up to six months of integrated co-located individual and/or group therapy that provided motivational, cognitive, and behavioral strategies to reduce alcohol consumption. The Timeline Followback (TLFB) Method was used to evaluate alcohol use at baseline, 3, 6, and 12 months. Primary outcomes are alcohol abstinence and fewer heavy drinking days, and for the cost-effectiveness analysis, measures included grams of alcohol consumed.

DISCUSSION

This study will determine whether Hep ART, a six-month integrated alcohol treatment, compared to enhanced TAU, is both clinically effective and cost-effective in patients with a history of comorbid HCV and alcohol use.

Changes in substance use-related health risk behaviors on the timeline follow-back interview as a function of length of recall period

The timeline follow-back (TLFB) interview was adopted to collect retrospective data on daily substance use and violence from 598 youth seeking care in an urban Emergency Department in Flint, Michigan during 2009-2011. Generalized linear mixed models with flexible smooth functions of time were employed to characterize the change in risk behaviors as a function of the length of recall period. Our results suggest that the 1-week recall period may be more effective for capturing atypical or variable patterns of risk behaviors, whereas a recall period longer than 2 weeks may result in a more stable estimation of a typical pattern.

Modeling longitudinal drinking data in clinical trials: an application to the COMBINE study

BACKGROUND

There is a lack of consensus in the literature as to how to define drinking outcomes in clinical trials. Typically, separate statistical models are fit to assess treatment effects on several summary drinking measures. These summary measures do not capture the complexity of drinking behavior. We used the COMBINE study to illustrate a statistical approach for examining treatment effects on high-resolution drinking data.

METHODS

This is a secondary data analysis of COMBINE participants randomly assigned to naltrexone, acamprosate, with medical management and/or combined behavioral intervention (CBI). Using a Poisson hurdle model, abstinence and number of drinks were simultaneously modeled as a function of treatment and covariates. An emphasis was placed on the evaluation of "risky drinking" (3 drinks/day for women and 4 for men).

RESULTS

During treatment, naltrexone increased the odds of abstinence vs placebo naltrexone (OR=1.35 [1.06, 1.65]) but receiving CBI in addition to naltrexone (vs not) obscured this effect; thus, the naltrexone effect was largest in the group not receiving CBI (OR=1.87 [1.29, 2.46]). Naltrexone vs placebo naltrexone also reduced the risk of drinking in those who resumed risky drinking (RR=0.58 [0.24, 0.93]) and increased the odds of maintaining low risk drinking (OT=1.99 [1.07, 2.90]). Both effects were strongest in the absence of CBI when only "medical management" was provided.

CONCLUSIONS

The hurdle model is an appropriate statistical tool for assessing the effect of treatment on the two part drinking process, abstinence and number of drinks. When applied to COMBINE, results bolster the use of naltrexone in promoting abstinence and reduction in risky drinking.

Variation in substance use relapse episodes among adolescents: a longitudinal investigation

Substance use disorders are chronically relapsing conditions, and there is a need to evaluate whether relapse precursors are consistent across multiple relapses. We identified latent groups of relapse characteristics over time in adolescents with alcohol and substance use disorders following an inpatient treatment episode. Youth (N = 124, mean age = 16 years, 56% male, 60% Caucasian) were interviewed while in treatment and biannually during the first year after treatment to gather contextual information about first and second relapse episodes. We identified two latent classes of relapse precursors labeled aversive-social (41% at initial relapse, 57% at subsequent relapse) and positive-social (59% at initial relapse, 43% at subsequent relapse). Classes were stable in structure over time; however, only 61% of those assigned to aversive-social and 39% assigned to positive-social classes at initial relapse remained there for the subsequent relapse. Findings highlight the dynamic nature of relapse for youth and have important clinical implications.

Using daily drinking data to characterize the effects of a brief alcohol intervention in an emergency room

Clinical trials often aggregate daily alcohol consumption data across long-term follow-up intervals (e.g., 6 or 12 months). Although important in understanding general treatment outcomes, these analyses tell us little about when treatment effects emerge or decline. We previously demonstrated that motivational interviewing (MI) reduced heavy drinking (vs. personalized feedback only; FO) among young adult drinkers (N=198; ages 18-24) recruited in a hospital emergency room (ER) using aggregated drinking data from a 6-month follow up. In the current study, we used daily alcohol consumption data from a calendar-assisted interview (Timeline Followback) to examine the timing and course of these treatment effects. Participants in both conditions received brief telephone booster sessions at 1 and 3 months. There were no treatment effects in the time between the initial intervention session and the 3-month booster session. Significant effects emerged after the 3-month booster and were driven by an increase in heavy drinking within the FO group. This suggests that the effects of brief interventions may not emerge immediately following an initial session. Aggregated data would be unable to detect this time trend. This research underscores the potential value added by examining the day-to-day timing of effects following treatments for alcohol use.

Atomoxetine treatment of adults with ADHD and comorbid alcohol use disorders

OBJECTIVE

Adults with attention-deficit/hyperactivity disorder (ADHD) have higher rates of alcohol and drug use disorders than adults without ADHD. The study aim was to determine if atomoxetine was superior to placebo in improving ADHD and alcohol use in recently abstinent adults with ADHD and comorbid alcohol use disorder.

METHODS

Adults with DSM-IV diagnoses of ADHD and alcohol abuse and/or dependence were abstinent from alcohol at least 4 days (maximum 30 days) before study randomization. Participants received atomoxetine (25-100mg daily) or placebo for 12 weeks. ADHD symptoms were assessed using ADHD Investigator Symptom Rating Scale (AISRS) total score. Time-to-relapse to heavy alcohol use was analyzed using a 2-sided log-rank test based on Kaplan-Meier estimates and cumulative heavy drinking events over time were evaluated post hoc with recurrent-event analysis.

RESULTS

Subjects received atomoxetine (n=72) or placebo (n=75) and 80 subjects completed the 12-week double-blind period (n=32 and 48, respectively). ADHD symptoms were significantly improved in the atomoxetine cohort compared to placebo (AISRS total score mean [S.D.], atomoxetine: -13.63 [11.35], P<.001; placebo: -8.31 [11.44], P<.001, difference: P=.007; effect size=0.48). No significant differences between treatment groups occurred in time-to-relapse of heavy drinking (P=.93). However, cumulative heavy drinking days were reduced 26% in atomoxetine-treated subjects versus placebo (event ratio=0.74, P=.023). There were no serious adverse events or specific drug-drug reactions related to current alcohol use.

CONCLUSIONS

This 3-month, double-blind, placebo-controlled study of atomoxetine in adults with ADHD and comorbid alcohol use disorder demonstrates clinically significant ADHD improvement, and inconsistent effects on drinking behavior.

Targeted Nalmefene With Simple Medical Management in the Treatment of Heavy Drinkers: A Randomized Double-Blind Placebo-Controlled Multicenter Study

BACKGROUND

Clinical studies with opioid antagonists for treatment of problem drinking have mainly been conducted in specialized alcohol treatment centers, included structured psychosocial treatment, and have focused on maintaining abstinence after a period of abstinence from alcohol.

METHODS

This multisite, randomized double-blind study investigated targeted nalmefene in reducing heavy drinking. Specialized alcohol treatment centers and private general practices enrolled 403 subjects (328 men, 75 women). Subjects were instructed to take nalmefene 10 to 40 mg (n=242) or placebo (n=161) when they believed drinking to be imminent. After 28 weeks, 57 subjects from the nalmefene group continued into a 24-week randomized withdrawal extension. Concomitant psychosocial intervention was minimal and no treatment goals were imposed. Alcohol consumption was recorded using the time-line follow-back method. Biochemical indicators of alcohol use were also measured.

RESULTS

The mean monthly number of heavy drinking days (HDDs) during the 12-week period before inclusion was 15.5 (SD 6.9) in the nalmefene group and 16.2 (SD 6.9) in the placebo group. During treatment, the mean numbers of HDDs were 8.6 to 9.3 in the nalmefene group and 10.6 to 12.0 in the placebo group (p=0.0065). The levels of serum alanine aminotransferase and gamma-glutamyl transferase decreased in the nalmefene group compared with the placebo group (p=0.0088 and 0.0023). During the randomized withdrawal period, subjects randomized to placebo apparently returned to heavier drinking. Subjects receiving nalmefene reported more nausea, insomnia, fatigue, dizziness, and malaise than subjects on placebo.

CONCLUSIONS

Nalmefene appears to be effective and safe in reducing heavy drinking, even when accompanied by minimal psychosocial support.

Reduction in heavy drinking as a treatment outcome in alcohol dependence

In the field of clinical alcohol disorders treatment in North America, abstinence continues to be largely viewed as the optimal treatment goal; however, there is a growing awareness of limitations when abstinence is considered the only successful outcome. Although this issue has been discussed in research settings, new studies on the public health significance of heavy drinking (defined as five or more standard drinks per drinking day in men, and four or more standard drinks per drinking day in women) in the past 10 years suggest that clinical providers should consider the value of alternative outcomes besides abstinence. A focus on abstinence as the primary outcome fails to capture the impact of treatment on reduction in the pattern and in the frequency of alcohol consumption. In addition, evaluating reduction in drinking as "positive" has value for patients as an indicator of clinical progress. Measurement of continuous variables, such as the quantity and the frequency of alcohol consumption, has provided a clearer understanding of the scope of alcohol-related morbidity and mortality at the societal level, and of the relationship between individual patient characteristics and the naturalistic course of alcohol use, abuse, and dependence. A review of these characteristics suggests that there are clinical benefits associated with reducing heavy drinking in alcohol-dependent patients. Given the significant public health consequences associated with heavy drinking and the benefits associated with its reduction, it is proposed that researchers, public health professionals, and clinicians consider using reduction in heavy drinking as a meaningful clinical indicator of treatment response, and that outcomes be individualized to patients' goals and readiness to change.

New insights into the efficacy of naltrexone based on trajectory-based reanalyses of two negative clinical trials

BACKGROUND

The heterogeneity of clinical findings in studies evaluating the efficacy of naltrexone in the treatment of alcohol dependence has led to growing efforts to explore novel approaches to data analysis. The objective of this study was to identify distinct trajectories of daily drinking over time in two negative clinical trials and to determine whether naltrexone affected the probability to follow a particular trajectory.

METHODS

The Veterans Affairs (VA) Cooperative Study #425 and the Women's Naltrexone Study failed to demonstrate efficacy on primary outcome variables. Separately for each study, we analyzed daily indicators of any drinking and heavy drinking using a semiparametric group-based approach.

RESULTS

We estimated three distinct trajectories of daily drinking (both any and heavy drinking) which we described as "abstainer," "sporadic drinker," and "consistent drinker." Naltrexone doubled the odds of following the abstainer trajectory instead of the consistent drinker trajectory but did not significantly change the odds of following the abstainer trajectory as contrasted with the sporadic drinker trajectory.

CONCLUSIONS

Naltrexone may have a clinically meaningful effect for alcohol-dependent patients with a high chance of consistent drinking, even in studies where it failed to show efficacy in planned analyses.

Extended-release intramuscular naltrexone

An extended-release intramuscular formulation of naltrexone that provides sustained release of the drug over a 28-day period has been developed with the aim of improving treatment adherence in patients treated with naltrexone for alcohol dependence. Biodegradable polylactide-co-glycolide polymer microspheres containing 34% w/w naltrexone are reconstituted in an aqueous suspension just prior to intramuscular administration. Extended-release intramuscular naltrexone 380 mg administered once every 4 weeks, in combination with psychosocial therapy, demonstrated superior efficacy to placebo plus psychosocial therapy in reducing the heavy drinking event rate (primary endpoint) in adult patients with alcohol dependence in a 6-month well controlled trial. Among the subset of patients who abstained completely from drinking during the 7 days prior to the first dose of medication (n = 53; 8% of the total study population), those treated with extended-release intramuscular naltrexone 380 mg had greater reductions in the number of drinking days and the number of heavy drinking days compared with placebo recipients. Treatment with extended-release intramuscular naltrexone 380 mg once every 4 weeks for up to 18 months was generally well tolerated, with infrequent treatment-related serious adverse events. The most common treatment-emergent adverse events leading to treatment discontinuation were nausea, injection site reaction and headache. The proportion of patients with clinically significant plasma transaminase elevations was not different between patients receiving extended-release intramuscular naltrexone and those receiving placebo.

Conceptual, methodological, and analytical issues in the study of relapse

This article examines conceptual, methodological, and analytic issues in research on relapse to alcohol and other drug use. The review notes the continued move in relapse research from a primary reliance on retrospective assessment of factors surrounding the onset of relapse episodes to an increased focus on the use of new technologies to obtain "near real time" data on proximal factors in relapses. Recent advances in neurobiology have yielded important gains in our understanding of vulnerability to relapse in alcohol and other drug abusers. New statistical techniques are also available to analyze data on relapse. From a theoretical standpoint, there has been an increasing appreciation for the complicated and dynamic interplay of distal and proximal factors in the relapse process. At this point, the strongest and most detailed data on factors in the onset and course of relapse have been generated by studies of smoking relapses that have made use of Ecological Momentary Assessment (EMA) technology. However, there is still limited "near real" time data on proximal factors in alcohol and other drug relapses, and no such data on factors that influence the course of these relapses, once they have begun. Nevertheless, important methodological advances have been and continue to be made in the study of relapse, and our knowledge about the nature and process of relapse has increased considerably over the past 10 years.

Transitions during effective treatment for cocaine-abusing homeless persons: establishing abstinence, lapse, and relapse, and reestablishing abstinence

Data are reported on drug use among cocaine-dependent homeless persons who participated in a clinical trial that compared day treatment only (DT, n = 69) with day treatment plus abstinent-contingent housing and work (DT+, n = 72). Drug use was measured with multiple weekly urine toxicologies. Compared with DT participants, more DT+ participants established abstinence, maintained abstinence for longer durations, were marginally significantly more likely to lapse, and significantly less likely to relapse. Of all participants who established abstinence and then relapsed, DT+ participants relapsed later and were more likely to reestablish abstinence. These analyses yield information on the processes involved in the manner in which drug use changes as a result of abstinent-contingent housing and work.