Megan Kirouac

Project-Based Housing First for Chronically Homeless Individuals With Alcohol Problems: Within-Subjects Analyses of 2-Year Alcohol Trajectories

OBJECTIVES Two-year alcohol use trajectories were documented among residents in a project-based Housing First program. Project-based Housing First provides immediate, low-barrier, nonabstinence-based, permanent supportive housing to chronically homeless individuals within a single housing project. The study aim was to address concerns that nonabstinence-based housing may enable alcohol use. METHODS A 2-year, within-subjects analysis was conducted among 95 chronically homeless individuals with alcohol problems who were allocated to project-based Housing First. Alcohol variables were assessed through self-report. Data on intervention exposure were extracted from agency records. RESULTS Multilevel growth models indicated significant within-subjects decreases across alcohol use outcomes over the study period. Intervention exposure, represented by months spent in housing, consistently predicted additional decreases in alcohol use outcomes. CONCLUSIONS Findings did not support the enabling hypothesis. Although the project-based Housing First program did not require abstinence or treatment attendance, participants decreased their alcohol use and alcohol-related problems as a function of time and intervention exposure.

Development and evaluation of a mobile intervention for heavy drinking and smoking among college students

Nearly all college student smokers also drink alcohol, and smoking and heavy episodic drinking (HED) commonly co-occur. However, few studies have examined the factors that concurrently influence smoking and HED among college students and, to date, no interventions have been developed that target both HED and smoking in this population. The objective of the current study was to develop and evaluate a mobile feedback intervention that targets HED and smoking. Participants (N = 94) were non-treatment-seeking college students (M(age) = 20.5 years, SD = 1.7) who engaged in at least a single HED episode in the past 2 weeks and reported concurrent smoking and drinking at least once a week. Participants were randomized to receive either the mobile intervention for 14 days, complete mobile assessments (without intervention) for 14 days, or complete minimal assessments (without intervention or mobile assessments). At a 1-month follow-up, compared with the minimal assessment condition, we observed significant reductions in the number of cigarettes per smoking day in both the mobile intervention (d = 0.55) and mobile assessment (d = 0.45) conditions. Among those randomized to the mobile intervention, receiving more modules of the intervention was significantly associated with a lower likelihood of any drinking during the 14-day assessment period and significant reductions in smoking at 1-month follow-up. The mobile intervention did not result in significant reductions in HED or concurrent smoking and drinking. Future research should continue to examine ways of using technology and the real-time environment to improve interventions for HED and smoking.

Pain as a predictor of heavy drinking and any drinking lapses in the COMBINE study and the UK Alcohol Treatment Trial

AIMS To test the association between pain and heavy drinking lapses during and following treatment for alcohol use disorders (AUD). DESIGN Secondary data analysis of data from two clinical trials for AUD. SETTING AND PARTICIPANTS Participants included 1383 individuals from the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study in the United States [69.0% male, 76.8% non-Hispanic White average age=44.4, standard deviation (SD) = 10.2] and 742 individuals from the UK Alcohol Treatment Trial (UKATT) in the United Kingdom [74.1% male, 95.6% White, average age=41.6 (SD=10.1)]. MEASUREMENTS Form-90 (a structured assessment interview) was used to assess the primary outcome: time to first heavy drinking day. The Short Form Health Survey and Quality of Life measures were used to assess pain interference and pain intensity. FINDINGS Pain was a significant predictor of heavy drinking lapses during treatment in UKATT [odds ratio (OR)=1.19, 95% confidence interval (CI)=1.08, 1.32, P=0.0003] and COMBINE (OR=1.12, 95% CI=1.03, 1.21, P=0.009), and was a significant predictor of heavy drinking lapses following treatment in COMBINE (OR=1.163, 95% CI=1.15, 1.17, P<0.00001). After controlling for other relapse risk factors (e.g. dependence severity, self-efficacy, temptation, psychiatric distress), pain remained a significant predictor of heavy drinking lapses during treatment in UKATT (OR=1.19, 95% CI=1.06, 1.34, P=0.004) and following treatment in COMBINE (OR=1.44, 95% CI=1.07, 1.92, P=0.01). CONCLUSIONS Among people treated for alcohol use disorder, being in physical pain appears to predict heavy drinking lapses during or after treatment.

Exploring Transitions Within a Project-based Housing First Setting: Qualitative Evaluation and Practice Implications

The Housing First (HF) approach is a model of housing that entails the provision of immediate, permanent, low-barrier, supportive housing to chronically homeless individuals either in separate apartments within a larger community (known as scattered-site HF) or in a single building (known as project-based HF). One recent innovation is the application of project-based HF with chronically homeless individuals with alcohol problems. Although initial studies have shown its effectiveness, there is currently no research on residents’ and staff ’s experiences living and working in a project-based HF program. The purpose of this article was to document these experiences and highlight strengths and challenges of project-based HF programs. Using data collected from naturalistic observations, agency documentation, one-on-one resident interviews, and a staff focus group, we delineated transitional periods, including moving into project-based HF, community-building, managing day-to-day, and transitions from project-based HF. Findings are interpreted to help health care policymakers and providers envision the role of project-based HF in comprehensive public health efforts and to integrate lessons learned into their own clinical practice.

The indirect effect of the therapeutic alliance and alcohol abstinence self-efficacy on alcohol use and alcohol-related problems in Project MATCH.

BACKGROUND Empirical literature indicates that the therapeutic alliance explains a modest but reliable proportion of variance in predicting alcohol-related outcomes among individuals in treatment for alcohol use disorders (AUDs). Hartzler and colleagues (2011) showed in the COMBINE data set that alcohol abstinence self-efficacy is a potentially important statistical mediator of the relationship between the alliance and client outcomes. METHODS The purpose of this study was to replicate this finding in the Project MATCH data set. We used total alliance ratings on the Working Alliance Inventory and tested both client and therapist ratings in mediation analyses. RESULTS We found that posttreatment self-efficacy accounted for the effect of therapist and client ratings of alliance (measured at session 2) on posttreatment drinking outcomes (drinks per drinking day and alcohol-related problems). In addition, we found a moderation effect of treatment, such that the association between the clients rating of the alliance and self-efficacy changes was positive for individuals in the cognitive behavioral treatment group but negative for those receiving motivation enhancement or Twelve-Step Facilitation. CONCLUSIONS This study reaffirms the importance of the therapeutic alliance and self-efficacy in predicting AUD outcomes. Future research should examine changes in the therapeutic alliance throughout treatment and how these changes are related to self-efficacy and AUD treatment outcomes over time.

Association between Physical Pain and Alcohol Treatment Outcomes: The Mediating Role of Negative Affect

OBJECTIVE Physical pain and negative affect have been described as risk factors for alcohol use following alcohol treatment. The current study was a secondary analysis of 2 clinical trials for alcohol use disorder (AUD) to examine the associations between pain, negative affect and AUD treatment outcomes. METHOD Participants included 1,383 individuals from the COMBINE Study (COMBINE Pharmacotherapies and Behavioral Interventions for Alcohol Dependence; COMBINE Study Research Group, 2003; 31% female, 23% ethnic minorities, average age = 44.4 [SD = 10.2]), a multisite combination pharmacotherapy and behavioral intervention study for AUD in the United States, and 742 individuals from the United Kingdom Alcohol Treatment Trial (UKATT Research Team, 2001; 25.9% female, 4.4% ethnic minorities, average age = 41.6 [SD = 10.1]) a multisite behavioral intervention study for AUD in the United Kingdom. The Form-90 was used to collect alcohol use data, the Short Form Health Survey and Quality of Life measures were used to assess pain, and negative affect was assessed using the Brief Symptom Inventory (COMBINE) and the General Health Questionnaire (UKATT). RESULTS Pain scores were significantly associated with drinking outcomes in both datasets. Greater pain scores were associated with greater negative affect and increases in pain were associated with increases in negative affect. Negative affect significantly mediated the association between pain and drinking outcomes and this effect was moderated by social behavior network therapy (SBNT) in the UKATT study, with SBNT attenuating the association between pain and drinking. CONCLUSION Findings suggest pain and negative affect are associated among individuals in AUD treatment and that negative affect mediated pain may be a risk factor for alcohol relapse.

The search for an elusive cutoff remains: Problems of binary classification of heavy drinking as an endpoint for alcohol clinical trials

BACKGROUND To examine whether a clinically meaningful alcohol consumption cutoff can be created for clinical samples, we used receiver operator characteristic (ROC) curves to derive gender-specific consumption cutoffs that maximized sensitivity and specificity in the prediction of a wide range of negative consequences from drinking. METHODS We conducted secondary data analyses using data from two large clinical trials targeting alcohol use disorders: Project MATCH (n=1726) and COMBINE (n=1383). RESULTS In both studies, we found that the ideal cutoff for men and women that maximized sensitivity/specificity varied substantially both across different alcohol consumption variables and alcohol consequence outcomes. Further, the levels of sensitivity/specificity were poor across all consequences. CONCLUSIONS These results fail to provide support for a clinically meaningful alcohol consumption cutoff and suggest that binary classification of levels of alcohol consumption is a poor proxy for maximizing sensitivity/specificity in the prediction of negative consequences from drinking. Future research examining consumption-consequence associations should take advantage of continuous measures of alcohol consumption and alternative approaches for assessing the link between levels of consumption and consequences (e.g., ecological momentary assessment). Clinical researchers should consider focusing more directly on the consequences they aim to reduce instead of relying on consumption as a proxy for more clinically meaningful outcomes.

Examining Temptation to Drink From an Existential Perspective: Associations Among Temptation, Purpose in Life, and Drinking Outcomes

Temptation to drink (TTD), defined as the degree to which one feels compelled to drink in the presence of internal or external alcohol-related cues, has been shown to predict alcohol-treatment outcomes among individuals with alcohol-use disorders (AUDs). Research examining TTD from an existential perspective is lacking and little is known about how existential issues such as purpose in life (PIL) relate to TTD, which is surprising given the role of existential issues in many treatments and mutual help approaches for AUDs. In the current study, we examined the longitudinal associations in a sample of 1726 among TTD, PIL, and drinking outcomes using data from Project MATCH (1997, 1998). Parallel process latent growth curve analyses indicated that PIL and TTD were significantly associated across time, such that higher initial levels of PIL and increases in PIL over time were associated with lower initial levels of TTD and decreases in TTD over time. Higher initial levels of TTD, lower initial levels of PIL, increases in TTD, and decreases in PIL were significantly associated with greater intensity and frequency of drinking and greater drinking-related consequences at the 15-month follow-up. Accordingly, TTD and PIL may be important constructs for clinicians to consider throughout the course of treatment. Future studies should examine if and how various kinds of treatments for AUDs are associated with increases in PIL, and whether these increases are related to decreased TTD and reduced drinking.

Toward the Operationalization and Examination of “Hitting Bottom” for Problematic Alcohol Use: A Literature Review

“Hitting bottom” among individuals with alcohol use disorders (AUDs) has empirical and theoretical support; however, it has never been operationalized and, therefore, remains largely unexplored. To operationalize and evaluate hitting bottom, it is important to understand the emergence of the construct, how it is used by researchers, and how it is perceived by individuals recovering from AUDs. Accordingly, the authors review extant literature on hitting bottom for individuals with AUDs. Specifically, the authors discuss historical evolution of “hitting bottom” to inform future research efforts to operationalize and evaluate the concept of hitting bottom for individuals with problematic alcohol use.

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

Alcohol-related consequences are linked directly to the diagnostic criteria for alcohol use disorder (AUD). However, alcohol consumption outcome variables (e.g., percent days abstinent, heavy drinking days) remain the dominant outcome in AUD treatment research. Two reasons AUD treatment researchers have not shifted to include alcohol-related consequences as a primary outcome may be that previous studies have failed to provide convincing evidence of (1) the psychometric properties of measures of alcohol-related consequences, and (2) whether consequences measures are sensitive to change following treatment. The present study directly addresses these two concerns via psychometric evaluation and sensitivity/specificity testing of the Drinker Inventory of Consequences (DrInC; Miller, Tonigan, & Longabaugh, 1995) in two of the largest multisite clinical trials ever conducted (COMBINE Study, Anton, et al., 2006; and Project MATCH, Project MATCH Research Group, 1997). Results indicated that the five subscales commonly used for the DrInC had poor construct validity and were noninvariant across time. A newly developed three-factor model consisting of mild, moderate, and severe consequences had excellent psychometrics, including good internal consistency reliability, construct validity, and measurement invariance over time. The three-factor model of the DrInC was also sensitive and specific for detecting consumption outcomes in both COMBINE and MATCH and had convergent validity with measures of consumption and wellbeing. In conclusion, the three-factor DrInC may be a useful tool for defining AUD treatment success in a clinically meaningful way that aligns with diagnostic criteria.