The Effectiveness of Spaced Versus Massed Alcohol Avoidance Training in Inpatient Alcohol Use Disorder Treatment: A Multisite Randomized Trial

1. INTRODUCTION AND RATIONALE

1.1. Dual Process Models in Addiction Dual-process models have provided more insight as to how individuals with an addiction can be 'drawn in' by alcohol-related cues at an implicit level, while at the same time more controlled, conscious cognitive processes may be invested in actively trying to avoid substances. Even when patients with substance abuse are made aware of long-term negative consequences, learn to seek alternatives, deal with group-pressure or craving, they are still susceptible to their immediate attention being subconsciously hijacked by substance related cues that trigger an automatic implicit approach-tendency towards the substance. Therapeutic interventions that aim to reduce these implicit approach tendencies have been developed.

1.2. Alcohol Avoidance Training Alcohol Avoidance Training (AAT), is one of several Cognitive Bias Modification paradigms that is used to retrain alcohol approach biases. Pictures of alcoholic and non-alcoholic beverages are used as stimulus material. Participants are instructed to react with a joystick to the tilt of pictures, presented on a computer screen. For instance, participants make an approach movement (pull) with left-tilted pictures, and make an avoidance movement (push) with right-tilted pictures. Pulling increases the size of the pictures whereas pushing decreases their size. After the correct movement is made, the pictures disappear, otherwise they do not, until the correct response is made. It has been demonstrated in lab studies, that a change in approach bias (increased avoidance of the targeted substance) predicts consumption behaviour of the targeted substance. Therefore, when a strong training effect can be demonstrated, a clinical effect is likely to ensue.

Research thus far indeed suggests that AAT provides a clinical effective add-on to TAU in the treatment of Alcohol Use Disorder (AUD). The first study on the effectiveness of AAT in problematic alcohol use was conducted in a non-clinical sample of 42 male students, classified as hazardous drinkers. The results showed that the automatic action tendencies to approach alcohol were reduced. In 2010, the first Randomized Controlled Trial (RCT) using AAT in patients with AUD was conducted. The sample consisted of 214 inpatients. When AAT was added to TAU, the total number of relapses after one year decreased by about 10% compared with patients who had received a sham or no training. Importantly, the clinical effect was replicated. In addition, analyses revealed four to six AAT sessions to be the mean optimum number of sessions needed. Although the effect sizes found are small to medium, the results are interesting given the high relapse rates in addiction treatment and minor burden related to the intervention.

Apart from the replicated clinical effectiveness, in our own clinical experience, AAT can be easily integrated with (inpatient) TAU. It does not require highly trained therapists as is the case in Cognitive Behavioral Therapy (CBT) or Community Reinforcement Approach (CRA). In addition, six AAT sessions will take the participant an average of 60 to 90 minutes total to complete. Therefore, the burden in time is low which may increase engagement and attendance and decrease drop-out. Finally, AAT can be provided as early as during detoxification and may even be more effective than when provided after detoxification. In comparison, traditional CBT and CRA interventions are thought to be less effective during detoxification as a result of dampened cognitive functioning in attention and often executive functioning as a result of prolonged abuse.