Computer Delivered Interventions:
A stepped care approach for problem drinkers
Reid K. Hester, Ph.D.
Director, Research Division
Behavior Therapy Associates, LLP
www.behaviortherapy.com
reidhester@behaviortherapy.com
Tel. 505.345.6100
Thanks & Conflict of Interest
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NIAAA for funding
Research staff (RAs, T. Haney, H.
Delaney, Bo & Bill Miller, consultants)
Conflict of interest: I own copyright and
patent pending on these programs.
Overview
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Problem drinkers: The big picture
Stages of Change & matched
interventions
Stepped care: only as much as needed
BMIs
Action-oriented protocols
Management issues
Consumption & alcohol
related problems
None
Mild
Moderate
Consumption
Substantial
Severe
Severe
Substantial
Mild
None
Moderate
Alcohol Problems
IOM, 1990
Spectrum of intervention
responses
Brief intervention, moderation training
Specialized treatment
Threshold
for action
Severe
Substantial
Moderate
Mild
None
Alcohol Problems
Stages of Change
Permanent exit
Relapse
Precontemplation
Maintenance
Contemplation
(Should I
change my
drinking?)
[DCU/CDCU]
Action (How do
I change my
drinking?)
[MD.com/OA]
Preparation
(Goals, What
Would it look
like?
[DCU/CDCU]
Using a stepped care model
for screening & intervention
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Using the minimal amount of
intervention needed to resolve
problems (Sobell & Sobell, 2000).
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Screening (1 question)
BMIs
Action-oriented protocols
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Moderation programs
Abstinence programs
Detecting & screening for
alcohol-related problems
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Screen as integral part of lifestyle
assessment
Ask routinely as you would about
smoking, exercise, sleep, etc.
Consider drinking from health
standpoint, not disease standpoint
When Pt. Screens positive: Next step
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Assess extent of drinking & for heavy
drinkers answer question, “Should I
change my drinking?”
BMIs
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The Drinker’s Check-up (25+ y/o)
The College Drinker’s Check-up (<25 y/o)
The Drinker’s Check-up (DCU)
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Windows version for healthcare
providers
Web version www.drinkerscheckup.com
Randomized clinical trial: moderate
drinking outcomes far more common
than abstinence (10%) (Hester et al.,
2005).
The College Drinker’s Check-up (CDCU)
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Windows & web versions
www.collegedrinkerscheckup.com
RCT: outcomes similar to the DCU for
older adults (Hester et al., under
review).
DCU Outcomes:
Log Average Drinks/Day (Form 90)
0.8
0.7
0.6
Immediate
Delayed
0.5
0.4
0.3
Baseline
4 weeks
8 weeks
12 mo
Average Peak BAC per
Drinking Day (DCU)
200
150
100
50
0
Immediate
Delayed
Baseline
4 weeks
8 weeks
12 mo
193.9
102.8
150.8
108.4
115
66.7
75
Effect Sizes d
Baseline
vs 4 wks
Baseline
vs 8 wks
Baseline
vs 12 mo
Log Av Drinks
Immediate
1.12
1.32
1.23
Delayed
.27
.47
1.24
Immediate
.78
.70
.752
Delayed
.15
.58
.68
Log Drinks/Drink Day
Effect Sizes d
Baseline
vs 4 wks
Baseline
vs 8 wks
Baseline
vs 12 mo
Log Av peak BAC
Immediate
.89
.79
1.16
Delayed
.22
.47
.87
Immediate
.93
.94
1.05
Delayed
.21
.51
.93
.57
.72
.99
Mean of all Form 90 q/f
variables
Overall Mean
Preparation State: Goals of
Change
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Cut back or abstain
Natural recovery literature (Sobell et al.)
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Most people w/alcohol problems reduce their
drinking w/o any professional or self-help
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Tend to be the less dependent drinkers
Relationship of hx. alcohol problems &
success in reducing alcohol problems
w/moderation (Miller et al., 1992)
Non-Dependent Problem Drinkers
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Prevalence is increasing (NIAAA, 2004)
Tend to not seek abstinence-oriented
treatment.
Constitute the majority of those who
recover w/o formal treatment (i.e.
natural recovery)
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At same time they have long histories of
alcohol-related problems.
Moderate Drinking
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2-3 Std drinks for men, 1-2 for women
3-4 days/wk
Peak BACs <.055
Maximum limits 3/7 day/week women,
4/14 day/week men (<65 y/o)
Resources
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Moderation Management
(www.moderation.org)
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Only mutual-help group reaching out to
non-dependent problem drinkers
Supportive of both moderate drinking &
abstaining
Online & face-to-face meetings, listserv,
forum
Moderation training protocols
Are moderation protocols
effective?
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Reviews of the literature 1980-2003
Outcome summary from Hester & Miller
(2003) www.behaviortherapy.com/whatworks.htm
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More controlled clinical trials of BSCT than
any other treatment until recently (e.g. MI,
BMIs)
Tested in wide variety of clinical pop.
Variety of ways to provide the tx. (faceto-face, bibliotherapy, web app.)
Moderate Drinking & Moderation Management:
Results of a randomized clinical trial
In God We Trust.
Everyone else has to show their data
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80 heavy drinkers randomly
assigned to either a) MD + MM or
b) MM alone
Follow-ups at 3, 6, & 12 mo.
73% had outcome data at all 3 f-up
points
Hypotheses
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1. Both groups will reduce their drinking
and alcohol-related problems at followups.
2. The experimental group (MD + MM)
will have reduce their drinking and
alcohol-related problems to a greater
extent than the control group.
Baseline Data
Group
MD +MM
MM only
Age
48.7
52.1
Education in Years
15.7
15.1
MAST score
14.1
13.2
Drinks (SECs)/Week
33.0
35.4
Percent Days Abstinent (PDA)
16.3
16.2
Mean Drinks per Drinking Day
5.5
6.1
Group
MD +MM
MM only
Mean Peak BAC per Drinking
Day
111mg%
119mg%
Hours BAC > 80 mg%
21.9
26.1
DrInC Recent Total score
24.3
21.3
AUDIT score
17.7
18.3
(in prior week, descending curve)
Median Peak BAC/Drinking
Day
100
90
80
70
60
50
40
Baseline
3 Mo F-up
MD + MM
6 Mo F-up
MM only
12 Mo F-up
Hypothesis 2:
PDA by Group
50
40
30
20
10
0
Baseline
3 Mo F-up
MD + MM
6 Mo F-up
MM only
12 Mo F-up
Hypothesis 2:
DrInC Recent Total Scores
30
20
10
0
Baseline
3 Mo F-up
MD + MM
6 Mo F-up
MM only
12 Mo F-up
Heavier vs. Less Heavy Drinkers
•
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A consistent research finding: those
with greater symptoms of dependence
benefit less from moderation protocols.
Participants whose drinking, on
average, did not meet NIAAA's
definition of binge drinking, had
somewhat better outcomes in the
experimental group which had access to
more resources and more opportunities
to learn moderate drinking skills.
Moderation in drinking
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AUDIT score over 8
MAST score under 20
Give medical history to screen for
contraindications
Clients with less severe alcohol-related
problems
Clients who refuse abstinence without
first trying moderation
Ethical and practical issues
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Moderation achievable by many, but not
all
Predictors of success not perfect
Lack of success by 6-8 weeks not good
sign for chances of long term success in
moderation
Explore client's concerns/thoughts
about drinking
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Listening to clients tells you their Stage
of Change
Negotiate goals of change and option of
moderation
Chances of success (Table from Proj.
MATCH MET manual, pg. 33)
What to do with the clearly
dependent client
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Share info about likelihood of success with
moderating drinking
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(Miller, Leckman, Delaney, & Tinkcom 1992)
Discourage abstinent alcoholics from trying
moderation
Urge "vacation" from drinking
Agree to BSCT trial w/contract to abstain if
unsuccessful
Moderation issues
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Most significantly dependent clients won't opt
for moderation, especially once it is explained
to them
Clients will always choose their own goal
Sanchez-Craig's BSCT study w/abstinence &
moderation gps
Behavioral contracting w/dependent clients
unwilling to consider abstinence w/o trial of
moderation training first
Abstinence Oriented protocol
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Overcoming Addictions, A SMART
Recovery web application
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Under development, RCT 9/1/11
A 4-step, CB-T & MET protocol
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Build, maintain motivation
Dealing w/urges, cravings
Managing thoughts, feelings, actions
Lifestyle balance for relapse prevention
SMART Recovery
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www.smartrecovery.org
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800+ face-to-face meetings
Daily online meetings
Forum for support
Manuals, etc. on their web site
Clinical Management
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For many problem drinkers, BMI is
sufficient
Some will benefit from moderation
protocols, some will need abstinenceoriented protocols
Brief follow-ups key to knowing how
much has been enough
Implementation
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Clinical
IT issues
References
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Hester, R.K., Delaney, H.D., & Campbell, W. (Under review). The
College Drinker’s Check-up: Outcomes of two randomized clinical
trials of a computer-based brief motivational intervention.
Hester, R.K., Delaney, H.D., & Campbell, W., (In press).
Moderatedrinking.com and Moderation Management: 12-month
outcomes of a randomized clinical trial. Journal of Consulting and
Clinical Psychology. Abstract at
http://psycnet.apa.org/psycinfo/2011-03047-001
Hester, R.K., Delaney, H.D., Campbell, W., & Handmaker,
N.(2009). A web application for moderation training: Initial results
of a randomized clinical trial. Journal of Substance Abuse
Treatment, 37(3), 266-276.
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Hester, R.K., Squires, D.D., & Delaney, H.D. (2005). The
Computer-based Drinker’s Check-up: 12 month outcomes of a
controlled clinical trial with problem drinkers. Journal of
Substance Abuse Treatment, 28(2), 159-169.
Hester, R.K., & Miller, W.R. (Eds.) (2003). Handbook of
alcoholism treatment approaches: Effective alternatives, (3rd
edition). Boston, MA: Allyn & Bacon.
Hester, R.K. (2003). Self-control training. In R.K. Hester & W.R.
Miller (Eds.), Handbook of alcoholism treatment approaches:
Effective alternatives, (3rd edition). Boston, MA: Allyn & Bacon.
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Miller, W. R., Leckman, A. L., Delaney, H. D., & Tinkcom, M.
(1992). Long-term follow-up of behavioral self-control training.
Journal of Studies on Alcohol, 53, 249-261.
National Institute on Alcohol Abuse and Alcoholism. (2004a).
Alcohol abuse increases, dependence declines across decade.
www.niaaa.nih.gov/press/2004/NESARCNews.htm
Sobell, M. B., & Sobell, L. C. (2000). Stepped care as a heuristic
approach to the treatment of alcohol problems. Journal of
Consulting and Clinical Psychology, 68, 573–579.
Presentation online
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www.behaviortherapy.com/2011ASAMC
DIPresentation.pptx