Reid K. Hester, Ph.D.
Director, Research Division
Behavior Therapy Associates, LLC
www.behaviortherapy.com
reidhester@behaviortherapy.com
Tel. 505.345.6100
ASAM Disclosure of
Relevant Financial Relationships
Content of Activity:
2013 State of the Art Course in Addiction Medicine
Name
Commercial
Interests
Reid K Hester, DCU
Ph.D.
Relevant
Financial
Relationships:
What Was
Received
Owns copyright
CDCU
Owns copyright,
patent pend.
ModerateDrinking
app
Owns copyright
Overcoming
Addictions app
Owns copyright
Checkup &
Choices app
Owns copyright,
patent pending
Relevant
Financial
Relationships:
For What Role
No Relevant
Financial
Relationships
with Any
Commercial
Interests



NIAAA for funding
Research staff (RAs, T. Haney, H. Delaney, Bo &
Bill Miller, consultants)
Study participants






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
Brief intervention, moderation training
Abstinence focused
treatment
Threshold
for action
Severe
Substantial
Moderate
Mild
None
Alcohol Problems
Relapse
Permanent exit
Maintenance
Precontemplation
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 the minimal amount of intervention
needed to resolve problems (Sobell & Sobell,
2000).
 Screening (1 question)
 BMIs
 Action-oriented protocols
 Moderation programs
 Abstinence programs


Screen as integral part of lifestyle assessment
Consider drinking from health standpoint, not
disease standpoint


Assess extent of drinking & for heavy drinkers
answer question, “Should I change my drinking?”
BMIs
 The Drinker’s Check-up (25+ y/o)
 The College Drinker’s Check-up (<25 y/o)


Web version www.drinkerscheckup.com
Randomized clinical trial: moderate drinking
outcomes far more common than abstinence
(10%) (Hester et al., 2005).
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


Cut back or abstain
Natural recovery literature (Sobell et al.)
 Most people w/alcohol problems reduce their drinking
w/o any professional or self-help
 Tend to be the less dependent drinkers

Relationship of hx. alcohol problems & success in
reducing alcohol problems w/moderation (Miller
et al., 1992)


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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)
 At same time they have long histories of alcoholrelated problems.

Outcome summary from Hester & Miller (2003)
www.behaviortherapy.com/whatworks.htm
 More controlled clinical trials of BSCT than any other
treatment until recently
 Variety of ways to provide the tx. (face-to-face,
bibliotherapy, web app.)


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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)


Moderation Management
(www.moderation.org)
Moderation training protocols (e.g.,
www.moderatedrinking.com)
 80 heavy drinkers randomly assigned to:
a) MD + MM or b) MM alone
 Follow-ups at 3, 6, & 12 mo.
 73% had outcome data at all 3 f-up
points
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)
100
90
80
70
60
50
40
Baseline
3 Mo F-up
MD + MM
6 Mo F-up
MM only
12 Mo F-up
50
40
30
20
10
0
Baseline
3 Mo F-up
MD + MM
6 Mo F-up
MM only
12 Mo F-up
30
20
10
0
Baseline
3 Mo F-up
MD + MM
6 Mo F-up
MM only
12 Mo F-up

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AUDIT score over 8
MAST score under 20
Medical hx to screen for contraindications
Clients with less severe alcohol-related problems
Clients who refuse abstinence without first trying
moderation



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

Share info about likelihood of success with
moderating drinking
 (Miller, et al., 1992)



Discourage abstinent alcoholics from trying
moderation
Urge "vacation" from drinking
Agree to moderation trial w/contract to abstain if
unsuccessful


Most significantly dependent clients won't opt for
moderation, especially once it is explained to them
Clients will always choose their own goal (see
Sanchez-Craig's BSCT study w/abstinence &
moderation gps)


Overcoming Addictions, A SMART Recovery web
application (www.overcomingaddictions.net)
A 4-step, CB-T & MET protocol




Build, maintain motivation
Dealing w/urges, cravings
Managing thoughts, feelings, actions
Lifestyle balance for relapse prevention

www.smartrecovery.org


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1,000+ face-to-face meetings
30 Online meetings/week
Forum for support
Manuals, etc. on their web site
Baseline characteristics
Variable
Overall
Group
SR
SR + OA
OA
(n = 86)
(n = 83)
(n = 19)
Female n (%)
114 (60.6%)
52 (61%)
50 (60%)
12 (63%)
Age M (SD)
44.3 (10.9)
43.4 (10.6)
44.6 (11.1)
48.3 (8.4)
170 (90.4%)
76 (88.4%)
77 (92.8%)
17 (89.5%)
Hispanic
5 (2.7%)
3 (3.5%)
1 (1.2%)
1 (5.3%)
Other
7 (6.9%)
7 (8.1%)
5 (6.0%)
1 (5.3%)
Ethnicity n (%)
White
Education M
(SD)
16.1 (2.4)
15.93 (2.5)
16.0 (2.3)
17.3 (2.1)
AUDIT M (SD)a
24.7 (8.1)
24.8 (8.1)
23.95 (8.2)
27.4 (7.2)
BSI M (SD)b
17.4 (12.9)
19.35 (12.5)
15.95 (13.6)
14.8 (11.0)
InDUC M (SD)c
41.4 (17.9)
42.2 (19.0)
40.6 (17.5)
40.8 (15.6)
85
75
65
OA only
55
OA + SR
SR only
45
35
OA only
OA + SR
SR only
Baseline
36.46
46.63
41.72
3 months
59.24
82.47
71.5
6 months
54
77.2
74.48
10
9
8
7
6
5
OA only
4
OA + SR
3
SR only
2
1
0
OA only
OA + SR
SR only
Baseline
8.7
6.8
8.6
3 months
4.7
3.6
4.7
6 months
6.2
4.2
3.8
40
30
20
OA only
OA + SR
SR only
10
0
OA only
OA + SR
SR only
Baseline
40.8
35.4
41.2
3 months
19.5
17.8
18.6
6 months
22.1
15.4
17.8

Our newest web app integrates:
 DCU, CDCU, MD, & OA
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Designed for use with patients in primary care
Screens for heavy drinking, drug use
Provides BMI
Segues to MD & OA

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For many problem drinkers, BMI is sufficient
Some will benefit from moderation protocols,
some will need abstinence-oriented protocols
Brief follow-ups key to knowing how much has
been enough

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Hester, R.K., Delaney, H.D., & Campbell, W. (2012). The College
Drinker’s Check-up: Outcomes of two randomized clinical trials of
a computer-based brief motivational intervention. Psychology of
Addictive Behaviors,
Hester, R.K., Delaney, H.D., & Campbell, W., (2011).
Moderatedrinking.com and Moderation Management: 12-month
outcomes of a randomized clinical trial. Journal of Consulting and
Clinical Psychology, 79, 215-224. 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., Lenberg, K.L., Campbell, W., & Delaney, H.D.D.
(2013). Overcoming Addictions, a web-based application, and
SMART Recovery, an online and in-person mutual help group for
problem drinkers Part 1: Three-Month Outcomes of a Randomized
Controlled Trial. Journal of Medical Internet Research, 15(7):e134.
Hester, R.K., Squires, D.D., & Delaney, H.D. (2005). The Computerbased Drinker’s Check-up: 12 month outcomes of a controlled
clinical trial with problem drinkers. Journal of Substance Abuse
Treatment, 28(2), 159-169.
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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.