Course of remission from and relapse to heavy drinking following outpatient treatment of alcohol use disorder

Abstract

Post-treatment change in alcohol use is a process in which individuals variably transition in and out of "relapse" and "remission" statuses. "Any heavy drinking" following treatment is not necessarily a sign of treatment failure. A more nuanced look at the process of AUD change by considering whether individuals are able to transition to and sustain periods of remission seems warranted.

Reduction in non-abstinent WHO drinking risk levels and depression/anxiety disorders: 3-year follow-up results in the US general population

“…Recognizing that abstinence may be an overly narrow, insensitive outcome, the Food and Drug Administration (FDA) now accepts an additional outcome, i.e., no heavy drinking days (HDD; >3 drinks for females, >4 for males) (Food and Drug Administration, 2015), with the percentage of participants having no HDD compared between treatment arms. However, the no-HDD outcome may also be overly narrow and insensitive, since it classifies patients as treatment failures after any HDD, although some of these patients substantially reduce their drinking and improve in how they feel and function (Maisto et al, 2018;Wilson et al, 2016;Witkiewitz et al, 2017c). An alternative clinical trials outcome to those currently accepted (Food and Drug Administration, 2015;Maisto et al, 2018;Wilson et al, 2016;Witkiewitz et al, 2017c), which is used by the European Medicines Agency (EMA), is a 2-level reduction in the World Health Organization (WHO) 4-category classification of risk drinking levels: veryhigh, high, moderate and low (European Medicines Agency, 2010;World Health Organization, 2000).…”

“…However, the no-HDD outcome may also be overly narrow and insensitive, since it classifies patients as treatment failures after any HDD, although some of these patients substantially reduce their drinking and improve in how they feel and function (Maisto et al, 2018;Wilson et al, 2016;Witkiewitz et al, 2017c). An alternative clinical trials outcome to those currently accepted (Food and Drug Administration, 2015;Maisto et al, 2018;Wilson et al, 2016;Witkiewitz et al, 2017c), which is used by the European Medicines Agency (EMA), is a 2-level reduction in the World Health Organization (WHO) 4-category classification of risk drinking levels: veryhigh, high, moderate and low (European Medicines Agency, 2010;World Health Organization, 2000). For the FDA to accept reductions in the WHO drinking risk levels as an efficacy outcome, information is needed on the clinical benefit provided by such reductions, i.e., whether they predict improvements in how individuals feel and function.…”

Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning

“…In the abovementioned study on patterns during the 18 months following treatment, there were no differences amongthe groups in the following factors assessed at intake: age; education level; readiness for treatment; employment; legalstatus;and severitylevelsofthe Addiction Severity Indexsubscales for alcohol use, drug use, or for legal, employment, familymedical, and psychological problems (Siegalet al, 2002). Importantly, in the alcohol treatment field there are several studies on distinct patterns of alcohol use over time, as well as baseline client factors and long-termo utcomes associated with these patterns (Goodwin et al, 2017;Halonen et al, 2017;Kelso-Chichetto et al, 2018;Maisto et al, 2018;Witkiewitz et al, 2014aWitkiewitz et al, , 2017aWitkiewitz et al, , 2018. Fore xample, sevend rinking patterns across three alcohol clinical trials were identified using repeated measures latent class analysis (RMLCA); individuals with patterns of abstinence or lowrisk drinking had the best long-termo utcomes, including fewerdrinks per drinking day, lowerdrinking consequences, and better mental health (Witkiewitz et al, 2017b).…”

Reductions in Drinking Predict Increased Distress: Between‐ and Within‐Person Associations between Alcohol Use and Psychological Distress During and Following Treatment

“…This may be true even if lapses occur only a few times within the 90‐day assessment period. Indeed, Maisto et al (2018) found that changes in alcohol use posttreatment represent a process in which individuals transition in and out of “remission” and “relapse” status (defined as heavy drinking day), identifying 6 profiles (remission, transition to remission, few long transitions, many short transitions, transition to relapse, and relapse). Findings also indicated that those with numerous short transitions (quick lapses and returns to remission) and few longer transitions reported similar levels of depression when compared to those who transition to relapse or had continuous relapse at 1‐year follow‐up, which was higher when compared to those in remission and those with one transition to remission.…”

“…Concerns over the low variability, however, are somewhat mitigated by our findings that prior within‐person PDA and PHD significantly predicted distress at the next assessment after controlling for prior distress scores. It is also possible that prior distress may be a stronger predictor of time to first lapse or relapse; however, due to both theoretical concerns (i.e., definitions of lapse/relapse and its utility as a construct; see Maisto et al, 2018; Maisto et al, 2016a,b) and the nature of our data collection (i.e., TLFB 90‐day form instead of more frequent assessments of alcohol use instead of weekly to obtain more accurate daily levels of alcohol use; see Hoeppner et al, 2010), examination of the between‐ and within‐person associations between distress and time until first drink following treatment was beyond the scope of this study. As mentioned previously, future research examining this topic would do well to include assessments of alcohol use on a daily or weekly level to examine these associations in more granular detail and possibly capture more within‐person variations in distress.…”