Using Motivation to Change to Tailor Alcohol Dependence Treatment
People seeking help for their alcohol or other drug problems enter treatment with very different levels of motivation to change. Differences in motivation appear to make a critical difference in which patients seek, comply with, and complete treatment. Findings from a study of the extent to which motivation and self-efficacy – the confidence to resist temptation and to abstain from drinking – changed during treatment, and the degree to which these variables affected drinking behaviors, indicate that treatments tailored to specific subgroups may be more effective.
Results will be published in the September 2011 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.
"There are a number of different ways to talk about motivation," said J. Kim Penberthy, associate professor of psychiatry & neurobehavioral sciences at the University of Virginia School of Medicine as well as corresponding author for the study.
"We decided to focus on motivation in the form of stages of change and self-efficacy," Penberthy explained. "The model we are using conceptualizes motivation as a level of readiness to change and self-efficacy as a combination of temptation to drink alcohol and confidence to abstain from drinking. For example, people who are in a stage such as action and maintenance have completed early tasks related to overcoming ambivalence, decision making, and commitment to a plan and are, therefore, more motivated to change their behavior by reducing drinking prior to treatment onset. Similarly, people who have developed a strong belief in their ability to resist temptations to drink are more confident and think about tempting situations differently, thereby increasing their motivation to not drink and not relapse."
While the effects of patient motivation and self-efficacy on change has not been extensively studied in clinical pharmacobehavioral trials, she added, they are crucially important in terms of who responds to treatment and when, particularly over time.
Penberthy and her colleagues evaluated changes in motivation, temptation to drink, confidence to abstain, and drinking behaviors during the treatment phase of a pharmacobehavioral study of 321 (226 men, 95 women) alcohol-dependent individuals. Participants received cognitive behavioral therapy (CBT) and either ondansetron or a placebo. The researchers also examined the degree to which individual variables such as initial drinking severity, age of onset of alcohol dependence, and medication status influenced changes in motivation, self-efficacy, and drinking behaviors.
"Certain factors – increased motivation to change, reduced temptation to drink, and increased confidence to abstain – predict reductions in drinking behavior regardless of treatment provided," said Penberthy. "This indicates that tailored treatments targeted to specific subgroups may be more effective."
For example, an anti-craving medication called ondansetron was more effective in early-onset versus late-onset drinkers in reducing drinks per drinking day, increasing percent of days abstinent, as well as decreasing temptation to drink. However, ondansetron did not have a different impact on early- versus late-onset alcoholics in terms of increased motivation or confidence to abstain from drinking.
"It was also found that reductions in drinking behavior in early-onset drinkers may be mediated by reduced temptation to drink," said Penberthy. "This supports the idea of early-onset alcoholism being a biologically based disease and more responsive to selective serotonergic agents to reduce temptation to drink, which in turn, leads to decreased drinking behavior."
Penberthy added that clinicians and researchers need to focus their research and clinical work on tailoring treatment approaches to patients based upon the stage of their disease, the patients stage or level of motivation, their self-efficacy, and biological responsiveness to medications.
"The current research is a first step in understanding more about which alcohol-dependent individuals respond to treatment and what mechanisms may be involved in the changes in drinking and drinking-specific changes in frequency and intensity of drinking," she said. "Such knowledge is needed in order to understand inconsistent results from prior pharmacobehavioral trials, and to tailor treatments more effectively to individuals. Additional research is needed to fully understand the interplay between medication, demographic variables, and psychological variables in treatment for alcohol dependence."=