Posted: October 27th, 2022
****Must use the attached articles ****
· Present an argument for your stance with respect to the first controversial issue regarding substance-related disorders: Is it possible for individuals with substance-related disorders, such as those who abuse alcohol, to moderate their use instead of taking the abstinence approach to treatment? Support your argument with evidence from this week’s required Learning Resources.
· Present an argument for your stance with respect to the second controversial issue—namely, is a substance-related disorder a disease? Again, support your argument with evidence from this week’s required Learning Resources.
References MUST come from the attached articles:
1. The Effects of Drinking Goal on Treatment Outcome for Alcoholism
2. Behavioural self-management with problem drinkers: One-year follow-up of a controlled drinking group treatment approach
3. Comer, R. J., & Comer, J. S. (2019). Fundamentals of abnormal psychology (9th ed.). Worth.
Chapter 10, “Substance Use and Addictive Disorders”
Addiction Research and Theory
February 2006; 14(1): 35–49
Behavioural self-management with problem
drinkers: One-year follow-up of a controlled
drinking group treatment approach
University of Applied Sciences in Nuremberg, Bavaria, Germany
(Received in final form 14 November 2005)
The present study tested the effectiveness of a German behavioural self-control training
(BSCT) for subgroups of drinkers differentiated by sex, ICD-10 diagnosis, and severity of
dependence. Hazardous, harmful, and dependent drinkers were recruited through local
mass media or referred by other treatment agencies. N¼53 subjects (60% men, mean age
48.9 years, 76% employed, 64% alcohol dependent) participated in 10 weekly group
treatment sessions and were assessed at intake, end of treatment, and 1-year follow-up
(with 81% successfully contacted). Improvements made during BSCT remained
stable over the 1-year follow-up period with 52% of subjects classified as improved
(8% abstinent, 44% with a decline in alcohol consumption of at least 30%). In women,
alcohol abusers and low dose drinkers (<800 g ethanol/w), alcohol intake had declined less than in men, alcohol dependent subjects, and high dose drinkers (>800 g/w). This study,
as others, indicates that alcohol dependence in itself is no contraindication for controlled
drinking (CD) treatment.
Keywords: Behavioural self-control training, controlled drinking, implementation
Currently the disease model of alcoholism, with its focus on total and lifelong
abstinence from alcohol, dominates addiction treatment in Germany and many
other countries. This holds true despite numerous theoretical and empirical
arguments put forward in favour of supplementing abstinence-oriented treatment
approaches by interventions aimed at moderate, asymptomatic or controlled
Correspondence: Prof. Dr Joachim Koerkel, University of Applied Sciences, Baerenschanzstr. 4,
D-90429 Nuremberg, Germany. Tel: þ49-911-27253829. Fax: þ49-911-27253813. E-mail:
ISSN 1606-6359 print: ISSN 1476-7392 online � 2006 Taylor & Francis
drinking (CD; see Heather & Robertson, 1983; Hester, 2003), which are set out
First, there is compelling scientific evidence that CD treatment, especially
behavioural self-control training (BSCT), is effective compared to alternative
interventions or no treatment in decreasing both amount and frequency of
alcohol intake (Rosenberg, 1993; Saladin & Santa Ana, 2004). According to
Walters’ (2000) meta-analysis BSCT ‘is equivalent to abstinence-oriented forms
of intervention in terms of overall effectiveness, stability of outcomes, and
potential clientele’ (p. 146). Even clients with higher levels of dependence may
benefit from moderation-oriented treatment (Dawe, Rees, Mattick, Sitharthan, &
Heather, 2002; Heather, Robertson, MacPherson, Allsop, & Fulton, 1987), and
reductions in alcohol consumption may already be expected when clients work
on their own with written self-help manuals (Apodaca & Miller, 2003).
Second, offering goal options (i.e. abstinence or CD) may attract more people
into treatment and thereby improve range and effectiveness of the existing health
care system (Institute of Medicine, 1990). For example, in Germany, 21.7% of
the adult population (18–59 years) are potential candidates for alcohol-related
interventions, as defined by the Alcohol Use Disorders Identification Test (Kraus &
Bauernfeind, 1998). But even among those with a pattern of alcohol dependence,
only about 5% are in treatment for their addiction and nearly no drinkers with
harmful or hazardous alcohol intake (Koerkel, 2002). One of the reasons for this
low rate of heavy drinkers seeking treatment is that many of them do not regard
themselves as ‘alcoholics’ and do not want to completely abstain from alcohol.
Third, from a therapeutic point of view it is much easier to work with clients
when they feel free to talk about their ‘true’ consumption goals, i.e. people
are much more committed in treatment when working on self-selected goals
(Miller & Rollnick, 2002; Sobell, Sobell, Bogardis, Leo, & Skinner, 1992).
Fourth, from an ethical point of view everybody should be granted the right
of self-determination (autonomy). In terms of treatment, this implies respecting
freedom of choice concerning treatment goals – not excluding discussion of the
pros of abstinence and cons of moderate consumption if done in an egalitarian
way (Miller & Rollnick, 2002).
On grounds of the arguments outlined above we developed a BSCT called the
‘Outpatient Group Treatment Program for Controlled Drinking’ (in German
‘Ambulantes Gruppenprogramm zum kontrollierten Trinken’, AkT; Koerkel,
Schellberg, Haberacker, Langguth, & Neu, 2002). The first AkT group started
in Nuremberg (located in southern Germany) in October 1999 as an additional
service of a ‘traditional’ abstinence-oriented outpatient counselling centre for
legal drugs and ended after ten weekly group sessions in January 2000. In a first
empirical study the effect of AkT was compared with that of a waiting list (WL)
control group to determine whether the decision to seek treatment and getting
intensive pre-assessment of about 3 h (including instructions to use a drinking
diary) influenced consumption patterns (Koerkel, 2002).
Results supported the effectiveness of AkT. Subjects randomly assigned to the
first AkT group (n¼ 13; 11 with a diagnosis of alcohol dependence according
36 J. Koerkel
to the International Classification of Diseases, ICD-10) fared significantly better
( p< 0.05) than those in the waiting list control condition (WL; n¼ 11, 8 of whom were alcohol dependent; Koerkel, 2002). Alcohol consumption in the week after end of treatment dropped to about half of that in the week before the intake interview (from 678 g [intake] to 354 g [end of treatment]); number of abstinent days per week increased (from 1.0 [intake] to 2.7 [end of treatment]) and GGT values declined (from 44.2 [intake] to 35.4 [end of treatment]). All changes in the WL group were statistically not significant. The same pattern of results emerged in a second analysis where five AkT groups (n¼ 46) were compared with a WL condition (n¼ 12; Haberacker, 2003).
The present study assessed the stability of change after CD treatment. With
that aim, pre-treatment, post-treatment, and one-year follow-up data of the first
five AkT groups offered in Nuremberg were analyzed. The second aim was to test
the effectiveness of AkT for subgroups of clients (differentiated by sex, ICD-1
diagnosis, and severity of dependence).
Recruitment of subjects
About three-quarters of clients were recruited through local mass media
(newspaper, radio, and television), the other quarter were referred by local
treatment agencies who do not offer CD treatment.
Subjects with hazardous or excessive alcohol consumption (including an actual
diagnosis of alcohol dependence) were accepted for the trial if they were
motivated to change drinking behaviour and stated that they preferred
moderation over abstinence. However, once admitted to the trial, clients were
free to select abstinence if they desired and to switch from one goal to the other at
any time (as has been reported in an Australian trial; Dawe & Richmond, 1997,
p. 83). People with alcohol-related physical damage (like diabetes or liver disease)
were also admitted to AkT if they could not be motivated to completely abstain
from alcohol. Exclusion criteria from AkT were: (1) Prior diagnosis of alcohol
dependence and currently abstinent (‘recovering alcoholic’); (2) severe psychiatric
comorbidity (like depression); (3) severe cognitive impairment; (4) current dependence
on other drugs (excluding nicotine); (5) other barriers for participating in a 10-sessions
group treatment program (like hearing disabilities or no eligibility for all 10 sessions
because of vacations planned during the treatment period).
Of 65 subjects who passed pre-assessment, seven were not accepted for the trial
because of: hearing defect (n¼ 1), severe social and cognitive impairment (n¼ 1),
comorbid psychiatric disturbance (anxiety disorder, depression; n¼ 2),
concurrent use of high doses of cannabis (n¼ 2), and alcohol use at only two
or three short episodes during the year (binge drinking; n¼ 1). Because there
were no drop-outs between pre-assessment and start of treatment, a total of
Behavioural self-management with problem drinkers 37
N¼ 58 subjects (23 women, 35 men) entered one of five AkT groups run in
an outpatient addiction counselling centre in Nuremberg. With five clients
(2 women, 3 men) finishing treatment prematurely, attrition rate was small.
Reasons for drop-out were referral to abstinence-oriented detox (n¼ 2) or
rehabilitation treatment (n¼ 1), a non-alcohol-related physical disease that
needed inpatient treatment (n¼ 1), and lack of interest in staying in the program
(n¼ 1). All other 53 subjects (21 women, 32 men) attended at least 8 of the
10 AkT sessions and were included in the following analyses. Mean age of the
remaining 53 subjects was 48.9 years (SD¼ 8.9, range 31–63 years); 66% were
married; and 76% were employed. Their weekly alcohol consumption amounted
to 26.54 German standard units (SD¼ 16.78, range 0–69.1; 1 German
SU¼ 20 g ethanol). According to ICD-10 nearly two out of three clients
(n¼ 34 or 64%) were alcohol dependent; the rest (n¼ 18 or 34%) were classified
as showing harmful use or abuse (ICD-10 missing data for one client). About
two-thirds of the clients (n¼ 34 or 64%) had never been in addiction treatment
before. All Ss considered their drinking a major problem that had created other
life problems (e.g. at work or in the family).
Mostly in a brief telephone interview, sometimes in a short personal interview,
potential clients were informed about details of AkT and screened for eligibility.
Appropriate subjects were scheduled for two (sometimes three) pre-assessment
sessions. Clients who clearly did not meet eligibility criteria were screened-out
and offered other forms of treatment.
Pre-treatment assessment encompassed three individual sessions lasting about
60 min each. Sessions 1 and 2 consisted of a structured interview that assessed
current and past alcohol consumption (last week, last 4 weeks, and last
12 months), other drug use, problems associated with drinking and earlier
treatment experiences, treatment goals (including a discussion about pros and
cons of abstinence), and demographic data. At the end of session 1 subjects were
handed a drinking diary (used throughout the program) to collect baseline
drinking data. In cases of lack of program suitability no further assessment
sessions were scheduled after session 1 and the client was offered another form of
treatment or was referred to other agencies. In session 3 a physical examination
by the medical doctor affiliated to the counselling centre was carried out to assess
health status and to take a blood sample for measurement of alcohol markers
(GGT, GOT, and GPT).
At the end of the pre-treatment assessment phase all clients signed informed
consent. The first treatment session started about one to two weeks after
During assessment sessions 1 and 2 the following instruments were applied for
38 J. Koerkel
Short version of the European Addiction Severity Index (EuropASI). Most data
were collected with a shortened European version of the Addiction Severity Index
(EuropASI; Gsellhofer, Küfner, Vogt, & Weiler, 1997), a widely used structured
interview addressing demographic background, substance use and negative
consequences of use. The main outcome variables were derived from data
collected with the EuropASI: total drinks per week (TDW), drinks per drinking
day (DDD), and abstinent days per week (ADW). All drinking data reported in
this article refer to the week before assessment (at pre-treatment, post-treatment,
International Classification of Diseases (ICD-10). Alcohol abuse and dependence
were diagnosed according to ICD-10 (Dilling, Mombour, & Schmidt, 1991).
DIA-X-Interview. To screen out clients with comorbid psychiatric problems,
the DIA-X-Interview (Wittchen & Pfister, 1997) was applied. DIA-X-Interview
consists of 16 questions each assessing the existence of a key symptom of the main
DSM-IV diagnoses (axis I). If a client agreed with the existence of a key symptom
a more detailed exploration followed.
Abstinence confidence questionnaire (KAZ-35). The modified KAZ-35 (KAZ-
35(kT); Koerkel & Schindler, 1996) is a self-rating questionnaire with good
psychometric properties. It serves to assess the confidence of clients in being able
to limit alcohol intake in 35 high-risk situations to the limits fixed by oneself.
The 35 items can be summed to a total score or they may be grouped into four
factorial dimensions (‘unpleasant emotions’, ‘social pressure’, ‘testing personal
control’, and ‘positive emotional states’).
About one week following the last AkT session, post-treatment assessment,
lasting about 2 h, took place. The abbreviated version of the EuropASI and the
KAZ-35(kT) were administered again and the physical examination (including
blood samples) was repeated.
Again after 6 months and 12 months post-assessment AkT participants were
interviewed with the abbreviated EuropASI and – if seen personally – a blood
sample was taken to test changes in GGT, GPT, and GOT. In most cases follow-
up interviews were carried out in the addiction counselling centre. Some subjects
who could not arrange to come to the centre were interviewed by phone. The
follow-up sessions lasted about 60 min. Follow-up data reported in this article
restricted to the one-year follow-up.
Behavioural self-management with problem drinkers 39
Parametric and nonparametric statistics were calculated for all comparisons and
statistical significance was set at the 5% level.
Treatment structure, content, and methods. Each AkT group consisted of
10 structured group sessions of BSCT with one session of 2¼ h weekly (including
a 15 min break). The AkT sessions were delivered according to a detailed
procedures manual (Koerkel & Projektgruppe kT, 2001) based on principles of
behaviour therapy as well as solution-oriented therapy and grounded in the spirit
of motivational interviewing (Miller & Rollnick, 2002). The first half of each of
the 10 AkT sessions was reserved for reviewing the records of the previous week’s
drinking, goal setting for the next week, and recommendations for reliable use of
the drinking diary. In the second half of each AkT session topics typical for BSCT
were covered: basic information about alcohol, reasons for change, weekly goal
setting, coping with high risk situations for excessive alcohol consumption,
strategies to avoid or limit alcohol intake (e.g. rate control, resisting temptations
and social pressure), coping with lapses, planning alcohol-free leisure time
activities, and problem solving without alcohol. In order to make the program
more interactive and capitalize on the advantages of group support, the sessions
included small group exchange, role playing, working on written material,
reporting experiences with one’s drinking plan and the like.
Therapists. Two of three AkT therapists (one social worker, one physician,
one psychologist), sometimes assisted by a trainee, conducted each of the group
sessions as well as the assessments. All therapists were experienced in treating
alcohol problems, two of them with extensive training in behaviour therapy.
Treatment integrity. Besides delivering treatment by experienced addiction
therapists and in accordance with the detailed AkT manual, treatment integrity
was addressed by weekly supervision of therapists based on written protocols of
each AkT session.
A total of 43 clients (81% of 53 participants finishing the AkT per protocol) could
be contacted at all assessment points, i.e. at pre-treatment, post-treatment, and
12-month follow-up. Reasons for loss to follow-up were: refused (n¼ 2), unable
to trace (n¼ 7), and moved away (n¼ 1). Preliminary analyses revealed that
subjects not found for follow-up did not differ significantly from the follow-up
sample in any of the drinking outcome variables (i.e. TDW, ADW, and DDD;
all p> 0.05).
All results reported in the following sections refer to the clients with
pre-treatment, post-treatment and follow-up data (n¼ 43). Only self-report
40 J. Koerkel
data of drinking behaviour are reported because in this (cf Haberacker, 2003)
as in other CD studies (e.g., Alden, 1988; Heather et al., 2000) self-reports
have been shown to be generally valid as corroborated by liver function
tests (Haberacker, 2003; Heather et al., 2000) or significant others’ reports
Changes from pre-treatment to post-treatment
Total sample. There was 45% reduction in drinks per week from pre-treatment
to post-treatment assessment (t(42)¼ 5.42, p< 0.001), a 25% reduction in amount of alcohol consumed on drinking days (t(42)¼ 3.39, p< 0.01), and a 89% increase in abstinent days (t(42)¼�5.53, p< 0.001) (see Table I). Concomitant with the changes in drinking behaviour, self-efficacy to maintain self-control in high-risk situations increased (KAZ-35(kT), total score; t¼�2.5, p< 0.05; Haberacker, 2003).
Sex. During treatment there was a statistically significant decrease of 47% TDW
in men (t(24)¼ 4.71, p< 0.01) and 42% in women (t(17)¼ 2.81, p< 0.05). Decrease in DDD was also highly significant in men (t(24)¼ 3.01, p< 0.01), but not in women (t(17)¼ 1.65, p> 0.05). There was an increase in ADW in men
(t(24)¼�5.82, p< 0.001) as well as women (t(17)¼�2.11, p¼ 0.05; see Table I).
ICD-10 diagnosis (alcohol misuse/alcohol dependence). A statistically significant
decrease in TDW was observed in subjects with alcohol abuse (t(13)¼ 2.64,
p< 0.05), as well as those with alcohol dependence (t(27)¼ 4.95, p< 0.001). Changes in DDD were significant for both subgroups (alcohol abuse,
Table I. Consumption measures: Means (and standard deviations) at pre-treatment, post-
treatment, and 12-months follow-up (by total sample and sex).
Outcome variable M SD M SD M SD
Total drinks per week
Pre-treatment 26.68 (17.92) 30.66 (19.31) 21.14 (14.53)
Post-treatment 14.56 (13.19) 16.18 (16.28) 12.31 (6.81)
12-months follow-up 16.45 (15.98) 17.47 (19.00) 15.04 (10.87)
Drinks per drinking day
Pre-treatment 4.24 (2.56) 4.82 (2.65) 3.43 (2.24)
Post-treatment 3.18 (1.87) 3.56 (2.16) 2.64 (1.26)
12-months follow-up 3.16 (2.42) 3.41 (2.87) 2.81 (1.63)
Abstinent days per week
Pre-treatment 1.49 (2.12) 1.18 (1.86) 1.92 (2.43)
Post-treatment 2.82 (1.95) 2.90 (1.93) 2.72 (2.04)
12-months follow-up 2.81 (2.14) 2.88 (2.16) 2.71 (2.19)
Behavioural self-management with problem drinkers 41
t(13)¼ 2.43, p< 0.05; alcohol dependence: t(27)¼ 2.70, p< 0.05) whereas the
increase in ADW approached significance in alcohol abusers (t(13)¼�2.07,
0.10 > p> 0.05) and was highly significant in subjects with alcohol dependence
(t(27)¼�5.45, p< 0.001; see Table II).
Severity of dependence (high/low). Even more support for the assumption that
people with excessive alcohol consumption can benefit from a CD program
comes from a comparison of people categorized as ‘high dose drinkers’ (defined
as consuming more than 40 SU or 800 g per week; n¼ 10) and those categorized
as ‘low dose drinkers’ i.e. <40 SU/w, n¼ 33 (see Heather et al., 2000 for this categorization; Table II and Figure 3). From the beginning to end of AkT both groups significantly decreased their weekly alcohol intake (low dose group: t(32)¼ 3.96, p< 0.001; high dose group: t(9)¼ 6.45, p< 0.001) and the amount of alcohol consumed at drinking days (low dose: t(32)¼ 1.23, p< 0.05; high dose: t(9)¼ 6.85, p< 0.001) while abstinent days increased (low dose: t(32)¼�4.28, p< 0.001; high dose: t(9)¼�4.13, p< 0.01; see Table II).
To test the stability of change, drinking outcomes at end of treatment and
one-year follow-up were compared.
Total sample. All changes made during treatment remained stable during the
follow-up period: drinks per week (t(42)¼�0.96, p> 0.05), amount of alcohol
consumed on drinking days (t(42)¼ 0.07, p> 0.05), and weekly abstinent days
(t(42)¼ 0.05, p> 0.05).
Table II. Consumption measures: Means (and standard deviations) at pre-treatment, post-
treatment, and 12-months follow-up (by diagnosis and severity of dependence).
ICD-10 diagnosis Severity of dependence
Outcome variable M SD M SD M SD M SD
Total drinks per week
Pre-treatment 19.49 (13.88) 30.87 (18.75) 18.94 (11.03) 52.21 (11.05)
Post-treatment 10.91 (5.56) 16.37 (15.67) 12.14 (6.80) 22.56 (23.56)
12-months follow-up 15.05 (9.57) 17.23 (18.75) 15.09 (9.90) 20.95 (28.55)
Drinks per drinking day
Pre-treatment 3.36 (1.86) 4.76 (2.13) 3.23 (1.84) 7.56 (1.56)
Post-treatment 2.37 (0.93) 3.59 (2.13) 2.89 (1.35) 4.12 (2.94)
12-months follow-up 2.89 (1.51) 3.28 (2.82) 2.82 (1.51) 4.28 (4.19)
Abstinent days per week
Pre-treatment 1.82 (2.25) 1.30 (2.11) 1.94 (2.24) 0.00 (0.00)
Post-treatment 2.64 (1.82) 2.94 (2.07) 2.94 (1.99) 2.45 (1.88)
12-months follow-up 2.51 (1.96) 2.93 (2.29) 2.58 (2.04) 3.55 (2.41)
42 J. Koerkel
Sex. For men and women improvements made during treatment remained
constant over the one-year follow-up period in TDW (men: t(24)¼�0.48,
p> 0.05; women: t(17)¼�0.92, p> 0.05), DDD (men: t(24)¼ 0.38, p> 0.05;
women: t(17)¼ 0.36, p> 0.05), and ADW (men: t(24)¼ 0.04, p> 0.05; women:
t(17)¼ 0.03, p> 0.05; see Table I and Figure 1). This also means that there was
no decrease in DDD for women from pre-treatment to one-year follow-up.
ICD-10 diagnosis (alcohol misuse/alcohol dependence). At one-year follow-up
TDW, DDD, and ADW of alcohol dependent clients as well as alcohol abusers
did not differ significantly from outcome values at post-treatment (TDW: alcohol
abuse, t(13)¼�2.10, p> 0.05, alcohol dependence: t(27)¼�0.30, p> 0.05,
p> 0.05; DDD: alcohol abuse, t(13)¼�1.93, p> 0.05, alcohol dependence:
t(27)¼ 0.71, p> 0.05; ADW: alcohol abuse, t(13)¼ 0.27, p> 0.05, alcohol
dependence: t(27)¼ 0.04, p> 0.05; see Table II and Figure 2). This also implies
that alcohol abusers did not increase the number of abstinent days during
treatment and one-year follow-up.
Pre-treatment Post-treatment 12 Months
Men (N = 25) Women (N = 18)
Figure 1. Changes in weekly alcohol consumption during AkT and follow-up (by sex; N¼ 43).
Pre-treatment Post-treatment 12 Months
Alcohol dependence (N = 28)
Alcohol misuse (N = 14)
Figure 2. Changes in weekly alcohol consumption during AkT and follow-up (by diagnosis;
Behavioural self-management with problem drinkers 43
Severity of dependence (high/low). From end of AkT to follow-up, low and
high dose drinkers maintained their treatment gains (TDW for low
dose: t(32)¼�1.50, p> 0.05, for high dose: t(9)¼ 0.29, p> 0.05; DDD for
low dose: t(32)¼ 0.24, p> 0.05, for high dose: t(9)¼�0.19, p> 0.05; ADW for
low dose: t(32)¼ 0.95, p> 0.05, for high dose: t(9)¼�1.19, p> 0.05; see Table II
and Figure 3).
Individual changes. The use of an improvement classification scheme provided
an index of the status of each individual at one-year follow-up. Each client
was assigned to one of six improvement categories similar to those used by
Miller (1978; see Figure 4).
According to this classification scheme, twelve months after end of treatment
8% of all clients followed-up had chosen to prefer abstinence over moderation,
i.e. they abstained from alcohol completely. Twenty-five percent had
considerably improved insofar as they showed a 50% reduction in alcohol intake.
Pre-treatment Post-treatment 12 Months
Weekly alcohol intake > 800 g (n = 10)
Weekly alcohol intake < 800 g (n = 33)
Figure 3. Changes in weekly alcohol consumption during AkT and follow-up (for high and
low dose drinkers; N¼ 43).
Figure 4. Individual changes in drinks per week (TDW) from pre-treatment to 1-year follow-up
44 J. Koerkel
Moderate improvement was observed in 19% of subjects who had cut down their
alcohol intake between 30% and 50%. Six percent were classified as ‘slightly
improved’. Those 25% clients with less than a 10% reduction were rated as ‘not
improved’. Follow-up data were missing from 17% of clients treated.
The CD program reported here, the AkT, attracted people with alcohol abuse
(one-third) or alcohol dependence (two-thirds) who reported excessive alcohol
Figure 5. AkT trainers in Germany.
Behavioural self-management with problem drinkers 45
consumption and associated life problems. In accordance with one of the goals
of offering CD programs, namely to get more people into treatment, the AkT
seems to be attractive to many people who had not previously sought help for
their alcohol problem; two-thirds of AkT participants had never been treated by
an addiction professional before. So, even if outcome in such a program is not
favourable, most clients can be motivated to stay in the wheel of change and may
then be referred to abstinence-oriented forms of treatment. This can be done in
a very simple and effective way within the treatment centre where this study was
done because abstinence and CD programs are offered in the same institution
by the same staff.
Drinking outcome variables reported in this study provide evidence that AkT
is an effective approach to foster self-control skills and to cut down alcohol intake
in different subgroups of clients at least over a one-year period – including
drinkers with severe and chronic alcohol problems that often are excluded
in other trials (e.g. Alden, 1988). Fifty-two percent of AkT participants could be
classified as improved overall, including 8% of subjects who were completely
abstinent. This outcome of AkT compares well with those of other trials of
BSCT in the USA (e.g. Miller, 1978), Canada (e.g. Alden, 1988) and UK
(e.g. Heather et al., 2000). Nevertheless many clients continued drinking at
dangerous levels, so that benefits of treatment sometimes took the form of harm
Although statistically not significant, considerable differences in change did
emerge between women and men, between clients with alcohol abuse and alcohol
dependence and between high dose and low dose drinkers. In women, alcohol
abusers and low dose drinkers, alcohol intake had declined much less than in the
other subgroups. One might well argue that a larger sample size would be needed
to draw substantial conclusions concerning subgroup differences, and indeed
statistical power needs to be increased by collecting and analyzing more follow-up
data in the future. Anyway, follow-up results of this and other studies (e.g. Dawe
et al., 2002; Heather et al., 2000; Miller, Leckman, Delaney, & Tinkcom, 1992)
indicate that alcohol dependent subjects do not perform worse than subjects with
alcohol misuse and that alcohol dependence in itself is no contraindication for
CD treatment. In our study even drinkers with very high levels of alcohol intake
(at least 800 g/w) showed an enormous and stable reduction in weekly alcohol
consumption from pre-treatment to post-treatment and follow-up that was much
more impressive than the decrease observed in the low dose group (with intake
consumption <800 g/w).
This might be a result of regression towards the mean in the ‘high dose
group’. But in face of their constantly high alcohol consumption level at
pre-treatment it is unlikely that their values could be expected to decrease
without treatment. Assuming our results are valid it seems justified to accept
even heavy drinkers with presumably high levels of dependence in CD
treatment programs – a conclusion also drawn in other studies addressing
this topic (cf Heather et al., 2000, p. 568f.). In accordance with this line of
reasoning and starting in January 2004, we have successfully implemented
46 J. Koerkel
different individual and group treatment CD programs in sheltered houses
for chronically alcohol dependent homeless people in Munich, Germany
(Koerkel, Gehring, König, & Drinkmann, 2005). A great number of them
deliberately join the programs and decrease their alcohol intake considerably or
opt for abstinence later on.
One of the limitations of this study is the attrition rate of 19% in the one-year
follow-up – a rate comparable to other CD follow-up studies (e.g. Alden, 1988;
Miller, 1978). It is unclear to what extent overall success rates may have been
overestimated by excluding possible failures from the analyses. On the other hand
subjects unlocated at follow-up did not show any differences in drinking
behaviour at post-treatment than cases followed-up, so that our findings may
represent true remission rates.
To stabilize treatment effects an aftercare system – with booster sessions,
self-help groups, online counselling, and the like – for subjects who complete a
CD program is needed. Consistent with this line of reasoning, in several German
cities AkT participants have founded self-help groups (first in June 2000 in
Nuremberg) for people that completed a CD treatment. Members of these groups
are free to opt for CD or abstinence. The groups exchange experiences
concerning ways and problems of maintaining CD or abstinence in everyday
life. The meetings (monthly in Nuremberg with an average of 10 members)
are informal and do not follow a fixed agenda as in Moderation Management
(cf Kishline, 1994).
Considered as a whole, the follow-up data of the AkT reported here, as well as
similar results with other forms of BSCT, provide support for integrating CD
treatment approaches in routine addiction treatment delivery. This also includes
implementing CD programs into drug treatment to enable drug addicts to control
their alcohol intake whenever problems with alcohol consumption become
evident. This happens very often. For example, people who are dependent on
illegal drugs are exposed to a much higher risk of dying when consuming illicit
drugs in combination with alcohol, medicinal HIV treatment can become
ineffective when high doses of alcohol are consumed, and many heroin addicts
treated in outpatient methadone or heroin programs develop serious alcohol
problems that need to be addressed (Gossop, 2004).
Given the fact that ‘pessimism over the viability of controlled drinking
treatment . . . seems based on political rather than scientific considerations’
(Heather, 1989) much effort still has to be made to ensure that CD programs
become an integral part of (German) addiction treatment systems and that health
insurances also pay for moderation-oriented interventions. One step in this
direction has been made: since 2001 we have trained about 400 German-
speaking addiction professionals (social workers, psychologists, physicians, and
others) in three-day to seven-day workshops to carry out AkT groups and its
variants (especially one variant called ‘EkT’ that is suitable for individual
treatment and encompasses 10 sessions as in the AkT; Gehring & Projektgruppe
kT, 2003). CD trainers are widespread over west Germany (see Figure 4) and
Behavioural self-management with problem drinkers 47
can be located on the internet (www.kontrolliertes-trinken.de), so that it is not
too difficult to find a CD trainer close by.
The author would like to thank Wilfried Langguth and Birgit Schellberg of
the Caritas Nuremberg Outpatient Counselling and Treatment Centre for
Addictions (Psychosoziale Beratungs- und Behandlungsstelle für Suchtkranke
im Caritasverband Nuremberg e.V.) for their considerable help in designing
this research and running the assessment and treatment sessions (together with
Claudia Kerlin and Birgit Neu). The author would also like to thank the
Caritasverband Mittelfranken e.V. and its head Mr Werber for funding this
research as a program development project.
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Behavioural self-management with problem drinkers 49
University of California, Los Angeles
Stephanie S. O’Malley
Yale University School of Medicine
Katy Lunny and Lara A. Ray
University of California, Los Angeles
Objective: It is well known to clinicians and researchers in the field of alcoholism that patients vary with
respect to drinking goal. The objective in this study was to elucidate the contribution of drinking goal to
treatment outcome in the context of specific behavioral and pharmacological interventions. Method:
Participants were 1,226 alcohol-dependent individuals enrolled in a large, multisite trial of combined
behavioral intervention, acamprosate, and naltrexone. Drinking goal was coded as follows: (a) controlled
drinking, (b) conditional abstinence, and (c) complete abstinence. Results: Analysis revealed a main
effect of drinking goal on percent days abstinent (p � .0001), days to relapse to heavy drinking (p �
.0001), and global clinical outcome (p � .001). These results were such that a goal of complete
abstinence was associated with the best outcomes, followed by conditional abstinence; controlled
drinking was associated with the poorest outcomes. Conversely, a main effect of drinking goal was
observed on drinks per drinking day (p � .01), such that controlled drinking was associated with fewer
drinks per drinking day whereas complete abstinence was associated with the highest number of drinks
per drinking day. Combined behavioral intervention performed better than medical management alone for
participants whose drinking goal was not complete abstinence. Conclusion: These results suggest that
drinking goal represents a highly predictive clinical variable and should be an integral part of the clinical
assessment of patients with alcohol dependence. Assessment of patients’ drinking goals may also help
match patients to interventions best suited to address their goals and clinical needs.
Keywords: COMBINE study, drinking goal, alcoholism, treatment outcome
It is well known to both clinicians and researchers in the
addiction field that patients in alcoholism treatment vary dramat-
ically with respect to their alcohol use goals. Patients differ on the
continuum between not wanting to change their drinking at all to
seeking complete and long-term abstinence from alcohol. Al-
though drinking goal represents an important clinical variable, the
literature is relatively limited as to the specific influence of drink-
ing goal on treatment outcomes for alcoholism. Likewise, the
clinical implications of drinking goal on treatment matching are
Drinking Goals in Alcoholism Treatment
Earlier research utilizing drug use goals analogous to goals used
in the present study found commitment to absolute abstinence,
measured at the end of treatment, to predict days to relapse across
nicotine, alcohol, and opiate dependence (Hall & Havassy, 1986;
Hall, Havassy, & Wasserman, 1990). These findings were such
that participants committed to complete abstinence took longer to
slip and longer to relapse, defined as drug use on four or more days
in a week. Critically, Hall and Havassy (1986) and Hall et al.
(1990) examined participants with an abstinence goal allowing for
occasional slips and found that these participants did not fare as
well as participants with complete abstinence goals.
Abstinence continues to be the dominant approach to alcohol
treatment in the United States, whereas nonabstinent approaches
tend to be more acceptable abroad (Klingemann & Rosenberg,
2009; Luquiens, Reynaud, & Aubin, 2011). The debate between
abstinence and nonabstinence approaches, specifically controlled
drinking (CD), has remained a controversial topic in the alcohol-
This article was published Online First December 10, 2012.
Spencer Bujarski, Department of Psychology, University of California,
Los Angeles; Stephanie S. O’Malley, Department of Psychiatry, Yale
University School of Medicine; Katy Lunny and Lara A. Ray, Department
of Psychology, University of California, Los Angeles.
Stephanie S. O’Malley reports the following activities in the past 2
years: member of the ACNP work group, the Alcohol Clinical Trials
Initiative, supported with funding from Abbott Laboratories, Alkermes, Eli
Lilly, GlaxoSmith Kline, Johnson & Johnson, Lundbeck, Pfizer, and Scher-
ing Plough; consultant/advisory board member, Pfizer Pharmaceuticals,
Gilead Sciences Inc.; contract as a site for a multisite study, NABI
Pharmaceuticals; medication supplies, Pfizer; partner, Applied Behavior
Research; scientific panel member, Hazelden Foundation. Lara A. Ray is
also a consultant for GlaxoSmith Kline. Data presented in this report were
collected as part of the multisite COMBINE trial sponsored by the National
Institute on Alcohol Abuse and Alcoholism (NIAAA), in collaboration
with the Combine Study Research Group. (A full listing of COMBINE
study staff can be found at http://www.cscc.unc.edu/combine/). Funding
for the COMBINE study was through NIAAA Cooperative Agreements
U10AA11715, 11716, 11721, 11727, 11756, 11768, 11773, 11776, 11777,
11783, 11787, 11799, and 11773.
Correspondence concerning this article should be addressed to Lara A.
Ray, University of California, Los Angeles, Department of Psychology,
1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563. E-mail:
Journal of Consulting and Clinical Psychology © 2012 American Psychological Association
, Vol. 81, No. 1, 13–22 0022-006X/13/$12.00 DOI: 10.1037/a0030886
ism field since the 1960s (Davies, 1962; Miller & Caddy, 1977).
As far as treatment outcomes are considered, there is no univer-
sally accepted definition of what constitutes successful CD. Other
terms have been used in the literature, including harm reduction
and moderation, yet these terms also lack an operational definition
although the field has increasingly focused on the reductions in
heavy drinking days (typically defined by four or more standard
drinks on an occasion for women and five or more drinks per
occasion for men; Marlatt & Witkiewitz, 2002). It has been sug-
gested that CD, and more specifically a reduction in heavy drink-
ing, has a number of clinical benefits that should be taken into
consideration when discussing drinking goals (Gastfriend, Garbutt,
Pettinati, & Forman, 2007). For example, Maisto, Clifford, Stout,
and Davis (2006, 2007) analyzed treatment outcome data from
Project Match and found that patients classified as moderate drink-
ers, defined by at least one drink but no more than 5 heavy
drinking days during the 1-year follow-up, had better clinical
outcomes at 3-year follow-up than did those classified as heavy
drinkers (6 or more heavy drinking days at the 1-year follow-up).
Although abstainers had the best outcomes, this study suggests that
moderate drinking may be considered a viable drinking goal option
for some individuals who may not be willing or able to abstain
Although there are many obstacles to the widespread acceptance
of CD as a treatment approach (Sobell & Sobell, 2006), it is
important to note that not all individuals entering treatment do so
with the goal of achieving abstinence. To that end, the use of
abstinence as the dominant drinking goal across alcoholism treat-
ment programs in the United States may in fact deter individuals
who would otherwise seek treatment for alcohol problems should
CD be proposed as an acceptable goal. Sobell, Sobell, Bogardis,
Leo, and Skinner (1992) found that many patients entering an
outpatient treatment facility for alcohol problems preferred self-
selection of treatment goals to adoption of the goals selected by the
therapist. Treatment programs that allow for and encourage
patient-driven treatment goals may be more appealing and may
lead to greater treatment utilization and engagement. This is par-
ticularly important in light of the overall low treatment-seeking
rates for alcoholism, with only 27.8% of alcohol-dependent indi-
viduals seeking treatment in the past year (Cohen, Feinn, Arias, &
Tailoring treatment approaches to patients’ goals, whether com-
plete or conditional abstinence or controlled drinking, may have
positive results on treatment outcome. Additionally, for some
individuals entering treatment, CD may be a viable drinking goal.
For example, a recent study found that patients stating a preference
for abstinence had better treatment outcome than those stating a
preference for nonabstinence (Adamson, Heather, Morton, & Ra-
istrick, 2010). These effects, however, were seen for percent days
abstinent but not for drinking intensity, suggesting that a compa-
rable number of drinks per drinking episode may be achieved
regardless of drinking goal. These results suggest that carefully
considering drinking goals at treatment entry represents an impor-
tant aspect of the initial assessment. As noted by Adamson et al.
(2010), treatment goals may change over the course of treatment
and must be continuously evaluated in order to promote the best
Approaches to Alcoholism Treatment
Cognitive behavioral therapy (CBT) for alcoholism has received
empirical support since the 1980s (Marlatt & Gordon, 1985). CBT
for alcohol use disorders is grounded in social-cognitive theory
(Bandura, 1986) and employs skills training in order to help
patients cope more effectively with substance use triggers, includ-
ing life stressors (Longabaugh & Morgenstern, 1999; Morgenstern
& Longabaugh, 2000). The ultimate goal of CBT is to provide the
skills that can prevent a relapse and maintain drinking goals,
whether they be abstinence or controlled drinking (Marlatt &
Gordon, 1985; Marlatt & Witkiewitz, 2005). A recent meta-
analysis of CBT for substance use disorders found support for a
modest benefit of CBT over treatment as usual (Magill & Ray,
2009). Furthermore, one report using a trajectory analysis of the
COMBINE study data found the combined behavioral intervention
(CBI), which is principally grounded in CBT, to reduce the risk of
being in an “increasing to nearly daily drinking” trajectory. This
study suggests that CBI may help participants control their drink-
ing as opposed to simply encouraging abstinence (Gueorguieva et
al., 2010). However, no studies to date have assessed the moder-
ating role of drinking goal on CBI efficacy.
Regarding pharmacological interventions for alcohol use disor-
ders, recent laboratory studies of naltrexone have elucidated its
mechanisms of action. Studies have suggested that naltrexone
reduces alcohol-induced stimulation (Drobes, Anton, Thomas, &
Voronin, 2004), decreases liking of alcohol (McCaul, Wand,
Stauffer, Lee, & Rohde, 2001), increases fatigue and tension
following alcohol use (King, Volpicelli, Frazer, & O’Brien, 1997),
and slows the progression of drinking (Anton, Drobes, Voronin,
Durazo-Avizu, & Moak, 2004; O’Malley, Krishnan-Sarin, Farren,
Sinha, & Kreek, 2002). These effects are dependent upon alcohol
use during the course of treatment. Importantly, one study exam-
ined the effects of naltrexone on alcohol nonabstainers and found
that participants who drank regularly during the treatment period
benefited more from naltrexone relative to placebo (Ray, Krull, &
Leggio, 2010). Together, these findings suggest that naltrexone
may be better suited to a controlled drinking approach and thus
may be more effective among patients with controlled drinking
The second pharmacotherapy assessed in the COMBINE study
was the glutamatergic NMDA receptor antagonist, acamprosate.
Several studies have begun to elucidate the mechanism of action
for acamprosate and have found support for acamprosate-mediated
reductions in protracted withdrawal and associated alcohol craving
(Spanagel & Zieglgansberger, 1997). Critically, one study found
patient motivation toward abstinence to be a significant moderator
of acamprosate efficacy such that acamprosate was more effective
among patients who were more highly motivated toward absti-
nence (Mason, Goodman, Chabac, & Lehert, 2006).
Present Study Aims
In summary, although drinking goal at treatment entry repre-
sents an important and readily accessible clinical variable, few
studies have empirically examined its predictive utility in terms of
clinical outcome. To our knowledge, no studies to date have
examined whether specific treatment approaches may be better
suited for patients stating a preference for abstinence versus non-
abstinence. To that end, the present study examined drinking goal
14 BUJARSKI, O’MALLEY, LUNNY, AND RAY
as a predictor of treatment outcome in the COMBINE study and
tested whether drinking goal interacts with treatment modality
(i.e., cognitive behavioral intervention, naltrexone, and acampro-
sate). Primary outcomes in the COMBINE study were percent days
abstinent, days to relapse to heavy drinking, and global clinical
outcome. In addition to examining these three primary outcomes,
we tested the effect of drinking goal on drinks per drinking day.
Consistent with current literature, it is hypothesized that patients
whose stated drinking goal is complete abstinence will have better
clinical outcomes than patients whose drinking goal is conditional
abstinence, with controlled drinking having the worst outcome.
Moreover, in light of the literature suggesting that patients who
drink regularly appear to benefit from naltrexone (Anton et al., 1999;
Ray, Krull, & Leggio, 2011), a drinking goal � naltrexone interaction
is hypothesized, such that the effect of naltrexone will be greater
among patients with controlled drinking goals than those with absti-
nence goals, whereas patients who are more motivated toward com-
plete abstinence would have better outcomes on acamprosate than
would patients with controlled drinking goals. Together, these anal-
yses seek to further elucidate the predictive utility of drinking goal as
well as to identify specific treatment approaches that may be better
suited for patients whose goals are abstinence versus nonabstinence
oriented. Given the widespread recognition of individual differences
in drinking goals for alcoholism treatment, as well as the accessible
nature of this clinical variable to treatment providers, the potential
clinical utility of such findings is high.
Summary of the COMBINE Study
The rationale and methods of the COMBINE study have been
described in detail elsewhere (COMBINE Study Research Group,
2003a, 2003b). In brief, the COMBINE study was a large multisite
treatment study of two pharmacotherapies (i.e., naltrexone and
acamprosate), and cognitive behavioral intervention for alcohol-
ism. In total, 1,383 participants were recruited at 11 U.S. sites (see
Figure 1). All of them met criteria for alcohol dependence and had
been drinking heavily for the 90-day period preceding study en-
rollment (i.e., at least 2 heavy drinking days; defined as four
drinks/day for women and five drinks/day for men, during a
consecutive 30-day period within the 90 days prior to baseline
evaluation). Exclusion criteria were any serious mental illnesses or
unstable medical conditions; current abuse of or dependence on
any drug other than nicotine or marijuana; and taking or requiring
any medication that interfered with the study medications, includ-
ing any current opioid use.
Two levels of behavioral intervention were investigated in the
COMBINE study. The first, medical management (MM), consisted
of nine brief sessions delivered by a licensed health care profes-
sional and was intended to approximate a primary care interven-
tion. Medications were also dispensed during each of these ses-
sions. The second, combined behavioral intervention (CBI),
consisted of up to twenty, 50-min sessions that integrated aspects
of cognitive behavioral therapy, 12-step facilitation, motivational
interviewing, and involvement of support systems.
Participants were randomly assigned to one of nine treatment
conditions and received 16 weeks of active treatment. Eight of
these groups (n � 1,226) received medical management plus a
combination of either active/placebo naltrexone or active/placebo
acamprosate. These four medication groups were then further
divided by two levels of behavioral counseling (i.e., CBI vs. no
CBI). A ninth group (n � 157) received CBI alone, without MM
or pills; however, this group was excluded from the analyses
presented herein. The target naltrexone dose in the COMBINE trial
was 100 mg per day (after a 7-day titration), and the target
acamprosate dose was 3 g per day.
The primary outcomes for the trial were (a) percent days absti-
nent and (b) days to relapse to heavy drinking (operationalized as
five or more drinks in a day for men and four or more drinks in a
day for women). A composite variable called global clinical out-
come was analyzed to assess the clinical relevance of the findings.
The global clinical outcome variable takes into account alcohol
consumption as well as alcohol-related problems (Cisler & Zwe-
ben, 1999). In general, the results of the COMBINE study found a
CBI � naltrexone interaction across a range of outcomes. The
pattern of findings was that either naltrexone or CBI was associ-
ated with improved outcome but that there was no additional
advantage of the combination of CBI and naltrexone. In addition,
there were no significant effects of acamprosate alone or in com-
bination with the other treatments.
Drinking goal was assessed as part of the Treatment Experi-
ences and Expectancies Questionnaire (Item 6) that was adminis-
tered prior to treatment using a question from the Thoughts About
Abstinence Scale (Hall et al., 1990). The item asked the following:
“We would like to know what GOAL you have chosen for yourself
about using alcohol at this time,” and seven responses were pos-
sible (see the Appendix). From participants’ responses to this
question, drinking goal was categorized into three groups as fol-
lows: controlled drinking goal (i.e., “I want to use alcohol in a
controlled manner—to be in control of how often I use and how
much I use” and “I don’t want using alcohol to be a habit for me
anymore, but I would like to occasionally use alcohol when I really
have an urge”); and complete abstinence goal (i.e., “I want to quit
n = 1226
n = 1113
Valid data for ≥
n = 1113
n = 113
n = 952
n = 907
n = 814
n = 299
Figure 1. Flowchart indicating the number of participants with complete
data who were included in study analyses. GCO � global clinical outcome;
DPDD � drinks per drinking day; PDA � percent days abstinent; DV �
15DRINKING GOAL AND CLINICAL OUTCOMES
using alcohol once and for all, to be totally abstinent, and never use
alcohol ever again for the rest of my life”). An intermediate group
of conditional abstinence was created based upon face validity,
clinical plausibility, and prior work with the measure in order to
allow for accurate hypothesis testing. Responses encoded as con-
ditional abstinence included “I want to be totally abstinent from all
alcohol use for a period of time, after which I will make a new
decision about whether or not I will use alcohol again in any way”
and “I want to quit using alcohol once and for all, even though I
realize I may slip up and use alcohol once in a while.”
The Alcohol Dependence Scale (ADS; Skinner & Allen, 1982)
was used to assess severity of alcohol dependence. This 25-item
scale measures alcohol dependence symptoms over the past 12
months and has been shown to contain items that are very relevant
for alcohol-dependent drinkers (Kahler, Strong, Stuart, Moore, &
Ramsey, 2003), such as the ones recruited in the present study. The
ADS contains both yes/no items and items answered on a 3- or
4-point Likert scale. Total score on the ADS is computed through
a simple arithmetic sum.
The Form 90 (Miller & Del Boca, 1994; Tonigan, Miller, &
Brown, 1997) was used to obtain pretreatment measures of drink-
ing, and the Time Line Follow-Back (TLFB) interview (Sobell &
Sobell 1992) was used to obtain daily reports of the number of
drinks consumed during the 16-week treatment period. The Form
90 is a standardized 90-day retrospective drinking interview. De-
veloped for Project MATCH, the Form 90 incorporates aspects of
TLFB and grid-averaging methodologies in order to accurately
assess participants’ alcohol consumption. Percent days abstinent
(PDA), drinks per drinking day (DPDD), and days to relapse
during treatment were calculated from the TLFB interview data.
Data Analytic Strategy
Outcome variables and base covariates were culled from the
COMBINE database. Some additional covariates were added (de-
tailed below). The results presented are based on data collected
through the 16 weeks of treatment. Three of the outcome variables
were identical to those in the primary COMBINE report: (a) PDA;
(b) days to relapse to heavy drinking, as defined as more than five
drinks in a day for men and more than four drinks in a day for
women (relapse); and (c) global clinical outcome (GCO), which is
a binary composite measure of treatment outcome. Because the
four outcome levels of GCO are not linearly distributed and
consistent with the primary COMBINE paper, we coded partici-
pants as either having a good clinical outcome (i.e., abstinent or
moderate drinking without problems; coded as 1) or not (i.e.,
heavy drinking with or without problems; coded as 0). In light of
the aims in the present study we also examined DPDD.
Participants for whom there was missing data or who had
dropped out of the study (n � 258) were not included in these
analyses. Additionally, for days to relapse, participants who did
not relapse during the treatment period (n � 299) were not ana-
lyzed for this outcome. Drinking goal was not associated with
treatment dropout, F(2, 1158) � 0.03, p � .97.
The analytical strategy for the present study was consistent with
the primary COMBINE report (Anton et al., 2006). Thus, PDA
was tested with a mixed effects general linear model (PROC
MIXED), relapse and DPDD were tested with a proportional
hazards model (PROC PHREG), and GCO was analyzed with a
logistic regression model (PROC LOGISTIC).1 All analyses were
conducted with SAS Statistical Software version 9.2. Analysis
accommodated the clustering of observations by site through the
estimation of a random intercept term. All other factors were
treated as fixed effects.
As a data check, all outcomes presented in the primary COM-
BINE manuscript were replicated prior to any model testing for
this study. Additionally, drinking goal was initially analyzed as a
five-level variable, keeping all possible self-report responses sep-
arate. Visual inspection of these results supported our classifica-
tion system (i.e., controlled drinking, conditional abstinence, and
complete abstinence) in that the two possible responses for both
controlled drinking and conditional abstinence clustered together
across outcomes. Because drinking goal is a three-level variable,
following the omnibus test, we conducted planned analyses to test
differences between the three drinking goal groups for effects
observed on all outcome variables.
Full demographic and baseline drinking results can be found in
the primary COMBINE report (Anton et al., 2006). In total 1,383
(428 women) alcohol-dependent participants with a mean age of
44.12 years (SD � 10.17) were randomized in the trial. The mean
number of Diagnostic and Statistical Manual of Mental Disorders
(4th ed.; DSM–IV; American Psychiatric Association, 1994)
alcohol-dependence symptoms met was 5.5 (SD � 1.3), and the
mean ADS score was 16.68 (SD � 7.32). In this study, 346
(25.0%) of participants had a controlled drinking goal, 453
(32.8%) of participants had a goal of conditional abstinence, and
506 (36.6%) of participants had a drinking goal of complete
abstinence. A total of 78 (5.6%) participants reported “I really
don’t have a clear goal in mind” or that the other categories did not
apply to them, and they were thus excluded from further analyses.
Prior to analysis of the study hypotheses, we performed random-
ization checks for the drinking goal variable. Drinking goal was not
found to be significantly associated with randomization cell, F(2,
1158) � 0. 31, p � .74; naltrexone condition, F(2, 1158) � 1.17, p �
.31; acamprosate condition, F(2, 1158) � 1.64, p � .20; or CBI
condition, F(2, 1158) � 0.57, p � 0.57. Drinking goal was signifi-
cantly associated with sex, F(2, 1119) � 9.86, p � .0001, and with
age, F(2, 1119) � 3.29, p � .05, so age and sex were entered as initial
covariates in all models.
Additionally, drinking goal was significantly associated with
ADS total score, F(2, 1297) � 68.34, p � .0001, such that those
with higher ADS scores were more likely to have abstinence-
oriented goals than controlled drinking goals. These findings are
consistent with prior research suggesting that severity of depen-
dence is positively associated with selection of abstinence goals
(Heather, Adamson, Raistrick, & Slegg, 2010; Sobell & Sobell,
1995). However, results revealed that higher PDA at baseline was
1 Hazard ratios and/or odds ratios are not reported for significant inter-
actions. Because no single hazard or odds ratio statistic exists to be
reported for interactions, chi-square values are reported instead for sim-
plicity of interpretation (Allison, 2010). Chi-square scores were obtained
from the same statistical procedures listed.
16 BUJARSKI, O’MALLEY, LUNNY, AND RAY
also associated with preference for abstinence, F(2, 1158) � 9.28,
p � .0001, perhaps as a result of efforts to reduce drinking prior to
enrollment. In light of these baseline differences, all initial models
controlled for age, sex, ADS total score, and baseline PDA; how-
ever, only control variables that were significantly predictive were
retained in the final models presented below.
Percent Days Abstinent
Analysis of percent days abstinent (see Figure 2) revealed a
significant main effect of drinking goal, t(2839) � 9.03, p �
.0001, B � 9.34, SE � 1.04, after controlling for sex (p � .08) and
baseline PDA (p � .0001). Additionally, a main effect of CBI,
t(2838) � �2.35, p � .05, B � �6.75, SE � 2.87, and a
significant drinking goal � CBI interaction were found, t(2839) �
1.97, p � .05, B � 4.03, SE � 2.05. These results suggest that
individuals with a complete abstinence goal had more days absti-
nent and that the effects of CBI on PDA were moderated by
drinking goal. The moderation was such that CBI performed better
than MM alone, but not for participants with a goal of complete
abstinence. No significant goal � naltrexone or goal � acampro-
sate interactions were found (ps � .10).
Planned comparisons between participants with a controlled
drinking goal and those with a conditional abstinence goal re-
vealed a significant main effect of drinking goal, t(1718) � 5.10,
p � .0001, B � 11.83, SE � 2.32, and a main effect of CBI,
t(1717) � �2.09, p � .05, B � �7.19, SE � 3.43. No significant
goal � CBI interaction was found (p � .10) Analysis comparing
controlled drinking and complete abstinence goals revealed a
significant main effect of goal, t(1858) � 8.95, p � .0001, B �
9.55, SE � 1.07; a significant main effect of CBI, t(1858) �
�2.16, p � .05, B � �7.10, SE � 3.29; and a significant goal �
CBI interaction, t(1858) � 1.95, p � .05, B � 4.09, SE � 2.10. As
seen in Figure 1, these results suggest that CBI resulted in greater
percentage of days abstinent among patients with a controlled
drinking goal than among patients with a complete abstinence
goal. When participants with a complete abstinence goal and those
with a conditional abstinence goal were compared, a main effect of
goal was observed, t(2100) � 4.15, p � .0001, B � 7.43, SE �
1.79. No significant main effect of CBI or goal � CBI interaction
was found (ps � 0.10).
Days to Relapse to Heavy Drinking
Analysis of days to relapse (see Figure 3) revealed a significant
main effect of drinking goal (hazard ratio [HR] � 0.688; 97.5% CI �
0.616–0.769; p � .0001) after controlling for age (p � .001), ADS
score (p � .01), and baseline percent days abstinent (p � .01),
suggesting that participants reporting complete abstinence as their
goal had significantly longer time to relapse. No significant main
effect of CBI was observed, nor was there a significant goal � CBI
interaction. Additionally, no significant goal � medication interac-
tions were found (ps � 0.10).
Planned comparisons between controlled drinking and condi-
tional abstinence revealed a significant main effect of drinking
goal with respect to days to relapse (HR � 0.685; 97.5% CI �
0.551–0.853; p � .0001). Comparing controlled drinking goal to a
goal of complete abstinence revealed a significant main effect of
drinking goal (HR � 0.683; 97.5% CI � 0.610–0.766; p �
.0001). Comparing goals of conditional abstinence to goals of
complete abstinence revealed a significant main effect of drinking
goal (HR � 0.697; 97.5% CI � 0.567–0.856; p � .0001). There
was no significant main effect of CBI or a goal � CBI interaction
when comparing these groups (ps � 0.10).
Global Clinical Outcome
There was a significant main effect of drinking goal on global
clinical outcome (see Figure 4; odds ratio [OR] � 0.704; 95% CI �
0.581–0.854; p � .001) after controlling for age (p � .05) and
baseline percent days abstinent (p � .05). This effect was such that
participants with a goal of complete abstinence were more likely to be
classified as having a good clinical outcome. Additionally, a main
effect of CBI was found (�2 � 6.59, p � .05) as well as a trend level
goal � CBI interaction (�2 � 3.11, p � .08). No significant goal �
medication effects were found (ps � 0.10).
Planned comparisons between controlled drinking and condi-
tional abstinence revealed neither a significant main effect of goal
nor a significant goal � CBI interaction (ps � 0.10). However, a
significant main effect of CBI was found (�2 � 5.13, p � .05).
When comparing patients with a controlled drinking goal to those
with a goal of complete abstinence, there was a significant main
effect of drinking goal (OR � 0.714; 95% CI � 0.588–0.868; p �
.001). There was also a significant main effect of CBI (�2 � 4.90,
p � .05) and a trend-level goal � CBI interaction (�2 � 2.94, p �
.09). Drinking goal also had a significant effect on GCO when
comparing participants with complete abstinence goals to those
with a conditional abstinence goal (OR � 0.639; 95% CI �
0.444–0.921; p � .05), such that those with total abstinence goal
were more likely to be classified as having a good clinical out-
come. There was, however, no significant main effect of CBI or a
goal � CBI interaction (ps � 0.10).
Figure 2. Percent days abstinent by drinking goal (i.e., controlled drink-
ing, conditional abstinence, and complete abstinence). Overall main effect
of drinking goal is significant (p � .0001). Lines denote significant
planned comparisons. Error bars represent standard errors. MM � medical
17DRINKING GOAL AND CLINICAL OUTCOMES
Drinks per Drinking Day
Analysis revealed a significant main effect of drinking goal on
DPDD (see Figure 5; HR � 0.876; 97.5% CI � 0.786–0.977; p �
.01) after controlling for baseline PDA (p � .05), baseline DPDD
(p � .0001), sex (p � .0001), and ADS score (p � .0001). These
results were such that a controlled drinking goal was associated
with the fewest DPDD, with complete abstinence associated with
the greatest number of DPDD, suggesting an abstinence violation
effect (Larimer, Palmer, & Marlatt, 1999; Marlatt & Gordon,
1985). A significant drinking goal � acamprosate interaction was
observed (�2 � 3.99, p � .05) such that acamprosate was associ-
ated with a greater number of DPDD compared to placebo but only
among patients with a goal of complete abstinence. No significant
main effect of CBI was observed, nor were there any significant
goal � CBI or goal � naltrexone interactions (p � .10).
Planned comparisons between controlled drinking and condi-
tional abstinence goals did not reveal a significant main effect of
goal (p � .10). A significant drinking goal � acamprosate inter-
action was observed (�2 � 6.27, p � .05) such that acamprosate
was associated with fewer DPDD than placebo, but only in patients
with a controlled drinking goal. Comparing controlled drinking to
complete abstinence goals revealed a significant main effect of
drinking goal on DPDD (HR � 0.876; 97.5% CI � 0.781–0.983;
p � .01) and a significant goal � acamprosate interaction (�2 �
4.62, p � 0.05). No significant drinking goal � CBI or naltrexone
interactions were observed (p � .10). When comparing partici-
pants with a goal of conditional versus complete abstinence, anal-
ysis revealed a significant main effect of drinking goal (HR �
0.809; 97.5% CI � 0.664–0.986; p � .05). No significant drinking
goal � medication or drinking goal � CBI interactions were
This study examined the effects of drinking goal on clinical
outcomes in the COMBINE Study. It was hypothesized that pa-
tients whose drinking goals were oriented toward complete absti-
nence would have better treatment outcomes as indexed by a
greater percentage of days abstinent, longer period until relapse,
and an overall higher global clinical outcome. These hypotheses
were supported by the present study, such that participants with a
self-reported goal of complete abstinence had better overall clin-
ical outcomes following 16 weeks of alcohol-dependence treat-
ment. Participants with a goal of controlled drinking had the worst
Figure 3. Days to relapse to heavy drinking by drinking goal (i.e.,
controlled drinking, conditional abstinence, and complete abstinence).
Overall main effect of drinking goal is significant (p � .0001). Lines
denote significant planned comparisons. Error bars represent standard
Figure 4. Global clinical outcome by drinking goal (i.e., controlled
drinking, conditional abstinence, and complete abstinence) and behavioral
therapy condition (i.e., MM alone vs. CBI � MM). Overall main effect of
drinking goal is significant (p � .001). Lines denote significant planned
comparisons. Error bars represent standard errors. MM � medical man-
agement; CBI � combined behavioral intervention.
Figure 5. Drinks per drinking day as a function of drinking goal (i.e.,
controlled drinking, conditional abstinence, and complete abstinence) and
acamprosate condition. Overall main effect of drinking goal is significant
(p � .01). Lines denote significant planned comparisons. Error bars rep-
resent standard errors.
18 BUJARSKI, O’MALLEY, LUNNY, AND RAY
drinking outcomes, whereas those with a conditional abstinence
goal made up an intermediate group between complete abstinence
and controlled drinking. This pattern of results was robust and was
replicated across all primary outcome measures. In addition, post
hoc analysis of drinks per drinking day revealed that participants
with a goal of controlled drinking reported fewer drinks per
drinking day and those oriented toward complete abstinence as a
goal reported greater drinks per drinking day.
In sum, consistent with the available literature, the present study
found a goal of complete abstinence to predict better clinical
outcomes than did controlled drinking goals (Adamson et al.,
2010; Hall & Havassy, 1986; Hall et al., 1990; Maisto et al., 2006).
However, contrary to much of the previous research, which split
participants into two groups (i.e., abstinence vs. nonabstinence
goals), the present study examined an intermediate group; namely,
those with conditional abstinence goals. Notably, some prior re-
search has looked at differences in time to relapse between com-
plete abstinence and less-restrictive outcomes (including condi-
tional abstinence) and found that a goal of complete abstinence
was associated with longer time to relapse (Hall & Havassy, 1986;
Hall et al., 1990). Importantly, the present study suggests that this
intermediate group may be clinically dissociable from the com-
plete abstinence group in that clinical outcomes were significantly
different between the two abstinence-oriented groups. A previous
study created a third drinking goal group, called “heavy, over
guidelines drinkers,” and found that patients with moderate drink-
ing and abstinence goals had similar drinking outcomes (Adamson
& Sellman, 2001). The present results do not seem to support this
finding, although this study was not able to split the controlled
drinking group based upon self-selected acceptable consumption.
Although participants with goals of complete abstinence did
succeed in drinking less frequently and taking longer to relapse to
heavy drinking than did participants with controlled drinking or
conditional abstinence goals, they drank more per drinking day, on
average. This finding is consistent with an abstinence violation
effect, wherein abstinence-oriented participants are more likely to
engage in heavy drinking following an initial lapse (Marlatt &
Gordon, 1985). Although CBI should theoretically reduce the
impact of the abstinence violation effect by providing the oppor-
tunity to accurately process a lapse, the results presented herein did
not support this effect (i.e., no goal � CBI interaction was ob-
It was also hypothesized that, given naltrexone’s effect on
hedonic response to alcohol (King et al., 1997; McCaul et al.,
2001; Ray et al., 2010), naltrexone would be more effective among
those with a controlled drinking goal than those with an
abstinence-oriented goal. This hypothesis was not supported by the
data in that there was no significant drinking goal � naltrexone
interaction in any of the outcome measures. This may be due to the
fact that the vast majority of participants (78%) consumed alcohol
during the trial, such that the drinking-mediated effects of naltrex-
one were not restricted to patients with controlled drinking goals.
Furthermore, we hypothesized that a goal of complete absti-
nence would be associated with better response to acamprosate
(Mason et al., 2006). Although there was some evidence the
acamprosate may interact with drinking goal, this interaction was
not in the hypothesized direction. Instead, our results were such
that acamprosate was associated with more drinks per drinking day
than placebo, but only for patients with a complete abstinence
goal. As a whole, however, we found largely null results concern-
ing the interaction of drinking goal with acamprosate. This finding
limits the conclusions that can be drawn about acamprosate effects.
Further, analyses revealed several drinking goal � CBI inter-
actions such that the benefit of combined behavioral intervention
over medical management was not supported for participants
whose reported goal was complete abstinence. These findings were
evident in two of four outcome measures, and some were trend
level. Given the sample size of the present study, this limits the
conclusions that can be drawn about matching of behavioral in-
tervention based on drinking goal. Additionally, Type I error
correction was not implemented; caution is therefore warranted
when interpreting marginally significant interactions. It is, how-
ever, an important clinical finding that CBI conferred no advantage
over a brief, medically oriented intervention for participants whose
drinking goal was complete abstinence. However, although de-
signed to approximate the style of intervention delivered in a
primary care setting, the medical management delivered in the
COMBINE study was confounded with extensive and state-of-the-
art assessment and follow-up. As such, further research may be
required before these findings can be generalized to real-world
primary care settings.
These results presented herein should be interpreted in the
context of the study’s strengths and limitations. Study strengths
include the large and well-characterized sample as well as the
methodological rigor of the COMBINE study. These results also
represent treatment outcomes in a naturalistic drinking context
(i.e., amount of participants’ drinking across 16 weeks of treat-
ment), and in a treatment-seeking sample of participants with a
current DSM–IV diagnosis of alcohol dependence, thus providing
high external validity. One potential limitation of the study stems
from the choice of outcome variables, particularly percent days
abstinent, which may not be ideally suited for capturing treatment
success for participants with a goal of controlled drinking. Nev-
ertheless, the pattern of results seen for PDA was the same for
GCO and days to relapse, both of which allow for moderate
alcohol use, suggesting that the results are not merely the result of
outcome measure selection. Interestingly, examination of DPDD
revealed that participants with controlled drinking goals were more
successful at limiting the quantity of alcohol use per episode (mean
DPDD � 5.61) than were patients with conditional and complete
abstinence goals (mean DPDD � 7.00 and 8.83, respectively);
however, only the comparison between complete abstinence and
controlled drinking reached statistical significance. These results
must be interpreted in the context of the percentage of days in
which patients drank, which was markedly less frequent in com-
plete abstinence-oriented participants than for participants with
conditional abstinence or controlled drinking (15.9%, 23.28%, and
35.8%, respectively). Taken together, these results suggest that
participants committed to a goal of complete abstinence had su-
perior outcomes, followed by those with a goal of conditional
abstinence and then of controlled drinking. Moreover, post hoc
analyses of drinks per drinking day revealed a pattern consistent
with the abstinence violation effect, whereby participants seeking
complete abstinence reported fewer drinking episodes yet con-
sumed a higher number of drinks per drinking episode.
Additionally, given the nature of the COMBINE study, the
effects of a medically oriented intervention (i.e., MM) without a
pharmacological component could not be investigated. Further-
19DRINKING GOAL AND CLINICAL OUTCOMES
more, it should be noted that the literature does not offer consensus
on the operational definition of drinking goal (Luquiens et al.,
2011). Instead, the authors categorized responses to the commit-
ment to abstinence item based largely on clinical judgment and
prior research using this measure. To that end, it should be noted
that the distribution of clinical outcomes across the three levels of
drinking goal (complete abstinence, conditional abstinence, and
controlled drinking) provided strong support for the validity of this
coding system. Importantly, clinical assessment of drinking goal is
a readily accessible clinical variable that, given the results pre-
sented herein, is potentially critical to treatment planning and
Future research should assess the dynamic nature of drinking
goal in predicting treatment outcomes. Clinicians have long rec-
ognized that a client’s attitudes and goals toward drinking change
throughout the course of treatment. The dynamic nature of drink-
ing goal may be an important clinical variable in its own right
(Hodgins, Leigh, Milne, & Gerrish, 1997). The present study was
limited to the assessment of drinking goal at the onset of treatment,
and future studies examining drinking goals over the course of
treatment seem warranted. Likewise, further research should con-
sider matching patients’ drinking goals to specific treatment mo-
dalities, whether behavioral or pharmacological in nature.
In summary, these analyses of the COMBINE study provide
strong evidence that drinking goal represents an important clinical
predictor of treatment outcomes and thus should be an integral part
of the clinical assessment of problem drinkers. Further, results
from this study suggest that drinking goal may be useful in
selecting a treatment approach. In particular, medically oriented
treatments emphasizing abstinence appear to be an effective and
cost-efficient treatment modality for patients whose goals are
oriented toward complete abstinence. Conversely, more intensive
behavioral interventions may be particularly beneficial for patients
whose goals are conditional abstinence or controlled drinking. On
balance, this study is one of the few to empirically examine the
effect of drinking goal on treatment outcome and, in particular,
matching treatment options to drinking goals. If supported in
future studies, these results could be used to inform treatment
planning for patients with alcoholism. To that end, an important
feature of this study is the accessibility and clinical appeal of the
drinking goal measure, which can be readily applied to a wide
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21DRINKING GOAL AND CLINICAL OUTCOMES
Drinking Goal Item of the Treatment Experiences and Expectations Questionnaire
We would like to know what GOAL you have chosen for yourself about using alcohol at this time . . . Pick
only one of the following goals.
A. I really don’t have a clear goal in mind.
B. I want to use alcohol in a controlled manner—to be in control of how often I use and how much I use.
C. I want to be totally abstinent from all alcohol use for a period of time, after which I will make a new
decision about whether or not I will use alcohol again in any way.
D. I don’t want using alcohol to be a habit for me anymore, but I would like to occasionally use alcohol
when I really have an urge.
E. I want to quit using alcohol once and for all, even though I realize I may slip up and use alcohol once
in a while.
F. I want to quit using alcohol once and for all, to be totally abstinent, and never use alcohol ever again for
the rest of my life.
G. None of the above applies exactly to me. My own goal is:
Received October 27, 2011
Revision received August 22, 2012
Accepted October 9, 2012 �
22 BUJARSKI, O’MALLEY, LUNNY, AND RAY
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