Evaluating a 30-day alcohol abstinence challenge in heavy-drinking individuals with and without chronic pain: feasibility, safety, and perceived benefits

Abstract

Introduction:

To combat high-risk alcohol consumption, we introduced a 30-day alcohol abstinence challenge targeted at heavy drinkers with and without chronic pain. Our study aimed to assess the challenge’s feasibility and safety and to explore its perceived benefits. Our exploratory aim was to identify participants’ coping strategies during the challenge.

Methods:

Our single-arm study recruited heavy drinkers from a pain clinic and a university setting (n = 34, 64.7% chronic pain). Participants underwent a modified community-based 30-day challenge, which included motivational interviewing, an individualized start date, and weekly phone check-ins.

Results:

We found the 30-day challenge was feasible and safe; 72.3% of eligible heavy drinkers participated in the challenge with no serious adverse events. Most challengers (94.1%) reported some benefit from the challenge, which included improvements in alcohol withdrawal symptoms, sleep, and alcohol abstinence self-efficacy, but not in pain. We identified 25 perceived benefits and 21 coping strategies.

Conclusion:

Our study confirms that a 30-day alcohol abstinence challenge is a feasible and safe intervention for heavy drinkers with and without chronic pain, yielding notable health benefits. The challenge also facilitated the development of effective coping strategies. Future studies should explore the long-term benefits of such interventions in broader outpatient settings.

INTRODUCTION

Alcohol is the most commonly used and misused substance in the United States (US; [1] and worldwide [2]. The US 2022 national survey revealed that 137.4 million people aged 12 or older (48.7%) have used alcohol in the past month and 16.1 million (5.7%) report heavy drinking [1]. Alcohol remains the most frequently used substance by patients with chronic pain (> 15%) [3–5]. Heavy drinking is the third leading preventable cause of mortality in the US. In 2020, alcohol contributed to more deaths (178,307) [6] than any other substances (106,699) [7]. Among patients with chronic pain, heavy drinking is associated with greater pain interference [8], poor sleep [9], and higher emotional distress [10, 11]. The estimated social cost for heavy drinking in the US is $250 billion [12]. This cost is primarily due to the loss of workplace productivity (72%), followed by healthcare costs (11%), and other costs such as criminal justice [12]. To reduce the negative consequences of heavy drinking, US Health official recommends drinking alcohol moderate or less amount (≤ 2 drinks/day for men and ≤ 1 drink/day for women) or avoiding alcohol completely when taking medications, having a medical condition that can be worsened by alcohol (e.g., chronic pain), or having Alcohol Use Disorder (AUD) [13].

Theoretical models have been developed to explain the bidirectional relationship between alcohol and chronic pain. Egli and colleagues describe the phasic interactions between alcohol and pain [14]. Initially, alcohol induces a rewarding and analgesic effect. However, with prolonged heavy drinking, the positive reinforcement diminishes. When negative reinforcement takes over, the brain’s reward systems become dysfunctional, leading to persistent withdrawal symptoms characterized by negative emotions and hyperalgesia (enhanced pain) in the absence of drinking. In the later phase, persistent negative emotions and chronic pain become a strong motivation for drinking. This shift highlights the complex and detrimental cycle of heavy drinking and chronic pain, emphasizing the need for treatment approaches that address the physical and psychological components of this relationship.

To reduce heavy drinking, a 30-day alcohol abstinence challenge (also known as ‘Dry January’ or ‘Sober October’) was developed and successfully implemented as a community intervention. For the Dry January, large number of community-dwelling adults (N = 4,000 ~ 60,000) voluntarily attempt to abstain from alcohol for 30 days [15]. Dry January has shown a high success rate for abstaining alcohol 30 days (66%) [15–18]. More importantly, both successful and unsuccessful challengers report perceived health benefits from the challenge [16, 19]. Furthermore, the 30-day challenge impacts drinking behavior beyond the challenge period. Specifically, successful challengers reduce the number of drinking days per week (d = 0.53) and drinks per episode (d = 0.25) at 6 months after the challenge [18]. Unsuccessful challengers also reduce the number of drinking days per week (d = 0.45) and drinks per episode (d = 0.18) even at 6 months later [18]. Regardless of success, challengers report improvement in perceived physical health (d = 0.38) [17] and mental health (d = 0.34) [18]. The most frequently reported benefits are saving money (63%), improved sleep (56%), more energy (52%), better overall health (50%), and weight loss (38%) [18].

Based on the promising results of Dry January, we designed the current study to examine the feasibility of a 30-day abstinence challenge as a clinical intervention among heavy-drinking individuals with chronic pain. To date, many outpatient clinics routinely screen alcohol use and make a referral to a specialty clinic for addressing heavy drinking. However, empirical data reveal that only 14% of people with substance use disorder (SUD) receive treatment for SUD at a specialty clinic [1]. Therefore, we need alcohol treatment strategies that can be easily applied in outpatient settings where heavy drinking individuals receive medical care for non-alcohol issues. Our primary aim was to examine the feasibility and safety of a 30-day alcohol abstinence challenge in heavy drinkers with and without chronic pain and to deeply characterize its perceived benefits using quantitative and qualitative data analysis. Our overriding hypothesis was that a structured abstinence program could significantly improve health outcomes and promote sustainable changes in alcohol consumption behavior. We tested its feasibility by inviting participants with and without chronic pain at various places such as a university-affiliated pain clinic, hospital employees, and university student organizations to understand if heavy drinkers with chronic pain would participate in the challenge. We hypothesized that a 30-day alcohol abstinence challenge would be feasible, that the risks would be minimal, and that most participants would report perceived health benefits of the challenge. We defined feasibility as ≥ 25% of eligible heavy drinkers participating in the challenge. Minimal risk was defined as no one needing to discontinue the challenge for safety issue (e.g., emergency room visit, hospital admission, death). Finally, participants would report significant improvement in health after the challenge, including sleep, anxiety, depression, anger, alcohol abstinence self-efficacy, general self-efficacy, and global impression of health improvement. Our secondary exploratory aim was to identify coping strategies, so we added one exploratory open-ended question and one multiple-choice question about coping strategies that participants utilized to help with abstinence during the 30-day challenge.

METHOD

Study design

The Stanford University Institutional Review Board approved the study procedures. All participants signed the online informed consent. We recruited heavy-drinking individuals visiting a tertiary pain clinic, working at a university hospital, and engaging in university social organizations from 11/2/2022 to 4/6/2023. Potential participants received an email invitation, an internal advertisement through the listservs, or a research flyer with a QR code. Interested participants clicked a survey link to read the study purpose, design, and eligibility criteria and provided their contact information. Inclusion criteria were at least 21 years old, at least 2 years of drinking history, at least one prior attempt to quit drinking, currently drinking at least 7 (women) or 14 (men) drinks per week in the past 30 days [20], and English fluency. The current study used 21 as a lower age limit because 21 is the legal drinking age. A minimum 2-year of drinking history was required to allow alcohol-related changes to occur [21, 22], so that challengers would perceive some benefits of not drinking. For safety reasons, we recruited people with at least one prior attempt to quit drinking, so all participants understood alcohol withdrawal symptoms from their previous experience. Finally, only English-speaking individuals were invited since the informed consent and all the study materials were written in English. Exclusion criteria included not currently seeking or receiving treatment for alcohol, severe depression, and pregnancy. We excluded those seeking or receiving alcohol treatment. We also excluded people with severe depression and pregnancy for safety reasons. Particularly, alcohol use disorder (AUD) and co-morbid depression disorders are known to be associated with worse severity and prognosis for both disorders [23] and the current study was the first to examine the feasibility of a 30-day abstinence challenge in people with and without chronic pain conditions. Depression symptoms were assessed with the Patient-Reported Outcomes Measure Information System (PROMIS)-Depression 4a short-form. The raw summed score of 14 or higher (> 65T) was considered as severe depression. Eligible participants received the informed consent form via email and signed the consent.

The study timeline is shown in Figure 1. First, participants chose their first day of the challenge and participated in a brief 10-minute motivational interview session via a phone call, which a licensed psychologist conducted within a week of the first day. During the motivational interview, participants had an opportunity to make plans for withdrawal symptom management. These plans included discussing withdrawal symptom management with their treating physicians and drinking alcohol as needed to manage withdrawal symptoms. Participants were allowed to take medications to manage withdrawal symptoms as recommended by their treating physician. All participants received mental health treatment resources such as the following websites and contact information: a) https://findtreatment.samhsa.gov/locator, b) SAMSHA’s National Helpline: 1-800-662-HELP (4357), and c) National Suicide Prevention Lifeline: 1-800-273-TALK (8225) | TTY: 1-800-799-4889, https://suicidepreventionlifeline.org/. Then, participants completed the baseline questionnaire. During the initial interview or weekly check-in, participants received additional resources, which included applications, websites, therapy, support groups, stress management, and communication skills as appropriate for each participant. Participants were informed that there were no limitations in receiving medical or psychological/alcohol treatment at any time. During the challenge, participants completed a daily questionnaire and 5-min weekly phone check-in with a licensed psychologist. Lastly, participants completed the exit questionnaire and semi-structured interview with a licensed psychologist. Because this manuscript focused on feasibility, safety, and perceived benefits of the 30-day challenge, we did not analyze daily data, which will be analyzed and published later. Participants were compensated based on the tasks completed such as baseline questionnaire ($20), daily survey ($5 for each, totaling $150), and exit questionnaire ($30) so participants could receive up to $200 in compensation. The compensation was based on task completion, but not on successful abstinence, which was to promote internal motivation for abstinence and to help challengers continue the challenge up to 30 days regardless of success. During the final survey, participants received the mental health treatment resources again.

Figure 1.

Study timeline

Measures

Demographic information about sex, race/ethnicity, and chronic pain status were collected. Alcohol-related characteristics were assessed during phone screening to determine eligibility. Participants were asked to report the amount of typical drinking per week in the past 30 days, drinking duration, and the number of prior attempts to stop drinking. The following questionnaires were administered at baseline via REDCap, a HIPAA compliant electronic data capture system (see Table 1). The Alcohol Use Disorders Identification Test (AUDIT) [24] was administered to assess the severity of problematic drinking, and the AUDIT total scores of ≥ 8 would indicate screening positive for harmful or hazardous drinking [24]. The 11-item Alcohol Use Disorder (AUD) symptom checklist was administered to assess AUD severity [25]. AUD diagnosis criteria were met when endorsing at least 2 symptoms. Alcohol severity was defined as mild (2–3 symptoms), moderate (4–5 symptoms), and severe (6–11 symptoms) [25]. The 5-item Penn Alcohol Craving Scale (PACS) was administered to assess the level of craving during the past week [26]. Each item is rated on a 0–6 Likert scale and the total scores range from 0 to 30, with higher scores indicating greater craving. A cutoff score of ≥ 15 is considered as clinically significant alcohol craving [27]. The 15-item Drinking Motive Questionnaire (DMQ) was administered to understand the participants’ drinking motives [28]. Each item is rated on a 4-point Likert scale (1:Never/Almost Never to 4:Always/Almost Always) to assess the three motives of social reasons, stress coping, and mood enhancement. Five items were used to calculate the average scores of each motive, with higher scores indicating higher motive for each domain measured. To examine pain relief as a potential motivation for drinking in people with chronic pain, we added one item about “I drink to manage pain.” During a motivational interviewing, participants were asked to rate the importance of temporarily not drinking for 30 days, their confidence, and readiness level on a 0 (not at all) to 10 scale (most important, 100% confident or ready) [29, 30].

Table 1.

Questionnaires

	Baseline	Post-Challenge
[Alcohol related Variables]
AUDIT	X
AUD symptom checklist	X
PACS	X
DMQ	X
MI Questions	X
Importance	X
Confidence	X
Readiness	X
[Perceived Benefits]
GIC		X
PROMIS measures
Sleep Disturbance	X	X
Depression	X	X
Anxiety	X	X
Anger	X	X
Average Pain Intensity (a 0–10 scale)	X	X
AWSC	X	X
AASE	X	X
GSE	X	X

NOTE: AUDIT: Alcohol Use Disorders Identification Test; DSM-5 AUD symptom checklist; PACS: Penn Alcohol Craving Scale; DMQ: Drinking Motive Questionnaire; MI: Motivational Interviewing; GIC: Global Impression of Change; PROMIS measures - sleep disturbance, depression, anxiety, and anger; AWSC: Alcohol Withdrawal Symptom Checklist; AASE: Alcohol Abstinence Self-Efficacy Scale; GSE: General Self-Efficacy.

The following measures were administered to assess perceived benefits (see Table 1). First, a single-item global impression of change (GIC) was administered to assess participant’s overall rating of their health improvement after the challenge compared to the time before the challenge [31]. The GIC was rated on a 1 (very much worse) to 4 (no change) to 7 (very much improved) scale. Additionally, the 17-item Alcohol Withdrawal Symptom Checklist (AWSC) was administered to assess alcohol withdrawal symptoms in the past month [32]. Each item is rated on a 0 (not at all) to 4 (extreme) and the total scores range from 0 to 68, with higher scores indicating worse withdrawal symptoms. AWSC total scores of ≥ 23 indicate a clinical withdrawal symptom. The PROMIS-Sleep Disturbance (8b) [33], Depression (8b), Anxiety (8a), and Anger (5a) short-forms [34] were administered to assess the potential benefits of the 30-day challenges on sleep and emotional distress. Each item is rated on a 5-point Likert scale. The raw responses were scored using the online scoring system (https://www.healthmeasures.net/) to calculate each participant’ T-scores (M = 50, SD = 10). Higher T scores indicate worse symptoms of each measure. An 11-point numerical pain rating scale was administered to assess average pain within the past 24 hours [35]. Finally, the 10-item Alcohol Abstinence Self-Efficacy (AASE) and 8-item General Self-Efficacy (GSE) were administered to assess the potential benefits of the challenge on domain-specific (i.e., alcohol abstinence) [36] and domain-general self-efficacy [37], respectively.

Data about adverse events were collected over the phone during the weekly check-in, and appropriate action plans were discussed as indicated. After the challenge, participants completed the following questions about perceived benefits of a 30-day challenge and struggles and coping strategies during the 30-day challenge. A multiple-choice question was also asked to identify study-related components that helped participants during the challenge. Their responses on all free-text questions were reviewed during the exit interview. Participants confirmed or modified their initial responses or added new responses during the interview. The following questions were asked to identify coping strategies that were unrelated to research components.

1. Question 1) Please describe what changes (if any) you have noticed during the 30-day alcohol-free challenge. (Positive, Negative, or both).

2. Question 2) Please describe any coping strategies that were helpful during the 30-day alcohol free challenge.

3. Question 3) Any of the following study-related components helped you not to drink for the past 30 days? (check all that apply)

   1. The initial interview (motivational interviewing)
   2. Setting my down start date
   3. Daily survey
   4. Weekly check-in
   5. Compensation (up to $200)
   6. Coping resources
   7. That fact that I am doing it for research
   8. Nothing related to study component

Analysis Methods

Paired sample t-tests were used to examine quantitative health outcome data change between pre- and post-challenge. One-sided p values of < .05 were considered a significant change between the two time points. Descriptive statistics were used to report the type and frequency of adverse events. Qualitative data were analyzed using the deductive approach [38]. Specifically, responses were coded into one of the existing [15–19] or new categories as needed. We calculated the relative frequency of perceived benefits [39]. SPSS 29 software was used for quantitative data analysis and NVIVO 14 was used for qualitative data analysis.

Power Analysis

The PASS 2023 software was used to calculate a minimum sample needed to detect a moderate effect (d = 0.5) for one-tailed paired-t test, with alpha of .05 and power 0.8. The result indicated that at least 27 participants were needed. Eventually, a total of 34 people participated in the study.

Missing value

Missing values were found only in the baseline AWSC and BCSC measures, and the missing rate was minimum (5.9%). Therefore, missing values were replaced with means.

RESULTS

Feasibility

A study coordinator emailed 98 people who provided their contact information to schedule a phone screening (Appendix 1). Out of 65 people who completed the phone screening, 47 were eligible for the current study. Reasons for ineligibility were not meeting criteria for heavy drinking (n = 9), followed by not ready to do the challenge (n = 5), seeking or receiving alcohol treatment (n = 3) and currently participating in Dry January (n = 1). Then, of the 47 eligible participants who received the consent link, 43 signed the consent, and 34 participated in the challenge. Once participants started the challenge, no one withdrew it. Notably, attrition occurred before the 30-day challenge (19.1%). Reasons for dropping out were not ready, pregnant, and unknown (lost to contact, n = 9). The current study defined feasibility as at least 25% of eligible heavy drinkers would participate in the challenge. In this study, out of 47 eligible heavy-drinking individuals, 72.3% (n=34) participated in and completed the 30-day challenge.

Baseline demographics and clinical characteristics

Table 2 summarizes the sample characteristics. The mean age of our sample was 51.7 years old (SD = 15.3, 35–64 years old). Our sample was predominantly middled-aged (88.3%), female (61.8%), White/Caucasian (88.2%) and non-Hispanic (94.1%). The mean drinking duration was 24.5 years (SD = 15.8). The average typical weekly drinks were 12.3 (SD = 4.8) for females and 18.3 (SD = 4.8) for males. Additionally, our participants reported on average 3.6 previous attempts to quit drinking (SD = 3.8). The mean AUDIT score was 10.5 (SD = 4.9) and 61.8% screened positive for harmful drinking. Our heavy drinking participants were also heterogenous in AUD symptom severity such that 35% met criteria for mild AUD, 26% moderate, 18% severe, and 21% did not meet the criteria for AUD. We recruited participants predominantly from a pain clinic so 64.7% endorsed having a chronic pain condition. Participants with chronic pain endorsed having on average 11.3 years of pain (SD = 9.9) and rated their pain intensity to be on average 4.5 (SD = 2.2) on a 0–10 scale for the average pain and 6.0 (SD = 2.4) for the worst pain (Table 2). They also endorsed back pain (45.5%), headache/migraine (18.2%), and neck pain (13.6%) as being the three most common pain conditions (Appendix 2 for all pain conditions). DMQ three factor scores indicated that drinking motives were strongest for social reasons (M = 3.0, SD = 0.7), followed by mood enhancement (M=2.4, SD = 0.8) and stress coping (M= 2.3, SD = 0.7). Pain management was not a strong motive in our sample (M = 1.7, SD = 1.1 for the total sample, M = 2.0, SD = 1.3 for participants with chronic pain). Finally, participants reported on average moderate importance of stopping drinking for 30 days (M = 6.4, SD = 2.2) and high levels of confidence (M = 8.2, SD = 1.9) and readiness (M = 9.2, SD = 1.1). Notably, readiness was high partly because people who were not ready could not choose a start date and did not participate in the challenge.

Table 2.

Sample Characteristics (N = 34)

Demographic Characteristics	Study Population
Age, Mean Years (SD)	51.7	(15.3)
Age Categories, No. (%)
21–34	1	(2.9)
35–64	30	(88.3)
≥65	3	(8.8)
Sex, No. (%)
Female	21	(61.8)
Male	13	(38.2)
Race, No. (%)
White	30	(88.2)
Asian	1	(2.9)
Other	2	(5.9)
Race Missing	1	(2.9)
Ethnicity, No. (%)
Hispanic	2	(5.9)
Non-Hispanic	32	(94.1)
Alcohol Use Characteristics
Drinking duration, Mean Years (SD)	24.5	(15.8)
Typical drinks per week
Female, Mean Standard Drinks (SD)	12.3	(4.8)
Min, Max	7	25
Male, Mean Standard Drinks (SD)	18.3	(4.8)
Min, Max	14	30
Number of previous attempts to quit	3.6	(3.8)
AUDIT scores, Mean (SD)	10.5	(4.9)
Harmful drinking (≥8), No. (%)	21	(61.8)
AUD symptoms, no (%)
No AUD	7	(21)
Mild AUD	12	(35)
Moderate AUD	9	(26)
Severe AUD	6	(18)
People with chronic pain condition, No. (%)	22	(64.7)
DMQ, Mean (SD)
Social motive	3.0	0.7
Stress coping	2.3	0.7
Mood enhancement	2.4	0.8
Pain management (single item)	1.7	1.1
Motivational factors, Mean (SD)
Importance	6.4	(2.2)
Confidence	8.2	(1.9)
Readiness	9.2	(1.1)
Pain Characteristics
Chronic pain duration, Mean Years (SD)	11.3	(9.9)
Average pain in the past 7 days, Mean (SD)	4.5	(2.2)
Worst pain in the past 7 days, Mean (SD)	6.0	(2.4)

Safety of 30-day abstinence challenge

Table 3 summarizes the reported adverse events. Fifteen participants (44.1%) report one or more adverse events. Of the participants reporting adverse events, the mean number of adverse events was 1.5 per person (SD = 0.9, range = 1–4). The most frequent adverse event was withdrawal symptoms during the first week of challenge (14.7%), but no one used medications to manage withdrawal symptoms. Some reported using other substances more (e.g., cigarettes, marijuana, 11.8%), and consuming more food or sweets (8.8%) as adverse events. Notably, in some cases, adverse events were related to their reasons for drinking. For example, difficulty falling asleep, increased pain, and increased anxiety during the challenge were adverse events because they used alcohol for sleep, pain, and anxiety management, respectively. Two people with difficulty falling asleep used melatonin for sleep during the challenge. Three participants with chronic pain enrolled in a pain management program after the challenge as they had increased pain, increased smoking to manage pain, or had become interested in a pain self-management program. One participant with increased anxiety engaged in psychotherapy during the challenge. In sum, no one discontinued the challenge due to safety concerns. Therefore, the 30-day alcohol abstinence challenge could be done safely at an outpatient setting.

Table 3.

List of adverse events (N = 34)

Adverse events	Frequency (%)
1. Alcohol withdrawal symptoms in the first week of challenge	5	(14.7)
2. Increased other substance use	4	(11.8)
3. Consuming more food or sweets	3	(8.8)
4. Increased craving during the challenge	3	(8.8)
5. Difficulty falling asleep	2	(5.9)
6. Increased physical pain	2	(5.9)
7. Increased online shopping	1	(2.9)
8. Weight gain	1	(2.9)
9. Increased anxiety during the challenge	1	(2.9)

Note: Sum is > 100% because some participants endorsed more than one event.

Perceived Benefits – Quantitative Data analysis

Of the total 34 participants, 67.6% successfully abstained from alcohol for 30 days and 32.4% reported abstinence on average 22.5 days (SD = 3.0). This would mean that successful challengers reduced their typical standard drinks, on average, from 12.2 (female)/17.0 (male) per week to zero for 30 days. The mean GIC score was 5.4 (SD = 1.0), suggesting that challengers on average reported minimal improvement of health after the challenge. One participant who endorsed being “much worse” (2.9%) with increased anxiety and engaged in psychotherapy during the challenge. On the GIC, no change, minimally improved, much improved, and very much improved were reported by 11.8%, 41.2%, 32.4%, and 11.8% of participants respectively. In sum, about 85.3% reported some improvement of their health after the challenge.

Paired-t tests were conducted to examine if participants reported significant changes in withdrawal symptoms, sleep, depression, anxiety, anger, and pain intensity rating (Table 4). Findings show that the AWSC, PROMIS-Sleep Disturbance, and AASE scores were significantly different at post-challenge. Specifically, a large reduction was observed in the AWSC scores (Cohen’s d = 0.79), followed by sleep disturbance (Cohen’s d =0.63). Pain ratings did not change significantly after the challenge. Pain ratings remained unchanged when examining only participants with chronic pain conditions (n = 22, t = 0.34, p = .369).

Table 4.

Changes in subjective health outcomes after the challenge (n = 34)

	Pre		Post
	M	(SD)	M	(SD)	t	p	d
PROMIS
Sleep Disturbance	52.2	(7.9)	46.5	(9.1)	3.69	< .001	0.63
Anxiety	52.6	(6.8)	51.0	(8.3)	1.21	.118	0.21
Depression	50.1	(6.8)	49.3	(8.3)	0.85	.201	0.15
Anger	48.8	(8.8)	47.2	(9.3)	1.02	.158	0.18
Pain Intensity (0–10)	2.3	(2.4)	2.4	(2.2)	0.34	.738	−0.06
AWSC	10.3	(5.6)	7.3	(5.3)	4.60	< .001	0.79
AASE	35.7	(8.8)	40.0	(5.6)	−3.27	.001	−0.56
GSE	25.6	(3.3)	26.0	(3.9)	−0.68	.252	−0.12

Note: Bold values represent significant results. AWSC: Alcohol Withdrawal Symptoms Checklist; AASE: Alcohol Abstinence Self-Efficacy, GSE: General Self-Efficacy.

Paired-t tests were also conducted to examine if participants reported increased self-efficacy in alcohol abstinence and general life domains after the challenge. Our results indicated that the AASE scores significantly increased to a large degree (d= −0.56), but the GSE scores did not significantly change after the challenge.

Perceived Benefits – Qualitative Data analysis

Table 5 outlines the list of perceived benefits. There were 25 different types of perceived benefits and one participant reported on average 3.3 benefits (SD = 1.9). Perceived benefits were classified into four categories: physical, mental, alcohol-related, and other benefits. The most common benefit was physical health (76.5%). The three most frequently endorsed physical health benefits were improved sleep (50.0%), followed by more energy/less fatigue (32.4%) and weight loss (17.6%). Mental health benefits were endorsed by 55.9% of participants. The most common mental health benefits were improved cognitive function and less anxiety (both 20.6%), followed by better mood and general self-efficacy (both 14.7%). Alcohol-related benefits were endorsed by 38.2% of participants. Specifically, alcohol-related benefits included increased alcohol self-efficacy (26.5%), less craving/desire for alcohol (17.6%) and no hangover/withdrawal symptoms (5.9%). Examples of how participants described alcohol self-efficacy are “I realize that I am okay to say no in social drinking setting,” “No one cares about my drinking,” “I don’t miss alcohol anymore,” “Overall, I feel more confident in managing alcohol,” and “I do not need alcohol under any circumstance,” and “I have removed alcohol from my ‘pain’ cycle needs.” Other benefits included improved productivity, making better choices in life, more active/exercise, saving money, better food taste, and improved relationship with partner. It should also be noted that most challengers (94.1%) reported some benefits from the challenge and only 2 (5.9%) reported no benefit.

Table 5.

List of perceived benefits (N = 34)

Benefits	Frequency (%)
Physical Health	26	(76.5)
1. Better sleep	17	(50.0)
2. More energy/less fatigue	11	(32.4)
3. Weight loss	6	(17.6)
4. Overall better health	4	(11.8)
5. Lower blood pressure	4	(11.8)
6. Improved GI symptoms (e.g., acid reflux, nausea)	3	(8.8)
7. Less physical pain	2	(5.9)
8. Less leg cramps at night	1	(2.9)
9. Less severe hot flashes	1	(2.9)
10. Less facial puffiness in the morning	1	(2.9)
Mental Health	19	(55.9)
1. Better cognitive function (e.g., focus, memory)	7	(20.6)
2. Less anxiety symptoms	7	(20.6)
3. Better mood	5	(14.7)
4. Increased general self-efficacy	5	(14.7)
5. More present focused	4	(11.8)
6. More patience/not easily frustrated	2	(5.9)
Alcohol-Related	13	(38.2)
1. Increased self-efficacy about alcohol use/abstinence	9	(26.5)
2. Reduced craving/desire for alcohol	6	(17.6)
3. No hangover/withdrawal symptoms	2	(5.9)
Other	13	(38.2)
1. Improved productivity/efficiency at work	5	(14.7)
2. Make better choices in life	4	(11.8)
3. More active/exercise	3	(8.8)
4. Save money	2	(5.9)
5. Better food taste	1	(2.9)
6. Improved relationship with a partner	1	(2.9)

Note: Some participants reported more than one benefit. GI: gastrointestinal

Coping strategies used during the challenge – Exploratory analysis

Figure 2 shows the list of coping strategies reported during the challenge and the proportion of participants who used each coping strategy. Participants reported 21 different coping strategies and the mean number of coping strategies used by each participant was 3.5 (SD=1.8, Range = 1–8). The most frequently endorsed coping strategy was finding non-alcoholic substitutes (44.1%) like sparkling water with lime, followed by commitment to the challenge (38.2%), and increased healthy habits (32.4%) such as exercise and more water intake. About 23.5% reported that they reached out to a support person/system including family, friends, and alcohol abstinence support group. About 23.5% indicated that certain research related components were helpful, including daily surveys, research compensation, and weekly check-ins. In addition, 23.5% reported avoiding drinking situations as their coping strategy. Some (17.6%) reported that the structure of the challenge was helpful, specifically “Having a specific time frame in a specific purpose is to what I was doing it,” “Counting down the days,” and “Being part of a “program,” and “It set boundaries and really helped me get in the mindset to simply not drink.”

Figure 2.

Bar graphs of coping strategies used by proportions of participants during the challenge. A total > 100 % as participants endorsed more than one coping strategy.

Helpful study related components for the 30-day abstinence challenge – Exploratory analysis

Figure 3 shows study-related components that participants perceived as helpful to avoid drinking. Only 11.8% did not find the study components helpful to avoid drinking during the challenge. More than half reported that doing the challenge for research (64.7%), daily surveys (58.8%), setting my own start date (55.9%), research compensation (52.9%), and weekly check-in were helpful. Some explained how the daily surveys helped them abstain “getting the daily survey and asking a question about [my] confidence about past 24 hours and next 24 hours are helpful” “the daily survey reinforces me not to drink” and “[helpful to] monitor my daily use of pain, anxiety, depression, and sleep medications” and “I noticed that I use less pain medication.” About 35.3% reported the initial motivational interview as helpful and 17.6% indicated that receiving coping resources during the initial interview and weekly check-ins were helpful.

Figure 3.

Study related components that participants perceived as helpful for the 30-day abstinence challenge. MI: motivational interviewing

DISCUSSION

The current study was the first to examine the feasibility, safety, and perceived benefits of a 30-day alcohol abstinence challenge in heavy drinking individuals with and without chronic pain. We demonstrated that the 30-day abstinence challenge is feasible, as 72.3% of eligible heavy drinkers participated in the challenge. Attrition occurred before the first day of challenge (19.1%). Once participants started the challenge, all participants attempted to abstain from alcohol for the entire 30 days. The current study also demonstrated that the 30-day challenge could be done safely in an outpatient setting as serious adverse events requiring urgent medical attention or inpatient hospitalization were not observed or reported. The current results revealed that 67.6% were successful in abstaining from alcohol for 30 days. This success rate is consistent with community intervention studies (66%) [15–18]. Regardless of success, however, most participants (85.3%) reported some benefits from the challenge, such as completely abstaining or drinking less for 30 days. Our study identified 25 different types of perceived benefits and one challenger reported about 3.3 perceived benefits (SD = 1.9). Both quantitative and qualitative data suggest reduced alcohol withdrawal symptoms, improved sleep, and increased alcohol self-efficacy as perceived benefits of the challenge.

For the long-term goal of implementing the 30-day alcohol abstinence challenge in an outpatient setting, our study used a modified, community intervention protocol. First, we demonstrated that researchers could recruit heavy drinkers from a tertiary pain clinic and a university. We were also successful in recruiting male and female heavy drinkers. Second, unique aspects of the current challenge protocol included motivational interviewing session over the phone and individual decision of the start date. In addition, this study recruited individuals with at least one prior attempt to stop drinking, and during the initial interview, participants reflected on their past withdrawal symptoms (if any) and formulated withdrawal management plans that include consulting with their treating physician as well as drinking alcohol as needed. Finally, the current challenge protocol included a) the weekly check-in phone call, b) no limitations on receiving necessary medical, psychological, and alcohol treatments throughout the challenge, and c) a flexible guideline about alcohol use during the challenge. Participants evaluated daily struggles and coping strategies during the initial motivational interviewing call and ongoing weekly check-ins. Indeed, all participants reported using one or more self-management strategies. Our exploratory, qualitative data analysis identified 21 different coping strategies for the 30-day challenge. Importantly, most participants (64.7%) selected doing the challenge for research as being helpful to completely abstain or drink less, so that a pragmatic study in non-research setting is needed to determine the effectiveness of its real-world application. Other helpful components related to the study were completing a daily survey, choosing their own start date, and a brief weekly phone check-in, which might be easily incorporated into clinical practice. Overall, our 30-day alcohol abstinence protocol would require a minimum clinician involvement and participants would utilize coping strategies of their own choice for the challenge.

The results of quantitative and qualitative data analyses provide insight into potential mechanisms of behavioral change. Such mechanisms include self-efficacy, self-regulation, and readiness. According to the self-efficacy theory, behavioral change is driven by ‘expectations of personal effectiveness’ [40]. Higher levels of perceived self-efficacy lead to the initiation of behavioral changes and the persistence in the pursuit of planned goals even when facing challenges [40]. Our participants reported high levels of confidence about not drinking for 30 days prior to the challenge (M = 8.2 on a 0–10 scale, SD = 1.9) and alcohol abstinence self-efficacy as measured with AASE measure were significantly increased after the challenge, to a large degree (d = 0.56).

Another candidate mechanism of change is self-regulation. The self-regulation theory [41, 42] defines self-regulation as a dynamic process of taking action towards a goal [43] by self-regulating one or more of the following domains: cognition, emotion, behavior or impulse [44]. Based on this theory, these domains of self-regulation will play a significant role for successful behavioral change [45]. Aligning with self-regulation theory, our qualitative data analysis showed that participants reported using several self-regulation strategies. For example, participants found reflecting on their drinking as a helpful coping strategy (cognition). Others learned that people did not care about their drinking (cognition), that they did not need to use alcohol to manage anxiety (cognition and emotion), and that they felt more confident or proud of themselves in controlling their alcohol use (cognition and emotion). Additionally, about one in four participants reached out to their support system or engaged in talk therapy for anxiety management (emotion). Many participants also used behavioral self-regulation strategies, which include drinking non-alcoholic beverages instead of alcohol, avoiding social drinking situations, doing the challenge with others, removing alcohol in the house, changing daily routine, and exercising. Finally, a few reported using impulse control strategies such as being more present focused, being more patient, taking one day at a time, and thinking about children when experiencing the urge to drink.

Finally, readiness is an important variable for behavioral change [46]. Due to the voluntary nature of the challenge, those who were not ready did not start the challenge. The level of readiness was expectedly high in our participants (M = 9.2 on a 0–10 scale, SD = 1.1), and 67.6% of our participants were successful in the 30-day abstinence challenge. Previous studies revealed that only 14% of people who had SUD symptoms received SUD treatment [1]. This finding suggests that most people with SUD may not be ready for alcohol treatment and therefore, clinicians should assess and promote each person’s readiness first. When ready, people are more likely to take an active role in long-term behavioral change. The spontaneous recovery literature provides some evidence supporting readiness as a critical component for successful behavioral change. Specifically, a survey study finds that people with AUD quit drinking on average after 5 serious attempts [47]. A long-term follow-up study has demonstrated that spontaneous recovery is not a short-lived phenomenon [48, 49]. The majority of untreated remitters (92.3%) stay in remission without treatment at 24 months after the first interview [48].

The biopsychosocial mechanisms involved in the complex, comorbid heavy drinking and chronic pain disorders [14] should also be considered when treating heavy drinking in patients with chronic pain. A recent theoretical model explains negative emotion as a key mediator of the effect of chronic pain on heavy drinking [50]. However, in our sample, the most common drinking motive was social, rather than pain, stress, and mood management. Subsequently, several social coping strategies were used during the challenge such as finding alcohol substitutes for social events, avoiding social drinking completely, informing others about the 30-day challenge, and asking others to do the challenge together. While no significant changes in pain ratings and negative affect were observed after the challenge, significant improvements in sleep, withdrawal symptoms, and alcohol abstinence self-efficacy were observed. Taken together, without worsening or improving pain and negative affect, the 30-day challenge might help participants a) increase their alcohol abstinence self-efficacy and b) perceive the health benefits of drinking less or no alcohol. These two may be critical factors in reducing or abstaining from alcohol during the challenge. It should be noted that our heavy drinking participants were heterogenous in terms of AUD severity (21% no AUD, 35% mild AUD and 44% moderate-to-severe AUD). Future treatment studies should examine the role of pain and negative affect in moderate-to-severe AUD.

Our study lays the groundwork for integrating the 30-day alcohol abstinence challenge within outpatient healthcare settings such as primary care clinic and pain clinics, where individuals frequently seek treatments for non-alcohol related issues. By capturing both quantitative and qualitative data, we have illustrated the challenge’s efficacy in reducing alcohol consumption and its associated health risks. Although this study provides robust preliminary findings, several limitations much be considered. The small sample size limited our ability to detect significant small effects and restricted the generalizability of our results. Another limitation was unknown personal and family alcohol history and its relationship with antecedent or consequent pain and other health issues. Furthermore, while we identified numerous perceived benefits and coping strategies, the qualitative aspect was not designed to achieve data saturation, suggesting the need for more extensive future studies to explore these elements thoroughly [51, 52]. Our study included a mix of adults with and without chronic pain. More studies are warranted to determine the clinical applicability of a 30-day alcohol abstinence challenge in heavy drinking individuals with chronic pain. Future investigation should focus on: a) optimizing the eligibility criteria, b) evaluating the safety of its application in heavy drinking individuals with comorbid medical conditions, c) determining its effectiveness through large-scale randomized clinical trials with a control group and objective measures of alcohol abstinence (e.g., alcohol metabolites [53–56]), d) developing and refining clinical intervention strategies to increase the success rate, and e) elucidating mechanisms underlying behavioral change during and after the 30-day challenge.

In conclusion, our study demonstrates that a 30-day alcohol abstinence challenge is both feasible and beneficial for individuals with and without chronic pain. The reported improvements in physical and emotional health, alongside enhanced self-regulation concerning alcohol use, provide a strong basis for further research. Our findings underscore the challenge’s potential as a transformative tool in outpatient settings, particularly for patients with chronic pain, where traditional alcohol treatment programs may fall short. Future studies should aim to optimize eligibility criteria, confirm the safety of the challenge among those with comorbid medical conditions, and evaluate the intervention’s effectiveness through larger-scale clinical trials. Our results pave the way for a paradigm shift in how alcohol misuse is managed in clinical settings, promising to reduce the healthcare burden associated with alcohol-related conditions and enhance the quality of life for those affected.

HIGHLIGHTS.

• A 30-day alcohol abstinence challenge was feasible for heavy drinking individuals with and without chronic pain.

• No significant change in pain intensity was observed after the challenge.

• About two thirds of challengers reported successful alcohol abstinence for 30 days.

• Regardless of success, most challengers (94.1%) reported some health benefit from the challenge by drinking zero or less for 30 days.

• The three most frequently endorsed benefits were a) improved sleep, b) less fatigue/more energy, and c) increased alcohol abstinence self-efficacy.

Data availability statement

The data sets generated and analyzed during this study are available upon study team approval of written requests with analytic plan included in the request.