Abstract
Aims:
Psychosocial functioning among individuals who exceed low risk drinking limits (exceed 3/4 standard drinks for women/men) is heterogeneous. Among those who receive treatment for alcohol use disorder (AUD), recent research found over one-half of those who exceeded low-risk limits (i.e., treatment non-responders) reported good psychosocial functioning commensurate with those who were abstinent or low risk drinkers (i.e., treatment responders) up to one year following treatment. It is unclear if functioning is maintained beyond one year.
Design:
Secondary analysis of three-year follow-up data from Project MATCH and COMBINE, multisite alcohol clinical trials conducted in the United States.
Setting:
Eleven sites in COMBINE and nine sites in Project MATCH.
Participants:
Individuals with AUD from COMBINE and Project MATCH (n=1383 and n=1726) characterized in terms of drinking/functioning at one-year follow-up (n=962 and n=1528) and retained at three-year (n=641 and n=790) post-treatment follow-ups.
Measurements:
Alcohol consumption measured by Form-90 and psychosocial functioning assessed by various instruments at three years post-treatment.
Findings:
High-functioning non-responders at one-year post-treatment maintained a high level of functioning two years later and were not significantly different from the abstainers/low risk drinkers on any functional outcomes (e.g., SF12 Mental Health Mean difference: −1.38 (95% CI: −4.34, 1.57), SF12 Physical Health Mean difference: −0.43 (95% CI: −2.28, 3.13)).
Conclusions:
About one-half of those who engage in some heavy drinking in the year following treatment maintain high levels of psychosocial functioning up to three years following treatment. Recovery from AUD that includes heavy drinking is achievable and can be maintained over time.
Keywords: Alcohol Use Disorder, Psychosocial Functioning, Alcohol Treatment, Latent Profile Analysis
Introduction
For decades, researchers have proposed conceptualizations of alcohol use disorder (AUD) treatment response and recovery that are less focused on alcohol abstinence and more focused on psychosocial functioning (1–4). Despite this, abstinence has persisted as an indicator of successful treatment response and is ubiquitous in definitions of recovery from AUD (5). Regulatory agencies, including the Food and Drug Administration in the United States and the European Medicines Agency in Europe, have defined treatment response as no heavy drinking days, where a heavy drinking day is defined as more than 4 drinks for men and more than 3 drinks for women in the US (6) and more than 60 grams of pure alcohol in men and more than 40 grams in women in Europe (7). Yet, the no heavy drinking days (i.e., “low risk” drinking) cutoffs have not been found to be sensitive or specific in predicting outcomes in clinical populations (8) or general population samples (9). Although there is a reliable association between alcohol use and broad-spectrum alcohol consequences measures (strongest rw=.368 for drinks per drinking day), most of the variance in negative consequences is not explained by any particular indicator of alcohol use (10). Given the questionable utility of consumption-based measures for AUD clinical trials, the present study investigated whether high psychosocial functioning is possible three years following treatment among individuals who engage in heavy drinking (i.e., “non-responders”) following alcohol treatment.
In a secondary data analysis of two AUD clinical trials(Project MATCH(11) and COMBINE(12)), Wilson et al. (13) explored heterogeneity in psychosocial functioning up to 1-year following treatment among a sample of individuals who would traditionally be considered treatment non-responders by virtue of engaging in one or more episodes of heavy drinking. They found high functioning non-responders had equal or better psychosocial functioning than the treatment responders on nearly all outcomes, with the exception of drinking-related consequences. Overall, these findings call into question the use of the current >3 drinks/>4 drinks heavy drinking definition as indicative of non-responders in clinical populations.
The Wilson et al. (13) study was limited to measures of psychosocial functioning up to 1-year following treatment. High-functioning non-responders may have experienced more distress than traditional treatment responders (i.e., abstainers/low-risk drinkers) after the 12-month follow-up. To address this limitation, we examined the association between four groups of treatment non-responders/responders at 12-month follow-up with (1) psychosocial functioning and (2) drinking outcomes at 3-year follow-ups in COMBINE and Project MATCH.
Method
Participants and Procedure
Data for the present study came from two multisite randomized clinical trials, the COMBINE study (12), and Project MATCH (11). The COMBINE study recruited 1,383 participants from inpatient and outpatient referrals at 11 study sites and in the surrounding communities. Participants were randomly assigned pharmacotherapy (acamprosate, naltrexone, or placebo) and medication management and/or combined behavioral intervention. Of the 1383 patients recruited for COMBINE, 874 patients (63%) from nine sites consented to the follow-up (14,15) and 694 (79%) provided data at the three-year assessment. Project MATCH recruited 1,726 participants from 27 inpatient and outpatient treatment sites across nine research sites. The participants were randomly assigned to cognitive behavioral therapy, motivational enhancement therapy, or 12-step facilitation. Of the 952 outpatients recruited for MATCH, 806 outpatients (85%) completed the three-year follow-up assessment.
Measures
For more details on the measures and the psychosocial functioning indicators used to define treatment responders and non-responders, see Wilson et al. (13). These measures are briefly summarized in Table 1.
Table 1.
Summary of Constructs, Measures, and How They Were Used at 12- and 15-month Follow-Up in COMBINE and Project MATCH
| Construct | Measure | Time Window | How it Was Used |
|---|---|---|---|
| Alcohol consumption: | Form-90 (16) | Past 90 days | To divide treatment responders vs. non-responders |
| Alcohol consequences | Drinker Inventory of Consequences (DrInC) (19) | Past 3 months Since last interview | Functioning indicator in Project MATCH COMBINE |
| Health: Physical Health Mental Health | SF-12 (16) | Past 4 weeks | Functioning indicator in COMBINE |
| Quality of Life: Environment Social Psychological Physical | World Health Organization Quality of Life Scale- Brief Version (WHOQOL-BREF) (18) | Past 2 weeks | Functioning indicator in COMBINE |
| Mental health symptoms | Brief Symptom Inventory (26) | Past 7 days | Functioning indicator in COMBINE |
| Social Functioning | Psychosocial Functioning Inventory (20) | Past month | Functioning indicator in Project MATCH |
Alcohol consumption.
In both studies, indicators of alcohol consumption were assessed using the Form 90 interview (16), which is a calendar-based measure in which participants report the number of standard drinks they consumed on each day during the response period (e.g., past 90 days). Indicators included percent drinking days (PDD), drinks per drinking day (DDD), and percent heavy drinking days (PHDD).
COMBINE Outcomes.
Mental health and physical health were assessed using the 12-item SF-12 (17). Quality of life was assessed using the 25-item World Health Organization Quality of Life Scale-Brief Version (WHOQOL-BREF) (18). We used the physical health (7 items), psychological (6 items), social relationships (3 items), and environment (8 items) subscales as indicators of overall biopsychosocial functioning.
Project MATCH outcomes.
Alcohol consequences were assessed among drinkers using the Drinker Inventory of Consequences (DrInC) (19). We used a total score as a global indicator of negative consequences. Social behavior role scale (14 items) of the 81-item Psychosocial Functioning Inventory (PFI: (20)) was used as an indicator of psychosocial functioning. A series of single-item binary indicators from the PFI were used to assess life satisfaction (0=satisfied or happy; 1=dissatisfied or unhappy). The Addiction Severity Index (21) was used to measure employment status and experiences of “serious depression,” cognitive difficulty (“experienced trouble understanding, concentrating, or remembering”), and experiences of “serious anxiety or tension” in the past 30 days. All items were binary indicators based on individual interview questions where 0=employed or symptom not present and 1=unemployed or symptom present.
Statistical Analysis
Treatment non-responders were identified as individuals reporting >0% heavy drinking days (>3/4 standard drinks for females/males) in the past 90 days at the 12-month and 15-month follow-up periods in COMBINE and Project MATCH, respectively. In both samples, three classes of non-responders were identified using latent profile analysis defined by relatively low functioning (~10% and ~6% of the sample in COMBINE and MATCH, respectively), average functioning (~20% and ~18% of the sample in COMBINE and MATCH, respectively), or high psychosocial functioning (~23% and ~28% of the sample in COMBINE and MATCH, respectively) (see Supplemental Materials for description of the latent profile analyses) (13). Treatment responders were identified as individuals reporting 0% heavy drinking days (i.e., abstainers/low-risk drinkers) (~48% of the sample in both COMBINE and MATCH). Thus, in each sample, we had four groups: three non-responder groups and one responder group. For continuous outcomes, we conducted one-way ANOVAs with Tukey post-hoc comparisons to explore group differences. For binary outcomes, we conducted chi-square tests (4×2) with column proportion tests with Bonferroni alpha correction to explore group differences. Sensitivity analyses were conducted to examine those with complete data in the analytic sample, as compared to the excluded sample on baseline indicators of psychosocial functioning, and to test differences by treatment sites, tests of outcomes using non-parametric statistics, and using multiple imputation.
Results
COMBINE Sample
Of the 694 total participants at the three-year follow-up of COMBINE, 641 provided data during the 12-month follow-up period used to determine the four groups and completed the 3-year follow-up measures used in the primary analyses.
Mean comparisons across all classes on 3-year outcomes are shown in Table 2 and Figures 1 and 2 (scores standardized for visual comparisons). The low functioning non-responder class reported significantly worse SF-12 physical health than the high functioning non-responder and abstainer/low-risk drinker groups, but the average functioning class was not significantly different from any of the classes. For SF-12 Mental Health and WHO Quality of Life indicators, the low functioning non-responder class exhibited significantly poorer functioning than the average functioning non-responder class, and both of these classes exhibited significantly poorer functioning than the high functioning non-responder class and the abstainer/low-risk drinker group, which did not significantly differ from each other.
Table 2.
Mean comparisons between classes identified up to 12-months following treatment on outcomes at 3 years post-treatment in COMBINE based on most-likely class membership
| Non-responder Class 1: Low Functioning (≈10%) | Non-responder Class 2: Average Functioning (≈20%) | Non-responder Class 3: High Functioning (≈23%) | Responders: Abstainers/ Low-risk Drinkers (48%) | |
|---|---|---|---|---|
| Sample size range by group* | 50 – 67 | 106 – 138 | 126 – 158 | 129 – 275 |
| Percent Drinking Days (n = 638) M (95% Confidence Interval) | 39.11a (30.29, 47.92) | 39.53a (33.01, 46.04) | 40.66a (34.54, 46.77) | 19.68b (15.79, 23.58) |
| Drinks per Day (n = 411, abstainers excluded) M (95% Confidence Interval) | 3.92a (2.83, 5.01) | 3.55a (2.62, 4.48) | 2.85a (2.30, 3.39) | 0.89b (0.66, 1.11) |
| Drinks per Drinking Day (n = 638) M (95% Confidence Interval) | 10.83a (9.03, 12.63) | 10.13a (8.67, 11.59) | 7.68b (6.73, 8.62) | 5.43c (4.35, 6.52) |
| Percent Heavy Drinking Days (n = 638) M (95% Confidence Interval) | 32.86a (24.40, 41.32) | 29.31a (23.62, 35.00) | 27.89a (22.52, 33.27) | 7.49b (5.04, 9.93) |
| SF-12: Physical Health T-Score (n = 457) M (95% Confidence Interval) | 45.51a (42.32, 48.71) | 49.27ab (47.61, 50.93) | 51.19b (49.55, 52.83) | 51.61b (50.39, 52.84) |
| SF-12: Mental Health T-Score (n = 457) M (95% Confidence Interval) | 38.06a (34.39, 41.73) | 43.82b (42.09, 45.55) | 51.25c (49.67, 52.84) | 49.87c (48.42, 51.31) |
| WHOQOL-BREF: Physical Health (n = 591) M (95% Confidence Interval) | 23.59a (22.23, 24.95) | 27.25b (26.54, 27.96) | 29.74c (29.16, 30.32) | 29.36c (28.83, 29.89) |
| WHOQOL-BREF: Psychological Domain (n = 591) M (95% Confidence Interval) | 18.52a (17.35, 19.70) | 21.37b (20.78, 21.97) | 24.22c (23.72, 24.72) | 23.76c (23.30, 24.22) |
| WHOQOL-BREF: Social Relationships Domain (n = 590) M (95% Confidence Interval) | 8.64a (7.88, 9.39) | 10.03b (9.61, 10.45) | 11.57c (11.21, 11.92) | 11.54c (11.26, 11.83) |
| WHOQOL-BREF: Environment Domain (n = 591) M (95% Confidence Interval) | 26.92a (25.15, 28.69) | 29.72b (28.87, 30.57) | 32.79c (32.09, 33.50) | 32.71c (32.13, 33.28) |
Note. SF-12=Short Form Health Survey, WHOQOL-BREF=World Health Organization Quality of Life Assessment-BREF. Means sharing a subscript in a row indicate means that are not significantly different from each other based on Tukey post-hoc comparisons.
Sample sizes ranged based on missingness on the various outcome variables.
Figure 1.
Standardized mean scores (sample mean = 0 and standard deviation = 1) on each of the continuous non-drinking outcomes at three years following treatment by classes.
WHO = World Health Organization Quality of Life Scale. Error bars represent 95% Confidence Intervals of the Mean.
Figure 2.
Standardized mean scores (sample mean = 0 and standard deviation = 1) on each of the continuous drinking outcomes at three years following treatment by classes.
PDD = percentage drinking days; PHDD = percentage heavy drinking days; DDD = drinks per drinking day; DrIncC = Drinking Inventory of Consequences. Error bars represent 95% Confidence Intervals of the Mean.
On drinking measures (Table 1 and Figure 2), the abstainer/low-risk drinker group reported significantly lower frequency and quantity of drinking on all metrics compared to all non-responder classes. For drinks per drinking day, the high functioning non-responder class reported significantly lower consumption compared to the low and average functioning non-responder classes, but significantly greater drinking compared to the abstainer/low-risk drinker group. For the remaining drinking metrics, there were no significant differences across the non-responder classes.
Project MATCH Sample
Of the 806 participants who completed the three-year follow-up in Project MATCH, 790 provided data during the 12-month follow-up period used to determine the four groups and completed the 3-year follow-up measures used in the primary analyses.
Comparisons across all classes on 3-year outcomes are shown in Table 3 and comparisons for continuous measures of social behavior and being troubled with psychological problems is provided in Figure 1 (scores standardized for visual comparisons). For most psychosocial indicators, we found a consistent pattern such that the low and average functioning non-responder classes did not significantly differ from each other, the high functioning non-responder class and the abstainer/low risk drinker group did not significantly differ from each other, but one or both of these higher functioning groups reported significantly higher functioning than one or both of the lower functioning groups.
Table 3.
Mean comparisons between classes identified up to 12-months following treatment on outcomes at 3 years post-treatment in Project MATCH based on most-likely class membership
| Non-responder Class 1: Low Functioning (≈6%) | Non-responder Class 2: Average Functioning (≈18%) | Non-responder Class 3: High Functioning (≈28%) | Responders: Abstainers/ Low-risk Drinkers (48%) | |
|---|---|---|---|---|
| Sample size range by group* | 23 – 35 | 92 – 123 | 246 – 280 | 185 – 352 |
| DrInC: Total Consequences (n = 546, abstainers omitted) M (95% Confidence Interval) | 61.04a (48.58, 73.51) | 47.58a (42.12, 53.04) | 30.48b (27.89, 33.08) | 25.54b (22.12, 28.94) |
| Percent Drinking Days (n = 790) M (95% Confidence Interval) | 29.33ab (17.03, 41.64) | 38.98b (32.37, 45.59) | 43.56b (39.24, 47.87) | 17.95a (14.87, 21.02) |
| Drinks per Drinking Day (n = 790) M (95% Confidence Interval) | 7.04a (4.17, 9.91) | 6.12a (5.09, 7.16) | 6.17a (5.56, 6.78) | 2.43b (2.07, 2.79) |
| Percent Heavy Drinking Days (n = 790) M (95% Confidence Interval) | 24.10a (12.92, 35.27) | 30.25a (24.23, 36.28) | 28.66a (24.88, 32.44) | 8.41b (6.24, 10.58) |
| Social Behavior Score (n = 766) M (95% Confidence Interval) | 3.06a (2.87, 3.26) | 3.19a (3.10, 3.27) | 3.50b (3.45, 3.56) | 3.49b (3.45, 3.54) |
| Troubled by Psych Problems (n = 787) M (95% Confidence Interval) | 1.57a (1.02, 2.12) | 1.33a (1.07, 1.59) | 0.70b (0.56, 0.84) | 0.75b (0.62, 0.88) |
| Unhappy – Life (n = 748) Proportion | .50a | .40a | .18b | .16b |
| Unhappy – Living Situation (n = 752) Proportion | .40a | .29a | .20ab | .17b |
| Unhappy – Personal Relationship (n = 750) Proportion | .54a | .34ab | .22bc | .15c |
| Dissatisfied – Leisure (n = 759) Proportion | .49a | .46a | .19b | .18b |
| Unemployed (n = 789) Proportion | .31a | .24a | .11b | .12b |
| Experienced serious depression (n = 789) Proportion | .34a | .26ab | .12c | .16bc |
| Experienced anxiety/tension (n = 789) Proportion | .43ab | .38b | .22c | .23ac |
Note. DrInC=Drinker Inventory of Consequences, ASI=Addiction Severity Index, BDI=Beck Depression Inventory, PFI=Psychosocial Functioning Inventory. Means/proportions sharing a subscript in a row indicate means that are not significantly different from each other based on Tukey post-hoc comparisons/cross-tabulation tests of significance.
Sample sizes ranged based on missingness on the various outcome variables.
On drinking measures (Table 3 and Figure 2), the abstainer/low-risk drinker group reported lower drinking than all non-responder classes, which largely did not differ significantly from each other. On negative alcohol-related consequences (i.e., DrInC total score), we found that the low and average functioning non-responder classes reported significantly higher consequences than the high functioning non-responder class and the abstainer/low-risk drinker group, which did not significantly differ from each other. Only individuals who reported drinking completed the DrInC, thus these differences (or lack thereof) are among those who were drinking, which was a smaller percentage of the abstainer/low-risk drinker group relative to the other classes.
Sensitivity Analyses
The analytic samples in both studies were similar to the excluded samples on baseline psychosocial functioning indicators (Tables S1 and S2). The pattern of results was very similar when controlling for treatment assignment and recruitment sites (Tables S3/S4), when conducting non-parametric statistics (Tables S5/S6), and when using multiple imputation to estimate outcomes (Tables S7/S8).
Discussion
In this re-analysis of the COMBINE and MATCH three-year outcome data, we found those who were categorized as high functioning heavy drinkers (i.e., non-responders) up to 12-months following treatment were not significantly different from abstainers/low risk drinkers (i.e., responders) on any measure of psychosocial functioning including mental health and physical health measured by the SF-12, nor any of the four quality of life domains (physical health, psychological, social relationships, environment) assessed by the WHOQOL-BREF, nor on measures of life satisfaction, psychiatric functioning, or employment indicators at three years following treatment. Heavy drinkers who had average to below average functioning up to 12-months following treatment had significantly worse functioning at three years following treatment, as compared to high functioning heavy drinkers and abstainers/low risk drinkers. Importantly, level of functioning among high functioning heavy drinkers was still similar to abstainers/low-risk despite significant differences in the quantity and frequency of drinking at the 3-year follow-up. These data provide further evidence that quantity and frequency of consumption may be less useful in predicting recovery from AUD and functional outcomes are important to assess in broadening the conceptualization of alcohol recovery (22,23).
Several limitations of the current analyses should be noted. Drinking and functioning outcomes were entirely based on self-report and the perspectives of significant others were not considered with respect to functioning status (e.g., family members may have different perspectives on functioning status). Additionally, these outcomes were not measured between the 1-year and 3-year follow-up assessments, therefore some granularity is lost. Even using two of the largest alcohol clinical trials datasets to date, our analytic subsamples were substantially smaller given attrition and missing data, and did exhibit significantly worse baseline psychosocial functioning on multiple indicators compared to the excluded subsamples. Although such baseline differences may limit the generalizability, these differences tended to be small and likely not large enough to negate our substantive findings. Another limitation is that heavy drinking is associated with considerable health consequences (24) and only one measure of physical health (the SF-12) was included in the current analyses.
Reductions in drinking have been shown to be associated with stable improvements in functioning and health over time (25), and some individuals can achieve meaningful improvements in health by reductions in drinking, even if they still occasionally exceed low risk drinking limits. The results from the current study suggest approximately one-half of individuals who engage in occasional heavy drinking can achieve and maintain high levels of functioning that is comparable to abstainers and low risk drinkers. The current results further question the utility of alcohol consumption alone in defining successful outcomes in alcohol clinical trials.
Supplementary Material
Funding:
This secondary data analysis was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) awarded to Dr. Witkiewitz (R01-AA022328). MRP is supported by a career development grant from the NIAAA (K01-AA023233). ADW is supported by an individual fellowship award from the NIAAA (F31-AA026773). DKR is supported by an individual fellowship award from the NIAAA (F32-AA028712).
Disclosures. Dr. Witkiewitz is a member of the American Society of Clinical Psychopharmacology’s Alcohol Clinical Trials Initiative (ACTIVE Group), which over the time that this paper was developed was supported by Abbvie, Ethypharm, Indivior, Lilly, Lundbeck, Mitsubishi, Otsuka, and Pfizer. Drs. Pearson and Richards and Mr. Wilson have no disclosures.
Contributor Information
Matthew R. Pearson, Center on Alcohol, Substance use, & Addictions, University of New Mexico, Albuquerque, NM, USA
Adam D. Wilson, Center on Alcohol, Substance use, & Addictions, Department of Psychology, University of New Mexico, Albuquerque, NM, USA
Dylan K. Richards, Center on Alcohol, Substance use, & Addictions, University of New Mexico, Albuquerque, NM, USA
Katie Witkiewitz, Center on Alcohol, Substance use, & Addictions, Department of Psychology, University of New Mexico, Albuquerque, NM, USA.
References
- 1.Longabaugh R, Mattson ME, Connors GJ, Cooney NL. Quality of life as an outcome variable in alcoholism treatment research. J Stud Alcohol. 1994;Supplement:119–29. [DOI] [PubMed] [Google Scholar]
- 2.Maisto SA, McCollam JB. The use of multiple measures of life health to assess alcohol treatment outcome: A review and critique. In: Sobell LC, Sobell MB, Ward, editors. Evaluating Alcohol and Drug Abuse Treatment Effectiveness Recent Advances. New York, NY: Pargamon Press; 1980. p. 15–76. [Google Scholar]
- 3.Pattison EM. A conceptual approach to alcoholism treatment goals. Addict Behav. 1976;0:177–92. [Google Scholar]
- 4.Pattison EM, Sobell MB, Sobell LC. Toward an emergent model. In: Pattison EM, Sobell MB, Sobell LC, editors. Emerging Concepts of Alcohol Dependence. New York, NY: Springer; 1977. p. 189–211. [Google Scholar]
- 5.Betty Ford Institute Consensus Panel. What is recovery? A working definition from the Betty Ford Institute. J Subst Abuse Treat. 2007. October;33(3):221–8. [DOI] [PubMed] [Google Scholar]
- 6.Food and Drug Administration. Alcoholism: Developing drugs for treatment. Silver Spring, MD; 2015. Report No.: FDA D-0152–001. [Google Scholar]
- 7.European Medicines Agency. Guideline on the development of medicinal products for the treatment of alcohol dependence. United Kingdom: European Medicines Agency; 2010. [Google Scholar]
- 8.Pearson MR, Bravo AJ, Kirouac M, Witkiewitz K. The search for an elusive cutoff remains : Problems of binary classification of heavy drinking as an endpoint for alcohol clinical trials. Drug Alcohol Depend [Internet]. 2017;171:91–6. Available from: 10.1016/j.drugalcdep.2016.11.015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Linden-Carmichael AN, Vasilenko SA, Lanza ST, Maggs JL. High-Intensity Drinking versus Heavy Episodic Drinking: Prevalence Rates and Relative Odds of Alcohol Use Disorder across Adulthood. Alcohol Clin Exp Res. 2017. August; [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Prince MA, Pearson MR, Bravo AJ, Montes KS. A quantification of the alcohol use-consequences association in college student and clinical populations: A large, multi-sample study. Am J Addict. 2018;27(2). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Group PMR. Project MATCH: Rationale and Methods for a Multisite Clinical Trial Matching Patients to Alcoholism Treatment. Alcohol Clin Exp Res. 1993;17(6):1130–45. [DOI] [PubMed] [Google Scholar]
- 12.Anton RF, Malley SSO, Ciraulo DA, Cisler RA, Couper D, Donovan DM, et al. Combined Pharmacotherapies and Behavioral Interventions for. J Am Med Assoc. 2006;295(17):2003–17. [DOI] [PubMed] [Google Scholar]
- 13.Wilson AD, Bravo AJ, Pearson MR, Witkiewitz K. Finding success in failure: using latent profile analysis to examine heterogeneity in psychosocial functioning among heavy drinkers following treatment. Addiction. 2016;111(12):2145–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Zarkin GA, Bray JW, Aldridge A, Mills M, Cisler RA, Couper D, et al. The effect of alcohol treatment on social costs of alcohol dependence. Med Care. 2010. May;48(5):396–401. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Zarkin GA, Bray JW, Aldridge A, Mitra D, Mills MJ, Couper DJ, et al. Cost and cost-effectiveness of the COMBINE study in alcohol-dependent patients. Arch Gen Psychiatry. 2008. October;65(10):1214–21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Miller WR. Form 90: A structured assessment interview for drinking and related behaviors. Project MA. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 1996. [Google Scholar]
- 17.Ware JE, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996. March;34(3):220–33. [DOI] [PubMed] [Google Scholar]
- 18.World Health Organization. World Health Organization Quality of Life. Geneva, Switzerland: World Health Organization; 1998. [Google Scholar]
- 19.Miller WR, Tonigan JS, Longabaugh R. The Drinker Inventory of Consequences (DrInC). Project MA. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; 1995. [Google Scholar]
- 20.Feragne MA, Longabaugh R, Stevenson JF. The Psychosocial Functioning Inventory. Eval Health Prof. 1983. March;6(1):25–48. [DOI] [PubMed] [Google Scholar]
- 21.McLellan a T, Kushner H, Metzger D, Peters R, Smith I, Grissom G, et al. The Fifth Edition of the Addiction Severity Index. J Subst Abuse Treat. 1992. January;9(3):199–213. [DOI] [PubMed] [Google Scholar]
- 22.Neale J, Finch E, Marsden J, Mitcheson L, Rose D, Strang J, et al. How should we measure addiction recovery? Analysis of service provider perspectives using online Delphi groups. Drugs Educ Prev Policy. 2014. August;21(4):310–23. [Google Scholar]
- 23.Witkiewitz K, Wilson AD, Pearson MR, Montes KS, Kirouac M, Roos CR, et al. Profiles of recovery from alcohol use disorder at three years following treatment: Can the definition of recovery be extended to include high functioning heavy drinkers? Addiction. 2019;114:69–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gonzales K, Roeber J, Kanny D, Tran A, Saiki C, Johnson H, et al. Alcohol-attributable deaths and years of potential life lost--11 States, 2006–2010. MMWR Morb Mortal Wkly Rep. 2014. March;63(10):213–6. [PMC free article] [PubMed] [Google Scholar]
- 25.Witkiewitz K, Falk DE, Litten RZ, Hasin DS, Kranzler HR, Mann KF, et al. Maintenance of World Health Organization Risk Drinking Level Reductions and Posttreatment Functioning Following a Large Alcohol Use Disorder Clinical Trial. Alcohol Clin Exp Res. 2019. May;43(5):979–87. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Derogatis LR, Melisaratos N. The brief symptom inventory: An introductory report. Psychol Med. 1983;13(3):595–605. [PubMed] [Google Scholar]
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