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. Author manuscript; available in PMC: 2023 Aug 1.
Published in final edited form as: Addict Behav. 2022 Apr 12;131:107337. doi: 10.1016/j.addbeh.2022.107337

Alcohol-related consequences and the intention to seek treatment in women and men with severe, untreated alcohol use disorder

Kenneth R Conner a, Beau Abar a, Aileen Aldalur a, Andrew Chiang a, Morica Hutchison b, Stephen A Maisto c, Tracy Stecker d
PMCID: PMC9717617  NIHMSID: NIHMS1850602  PMID: 35483181

Abstract

Introduction:

Research on treatment utilization for alcohol use disorder (AUD) is based primarily on clinical samples and community samples of low AUD severity that may not need formal care. Using a community sample of adults with untreated but severe AUD symptoms, we tested the hypothesis that alcohol-related consequences, but not alcohol consumption levels, are associated with the intention to seek AUD treatment, examined associations of specific types of alcohol-related consequences with intention, and explored sex differences in these associations.

Methods:

The sample was recruited using social media ads for a randomized controlled trial to test a brief intervention to promote AUD treatment seeking. This report is based on analysis of baseline data collected prior to treatment intervention. Multiple linear regressions examined associations of measures of alcohol consumption, alcohol-related consequences broadly, and specific alcohol-related consequences with the intention to seek treatment. Moderating effects of sex on associations were explored.

Results:

Subjects (n=349) averaged 41 years of age, 48% were female, 6% were Latinx, 80% were white, 15% were Black, and 92% met criteria for severe AUD. Alcohol consumption measures were not associated with intention to seek treatment whereas interpersonal- and intrapersonal- consequences were associated with intention. Sex served as a moderator, with intrapersonal consequences (e.g., sad mood) showing a stronger association with intention in women and social responsibility consequences (particularly financial) associated with intention in men.

Conclusion:

Select alcohol-related consequences may be keys to understanding increased intention to seek AUD treatment including intrapersonal consequences in women and financial consequences in men.

Keywords: community sample, alcohol use disorder, alcohol consequences, treatment intention, treatment utilization, sex differences

1. Introduction

A small percentage of individuals with alcohol use disorder (AUD) obtain alcohol-related car (Blanco et al., 2015; Dawson et al., 2012; IIgen et al., 2011). Even among those who seek care, long delays from the onset of AUD to the seeking of treatment are typical (Blanco et al., 2015; Kessler et al., 2001), despite evidence that treatment for AUD is effective (Cunningham, 2005; Dawson et al., 2012; Moos & Moos, 2005). These observations have led to research to understand correlates and patterns of AUD treatment seeking, with a consistent finding that indications of greater AUD severity including severe AUD versus mild or moderate AUD, longer duration of AUD, heavier alcohol consumption, and greater craving of alcohol, are associated with AUD treatment seeking (Venegas et al., 2021). Yet, the breadth of ways in which AUD severity may be conceptualized and measured begs the question “what is it about more severe AUD that promotes treatment seeking?”

There are different strategies to dissect AUD, but a parsimonious, validated solution is to consider two major dimensions representing alcohol consumption and the consequences of alcohol use. Along these lines, a two-factor solution of alcohol consumption and alcohol-related consequences to the 10-item Alcohol Use Disorders Identification Test has consistently emerged in both men and women, with items designed to measure alcohol-related consequences and symptoms, loading onto a single factor that has been labeled “consequences” (Moehring et al., 2018). Re-examination of the literature on AUD severity and treatment seeking through the lens of alcohol consumption and alcohol-related consequences does not rule out a role of alcohol use in treatment seeking, but generally shows that alcohol-related consequences are the more consistent and potent correlate of AUD treatment-seeking (Dawson et al., 2012; Finney & Moos, 1995; Grella et al., 2009; Watkins et al., 2018). For example, Dawson and colleagues (2012) analyzed National Epidemiological Survey on Alcohol and Related Conditions (NESARC) data and showed that select measures of alcohol-related consequences (i.e., injury, financial problems, medical conditions), but no measures of alcohol consumption considered (e.g., volume of alcohol per day), were associated with seeking one or more type of alcohol-related care over 3-year follow-up. The primacy of alcohol-related consequences compared to alcohol consumption in treatment seeking is logical insofar as individuals with AUD may use alcohol for a range of desired effects, including alleviation of stress, to socialize, or to enhance mood, all of which may serve to reinforce the use of alcohol, whereas consequences stemming from alcohol use are inherently undesirable (Witkiewitz et al., 2019).

Although research points to the importance of alcohol-related consequences in AUD treatment seeking, the data are primarily based on clinical samples that may not be generalizable to untreated individuals in the community (Finney & Moos, 1995; Saunders et al., 2006; Weisner et al., 2001). More limited research of community samples primarily contain individuals with “at-risk” drinking or subthreshold AUD or alcohol abuse symptoms (Blanco et al., 2015; Cohen et al., 2007; Fortney et al., 2004; Probst et al., 2015; Wells et al., 2007), rather than more severe AUD samples that can be expected to require treatment, particularly alcohol specialty care (Babor & Robaina, 2016; Rehm et al., 2016). Studies of community samples have also used cross-sectional designs that rely on retrospective reports (Blanco et al., 2015; Grant, 1997; Probst et al., 2015) or longitudinal assessments spaced widely apart (Dawson et al., 2012; IIgen et al., 2011), resulting in subject interviews that may occur months or years from the time of treatment seeking. More research on the specific alcohol-related consequences that are most likely to promote AUD treatment seeking is also needed. It is also unclear if the most salient consequences for treatment seeking differ by population characteristics. For example, differences between women and men in the etiology and consequences of AUD (White, 2020) and in AUD treatment seeking and response (Holzhauer et al., 2020) warrants exploration of sex differences in the types of consequences that are most likely to promote treatment seeking.

We address the aforementioned gaps in the literature on alcohol-related consequences and treatment seeking through examination of a community sample of treatment naïve individuals with severe AUD. This is arguably the most important population to train research on treatment seeking because severe AUD clearly marks the need for alcohol specialty care (Babor & Robaina, 2016; Rehm et al., 2016) and due to data showing long latencies from the onset of AUD to seeking treatment for the first time (Blanco et al., 2015; Kessler et al., 2001). These data compel the need to examine factors that may lead to the first episode of care in individuals with severe AUD. Informed by the Theory of Planned Behavior (Ajzen, 1991, 2002), we focused on the intention to seek treatment in particular. Our examination of the intention to seek treatment is advantageous because it represents a critical step that precedes treatment entry, it is a subjective variable that is amenable to brief intervention, and it is less prone to be influenced by practical barriers (e.g., insurance coverage) or mandates to treatment (e.g., for driving while intoxicated) than examinations of AUD treatment utilization per se. The intention to seek treatment is also expected to be more predictive of treatment seeking in the near term than other subjective measures such as “perceived need” for treatment (Moeller et al., 2020).

The purposes of the study are as follows. First, we tested the hypothesis that assessments of consequences of AUD, but not of alcohol consumption, are associated with the intention to seek treatment. Second, we examined associations of specific categories of AUD-related consequences (e.g., interpersonal problems) with the intention to seek AUD treatment. Third, we explored sex differences in the strengths of associations between specific categories of AUD-related consequences and intentions to seek AUD treatment. To our knowledge, this is the first study to examine these questions in treatment naïve adults with severe AUD.

2. Methods

2.1. Study design and population

The sample was gathered for a phase-II randomized controlled trial (RCT) that aims to test the efficacy of a one-session telephone intervention, Cognitive Behavioral Therapy for Treatment Seeking (CBT-TS), to promote the use of alcohol-related treatment and improve drinking outcomes in individuals whose AUD is severe but untreated. Although “CBT-TS” is a new name for the intervention, it has an evidence base going back several years (Stecker et al., 2016; Stecker et al., 2010; Stecker et al., 2012). Subjects were recruited through social media advertisements, primarily Facebook, from a contiguous 17-county area of western and central New York State that included the midsized cities of Rochester, Buffalo, and Syracuse. Study inclusion criteria included: age 18 and older; score of 16 or greater on the AUDIT (Saunders et al., 1993), and alcohol use in the past 30 days exceeding the limits for low-risk drinking (U.S. Department of Health and Human Services and U.S. Department of Agriculture, 2015). Exclusion criteria included: non-English speaking; lifetime history of AUD treatment; alcohol withdrawal necessitating immediate medical evaluation; and residency outside the study area. After we confirmed their eligibility with the use of screening instruments, subjects were: administered a baseline assessment, randomized to the CBT-TS condition or the control condition that included being read a pamphlet on AUD treatment (National Institute on Alcohol Abuse and Alcoholism, 2014), and reassessed over 12 month follow-up. The current analyses use cross-sectional data from the baseline assessment that was administered prior to randomization to treatment conditions (n=349). It was approved by the Internal Review Board at the University of Rochester Medical Center (URMC). Measures obtained from subjects that are salient to the current analyses are as follows.

2.2. Measures

Demographics.

A structured survey was used to assess self-reported age, sex, race, ethnicity, and other socio-demographic information to describe the sample. Assessments of sex, age, and race (i.e., white, individual of other racial background) were used as covariates in analyses, and sex (i.e., self-reported male or self-reported female) was used as an exploratory moderator of associations of alcohol-related consequences and intention to seek treatment.

World Health Organization Quality of Life measure (WHOQOL).

The WHOQOL is a widely used 23-item assessment of quality of life (Skevington et al., 2004) that has been validated for use with individuals with AUD (Kirouac et al., 2017). The items were summed to generate a global assessment of self-reported quality of life (Skevington et al., 2004), a covariate.

Alcohol Use Disorders Identification Test (AUDIT).

The 10-item AUDIT (Saunders et al., 1993) was used to identify the study sample. We used a cutoff of 16 or higher as the basis for eligibility to recruit an AUD sample in need of alcohol specialty treatment, consistent with extant research of the AUDIT (Babor & Robaina, 2016) and prior research of CBT-TS in individuals with untreated AUD (Stecker et al., 2012).

Alcohol Use Disorders and Associated Disabilities Interview Schedule-5 (AUDADIS-5).

The AUDADIS-5 (Grant et al., 2011; Grant et al., 2015) provided a structured assessment of the 11 symptoms of AUD in the past 12 months to confirm that the sample consists primarily of individuals with severe AUD, defined by meeting the threshold of 6-plus AUD symptoms (American Psychiatric Association, 2013).

Time Line Follow Back Interview (TLFB).

The TLFB was used to provide measures of the use of alcohol in the prior 30 days (Sobell & Sobell, 1996). Extensive research of the TLFB includes validation by telephone administration (Maisto et al., 2008; Sobell & Sobell, 1996). TLFB data were used to calculate three measures of alcohol use in the prior 30 days: 1) the number of drinking days, a measure of drinking frequency; 2) average number of standard drinks per drinking day, an assessment of average intensity of alcohol use; and 3) number of days of heavy episodes of drinking (i.e., 4-plus for women, 5-plus for men), a measure of heavy, episodic alcohol use.

Inventory of Drug Use Consequences (INDUC).

The 15-item short form of the INDUC (Blanchard et al., 2003) was used to assess consequences related to alcohol or drug use over the past 90 days. Research supports the psychometric properties of the INDUC (Tonigan & Miller, 2002), including the short form (Blanchard et al., 2003). The INDUC assesses alcohol and drug use consequences across five domains, each measured with three items: 1) physical, 2) interpersonal, 3) intrapersonal, 4) impulse control, and 5) social responsibility. Example items include: Because of my alcohol or drug use…I have lost weight or not eaten properly (physical), my family has been hurt (interpersonal), I have been unhappy (intrapersonal), I have taken foolish risks (impulse control), and I have had money problems (social responsibility). Items are scored on a Likert scale ranging from 0 (never) to 3 (daily or almost daily). Items were summed across the 5 consequences domains with total scores ranging from 0 – 9 for each.

The Modifying Perceptions of Services Scale (iMPASSe).

The iMPASSe is a 23-item scale designed to assess beliefs about AUD treatment (Stecker et al., 2012). The Perceptions of Services Scale (PASS) is the predecessor to the iMPASSE that was validated for the assessment of beliefs about behavioral health treatment more generally (Stecker et al., 2007). Modifications to the PASS to create the iMPASSe consisted of minor word changes, for example substitution of the phrase “treatment” for “alcohol treatment.” Guided by the Theory of Planned Behavior (Ajzen, 1991, 2002), PASS and iMPASSe items are divided into four sub-scales corresponding to attitudes towards treatment, subjective norm, perceived behavioral control over treatment, and intention to seek treatment. The dependent variable for the current report is based on the 3-item intention to seek treatment subscale of the iMPASSE, with the items consisting of “I intend to go to treatment”, “I will try to go to treatment”, and “I have decided to go to alcohol treatment”. Each item was assessed on a 7-point scale from strongly disagree to strongly agree and total scores were derived by summing the items (range 3–21).

2.3. Data analysis

Continuous variables were described using means and standard deviations, and categorical variables were described using frequencies and percentages. Multiple linear regression modeling was used to predict intentions to seek alcohol treatment using subject demographic characteristics, perceived quality of life, alcohol consumption and AUD symptoms, and experienced negative consequences of alcohol use. Moderation of the associations between consequences and intentions by subject sex were examined using multiplicative interaction terms. Consequences and sex were mean-centered prior to creating interaction terms.

An a priori two-tailed alpha level of 0.05 was used to indicate statistical significance. Overall model fit was evaluated using R2 values, and the added predictive utility of the interaction terms was evaluated using Δ R2. Multicolinearity concerns were evaluated using Variance Inflation Factors. All analyses were performed using IBM SPSS 27.

3. Results

A total of 1613 subjects were screened for eligibility for the RCT between 3/1/2019 and 8/25/2021, and 349 (21.6%) subjects were enrolled, representing the study sample for the current analyses. Subjects were deemed ineligible during the screening process due to: history of alcohol-related treatment (n=625, 38.7%), AUDIT score <16 (n=335, 20.8%), not exceeding the recommended limits for low-risk drinking (n= 189, 11.7%), residing outside of the area (n=70, 4.3%), being non-English speaking (n= 1, <1%), and for being provided the recommendation to seek immediate medical evaluation for alcohol withdrawal (n= 4, <1%). The remaining subjects declined to consent to the study or withdrew their participation during the baseline assessment (n=40, 2.5%).

Characteristics of the sample are described in Table 1. Subjects were on average 41 years of age, with 48% female, 6% Hispanic/Latinx, 80% white and 20% persons of other racial backgrounds, most commonly individuals who identified as Black (12%) or as multiracial including Black race (3%). Consistent with a severe AUD sample, subjects had an average of 8 AUD symptoms and 319 (91.6%) met criteria for severe AUD. Alcohol consumption was high, with subjects drinking on average 22 out of the past 30 days, consuming on average 7 standard drinks per drinking day, and exceeding the 4/5 drink limits for women/men on about half of the days in the past 30 days. Subjects also routinely reported consequences of alcohol and other drug use, reporting intrapersonal consequences most often and interpersonal consequences least often.

Table 1.

Sample characteristics (n=349).

Variable M SD Frequency Percent
Age 40.8 10.7
Gender
  Male 180 58.6
  Female 168 48.1
  Missing 1 0.3
Hispanic/Latinx
  Yes 21 6
  No 328 94
Race
  White 278 79.7
  Black 42 12
  Asian 8 2.3
  Multiracial 9 2.6
  Other 11 3.2
WHOQOL 32.3 4.6
AUD symptoms 8.2 1.9
AUDIT 22.6 5.3
TLFB - # drinking days (past 30 days) 22.2 7.2
TLFB - # drinks per drinking day (30 days) 6.9 3.9
TLFB – # days with heavy episodes of drinking (30 days) 15.4 9.1
INDUC - Physical consequences 2.9 2.3
INDUC - Interpersonal consequences 1.6 1.8
INDUC - Intrapersonal consequences 4.5 2.4
INDUC - Impulse Control consequences 2.0 1.4
INDUC - Social responsibility consequences 2.5 2.1
iMPASSe - Intentions to seek treatment 9.6 4.9
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Note. Multiracial category included 9 (100%) individuals who reported being Black as part of their racial identity. WHOQOL = World Health Organization Quality of Life measure (total score). AUDIT = Alcohol Use Disorders Identification Test (total score). TLFB – Timeline Followback Interview derived assessments of alcohol use in past 30 days (# drinking days, etc.). INDUC = Inventory of (Alcohol) and Drug Use Consequences, with INDUC subscale scores shown (physical consequences, etc.) iMPASSe = The Modifying Perceptions of Services Scale, with results for the “intentions to seek treatment subscale” shown.

Twenty-eight subjects (8%) were missing data on at least one of the predictors of interest or covariates. Comparisons between subjects with missing data (listwise deleted in the regression analysis) and those with complete data showed that those with any missing data tended to have less education, higher AUDIT scores, and higher drinks per occasion (p’s < 0.05). No other differences were observed. Bivariate associations between predictors/covariates and the outcome (intentions) were similar when including all cases and when eliminating those who were listwise deleted (difference in r’s < 0.02).

The results of the multiple regression model examining predictors of greater intention to seek alcohol-related treatment are shown in Table 2. After multivariable adjustment, results show that white individuals overall had lower intention to seek treatment (p=0.001). Moreover, greater intention to seek treatment was predicted by more interpersonal consequences (p=0.005) and intrapersonal consequences (p=0.001). Exploratory tests of interaction between sex and the consequences scales showed that the association of intrapersonal consequences was moderated by sex, with intrapersonal consequences showing a greater association with intention to seek alcohol-related treatment in women than men (see Figure 1). Moreover, greater social responsibility consequences were associated with greater intention to seek treatment in men, whereas in women, the intention to seek treatment decreased with greater social responsibility consequences (see Figure 2). Due to the fact that two of the three items on the scale pertained to financial consequences, we explored item-level analyses, to determine if financial consequences explained the moderating effect. The results show that the interaction between social responsibility consequences and sex was attributable to the financial consequences items.

Table 2.

Multiple regression model predicting intentions to seek treatment

Standardized Beta Coefficients p-values 95% Confidence Intervals
Covariates
 Gender 0.11 0.059 −0.00, 0.22
 Age 0.06 0.277 −0.05, 0.18
 Hispanic ethnicity 0.06 0.280 −0.05, 0.18
 Race (white = 1; person of color = 0) −0.18 0.001 −0.30, −0.07
 Years of education −0.10 0.059 −0.21, 0.00
 WHOQOL −0.02 0.782 −0.14, 0.10
Alcohol use measures (past 30 days)
 # drinking days 0.01 0.914 −0.15, −0.16
 # drinks per drinking day −0.06 0.443 −0.21, 0.09
 #days with heavy episodes of drinking −0.00 0.985 −0.18, 0.17
Consequences of alcohol use
 Physical consequences −0.08 0.225 −0.21, 0.05
 Interpersonal consequences 0.20 0.005 0.06, 0.34
 Intrapersonal consequences 0.24 0.001 0.11, 0.38
 Impulse control consequences −0.02 0.735 −0.15, 0.10
 Social responsibility consequences 0.01 0.870 −0.13, 0.15
Interactions – gender X consequences
 gender X physical 0.10 0.124 −0.03, 0.22
 gender X interpersonal −0.02 0.735 −0.16, 0.11
 gender X intrapersonal −0.14 0.034 −0.27, −0.01
 gender X impulse control 0.09 0.159 −0.03, 0.21
 gender X social responsibility 0.18 0.008 0.05, 0.32
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Note: WHOQOL = World Health Organization Quality of Life measure (total scores). Overall adjusted R2 = 0.18, p < 0.001. ΔR2 Interactions = 0.05, p = 0.001. Bolded coefficients indicate p < 0.05 (also bolded). Person of color includes individuals self-reporting as Black, Asian, Multiracial, and Other Race. Gender and consequence variables were mean centered prior to creating multiplicative interaction terms. All variables of interest had Variance Inflation Factors (VIFs) less than 2.0, implying negligible multicolinearity. The Alcohol use variables had VIFs between 1.96 and 3.09. Models were also performed by eliminating individual alcohol use variables to mitigate multicolinearity; no change in coefficient significance or overall prediction was observed, so the more inclusive model was retained.

Figure 1.

Figure 1.

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Two-way interaction of intrapersonal consequences and gender in predicting intention to seek alcohol treatment. The simple for women is 0.77, p < 0.001; the simple slope for men is 0.20, p = 0.302

Figure 2.

Figure 2.

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Two-way interaction of social responsibility consequences and gender in predicting intention to seek alcohol treatment. The simple for women is −0.41, p = 0.069; the simple slope for men is 0.43, p = 0.047.

4. Discussion

We examined associations of alcohol-related consequences with the intention to seek treatment in adults with severe, untreated AUD recruited from the community. Consistent with available evidence and our hypothesis, measures of alcohol-related consequences but not alcohol consumption were associated with the intention to seek AUD treatment. Uniquely, interpersonal consequences of AUD were associated with the intention to seek treatment in both men and women. The interpersonal consequences scale items refer to “hurt” or “damage” in close relationships including family. The idea that threats to close interpersonal relationships are especially painful is central to influential theories of human development (Bretherton, 1992), depression (Coyne, 1976a, 1976b), and suicide (Joiner, 2005). Individuals with AUD are vulnerable to distress associated with interpersonal difficulties, for example disruptions in close interpersonal relationships is a potent risk factor for suicidal behavior in individuals with AUD (Conner et al., 2003; Conner et al., 2012; Murphy et al., 1979). Because problems in close interpersonal relationships are especially distressing, their occurrence in the context of AUD may activate intentions to seek treatment in an effort to alleviate such distress and to repair relationships.

Our exploration of sex differences suggests the importance of two additional types of alcohol-related consequences (intrapersonal, social responsibility) in the intention to seek AUD treatment. First, intrapersonal consequences of AUD were more strongly associated with the intention to seek treatment in women. The intrapersonal consequences scale items include being “unhappy” and having felt “guilty or ashamed” due to alcohol use. The finding that such consequences are more strongly associated with intention to seek treatment in women seems consistent with extant data that women with AUD are more likely than men to have co-occurring depression, to use alcohol to alleviate sadness, and to express a desire for treatment of depression (Holzhauer et al., 2020; White, 2020). Second, social responsibility consequences of AUD, particularly financial difficulties, were associated with the intention to seek treatment in men but not women. Financial consequences of AUD may be especially threatening to men, possibly due to the central importance of breadwinning and financial achievement in men’s self-esteem (Gecas & Seff, 1989; Twenge & Campbell, 2002).

4.1. Limitations

There were limitations of the study that should be considered in interpreting its findings. The analyses were based on cross-sectional data collected from a single site. Subjects were recruited through social media for an RCT examining treatment seeking and may not be representative of treatment-naïve individuals with severe AUD in the general population. The consequences scale assesses problems due to “alcohol or drugs” rather than alcohol per se. However, it seems unlikely that other drug use explained the results because, with the exception of common tobacco use and some cannabis use, drug use was generally low in this community-based sample. Due to modest sample sizes of racial and ethnic minority participants, we could not examine race or ethnicity as moderators of the association of consequences and intention to seek treatment. This limitation is noteworthy in light of differences in alcohol use, alcohol-related consequences, and treatment utilization in Blacks versus white (or white non-Hispanic) individuals, for example (Chartier et al., 2013; Pinedo, 2019; Vaeth et al., 2017; Zapolski et al., 2014). Alcohol consumption is presumed to have been a necessary, but not sufficient, condition for the unfolding of alcohol-related consequences. However, the nature of the study (cross-sectional design, limited sample size) precluded the modeling of more complex pathways between alcohol consumption, alcohol-related consequences, and intention.

4.2. Future directions

Forming intention is a critical step in carrying out volitional behavior (Ajzen, 1991, 2002), including the decision to seek treatment for AUD (Stecker et al., 2012). The results of the current study underscore the importance of alcohol-related consequences in intention. Results suggest that interpersonal consequences of AUD are a robust correlate of treatment intention regardless of sex, whereas intrapersonal consequences and financial consequences of AUD are linked with intention in women and men, respectively. These results may inform efforts to increase intention to seek treatment as part of the effort to promote treatment utilization in individuals with severe AUD, a population who show low treatment use but who have urgent need for care. For example, given robust associations of interpersonal consequences with treatment intention, interpersonal consequences of AUD may provide a compelling hook for media campaigns and other efforts to promote utilization of AUD treatment.

Footnotes

Declaration of interest: None

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