Mediational Analyses of the Effects of Social Behaviour and Network Therapy on Alcohol Use.

INTRODUCTION: Social behaviour and network therapy involves an active participation of the practitioner in recruiting a supportive network to change the client's alcohol use. Despite achieving beneficial effects on alcohol consumption, its possible mechanisms of change are a relatively under-studied topic compared to those of other alcohol treatment interventions. This study aimed to explore therapist skills through which social behaviour and network therapy may achieve effects on alcohol consumption in comparison with motivational enhancement therapy. METHODS: This study was secondary analysis of data from the UK Alcohol Treatment Trial, a multicentre, pragmatic, randomized controlled trial. The sample comprised 376 participants randomized to motivational enhancement therapy or social behaviour and network therapy. We used the UK Alcohol Treatment Trial Process Rating Scale to assess therapist skills. Outcomes drinks per drinking day and percentage of days abstinent were assessed 12 months after treatment initiation. Analyses were conducted in a simple mediation framework. RESULTS: Therapist skills score (combining frequency and quality) for involving others in behaviour change mediated social behaviour and network therapy effects on percentage of days abstinent (b = 0.06, 95% CI: 0.02; 0.10, p = 0.01). The frequency with which therapists acted as an active agent for change also mediated the effects of social behaviour and network therapy on percentage of days abstinent (b = 0.03, 95% CI: 0.003; 0.05, p = 0.03). The frequency with which the therapist stressed social support as a key factor in achieving change unexpectedly mediated an increase in drinks per drinking day (b = 0.10, 95% CI: 0.01; 0.18, p = 0.02). The two latter mediation effects were not sustained when quality was considered. All other indirect effects tested were non-significant. DISCUSSION/CONCLUSIONS: How social behaviour and network therapy exerts effects on alcohol outcomes is not yet well understood and in this study was not attributable to observed ratings of therapist treatment-specific skills. Therapist skill in planning the involvement of others during treatment, however, warrants further study. We suggest that the present findings should be regarded as hypothesis generating as it identifies specific targets for further investigation in alcohol treatment process studies.

Indeed, not really a brain disorder: Implications for reductionist accounts of addiction.

Borsboom et al.'s formulation provides an opportunity for a fundamental rethink about the "brain disease model" of addiction that dominates research, treatment, policy, and lay understanding of addiction. We also demonstrate how the American opioid crisis provides a contemporary example of how "brain disease" is not moderated by the environmental context but is instead crucially dependent upon it.

Toward an understanding of the effective mechanisms of alcohol brief interventions.

Research on effective mechanisms of alcohol brief interventions has been neglected, but Bertholet and colleagues provide an example of such research in a re-analysis of combined data from 3 trials of brief motivational interviewing (BMI). However, it is disappointing that, in a well-designed and well-conducted analysis, little support was found for highly plausible hypotheses relating treatment processes to outcome of intervention. It is argued here that, because BMI must be assumed to work by increasing client motivation to cut down drinking, some measure of overall motivation before and after intervention is necessary to elucidate the pathway by which treatment processes are translated into positive outcomes. In pioneering research on physician advice on smoking cessation by Russell and colleagues, it was possible to distinguish between whether intervention worked by motivating more people to try to stop smoking, by increasing the success rate among those who did try, or by reducing the relapse rate among those who quit. It is recommended that similar measures be employed in research on how alcohol brief interventions work. A further consideration bearing on the relationship between treatment processes and outcome is whether or not individuals are dependent on alcohol and this is reminiscent of a dispute in the literature concerning the relative priority that should be given to motivational or dependence variables in the prediction of smoking cessation. In order to improve the effectiveness of alcohol brief interventions, future research should focus more on effective mechanisms of behavior change.

Alcohol screening and brief interventions for offenders in the probation setting (SIPS Trial): a pragmatic multicentre cluster randomized controlled trial.

AIM: To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in the probation setting. Offender managers were randomized to three interventions, each of which built on the previous one: feedback on screening outcome and a client information leaflet control group, 5 min of structured brief advice and 20 min of brief lifestyle counselling. METHODS: A pragmatic multicentre factorial cluster randomized controlled trial. The primary outcome was self-reported hazardous or harmful drinking status measured by Alcohol Use Disorders Identification Test (AUDIT) at 6 months (negative status was a score of <8). Secondary outcomes were AUDIT status at 12 months, experience of alcohol-related problems, health utility, service utilization, readiness to change and reduction in conviction rates. RESULTS: Follow-up rates were 68% at 6 months and 60% at 12 months. At both time points, there was no significant advantage of more intensive interventions compared with the control group in terms of AUDIT status. Those in the brief advice and brief lifestyle counselling intervention groups were statistically significantly less likely to reoffend (36 and 38%, respectively) than those in the client information leaflet group (50%) in the year following intervention. CONCLUSION: Brief advice or brief lifestyle counselling provided no additional benefit in reducing hazardous or harmful drinking compared with feedback on screening outcome and a client information leaflet. The impact of more intensive brief intervention on reoffending warrants further research.

Post-treatment stage of change predicts 12-month outcome of treatment for alcohol problems.

AIMS: To evaluate relationships between clients' self-reported 'stage of change' and outcomes after treatment for alcohol problems. METHODS: Using data from the 'United Kingdom Alcohol Treatment Trial', clients who had received at least one session of treatment and who had complete data (n = 392) entered the analysis. Two continuous measures of drinking behaviour (% days abstinent (PDA) and drinks per drinking day (DDD)) and categorical outcomes at the 12-month follow-up were compared between clients in Pre-action and Action stages of change at either pre- or post-treatment assessment. Multiple and logistic regression analyses examined the relationships between stage of change and treatment outcomes, evaluating the strength of these relationships by controlling for likely confounders. RESULTS: Pre-treatment stage of change did not predict outcome but post-treatment stage of change predicted PDA and DDD at the 12-month follow-up. In unadjusted and adjusted analyses, clients in Action at post-treatment were two to three times more likely to show a favourable categorical outcome, variously defined, than those in Pre-action. There were no differences between clients who had received Motivational Enhancement Therapy and those who had received Social Behaviour and Network Therapy in proportions maintaining or moving towards Action from before to after treatment. CONCLUSIONS: These findings confirm previous reports that motivational variables predict outcome of treatment but add that such a relationship is seen for post-treatment stage of change. For therapists, it would seem important to monitor the client's stage of change-which in good clinical practice often occurs in informal ways-and have strategies to deal with low motivation to change whenever it occurs throughout treatment. The findings are also consistent with a 'common factors' perspective on effective treatment for alcohol problems.

Commentary on Seppänen and colleagues (2012): Institutionalization of brief alcohol intervention in primary health care-the Finnish case.

Despite good evidence for the effectiveness of brief intervention (BI) for hazardous and harmful drinking delivered in primary health care, the uptake of such interventions among physicians and other healthcare staff still leaves much to be desired. Seppänen and colleagues (2012) report an evaluation of efforts funded by the Finnish government to "institutionalize" BI among primary care physicians in Finland. The evaluation was based on 2 surveys of Finnish primary healthcare physicians, one conducted in 2002 before the government-funded implementation project had begun and the other in 2007 after it had ended. Major findings were that the proportion of physicians offering BI had increased between the 2 surveys from 59.2 to 78.5% and that, of those who said they offered BI in 2007, 52.4% reported increased activity compared with 5 years earlier. However, in the 2007 survey, regular BI activity was reported by 17.2% of the sample but 61.3% reported only occasional activity. Also, a separate survey of the Finnish general population indicated that the extent to which people are asked by health professionals about their alcohol consumption, and the extent to which heavy drinkers receive advice about it, still appears to be low. Thus, the claim that the institutionalization of BI in the Finnish primary care system has been successful is tentative. The clinical benefits of increased BI activity are unquestionable but it can be argued that, for a public health benefit to occur, a greater proportion of hazardous and harmful drinkers need to receive BI than is suggested in the data reported by Seppänen and colleagues.

Screening for alcohol use in criminal justice settings: an exploratory study.

AIMS: To examine the feasibility and acceptability of alcohol screening and delivery of brief interventions within criminal justice settings. METHODS: A quantitative survey of those aged 18 or over in English criminal justice settings (three custody suites within police stations, three prisons and three probation offices). MEASUREMENTS: The Fast Alcohol Screening Test (FAST) and a modified version of the Single Alcohol Screening Question (M-SASQ) were compared with the Alcohol Use Disorders Identification Test (AUDIT) as the 'gold standard'. Participants completed a health status questionnaire (EQ5D), questions on service utilization and the Readiness to Change Questionnaire. Questions relating to the acceptability and feasibility of delivering brief interventions and about perception of coercion were included. FINDINGS: Five hundred and ninety-two individuals were approached and 251 were eligible. Of these, 205 (82%) consented to take part in the study. The mean AUDIT score was 19.9 (SD 13.5) and 73% scored 8 or more on AUDIT. A higher percentage of those approached in the probation setting consented to take part (81%: prison 36%, police setting 10%). Those scoring AUDIT positive were more likely to be involved in violent offences (36.5 vs 9.4%; P < 0.001) and less likely to be involved in offences involving property (27.7 vs 45.3%; P = 0.03). Three quarters of the sample (74%) reported that they would not feel coerced to engage in an intervention about their alcohol use. FAST and M-SASQ had acceptable screening properties when compared with AUDIT with area under the curves of 0.97 and 0.92, respectively. CONCLUSIONS: The results confirm that there is a major problem with alcohol use in the criminal justice system and this impacts on health and criminal behaviour. Of the three criminal justice settings, probation was found to be the most suitable for screening. Participants were positive about receiving interventions for their alcohol use in probation settings.

Serial mediation analysis of treatment-specific processes in two contrasting alcohol treatments.

INTRODUCTION: This study explored whether treatment-specific processes linking therapist behaviors, post-session client ratings, and 3-month proximal outcomes (i.e., end of treatment) can explain 12-month outcomes for two contrasting alcohol treatment conditions with equivalent overall outcomes. METHODS: This study is a secondary analysis of the UK Alcohol Treatment Trial (UKATT), a multi-center randomized controlled trial of treatment for alcohol problems comparing 3-session motivational enhancement therapy (MET) to 8-session social behaviour and network therapy (SBNT). Among 742 adult clients included in UKATT, 351 had one treatment session recorded and coded and were followed-up 3 and 12 months after baseline. The study team conducted serial mediation analyses to test whether the frequency and quality of MET and SBNT skills were related to 12-month alcohol outcomes (drinks per drinking day) through postsession client ratings of treatment progress (Processes of Change Questionnaire, PCQ), readiness to change (RTC) and social support for drinking after 3-months. RESULTS: Higher quality of MET skills was related to higher PCQ scores, which were in turn related to greater post-treatment RTC, and subsequently to better alcohol outcomes. Total indirect effect was consistently significant. In contrast, only PCQ was predictive of treatment outcome in the SBNT portion of the model. CONCLUSIONS: This study provides evidence from a large pragmatic trial that the quality of MET skills positively influences alcohol outcomes in part through improvements in motivation during treatment and actively trying to change when treatment ends. Research should explore the ways in which SBNT secured outcomes that were equivalent to MET.

New developments in brief interventions to treat problem drinking in nonspecialty health care settings.

The delivery of brief interventions (BIs) in health care settings to reduce problematic alcohol consumption is a key preventive strategy for public health. However, evidence of effectiveness beyond primary care is inconsistent. Patient populations and intervention components are heterogeneous. Also, evidence for successful implementation strategies is limited. In this article, recent literature is reviewed covering BI effectiveness for patient populations and subgroups, and design and implementation of BIs. Support is evident for short-term effectiveness in hospital settings, but long-term effects may be confounded by changes in control groups. Limited evidence suggests effectiveness with young patients not admitted as a consequence of alcohol, dependent patients, and binge drinkers. Influential BI components include high-quality change plans and provider characteristics. Health professionals endorse BI and feel confident in delivering it, but training and support initiatives continue to show no significant effects on uptake, prompting calls for systematic approaches to implementing BI in health care.

Intervention against excessive alcohol consumption in primary health care: a survey of GPs' attitudes and practices in England 10 years on.

AIMS: To ascertain the views of general practitioners (GPs) regarding the prevention and management of alcohol-related problems in practice, together with perceived barriers and incentives for this work; to compare our findings with a comparable survey conducted 10 years earlier. METHODS: In total, 282 (73%) of 419 GPs surveyed in East Midlands, UK, completed a postal questionnaire, measuring practices and attitudes, including the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). RESULTS: GPs reported lower levels of post-graduate education or training on alcohol-related issues (<4 h for the majority) than in 1999 but not significantly so (P = 0.031). In the last year, GPs had most commonly requested more than 12 blood tests and managed 1-6 patients for alcohol. Reports of these preventive practices were significantly increased from 1999 (P < 0.001). Most felt that problem or dependent drinkers' alcohol issues could be legitimately (88%, 87%) and adequately (78%, 69%) addressed by GPs. However, they had low levels of motivation (42%, 35%), task-related self-esteem (53%, 49%) and job satisfaction (15%, 12%) for this. Busyness (63%) and lack of training (57%) or contractual incentives (48%) were key barriers. Endorsement for government policies on alcohol was very low. CONCLUSION: Among GPs, there still appears to be a gap between actual practice and potential for preventive work relating to alcohol problems; they report little specific training and a lack of support. Translational work on understanding the evidence-base supporting screening and brief intervention could incentivize intervention against excessive drinking and embedding it into everyday primary care practice.

Alcohol use disorders and hazardous drinking among undergraduates at English universities.

AIMS: To report on alcohol use disorders and hazardous drinking from a survey of university students in England in 2008-2009. METHODS: A cross-sectional survey using the Alcohol Use Disorders Identification Test (AUDIT) was carried out in a purposive sample of 770 undergraduates from seven universities across England. RESULTS: Sixty-one per cent of the sample (65% men; 58% women) scored positive (8+) on the AUDIT, comprising 40% hazardous drinkers, 11% harmful drinkers and 10% with probable dependence. There were large and significant differences in mean AUDIT scores between the universities taking part in the survey. Two universities in the North of England showed a significantly higher combined mean AUDIT score than two universities in the Midlands which in turn showed a significantly higher mean AUDIT score than three universities in the South. When the effects of university attended were extracted in a binary logistic regression analysis, independent significant predictors of AUDIT positive status were younger age, 'White' ethnicity and both on-campus and off-campus term-time student accommodation. CONCLUSIONS: Undergraduates at some universities in England show very high levels of alcohol-related risk and harm. University authorities should estimate the level of hazardous drinking and alcohol use disorders among students at their institutions and take action to reduce risk and harm accordingly. Research is needed using nationally representative samples to estimate the prevalence of alcohol risk and harm in the UK student population and to determine the future course of drinking problems among students currently affected.

An application of moderated nonlinear factor analysis to develop a commensurate measure of alcohol problems across four alcohol treatment studies.

BACKGROUND: Self-report measures of alcohol problems are commonly included in studies evaluating treatment and recovery from alcohol use disorder (AUD), but no prior study has examined the replicability of the measurement of alcohol problems across studies with various measures and diverse samples. Further, it is unclear which items may be better indicators of alcohol problems for patient subgroups. In the present study, we integrated data from four large alcohol treatment studies to develop a commensurate measure of alcohol problems using moderated nonlinear factor analysis (MNLFA). METHODS: Data were from the COMBINE study, Project MATCH, the Relapse Replication and Extension Project (RREP), and the United Kingdom Alcohol Treatment Trial (UKATT), yielding a total sample size of 4414. MNLFA was carried out on the Drinker Inventory of Consequences (COMBINE, MATCH, RREP) and Alcohol Problems Questionnaire (UKATT). RESULTS: We successfully created a 78-item commensurate measure of alcohol problems and examined differential item functioning (DIF) by study membership, time, and socio-demographic characteristics. Sixty-two items demonstrated intercept DIF, suggesting differences in rates of item endorsement for clients with the same underlying levels of alcohol problems across patient subgroups. Six items demonstrated loading DIF, suggesting differences in the extent to which the items were indicative of alcohol problems across patient subgroups. CONCLUSIONS: The self-reported measurement of alcohol problems replicates across measures and diverse samples. Items with DIF have clinical implications for the treatment of AUD. Finally, MNLFA scores can be used to test substantive research questions across these studies.

The "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) Core Outcome Set: International Consensus on Outcomes to Measure in Efficacy and Effectiveness Trials of Alcohol Brief Interventions.

OBJECTIVE: The purpose of this study was to report the "Outcome Reporting in Brief Intervention Trials: Alcohol" (ORBITAL) recommended core outcome set (COS) to improve efficacy and effectiveness trials/evaluations for alcohol brief interventions (ABIs). METHOD: A systematic review identified 2,641 outcomes in 401 ABI articles measured by 1,560 different approaches. These outcomes were classified into outcome categories, and 150 participants from 19 countries participated in a two-round e-Delphi outcome prioritization exercise. This process prioritized 15 of 93 outcome categories for discussion at a consensus meeting of key stakeholders to decide the COS. A psychometric evaluation determined how to measure the outcomes. RESULTS: Ten outcomes were voted into the COS at the consensus meeting: (a) typical frequency, (b) typical quantity, (c) frequency of heavy episodic drinking, (d) combined consumption measure summarizing alcohol use, (e) hazardous or harmful drinking (average consumption), (f) standard drinks consumed in the past week (recent, current consumption), (g) alcohol-related consequences, (h) alcohol-related injury, (i) use of emergency health care services (impact of alcohol use), and (j) quality of life. CONCLUSIONS: The ORBITAL COS is an international consensus standard for future ABI trials and evaluations. It can improve the synthesis of new findings, reduce redundant/selective reporting (i.e., reporting only some, usually significant outcomes), improve between-study comparisons, and enhance the relevance of trial and evaluation findings to decision makers. The COS is the recommended minimum and does not exclude other, additional outcomes.

Initial preference for drinking goal in the treatment of alcohol problems: I. Baseline differences between abstinence and non-abstinence groups.

AIMS: To compare baseline characteristics of clients initially preferring abstinence with those preferring non-abstinence at the screening stage of a randomized controlled trial of treatment for alcohol problems (UKATT) and to identify predictors of goal preference from client characteristics present before the preference was stated. METHODS: From discussions with clients entering the trial (N = 742), screeners noted whether clients were aiming for abstinence 'probably yes' or 'probably no'. Differences between the two groups thus formed were explored by univariate comparisons among client characteristics recorded at baseline assessment and by logistic regression analysis with pre-existing characteristics as independent variables. RESULTS: Across all UKATT sites, 54.3% of clients expressed a preference for abstinence and 45.7% for non-abstinence. In univariate comparisons, clients preferring abstinence were significantly (P < 0.01) more likely to: (i) be female, (ii) be unemployed, (iii) report drinking more heavily but less frequently, (iv) have been detoxified in the 2 weeks prior to assessment, (v) report more alcohol problems, (vi) be in the action stage of change, (vii) report greater negative expectancies of drinking, (viii) report greater mental and physical ill-health, (ix) report less social support for drinking and (x) be more confident of their ability to resist heavy drinking in tempting situations. In the logistic regression model, the strongest predictors of goal preference were gender, drinking pattern, recent detoxification and social support for drinking. CONCLUSION: The implications of these findings for service delivery are best considered in conjunction with findings from a companion paper reporting treatment outcomes associated with each goal preference.

Initial preference for drinking goal in the treatment of alcohol problems: II. Treatment outcomes.

AIMS: To compare treatment outcomes between clients preferring abstinence and those preferring non-abstinence at the screening stage of a randomized controlled trial of treatment for alcohol problems (the United Kingdom Alcohol Treatment Trial) and to interpret any differential outcome in light of baseline differences between goal preference groups outlined in an accompanying paper. METHODS: Outcomes at 3 and 12 months' follow-up were recorded both in categorical terms (abstinence/non-problem drinking/much improved/somewhat improved/same/worse) and on continuous measures (percent days abstinent, drinks per drinking day/dependence score). RESULTS: Clients initially stating a preference for abstinence showed a better outcome than those stating a preference for non-abstinence. This superior outcome was clearer at 3 months' follow-up but still evident at 12 months' follow-up. The better outcome consisted almost entirely in a greater frequency of abstinent days, with only a modest benefit in drinking intensity for goal abstainers that disappeared when baseline covariates of goal preference were controlled for. Type of successful outcome (abstinence/non-problem drinking) was related to initial goal preference, with clients preferring abstinence more likely to obtain an abstinent outcome and those preferring non-abstinence a non-problem drinking outcome. CONCLUSION: The client's personal drinking goals should be discussed in assessment at treatment entry and as a basis for negotiation. Clinicians should be prepared to identify and support goal change as an unexceptional part of the treatment process that need not jeopardize good outcome.

The concept of akrasia as the foundation for a dual systems theory of addiction.

The aim of this article is to argue that the ancient concept of akrasia can serve as the conceptual foundation and theoretical justification for a dual systems theory of addiction. Akrasia refers to acting against one's better judgement and thus to behaviour that agents know is bad for them and have previously resolved to abjure, addiction being seen as an extreme form of akrasia. In this way akrasia can provide the basis for accounts of addictive behaviour that stress its inconsistency over time and the great difficulty addicts experience in changing it. A definition of addiction consistent with this view is offered and defended, and some of its general advantages for understanding and responding to addiction described. A consequence of defining addiction in this way is that it should be seen as a disorder of choice or, alternatively, of self-regulation, and reasons are given why the latter term should be preferred. It is then proposed that the concept of akrasia and the perspective on addiction that follows from it lead logically to the need for a dual systems theory of addiction. Although no such theory is presented here, terminological issues are clarified, criticisms of dual systems theories are noted, and a rudimentary description of what an integrated dual systems theory of addiction might look like is provided.

Recovery from addiction: Behavioral economics and value-based decision making.

Behavioral economics provides a general framework to explain the shift in behavioral allocation from substance use to substance-free activities that characterizes recovery from addiction, but it does not attempt to explain the internal processes that prompt those behavioral changes. In this article we outline a novel analysis of addiction recovery based on computational work on value-based decision making (VBDM), which can explain how people with addiction are able to overcome the reinforcement pathologies and decision-making vulnerabilities that characterize the disorder. The central tenet of this account is that shifts in molar reinforcer preferences over time from substance use to substance-free activities can be attributed to changes in evidence accumulation rates and response thresholds in the context of choices involving substance use and substance-free alternatives. We discuss how this account can be reconciled with the established mechanisms of action of psychosocial interventions for addiction and demonstrate how it has the potential to empirically address longstanding debates regarding the nature of impairments to self-control in addiction. We also highlight conceptual and methodological issues that require careful consideration in translating VBDM to addiction and recovery. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

World Health Organization risk drinking level reductions are associated with improved functioning and are sustained among patients with mild, moderate and severe alcohol dependence in clinical trials in the United States and United Kingdom.

AIMS: To examine whether World Health Organization (WHO) risk-level reductions in drinking were achievable, associated with improved functioning and maintained over time among patients at varying initial alcohol dependence severity levels. Design and setting Secondary data analysis of multi-site randomized clinical trials: the US Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) study and the UK Alcohol Treatment Trial (UKATT). PARTICIPANTS: Individuals with alcohol dependence enrolled in COMBINE (n = 1383; 68.8% male) and seeking treatment for alcohol problems in UKATT (n = 742; 74.1% male). Interventions Naltrexone, acamprosate or placebo, and combined behavioral intervention or medication management in COMBINE. Social behavior network therapy or motivational enhancement therapy in UKATT. MEASUREMENTS: WHO risk-level reductions were assessed via the calendar method. Alcohol dependence was measured by the Alcohol Dependence Scale, the Leeds Dependence Questionnaire and the Diagnostic and Statistical Manual of Mental Disorders. Measures of functioning included alcohol-related consequences (Drinker Inventory of Consequences and Alcohol Problems Questionnaire), mental health (Short Form Health Survey) and liver enzyme tests. FINDINGS: One- and two-level reductions in WHO risk levels in the last month of treatment were maintained at the 1-year follow-up [adjusted odds ratio (OR), 95% confidence interval (CI) = one-level reduction in COMBINE: 3.51 (2.73, 4.29) and UKATT: 2.65 (2.32, 2.98)] and associated with fewer alcohol-related consequences [e.g. B, 95% CI = one-level reduction COMBINE: -26.22 (-30.62, -21.82)], better mental health [e.g. B, 95% CI = one-level reduction UKATT: 9.53 (7.36, 11.73)] and improvements in γ-glutamyltransferase [e.g. B, 95% CI = one-level reduction UKATT: -89.77 (-122.50, -57.04)] at the end of treatment, even among patients with severe alcohol dependence. Results were similar when abstainers were excluded. Conclusions Reductions in World Health Organization risk levels for alcohol consumption appear to be achievable, associated with better functioning and maintained over time in both the United States and the United Kingdom.