Attentional Bias, Alcohol Craving, and Anxiety Implications of the Virtual Reality Cue-Exposure Therapy in Severe Alcohol Use Disorder: A Case Report.

Aims: Attentional bias (AB), alcohol craving, and anxiety have important implications in the development and maintenance of alcohol use disorder (AUD). The current study aims to test the effectiveness of a Virtual Reality Cue-Exposure Therapy (VR-CET) to reduce levels of alcohol craving and anxiety and prompt changes in AB toward alcohol content. Method: A 49-year-old male participated in this study, diagnosed with severe AUD, who also used tobacco and illicit substances on an occasional basis and who made several failed attempts to cease substance misuse. The protocol consisted of six VR-CET booster sessions and two assessment sessions (pre- and post-VR-CET) over the course of 5 weeks. The VR-CET program consisted of booster therapy sessions based on virtual reality (VR) exposure to preferred alcohol-related cues and contexts. The initial and final assessment sessions were focused on exploring AB, alcohol craving, and anxiety using paper-and-pencil instruments and the eye-tracking (ET) and VR technologies at different time points. Results: Pre and post assessment sessions indicated falls on the scores of all instruments assessing alcohol craving, anxiety, and AB. Conclusions: This case report, part of a larger project, demonstrates the effectiveness of the VR-CET booster sessions in AUD. In the post-treatment measurements, a variety of instruments showed a change in the AB pattern and an improvement in craving and anxiety responses. As a result of the systematic desensitization, virtual exposure gradually reduced the responses to significant alcohol-related cues and contexts. The implications for AB, anxiety and craving are discussed.

Predictors of Changes in Alcohol Craving Levels during a Virtual Reality Cue Exposure Treatment among Patients with Alcohol Use Disorder.

BACKGROUND/OBJECTIVE: Determining the predictive variables associated with levels of alcohol craving can ease the identification of patients who can benefit from treatments. This study aimed to describe changes (improvement or no change/deterioration) in alcohol craving levels and explore the predictors of these changes from admission to discharge in outpatients with alcohol use disorder (AUD) undergoing treatment-as-usual (TAU), or treatment-as-usual supplemented with virtual reality cue-exposure therapy (TAU + VR-CET). METHOD: A prospective cohort study was conducted amongst 42 outpatients with AUD (n = 15 TAU + VR-CET and n = 27 TAU) from a clinical setting. Changes in the levels of alcohol craving between admission and discharge were assessed with the Multidimensional Alcohol Craving Scale. Sociodemographic characteristics (age, gender, education, and socioeconomic and civil status), cognitive-affective behavioral patterns (AUD severity, abstinence duration, psychiatric comorbidity, state anxiety, attentional bias, and substance use), and type of treatment (TAU + VR-CET and only TAU) were also evaluated. RESULTS: The TAU + VR-CET group showed greater changes of improvement in the levels of alcohol craving than the TAU group (χ2 = 10.996; p = 0.001). Intragroup changes in alcohol craving from pre to post-treatment were significant in the TAU + VR-CET group (χ2 = 13.818; p = 0.003) but not within the TAU group (χ2 = 2.349; p = 0.503). The odds of an improvement in any of the craving levels between pre- and post-test was 18.18 (1/0.055) times higher in the TAU + VR-CET group with respect to the TAU group. The use of illicit drugs in the month prior to the test increased the odds of having a positive change by 18.18 (1/0.055) with respect to not having consumed. CONCLUSIONS: Including VR-CET in TAU programs may provide benefits in the treatment of AUDs mainly among patients with intense alcohol craving and individuals having used illicit substances prior to treatment.

Phosphatidylethanol for Monitoring Alcohol Use in Liver Transplant Candidates: An Observational Study.

Liver transplantation remains an essential procedure for many patients suffering from alcoholic liver disease. Alcohol use monitoring remains paramount all through the stages of this complex process. Direct alcohol biomarkers, with improved specificity and sensibility, should replace traditional indirect markers. Phosphatidylethanol (PEth) has been recently tested in alcoholic liver disease patients, but more evidence is needed, especially in comparison with other direct biomarkers. We conducted an observational study among patients awaiting liver transplantation. We analyzed Peth in blood, ethylglucuronide (EtG) in hair and urine and ethylsulphate (EtS) in urine, using mass spectrometry methods. In addition, transaminases, and self-reports were analyzed. A total of 50 patients were included (84% men, mean age 59 years (SD = 6)). 18 patients (36%) screened positive for any marker. Self-reports were positive in 3 patients. EtS was the biomarker with more positive screens. It also was the most frequently exclusive biomarker, screening positive in 7 patients who were negative for all other biomarkers. PEth was positive in 5 patients, being the only positive biomarker in 2 patients. It showed a false negative in a patient admitting alcohol use the previous week and screening positive for EtG and EtS. Hair EtG was positive in 3 patients who had negative Peth, EtG. EtG did not provide any exclusive positive result.A combination of biomarkers seems to be the best option to fully ascertain abstinence in this population. Our study suggest EtS might also play a significant role.

Cue-Elicited Anxiety and Alcohol Craving as Indicators of the Validity of ALCO-VR Software: A Virtual Reality Study.

BACKGROUND: This study is part of a larger project aiming to develop a virtual reality (VR) software to be implemented as a clinical tool for patients diagnosed with alcohol use disorder (AUD). The study is based on previous research in which we identified factors that elicit craving for alcohol in a sample of AUD patients, and which led to the development of a virtual reality software to be used in cue exposure treatments of alcohol use disorder (ALCO-VR). The main objective of this study was to test the effectiveness of ALCO-VR to elicit cue-induced craving and anxiety responses among social drinkers (SD) and AUD patients. Our secondary objective was to explore which responses (cue-induced craving or anxiety) can best differentiate between AUD patients and the SD group. METHOD: Twenty-seven individuals (13 AUD patients and 14 SD) participated in this study after giving written informed consent. Their anxiety and alcohol craving levels were measured by different instruments at different stages of the procedure. The VR equipment consisted of Oculus Rift technology, and the software consisted of the ALCO-VR platform. RESULTS: Our data indicate that the ALCO-VR software can elicit responses of anxiety and alcohol craving, especially in the group of AUD patients. The cue-induced anxiety response differentiated AUD patients and the SD group better than the cue-induced craving response. CONCLUSIONS: The general interest in applying new technologies to the assessment and treatment of mental health disorders has led to the development of immersive real-life simulations based on the advantages of VR technology. Our study concluded that the ALCO-VR software can elicit anxiety and craving responses and that cue-induced anxiety responses can distinguish between AUD and SD groups better than cue-induced craving. The data on craving and anxiety were assessed consistently by different instruments. In addition, we consider that ALCO-VR is able to ecologically assess cue-induced anxiety and alcohol craving levels during exposure to VR alcohol-related environments.

What Do Real Alcohol Outpatients Expect about Alcohol Transdermal Sensors?

OBJECTIVE: Little is known about the potential acceptability of alcohol transdermal sensors among alcohol-dependent outpatients in routine clinical settings. The aim of the present study was to investigate patients' attitudes towards alcohol transdermal sensors, as well as features associated with enhanced acceptability and usability. METHODS: A cross-sectional survey among routine alcohol outpatients was conducted. The Drug Attitude Inventory (DAI-10) was adapted to the field of alcohol transdermal sensors for attitudes assessment. Likert-type and multiple-choice questions were used for acceptability and usability evaluation. RESULTS: 68 patients completed the questionnaire, and the DAI-10 mean score was 3 (standard deviation (SD) = 6.5). Internal consistency revealed a Cronbach alpha of 0.613. The score of a single The score of a single Likert-type question about overall perceived value was 7.4 (SD = 2.6). Its correlation with mean DAI-10 scores was r = 0.633, with p < 0.001. Relapse prevention and a stricter treatment control from therapists were the main reported advantages. Perceived stigma was the main disadvantage. Features increasing device discretion would enhance its acceptability. CONCLUSIONS: The data suggest that transdermal sensors could play a role in the clinical treatment of alcohol outpatients and concerns regarding stigma should be taken into account. Future designs should try to minimize size and visibility and stigma concerns should be discussed with patients.

Identifying Triggers of Alcohol Craving to Develop Effective Virtual Environments for Cue Exposure Therapy.

Background: Many studies have indicated that alcohol craving is a core mechanism in the acquisition, maintenance, and precipitation of relapse in alcohol use disorder (AUD). A common treatment approach in AUD is cue exposure therapy (CET). New technologies like virtual reality (VR) have the potential to enhance the effectiveness of CET by creating realistic scenarios in naturalistic environments. In this study, we aimed to determine relevant triggers of alcohol craving in patients with AUD. Methods: We enrolled 75 outpatients diagnosed with AUD according to the DSM-5 criteria Participants completed the Alcohol Use Disorder Identification Test and a self-administered questionnaire to assess alcohol craving. The variables included in the craving questionnaire were as follows: presence of others, situations, time of the day, day of the week, mood, and type of alcoholic beverage. Results: Greater levels of alcohol craving were seen in many situations, including being at a party, in a restaurant, in a bar or pub, and at home. Drinking alone and drinking with two or more friends were equally associated with higher levels of craving. Drinking at night and drinking at weekends also emerged as triggers for alcohol craving. Emotional states like anxiety or tension, sadness, stress, frustration, or irritability were highly associated with urges to drink alcohol. The alcoholic drinks most highly associated with increased levels of craving were beer, wine, and whisky. Gender and age implications were discussed. Conclusion: This study is part of a larger project aiming to develop and validate CET based on VR technology for patients with AUD who are resistant to classical treatment. The identified triggers have been used to develop relevant VR environments for CET, and further research is ongoing to implement our findings.

Filling the gap between lab and clinical impact: An open randomized diagnostic trial comparing urinary ethylglucuronide and ethanol in alcohol dependent outpatients.

BACKGROUND: Efforts aimed at reducing alcohol-related harm include early detection of risky drinkers as well as detection of early relapse in patients with alcohol dependence. Ethyl glucuronide (EtG) has been proven to be a reliable biomarker for the detection of recent drinking; however, no randomized, diagnostic trial to date has tested its impact on drinking outcomes. The aim of this study was to assess, in a randomized design, the implications of EtG screening on alcohol outcomes, compared to screening with a low sensitivity biomarker such as ethanol. METHODS: Alcohol dependent outpatients were randomized to either 24 weeks of continuous screening with EtG or ethanol. Patients were aware of screening methods and results. After 24 weeks, all participants were screened with EtG. Self-reports were also gathered. A logistic regression compared the rate of EtG positive results at study end between groups. Generalized estimating equations evaluated the descending monthly rate of EtG positive patients in the EtG group. RESULTS: A total of 162 patients were randomized. During the study period, the ethanol group showed less patients with positive screens (19/64 (29.7%) vs 58/98 (59%)). After 24 weeks, the EtG group showed a greater number of patients having a negative screening test compared to ethanol subjects when they were all screened with EtG (5/62 (8.1%) vs 13/39 (33.3%)). A significant decrease in the rate of EtG positive patients was found for the first three months of the study. CONCLUSIONS: Routine screening with EtG seems to reduce drinking and improve abstinence rates in alcohol dependent outpatients.

One Year Clinical Correlates of EtG Positive Urine Screening in Alcohol-Dependent Patients: A Survival Analysis.

AIMS: Little evidence exists supporting the efficacy of regular alcohol urine screening (RAUS) in the management of alcohol dependence, despite recent improvements in urine biomarkers. In this study, we aimed at investigating 1 year, differential clinical correlates between a positive and a negative baseline urine ethyl glucuronide (EtG) screening. METHODS: Alcohol-dependent outpatients participating in a previous cross-sectional study where EtG and ethanol diagnostic performances were compared in a double blind design were included. After 1 year, the presence of relapse, the number of hospitalizations and whether patients had abandoned treatment or not were assessed from electronic medical records. A survival analysis was conducted to compare time to relapse between EtG negative and positive subjects. Regression models were performed to compare the mean number of days hospitalized between groups, the risk of being lost to follow-up and treatment expenses. RESULTS: Of note, 152 patients (mean age 52, 67% males) were included. The mean time to relapse was of 163 days in EtG positive subjects, compared to 329 days in those with a negative result. In the Cox-regression model, only EtG positivity yielded significant results, with a hazard ratio of 5:3 (95% CI: 3.1-9.1). EtG positive was also the only significant predictor of a greater number of hospitalization days and treatment expenses. Younger age was the only variable predicting a greater risk of treatment abandonment. CONCLUSION: RAUS with sensible biomarkers could improve clinicians' ability to assess patients' relapse risk. Further prospective studies will have to determine if this can be translated into a better prevention capacity. SHORT SUMMARY: Positive urine screenings, when conducted with highly sensible alcohol biomarkers, significantly indicate a greater risk of relapse in alcohol-dependent patients and have the capacity to predict a greater risk of hospitalization and greater treatment expenses.

Patients' Knowledge and Attitudes Towards Regular Alcohol Urine Screening: A Survey Study.

BACKGROUND: Despite its wide implementation, there is a paucity of data supporting the effectiveness of regular alcohol urine screening (RAUS) in maintaining abstinence. This study aims at investigating if RAUS serves other purposes, what attitudes patients display towards it, and patients' technical knowledge about basic screening notions. METHOD: We conducted a cross-sectional survey among adults with alcohol dependence, attending outpatient alcohol-dependence treatment. It aimed at investigating patients' attitudes and beliefs towards RAUS, and technical notions of alcohol urine screening. For attitude assessment, we adapted the Drug Attitude Inventory (DAI-10) to the field of alcohol urine screening. Internal consistency, test-retest reliability, and concurrent validity were evaluated for the adapted questionnaire. RESULTS: In all, 128 patients completed the questionnaire. Patients rated RAUS as high. The DAI-10 mean score was 7.2 (SD = 3.6). Internal consistency analysis revealed a Cronbach alpha of 0.718. Test-retest reliability evaluation yielded an intraclass correlation coefficient of 0.932. The score of a single Likert-type question about overall perceived value was 8.5 (SD = 2). Their correlation with mean DAI-10 score was of r = 0.254, with P = 0.009. Apart from relapse prevention, patients frequently reported other functions such as showing professionals and family members that they do not drink, or having a closer contact with professionals. A majority of patients believed alcohol use goes undetected after 48 hours from last ingestion. CONCLUSION: Regular alcohol screening is highly valued by alcohol outpatients. It seems that apart from relapse prevention, other functions related to therapeutic alliance building, social desirability, and impression management also play a key role.

Urine Ethyl Glucuronide Unraveling the Reality of Abstinence Monitoring in a Routine Outpatient Setting: A Cross-Sectional Comparison with Ethanol, Self Report and Clinical Judgment.

AIMS: To test the screening performance of urinary ethyl glucuronide (EtG) under routine clinical conditions in a sample of alcohol-dependent outpatients, comparing it against urinary ethanol, self reports and clinical judgment. METHODS: A cross-sectional study under routine conditions was conducted in February 2015, where 613 consecutive urinary samples, provided by 188 outpatients with alcohol use disorders, were analyzed for ethanol and EtG (cut-off level = 500 ng/ml). Clinical variables such as the presence of aversive medication, comorbidities and clinician judgment were also collected. The discrepancy between the number of alcohol and EtG positives was recorded. A logistic regression analysis including clinical variables was conducted to assess for predictors of EtG positivity. RESULTS: Urinary alcohol yielded 9 positives (1.5% of all urine samples) belonging to 8 patients. EtG yielded 136 positives (22% of all urine samples) belonging to 74 patients. Of these, 93.4% (127 of 136) were negative for alcohol. All urinary alcohol positives resulted in EtG positives. The clinician judged 48 samples from 26 patients as belonging to not abstinent patients and 550 samples from 178 patients as belonging to abstinent patients. She was unsure in 15 samples from 15 patients. When comparing it against EtG as the gold standard, the area under the curve was 0.592. Self reports were extremely unreliable in this study, with only 5 patients reporting drinking in a total of 6 urine samples. In the logistic regression model, only aversive medications (OR 2.1, 95% CI 1.3-3.3) and clinician judgment (OR 2, 95% CI 1.4-2.9) resulted in significant effects. CONCLUSIONS: EtG performed largely better than ethanol for urine screening in alcohol outpatients, detecting an extra 20.4% (125 out of 613) of positives. It means that for each alcohol-positive sample, there were 15 EtG-positive samples. Although better than ethanol, clinician judgment was also not performed efficiently. If routinely implemented in the screening of alcohol outpatients, EtG might bring relevant changes that merit further research.

Alcohol in Primary Care. Differential characteristics between alcohol-dependent patients who are receiving or not receiving treatment. / El Alcohol en Atención Primaria. Características diferenciales entre los pacientes dependientes del alcohol que han solicitado o no tratamiento.

primary health care services for other reasons. The aim of the present study is to describe the differential characteristics of AD patients in primary care, distinguishing between those who receive treatment and those who do not, and their reasons for not seeking it. In a cross-sectional study patients were evaluated by their general practitioner (GP) and interviewed by a member of the research team. Sociodemographic, diagnostic and clinical data were collected. From 1,372 patients interviewed in Catalonia, 118 (8.6%) were diagnosed as AD. These patients showed a lower socioeconomic status (48.3% vs 33.3%, odds ratio 2.02), higher unemployment rates (32.2% vs 19.2 %, odds ratio 2.11), and greater psychological distress and disability. Patients with AD receiving treatment (16.9%), were older (44 vs 36 years of age), reported higher unemployment rates (66% vs 25.5%, odds ratio 6.32) and higher daily alcohol consumption (61.5 vs 23.7 grams), suggesting a more advanced disease. Patients with AD in general showed a higher degree of comorbidity compared to other patients, with patients in treatment showing the most elevated level. The main reasons given for not seeking treatment were shame, fear of giving up drinking and barriers to treatment. Taken together, the data suggest the need to implement earlier strategies for the detection and treatment of AD.

A pesar de la elevada morbi-mortalidad de la dependencia del alcohol (DA), pocos pacientes afectos reciben tratamiento. Sin embargo, muchos de ellos son visitados en atención primaria por otras razones. El objetivo del presente estudio es describir las características diferenciales de los pacientes dependientes del alcohol atendidos en Atención Primaria, distinguiendo también entre aquellos que realizan tratamiento o no, y los motivos por los que no lo solicitan.Se trata de un estudio transversal en el que los pacientes fueron entrevistados tanto por sus médicos de atención primaria (MAP) como por un investigador del estudio. Se recabaron datos sociodemográficos, diagnósticos y clínicos.De 1372 entrevistados, 118 (8,6%) fueron diagnosticados de DA. Éstos presentaron un nivel socioeconómico más bajo (48.3% vs 33.3%, odds ratio 2.02), más desempleo (32.2% vs 19.2 %, odds ratio 2.11), y mayores niveles de malestar psicológico y de incapacidad. Los que recibían tratamiento (16,9%), tenían más edad (44 vs 36 años), mayores tasas de desempleo (66% vs 25.5%, odds ratio 6.18) y mayor consumo diario de alcohol (61.5 vs 23.7 gramos), sugiriendo una mayor evolución de la enfermedad. La mayoría de variables clínicas analizadas mostraron una mayor comorbilidad en los pacientes afectos de dependencia del alcohol, y dentro de éstos, una mayor gravedad en los que recibían tratamiento respecto a los que no lo hacían. Las principales razones esgrimidas para no acudir a tratamiento fueron la vergüenza, el miedo a dejar de beber y las barreras para acceder al tratamiento. Estos datos sugieren pues la necesidad de implementar estrategias de detección y tratamiento precoces de la DA.

El Alcohol en Atención Primaria. Características diferenciales entre los pacientes dependientes del alcohol que han solicitado o no tratamiento / Alcohol in Primary Care. Differential characteristics between alcohol dependent patients receiving or not treatment

A pesar de la elevada morbi-mortalidad de la dependencia del alcohol (DA), pocos pacientes afectos reciben tratamiento. Sin embargo, muchos de ellos son visitados en atención primaria por otras razones. El objetivo del presente estudio es describir las características diferenciales de los pacientes dependientes del alcohol atendidos en Atención Primaria, distinguiendo también entre aquellos que realizan tratamiento o no, y los motivos por los que no lo solicitan. Se trata de un estudio transversal en el que los pacientes fueron entrevistados tanto por sus médicos de atención primaria (MAP) como por un investigador del estudio. Se recabaron datos sociodemográficos, diagnósticos y clínicos. De 1372 entrevistados, 118 (8,6%) fueron diagnosticados de DA. Éstos presentaron un nivel socioeconómico más bajo (48.3% vs 33.3%, odds ratio 2.02), más desempleo (32.2% vs 19.2 %, odds ratio 2.11), y mayores niveles de malestar psicológico y de incapacidad. Los que recibían tratamiento (16,9%), tenían más edad (44 vs 36 años), mayores tasas de desempleo (66% vs 25.5%, odds ratio 6.18) y mayor consumo diario de alcohol (61.5 vs 23.7 gramos), sugiriendo una mayor evolución de la enfermedad. La mayoría de variables clínicas analizadas mostraron una mayor comorbilidad en los pacientes afectos de dependencia del alcohol, y dentro de éstos, una mayor gravedad en los que recibían tratamiento respecto a los que no lo hacían. Las principales razones esgrimidas para no acudir a tratamiento fueron la vergüenza, el miedo a dejar de beber y las barreras para acceder al tratamiento. Estos datos sugieren pues la necesidad de implementar estrategias de detección y tratamiento precoces de la DA

Despite its high associated morbidity and mortality, few alcoholdependent (AD) patients receive treatment. However, many use primary health care services for other reasons. The aim of the present study is to describe the differential characteristics of AD patients in primary care, distinguishing between those who receive treatment and those who do not, and their reasons for not seeking it. In a cross-sectional study patients were evaluated by their general practitioner (GP) and interviewed by a member of the research team. Sociodemographic, diagnostic and clinical data were collected. From 1,372 patients interviewed in Catalonia, 118 (8.6%) were diagnosed as AD. These patients showed a lower socioeconomic status (48.3% vs 33.3%, odds ratio 2.02), higher unemployment rates (32.2% vs 19.2 %, odds ratio 2.11), and greater psychological distress and disability. Patients with AD receiving treatment (16.9%), were older (44 vs 36 years of age), reported higher unemployment rates (66% vs 25.5%, odds ratio 6.32) and higher daily alcohol consumption (61.5 vs 23.7 grams), suggesting a more advanced disease. Patients with AD in general showed a higher degree of comorbidity compared to other patients, with patients in treatment showing the most elevated level. The main reasons given for not seeking treatment were shame, fear of giving up drinking and barriers to treatment. Taken together, the data suggest the need to implement earlier strategies for the detection and treatment of AD