# Psychosocial Treatments and Combined Approaches -- APA 2018

## Statement 8: Evidence-Based Treatment Planning (1C)

APA recommends (1C) that patients with alcohol use disorder have a **documented comprehensive and person-centered treatment plan** that includes evidence-based nonpharmacological and pharmacological treatments.

- Treatment plans should integrate psychosocial interventions with pharmacotherapy.
- The treatment plan should be individualized based on AUD severity, patient preference, co-occurring conditions, prior treatment response, and psychosocial resources.
- Plans should be documented and revisited regularly.

## Evidence-Based Psychosocial Treatments

### Motivational Enhancement Therapy (MET) / Motivational Interviewing (MI)

- **Description:** A brief, patient-centered approach that helps patients explore and resolve ambivalence about changing drinking behavior.
- **Key principles:** Express empathy, develop discrepancy between current behavior and goals, roll with resistance, support self-efficacy.
- **Evidence:** Project MATCH (1997) demonstrated that MET (4 sessions) produced comparable outcomes to more intensive CBT (12 sessions) and Twelve-Step Facilitation (12 sessions) on drinking outcomes at 1-year follow-up.
- **Best suited for:** Patients who are ambivalent about change, early engagement, patients with mild-to-moderate AUD.
- **Typical format:** 1-4 sessions.

### Cognitive-Behavioral Therapy (CBT)

- **Description:** A structured psychotherapy that teaches patients to identify and modify maladaptive thoughts and behaviors related to drinking, develop coping skills, and manage triggers.
- **Core components:**
  - Functional analysis of drinking behavior
  - Coping skills training (refusal skills, problem-solving, managing cravings)
  - Cognitive restructuring (challenging beliefs about alcohol)
  - Relapse prevention planning
- **Evidence:** Multiple RCTs demonstrate efficacy in reducing drinking and maintaining sobriety. CBT combined with pharmacotherapy (naltrexone) showed improved outcomes in the COMBINE trial.
- **Typical format:** 12-20 sessions, individual or group.

### Twelve-Step Facilitation (TSF)

- **Description:** A structured clinical intervention designed to increase engagement with Alcoholics Anonymous (AA) and other 12-step mutual-help organizations.
- **Core components:**
  - Education about the 12-step model of recovery
  - Acceptance of AUD as a chronic condition
  - Active engagement in AA meetings and activities
  - Sponsor relationship development
- **Evidence:** Project MATCH found TSF produced outcomes comparable to CBT and MET. Cochrane review (Ferri et al.) found participation in AA/TSF programs was associated with significantly higher rates of continuous abstinence.
- **Best suited for:** Patients whose goal is abstinence, patients who benefit from peer support and social reinforcement.

### Contingency Management

- **Description:** Provides tangible reinforcements (e.g., vouchers, prizes) contingent on documented abstinence (e.g., negative breathalyzer or urine tests).
- **Evidence:** Strong evidence for increasing short-term abstinence rates. Effects may diminish after contingencies are removed.
- **Best suited for:** Patients in structured treatment settings (e.g., intensive outpatient programs, Veterans Affairs settings).

### Community Reinforcement Approach (CRA)

- **Description:** A comprehensive behavioral intervention that restructures the patient's social and vocational environment to make sober behavior more rewarding than drinking.
- **Core components:**
  - Functional analysis of drinking
  - Skills training (communication, problem-solving, drink refusal)
  - Social/recreational counseling
  - Job skills training
- **Evidence:** Multiple controlled trials show efficacy, particularly when combined with contingency management.

## Combined Pharmacotherapy and Psychosocial Treatment

### The COMBINE Trial

The COMBINE trial (Anton et al., JAMA 2006) was the largest U.S. multisite RCT evaluating AUD treatments (n=1,383). Key findings:

| Treatment Arm | Outcome (% days abstinent) | Notes |
|---|---|---|
| **Naltrexone + medical management** | 80.6% | Effective; medical management alone provides benefit |
| **CBI (combined behavioral intervention) alone** | 79.2% | Effective without pharmacotherapy |
| **Naltrexone + CBI** | 77.1% | Not significantly better than naltrexone + medical management |
| **Acamprosate + medical management** | 74.5% | Not significantly different from placebo in this trial |
| **Placebo + medical management** | 75.1% | Medical management provides substantial benefit |

### Key Implications for Combined Treatment

- **Pharmacotherapy with basic medical management** can produce outcomes comparable to more intensive behavioral interventions.
- **Medical management** (brief visits with medication monitoring, encouragement, and direct advice to reduce/stop drinking) is an effective delivery platform for pharmacotherapy.
- Adding **intensive behavioral intervention (CBI) to naltrexone** did not produce significant additional benefit beyond naltrexone with medical management alone.
- **Either pharmacotherapy or specialized behavioral intervention** can be effective, and the combination does not necessarily produce additive benefits.
- The choice between pharmacotherapy and psychosocial treatment should be guided by patient preference, availability, and clinical context.

## Treatment Setting Selection

```
AUD severity assessment
  -> Mild AUD (2-3 criteria)
      -> Brief intervention / motivational interviewing
      -> Consider outpatient psychosocial treatment
      -> Pharmacotherapy may be considered but is not routinely recommended for mild AUD by this guideline
  -> Moderate AUD (4-5 criteria)
      -> Outpatient treatment (pharmacotherapy + psychosocial intervention)
      -> Naltrexone or acamprosate (1B) + psychosocial treatment
      -> Consider IOP (intensive outpatient program) if outpatient insufficient
  -> Severe AUD (6+ criteria)
      -> Pharmacotherapy strongly recommended
      -> Structured treatment program (IOP or residential)
      -> Medical withdrawal management if needed
      -> Consider injectable naltrexone for adherence
  -> Co-occurring severe psychiatric disorder?
      -> Integrated dual-diagnosis treatment
      -> Coordinate addiction and psychiatric care
  -> Medical withdrawal risk (history of seizures, DT)?
      -> Inpatient medical detoxification before outpatient treatment
```

## Mutual-Help Organizations

- **Alcoholics Anonymous (AA)** and other 12-step programs are widely available, free, and provide ongoing peer support.
- APA notes that mutual-help participation is associated with improved long-term outcomes and should be encouraged as an **adjunct** to formal treatment, not as a replacement.
- Referral to mutual-help organizations should be offered to all patients with AUD.
- Alternative mutual-help organizations (e.g., SMART Recovery, Moderation Management) may be appropriate for patients who do not align with the 12-step model.

## Monitoring and Follow-Up

- **Regular follow-up** is essential to assess treatment response, monitor medication adherence and side effects, and adjust the treatment plan.
- Use quantitative measures (AUDIT-C, self-reported drinking days, biomarkers) to track progress.
- Treatment response should be reassessed at **4-8 weeks**; if insufficient improvement, consider:
  - Increasing medication dose (within approved range)
  - Switching to an alternative medication
  - Adding or intensifying psychosocial treatment
  - Reassessing treatment goals and patient motivation

> **OpenMedicine Calculator:** `calculate_audit_c` -- available via MCP for automated scoring to monitor treatment response.

## Limitations

- The COMBINE trial, while seminal, may not generalize to all clinical settings or populations (e.g., participants were highly selected and relatively medically stable).
- Optimal sequencing and combination of psychosocial and pharmacological treatments remain incompletely understood.
- Few RCTs have directly compared different psychosocial modalities head-to-head in modern AUD populations.
- The guideline's pharmacotherapy focus means psychosocial recommendations are less extensively graded compared to medication statements.
- Long-term outcomes (> 1 year) for most combined treatment approaches remain under-studied.
