Do patients benefit from an Attentional Avoidance Training during an inpatient alcohol detoxification?

Alcohol addiction is a common disorder in the Netherlands, with 0.7% of the
Dutch people meeting the criteria of an alcohol addiction (965.331 persons, 15
years or older, ICD-10, WHO, 2014).
Nowadays, the treatment of addiction in the Netherlands is primarily
directed towards Cognitive Behavioural Therapy (CBT). This treatment targets
the conscious cognitive processes which might be a possible reason of the
limited success rates (Heitmann et.al., 2017). Dual process models became
increasingly important in the explanation and treatment of addiction problems.
It assumes that addictive behaviours are characterized by an imbalance between
two independent but interacting information processing systems (Bechara, 2005,
Stacy & Wiers, 2010, Manning, 2016), namely the impulsive and the
reflective/executive system. The hypothetical imbalance between impulsive and
reflective processes has been related to a number of cognitive biases (Wiers et
al, 2013). These cognitive biases include an attentional bias (the tendency for
alcohol-related cues in the environment to selectively capture attention) for
alcohol-related stimuli (Field & Cox, 2008), a memory bias for the automatic
activation of alcohol-related associations (Wiers, Van Woerden, Smulders, & De
Jong, 2002), and a bias toward automatically activated action tendencies to
approach alcohol (Palfai & Ostafin, 2003).
Cognitive Bias Modification (CBM) is a new training method to target
these cognitive biases (Wiers et al., 2013). Wiers and colleagues developed the
alcohol approach/avoidance task (Alcohol-AAT) to assess a potential bias in the
action tendency to approach (versus avoid) alcohol stimuli (Wiers, Rinck,
Dictus, & Van den Wildenberg, 2009). The use of alcohol-AAT in the treatment of
alcohol-addicted participants has proven to be effective in reducing alcohol
relapse in Germany and Australia (Manning et al., 2016, Eberl et al., 2013,
Wiers et al, 2011).
In his Australian study, Manning concludes that detoxification could be a
potential critical time to modify approach bias (Manning et al., 2016). Patient
detoxification may be an opportunity to capitalize on neural recovery via
neurocognitive interventions that retrain cognitive biases (Manning et al.,
2016). If confirmed, one reason could be that this early period of abstinence
from alcohol is a particularly high-risk time for relapse. Studies reporting
that 50 to 80% of addicted drinkers resume drinking following detoxification
(Garbusow et al., 2014; Miller and Kavanagh, 2011; Sanghani et al., 2015),
often within the first few days or weeks (De Wilde et al., 2014; Miller and
Kavanagh, 2011). Summarizing: the results that are achieved in previous CBM
studies with an AAT low-cost adjunctive treatment are promising, and more
research is highly desirable.

The aims of the present study are: (1) to assess for the first time in the
Netherlands the effectiveness of an adjunctive Alcohol Avoidance Training (AAT)
during inpatient alcohol detoxification to improve treatment outcomes. (2) To
investigate for the first time in Europe if the timing of the training is
distinctive comparing AAT during inpatient detoxification versus AAT after
inpatient detoxification in terms of improving treatment outcomes. (3) The
expectations, acceptability and feasibility of the AAT training will be
investigated. If proven effective and feasible, this AAT training could be
easily implemented as a low-cost adjunctive treatment to improve treatment
outcomes for alcohol-dependent patients.

A multicentre randomized controlled trial, with a repeated-measures design

After giving written informed consent, participants will be randomised and
allocated to one of the four Alcohol Avoidance Training (AAT) during or after
their inpatient alcohol detoxification (TAU):
1. a group of TAU + AAT during alcohol inpatient detoxification treatment
2. a group of TAU + placebo AAT during alcohol inpatient detoxification
treatment
3. a group of TAU + AAT after alcohol inpatient detoxification treatment
4. a group of TAU + placebo AAT after alcohol inpatient detoxification treatment

Participants will receive five AAT sessions during the first three weeks of
their inpatient treatment, or after week 3 to week 5 if they were allocated in
the after inpatient detoxification condition. During the AAT training,
participants are instructed to respond to certain types of images: with an
approach movement (pulling a joystick) or with an avoidance movement (pushing a
joystick). By pulling a joystick the size of the picture increases, while
pushing the lever decreases the size of the picture (Wiers et al., 2009).

There are no risks associated with participating in the study. Participants are
asked to complete the five AAT sessions during the first three weeks of the
inpatient alcohol detoxification treatment or after. AAT takes a maximum of 20
minutes per session. In addition, they are asked to report their level of
craving before and after each session (VAS, one question). Before the first AAT
and at the follow-up measurements, they are asked to complete five
questionnaires. Consisting of questions about substance use (4 questions),
craving (5 questions), psychological complaints (21 questions), AAT
expectations (4 questions) and AAT evaluation (acceptability and feasability)
(15 questions).