'Alcohol use disorder' (AUD) is used by several contemporary conceptualizations to identify, treat and prevent problems associated with alcohol use. Such conceptualizations encompass diagnostic ...classifications and broader frameworks for policy and practice. However, current AUD concepts are subject to multiple tensions and limitations in capturing and responding to the complex and heterogeneous nature of alcohol problems. Further, public understandings of alcohol problems are heavily divergent from professional AUD concepts and remain embedded within an 'alcoholism' master narrative in which disease model stereotypes come with multiple costs for prevention and 'recovery'. The persistence of a problematic 'alcoholism' paradigm reflects the coalescing of multiple forces including the cognitive appeal of reductionism, motives to stigmatize and 'other', and an over-emphasis on AUD as an individually located biomedical problem. Public misperceptions of AUD as a matter of the individual, the individual's essence, and misconceived notions of responsibility and control have been bolstered by industry interests and the ascension of neuroscience and genetics, in turn diverting attention from the importance of the environmental and commercial determinants of health and the effectiveness of under-utilized public health policies. We call for multiple stakeholders to support efforts to prioritize a public health first approach to advancing AUD research, policy and treatment in order to make significant advances in AUD prevention and treatment. We offer several recommendations to assist in shifting public understanding and scientific limitations in AUD concepts and responses.
Precision medicine has been advanced as a potential solution to the problem of alcohol use disorder heterogeneity and modest alcohol use disorder treatment efficacy. The success of precision medicine ...lies in our ability to first identify the etiologic and maintenance mechanisms at play for a given person and then choose the treatment that is most likely to address such mechanisms. There exist several frameworks that describe empirically supported substance use disorder (SUD) etiologic and maintenance mechanisms (e.g., the Etiologic, Theory-based, Ontogenetic, Hierarchical ETOH Framework). There also exists a large literature on mechanisms of behavior change in alcohol use disorder treatment. However, the mechanism of behavior change literature on alcohol use disorder treatments has focused broadly on mechanisms of change rather than more specifically on core alcohol use disorder etiologic and maintenance mechanisms. Thus, the two types of mechanisms have never been integrated or systematically evaluated for their overlap. As such, the aim of the present brief review is to demonstrate how commonly used alcohol use disorder treatments may overlap with and directly target certain alcohol use disorder etiologic and maintenance mechanisms (specifically those described by the ETOH framework). We delineate empirically plausible overlapping mechanisms and theoretically plausible overlapping mechanisms that warrant more research. Last, based on the identification of empirically and theoretically plausible overlapping mechanisms, we elaborate on how ongoing work related to alcohol use disorder precision medicine may test specific hypotheses regarding which treatments work best for whom.
Public Health Significance
This review highlights the overlap between processes that (a) cause and maintain an alcohol use disorder and (b) cause behavior change in alcohol use disorder treatment. By leveraging this overlap between processes, we may be able to better identify treatment targets and improve the efficacy of existing treatments.
Objective: Level of response (LOR) to alcohol is associated with several alcohol-related risk factors and outcomes. However, existing self-report measures of LOR have important limitations. For ...example, the Self-Rating of the Effects of Alcohol Scale assesses a limited range of alcohol-related effects. Although the Alcohol Sensitivity Questionnaire (ASQ) samples a broader range of effects, it uses different probes across effects, confounding type of effect with method variation associated with the use of different probes. Focusing on the ASQ, we systematically evaluate variation in estimated LOR as a function of how number of drinks to achieve an effect is probed. Our approach addresses a major limitation of existing LOR measures which fail to account for sensitivity variability across drinking occasions. Method: This study randomized 732 adult drinkers into one of four versions of the ASQ that assessed sensitivity to 15 alcohol-related effects, systematically varying the follow-up probes. Results: Accounting for (a) the minimum number of drinks consumed before feeling an effect and (b) the maximum number of drinks consumed without feeling an effect for all effects is superior to the original ASQ approach in predicting relevant outcomes. Conclusions: Assessments of sensitivity should probe for minimum and maximum number of drinks across each of the effects. If impractical to probe for both, consistently probing for maximum number of drinks is desirable.
Public Health Significance Statement
Level of response (LOR) to alcohol is associated with a range of alcohol-related risk factors and outcomes. The present study demonstrates the value of refining the assessment of LOR by considering variability in sensitivity across drinking occasions. Improved assessment can lead to improved detection of those with low LOR who may be at the most risk for alcohol dependence and related problems.
Modern nosologies (e.g., International Classification of Diseases, 11th edition ICD-11, Diagnostic and Statistical Manual of Mental Disorders, 5th edition DSM-5) for alcohol use disorder (AUD) and ...dependence prioritize reliability and clinical presentation over etiology, resulting in a diagnosis that is not always strongly grounded in basic theory and research. Within these nosologies, DSM-5 AUD is treated as a discrete, largely categorical, but graded, phenomenon, which results in additional challenges (e.g., significant phenotypic heterogeneity). Efforts to increase the compatibility between AUD diagnosis and modern conceptualizations of alcohol dependence, which describe it as dimensional and partially overlapping with other psychopathology (e.g., other substance use disorders), will inspire a stronger scientific framework and strengthen AUD's validity. We conducted a systematic review of 144 reviews to integrate addiction constructs and theories into a comprehensive framework to identify fundamental mechanisms implicated in AUD. The product of this effort was the Etiologic, Theory-based, Ontogenetic Hierarchical Framework (ETOH Framework) of AUD mechanisms, which outlines superdomains of cognitive control, reward, and negative valence and emotionality, each of which subsume narrower, hierarchically organized components. We also outline opponent processes and self-awareness as key moderators of AUD mechanisms. In contrast with other frameworks, we recommend an increased conceptual role for negative valence and compulsion in AUD. The ETOH framework serves as a critical step toward conceptualizations of AUD as dimensional and heterogeneous. It has the potential to improve AUD assessment and aid in the development of evidence-based diagnostic measures that focus on key mechanisms in AUD, consequently facilitating precision medicine.
Public Significance Statement
Alcohol use disorder is a significant public health problem, and there is a need for improving the identification and treatment of individuals with the disorder. The current review aims to identify the causal factors implicated in alcohol use disorder by synthesizing key findings into a comprehensive etiologic framework. This framework serves as a starting point for additional research and offers several implications for the diagnosis and treatment of alcohol use disorder.
Subjective effects generally describe the feelings one has when consuming substances. There are several tools available for measuring alcohol-related subjective effects but there are reasons to ...believe that effects are interpreted differently across participants. The assessment of alcohol-related subjective effects is further complicated by the fact that many people use other substances with alcohol, including cannabis. The present study used a mixed-methods approach to evaluate interpretations of 21 subjective effects used in common assessments among a college student sample (N = 99; primarily White 79%, Hispanic 60% women 74%, 72% of which reported lifetime couse of alcohol and cannabis). We sought to (a) estimate the prevalence of each effect and the amount of alcohol/number of drinks (and, for those with simultaneous use, amount of cannabis/number of hits) required to experience each effect and (b) evaluate how participants interpreted each effect that they had ever experienced when drinking (for our sample who had used only alcohol) or when simultaneously using alcohol and cannabis (for our sample who had reported simultaneous use). Across both samples, we found that several effects were far more common than others and participants had varied interpretations of each subjective effect. Further, qualitative results demonstrated that participants interpreted some subjective effects in a way that differed from the original intention of the measure. Results suggest a degree of measurement error when using common subjective effects assessment tools. Findings lay the groundwork for standardized measures of subjective effects for simultaneous use and have implications for future real-world assessment and intervention work.
Public Health Significance
Alcohol-related subjective effects, or feelings one has when consuming alcohol, are strongly related to alcohol use outcomes but little is known about how participants interpret individual effects on widely used scales. This study evaluated participant interpretations of subjective effects related to alcohol use only, as well as alcohol with cannabis use. Results suggest some effects were more common than others and participants had varied interpretations of each subjective effect, which may impact the reliability of assessments.
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