How does alcohol use begin? What are the effects of alcohol abuse? Why do some people begin using it in excess? Why is it so difficult for some to stop? How do we treat and prevent excessive alcohol use?
When you stop to think about it, virtually all of the major questions about alcohol abuse and dependence involve behavior: So it shouldn’t be surprising that psychology is one of the most common disciplines in alcohol research. Yet, some people might be surprised.
Compared to mental health, aging, or other areas of psychological research, alcohol research traditionally has not been regarded as a major specialty within psychology. But alcohol research presents a wide range of opportunities for psychologists, from basic brain research to treatment, prevention, and health services research. Most of these opportunities are through the National Institute on Alcohol Abuse and Alcoholism (NIAAA), which provides more than $50miJIion in funding for psychologists.
Looking at it another way, psychology doctorate is the most common degree among principle investigators (PI) funded by NIAAA, with approximately 30 percent of PIs having a degree in psychology.
Despite this strong showing, psychology has not been as visible within the field of alcohol research as other disciplines, such as neuroscience and pharmacology. However, the contributions of psychologists are increasingly being recognized. (One leader in the field, Henri Begleiter, is profiled on page 15.) And efforts are being made to expand behavioral science approaches in alcohol research.
“The consumption of alcohol is a complex behavior and efforts to understand this behavior are fundamental to alcohol research,” notes NIAAA Director Enoch Gordis. “It is thus not surprising that behavioral studies are an indispensable part of this field, advancing our understanding of why people drink, why some progress to harmful drinking, how drinking can influence risk-taking behaviors, and “how we can effectively prevent and treat the problems associated with alcohol abuse and alcoholism.”
NIAAA’s basic behavioral research portfolio focuses on the brain-based effects of alcohol, including studies on topics such as addictive behaviors in animals; inheritance patterns; genetic markers for alcohol risk; and deleterious effects of alcohol abuse on cognitive and behavioral functioning.
In studying brain damage from prenatal exposure to alcohol, for example, APS members Sarah Mattson and Edward Riley of San Diego State University have used neuroimaging techniques and behavioral evaluations to identify abnonnalities in brain structures of older children with a history of prenatal alcohol exposure and behavioral and cognitive problems. Significantly, these abnormalities were seen in individuals who were not diagnosed with fetal alcohol syndrome (FAS). The researchers also conducted animal studies that confirmed their findings in humans. These studies represent significant contributions to the knowledge base about the origins of behavioral deficits and other long-term effects from prenatal alcohol exposure.
NIAAA also has supported psychologist George Koob, a well-known neuroscientist who looked at brain systems involved in such behaviors as reward, motivation, and reinforcement in alcohol and drug abuse. In reviewing the research in this area, Koob, an APS member, noted that several studies point to a prominent role by the brain dopamine system in the pleasurable effects of even low amounts of alcohol. This information is important in understanding the neurochemical underpinnings of the transition from controlled use to addiction. It also sets the stage for future work in the psychopathology of alcohol abuse.
In conjunction with research into the interactions of individual environmental, and social factors involved in the use of alcohol and the transition to alcoholism, basic behavioral research plays an important role in understanding the origins and effects of alcohol abuse and in developing prevention and treatment strategies.
“Our challenge in future alcohol research,” according to Stephen Long, director of the NIAAA Office of Policy Analysis, “will be to learn more about how biology and behavior interact to influence drinking and its related problems and to apply this knowledge to the development of effective prevention and treatment strategies.”
Effects on Cognition
One of the most exciting areas of alcohol research is the work being done in alcohol abuse and cognition. Impaired cognition the acquiring, storing, retrieving, and use of knowledge- has long been associated with chronic abuse of alcohol. Variations in the cognitive deficits in detoxified alcoholics present significant challenges to researchers. Severe deficits were known to exist, but with more sensitive tests of psychological functioning, there is an accumulating body of evidence about the milder cognitive impairments resulting from chronic alcohol abuse. Understanding cognitive deficits has significant implications for treatment, since such deficits can affect the individual’s ability to learn-an ability that is necessary for many forms of alcohol therapies.
As coauthor of an NIAAA-sponsored paper, APS Member Marlene Oscar-Berman described the status of research in this area. She reports that several theoretical models of impaired cognition have been developed to explain different cognitive deficits. The models fall into two basic categories: those which focus on the relationship between brain structure and function, and those that are process-oriented, meaning they examine the nature of observed cognitive decline apart from brain structure.
Although no single model defines all the impairments alcoholics experience, process-oriented models are proving useful in describing alcohol-related cognitive deficits, and offer important alternatives to looking at impairment simply in terms of brain structure. For example, researchers have used this approach to assess different levels of impairment in separate dimensions of memory (i.e., long -term versus short-term, dec1arative versus procedural, episodic versus semantic). These distinctions are important since individuals can be impaired in one dimension but not in the others. This approach also has been used to pinpoint which of the various processes involved in storing and retrieving different kinds of information (i.e., episodic or context –bound information versus information related to language, logic and semantic knowledge) are affected by chronic alcohol abuse.
Treatment: Gotta MATCH?
In December, NIAAA announced the main findings from Project MATCH, which the Institute called “the largest and most statistically powerful clinical trial of psychotherapies ever undertaken.” Initiated in 1989 to test whether different types of alcoholics respond different! y to specific therapeutic approaches, Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) found that patient -treatment matching does not substantially alter treatment outcomes.
The study involved three distinct behavioral treatments: 12-step facilitation therapy (similar to the approach used by Alcoholics Anonymous); cognitive-behavioral therapy, based on social learning theory and designed to provide skills for avoiding relapse; and motivational enhancement therapy, based on motivational psychology and designed to help patients mobilize personal resources to effect change. (This last treatment includes educating the patient about the harmful effects of alcohol, such as liver or brain damage, plus a discussion of issues such as personal responsibility and choice, and information on specific strategies for changing drinking behaviors,)
Patient characteristics included severity of alcohol involvement, cognitive impairment, psychiatric severity, gender, readiness to change, social support for drinking versus abstinence, sociopathy, and typology of alcoholism. The outcomes were measured in terms of abstinent days and average number of drinks per drinking day during the year following treatment. With one exception, no significant matches were found. The only con finned match was between patients with low psychiatric severity and the 12-step therapy, Those patients had more abstinent days than patients receiving cognitive behavioral therapy. But regardless of the therapy received, participants showed significant and sustained improvement in rates of abstinence and decreased drinking.
The results of Project MATCH received a significant amount of publicity in the popular press, with varying degrees of accuracy due to media confusion about the aim of the study, Some headlines proclaimed that the 12-step therapy was the most effective treatment, while other reports said the study shows that treatment does not work. Given the chronic and relapsing nature of alcoholism, some researchers feel that the one-year follow-up period was not long enough to show the long-term effects of treatment.
As for NIAAA’ s plans now that Project MATCH is essentially over? “A logical next step for alcoholism treatment research is to test our quite excellent behavioral treatments in conjunction with promising pharmacological treatments for alcoholism,” said Richard K. Fuller, director of the NIAAA program that oversaw the project.
Health Services Research
The rapid and profound changes that are occurring in the health care system are affecting the availability and possibly the quality of alcohol treatment services, But exactly how? NIAAA is supporting $30 million in health services research to find the answer to this and related questions about how alcohol treatment and prevention services are organized and financed, as well as research on the effectiveness, quality, and availability of services for alcohol-related problems.
As psychologist Robert Huebner, chief of NIAAA’s health services research program, observes, “health services research shifts the locus of alcohol research from the laboratory and controlled clinical trials to real-world practice settings,” One of the main areas of concern these days is the impact of managed care on alcohol treatment services. “Psychologists working in applied psychology, methodology, organizational psychology, treatment outcomes research, health psychology, and consumer decision making can make potentially important contributions to understanding the impact of managed care and shed light on this increasingly controversial health policy issue,” said Huebner.
In mid-February, NIAAA’s advisory council finalized a national plan that will guide the Institute’s future directions in health services research. Improving the Delivery of Alcohol Treatment and Prevention Services: A National Plan for Alcohol Health Services Research was developed in response to a congressional mandate and reflects a consensus by dozens of experts- not only researchers, but also policy makers and industry representatives- who worked in three broad areas: organization and financing; utilization and cost; and effectiveness and outcomes. Within those areas, the priorities identified by plan include managed care, outcomes as they relate to costs, and methodology in health services research.
The national plan accompanies an expansion of NIAAA’ s health services research activities. In 1992, Congress mandated that NIAAA (as well as the institutes on mental health and drug abuse) devote a minimum of 15 percent of its extramural research budget to health services research.
The Future for Psychology
Young investigators and more established scientists should both take note: NIAAA is actively promoting new behavioral perspectives in alcohol research. Most of NIAAA ‘s current psychology research portfolio is in the areas of basic psychobiology, cognitive and behavioral neuroscience, clinical/behavioral therapies, and some behavioral genetics. In the past, there has been much less research funding for cognitive, developmental, social, and industrial/organizational psychology.
Gordis and Long are working with APS to bring in leading experts from these areas-senior psychologists who are not necessarily alcohol researchers-and asking them to help NIAAA think of new research questions that should be addressed. This brainstorming session will take place during the APS Convention in May.
In addition, NIAAA is one of several National Institutes of Health institutes that have been specifically asked by Congress 10 encourage young investigators in behavioral research. NIAAA is looking at the B/START model used by the National Institute of Mental Health and the National Institute on Drug Abuse.
B/START (Behavioral Science Track Awards for Rapid Transition) benefits young researchers by providing small grants to support the development of their pilot data. Institutes benefit from the supply of high-quality researchers that is created for a relatively small investment.
A Hearty Breakfast
During the APS Convention, NIAAA will be featured in an open breakfast meeting during which institute staff will present information about the Institute’s research opportunities for psychologists. For details, see the announcement in the Convention section on page 18 of this issue.