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Intervention Summary

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Broad Spectrum Treatment (BST) and Naltrexone for Alcohol Dependence

Broad Spectrum Treatment (BST) and Naltrexone for Alcohol Dependence is a 3- to 6-month program that uses manual-guided cognitive behavioral therapy in combination with naltrexone pharmacotherapy (50 mg daily) to treat adults with alcohol dependence. BST therapists deliver 8-14 individual sessions incorporating components of motivational enhancement therapy (MET), community reinforcement, and 12-step approaches.

BST begins with two MET sessions. MET is an individualized, nonconfrontational counseling approach that seeks to maximize a client's motivation to become abstinent by emphasizing the client's own control over drinking behavior. The first MET session, conducted in 90 minutes, is used to review the client's level of functioning across six psychosocial domains (cognitive, marital or significant other relationship, family, work, residential stability, and social network) and provide feedback on tests of liver function and neuropsychological performance. This session emphasizes the effects of drinking on the client's life as a motivational basis for change to achieve a goal of abstinence from alcohol. The session concludes with a planned change worksheet that becomes the basis for the second MET session, conducted in 30 minutes, that focuses on reviewing goals and redefining them if necessary.

Following these two MET sessions are sessions that increase support for abstinence by teaching skills for accessing and using available intrapersonal and community resources. Based on the specific needs of the client, these 60-minute sessions are selected from 24 modules related to the 6 psychosocial domains. Examples of these sessions include contingency management; reciprocity marriage counseling; family supportive therapy; involvement with Alcoholics Anonymous (AA) and Al-Anon; family contingency contracting; disengagement from prior social network; establishment of sober supports; vocational counseling and rehabilitation, job location, and employment contingencies; assertiveness training and drink refusal training; and cognitive restructuring.

The dissemination materials reviewed for this summary guide only the psychosocial component of the intervention. Naltrexone should be administered under medical supervision as an adjunct to treatment.

Descriptive Information

Areas of Interest Substance abuse treatment
Outcomes Review Date: November 2009
1: Alcohol use
2: Short-term alcohol abstinence
Outcome Categories Alcohol
Ages 26-55 (Adult)
Genders Male
Female
Races/Ethnicities American Indian or Alaska Native
Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
Geographic Locations Urban
Suburban
Implementation History The intervention was first implemented in 1993. Two sites, 1 in Massachusetts and 1 in Indiana, have implemented the intervention for 7 years, serving approximately 93 clients with alcohol dependence.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: November 2009

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Davidson, D., Gulliver, S. B., Longabaugh, R., Wirtz, P. W., & Swift, R. (2007). Building better cognitive-behavioral therapy: Is Broad-Spectrum Treatment more effective than motivational-enhancement therapy for alcohol-dependent patients treated with naltrexone? Journal of Studies on Alcohol and Drugs, 68(2), 238-247.  Pub Med icon

Davidson, D., Wirtz, P. W., Gulliver, S. B., & Longabaugh, R. (2007). Naltrexone's suppressant effects on drinking are limited to the first 3 months of treatment. Psychopharmacology, 194(1), 1-10.  Pub Med icon

Longabaugh, R., Wirtz, P. W., Gulliver, S. B., & Davidson, D. (2009). Extended naltrexone and Broad Spectrum Treatment or motivational enhancement therapy. Psychopharmacology, 206(3), 367-376.  Pub Med icon

Supplementary Materials

Agrawal, S., Sobell, M. B., & Sobell, L. C. (2008). The Timeline Followback: A scientifically and clinically useful tool for assessing substance use. In R. F. Belli, F. P. Stafford, & D. F. Alwin (Eds.), Calendar and time diary methods in life course research (pp. 57-68). Washington DC: Sage.

Gulliver, S. B., Longabaugh, R., Davidson, D., & Swift, R. (2005). The development of a Broad Spectrum Treatment for patients with alcohol dependence in early recovery. Cognitive and Behavioral Practice, 12, 53-63.

Outcomes

Outcome 1: Alcohol use
Description of Measures Alcohol use was measured as the median number of days to the first drink and the median number of days to the first heavy drinking day (at least five drinks for men, at least four drinks for women). Alcohol use data were gathered using the Timeline Followback (TLFB) interview, a calendar-based method for reconstructing days of drinking and other drug use over a specified time period.
Key Findings In a randomized clinical trial, alcohol-dependent clients were assigned to one of four treatment conditions: long-term naltrexone treatment (24 weeks of naltrexone) or short-term naltrexone treatment (12 weeks of naltrexone and 12 weeks of placebo), each paired with 12 weeks of BST or 12 weeks of MET. Both the BST and MET groups received the first (90-minute) and second (30-minute) MET session. Subsequently, the BST groups received 9-14 sessions specific to psychosocial functioning levels across the 6 domains, and the MET groups received 2 more MET sessions. Outcome measurements occurred at baseline and at 12-week intervals from 12 to 72 weeks after treatment initiation. Among the findings from this study were the following:

  • Clients in the BST plus long-term naltrexone condition reported the longest median time to the first drink (27.5 days) across the follow-up period compared with clients in the other three conditions (10 days for BST plus short-term naltrexone, 2 days for MET plus long-term naltrexone, and 6 days for MET plus short-term naltrexone; p < .02).
  • Clients in the BST plus long-term naltrexone condition reported the longest time to the first day of heavy drinking (61 days) across the follow-up period compared with clients in the other three conditions (17 days for BST plus short-term naltrexone, 11 days for MET plus long-term naltrexone, and 20 days for MET plus short-term naltrexone; p < .03).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 2: Short-term alcohol abstinence
Description of Measures Short-term alcohol abstinence while on naltrexone therapy was measured as the percentage of days abstinent in the prior 90 days. Abstinence data were collected using the TLFB interview, a calendar-based method for reconstructing days of drinking and other drug use over a specified time period.
Key Findings In a randomized clinical trial, alcohol-dependent clients were assigned to one of four treatment conditions: long-term naltrexone treatment (24 weeks of naltrexone) or short-term naltrexone treatment (12 weeks of naltrexone and 12 weeks of placebo), each paired with 12 weeks of BST or 12 weeks of MET. Both the BST and MET groups received the first (90-minute) and second (30-minute) MET session. Subsequently, the BST groups received 9-14 sessions specific to psychosocial functioning levels across the 6 domains, and the MET groups received 2 more MET sessions. Outcome measurements occurred at baseline and at 12-week intervals from 12 to 72 weeks after treatment initiation. Findings at the 12-week follow-up (at the end of psychosocial treatment) included the following:

  • Clients who received BST plus naltrexone reported a higher percentage of days abstinent than clients receiving MET plus naltrexone (74.3% vs. 66.1%; p = .04). Regardless of condition assignment, the percentage of days abstinent was significantly related to the number of treatment sessions attended; that is, the higher the percentage of days abstinent, the more treatment sessions were attended (p < .003 for BST plus naltrexone, p < .027 for MET plus naltrexone).
  • Among participants who had a relatively high level of support for drinking in their psychosocial network (top 50%) at baseline, clients receiving BST plus naltrexone reported a higher percentage of days abstinent than those receiving MET plus naltrexone (76.5% vs. 62.4%; p = .035) after adjusting for baseline alcohol use.
  • Contrary to expectations, BST plus naltrexone clients with a relatively low level of psychosocial domain dysfunction (bottom 50%) at baseline reported a higher percentage of days abstinent than their counterparts receiving MET plus naltrexone (73.3% vs. 57.4%; p = .032) after adjusting for baseline alcohol use. Among participants who had a relatively high level of psychosocial domain dysfunction (top 50%) at baseline, the reported percentage of days abstinent did not differ between clients receiving BST plus naltrexone and those receiving MET plus naltrexone (73.1% vs. 73.4%) after adjusting for baseline alcohol use.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 63% Male
37% Female
90% White
3% American Indian or Alaska Native
3% Black or African American
3% Hispanic or Latino
1% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Alcohol use 3.0 3.0 2.5 2.5 2.0 3.0 2.7
2: Short-term alcohol abstinence 3.0 3.0 2.5 2.5 2.0 3.0 2.7

Study Strengths

Extensive research has been conducted with the measures derived from the Timeline Followback method used in this study, and their psychometric properties are strong; they are the standard measures used in clinical research on alcohol dependence. The behavioral component of the intervention was based on manual-guided training. Attrition rates were acceptable at about 18% and were balanced across treatment conditions. This randomized clinical trial was adequately powered and used an appropriate intent-to-treat statistical strategy, an acceptable method for handling attrition, and a solid data analysis approach that included the evaluation of potential moderator effects for continued drinking behavior.

Study Weaknesses

The absence of any data to verify that the BST sessions differed from the MET sessions in their content raises the concern that the main difference between the two psychosocial conditions was simply the number of treatment sessions. Because a single therapist delivered both psychosocial conditions and treated most patients (89%) with likely knowledge of study hypotheses, it is conceivable that the comparison condition was less enthusiastically delivered than the experimental condition. The pairing of the first 12 weeks of BST with naltrexone precluded an independent determination of BST efficacy outside the context of naltrexone or some other type of medication. No special statistical models were used to estimate the impact of attrition on outcomes.

Readiness for Dissemination
Review Date: November 2009

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Broad Spectrum Treatment Adherence Checklist

Broad Spectrum Treatment training agenda

Gulliver, S. B., & Longabaugh, R. (n.d.). Broad Spectrum Treatment manual: A clinical research guide for the therapists treating individuals with alcohol dependence.

Therapist folder:

  • Behavior Chain
  • Broad Spectrum Treatment decision tree diagrams
  • Change Plan Worksheet
  • Cognitive-Behavioral Techniques Associated With Different Parts of the Functional Analysis
  • Functional Analysis of Alcohol and Drug Use
  • Patient Feedback Report
  • Understanding Your Personal Feedback Report

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
3.5 2.3 3.0 2.9

Dissemination Strengths

Implementation materials are well developed and highly practical for application in a variety of settings. Each treatment session has an outline of core components to facilitate the consistency of implementation across therapists, along with forms for structuring session activities and decision trees for guiding care. The manual provides guidance for adapting the intervention for clients with cognitive impairment. An organized process is in place for providing orientation training, booster sessions, and therapist and supervisor certification for new implementers. Multiple monitoring tools are provided to support quality assurance.

Dissemination Weaknesses

The materials do not include organizational guidance to support the delivery of this intervention. No formalized curriculum or information about how to obtain training is available. Recommended clinician credentials and competencies are not clearly defined. Specific assessment instruments are recommended for each of the psychosocial domains targeted by the intervention, but implementers must acquire these instruments independently. No guidance is provided for the measurement of program outcomes by new implementation sites.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
BST manual (includes adherence checklist) $5 each Yes
2-day, on-site training (includes feedback for taped sessions up to 60 days after training) $7,000 No
Additional feedback for taped sessions $500 per session No
Replications

No replications were identified by the developer.

Contact Information

To learn more about implementation, contact:
Dena Davidson, Ph.D.
(254) 297-5169
dena.davidson@va.gov

To learn more about research, contact:
Suzy Bird Gulliver, Ph.D.
(254) 297-3850
suzy.gulliver@va.gov

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.