Behavioral economic analysis of natural resolution of drinking problems using IVR self-monitoring

Autor: H. Russell Foushee, Jalie A. Tucker, Bethany C. Black
Rok vydání: 2008
Předmět:
Zdroj: Experimental and Clinical Psychopharmacology. 16:332-340
ISSN: 1936-2293
1064-1297
DOI: 10.1037/a0012834
Popis: Since its origins in the experimental analysis of choice behavior in animals (e.g., Rachlin & Green, 1972), behavioral economics has been widely applied to an analysis of drug self-administration and other addictive behaviors in humans (e.g., Bickel & Marsch, 2001; Green & Kagel, 1996; Vuchinich & Tucker, 1988, 1996, 1998; Vuchinich & Heather, 2003). Behavioral economics is a transdisciplinary merger of operant approaches to understanding choice behavior, impulsivity, and impulse control (Ainslie, 1975) with related concepts in micro-economic models of consumer behavior (Rachlin, Battalio, Kagel, & Green, 1981). Both foundation disciplines focus on how consumers allocate limited resources such as time, behavior, and money to obtain commodities available at different costs and over different delays. The merger has yielded conceptual synergies and robust findings about how behavioral allocation varies depending on what other activities are available in the context of choice and the constraints on access to them (e.g., cost to obtain, delay to receipt). For example, the well established matching law quantifies how humans and animals alike distribute or “match” their relative rates of responding in proportion to the relative rates of reinforcement available from each activity (Herrnstein, 1970; Rachlin & Laibson, 1997). Conversely, the relative reinforcement value of a given activity can be inferred from the relative resource allocated to obtain it. Behavioral economics is well suited to guide theory and research on substance abuse, given that the defining behavioral characteristic is excessive demand for drugs in relation to alternative activities that support adaptive functioning (e.g., education, employment, marriage). Substance abuse involves a persistent preference for short-term rewards that lead to long-term costs, and a devaluation of larger, delayed rewards that support adaptive functioning (Vuchinich & Tucker, 1988, 1998). Research has consistently shown that preference for substance use decreases as constraints on access to the substance increase, and as constraints on access to valued non-drug-related alternatives decrease. Moreover, persons with addiction problems tend to devalue, or discount, delayed rewards more than normal controls (Bickel & Marsch, 2001; Petry, 2001). Although the extent to which discounting is a cause or effect of addictive behaviors remains unclear, greater discounting indicates that control of current behavior is less sensitive to delayed consequences, such as the adverse long-term effects of substance use. When considered in relation to the resolution of alcohol and drug problems, this suggests that shifting control of behavior from shorter- to longer-term contingencies should promote and stabilize resolution, and that individuals with greater sensitivity to longer term contingencies, even when using substances excessively, should have a better prognosis. This behavioral economic perspective on resolution received initial support in our earlier prospective studies of natural and intervention-assisted resolution attempts among problem drinkers recruited from the community (Tucker, Vuchinich, & Rippens, 2002; Tucker, Vuchinich, Black, & Rippens, 2006). Shortly after the initiation of abstinence or moderation drinking without problems, participants’ expenditures on alcoholic beverages and other activities and commodities during the year prior to resolution onset were assessed comprehensively using an expanded version of the Timeline Followback (TLFB) interview (Sobell & Sobell, 1992). Of primary interest were the proportions of discretionary spending on alcoholic beverages compared to money put into savings for future use, which were conceptualized as representing the value of rewards available over shorter and longer time horizons, respectively. Non-essential expenditures (e.g., for entertainment, gifts, drinking) were the focus of study because personal preference structures should be readily expressed in this economic arena, particularly among middle-income problem drinkers who are typical of natural recovery samples. Relatively greater allocation to savings than to drinking, reflected in lower values on this “Alcohol-Savings Discretionary Expenditure” (ASDE) index, was considered indicative of higher relative preferences for delayed rewards made possible by savings compared with more immediate drinking. Lower ASDE values thus should predict resolution stability during the one to two year follow-up intervals used in this research. As hypothesized, problem drinkers who maintained stable abstinent or non-abstinent resolutions without any problem drinking had lower pre-resolution ASDE values compared with those who had unstable resolutions and relapsed at any point during the follow-up. In addition to contributing to the correct classification of outcomes of natural resolution attempts (Tucker et al., 2002), the ASDE index had unique incremental utility in predicting drinking outcomes in multivariate models that included multiple established predictors (e.g., drinking practices and problems, alcohol reinforcement and self-efficacy expectations, stage of change) (Tucker et al., 2006). It also had predictive utility across natural and intervention-assisted resolution groups (Tucker et al., 2006). Collectively, these studies showed that contextually sensitive, temporal relations between drinking and other activities as represented by the ASDE added unique information in an account of resolution outcomes. However, many more participants achieved stable abstinent than non-abstinent resolutions, so predictors of moderation apart from abstinence could not be investigated. This issue has gained renewed importance as interventions continue to expand beyond abstinence-oriented treatments for alcohol dependent persons to include population-based public health interventions for the untreated majority with less serious problems for whom moderation is a more common and acceptable outcome (Tucker, Donovan, & Marlatt, 1999). Although early treatment outcome research found moderation to be associated with lower problem severity, younger age, and stable life circumstances (reviewed Miller & Munoz, 2005; Rosenberg, 1993), there have been few recent advances (Saladin & Santa Ana, 2004). The present study was a conceptual replication and extension of our TLFB-based studies using Interactive Voice Response self-monitoring (IVR SM) to investigate relationships between behavior economic and drinking variables during the early natural resolution period. Untreated problem drinkers who had stopped drinking abusively within the past 1–3 months self-monitored their drinking, monetary expenditures, and surrounding contexts for up to 128 days. Our interest in the IVR application, which was similar to one previously implemented (Searles, Perrine, Mundt, & Helzer, 1995), was three-fold. First, using daily prospective data collection, we sought to replicate the ASDE-drinking outcome relationships observed in our studies that relied on retrospective TLFB interviews. Although the two methods often show good concordance (Sobell & Sobell, 2003), when differences have been found automated SM yielded higher and presumably more complete reports of sensitive information like substance use or sexual activities (Blumberg, Cynamon, Osborn, & Olson, 2002; Searles, Helzer, Rose, & Badger, 2002). Second, the IVR SM assessment focused on the early post-resolution period when the risk of relapse is high and drinking practices tend to be variable and unstable. Studying this dynamic period may illuminate the pathways, processes, and contexts that lead to long-term abstinence or moderation, and suggest avenues for stabilizing initial positive change. Compared to clinical samples, moderation outcomes are more common among untreated drinkers who quit on their own (Sobell, Cunningham, & Sobell, 1996). The present study offered an opportunity to investigate early change processes involving moderation and abstinence using new concepts and methods from behavioral economics. Third, IVR SM holds promise for telehealth applications with problem drinkers who will not seek clinical care but want to quit drinking abusively. In addition to serving as a data collection tool, SM often facilitates positive change (Miller & Wilbourne, 2002) and can be used to monitor progress over long intervals, thereby supporting stepped care when IVR users are at risk for or resume problem drinking (Mundt, Moore, & Bean, 2006). Based on our prior research, the main hypothesis was that higher ASDE values, reflecting proportionally more pre-resolution expenditures on alcohol and less on savings, should predict a return to abusive drinking during the IVR interval. Although more exploratory, we also sought to evaluate the utility of the ASDE index in predicting moderate drinking during the IVR interval. Over two decades ago, Marlatt (1985, pp. 329–344) suggested that moderation involves a different behavioral regulation process compared to abstinence or relapse, which may be opposite ends of the same dynamic regulation process reflecting over- and under-control of the discrete act of intoxication, respectively. Marlatt hypothesized that stable moderation involves a pattern of repetitive choices about drinking that remain well inside the boundaries of extreme restraint or loss-of-control drinking. Framed in terms of the present behavioral economic analysis, stable moderation appears to require organizing behavior into patterns over longer time frames compared to abstinence or relapse, which appear to reflect shorter term over- or under-control of the problem behavior. Thus, lower ASDE values, reflecting a relative shift in monetary allocation away from drinking toward saving for the future, should predict moderate drinking compared to other drinking outcomes, especially abusive drinking.
Databáze: OpenAIRE
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