AAT-APP (Alcohol Avoidance Training app)

Background

People with alcohol use disorder (AUD) are thought to have an unconscious bias towards alcohol related cues in the environment, known as an “approach bias”. This involves automatic impulses to ‘approach’ when encountering alcoholic drinks and other reminders of drinking, such as alcohol advertisements, bottle shops, pubs, etc. “Approach bias modification” (ApBM) is a type of ‘brain-training’ which is designed to reduce this automatic bias by repeatedly practising ‘pushing away’ alcohol-related images and ‘pulling’ non-alcohol images closer.

Previous studies of ApBM run with patients undergoing residential treatment (i.e., withdrawal or rehabilitation treatment) for alcohol have shown that it helps to prevent relapse to alcohol use after treatment. These studies have delivered ApBM while participants were still in treatment, using a computer and a joystick to complete the training task. Providing ApBM as a smartphone app would make it easier for people to use the training task outside of treatment settings, in places and at times that suit them, or when they feel vulnerable to cravings or relapse.

Turning Point researchers developed a smartphone app version of ApBM to increase access to the training. The app allowed participants to personalise the images included in the training by choosing from a library of images in the app, or by adding photos from their own phone, so that they could practice avoiding alcohol images that resembled the beverages they usually drank, and approach positive images that had personal meaning to them. Our previous study found that, after using this app for 4 weeks, people who had been drinking at hazardous levels reduced their weekly alcohol use, cravings, and severity of alcohol dependence. However, there was no control group for comparison in this previous study, so it was unclear whether these improvements occurred due to using the ApBM or for other reasons.

The AAT-App trials

The current research involved 2 randomised controlled trials testing whether the ApBM app (named “AAT-App", short for “alcohol avoidance training app”) can help people who were already accessing traditional forms of treatment for AUD. One of the trials tested the app for people receiving outpatient treatment for AUD to see if it helped them further reduce their alcohol use. The other one provided the app to people who had just completed inpatient or residential treatment, to see if it helped reduce their risk of relapse.

Participants in both studies who received the ApBM version of the app were instructed to complete two training sessions per week for four weeks. They could complete additional training if they desired. Participants in the control group received a version of the app that involved completing a similar-looking weekly ‘sham’ training, that was not designed to change their approach bias. Participants completed follow-up surveys after using the app for 4 weeks, and also one and three months afterwards. In the study involving people who had completed inpatient/residential treatment, they also completed a 6-month follow-up.

Trial results

Outpatient trial: We recruited 79 participants from six addiction treatment services in Melbourne for the study among outpatients. Participants were instructed to use the ApBM app while receiving outpatient treatment for AUD. We did not find any difference between groups in terms of how much their alcohol consumption reduced after 4 weeks of using the app. However, we found a delayed effect at the 3-month follow-up, when participants who received the ApBM version of the app significantly reduced their drinking by an average of 14.6 standard drinks per week (compared to their consumption before installing the app). This was a significantly larger reduction than the non-significant reduction of 2.1 weekly standard drinks among those who received the control version. Participants who received the ApBM training also reported a greater reduction in number of heavy drinking days per week (defined as number of days on which they drank at least 5 standard drinks), compared to the control group, at the 3-month follow-up.

Residential/inpatient rehabilitation trial results: For the residential/inpatient rehabilitation study, we recruited 134 participants from five different addiction treatment services in Victoria. Participants were sent a link to the ApBM app immediately after discharging from inpatient rehabilitation treatment, and were encouraged to install it and start using it as soon as possible. There were no significant differences in alcohol use or rates of abstinence between the ApBM and control group at any of the follow-up timepoints. However, participant ratings of the app supported its safety and acceptability.

Qualitative interviews

Clients: Researchers also interviewed 20 participants (10 from the outpatient and 10 from the inpatient study) who had received the ApBM version of the app to find out their thoughts on the app. Overall, participants tended to feel that the app aligned well with the other AUD treatment they were receiving. Participants reported using the app in various ways, including using the repetition of the training to help build a habit; using the app to distract them from alcohol cravings and to help prevent them from being triggered by reminders of alcohol in their environment; and to reinforce their recovery goals.

Clinicians: Researchers also interviewed 10 clinicians involved in the inpatient/residential treatment study to discuss their views on implementation of app-based interventions within treatment services. Overall, clinicians felt that an app’s alignment with existing AUD treatment models, leadership support, and promotion through trusted sources, would facilitate its implementation. However, barriers to implementation included limited time and capacity of clinicians, uncertainty whether the app will help, and limited patient access to smartphones while in treatment. Discharge planning was recognised as an ideal time to introduce apps, and clinicians valued that apps can provide ‘just-in-time' support in moments it was needed.

Funding

The outpatient trial was funded by a grant from the Victorian Alcohol and Drug Association's (VAADA) Alcohol and Drug Research Innovation Agenda (ADRIA). The residential/inpatient rehabilitation trial was funded by a grant from HCF Research Foundation.

Publications

Turning Point project team: Professor Victoria Manning, Doctor Joshua Garfield, Associate professor Bosco Rowland, Doctor Michael Savic, Mietta Bell, Marie Spehar, Doctor Ari Roxburgh, Doctor Emily Colton, Professor Dan Lubman

Project partners: Doctor David Jacka (Monash Health), James McGregor (Uniting Vic Tas), Professor Malcolm Hopwood (Ramsay Clinic Albert Road), Doctor Michael Maloney (The Melbourne Clinic), Olivia Nichols (Odyssey House), Doctor Rajnarayan Mahasuar (Wyndham Clinic Private Hospital), Silvia Violante (Star Health), Professor Yvonne Bonomo (St Vincent’s Hospital Melbourne)

Other participating organisations: Arrow Health, Monash Health, The Melbourne Clinic, Odyssey House, Ramsay Clinic Albert Road, St Vincent’s Hospital Melbourne, Star Health, Uniting Vic Tas, Wyndham Clinic Private Hospital.