J. Scott Tonigan, PhDCenter on Alcoholism, Substance Abuse, and Addictions

(CASAA), Albuquerque, NM

12th

Annual Pre-Conference Satellite Meeting onMechanisms of Behavior Change

June 25, 2016, New Orleans, LA

Process Matching: The ApplicationProcess Matching: The ApplicationOf Precision Medicine in BehavioralOf Precision Medicine in Behavioral

Treatment for AlcoholismTreatment for Alcoholism

Acknowledgements Acknowledgements

MOBC Program CommitteeMOBC Program CommitteeNIAAANIAAACoCo--Authors: Elizabeth A. McCallion,Authors: Elizabeth A. McCallion,

Tessa FroheTessa FroheMatthew Matthew ““MateoMateo””

R. PearsonR. Pearson

Richard Longabaugh, DistinguishedRichard Longabaugh, DistinguishedResearch Awardee, 2016Research Awardee, 2016

Rationale for 2016 MOBC WorkshopRationale for 2016 MOBC WorkshopWeaves Together Several NarrativesWeaves Together Several Narratives

Chapter 1Chapter 1

The Past is Not Far BehindThe Past is Not Far Behind

Building on President ObamaBuilding on President Obama’’s announcement in his s announcement in his State of the Union Address, today the Administration is State of the Union Address, today the Administration is unveiling details about the Precision Medicine Initiative, unveiling details about the Precision Medicine Initiative, a bold new research effort to revolutionize how we a bold new research effort to revolutionize how we improve health and treat disease.improve health and treat disease.

Launched with a Launched with a

$215 million investment in the President$215 million investment in the President’’s 2016 Budget, s 2016 Budget, the Precision Medicine Initiative will pioneer a new the Precision Medicine Initiative will pioneer a new model of patientmodel of patient--powered research that promises to powered research that promises to accelerate biomedical discoveries and provide accelerate biomedical discoveries and provide clinicians with new tools, knowledge, and therapies to clinicians with new tools, knowledge, and therapies to select select which treatments will work best for which which treatments will work best for which patientspatients.. The White House

Office of the Press SecretaryFor Immediate Release

January 30, 2015

Precision MedicinePrecision Medicine

$70 Million Allocated to NIH$70 Million Allocated to NIH

••

Recruit, consent, and follow 1,000,000 Recruit, consent, and follow 1,000,000 cohort sample of Americans.cohort sample of Americans.

••

Encourage the application of mobile Encourage the application of mobile technologies/devices for realtechnologies/devices for real--time, low time, low cost data collection in studies.cost data collection in studies.

••

Specifically targeted individual and Specifically targeted individual and public health consequences of alcohol public health consequences of alcohol and illicit drug use.and illicit drug use.

Precision Medicine Initiative Working Group ReportPrecision Medicine Initiative Working Group ReportSeptember 17, 2015September 17, 2015

June 9June 9thth: Dr. Koob presents strategic plan, : Dr. Koob presents strategic plan, 20162016--2020, to NIAAA Council.2020, to NIAAA Council.

Address alcohol misuse across lifespanAddress alcohol misuse across lifespanAddress coAddress co--occurring conditionsoccurring conditionsReduce health disparitiesReduce health disparitiesAdvance precision medicineAdvance precision medicineStrengthen research and clinical trainingStrengthen research and clinical training

Project MATCHProject MATCH

1988-1997 (2001)““The Big BookThe Big Book””

ClientClient--Treatment Matching AttributesTreatment Matching Attributes (N = 21)(N = 21)

Alcohol Dependence

Problem RecognitionAlcohol Involvement

Self-Efficacy: ConfidenceCognitive Impairment

Temptation minus ConfidencePsychopathology/Severity

Social NetworkSociopathy/ ASPD

Prior AAA versus B Alcohol Typology

Poor social FunctioningAnger Conceptual LevelMeaning SeekingReligiosityInterpersonal DependenceGenderMotivational Readiness

Project MATCHProject MATCH

Study Design:Study Design:

Screen Randomize 3 6 9 12 15 (39) Screen Randomize 3 6 9 12 15 (39) (120)(120)

Two Arms: Aftercare Sample N = 774, Outpatient Sample = 952Two Arms: Aftercare Sample N = 774, Outpatient Sample = 952

CBT

MET

TSF

98% 97% 95% 94% 92% 85%86%

MATCH FINDINGSMATCH FINDINGS

1.1.

400 400 ““a prioria priori””

interaction tests were per formed:interaction tests were per formed:(ignoring time effect)(ignoring time effect)

2 dependent measures x 40 hypothesized contrasts2 dependent measures x 40 hypothesized contrastsx 5 occasions (within and posttreatment &x 5 occasions (within and posttreatment &3939--month outpatient)month outpatient)

2. Only 12 contrasts met criteria for significance (3%)2. Only 12 contrasts met criteria for significance (3%)

Longabaugh, R. & Wirtz, P.W., (2001)Longabaugh, R. & Wirtz, P.W., (2001)Substantive Review and Critique,Substantive Review and Critique,Volume 8, Project MATCH MonographVolume 8, Project MATCH MonographSeries.Series.

Chapter 2Chapter 2The Era of Statistical MediationThe Era of Statistical Mediation

Process VariableProcess Variable

Time 1 Time 2 Time 3

IV

Mediator

DV

aa bb

cc’’

Areas of Rapid MOBC Behavioral Areas of Rapid MOBC Behavioral ResearchResearch

••

Motivational InterviewingMotivational Interviewing••

Cognitive Behavioral TherapyCognitive Behavioral Therapy

••

Alcoholics Anonymous and 12Alcoholics Anonymous and 12--Step Step TherapyTherapy

••

Brief Interventions: Normative FeedbackBrief Interventions: Normative Feedback••

Mindfulness TherapyMindfulness Therapy

••

Others?Others?

AddictionAddiction--related MOBC with related MOBC with Empirical SupportEmpirical Support

AbstinenceAbstinence--based Selfbased Self--EfficacyEfficacySocial Support for AbstinenceSocial Support for AbstinenceSpiritualitySpiritualityChange Talk Change Talk SelfSelf--RegulationRegulation

Delayed DiscountingDelayed DiscountingResponse InhibitionResponse InhibitionImpulsivityImpulsivity

One Trend in MOBC ResearchOne Trend in MOBC Research

An important stream of MOBC An important stream of MOBC research is diving deeper toresearch is diving deeper toachieve a better understandingachieve a better understandingof a given MOBC of a given MOBC CONSTRUCTCONSTRUCT

SelfSelf--reportreport

BehavioralBehavioral

Neural pathwaysNeural pathwaysNeuroimaging mechanisms of change in psychotherapy for addictive behaviors (R13)

An Alternative andComplimentaryPath for MOBCResearch

Two Exemplar Areas of MOBC Two Exemplar Areas of MOBC Treatment ResearchTreatment Research

Motivational Interviewing & AA MOBCMotivational Interviewing & AA MOBC

MetaMeta--analysis has been facilitated in these two areasanalysis has been facilitated in these two areas

because:because:1. Relative agreement on an 1. Relative agreement on an ““active ingredientactive ingredient””

mobilizingmobilizing

change.change.

2. Strong similarity in the types of MOBC under investigation.2. Strong similarity in the types of MOBC under investigation.

3. Strong similarity in outcome dimension (s).3. Strong similarity in outcome dimension (s).

4. Concordance in designs and methods within each area.4. Concordance in designs and methods within each area.

5. Sufficient number of studies to conduct meta5. Sufficient number of studies to conduct meta--analytic workanalytic work

The Q StatisticThe Q Statistic

The null hypothesis tested by the Q statistic is that studies share a common

effect size,

with differences in observed effect sizes reflecting only sampling error. Rejection of the null hypothesis therefore indicates the presence of multiple "common" effect sizes within a distribution or the action of an unidentified moderator.

Three MOBC in AA ResearchThree MOBC in AA Research(Tonigan in, Magill et al., 2015)(Tonigan in, Magill et al., 2015)

MOBCMOBC

#Studies#Studies # Subjects# Subjects

AA

BB

Spiritual GainsSpiritual Gains 99

5,0585,058

.22 *.22 *

.13 *.13 *

Social SupportSocial Support 1515

15, 48215, 482

.15 *.15 *

.12 *.12 *

SelfSelf--Efficacy Efficacy 1111 3, 7393, 739

.21 *.21 *

.33 *.33 *

B path: dependent measure is PDA-Abstinence based.

MI Therapist Consistent and InconsistentMI Therapist Consistent and InconsistentBehaviors: Change and Sustain TalkBehaviors: Change and Sustain Talk

(Magill et al., 2014)(Magill et al., 2014)

Therapist BehaviorTherapist Behavior

# Studies# Studies A BA B

MI Consistent SkillsMI Consistent Skills

77

.26 .26 **.06.06

MI Inconsistent SkillsMI Inconsistent Skills

66

--.17 .17 **

Therapist BehaviorTherapist Behavior

# Studies# Studies

AA

BB

MI Consistent SkillsMI Consistent Skills

88

.10.10 --.24 *.24 *

MI Inconsistent SkillsMI Inconsistent Skills 66

.07 *.07 *

Change TalkChange Talk

Sustain TalkSustain Talk

Two MOBC MetaTwo MOBC Meta--Analytic SummariesAnalytic SummariesYield Similar ConclusionsYield Similar Conclusions

Micro level analysis in MI MOBC researchMicro level analysis in MI MOBC researchMacro level analysis in AA MOBC researchMacro level analysis in AA MOBC research

Heterogeneity in Heterogeneity in ““aa””

and and ““bb””

may be the result of:may be the result of:

1. Variation in study designs1. Variation in study designs2. Differences in time frames MOBC are investigated2. Differences in time frames MOBC are investigated3. Measurement artifacts3. Measurement artifacts4. Sampling different populations of AUD4. Sampling different populations of AUD

Chapter 3Chapter 3

Some say po-ta-to, some say po- tah-to, some just say “spud”.

MetaMeta--Analytic Message to MOBC ResearchersAnalytic Message to MOBC Researchers

ActiveIngredient

Mediator

OutcomeCC’’

aa bbModerator Moderator

““ModeratedModerated--Mediation, Conditional IndirectMediation, Conditional IndirectEffects or Process MatchingEffects or Process Matching””

Responder and NonResponder and Non--Responder:Responder: ““aa””

Path Path

Responder: The active ingredient mobilized desired changein an underlying mechanism.

Non-Responder: The link between AI and Mediator is notsupported.

What can we infer from non-response?

1.

Did mediator change in desired direction, but not for thespecified reason?

2. Are there “families”

of active ingredients (AI) and a“AI family member”

mobilized change?

3. Why did the mediator not change?

Implications: Implications: ““aa””

Path Process MatchPath Process Match

••

Simplest caseSimplest case: A therapy with one active ingredient and one MOBC.

••

More likely caseMore likely case: A therapy with multiple active ingredients mobilizing “several”

MOBC. Here, there may be value in “matching”

active ingredients to

individuals.

Responder and NonResponder and Non--Responder:Responder: ““bb””

Path Process MatchPath Process Match

Responder: Mobilized change mechanism produced desired change in outcome.

Non-Responder: No association between mobilized MOBCand desired change in outcome.

What can we infer from non-response?1. MOBC was not “mobilized”2. MOBC was mobilized, but MOBC effect was conditional

on third variable.3. What is the nature of third variable and can it be

influenced (altered) within

treatment?

Implications: Implications: ““bb””

Path Process MatchPath Process Match

Implications of non-responding tied to nature of third variable:

Individual attribute/historySocial Network

Cultural values

Environmental

An Example: Treatment Seeking, AA LifetimeAn Example: Treatment Seeking, AA LifetimeHistory, and A and B PathsHistory, and A and B Paths

Does extent of past AA history advance or hinderthe influence of AA attendance on later spiritual gains(a path) and, in turn, does AA history advance or hinderthe influence of spiritual gains on later increasesin abstinence (b path)?

A majority of treatment seeking adults have prior AAA majority of treatment seeking adults have prior AAhistory and 76% of treatment providers include AA referral.history and 76% of treatment providers include AA referral.

So, we retrospectively investigatedSo, we retrospectively investigated: :

Relapse Replication Extension Project Relapse Replication Extension Project Lowman, Allen, Stout, 1996Lowman, Allen, Stout, 1996

N = 110

N = 136

X No AAI

83% of participants (N = 205 of 246)Interviewed at all time points

22

44

66

88

1010 1212Albuquerque

Buffalo

Providence

R01 AA022328 Witkiewitz (PI) NIAAAIntegrative Data Analysis to Predict Alcohol Clinical Course and

Inform Practice

Low AA History

High AA History(N = 194)

(N = 52)

Six-Month Comapsrins

Percent AA “Members”

`

Percent Days AA Attendance

Percent Having an AA sponsor

Percent Having Spiritual Awakening

Descriptive Statistics on AA ParticipationDescriptive Statistics on AA Participationby AA Lifetime History Statusby AA Lifetime History Status

Percent AA Percent AA ““MembersMembers””

Low AALow AA

37.137.1

49.349.3

44.344.3High AAHigh AA

80.880.8

81.181.1

66.766.7

Days AA AttendanceDays AA Attendance

Low AALow AA

.01 (.04).01 (.04)

.06 (.14).06 (.14)

.06 (.15).06 (.15)High AAHigh AA

.14 (.22).14 (.22)

.29 (.35).29 (.35)

.27 (.34).27 (.34)

Percent with AA SponsorPercent with AA Sponsor

Low AALow AA

10.810.8

30.330.3

34.234.2High AAHigh AA

71.271.2

61.161.1

40.040.0

N = 194, Low AA; N = 52 High AAN = 194, Low AA; N = 52 High AA

Baseline

6

12

AAAttendance

SpiritualPractices

AbstinencePDA

Months 1Months 1--66

Month 6Month 6

Months 7Months 7--1212

b = 2.46b = 2.46p < .029p < .029

b = 1.74b = 1.74p < .001p < .001

, t = 3.66, b = 7.54, p < .001

The indirect effect was significant (95% CI = 1.48The indirect effect was significant (95% CI = 1.48--11.85)11.85)

Simple MediationSimple Mediation

0 0.238 0.476 0.714 0.95219.26

19.90

20.54

21.18

21.82

AA

RB

B

AA_LIFE = 1

AA_LIFE = 2

Process Matching: A PathProcess Matching: A Path

High AA History(n = 52)

Low AA History (n = 194)

t = t = --

1.34, p < .181.34, p < .18

LL CI = LL CI = --

9.599.59ULCI = 1.83ULCI = 1.83

9.00 13.75 18.50 23.25 28.0076.65

81.27

85.89

90.52

95.14

RBB

PDA

AA_LIFE = 1

AA_LIFE = 2

Process Matching: B PathProcess Matching: B Path

Low AA History(n = 194)

High AA History (n = 52)

t = t = --

.944, p < .35.944, p < .35

LLCI = LLCI = --

2.212.21ULCI = .78ULCI = .78

Example SummaryExample Summary

AA attendance mobilized gains in spiritualpractices that, in turn, predicted laterincreases in abstinence, (simple mediation).

Extent of AA lifetime history did not moderatethe effect of AA meetings on spiritual gainsnor did AA lifetime history alter the influenceof spiritual gains on increased abstinence(moderated mediation).

Chapter 4Chapter 4

““

A story has no beginning or end, A story has no beginning or end, arbitrarily one chooses that momentarbitrarily one chooses that momentof experience from which to lookof experience from which to lookback or from which to look ahead.back or from which to look ahead.””

――

Graham GreeneGraham Greene

To SummarizeTo SummarizePrecision medicine has been assignedPrecision medicine has been assigned

a high priority by NIH and NIAAA.a high priority by NIH and NIAAA.

Strong possibility that MOBC pathways of interest are Strong possibility that MOBC pathways of interest are moderated.moderated.

Need additional metaNeed additional meta--analytic work on MOBC in analytic work on MOBC in evidenceevidence--based behavioral treatmentsbased behavioral treatments

ProcessProcess--matching provides a means to respond to matching provides a means to respond to ongoing trends in MOBC research as well as to ongoing trends in MOBC research as well as to support NIAAA strategic mission.support NIAAA strategic mission.