A randomised controlled trial of Cognitive Bias Modification training during early recovery from alcohol dependence.

CBM Intervention: Many substance abusers have impaired ability to regulate and monitor their behaviour. According to the "dual process" model, addiction arises from an imbalance between overactive “bottom-up” automatic (impulsive) processes that drive behaviours and impaired "top-down" controlling processes that stop behaviours associated with negative consequences. As a result, the individual’s addictive behaviour becomes more easily triggered by alcohol related cues in their environment, but less able to be inhibited once triggered. The exaggerated tendency to attend and react to alcohol related cues is called “cognitive bias”. Cognitive bias modification (CBM) is a computer based training paradigm that trains the brain to inhibit the tendency to approach negative/harmful cues. This approach both minimizes the overactive "bottom-up" processes and improves the "top-down" control processes. In the intervention CBM task, participants will be exposed to 240 computerised images of 40 different alcoholic and 40 different non-alcoholic drinks and instructed to respond with an approach or avoidance movement according to their orientation (landscape or portrait). While instructions are based on picture orientation, one orientation will contain images of alcoholic beverages 95% of the time (and non-alcoholic beverages 5% of the time) and will require an avoidance movement (pushing of a joystick, which decreases image size). The other orientation will contain non-alcoholic beverages 95% of the time and alcoholic beverages 5% of the time and will require an approach movement (pulling the joystick, which increases image size). The requirement to push away nearly all (95%) of alcohol images is intended to train participants to over-ride their pre-existing tendency to approach alcohol, and we hope that this will generalise to a reduced tendency to approach alcohol and its related cues following discharge from detoxification. This requirement will be reversed on 5% of trials to reduce the likelihood of participants being un-blinded to the nature of the training. The training task usually takes approximately 15 minutes. It will be repeated on each of the three following days, such that the participant receives four consecutive days of training while in detoxification. The intervention will be administered by trained and qualified researchers employed by Turning Point (Eastern Health) or Monash University. Training will commence no earlier than the 3rd day of inpatient withdrawal, though may be commenced later as long as there are 4 consecutive days available on which to conduct the training prior to the participant’s planned discharge day. In cases where participants receive the “standard” 7-day inpatient withdrawal, we aim to time sessions such that the final session will occur the day before discharge. However, due to variations in length of admission that sometimes occur, with some admissions lasting up to 2 weeks, the timing of training relative to the date of discharge will vary. Data collectors will report any deviations from intervention adherence to the project manager, who will maintain a record of these deviations. Deviations may include interruptions to training sessions (e.g. due to computer errors or other unexpected events), non-standard scheduling of sessions (e.g. skipping a day, due to a participant being unwell or unavailable on a day a session is planned), or failure to complete 4 sessions due to unexpected early discharge from the withdrawal unit. All participants who commence training will be included in analyses, according to intention-to-treat principles, but participants who do not complete 4 sessions will be excluded from secondary per-protocol analyses.