Articles of Public Interest

People with alcohol use disorder (AUD) may not respond typically to images of food (i.e., cues), according to a novel study using brain imaging. AUD is believed to reshape the brain circuitry involved in reward and motivation such that alcohol cues become emphasized over natural (or conventional) rewards, including life goals, food, and social connections. Alcohol cues are thought to trigger an enhanced dopamine release, relative to cues of conventional rewards, among people who are vulnerable to AUD, which may amplify their risk for problematic drinking. Consistently, a heightened response to alcohol cues has been linked to craving, heavy drinking, and vulnerability to relapse. Natural cues, meanwhile, may become less salient with the disease progression. AUD is associated with both malnutrition—raising the risk for liver disease—and social and emotional deficits, which could, in turn, undermine treatment and recovery efforts. Increasingly, treatment researchers are using brain responses to alcohol cues as a measure for evaluating the effectiveness of AUD medications in development. Despite the potential importance of the relationship between alcohol cues and natural rewards, it remains generally underexplored. For this study in Alcohol: Clinical & Experimental Research, the investigators used brain scans to compare the reward processing of people with AUD and light drinkers to a range of visual stimuli.

Researchers at the Medical University of South Carolina worked with 28 adults (average age 32). Forty-three percent were women; most were White. Fourteen met criteria for AUD; 14 were light drinkers. All participants provided detailed information on their use of alcohol and other substances and gave blood and urine samples for corroboration. The participants underwent a functional magnetic resonance imaging (fMRI) scanning session. They viewed images relating to alcohol—using an established protocol known to activate reward circuits in the brain—as well as non-alcohol beverages (control condition). They also viewed images of food, household images (control condition), positive social scenes, and images of people involved in everyday tasks (control condition). Researchers also examined brain activation from MRI data and used statistical analysis to look for associations between neurological patterns and imagery in both groups. The participants also reported their experience and intensity of positive and negative emotions while viewing the various images following the scanning session.

The participants with AUD reported an average of 4–5 drinks a day in the last month; just over half of those days involved heavy drinking. Light drinkers reported less than 1 alcohol-containing drink a day. During the scanning session, their brain activation patterns were consistent with their self-reported emotional responses. Among people with AUD, food images elicited abnormally low reward activation in two brain regions. These regions—the superior frontal gyrus and the caudate—have roles in motivation and goal-driven behaviors. The lower response to food images within the superior frontal gyrus was, in turn, linked to more recent heavy drinking days among AUD participants and higher craving and alcohol dependence across the whole sample. The groups’ reactions to social images did not differ significantly.

Heavy drinking appears to be associated with a reduced response to natural rewards, specifically food. These study findings are preliminary and may not generalize to other populations. If substantiated, they may point to an opportunity for enhancing natural brain reward activation as a treatment for AUD and co-occurring conditions. It is unknown whether reduced interest in food precedes or is caused by AUD.

Blunted reward-related activation to food scenes distinguishes individuals with alcohol use disorder in a case-control fMRI study. W. Mellick, L. McTeague, S. Hix, R. Anton, J. Prisciandaro. (https://doi.org/10.1111/acer.15419)

Drinking alcohol may predict experiencing physical, psychological, or sexual victimization during or shortly after alcohol use, according to a study published in Alcohol: Clinical and Experimental Research. The study, which collected real-time data from 18- to 25-year-olds in relationships, found that, often, physical and psychological victimization co-occur with alcohol use, and physical and sexual victimization occur within hours after alcohol use.

For the study, 170 participants were prompted at four random times daily to answer questions online about their alcohol use and any psychological, physical, or sexual violence they experienced since the prior survey.

At times when individuals reported alcohol use, they also were more likely to report psychological and physical, but not sexual, victimization at the same time. Physical and sexual, but not psychological, victimization were more likely to be preceded by alcohol use. Alcohol use was not more likely to be reported in the hours immediately after psychological, physical, and sexual victimization. The authors note that alcohol use following victimization may be delayed due to the need to tend to injuries immediately after experiencing violence. Individuals in the study who experienced more instances of victimization than others in the study were not more likely to drink more. Similarly, people who drank more than others in the study were not more likely to report experiencing any form of partner violence.

In general, participants completed three of the random surveys per day, four hours apart. On average, participants reported six instances of alcohol use, three instances of psychological victimization, one instance of physical violence, and less than one instance of sexual victimization over the 28-day study. Being pushed, shoved, shaken, slapped or hit, having their hair pulled, or having something thrown at them by their partner were categorized as physical violence. Psychological victimization included, for example, their partner calling them names, insulting them, or swearing, yelling, or screaming at them. Unwanted sexual contact or insisting or threatening by their partner to get them to do something sexual when they didn’t want to were considered sexual victimization.

Previous studies have found that 40 percent of young adults have experienced intimate partner violence in their lifetime. This study highlights a potential opportunity to use technology to provide real-time interventions for people at risk for intimate partner violence.

The authors of the study emphasize that perpetrators, not victims, are responsible for the victimization, and the perpetrator's drinking, which has previously been linked to an increased risk of partner violence, was not assessed. The results of the study may not be generalizable to a broader audience as the participant pool was predominantly White, heterosexual, and college students in relationships where they saw their partners at least twice a week. The study participants included only people who were not fearful of their partner and had a history of perpetrating intimate partner violence. Authors note that it is not uncommon for those who perpetrate intimate partner violence to also experience victimization.

Alcohol use and intimate partner violence victimization among young adults with a history of perpetration: An ecological momentary assessment study. L. Grocott, L. Brick, M. Armey, G. Stuart, R. Shorey. (https://doi.org/10.1111/acer.15417)

People with alcohol use disorder (AUD) who are at risk of advanced liver disease are less likely to be referred for liver evaluation and care if they present primarily with alcohol-related mental health issues or a mental health diagnosis, according to a study of referral practices in Virginia's largest health system. The findings point to the possibility of widespread missed opportunities for treating three conditions that commonly co-occur: AUD, mental health disorders, and liver disease. Recent years have seen notable increases in the USA in alcohol-related deaths, mental health disorders, and hospital admissions relating to alcohol use and concurrent mental health conditions. AUD is a significant cause of liver disease, and both addiction and co-occurring mental illness can be barriers to successful liver treatment. Integrating AUD treatment, mental health care, and hepatology (liver care) is necessary to improve outcomes, but data suggests this approach is not the norm. For the study in Alcohol: Clinical & Experimental Research, investigators evaluated which patients with excessive alcohol use and potentially advanced liver disease were referred to hepatology for evaluation and treatment.

Researchers worked with data representing 316 patients experiencing excessive alcohol use who were treated between 2013 and 2023. All the patients in the study had results from FIB-4—a blood test included in routine lab work—correlating to a high risk of advanced liver fibrosis. The researchers collected information on the participants’ demographics, alcohol-related hospital admissions, predicted mortality, referral patterns, and mental health diagnoses and hospitalizations. They used statistical analysis to explore factors associated with referral to hepatology.

Most patients were men, and the average age was 60. Six in 10 were Caucasian, and nearly 4 in 10 African American. Only 37% of patients with excessive alcohol use and a high risk of advanced liver disease were referred for liver care. Referrals to hepatology were associated with higher FIB-4 scores, more co-occurring health conditions, and hospitalization due to AUD-related liver issues or gastrointestinal concerns. Patients less likely to be referred for liver care included those admitted to the hospital for physical injury or alcohol-related mental health concerns, who presented with mental health disorders, or who were older. Of these, patients with depression or suicidal ideation were more frequently referred to hepatology than patients with other mental health diagnoses.

The study identified an opportunity to increase integration of care across specialties serving patients with alcohol-related liver disease and mental health conditions. People presenting with primarily mental health or addiction issues were especially unlikely to be referred for appropriate liver care. The findings highlight the need for healthcare providers to be educated about the importance of multispecialty care, including hepatology and GI referrals. Managing liver disease is necessary for reducing the risk of cirrhosis, cancer, and other conditions and for liver transplant evaluation. Similarly, early identification of AUD in patients with liver disease is essential for improving outcomes.

Referral to hepatology is lower in patients with excessive alcohol use who have mental health disorders despite a high FIB-4 index. K. Houston, S. Harris, A.Teklezghi, S. Silvey, A. D. Snyder, A. J. Arias, J. S. Bajaj. (https://doi.org/10.1111/acer.15422)

Young adults who drink heavily reported that a specific intervention that provides personalized feedback on daily drinking would be beneficial for people who want to reduce their drinking and would encourage self-reflection among those who are not yet ready to change their drinking habits. The young adults were participants in a pilot study of a first-of-its-kind technology aimed at reducing heavy drinking in young adults through self-selected goal setting and daily personalized feedback based on self-reported behaviors related to drinking. The study is described in Alcohol: Clinical and Experimental Research.

This second open trial pilot study of the intervention, called ’A-FRAME’ (Alcohol Feedback, Reflection, and Morning Evaluation), tested the feasibility and acceptability of new components and elicited more feedback on the tool. ’A-FRAME’ study participants received a text each morning with a link to a web-based survey, where they answered questions about their drinking and related behaviors, such as whether they took shots, played drinking games, or used cannabis. They were also asked to rate any negative consequences they experienced due to their drinking, such as injury, embarrassment, hangover, aggression, or nausea. Participants could choose to receive daily and biweekly feedback about their blood-alcohol content, how their behavior compares to national norms, the calories they consumed while drinking, how much money they spent on alcohol, their high-risk behaviors and consequences, as well as strategies for reducing drinking and related consequences. Calories and spending were newly added topics requested by participants in the first pilot study.

All 18 participants completed the study, including a post-test survey and interview. The response rate to the 28 daily surveys was 94 percent. Almost all participants said A-FRAME increased their awareness of current or future drinking, with one participant calling it ’eye-opening.’ Participants rated the intervention ’acceptable’ or better for engagement, aesthetics, information quality, and general perception. Sixteen of the eighteen participants stated they would use A-FRAME in the next year if available, and half reported sharing something they learned from the program with others.

Of the 100 daily feedback reports, half of the participants viewed blood alcohol content feedback, a quarter viewed calories consumed, and a fifth viewed their spending. About half of the participants viewed their 2-week and four-week feedback reports. Blood-alcohol content, comparison to norms, calories consumed, and spending were the most viewed topics in the reports. Consequences and strategies were the topics viewed least often. Participants reported they appreciated the ability to set goals, choose which feedback topics they reviewed, and see the trends over time.

The study involved a racially diverse but relatively small sample size of eighteen young adults who were in or who had graduated from a four-year college. Participants were required to be at least somewhat willing to make a change to their drinking, but readiness to change was not measured. The researchers will use the study's findings to refine the A-FRAME intervention and have planned a more extensive, randomized control trial to test its effectiveness in reducing heavy drinking.

Alcohol Feedback, Reflection, and Morning Evaluation (A-FRAME): Refining and testing feasibility and acceptability of a smartphone-delivered alcohol intervention for heavy-drinking young adults. J. Merrill, N. Gebru, R. Peterson, G. Lopez, C. Lau-Barraco, N. Barnett, K. Carey. (https://doi.org/10.1111/acer.15424)