Reducing problem drinking by training the subconscious brain

When we drink frequently, alcohol cues such as places, sights, smells, and social situations that remind us of drinking, subconsciously capture our attention and drive impulses to drink. This tendency is called a cognitive bias.

Your kitchen fridge on a Friday night is a perfect example of an "alcohol cue", says Associate Professor Victoria Manning from the Monash Addiction Research Centre and Turning Point, Australia’s leading national addiction treatment, education and research centre.

"A world-first, CBM app enables users to “personalise” their training by selecting the alcohol beverages or brands they want to train their brain to avoid."

As a society, Australians are continually bombarded with alcohol cues, be it from bottle shops, pubs, or advertising at sporting events. In fact, recent research suggests we're targeted on social media with an advertisement for alcohol every 35 seconds.

Read more: An avalanche of alcohol ads is coming, and there’s little protection for children

Researchers in Europe have demonstrated that a novel form of brain-training called cognitive bias modification (CBM) can reverse these impulses to drink.

In people who sought residential rehabilitation for alcohol misuse, CBM was shown to prevent alcohol relapse up to a year after treatment. CBM is a computerised program that works by training people to repeatedly (automatically) “avoid” alcohol-related stimuli and to “approach” neutral or positive stimuli.

In Australia, however, CBM is not yet available, and fewer than 16% of addiction treatment episodes in 2017-18 involved residential rehabilitation (AIHW, 2019).

Associate Professor Manning says that more than half of those who go through inpatient withdrawal are drinking again with two weeks of discharge.

“This is a problem because relapse hampers engagement in psychological, pharmacological or peer-based interventions that we know help people maintain long-term abstinence or less-harmful drinking.”

In 2016, Associate Professor Manning and a team of researchers from Monash University and Deakin University collaborated on the first trial of CBM during alcohol withdrawal treatment. The small, single-site pilot trial of 83 participants undertook four sessions of CBM that saw a reduction in early relapse by 30% relative to a sham-training control version of the task.

This world-first, CBM app enables users to “personalise” their training by selecting the alcohol beverages or brands they want to train their brain to avoid

Following the initial trial, the team secured funding from the National Health and Medical Research Council and aimed to replicate the pilot, this time in a multi-site, double-blind randomised control trial of CBM during alcohol withdrawal treatment, with 300 patients from four alcohol withdrawal units in Melbourne.

The results of the three-year study, published this week in JAMA Psychiatry, show that four sessions of CBM shifted a participant's natural response from "approaching" alcohol cues to "avoiding" them, and, importantly, significantly reduced early relapse by 17% relative to those who received sham-training (controls).

Associate Professor Manning says these results are extremely encouraging.

“Being easy to implement, safe and requiring only a laptop and joystick, we recommend CBM is routinely offered as an adjunctive intervention to inpatient withdrawal, to optimise patient outcomes,” she says.

One in six Australians drink at harmful levels, putting them at risk of alcohol-related disease or injury, and one in five will develop an alcohol use disorder during their lifetime.

Addiction treatment services cater for those with moderate to severe alcohol problems, but these represent only a minority of those wanting to reduce or stop drinking. We also know there are numerous barriers that prevent or delay treatment-seeking, including stigma, inconvenience and inaccessibility.

Smartphone apps are one way of overcoming these barriers, as they provide free, low-intensity, highly-accessible alcohol interventions to the broader non-treatment-seeking community.

Unfortunately, there have been few well-powered trials of smartphone apps aimed at reducing alcohol use, and those that do exist work to strengthen conscious, cognitive processes to control drinking, such as getting people to track and monitor their use, or plan and set goals around their drinking. As such, they fail to address and leave intact the automatic, subconscious processes that drive the desire to drink alcohol.

Changing habits with a swipe

Recent media stories of increasing alcohol consumption during the COVID-19 crisis have highlighted the need for novel scalable, accessible approaches that can help people change their unhealthy drinking habits.

Read more: COVID-19: Pandemic alcohol use and mental health problems

To address this, Monash researchers, led by Associate Professor Manning, have developed a program that delivers CBM via a smartphone app called SWiPE.

This world-first, CBM app enables users to “personalise” their training by selecting the alcohol beverages or brands they want to train their brain to avoid (by repeatedly swiping away those images). At the same time, it aims to strengthen motivation for drinking less by getting users to repeatedly swipe towards themselves, positive, meaningful goal-related images, such as family, hobbies, travel, friends, or exercise that they have selected from their photo libraries.

The team is currently running an open-label trial of SWiPE to test its feasibility, acceptability and effectiveness at reducing alcohol consumption and craving. App users complete two, five-minute training sessions a week for four weeks.

“Our hope is that SWiPE could offer a free, simple, easy-to-use, anonymous and convenient support tool to reduce alcohol craving and consumption irrespective of time and location, and at times when support is most needed.”

Capitalising on today’s "swipe culture" where we make instantaneous decisions with the mere flick of a finger, this app could be easily adapted to dampen the subconscious drivers of other unhealthy habits that many people want to break, such as smoking, or eating too much junk food.

Those interested in participating in the trial or learning more can email swipe-app@monash.edu.