A Controlled Trial of Cue Exposure Treatment in Alcohol Dependence D. Colin Drummond Addiction Research Unit, National Addiction Centre Institute of Psychiatry Steven Glautier Addiction Research Unit, National Addiction Centre Institute of Psychiatry ABSTRACT The clinical effectiveness of cue exposure (CE) treatment in alcohol dependence was evaluated in a controlled trial. Thirty-five men who were detoxified and severely alcohol dependent received either CE or relaxation control (RC) treatment. CE Ss had 400 min exposure to the sight and smell of preferred drinks over 10 days in a laboratory setting. RC Ss spent identical time in the laboratory but had relaxation therapy and only 20 min exposure to alcohol cues. During 6-month follow-up, personal interview was achieved with 91% of Ss. CE Ss had a more favorable outcome than the RC Ss in terms of latency (length of time) to relapse of heavy drinking ( p < .01) and total alcohol consumption ( p < .05). Significant predictors of latency to heavy drinking and dependence included skin conductance level ( p < .001). and experimental condition ( p < .01). Results point to the potential importance of cue exposure as a treatment for addictive behavior. This research was supported by Medical Research Council Programme Grant No. 7400. We thank Colin Taylor and Griffith Edwards for comments on a draft of this article. We thank the staff and patients of the Maudsley Hospital for their helpful cooperation in this study. Correspondence may be addressed to D. Colin Drummond, Division of Addictive Behaviour, St. George's Hospital Medical School, Hunter Wing, Cranmer Terrace, London, United Kingdom, SW17 ORE. Electronic mail may be sent to [email protected] Received: May 4, 1993 Revised: October 25, 1993 Accepted: October 25, 1993 Stimuli (or cues) associated with the ingestion of dependence-producing drugs have been repeatedly shown to have important response-eliciting properties in both animals and humans. There is evidence to support the view that, after repeated drug administration, cues that precede drug ingestion (such as the sight and smell of a glass of beer or the sight of a needle and syringe) elicit conditioned responses (for reviews, see Drummond, Cooper, & Glautier, 1990 ; Niaura et al., 1988 ). Furthermore, in the case of alcohol, the intensity of the response is positively related to the subject's degree of dependence ( Corty, O'Brien, & Mann, 1988 , Glautier & Drummond, 1994 ; Kaplan, Meyer, & Stoebel, 1983 ; Laberg, 1986 ). This adds more weight to a conditioning model of responses to pre-ingestion cues: Those with a higher degree of dependence will have experienced a greater frequency of drug-cue pairings and will be more likely to have experienced drug withdrawal, which is viewed as a powerful motivating factor in the maintenance of drug-taking behavior ( Edwards, 1990 ). Journal of Consulting and Clinical Psychology © 1994 by the American Psychological Association August 1994 Vol. 62, No. 4, 809-817 For personal use only--not for distribution. Page 1 of 1411/20/2000http://spider.apa.org/ftdocs/ccp/1994/august/ccp624809.htmlSuch evidence has pointed to the potential of cue exposure as a treatment in drug and alcohol dependence. It has been suggested that repeated exposure to pre-ingestion cues in the absence of drug ingestion will lead to extinction of conditioned responses, thus reducing the likelihood of relapse to drug-taking behavior ( Drummond, Cooper, et al., 1990 ). An alternative strategy has been proposed in which the drug taker is given an initial priming dose of the drug and encouraged to resist the temptation to consume more of an available drug ( Rankin, Hodgson, & Stockwell, 1983 ). Such a treatment aims to enhance self-control of drinking behavior rather than maintaining abstinence and has similarities to cue exposure and response prevention in obsessive—compulsive neurosis. Although one priming dose—response prevention study with participants dependent on alcohol showed that drinking behavior could be modified in a laboratory setting ( Rankin et al., 1983 ), this method has not been tested in a clinical follow-up study. Indeed, at the time of writing, we did not find a single published clinical trial of the former method of cue exposure in alcohol dependence. The results of cue exposure treatment trials in the case of heroin and nicotine dependence have so far not supported its effectivenss ( Dawe et al., 1993 ; McLellan, Childress, Ehrman, & O'Brien, 1986 ; Raw & Russell, 1980 ). This stands in contrast to the evidence for the effectiveness of cue exposure in the analogous condition of phobic neurosis ( Beech & Vaughan, 1978 ; Mathews, Gelder, & Johnston, 1981 ). In an unpublished manuscript from this controlled trial of cue exposure in individuals with severe alcohol dependence, we compared the effects of exposure to pre-ingestion cues on physiological and subjective responses in a laboratory setting with those of a control procedure involving relaxation training ( Drummond & Glautier, 1993 ). A significiant reduction in subjective tension was found in the cue exposure group, compared with the finding in the control group. Physiological responses were not, however, significantly influenced by cue exposure in comparison with controls, although both groups showed reductions in responsivity over time. In this article we examine the clinical effects of exposure to pre-ingestion cues. The main hypothesis was that cue exposure would reduce the likelihood of relapse following the patient's discharge from the hospital. More particularly, it was predicted that the effect of cue exposure would be an increased latency (or length of time) to initial lapse rather than to full reinstatemnt of dependence, given that the mechanism of treatment proposed by conditioning theory was extinction of responsivity. Hence, it was expected that following initial lapse, any benefits accrued through cue exposure would be lost because of reinstatement of conditioned responding. An alternative theory, however, was that the cue exposure subjects would acquire cognitive coping skills and increased self-efficacy in resisting the temptation to drink by virtue of practice in resisting temptation during treatment ( Drummond, Cooper, & Glautier, 1990 ; Marlatt, 1990 ). It was possible that, if such skills were acquired during treatment, they could exert an effect not only on latency to intial lapse but also on the
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