Alcohol Clin Exp Res (Hoboken). 2023 Dec 15. doi: 10.1111/acer.15242. Online ahead of print.
BACKGROUND: Understanding how treatments for alcohol use disorder (AUD) facilitate behavior change has long been recognized as an important area of research for advancing clinical care. Even after decades of research, however, the specific mechanisms of change for most AUD treatments remain largely unknown because most prior work in the field has solely focused on statistical mediation. Statistical mediation is a necessary but not sufficient condition for establishing evidence for a mechanism of change. Mediators are intermediate variables that statistically account for the relationship between an independent and dependent variable whereas mechanisms provide more detailed explanations of how an intervention leads to a desired outcome. Thus, mediators and mechanisms are not equivalent.
METHODS: To advance mechanisms of behavior change research, this critical review provides an overview of methodological shortfalls of existing AUD treatment mechanisms research and introduces an etiologically informed precision medicine approach that facilitates testing mechanisms of behavior change rather than treatment mediators.
RESULTS: We propose a framework for studying mechanisms in alcohol treatment research that holds promise for facilitating our understanding of behavior change and precision medicine (i.e., for whom a given mechanisms of behavior change operates under what conditions). The framework forwarded in this review has several overarching goals including providing a methodological roadmap for testing AUD recovery mechanisms. We provide two examples of our framework, one pharmacological and one behavioral, to facilitate future efforts to implement this methodological approach to mechanisms research.
CONCLUSIONS: The framework proposed in this critical review facilitates the alignment of AUD treatment mechanisms research with current theories of etiologic mechanisms, precision medicine efforts, and cross-disciplinary approaches to testing mechanisms. Although no framework can resolve all the challenges related to mechanisms research, our goal is to help facilitate a shift towards more rigorous and falsifiable behavior change research.