What is Alcohol Use Disorder? Concepts and measurement with Dr Cassie Boness

In this episode we talk to Dr Cassie Boness about the idea of ‘Alcohol Use Disorder’ (AUD) as a widely applied concept in the identification and treatment of alcohol problems.

Alcohol Use Disorder is the basis for identifying an alcohol problem in the American Psychiatric Association’s DSM, but also used as a broader term for alcohol-related problems including by the UK’s National Institute for Health & Care Excellence (NICE).

Cassie is a  Research Assistant Professor at the University of New Mexico's Center on Alcohol, Substance Use and Addictions (CASA) and a clinical psychologist. 

We discuss the basis of Alcohol Use Disorder and some of the issues around such attempts to identify the very complex nature of alcohol use and problems. This includes discussion on Cassie and others work on developing a new framework to better identify AUD - the  The Etiologic, Theory-Based, Ontogenetic Hierarchical Framework of Alcohol Use Disorder. 

Transcript

James Morris: 0:02

Thanks so much, Cassie for joining us. Can you just briefly tell me a bit about who you are and what you do?

Cassie Boness: 0:07

Yeah, sure. Thanks for having me. My name is Cassie Bowness. I am a research assistant professor at the University of New Mexico and the United States. I work at the centre on alcohol substance use and addictions, which is also often referred to as casa, I actually just started this position in the last six months or so. I just recently finished my PhD in Clinical Psychology, within emphasis in addiction science. So most of my research, and also my clinical work to date has really focused on addiction and most specifically on alcohol and harm reduction,

James Morris: 0:45

and specifically that work around I don't know, I guess how we conceptualise and understand what alcohol problems are. So can you start off maybe by telling us a bit about, you know, what the main ways alcohol problems are kind of captured or measured, you know, things like maybe in the DSM versus the audit, for instance?

Cassie Boness: 1:05

Yeah, sure, I'm of the mind that alcohol use itself obviously kind of exists on a continuum. And where a certain person falls on that continuum is determined by a number of factors. At at the more extreme end of the alcohol use continuum, we might start to see things like problems or what the DSM or the Diagnostic and Statistical Manual of Mental Disorders refers to as alcohol use disorder. So that would be kind of the more conceivably the more extreme end of the continuum. And most of my work really has focused on this DSM conceptualization of of alcohol use disorder, or AUD. And the way that they define that is, they define alcohol use disorder as being composed of these 11 symptoms. And these symptoms cover the domains of impaired control, social or interpersonal impairment, risky use and pharmacological criteria, like alcohol withdrawal, or tolerance, for example. So what I've largely focused on is this idea of DSM five conceptualization, which tends to kind of frame alcohol problems and AUD in terms of the psychosocial problems, but as you mentioned, and as you kind of alluded to there, other ways of conceptualising alcohol problems or disorder, so to speak, if we want to call it that one of those ways is ICD, ICD 11. There are actually several different diagnoses in the ICD that are related to alcohol use, there's kind of our classic dependence, right, this is thought to be repeated or continuous use that has some component of impaired control, you know, being unable to stop drinking, or only have one drink, sometimes accompanied by like craving, for example, but not always. And then obviously, other things like, you know, spending a lot of time using alcohol, or having those classic features like tolerance or withdrawal that really characterise what is thought to be alcohol dependence. And then I won't go too much into this. But ICD is interesting, because it also has a harmful pattern of use as a diagnosis. And then hazardous use, which is considered kind of a health risk factor. And these are thought to be kind of less severe manifestations of dependence. So previously, DSM, separated alcohol use disorder into alcohol abuse and alcohol dependence, a harmful pattern of use is thought to kind of map more onto what was formerly known as alcohol abuse.

James Morris: 3:41

Yeah, because because the idea of alcohol use disorder, I was going to ask you about this because in kind of UK or in England, at least we have, you know, it's kind of almost four categories, kind of derived from the audits, the alcohol use disorders, identification test of kind of low risk, which is essentially drinking within the guidelines, increasing risk, which is what used to be referred to as hazardous drinking. So maybe just drinking a bit above the guidelines, but maybe not having any manifestation of problems as such. And then yeah, the kind of harmful drinking or high risk drinking, it'd be called, which I think is that ICD, harmful pattern of drinking, and then we'd have a category of dependence, which might be split into sort of mild, moderate or severe. So think nice kind of use alcohol use disorders as an umbrella for all of the kind of hazardous or risky drinking that may not have any kind of actual problems associated with it yet. Whereas Am I right? That DSM AUD doesn't include that kind of risk those risky patterns where there's no harm yet manifested as inclusive of an AED?

Cassie Boness: 4:49

Yeah, it's it's tricky because a lot of what DSM includes in their diagnostic criteria are psychosocial consequences which are captured by those less kind of risky categories in the ICD. So, you know, perhaps if we, you know, if we had a better, I don't know, kind of way of determining the threshold for the DSM diagnosis that would allow us to capture, you know, only problems, problems plus these, you know, tolerance or withdrawal symptoms, just tolerance or withdrawal that would give us a little bit more information about kind of what this person's experiencing in their day to day life related to their alcohol use.

James Morris: 5:28

Yeah, that's a lot of what your work has been doing, isn't it kind of dissecting all these nuances or types of clusters or aspects or components of alcohol problems, that it's really heterogeneous kind of problem, it manifests in so many different ways of so many different causes. And your work is taking on this almost infinitely complex task of trying to disentangle and say, or what may be more useful and more accurate ways of trying to identify this kind of very broad concept of alcohol use disorder or alcohol problems.

Cassie Boness: 6:01

Yeah, one of I think, in many ways, one of the improvements of the DSM five substance use disorder diagnosis was moving away from this idea of abuse versus dependence, just because those things, you know, statistically, were not actually separating in the way that they were conceptually thought to separate. So in DSM five, they just combined it into like this alcohol use disorder, you know, diagnosis or construct. And while in some ways, that's an improvement, I really do think that it in other ways just provides us a lot less information. And a lot of what my work has focused on is this assumption that the DSM five makes that all of those 11 criteria used to define an alcohol use disorder are in some way created equally. And indeed, they're not. And they all provide unique information that's oftentimes overlooked when we just move into that categorical realm where we just say, you know, you have an alcohol use disorder, or you don't,

James Morris: 6:57

I guess, also that the abuse and dependence, you know, whilst sort of through your work, you've shown it doesn't really apply in real life, or they're not really, you know, they don't separate out as neatly as you'd want them to, to call them different things in a way they do sort of make more sense. Probably, you know, like, if we talk to people about alcohol problems, in general, they tend to think about, well, it's kind of binge drinking, which might be what DSM four called abuse, and then there's kind of dependence, which a lot of people are referred to as alcoholism or addiction or whatever. So I guess, you know, there's the marrying up of what are kind of useful concepts for people to try and make sense of and understand different types of alcohol problems in the real world, versus maybe how we want to try and really capture the real complex details and differences in research, policy, and certainly treatment, if we want to maybe target or tailor treatments more.

Cassie Boness: 7:51

Yeah, and that's where a lot of my more recent work has been moving towards is, you know, trying to tease apart this question of, you know, why do the treatments that we have for alcohol use disorder? Why are they perhaps not as effective as some other treatments that we have in for psychopathology, more generally, why

James Morris: 8:09

you mean is, as well as sort of mental health treatments?

Cassie Boness: 8:13

Correct. And I think one of the big pieces of that is this assumption that just because somebody meets criteria for an alcohol use disorder, you know, somehow implies that those, all those people are the same, and everything's going to work for them. Just because they have this alcohol use disorder diagnosis, when in reality that tells us nothing about their, you know, individual profile, you know, how they, how they acquired an alcohol use disorder, what their history is, what the social determinants of that are. So, really, in many ways, it does not surprise me that the research on alcohol use disorder treatment looks the way it does.

James Morris: 8:50

Yeah, I guess the the, you know, in alcohol treatment, you know, I think any good clinician would say, you know, you don't want to get too het up on the diagnosis, whatever it's, you know, working with the person in front of you, you want to kind of formulate their, their alcohol problems within the context of their life and who they are and how they feel about it. And so in that sense, that captures much more than nature of the person's alcohol problem in a kind of clinical context, but maybe our conceptualizations and alcohol as they exist through DSM, etc, at the moment, don't just quite capture the nuance in the same way as that.

Cassie Boness: 9:26

Yeah. And I, that's kind of really intricately for me tied in with this idea that the criteria are created equally. So what I mean by that is that you know, any of those 11 criteria all indicate like the same level of an alcohol problem or an alcohol use disorder. And really, if you think about it, you know, someone who meets criteria for alcohol use disorder on the, on the basis of like, social or interpersonal problems alongside something like you know, spending a lot of time using or getting over the effects of alcohol. Hall compared to a person that is experiencing alcohol withdrawal or drinking to avoid withdrawal, and tolerance, which are thought to be, you know, physiologic manifestations of an alcohol use disorder of dependence, those two individuals are very different. The treatments that work for them might also be different, right? So if we're, you know, saying somebody meets criteria on the basis of meeting to have these symptoms, although, for example, like a clinician, myself might recognise, oh, this person's experiencing withdrawal that's quite serious, perhaps this person's having interpersonal problems, perhaps that's less serious. I don't necessarily know that that's always informing the treatment decisions. And that's, that's partially because the treatment decisions are impacted by a lot of other factors, right, like, what's available there? Or what's reimbursed? What the What the clinicians training isn't? So, you know, yes, in practice, these things are probably being considered, but our ability to actually respond appropriately to those differences. Just, I don't think we're quite there yet.

James Morris: 11:05

So what about this idea of dimensionality? So, you know, you said at the start that alcohol use disorder, or alcohol use and problems, as I kind of like to say it, they are obviously on a continuum in the sense that, you know, you can drink a little bit, and then you can drink a bit more, and that then increases risk of a host of different problems. So, you know, one sense very logically, alcohol use is on a continuum. But then we've got this kind of, is it kind of multi dimensionality where you might look at different types of problems or aspects of it, and then they would exist on their own dimensions?

Cassie Boness: 11:42

Yeah, so one of the really interesting things here is that DSM five says, you know, alcohol use disorder is unidimensional, which means that it's kind of this one thing that exists on a continuum, right, like from low to high. Alcohol Use Disorder exists from low to high severity, and that that is what it is. But then when they're in the DSM, when they're describing what an alcohol use disorder is, they say that these symptoms cluster into like these symptom clusters, and then those are like subsets of symptoms, which would actually imply that perhaps alcohol use disorder isn't, you know, dimensional, and you know, that those symptoms are all like the same thing, essentially. So part of what myself and Dr. Ashley watts, who who led this recent paper found that as you add in more indicators of an alcohol use disorder, so as you assess it with more items, rather than just those 11 symptoms, let's say, we assess it with 50, or with 80, that we actually start to see kind of those indicators of there being kind of multiple dimensions, just statistically that those start to suggest that there actually is dimensionality here that there are kind of these more homogenous clusters of symptoms, that group together that perhaps implies that, you know, alcohol use disorder isn't just this homogenous construct that you can assess equally with 11 symptoms. So it you know, in many ways, supports the previous work I had done, but also builds on it to show that as we get more fine grained assessments of alcohol use disorder, we really start to see kind of more of that splitting of the types of things people might experience. So it really does seem to be the case that as you add in more information above and beyond these, just like 11 symptoms that you typically ask somebody about, we do start to see kind of these more distinct groupings of symptoms, which is really then helpful when you're thinking about, you know, profiles for people individually in a person's profile of risk, or perhaps where they're experiencing the most impairment, that's causing them to meet criteria for this alcohol use disorder. So it's, it's quite odd to me, and I haven't been able to resolve it fully why the DSM says, this is some sort of like, single factor unidimensional factor, when really, they then contradict themselves by saying these are their, their these domains. And I think probably a large part of that has been that they're just not really assessing it as in depth as they should be to get that level of information. And, yeah, it's, that's what's been interesting about our work in this area is we've, we've had the ability to ask, you know, 90 indicators of alcohol use disorder to people, whereas typically, this research related to DSM five is done with these, like large epidemiologic studies that can add you know, 90 items on alcohol use disorder in them.

James Morris: 14:30

So to some degree, it's just the kind of tension between conceptual utility that you know, we want to say there's alcohol problems as a kind of catch all and in some ways, it makes it easy theoretically to say, you know, these exists in a continuum of severity. But of course then when we want to do detailed research and understand causes, different manifestations and different populations, for different treatments, etc. And we have to sort row back and unpick it all a bit. So but but you know, the like the the continuum model, I think is useful in the sense that in the general population, people think about it as two categories. Either you have a problem or you don't. And, you know, like, famously that, you know, a large part of that derives from a medical model, particularly sort of medical model of alcoholism as such, where, you know, you'd either be an alcoholic or not. So you know, we want we want a kind of more continuum aligned model of thinking in terms of in terms of the public so they can go well, yeah, maybe I'm, I'm drinking a bit much. And maybe there are risks to that. And there's be some benefits are cutting down a bit, that that kind of conceptual continuing would be better in a in a more broader understanding. But yeah, for kind of our research and scientific purposes, we have to say, Actually, wait a minute, it's it's a bit more complex than a single unit dimensional construct.

Cassie Boness: 15:54

Oh, it's it's so complex. And I think that there's this growing understanding that at least the 11 criteria used to assess DSM, five AUD are are not equally severe, right, I think there's, there's kind of we're moving towards consensus on that. What is less understood, and what is less talked about that I'm really interested in, is, you know, within a given symptom, so let's say craving, for example, there's variation within craving itself, right. So somebody can be low on that somebody can be high on that. And then depending on the item that you're using to assess for craving, you could be capturing very different people, depending on where they fall in that continuum. And what the item is actually assessing. And so, you know, really, there's, there's, you know, dimensionality within each of these symptoms themselves and how we assess them. And that's one of my other kind of soapbox, as I go on is about, you know, measurement. And do we actually measure what we think we're measuring? And do participants understand or items? Because all of that plays in here?

James Morris: 16:57

Yeah. And across social psychology at large, for sure. Yeah. And then so what, what are some of the other interesting findings or key characteristics? Would you say have a kind of more useful formulation or idea of, of alcohol problems or alcohol use disorder? I mean, you know, one of the interesting things I think you found is that tolerance, perhaps isn't is not as closely linked to things that we'd expect it to be like, withdraw?

Cassie Boness: 17:23

Yeah. So I think there is this idea, right, that tolerance and withdrawal tend to kind of lump together because they're both these kind of physiological adaptations to prolonged use. And in that paper that was led by Dr. Ashley watt, she really found that actually, those two things weren't hanging together so much. And I believe that's actually been supported in analyses that look at kind of the the genotypic level, or the genetic level of some of these things, that those, those constructs actually don't really hang together in the way that they're supposed to, conceptually based on how they're conveyed in the DSM. So yeah, oftentimes, I'm left with just a lot of questions.

James Morris: 18:06

So I guess people would just sort of assume that, you know, the more you drink, the more tolerant you get, and the more tolerant you get, the more you're going to have a withdrawal. But it goes back to what we've been saying that actually not just our physiology, but the environment that we drink in and are kind of psychological mechanisms, and all those kinds of things are so complex and nuanced and interacting, that, you know, it kind of makes sense as well, when you're on picking that actually, maybe they're not related anywhere near as closely as you might assume on

Cassie Boness: 18:33

Yeah, and I don't know, you know, I, I still have a little bit of like, unease about that, about those kind of separating out because one of my concerns, and I don't know that I don't know that Dr. Watts agrees with me on this. So she can she can chime in, on Twitter, or wherever, you know, this, this shows up. But I really think at least tolerance is one of the symptoms, that's the hardest to assess. And there's some research showing some qualitative research showing that at least among adolescents, that tolerance is one of the most misunderstood criteria of alcohol use disorder. So when you're asking somebody, you know, questions from a structured interview, intended to assess for an alcohol use disorder, tolerance is commonly misunderstood. So what I asked myself sometimes when looking at these data is, you know, are we actually assessing tolerance? Like we think we are, is this just kind of a measurement issue we're seeing with these two constructs separating? Or is this actually true? So it's really complex. Can

James Morris: 19:31

you say a bit about the way in which you think tolerance might be misunderstood?

Cassie Boness: 19:36

Yeah, I. So part of what I got really into during my PhD was this this thing called cognitive interviewing, which is a kind of a way to assess whether or not participants are understanding items in the way that you intend for them to understand them. So some of this some of my concerns about tolerance come from my own work, but also comes From other researchers, so tolerance is tricky, because it kind of implies that there's some sort of like, acquired adaptation right like with with us over time you somehow become tolerant to the alcohol. And there's different ways that this has assessed. One of the questions, for example, is like, did you find that your usual number of drinks had much less an effect on you than it once did questions like that, that kind of, you know, because of the nature of tolerance being acquired, it requires you to kind of assess now versus sometime in the past, right? So part of what I think is difficult there is it really depends on what the participant is using as their frame of reference. Right. So then you once did, did it have much less of an effect than it once did? Well, what is that referring to? Is that referring to like, before I even started drinking? Is that referring to when I was 21? drinking every day all the time? Like, what is the reference period that we're referring to, and we're asking this person if they've experienced tolerance, and in my experience with participants, they choose wildly varying reference points to compare their current kind of used to. So it becomes really challenging to feel confident that you're kind of consistently assessing the same construct when you're asking this question to people. So I just, I doubt it. I doubt the measurement of tolerance. Yeah,

James Morris: 21:22

that seems legitimate, like so many other confound as well that, you know, just those questions, don't control for, like, you know, a situation that they were in thinking back to, how their drinking took place, then and then how it might take place now, etc. And what are some of the other core components of alcohol problems that you think are really important? So you've developed this kind of new framework kind of model for exploring alcohol problems that builds in a lot more of these kind of issues? Or questions that are really important? So So what kind of is that model? In a very, if it's possible to break it down? A bit? And what was the key kind of Yeah, aspects?

Cassie Boness: 22:02

Yeah, so I know, as maybe has been gathered by now is like, I'm really challenged by this idea that our, our diagnoses focus on the psychosocial consequences, largely right, of course, the other physiologic components, but I think, focusing on the psychosocial problems as a challenge, because they could be caused by so many things other than just alcohol use, right? And so part of what I've thought a tonne about in recent years is how can we how can we find a better approach? You know, and one thing that the DSM five doesn't really speak to is the aetiology of these disorders? Or what causes them, right? What are the processes, you know, are there cognitive or psychological or biological or neurobiological that cause somebody to then develop an alcohol use disorder or alcohol problem, and that's where I've really focused, this new framework is looking at the processes themselves, not the manifestation, or the phenotype, or the consequence that results from these processes, but the actual processes themselves. And I am a really big fan of this approach, because it moves away from some of the issues that I've mentioned already. Right? And in terms of, you know, what is actually driving an alcohol use disorder, we can't always answer that when we just purely asked about the psychosocial consequences. So this allows us to, you know, more directly, say, you know, what are the processes that are happening cognitively or psychologically, that's increasing somebody's risk. And the way that I've organised kind of those mechanisms, which are not mechanisms that I just like, created, I did a pretty systematic literature review on kind of, you know, what are the evidence based mechanisms for alcohol use disorder aetiology in the literature, and they really, they really kind of hang together and what I would refer to as like these higher order mechanisms or processes, so at the highest level of this framework, we have things like dysregulation and cognitive control, reward dysregulation and negative emotionality or negative effect. So

James Morris: 24:11

say negative effect would be like having high anxiety in lay terms. Yeah, exactly right about the cognitive ones that you said at the start, what would they be to sort of everyday pass?

Cassie Boness: 24:22

Yeah, that would be something like impulsivity, right, or what we sometimes refer to as like disinhibition having a hard time kind of stopping yourself from engaging in a behaviour and then just to be comprehensive, the reward related processes there would be things like sensitivity to alcohol, when you you know, when you drink alcohol, do you experience the same pleasurable effects as other people for example,

James Morris: 24:52

they could all be kind of they're probably all complex and interlinked, as well because you know, your perceived pleasure might be directly related to how much It relieves your negative emotionality or your anxiety or whatever. So,

Cassie Boness: 25:04

absolutely, yeah, these are, these are definitely interconnected. And I think, you know, that's definitely a challenge for kind of this kind of framework is thinking about, you know, the overlap and trying to try to parse apart things that are so interconnected, you know, perhaps more related to some processes like reward at different stages of the, you know, addiction or as you you know, use for a longer period, it becomes more driven by negative emotionality, for example. So what I really like about this framework as it talks about these higher order kind of components, and in some ways, that's what I was talking about before, when, you know, the alcohol use disorder symptoms kind of hang together in these groups, this is similar, but with a focus on mechanisms instead of consequences. And what's cool about this, I think, is that we can really start to think about, you know, if negative emotionality is really, you know, the driving process for somebody in your office with an alcohol use disorder, and they're also experiencing like comorbid major depression, for example, which is also largely driven by negative emotionality. Can we address that those symptoms with a treatment that kind of more broadly assesses negative emotionality, and then kind of has improvements for both alcohol use and major depressive disorder or major depressive episode? So what I like about this framework is it really can help us kind of address the comorbidity that we know is there the CO occurrence of disorders. And also, it can really, you know, like, I've heard you talk about a lot, if somebody for whatever reason, is hesitant to kind of identify with these alcohol use disorder symptoms or problems. And they're not really open to like focusing on that solely in treatment, but they are experiencing these symptoms, perhaps it's fine to come at it and say, you know, you're also experiencing this anxiety or this depression, would you be open to like doing working on a treatment or using this treatment approach that really will improve functioning in various areas of your life? You know, so, this, it just has so many possible implications and applications that I get really excited about?

James Morris: 27:28

Yeah, absolutely. Me too. And I think, you know, it kind of speaks to the problems that we have in dressing, co morbid alcohol, mental health problems. I mean, you know, so many people, you know, I've had a lot of people talk about, it's a false separation, to say, well, I've got an alcohol problem and a mental health problem, they're both one another, and, you know, you wouldn't have one without the other. So it's, it's, you know, we still certainly in the UK are really struggling to, after many decades, really kind of bring together effective treatments and services, so that, you know, we still have people, you know, being excluded from one service, because they have been told to go and stop drinking before you can access to their kind of mental health support, etc. And, you know, that's this is really kind of upsetting that still happening to this day. But I think in some ways, it does reflect a, you know, a degree of feeling like services or practitioners maybe don't have the tools or understanding or certainly capacity, in many cases, to be able to, to kind of know what to do in a more meaningful way, and to help people understand it in a way that might kind of align more with their experiences.

Cassie Boness: 28:40

Right? Yeah. And I think what's interesting about this, too, is there, I think there is really a big push right now and research and clinical work to move more towards these kind of trans diagnostic approaches, right? How can we given we know that there's a lot of CO occurrence of mental health problems and substance use disorders? How can we kind of make the most impact most efficiently as possible, right? How can we get treatments to the people that need them in a way that's efficient, and I really believe as a clinician, that moving more towards these trans diagnostic approaches that really target these kind of higher order processes or problems that occur across different mental health symptoms? Is really, I mean, the future I think of treatment.

James Morris: 29:27

Yeah. And I think that also fit fits with, you know, a lot of the criticisms that are levelled at DSM on the whole is, is is the problems of creating, you know, disorders or diagnoses based on sets of symptoms that, you know, don't kind of stand up much to scientific scrutiny, and I think those kind of bits of work happening more broadly across all the kinds of disorders in DSM but you're doing it really importantly, I think, but the GAO called specific side of it, where we, you know, equally need more More in depth understanding and less Reliance's, as you say, on these kinds of symptoms when the bigger picture is much more than that. Yeah, and

Cassie Boness: 30:08

it's, it's really unclear to me how the current symptoms even map on to these kind of well established etiologic processes and in some ways, you know, etiologic processes that we know, that are really core to alcohol use disorder are not captured by the DSM criteria. So, it's really interesting, and I understand why that approach is taken. And DSM has really said, you know, we're, we're a theoretical with respect to aetiology. And that was something that I think was decided back in like DSM three, when we didn't have a lot of this research. And so while that maybe made sense, in the past, and it was more, you know, these arguments between these camps of researchers, I, I wonder if we can start to kind of use that improve knowledge to really see if we can do a better job of assessing what is an alcohol use disorder, you know, what are the core processes that cause somebody to develop an alcohol use disorder, and start to actually assess those things and practice, you know, as much as possible with limitations of self report, and so on and so forth.

James Morris: 31:13

But yeah, and of course, you know, you can understand them trying to say, look, like we're being a theoretical habits, but, you know, the reality is, it's hugely influential, and people, you know, do make assumptions or decisions or whatever, basically, behaviours based on these ideas that are out there in the world and draw upon them and does is hugely influential in terms of how people think about and understand mental health disorders, so to speak. I mean, a lot of people don't like the term disorder, and I kind of sympathise but you know, it's a somewhat useful simplification, isn't it to call somebody a disorder?

Cassie Boness: 31:50

Yeah, I mean, it's, it's definitely, you know, diagnostic criteria are socially constructed. You know, even if we're relying relying on the research and the data, like, there's always going to be some component of bias that these experts bring to the table when coming up with these criteria, right. And it's always going to be influenced by culture, and you know, what our society's beliefs about people who use alcohol or people who use substances or what outcomes look like for those people like, it's always going to be influenced by that just by nature of being human. So I think, perhaps, if we can find a way to focus on these processes, these mechanisms, we can reduce some of that, I don't know that we can eliminate it fully. But I think we can perhaps reduce some of the bias that creeps in, or some of the really embedded beliefs that we have about people who use substances or prohibition, or like you mentioned the disease disease model, I think we can perhaps, you know, try to move away from the biases that inevitably play into this process. Yeah, a

James Morris: 32:51

bit of a Sisyphean task. But I'm sure yeah, the closer we can get to accurately, kind of pinning down some of the mechanisms, the more we can kind of help ourselves and others understand what is an alcohol use disorder, and what may be some of the responses or treatments might be that we might pursue,

Cassie Boness: 33:07

right? Yeah, a lot of these mechanisms are these kind of dysregulation, so to speak, actually, we do have treatments that target those mechanisms, right. So you know, in some ways, I've had a little bit of pushback of like, well, how is this any different from like, the brain disease model, right? It's caused by this, it's this brain disorder, I'm like, well, a lot of the way that we talk about that is like, these are processes or mechanisms that like they just are like, we can't change them. It's just these changes that have occurred. Now we're powerless. But these mechanisms that are in the framework that I talked about, actually do really have treatments that act upon those mechanisms, specifically, to reduce dysfunction or impairment, what sort

James Morris: 33:48

of treatments are they that would what would be a good example?

Cassie Boness: 33:51

Yeah, I mean, there's, there's a lot of options, right? I think there have been some treatments that are more alcohol specific, some that are more substance specific, right. But there's a lot of options. So I think, you know, perhaps if we're looking at something like reward dysregulation, there's a lot of research to support that mindfulness based interventions act upon those reward processes. So, you know, even if we don't necessarily understand the full picture of somebodies reward dysregulation, but we know that that's a driving component of their problems. Why can't we say hey, this, it seems like a mindfulness based intervention would be best for you or your negative emotionality. That seems to be a really important predictor of recovery. How can we use approaches that really target that like cognitive behavioural therapy approaches, cognitive restructuring, things like that, that can really help people reduce the impact of those negative emotions or anxiety or depression, for example, in their lives?

James Morris: 34:55

Yeah, I think mindfulness is something Yeah, I certainly try I'm always trying to build up you know, like, like, the metaphors is kind of a muscle that you need to work on. Because forever feel like, um, you know, I mean, I'm kind of, okay, if I'm doing yoga, I feel like that's easier, but just the actual pure mindfulness. Maybe I misunderstand that it's kind of complex. But I definitely think that would help helps me and yeah, I guess sleep as well as another kind of strong link isn't there between sleep and alcohol problems? And I think that's overlooked as a maybe a specific treatment intervention.

Cassie Boness: 35:31

Actually, yeah, sleep is something that I've become increasingly interested in because it impacts all three of those domains that I mentioned. cognitive control, reward and negative emotionality. And Dr. Mary Beth Miller at the University of Missouri actually is really interested in this and she's doing research to see if treating insomnia actually also reduces somebodies alcohol related risk or alcohol related problems. So yeah, I think there's a lot of approaches like that, right, like cognitive behavioural therapy for insomnia, that although they're targeting symptoms of insomnia, or sleep problems, actually might also impact hazardous use, or risky use and might reduce someone's use, overall. And

James Morris: 36:17

I think, and there's probably vicious and virtuous cycles, too, because we know that, you know, alcohol in the body really disrupts good quality or restorative sleep. So there's probably more stuff going on there as well, you know, if you if you're kind of cutting down and and that's improving asleep, and maybe there's an effect of that, and vice versa.

Cassie Boness: 36:36

I that's very Yeah, I actually, on in when I was on internship worked on a project that looked at the 11, add criteria, and then several dimensions of sleep and sleep quality and kind of circadian dysfunction, and found that there are kind of specific facets of sleep, or sleep related outcomes that are really driving the hazardous use criterion, which is oftentimes what's referred to as like risky drinking, right. It's like how using and hazardous situations and that certain aspects of sleep problems are kind of perhaps the association we're seeing between sleep problems and alcohol use disorder is really being driven by this hazardous use symptom. So people's use becomes more risky, perhaps, and they're experiencing sleep difficulties.

James Morris: 37:21

Yeah, I think that makes a lot of sense. And I'm certainly very grateful for my melatonin prescription, which I don't know how much of its placebo effect, but it seems to work in terms of what used to be a very long standing insomnia issue. So, so that's, that's been super insightful. I mean, so many questions. And, yeah, like, you know, the work continues in terms of developing this really amazing, complex work that you're doing to kind of unpack and kind of identify the heterogeneity Within this broad border AUD term in general. But do you have any kind of final reflections perhaps more broadly about? Kind of alcohol use? And, yeah,

Cassie Boness: 38:07

yeah, I mean, I think, you know, one of the things that I really love about this work is that it this one size, like this one size doesn't fit all perspective, right is like, you know, what, what might cause problems for one person might not necessarily cause problems for another person. And I think if we can really expand our thinking around substance use disorders, and understand that, there's, like, we have to look at kind of the whole person, right and think more holistically about how use is related to other aspects of functioning, and how that might differ based on the person's family history, for example, like, I know, for myself, have a really significant family history of alcohol use disorder. So the decisions that I make what I feel is maybe a safe decision for me to use alcohol in one situation might not be the same for someone else. Or I might feel less comfortable using alcohol in some situations, whereas others might not feel uncomfortable. And I think if we can start to think more holistically about what's risky, what's not risky, why for me, is that risky, and why not for someone else? And how does that relate to like you're saying, well being quality of life, sleep, things that are values based in many ways. And thinking about, you know, is my use consistent with my values are not consistent with my values? And does that cause me problems or not? I think if we can just, you know, think more holistically about these things move away. Again, I'm kind of with you and moving away from these categorical you know, you have an alcohol use disorder, you do not have an alcohol use disorder. I don't I don't necessarily endorse as a useful approach. But oftentimes, the challenge is like, well, what then what's the alternative? What does that look like? And I think, you know, again, taking a step back and looking at the bigger picture is really important. And it's going to be very person specific.

James Morris: 40:04

Yeah, absolutely. And I think, yeah, it's it's capturing that nuance and kind of enabling the conversations to be to be able to be held with, you know, more openness. You know, like, we know that alcohol problems add stigma risk, it's really heavy stigma. It's as heavy as many illicit drugs or serious mental health. So yeah, to kind of capture that kind of nuance and diversity, you know, obviously, at Vic covets, and others doing great work in terms of trying to represent these different pathways to recovery and different ways that alcohol problems manifest and so on. So yeah, I'm really grateful for you talking about the work you're doing. But yeah, also your own personal reflections. Because I think that's that's kind of how we can do it. It's just kind of opening up these conversations and encouraging people to Yeah, exactly. Think about all kinds of different contextual and subjective things going on that might make it what, what for one person is problematic might not be for another. So thank you so much.

Cassie Boness: 41:04

Yeah. Yeah, thank you so much for having me. And I think one thing that's really influenced my thinking in this area that I have to kind of give a shout out to is tick tock. Like, they're all these people and tick tock now that are kind of in this, like, you know, sober, curious or moderated drinking or harm reduction with alcohol. And I think it's so important for people to see those representations of you know, like, I am sober, I am not drinking, it's not because I had all these problems, but it's because I feel better I am coping better. You know, I think having these representations out in the world is just so important. And it has really helped me just to listen to people with different lived experiences to kind of just inform how I think about this. So, you know, there's, we should be listening to people out in the out in the community who are not PhD level researchers, who have a lot of really valuable insights on some of the things we're talking about.

James Morris: 42:00

Yeah, absolutely. Yeah, I think I mean, in the UK, it's sort of been branded sort of positive sobriety or new sobriety movement, and it seems to be pretty much associated with this decline in young people's drinking. We don't see in kind of middle or older aged adult groups, but yeah, I'm resisting downloading Tik Tok, and I'm going to continue to do that as long as I can.

Cassie Boness: 42:25

Thanks. Yeah, thank you for having me.