Drug and Alcohol Review - Clinician's Corner

Approach With Caution: A Pilot Randomised Controlled Trial of Approach Bias Modification for People Undergoing Residential Treatment for Methamphetamine Use Disorder

Methamphetamine use disorder (MUD) accounts for ~40% of residential rehabilitation treatment episodes [1], yet the majority (~75%) of patients will resume methamphetamine use within a year of discharge [2]. This underscores the need for innovative, adjunctive treatments that can bolster traditional treatments and prevent early relapse. A promising avenue is the modification of automatic cognitive biases to addiction cues, which drive impulses to use. Meta-analysis supports the use of a computerised cognitive training intervention called Approach Bias Modification (ApBM) to prevent relapse after leaving residential treatment for alcohol dependence [3]. However, its application to people undergoing residential rehabilitation for MUD has received scant research attention.

To address this knowledge gap, a pilot randomised controlled trial was conducted with 24 participants across four residential treatment sites investigating a novel form of personalised ApBM. Unlike previous ApBM protocols, where all patients were trained using the same images, each participant selected drug-related images specific to their own methamphetamine use (e.g., smoking vs. injecting paraphernalia), which they were trained to repeatedly avoid, and selected positive images aligned with their personal goals (e.g., family, exercise), which they were trained to repeatedly approach. Participants were randomised to six (15-minute) sessions of either ApBM or a sham-control training. Outcomes were assessed one and three months post-discharge.

Key Findings:
While the small sample size (impacted by COVID-19 restrictions) meant the study was underpowered to detect statistical significance, descriptive trends were encouraging.
• Abstinence: At the one-month follow-up, 71% of the ApBM group reported abstinence compared to 46% of the sham-trained control group. At the 3-month follow-up, these rates were 57% versus 33%, respectively. However, differences were not statistically significant in this very small sample.
• Relapse Delay: Survival analysis showed the ApBM group was slower to lapse, with a median time to first use of 35 days, compared to 14 days in the sham-trained control group.
• Other outcomes: Craving and MUD severity outcomes did not differ significantly between groups.
• Safety and acceptability: One in three participants had adverse psychological reactions to the training (due to the exposure to methamphetamine cues), requiring psychological or medication support following sessions. Three participants (12%) withdrew due to this distress. However, participants who completed training provided acceptability ratings indicating generally good acceptability.

Implications:
ApBM could help prevent early relapse, thereby extending the "window of opportunity" to engage in outpatient or peer-support/mutual aid during the vulnerable sub-acute withdrawal phase. Interventions that dampen automatic responses to drug-related cues may be particularly relevant given that impaired decision-making and impulsivity persist in the 3-6 months following methamphetamine withdrawal. However, with one-third of participants being “triggered” by methamphetamine cues in the training task, there is a need to improve ApBM’s safety profile.

Future Directions: Balancing Promise and Safety:
While these findings provide a promising signal, a fully-powered trial is needed to establish ApBM’s efficacy. Strategies to improve its safety could include commencing training after the early protracted withdrawal phase (i.e., in longer term rehabilitation settings), incorporating mindfulness/breathing exercises and closer clinical mon¬itoring after sessions, and using less potent/triggering images in the initial sessions of ApBM.

Prepared on behalf of the Investigator Team by Victoria Manning
Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Melbourne, Australia and Turning Point, Eastern Health, Melbourne, Australia

The full paper is available Open Access:
Manning V, Whelan D, Piercy H, Hopwood M, Maloney M, Kotler E, Okedara G, Lubman DI, Arunogiri S, Garfield JBB. Approach With Caution: A Pilot Randomised Controlled Trial of Approach Bias Modification for People Undergoing Residential Treatment for Methamphetamine Use Disorder. Drug Alcohol Rev. 2026 May;45(4):e70151. doi: 10.1111/dar.70151

References:

1. AIHW, “Alcohol and Other Drug Treatment Services in Australia Annual Report: Australian Institute of Health and Welfare,” (2025), https://www. aihw.gov.au/ reports/alcohol and other drug treatment services/ alcohol other drug treatment services Australia/contents/ about

2. McKetin R, Kothe A, Baker AL, Lee NK, Ross J, Lubman DI “Predicting Abstinence From Methamphetamine Use After Residential Rehabilitation: Findings From the Methamphetamine Treatment Evaluation Study,” Drug and Alcohol Review 37, no. 1 (2018): 70–78.

3. Pan T, Zhao X, Bartoš F, Larsen H, Manning V, Boffo M, Wiers RW. Cognitive bias modification in alcohol use disorder and problematic drinking: A revised and updated IPD Bayesian meta-analysis. Clin Psychol Rev. 2026 Mar;124:102709. doi: 10.1016/j.cpr.2026.102709