Brief intervention for harm reduction with alcohol-positive older adolescents in a hospital emergency department

Provider attitudes towards a brief behavioral intervention for sexual health in Moldova

Background

Brief behavioral interventions are seen as an efficient way to improve knowledge, change behavior, and reduce provider stigma regarding sexual health. When grounded in evidence-based behavioral change techniques and delivered using Brief Sexuality-related Communication (BSC) tools, brief behavioral interventions can address client-driven sexual health goals in a single session with their provider. Evidence for the efficacy of brief interventions for creating gains in sexual health comes largely from resource rich settings, and there is a lack of knowledge of how brief interventions can be implemented in the more resource constrained environments of low- and middle-income countries. As a first step in developing a brief intervention to address sexual health issues in Moldova, this paper reports on qualitative data collected from Moldovan providers to understand their attitudes, willingness and perceived barriers to the brief intervention and its implementation.

Methods

Thirty-nine in-depth interviews (IDI) were conducted between February and March 2020, with health providers recruited from three primary health care institutions, two Youth Friendly Health Centers and counselors from three NGOs who work with key populations in Moldova, including health centers selected from two cites - the capital city, Chisinau and from the Comrat Region. The IDI addressed four domains of provider attitudes: 1) attitudes towards the intervention; 2) willingness and motivation to implement the intervention; 3) logistics of providing the intervention and 4) ability to implement the intervention. A coding analysis approach was applied to all interview transcripts.

Results

Providers largely reported being willing to be trained in and implement the brief intervention. Willingness to implement the intervention stemmed from two perceptions: that it would improve the ability of providers to talk with their clients about sex, and that vulnerable groups would benefit from these conversations. However, while there were generally positive attitudes towards the intervention, providers consistently reported structural barriers to their perceived ability to implement the intervention.

Conclusions

While providers reported high levels of initial acceptance of a brief behavioral intervention, care is needed to ensure that brief interventions, and the training of providers on brief interventions, incorporate cultural attitudes and norms around sex, particularly in highly patriarchal settings, and provide opportunities for providers to practice the intervention in ways that address their assumptions and implicit biases.

Are non-abstinent reductions in World Health Organization drinking risk level a valid treatment target for alcohol use disorders in adolescents with ADHD?

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Changes in WHO alcohol risk level are highly variable in youth treated for ADHD/SUD.

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Achieving > 2-level reduction in WHO risk is linked to improvements in functioning.

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Achieving > 2-level reduction in WHO risk is linked to decreased ADHD symptoms.

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> 2-level reduction in WHO risk may be a valid non-abstinent AUD outcome in youth with ADHD/SUD.

Introduction

Abstinence from drinking represents the primary treatment target for alcohol use disorders (AUD) in youth, but few adolescents who engage in problematic drinking seek treatment. A reduction in World Health Organization (WHO) drinking risk level has been established as valid and reliable non-abstinent treatment target for AUD in adults but remains unstudied in youth.

Methods

The present study used data from the NIDA-CTN-0028 trial to examine associations between reductions in WHO drinking risk level and changes in global functioning and attention-deficit hyperactivity disorder (ADHD) symptoms during treatment in a sample of adolescents (ages 13–18 years) with ADHD and comorbid substance use disorder (SUD) (n = 297, 61% with AUD) receiving a 16-week intervention that combined ADHD pharmacotherapy (OROS-methylphenidate vs. placebo) and drug-focused cognitive-behavioral therapy.

Results

Shifts in drinking risk level during treatment were highly variable in adolescents treated for ADHD/SUD, and influenced by AUD diagnostic status. In the total sample, 15% of participants had a 2-level or greater reduction in WHO drinking risk level, with 59% and 24% showing no change or an increase in risk-level during treatment respectively. Achieving at least a 2-level change in WHO drinking risk level during treatment was associated with greater reduction in ADHD symptoms and better functional outcomes.

Conclusions

These findings parallel the adult AUD literature and provide preliminary support for the use 2-level reductions in WHO risk levels for alcohol use as a clinically valid non-abstinent treatment outcome for youth with ADHD and comorbid AUD.

Brief Intervention to Prevent Sexually Transmitted Infections and Unintended Pregnancies: Protocol of a Mixed Methods Feasibility Study

BACKGROUND

Sexual well-being is fundamental to physical and emotional health, and the ability to achieve it depends on access to comprehensive sexuality information and high-quality sexual health care from evidence-informed, nonjudgmental providers. Adequate and timely delivery of these components to individuals who are at high risk for sexually transmitted infections (STIs), including HIV, and unintended pregnancies promotes sexual health and mitigates consequences arising from risky sexual behavior. Brief interventions that allow health care providers to improve the information available to clients and motivate and help them to develop risk-reduction skills are seen as efficient ways to improve knowledge, change client behavior, and reduce provider stigma regarding sexual health.

OBJECTIVE

The aim of the study is to evaluate five aspects of feasibility (acceptability, willingness, safety, satisfaction, and process) of a brief sexuality-related communication (BSC) intervention based on motivational interviewing and behavior change techniques in primary health care settings in low- and middle-income countries (LMICs).

METHODS

This protocol outlines a multisite, multiphase study of feasibility of a BSC intervention in primary health care settings in LMICs that will be examined across four phases of the study. Phases I through III involve the collection of formative, qualitative data to examine provider and client perceptions of the feasibility of the intervention, adaptation of the intervention guide, and training providers on how to implement the final version of the BSC intervention. During phase IV, the feasibility of the intervention will be tested in a nonrandomized pre-post test trial where providers and clients will be followed for 6 months and participate in multiphase data collection.

RESULTS

Phase I is currently underway in Moldova, and phases I and II were completed in Peru in late 2019. Results are expected for the feasibility study in 2021.

CONCLUSIONS

This feasibility study will determine whether the implementation of brief intervention programs aimed at improving sexual health outcomes is possible in the constraints of LMIC health systems and will add to our understanding of factors shaping clinical practice among primary care providers.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15569.

Long-Term Outcome of a Brief Intervention to Address Adolescent Drug Abuse in a School Setting

The present study used data from a randomized controlled trial on brief interventions with adolescents to identify distinct longitudinal patterns of substance use and identify predictors, as well as outcomes associated with those use patterns. Data were originally collected for the purpose of evaluating two brief intervention conditions with adolescents who had been identified in a school setting as abusing alcohol or other drugs (total sample, N = 315). Adolescents were randomly assigned to a two-session adolescent only brief intervention (BI-A), a two-session adolescent- plus an additional parent session (BI-AP), or an assessment only control session (CON). We located 74 participants to assess them at approximately 3.5 years post-intervention. Three distinct cluster patterns were identified, including a low decreasing, moderate increasing, and high decreasing pattern of use. The low decreasing cluster was associated with the BI-A condition, mono-substance use, and comorbid anxiety symptoms at baseline. The moderate increasing cluster was associated with the BI-AP condition, polysubstance use, and comorbid conduct disorder symptoms at baseline. No variables were found to be predictive of membership within the high decreasing cluster. There were also no differences found between clusters on adjustment outcomes in young adulthood. Overall findings from this study support the long-term efficacy of a brief intervention, without parent involvement, for adolescents experiencing mild to moderate substance abuse problems. Findings also highlight the importance of early intervention and the tailoring of interventions to meet the unique needs of adolescents.

Brief Alcohol Interventions for Youth in the Emergency Department: Exploring Proximal and Distal Outcomes

Brief interventions (BI) for alcohol use in the emergency department (ED) have been shown efficacious among adolescents and young adults; however, whether these interventions extend to other outcomes - proximal and distal - are less explored. This study examined outcomes of ED BIs in four completed trials showing reductions in alcohol use. Limited and inconsistent effects were found on proximal outcomes including parental monitoring, and distal outcomes including tobacco use. Identifying the mechanisms that underlie alcohol-focused BIs as well the intervention processes that may lead to generalized, positive effects on other variables is an important area of future research.

Screening for Adolescent Alcohol Use in the Emergency Department: What Does It Tell Us About Cannabis, Tobacco, and Other Drug Use?

BACKGROUND

The pediatric emergency department (PED) represents an opportune time for alcohol and drug screening. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends a two-question alcohol screen for adolescents as a predictor of alcohol and drug misuse.

OBJECTIVE

A multi-site PED study was conducted to determine the association between the NIAAA two-question alcohol screen and adolescent cannabis use disorders (CUD), cigarette smoking, and lifetime use of other drugs.

METHODS

Participants included 12-17-year olds (n = 4834) treated in one of 16 participating PEDs. An assessment battery, including the NIAAA two-question screen and other measures of alcohol, tobacco and drug use, was self-administered on a tablet computer.

RESULTS

A diagnosis of CUD, lifetime tobacco use or lifetime drug use was predicted by any self-reported alcohol use in the past year, which indicates a classification of moderate risk for middle school ages and low risk for high school ages on the NIAAA two-question screen. Drinking was most strongly predictive of a CUD, somewhat weaker for lifetime tobacco use, and weakest for lifetime drug use. This same pattern held for high school and middle school students and was stronger for high school students over middle school students for all three categories. This association was also found across gender, ethnicity and race. The association was strongest for CUD for high school students, sensitivity 81.7% (95% CI, 77.0, 86.5) and specificity 70.4% (95% CI, 68.6, 72.1). Conclusions/Importance: A single question about past year alcohol use can provide valuable information about other substance use, particularly marijuana.

Adapting substance use brief interventions for adolescents: perspectives of adolescents living with adults in substance use disorder treatment

Background

Brief interventions (BIs) have shown potential to reduce both alcohol and drug use. Although BIs for adults have been studied extensively, little is known about how to adapt them to meet the needs and preferences of adolescents. This article examines adolescents' preferences to consider when adapting BIs for use with adolescents.

Methods

Eighteen adolescents (age 9-17 years) living in Los Angeles County with adults receiving substance use disorder treatment were interviewed and asked about their perspectives on how to adapt a BI originally developed for adults for use with adolescents. Questions focused on adolescents' preferences for who should deliver BIs, how BIs should be delivered, and what content they would want to be included in BIs. Interviews were recorded, transcribed, and coded using summative content analysis.

Results

Adolescents did not express any discernable opinions concerning who delivers BIs or what content they would want to be included, but they did share perspectives on how BIs should be delivered. Most adolescents did not endorse incorporating text messaging or social media into BIs. Instead they preferred having BIs delivered face-to-face or over the telephone. They reported that they did not want BIs to incorporate text messaging or social media due to concerns about trust, the quality of information they would receive, and challenges communicating in writing instead of speaking.

Conclusion

Although the study has limitations because of its small sample size, findings indicate that adolescents may not want text messaging or social media to be incorporated into BIs for substance use. These findings warrant further research and consideration, particularly as work to enhance BIs for adolescents continues.

Prevention of Underage Drinking on California Indian Reservations Using Individual- and Community-Level Approaches

OBJECTIVES

To evaluate combined individual- and community-level interventions to reduce underage drinking by American Indian/Alaska Native (AI/AN) youths on rural California Indian reservations.

METHODS

Individual-level interventions included brief motivational interviewing and psychoeducation for Tribal youths. Community-level interventions included community mobilization and awareness activities, as well as restricting alcohol sales to minors. To test effects, we compared 7 waves of California Healthy Kids Survey data (2002-2015) for 9th- and 11th-grade AI/AN and non-AI/AN students in intervention area schools with California AI/AN students outside the intervention area (n = 617, n = 33 469, and n = 976, respectively).

RESULTS

Pre- to postintervention mean past 30-day drinking frequency declined among current drinkers in the intervention group (8.4-6.3 days) relative to comparison groups. Similarly, heavy episodic drinking frequency among current drinkers declined in the intervention group (7.0-4.8 days) versus the comparison groups.

CONCLUSIONS

This study documented significant, sustained past 30-day drinking or heavy episodic drinking frequency reductions among AI/AN 9th- and 11th-grade current drinkers in rural California Indian reservation communities exposed to multilevel interventions. Public Health Implications. Multilevel community-partnered interventions can effectively reduce underage alcohol use in this population.

Start-Up Costs of SBIRT Implementation for Adolescents in Urban U.S. Federally Qualified Health Centers

OBJECTIVE

Understanding the costs to implement Screening, Brief Intervention, and Referral to Treatment (SBIRT) for adolescent substance use in primary care settings is important for providers in planning for services and for decision makers considering dissemination and widespread implementation of SBIRT. We estimated the start-up costs of two models of SBIRT for adolescents in a multisite U.S. Federally Qualified Health Center (FQHC). In both models, screening was performed by a medical assistant, but models differed on delivery of brief intervention, with brief intervention delivered by a primary care provider in the generalist model and a behavioral health specialist in the specialist model.

METHOD

SBIRT was implemented at seven clinics in a multisite, cluster randomized trial. SBIRT implementation costs were calculated using an activity-based costing methodology. Start-up activities were defined as (a) planning activities (e.g., changing existing electronic medical record system and tailoring service delivery protocols); and (b) initial staff training. Data collection instruments were developed to collect staff time spent in start-up activities and quantity of nonlabor resources used.

RESULTS

The estimated average costs to implement SBIRT were $5,182 for the specialist model and $3,920 for the generalist model. Planning activities had the greatest impact on costs for both models. Overall, more resources were devoted to planning and training activities in specialist sites, making the specialist model costlier to implement.

CONCLUSIONS

The initial investment required to implement SBIRT should not be neglected. The level of resources necessary for initial implementation depends on the delivery model and its integration into current practice.

Trajectories of in-session change language in brief motivational interventions with mandated college students

OBJECTIVE

Brief motivational interventions (BMIs) are currently the most efficacious individual intervention for mandated college students. However, little is known about how BMIs facilitate client language in relation to subsequent changes in alcohol use and problems in mandated student samples.

METHOD

The current study used the Motivational Interviewing Skills Code (MISC 2.0; Miller, Moyers, Ernst, & Amrhein, 2003) to code BMI sessions (N = 252) from 2 randomized clinical trials that led to significant reductions in alcohol use and alcohol-related problems in mandated student drinkers. A proportion of change language was calculated for each decile (1st to 10th) of the BMI sessions.

RESULTS

Latent class analyses of in-session speech indicated that there were 3 distinct trajectories of change language over the course of the session: high (n = 59), increasing (n = 122), and low (n = 71). Members of the high trajectory group showed higher rates of alcohol-related problems prior to the BMI and members of the low trajectory group were more likely to be male. Six months following the BMI, members of the high and low trajectory groups demonstrated significant reductions in alcohol use and problems, and members of the increasing trajectory group only reduced alcohol-related problems.

CONCLUSIONS

Associations among the 3 trajectories of client change language and subsequent reductions in alcohol use and problems partially supported the technical hypothesis of MI efficacy. Client factors as well as the nature of the discussion of personalized feedback may determine the link between in-session client language and subsequent behavior change. (PsycINFO Database Record

Would brief alcohol intervention be helpful in facial trauma patients?A Narrative Review

Facial trauma is commonly associated with excessive consumption of alcohol and is often associated with interpersonal violence or motor vehicle accidents. Alcohol-related trauma presentation to hospitals causes a major service burden, and there have been efforts to reduce such trauma load with educational programs and social support. Brief alcohol intervention (BAI) in an acute setting (emergency department or trauma centre) has been shown as an effective means to reduce future alcohol intake and the incidence of future alcohol-related injuries, especially in the period immediately following injuries. Less is known about the potential benefit of BAI when provided by the surgical team in the same clinical context. This article explores the individual component of brief alcohol intervention and its provision by an acute surgical service by way of a narrative review. The progress of research into brief alcohol intervention for facial trauma patients is also reviewed. The methods and rationale behind screening patients for targeted BAI are discussed in a separate article.

Factors associated with alcohol reduction in harmful and hazardous drinkers following alcohol brief intervention in Scotland: a qualitative enquiry

Background

Alcohol Brief Intervention (ABI) uses a motivational counselling approach to support individuals to reduce excessive alcohol consumption. There is growing evidence on ABI’s use within various health care settings, although how they work and which components enhance success is largely unknown. This paper reports on the qualitative part of a mixed methods study. It explores enablers and barriers associated with alcohol reduction following an ABI. It focuses on alcohol’s place within participants’ lives and their personal perspectives on reducing consumption. There are a number of randomised controlled trials in this field though few ABI studies have addressed the experiences of hazardous/harmful drinkers. This study examines factors associated with alcohol reduction in harmful/hazardous drinkers following ABI.

Methods

This qualitative study was underpinned by a realist evaluation approach and involved semi-structured interviews with ten harmful or hazardous alcohol drinkers. Participants (n = 10) were from the intervention arm of a randomised controlled trial (n = 124). All had received ABI, a 20 min motivational counselling interview, six months previously, and had reduced their alcohol consumption. Interviews were recorded, transcribed verbatim and thematically analysed.

Results

Participants described their views on alcohol, its’ place in their lives, their personal perspectives on reducing their consumption and future aspirations.

Conclusions

The findings provide an insight into participants’ views on alcohol, ABI, and the barriers and enablers to change. Participants described a cost benefit analysis, with some conscious consideration of the advantages and disadvantages of reducing intake or abstaining from alcohol. Findings suggest that, whilst hospital admission can act as a catalyst, encouraging individuals to reflect on their alcohol consumption through ABI may consolidate this, turning this reflective moment into action. Sustainability may be enhanced by the presence of a ‘significant other’ who encourages and experiences benefit. In addition having a purpose or structure with activities linked to employment and/or social and leisure pursuits offers the potential to enhance and sustain reduced alcohol consumption.

Trial registration

Trial registration number TRN NCT00982306 September 22nd 2009.

Effects on alcohol use of a Swedish school-based prevention program for early adolescents: a longitudinal study

BACKGROUND

The aim of the study was to address the lack of evaluations of school-based substance use prevention programs and to conduct a quasi-experimental evaluation of the alcohol use part of the Triad intervention.

METHODS

Eleven Swedish intervention schools (285 pupils) and three control schools (159 pupils) participated in the evaluation. Baseline measurements were conducted in 2011 before the alcohol part in the prevention program was implemented in the intervention schools (school year 6, ages 12-13). We estimated an Intention-To-Treat (ITT) Difference-in-Difference (DD) model to analyze the effectiveness of the intervention on subsequent alcohol use measured in grades 7, 8 and 9.

RESULTS

The main results show no effect on the likelihood of drinking alcohol or drinking to intoxication.

CONCLUSIONS

The lack of positive effects highlights the need for policy-makers and public health officials need to carefully consider and evaluate prevention programs in order to ensure that they are worthwhile from school, health, and societal perspectives.

Differences by gender at twelve months in a brief intervention trial among Mexican-origin young adults in the emergency department

In this study, we investigate the role of gender in prevalence and consequences of binge drinking and brief intervention outcomes among Mexican-origin young adults aged 18-30 years at the U.S.-Mexico border. We conducted a secondary analysis, stratified by gender, from a randomized controlled trial of a brief motivational intervention in a hospital emergency department. Intervention effects for males included reductions in drinking frequency, binge drinking, and alcohol-related consequences. For females the intervention was associated with reduction in drinking frequency and binge drinking but did not have a significant effect on alcohol-related consequences. Results suggest a new direction for tailoring interventions to gender.

Changes in Classes of Injury-Related Risks and Consequences of Risk-Level Drinking: a Latent Transition Analysis

Risk-level drinking, drinking and driving, and alcohol-related violence are risk factors that result in injuries. The current study sought to identify which subgroups of patients experience the most behavioral change following a brief intervention. A secondary analysis of data from a brief alcohol intervention study was conducted. The sample (N = 664) includes at-risk drinkers who experienced an injury and were admitted for care to a Level 1 trauma center. Injury-related items from the Short Inventory of Problems+6 were used to perform a latent transition analysis to describe class transitions participants experienced following discharge. Four classes emerged for the year before and after the current injury. Most individuals transitioned from higher-risk classes into those with lower risk. Some participants maintained risky profiles, and others increased risks and consequences. Drinking and driving remained a persistent problem among the study participants. Although a large portion of intervention recipients improved risks and consequences of alcohol use following discharge, more intensive intervention services may be needed for a subset of patients who showed little or no improvement.

Psychosocial Support Following Maxillofacial Trauma and its Impact on Trauma Recurrence

Background

Injuries sustained to the maxillofacial region can result in significant physical trauma and long lasting psychosocial impairment. Maxillofacial trauma has been reported in literature to be a potentially recurrent disease. Patients who suffer maxillofacial trauma can benefit from psychological support.

Aim

This study aims to identify maxillofacial trauma patient characteristics, investigate maxillofacial re-injury rate after provision of psychological support and report incidence of post traumatic stress disorder symptoms after maxillofacial trauma.

Method

A total of 100 patients were identified from the departmental trauma database over two time periods at Royal Darwin Hospital; 50 patients did not have psychosocial intervention and 50 patients received intervention. Data on demographics, trauma pattern and aetiology were collected. A brief counselling session was conducted on second patient group by a trained mental health nurse and a survey using Trauma Screening Questionnaire was completed one month following injury.

Results

The most common cause of injuries was assault in both groups followed by falls and the most common site of injuries was in the mandible in both groups. Almost half of all patients were in the15-24 and 25-34 age groups. 17 % of patients in pre-intervention period and 4 % of patients in intervention period had injury recurrence at 3 year follow up. Patient groups at risk of developing post traumatic symptoms included male, non-indigenous population, employed group with no alcohol involvement.

Conclusion

Maxillofacial trauma can cause considerable psychological morbidity and expose the patient to high risk of post traumatic disorder symptoms. This type of injury was found to affect particular groups of population and is associated with high rate of recurrence. Psychological support should be provided to these patients as a routine part of trauma aftercare.

Does mental status impact therapist and patient communication in emergency department brief interventions addressing alcohol use?

Motivational interviewing (MI) is often incorporated into screening, brief intervention, and referral to treatment (SBIRT) interventions in critical care settings to address alcohol and other drug use. However, cognitive status has been linked to differential response to MI sessions in emergency department (ED) settings. The current study examined one possible explanation for this differential response: whether higher versus lower mental status impacts patient response to clinician statements during MI sessions conducted in an ED. Participants were 126 patients receiving an MI-based single-session alcohol brief intervention, and 13 therapists who provided treatment. Participants completed a mental status exam (MSE) as part of the screening process. Intervention sessions were audio-taped, and transcribed and coded using the Motivational Interviewing Skills Code (MISC 2.0; Miller, Moyers, Ernst, & Amrhein, 2003). The MISC 2.0 coded therapist behaviors that are related to the use of motivational interviewing, and patient language reflecting movement toward (change talk) or away from (sustain talk) changing personal alcohol use. Overall, patients responded in a similar manner to therapist MI behaviors regardless of high versus low level of mental functioning at the time of the intervention. Group differences emerged on patient response to only three specific therapist skills: giving information, open questions, and complex reflection. Thus, the differential effects of SBIRT in critical care settings do not appear to be a result of differences in the therapist and patient communication process.

Prevalence of alcohol related attendance at an inner city emergency department and its impact: a dual prospective and retrospective cohort study

BACKGROUND

Alcohol related hospital attendances are a potentially avoidable burden on emergency departments (EDs). Understanding the number and type of patients attending EDs with alcohol intoxication is important in estimating the workload and cost implications. We used best practice from previous studies to establish the prevalence of adult alcohol related ED attendances and estimate the costs of clinical management and subsequent health service use.

METHODS

The setting was a large inner city ED in northeast England, UK. Data were collected via (i) retrospective review of hospital records for all ED attendances for four pre-specified weeks in 2010/2011 to identify alcohol related cases along with 12 months of follow-up of the care episode and (ii) prospective 24/7 assessment via breath alcohol concentration testing of patients presenting to the ED in the corresponding weeks in 2012/2013.

RESULTS

The prevalence rates of alcohol related attendances were 12% and 15% for the retrospective and prospective cohorts, respectively. Prospectively, the rates ranged widely from 4% to 60% across week days, rising to over 70% at weekends. Younger males attending in the early morning hours at weekends made up the largest proportion of alcohol related attendances. The mean cost per attendance was £249 (SD £1064); the mean total cost for those admitted was £851 (SD £2549). The most common reasons for attending were trauma related injuries followed by psychiatric problems.

CONCLUSIONS

Alcohol related attendances are a major and avoidable burden on emergency care. However, targeted interventions at weekends and early morning hours could capture the majority of cases and help prevent future re-attendance.

Trajectories of Adolescent Alcohol Use in the Year Following a Brief Alcohol Intervention

OBJECTIVE

Brief interventions have become increasingly popular for youth who engage in problematic drinking behavior. The purpose of this study was to examine the alcohol use trajectories of adolescents over a 12-month period following the receipt of a brief intervention.

METHOD

The current sample came from two independent studies and consisted of 206 adolescents (ages 13-19; 52% male) recruited through an emergency department or community institution (e.g., courts, schools). Timeline followback methods were used at four points over 1 year to obtain daily estimates of alcohol use behaviors, with daily data then aggregated at the monthly level to examine trajectories of total drinks consumed and maximum drinks on one occasion. Using latent growth curve analysis, we expected a general pattern of increasing use over time, with lower use during the month immediately following completion of the intervention.

RESULTS

Models with random intercepts, random linear slopes, and fixed quadratic trends provided good fit to the data for both total drinks and maximum drinks. For each outcome, there was an immediate decrease and then a gradual increase up to the 3- and 6-month assessments, with decreases seen in the months following assessments. Older age, White race, non-Hispanic ethnicity, and greater prior substance use were associated with greater initial levels of use and growth over time.

CONCLUSIONS

Interindividual differences were observed in alcohol use trajectories over time for high-risk adolescents following an alcohol use intervention. Subsequent research may demonstrate more uniform and permanent modification of trajectories by incorporating intervention-related materials into follow-up contacts.

Brief Intervention in the Emergency Department Among Mexican-Origin Young Adults at the US-Mexico Border: Outcomes of a Randomized Controlled Clinical Trial Using Promotores

AIMS

A randomized controlled trial of brief intervention (BI), for drinking and related problems, using peer health promotion advocates (promotores), was conducted among at-risk and alcohol-dependent Mexican-origin young adult emergency department (ED) patients, aged 18-30.

METHODS

Six hundred and ninety-eight patients were randomized to: screened only (n = 78), assessed (n = 310) and intervention (n = 310). Primary outcomes were at-risk drinking and Rapid Alcohol Problems Screen (RAPS4) scores. Secondary outcomes were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking.

RESULTS

At 3- and 12-month follow-up the intervention condition showed significantly lower values or trends on all outcome variables compared to the assessed condition, with the exception of the RAPS4 score; e.g. at-risk drinking days dropped from 2.9 to 1.7 at 3 months for the assessed condition and from 3.2 to 1.2 for the intervention condition. Using random effects modeling controlling for demographics and baseline values, the intervention condition showed significantly greater improvement in all consumption measures at 12 months, but not in the RAPS4 or negative consequences of drinking. Improvements in outcomes were significantly more evident for non-injured patients, those reporting drinking prior to the event, and those lower on risk taking disposition.

CONCLUSIONS

At 12-month follow-up this study demonstrated significantly improved drinking outcomes for Mexican-origin young adults in the ED who received a BI delivered by promotores compared to those who did not.

TRIAL REGISTER

ClinicalTrials.gov.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02056535.

SBIRT Implementation for Adolescents in Urban Federally Qualified Health Centers

BACKGROUND

Alcohol, tobacco, and other drug use remains highly prevalent among US adolescents and is a threat to their well-being and to the public health. Evidence from clinical trials and meta-analyses supports the effectiveness of Screening, Brief Intervention and Referral to Treatment (SBIRT) for adolescents with substance misuse but primary care providers have been slow to adopt this evidence-based approach. The purpose of this paper is to describe the theoretically informed methodology of an on-going implementation study.

METHODS

This study protocol is a multi-site, cluster randomized trial (N=7) guided by Proctor's conceptual model of implementation research and comparing two principal approaches to SBIRT delivery within adolescent medicine: Generalist vs. Specialist. In the Generalist Approach, the primary care provider delivers brief intervention (BI) for substance misuse. In the Specialist Approach, BIs are delivered by behavioral health counselors. The study will also examine the effectiveness of integrating HIV risk screening within an SBIRT model. Implementation Strategies employed include: integrated team development of the service delivery model, modifications to the electronic medical record, regular performance feedback and supervision. Implementation outcomes, include: Acceptability, Appropriateness, Adoption, Feasibility, Fidelity, Costs/Cost-Effectiveness, Penetration, and Sustainability.

DISCUSSION

The study will fill a major gap in scientific knowledge regarding the best SBIRT implementation strategy at a time when SBIRT is poised to be brought to scale under health care reform. It will also provide novel data to inform the expansion of the SBIRT model to address HIV risk behaviors among adolescents. Finally, the study will generate important cost data that offer guidance to policymakers and clinic directors about the adoption of SBIRT in adolescent health care.

Linked randomised controlled trials of face-to-face and electronic brief intervention methods to prevent alcohol related harm in young people aged 14-17 years presenting to Emergency Departments (SIPS junior)

BACKGROUND

Alcohol is a major global threat to public health. Although the main burden of chronic alcohol-related disease is in adults, its foundations often lie in adolescence. Alcohol consumption and related harm increase steeply from the age of 12 until 20 years. Several trials focusing upon young people have reported significant positive effects of brief interventions on a range of alcohol consumption outcomes. A recent review of reviews also suggests that electronic brief interventions (eBIs) using internet and smartphone technologies may markedly reduce alcohol consumption compared with minimal or no intervention controls. Interventions that target non-drinking youth are known to delay the onset of drinking behaviours. Web based alcohol interventions for adolescents also demonstrate significantly greater reductions in consumption and harm among 'high-risk' drinkers; however changes in risk status at follow-up for non-drinkers or low-risk drinkers have not been assessed in controlled trials of brief alcohol interventions.

DESIGN AND METHODS

The study design comprises two linked randomised controlled trials to evaluate the effectiveness and cost-effectiveness of two intervention strategies compared with screening alone. One trial will focus on high-risk adolescent drinkers attending Emergency Departments (Eds) and the other will focus on those identified as low-risk drinkers or abstinent from alcohol but attending the same ED. Our primary (null) hypothesis is similar for both trials: Personalised Feedback and Brief Advice (PFBA) and Personalised Feedback plus electronic Brief Intervention (eBI) are no more effective than screening alone in alcohol consumed at 12 months after randomisation as measured by the Time-Line Follow-Back 28-day version. Our secondary (null) hypothesis relating to economics states that PFBA and eBI are no more cost-effective than screening alone. In total 1,500 participants will be recruited into the trials, 750 high-risk drinkers and 750 low-risk drinkers or abstainers. Participants will be randomised with equal probability, stratified by centre, to either a screening only control group or one of the two interventions: single session of PFBA or eBI. All participants will be eligible to receive treatment as usual in addition to any trial intervention. Individual participants will be followed up at 6 and 12 months after randomisation.

DISCUSSION

The protocol represents an ambitious innovative programme of work addressing alcohol use in the adolescent population.

TRIAL REGISTRATION

ISRCTN45300218. Registered 5th July 2014.

A realist review of brief interventions for alcohol misuse delivered in emergency departments

BACKGROUND

Brief interventions (BIs) involve screening for alcohol misuse and providing feedback to patients about their use, with the aim of reducing alcohol consumption and related consequences. BIs have been implemented in various healthcare settings, including emergency departments (ED), where they have been found to contribute mixed results in their ability to address alcohol misuse among adults. Mechanisms through which BIs work and contextual factors impacting BI effectiveness are not clear. The purpose of this review was to understand how, for whom, and under what circumstances BIs work for adults misusing alcohol and who have been admitted to an ED. A realist review was chosen to answer these questions as realist reviews create context-mechanism-outcome configurations, leading to the development of comprehensive and detailed theories; in this case explaining how and for whom BIs work.

METHODS

Databases including PsycINFO, Healthstar, CINAHL, Medline, and Nursing and Allied Health were searched for articles published until December 2013. The search strategy focused on studies examining BIs that targeted alcohol misuse among adults admitted into the ED. The search identified 145 relevant abstracts, of which 36 were included in the review. The literature was synthesized qualitatively (immersion/crystallization).

RESULTS

Four mechanisms were found within reviewed studies, including engagement in/retention of BI materials, resolving ambivalence, increased awareness/insight into consequences of drinking, and increased self-efficacy/empowerment to use skills for change. The following contexts were found to impact mechanisms: emotional state, injury attributed to alcohol use, severity of alcohol use, and baseline stage of change.

CONCLUSIONS

This realist review provides advances in theories regarding which mechanisms to target during a BI and which contexts create the most favorable conditions for these mechanisms to occur, ultimately leading to optimal BI outcomes. These results can inform future clinical decision-making when delivering BIs in ED settings. Future research should conduct quantitative examination to confirm these findings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42013006549.

Exploring the use of Motivational Interviewing with a disengaged primary-aged child

Research suggests motivational interviewing (MI) techniques are both widely-used by educational psychologists (EPs) and effective in supporting young people of secondary age. To date, there has been no published research investigating the use of MI with primary-aged children. This study details the use of a short MI-based intervention with a primary-aged pupil identified as disengaged. A case-based approach was employed, using pupil and teacher interviews and observational fieldnotes to assess the usefulness of the intervention. Data were analysed using thematic analysis and the intervention checked for adherence to the MI spirit and principles. Here the process, structure and outcomes of the intervention are exemplified through an illustrative case study with a nine-year-old boy. Results indicate that the adapted intervention had a significant impact on learning motivation and classroom behaviour. The implications of the findings are discussed in relation to the use of school-based therapeutic interventions by EPs.

Components of Brief Alcohol Interventions for Youth in the Emergency Department

BACKGROUND

Alcohol brief interventions (BIs) delivered by therapists are promising among underage drinkers in the emergency department (ED); however, integration into routine ED care is lacking. Harnessing technology for identification of at-risk drinkers and delivery of interventions could have tremendous public health impact by addressing practical barriers to implementation. The paper presents baseline, within BI session, and posttest data from an ongoing randomized controlled trial (RCT) of youth in the ED.

METHODS

Patients (ages 14-20) who screened positive for risky drinking were randomized to computer BI (CBI), therapist BI (TBI), or control. Measures included demographics, alcohol consumption (Alcohol Use Disorders Identification Test--Consumption [AUDIT-C]), process questions, BI components (e.g., strengths, tools), and psychological constructs (i.e., importance of cutting down, likelihood of cutting down, readiness to stop, and wanting help).

RESULTS

Among 4389 youth surveyed (13.7% refused), 24.0% (n = 1053) screened positive for risky drinking and 80.3% (n = 836) were enrolled in the RCT; 93.7% (n = 783) completed the posttest. Although similar in content, the TBI included a tailored, computerized workbook to structure the session, whereas the CBI was a stand-alone, offline, Facebook-styled program. As compared with controls, significant increases were found at posttest for the TBI in "importance to cut down" and "readiness to stop" and for the CBI in "importance and likelihood to cut down." BI components positively associated with outcomes at posttest included greater identification of personal strengths, protective behavioral strategies, benefits of change, and alternative activities involving sports. In contrast, providing information during the TBI was negatively related to outcomes at posttest.

CONCLUSIONS

Initial data suggest that therapist and computer BIs are promising, increasing perceived importance of reducing drinking. In addition, findings provide clues to potentially beneficial components of BIs. Future studies are needed to identify BI components that have the greatest influence on reducing risky drinking behaviors among adolescents and emerging adults.

Individual versus significant-other-enhanced brief motivational intervention for alcohol in emergency care

OBJECTIVE

Effects of brief motivational interventions (BMIs) for heavy drinkers identified by alcohol-related emergency department (ED) visits are mixed. The successes of including significant others (SOs) in behavioral treatment suggest that involving SOs in ED-delivered BMI might prove beneficial. This study investigated the relative efficacy of an SO-enhanced motivational intervention (SOMI) compared with an individual motivational intervention (IMI) to address heavy drinking in emergency care settings.

METHOD

ED (n = 317) or trauma unit (n = 89) patients were randomly assigned to receive either an IMI or an SOMI and were reassessed at 6 and 12 months for alcohol consumption, alcohol-related consequences, and perceived alcohol-specific SO support.

RESULTS

Generalized estimating equation analyses showed consistent reductions over time for both alcohol consumption and consequences. At 1-year follow-up, the average reduction in total drinks consumed per week was greater for patients in the SOMI condition than the IMI condition. In SOMI, 9.4% more patients moved to within the national guidelines for weekly drinking than did IMI patients. Frequency of heavy drinking and negative alcohol consequences showed no differential effects of intervention.

CONCLUSIONS

Emergence of a modest treatment effect at 12 months suggests that SO involvement in the SOMI condition may have led to more sustained positive influence on patient drinking than in the IMI condition. Implications and limitations regarding SO involvement in brief treatment are discussed.

The Quik Fix study: a randomised controlled trial of brief interventions for young people with alcohol-related injuries and illnesses accessing emergency department and crisis support care

Background

Alcohol is a major preventable cause of injury, disability and death in young people. Large numbers of young people with alcohol-related injuries and medical conditions present to hospital emergency departments (EDs). Access to brief, efficacious, accessible and cost effective treatment is an international health priority within this age group. While there is growing evidence for the efficacy of brief motivational interviewing (MI) for reducing alcohol use in young people, there is significant scope to increase its impact, and determine if it is the most efficacious and cost effective type of brief intervention available. The efficacy of personality-targeted interventions (PIs) for alcohol misuse delivered individually to young people is yet to be determined or compared to MI, despite growing evidence for school-based PIs. This study protocol describes a randomized controlled trial comparing the efficacy and cost-effectiveness of telephone-delivered MI, PI and an Assessment Feedback/Information (AF/I) only control for reducing alcohol use and related harm in young people.

Methods/design

Participants will be 390 young people aged 16 to 25 years presenting to a crisis support service or ED with alcohol-related injuries and illnesses (including severe alcohol intoxication). This single blinded superiority trial randomized young people to (i) 2 sessions of MI; (ii) 2 sessions of a new PI or (iii) a 1 session AF/I only control. Participants are reassessed at 1, 3, 6 and 12 months on the primary outcomes of alcohol use and related problems and secondary outcomes of mental health symptoms, functioning, severity of problematic alcohol use, alcohol injuries, alcohol-related knowledge, coping self-efficacy to resist using alcohol, and cost effectiveness.

Discussion

This study will identify the most efficacious and cost-effective telephone-delivered brief intervention for reducing alcohol misuse and related problems in young people presenting to crisis support services or EDs. We expect efficacy will be greatest for PI, followed by MI, and then AF/I at 1, 3, 6 and 12 months on the primary and secondary outcome variables. Telephone-delivered brief interventions could provide a youth-friendly, accessible, efficacious, cost-effective and easily disseminated treatment for addressing the significant public health issue of alcohol misuse and related harm in young people.

Trial registration

This trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000108718.

Brief motivational intervention for adolescents treated in emergency departments for acute alcohol intoxication - a randomized-controlled trial

Background

Alcohol misuse among youth is a major public health concern and numbers of adolescents admitted to the emergency department for acute alcoholic intoxication in Germany are recently growing. The emergency setting offers an opportunity to reach at-risk alcohol consuming adolescents and provide brief interventions in a potential “teachable moment”. However, studies on brief interventions targeting adolescents in emergency care are scarce and little is known about their effectiveness when delivered immediately following hospitalization for acute alcohol intoxication. In this protocol we present the HaLT-Hamburg trial evaluating a brief motivational intervention for adolescents treated in the emergency department after an episode of acute alcoholic intoxication.

Methods

The trial design is a parallel two-arm cluster randomized-controlled trial with follow-up assessment after 3 and 6 months. N = 312 participants aged 17 years and younger will be recruited Fridays to Sundays in 6 pediatric clinics over a period of 30 months. Intervention condition is a manual-based brief motivational intervention with a telephone booster after 6 weeks and a manual-guided intervention for caregivers which will be compared to treatment as usual. Primary outcomes are reduction in binge drinking episodes, quantity of alcohol use on a typical drinking day and alcohol-related problems. Secondary outcome is further treatment seeking. Linear mixed models adjusted for baseline differences will be conducted according to intention-to-treat (ITT) and completers (per-protocol) principles to examine intervention effects. We also examine quantitative and qualitative process data on feasibility, intervention delivery, implementation and receipt from intervention providers, receivers and regular emergency department staff.

Discussion

The study has a number of strengths. First, a rigorous evaluation of HaLT-Hamburg is timely because variations of the HaLT project are widely used in Germany. Second, prior research has not targeted adolescents in the presumed teachable moment following acute alcohol intoxication. Third, we included a comprehensive process evaluation to raise external validity. Fourth, the study involved important stakeholders from the start to set up organizational structures for implementation and maintaining project impact.

Trial registration

Current Controlled Trials ISRCTN31234060 (April 30^th 2012).

A randomized controlled trial of guided self-change with minority adolescents

OBJECTIVE

Adolescent substance use and abuse is a pressing public health problem and is strongly related to interpersonal aggression. Such problems disproportionately impact minority youth, who have limited access to evidence-based interventions such as ecological family therapies, brief motivational interventions (BMIs), and cognitive behavioral therapies (CBTs). With a predominantly minority sample, our objective was to rigorously evaluate the efficacy of a school-based BMI/CBT, Guided Self-Change (GSC), for addressing substance use and aggressive behavior.

METHOD

We conducted a school-based randomized, controlled trial with 514 high school students (mean age 16.24 years, 41% female, 80% minority) reporting using substances and perpetrating aggression. We used structural equation modeling to compare participants randomly assigned to receive GSC or standard care (SC; education/assessment/referral-only) at posttreatment and at 3 and 6 months posttreatment on alcohol use, drug use, and interpersonal aggression outcomes as assessed by the Timeline Follow-Back.

RESULTS

Compared with SC participants, GSC participants showed significant reductions (p < .05) in total number of alcohol use days (Cohen's d = 0.45 at posttreatment and 0.20 at 3 months posttreatment), drug use days (Cohen's d = 0.22 at posttreatment and 0.20 at 3 months posttreatment), and aggressive behavior incidents (Cohen's d = 0.23 at posttreatment). Moreover, treatment effects did not vary by gender or ethnicity.

CONCLUSIONS

With minority youth experiencing mild to moderate problems with substance use and aggressive behavior, GSC holds promise as an early intervention approach that can be implemented with success in schools.

Prescription drug misuse and sexual risk behaviors among adolescents and emerging adults

OBJECTIVE

The purpose of this study was to evaluate associations between prescription drug misuse (PDM) and sexual risk behaviors (SRBs) among adolescents and emerging adults.

METHOD

In a hospital emergency department, 2,127 sexually active 14- to 20-year-olds (61% female) reported on past-year alcohol use severity (using the Alcohol Use Disorders Identification Test-consumption [AUDIT-C]), cannabis use, PDM (n = 422), and SRBs (inconsistent condom use, multiple partners, intercourse following alcohol/other drug use).

RESULTS

Bivariately, AUDIT-C score, cannabis use, and PDM of stimulants, opioids, and sedatives were positively associated with each SRB. Because many participants reported PDM for multiple drug classes (i.e., sedatives, stimulants, opioids), participants were categorized as (a) no PDM (n = 1,705), (b) PDM of one class (n = 251), (c) PDM of two classes (n = 90), or (d) PDM of three classes (n = 81). Three hierarchical logistic regression models evaluated the associations of number of classes of PDM with SRBs separately, after accounting for demographics (age, gender, race), AUDIT-C score, and cannabis use. Adding PDM statistically improved each model beyond what was accounted for by demographics, alcohol, and cannabis use. For inconsistent condom use and substance use before sex, PDM of one, two, or three classes was significantly associated with increased odds of these SRBs. PDM of two or three classes was associated with increased odds of reporting multiple partners.

CONCLUSIONS

Findings suggest that PDM, especially poly-PDM, may be a pertinent risk factor for SRBs among youth. Event-based research could further evaluate how PDM, as well as other substance use, is related to SRBs at the event level in order to inform interventions.

Alcohol screening and brief intervention for adolescents: the how, what and where of reducing alcohol consumption and related harm among young people

AIM

The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities.

METHODS

A review of existing reviews (2003-2013) and a systematic review of recent research not included in earlier reviews.

RESULTS

The CRAFFT and AUDIT tools are recommended for identification of 'at risk' adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm.

CONCLUSION

Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.

Injury-related consequences of alcohol misuse among injured patients who received screening and brief intervention for alcohol: a latent class analysis

BACKGROUND

Screening and brief alcohol intervention has demonstrated efficacy in improving drinking and other risk behaviors for some patient populations. However, it is not clear that brief interventions are helpful to all injured patients who drink at risk levels. This paper identifies latent classes of intervention recipients based on injury-related consequences and risks of alcohol misuse and then determines which profiles experienced the greatest improvements in drinking.

METHODS

A secondary analysis was conducted using data from injured patients (N = 737) who reported heavy drinking and received a brief alcohol intervention in a Level I trauma center. Latent class analysis was used to determine patient profiles, and 7 indicators commonly associated with alcohol-related injury from the Short Inventory of Problems+6 were used to determine the latent class measurement model. Covariates were regressed onto the model to assess factors related to class membership, and drinking outcomes were analyzed to examine improvements in drinking.

RESULTS

Five classes emerged from the data. The classes that reported the greatest improvements in drinking following discharge were those characterized by multiple alcohol-related risks and those characterized by a history of alcohol-related accidents and injuries. Attributing the current injury to drinking was a significant predictor of class membership among those classes that reported higher levels of improvement.

CONCLUSIONS

This study provides tentative evidence that subclasses exist among heavy drinking injured patients who received a brief intervention in a Level I trauma center, and some subclasses experience greater drinking improvements than others. Further research is required to substantiate the findings of this secondary analysis.

Motivational interviewing targeting risk behaviors for youth living with HIV in Thailand

Healthy Choices, a four-session motivational interviewing-based intervention, reduces risk behaviors among US youth living with HIV (YLWH). We randomized 110 Thai YLWH (16-25 years) to receive either Healthy Choices or time-matched health education (Control) over 12 weeks. Risk behaviors were assessed at baseline, 1, and 6 months post-session. The pilot study was not powered for between-group differences; there were no statistical differences in sexual risks, alcohol use, and antiretroviral adherence between the two groups at any visit. In within-group analyses, Healthy Choices group demonstrated decreases in the proportion of HIV-negative partners (20 vs 8.2%, P = 0.03) and HIV sexual risk scores (4.3 vs 3.3, P = 0.04), and increased trends in the proportion of protected sex (57 vs 76.3%, P = 0.07) from baseline to 1 month post-session. These changes were not sustained 6 months later. No changes were observed in Control group. Healthy Choices has potential to improve sexual risks among Thai YLWH.

Neural correlates of adaptive social responses to real-life frustrating situations: a functional MRI study

BACKGROUND

Frustrating situations are encountered daily, and it is necessary to respond in an adaptive fashion. A psychological definition states that adaptive social behaviors are "self-performing" and "contain a solution." The present study investigated the neural correlates of adaptive social responses to frustrating situations by assessing the dimension of causal attribution. Based on attribution theory, internal causality refers to one's aptitudes that cause natural responses in real-life situations, whereas external causality refers to environmental factors, such as experimental conditions, causing such responses. To investigate the issue, we developed a novel approach that assesses causal attribution under experimental conditions. During fMRI scanning, subjects were required to engage in virtual frustrating situations and play the role of protagonists by verbalizing social responses, which were socially adaptive or non-adaptive. After fMRI scanning, the subjects reported their causal attribution index of the psychological reaction to the experimental condition. We performed a correlation analysis between the causal attribution index and brain activity. We hypothesized that the brain region whose activation would have a positive and negative correlation with the self-reported index of the causal attributions would be regarded as neural correlates of internal and external causal attribution of social responses, respectively.

RESULTS

We found a significant negative correlation between external causal attribution and neural responses in the right anterior temporal lobe for adaptive social behaviors.

CONCLUSION

This region is involved in the integration of emotional and social information. These results suggest that, particularly in adaptive social behavior, the social demands of frustrating situations, which involve external causality, may be integrated by a neural response in the right anterior temporal lobe.

Impact of Physical Health on Treatment for Co-occurring Depression and Substance Dependence

OBJECTIVE

There is a high rate of comorbidity among substance dependence, depression, and physical health problems. This study aimed to examine the impact of pre-treatment physical health stressors (acute and chronic conditions) on outcomes of treatment in a sample of veterans with dual disorders (depression and substance dependence) who were randomized to integrated cognitive behavioral therapy versus 12-Step interventions.

METHODS

This study included 205 veterans (89.8% male, mean age = 49.5 years) enrolled in a clinical treatment outcomes trial. Chronic health problems (persistent, ongoing conditions lasting 2 weeks or more; e.g., arthritis, diabetes) and acute health events (occurring on a discrete date; e.g., injury, surgery, myocardial infarction) were coded dichotomously (presence versus absence) and evaluated separately. The impact of physical health stressors on abstinence (defined dichotomously), percentage of days abstinent, and depression symptoms were analyzed at the end of 12 and 24 weeks of treatment. Additionally, associations between intake motivation to change, health stressors, and substance use were examined.

RESULTS

Analyses revealed that participants who had experienced a pretreatment acute health event had higher rates of abstinence at 12-weeks, higher percentage of days abstinent at 24-weeks, and higher depression symptoms at intake. Participants with chronic health difficulties had more severe depression at intake and those participants with severe chronic difficulties had greater depression symptoms across all time points. Chronic health difficulties were related to the Taking Steps factor of motivation to change substance use, but acute health events were not related to motivation to change. Motivation to change was also not related to substance outcomes in our sample.

CONCLUSIONS

Physical health appears to have a complex relationship with co-occurring depression and substance dependence. Acute health problems predicted lower substance use, whereas chronic health problems were associated with higher depression levels. Explicitly addressing the connection between substance use and health events during treatment may improve addiction treatment outcomes. However, individuals with chronic health problems may benefit from extending treatment or adjunct strategies focused on addressing chronic health concerns. This is an analysis of data collected as part of a clinical trial registered at www.ClinicalTrials.gov as NCT00108407.

Effect of a significant other on client change talk in motivational interviewing

OBJECTIVE

To examine significant-other (SO) and therapist behaviors as predictors of client change language within motivational interviewing (MI) sessions.

METHOD

Participants from an emergency department received a single session of MI that included SO participation (N = 157). Sessions were coded using therapy process coding systems. Sessions were subdivided into 10 equal deciles to facilitate sequential analyses. Multilevel modeling was used to examine the relationships among the following variables: therapist MI-consistent and MI-inconsistent behaviors; client change talk and sustain talk; and SO Support Change and SO Against Change.

RESULTS

Therapist MI-consistent and MI-inconsistent behaviors failed to predict either client change talk or sustain talk at the decile level. Global measures of therapist MI spirit and acceptance were associated with lower levels of client sustain talk (p = .002 and p < .001, respectively). Higher levels of SO Support Change were more likely to be followed by higher levels of client change talk (p < .001) and lower levels of client sustain talk (p < .001). SOs who engaged in behaviors that discouraged the patient's drinking in the 6 months prior to the intervention had higher levels of SO Support Change language (p = .02). When analyzed at the aggregate level, therapist behavior was significantly associated with client change talk, but effect sizes were quite modest.

CONCLUSIONS

Within-session SO behavior impacts client verbalizations regarding changes in alcohol use. Results raise questions about the role of therapist behavior when an SO is present.

Attitudes and Beliefs towards Patients with Hazardous Alcohol Use: A Systematic Review

Objective. To describe emergency department (ED) staff attitudes and beliefs towards patients presenting with hazardous alcohol use and their clinical management. Methods. A search of MEDLINE, EMBASE, CINAHL, SCOPUS from 1990 to 2010, and reference lists from included studies was conducted. Two reviewers independently screened for inclusion and assessed study quality. One reviewer extracted the data and a second checked for completeness and accuracy. Results. Among nine studies four reported varied beliefs on whether screening was worthwhile for identifying hazardous alcohol use (physicians: 42%–88%; nurses: 50%–100%). Physicians in three studies were divided on intervention provision (32%–54% in support of intervention provision) as were nurses in two studies (39% and 64% nurses in support of intervention provision). Referral for treatment was identified in two studies as an important part of ED management (physicians: 62% and 97%; nurses: 95%). Other attitudes and beliefs identified across the studies included concern that asking about alcohol consumption would be seen as obtrusive or offensive, and a perceived lack of time and resources available for providing care and referrals. Conclusions. ED staff had varying attitudes towards ED management of patients with hazardous alcohol use. Investigations into improving clinical care for hazardous alcohol use are needed to optimize ED management for these patients.

Pathways to care: narratives of American Indian adolescents entering substance abuse treatment

Using data from 89 American Indian adolescents and guided by the Network Episode Model, this paper analyses pathways to residential substance abuse treatment and their correlates. These adolescents were recruited at admission to a tribally-operated substance abuse treatment program in the southern United States from October 1998 to May 2001. Results from the qualitative analyses of these adolescent's pathways to care narratives indicated that 35% ultimately agreed with the decision for their entry into treatment; 41% were Compelled to enter treatment by others, usually by their parents, parole officers, and judges; and 24% did not describe a clear pathway to care. In the multinomial logistic regression model examining correlates of these pathways to care classifications, adolescents who described pathways indicative of agreement also reported greater readiness for treatment than the adolescents who described compelled or no clear pathways to care. Adolescents who described a Compelled pathway were less likely to meet diagnostic criteria for Conduct Disorder and described fewer social network ties. We were unable to find a relationship between pathways classifications and referral source, suggesting these narratives were subjective constructions of pathways to care rather than a factual representation of this process. In the final logistic regression model examining correlates of treatment completion, articulating a pathway to care, whether it was one of agreement or of being compelled into treatment, predicted a greater likelihood of completing treatment. Overall, these narratives and their correlates are highly consistent with the Network-Episode Model's emphasis on the interaction of self, situation, and social network in shaping the treatment seeking process, demonstrating the applicability of this model to understanding the treatment seeking process in this special population and suggests important considerations for understanding the dynamics of service utilization across diverse communities.

Will emergency and surgical patients participate in and complete alcohol interventions? A systematic review

BACKGROUND

In the everyday surgical life, staff may experience that patients with Alcohol Use Disorders (AUDs) seem reluctant to participate in alcohol intervention programs. The objective was therefore to assess acceptance of screening and intervention as well as adherence to the intervention program among emergency department (ED) and surgical patients with AUDs.

METHODS

A systematic literature search was followed by extraction of acceptance and adherence rates in ED and surgical patients. Numbers needed to screen (NNS) were calculated. Subgroup analyses were carried out based on different study characteristics.

RESULTS

The literature search revealed 33 relevant studies. Of these, 31 were randomized trials, 28 were conducted in EDs and 31 evaluated the effect of brief alcohol intervention. Follow-up was mainly conducted after six and/or twelve months.Four in five ED patients accepted alcohol screening and two in three accepted participation in intervention. In surgical patients, two in three accepted screening and the intervention acceptance rate was almost 100%. The adherence rate was above 60% for up to twelve months in both ED and surgical patients. The NNS to identify one eligible AUD patient and to get one eligible patient to accept participation in alcohol intervention varied from a few up to 70 patients.The rates did not differ between randomized and non-randomized trials, brief and intensive interventions or validated and self-reported alcohol consumption. Adherence rates were not affected by patients' group allocation and type of follow-up.

CONCLUSIONS

Most emergency and surgical patients with AUD accept participation in alcohol screening and interventions and complete the intervention program.

Will emergency and surgical patients participate in and complete alcohol interventions? A systematic review

BACKGROUND

In the everyday surgical life, staff may experience that patients with Alcohol Use Disorders (AUDs) seem reluctant to participate in alcohol intervention programs. The objective was therefore to assess acceptance of screening and intervention as well as adherence to the intervention program among emergency department (ED) and surgical patients with AUDs.

METHODS

A systematic literature search was followed by extraction of acceptance and adherence rates in ED and surgical patients. Numbers needed to screen (NNS) were calculated. Subgroup analyses were carried out based on different study characteristics.

RESULTS

The literature search revealed 33 relevant studies. Of these, 31 were randomized trials, 28 were conducted in EDs and 31 evaluated the effect of brief alcohol intervention. Follow-up was mainly conducted after six and/or twelve months.Four in five ED patients accepted alcohol screening and two in three accepted participation in intervention. In surgical patients, two in three accepted screening and the intervention acceptance rate was almost 100%. The adherence rate was above 60% for up to twelve months in both ED and surgical patients. The NNS to identify one eligible AUD patient and to get one eligible patient to accept participation in alcohol intervention varied from a few up to 70 patients.The rates did not differ between randomized and non-randomized trials, brief and intensive interventions or validated and self-reported alcohol consumption. Adherence rates were not affected by patients' group allocation and type of follow-up.

CONCLUSIONS

Most emergency and surgical patients with AUD accept participation in alcohol screening and interventions and complete the intervention program.

Individual and family motivational interventions for alcohol-positive adolescents treated in an emergency department: results of a randomized clinical trial

OBJECTIVE

To determine whether a brief individual motivational interview (IMI) plus a family motivational interview (Family Check-Up [FCU]) would reduce alcohol use in adolescents treated in an emergency department after an alcohol-related event more effectively than would an IMI only.

DESIGN

Two-group randomized design with 3 follow-up time points.

SETTING

An urban regional level I trauma center.

PARTICIPANTS

Adolescents aged 13 to 17 years (N = 125) with a positive blood alcohol concentration as tested using blood, breath, or saliva.

INTERVENTIONS

Either IMI or IMI plus FCU.

MAIN OUTCOME MEASURES

Drinking frequency (days per month), quantity (drinks per occasion), and frequency of high-volume drinking (≥5 drinks per occasion).

RESULTS

Both conditions resulted in a reduction in all drinking outcomes at all follow-up points (P < .001 for all), with the strongest effects at 3 and 6 months. Adding the FCU to the IMI resulted in a somewhat better outcome than did the IMI only on high-volume drinking days at 3-month follow-up (14.6% vs 32.1%, P = .048; odds ratio, 2.76; 95% confidence interval, 0.99-7.75).

CONCLUSIONS

Motivational interventions have a positive effect on drinking outcomes in the short term after an alcohol-related emergency department visit. Adding the FCU to an IMI resulted in somewhat better effects on high-volume drinking at short-term follow-up than did an IMI only. The cost of extra sessions necessary to complete the FCU should be weighed against the potential benefit of reducing high-volume drinking when considering adding the FCU to an IMI for this population.

Predictors of treatment retention for substance-dependent adults with co-occurring depression

Low attendance in addiction treatment, particularly in cases of comorbidity, has been identified as a pervasive challenge. We examine predictors of treatment retention in a sample of veterans (N = 253) participating in a clinical trial comparing two types of psychotherapy for co-occurring depression and substance use disorders. The study protocol included 24 weeks of outpatient group psychotherapy in either a newly developed Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation Therapy (TSF). Using a model of treatment utilization developed by Aday and Anderson, we analyzed predictors categorized into predisposing factors, enabling resources, need for treatment, and type of treatment received. Outcome included total number of sessions attended (maximum of 36 sessions). Treatment retention did not differ between the two study interventions. Bivariate analyses indicated that predisposing factors were most predictive, with older participants, Caucasians, and those using only alcohol in the month before treatment attending more sessions, and individuals who had recently experienced a health event remained in treatment longer. Importantly, several factors were not related to treatment retention: marital status, education, neuropsychological functioning, financial stress, chronic health problems, treatment motivation, and psychiatric severity. In the combined model of predisposing, enabling and need factors, age and ethnicity were the only significant predictors.

Directionality Between Tolerance of Deviance and Deviant Behavior is Age-Moderated in Chronically Stressed Youth

Problem behavior theory posits that tolerance of deviance is an antecedent to antisocial behavior and substance use. In contrast, cognitive dissonance theory implies that acceptability of a behavior may increase after experiencing the behavior. Using structural equation modeling, this investigation tested whether changes in tolerance of deviance precede changes in conduct disorder criteria or substance use or vice versa, or if they change concomitantly. Two-year longitudinal data from 246 8- to 16-year-olds suggested that tolerance of deviance increases after conduct disorder criteria or substance use in 8-to-10- and 11-to-12-year-olds. These results were consistent with cognitive dissonance theory. In 13-to-16- year-olds, no directionality was suggested, consistent with neither theory. These results were replicated in boys and girls and for different types of conduct disorder criteria aggression (covert behavior), deceitfulness and vandalism (overt behavior), and serious rule-breaking (authority conflict). The age-specific directionality between tolerance of deviance and conduct disorder criteria or substance use is consistent with unique etiologies between early onset versus adolescent-onset subtypes of behavior problems.

Inside the physician's black bag: critical ingredients of brief alcohol interventions

Brief primary care interventions structured around patient workbooks have been shown to be effective in modifying hazardous drinking behavior. However, the critical ingredients of such interventions are not well understood, possibly contributing to their underutilization. Seventeen campus-based clinicians trained in a brief, workbook-based alcohol intervention participated in a qualitative study to identify the most promising clinician-patient interaction components within this shared approach, utilizing a focus group with the clinicians and ranking of the 24 workbook ingredients. Based on the clinicians' collective experience, consensus emerged around the perceived strength of 5 main components: (1) providing a summary of the patient's drinking level, (2) discussing drinking likes and dislikes, (3) discussing life goals, (4) encouraging a risk-reduction agreement, and (5) asking patients to track their drinking (on cards provided for this purpose). This is the first paper to examine primary care physician perspectives on potentially critical components of effective brief alcohol intervention.

Motivational interviewing with significant other participation: assessing therapeutic alliance and patient satisfaction and engagement

Inclusion of concerned significant others (SOs) in alcohol use treatment has demonstrated efficacy but has not been tested in the context of brief interventions. In this study, individual motivational interviewing (MI) sessions were compared with MI sessions including a significant other on within-treatment outcomes (alliance, fidelity, client satisfaction, and engagement). Participants (N = 382) were adult alcohol users recruited in a Level I trauma center. Perceived alliance did not differ across conditions, but patients and SOs reported higher alliance, satisfaction, and engagement than was perceived by the therapist. The occurrence of MI components, or discussion areas, was consistent across conditions. Higher baseline SO drinking was associated with lower patient engagement, whereas higher baseline SO acceptance of patient drinking was associated with lower SO engagement. Results suggest that individual MI sessions can be adapted to include an SO with minimal impact on patient acceptability and treatment fidelity. Research should, however, consider SOs' influence on participant outcomes and the relevance of specific SO characteristics.

Acceptability of the use of motivational interviewing to reduce underage drinking in a Native American community

Thirty-six Native American tribal leaders and members living on contiguous rural southwest California reservations were surveyed concerning their view of the acceptability of a motivational interviewing (MI) intervention with youth (aged 8-18 years) who are drinking and their families. The results suggest the following: (1) a substantial proportion of reservation youth would be willing to accept MI for behavior change; (2) relatively few are actually ready to change; (3) most reservation youth are in the precontemplation stage of change; and (4) MI may be well suited as an intervention to prevent underage drinking in that population. The study's limitations are noted.

Moderators and mediators of two brief interventions for alcohol in the emergency department

OBJECTIVE

To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department.

METHODS

Patients (18-24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow-ups. Gender, alcohol status/severity group [ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+], attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy and alcohol treatment seeking.

RESULTS

Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol-related injury at follow-up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found.

CONCLUSIONS

Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.

A brief motivational interview in a pediatric emergency department, plus 10-day telephone follow-up, increases attempts to quit drinking among youth and young adults who screen positive for problematic drinking

OBJECTIVES

Adolescents in their late teens and early 20s have the highest alcohol consumption in the United States; binge drinking peaks at age 21-25 years. Underage drinking is associated with many negative consequences, including academic problems and risk of intentional and unintentional injuries. This study tested the effectiveness of pediatric emergency department (PED) screening and brief intervention to reduce alcohol consumption and associated risks.

METHODS

A three-group randomized assignment trial was structured to test differences between intervention (I) and standard assessed control (AC) groups in alcohol consumption and alcohol-related behaviors from baseline to 12 months and to compare the AC group with a minimally assessed control (MAC) group to adjust for the effect of assessment reactivity on control group behavior. Patients aged 14-21 years were eligible if they screened positive on the Alcohol Use Disorders Identification Test (AUDIT) or for binge drinking or high-risk behaviors. The MAC group received a resource handout, written advice about alcohol-related risks, and a 12-month follow-up appointment. Patients in the AC group were assessed using standardized instruments in addition to the MAC protocol. The I group received a peer-conducted motivational intervention, referral to community resources and treatment if indicated, and a 10-day booster in addition to assessment. Measurements included 30-day self-report of alcohol consumption and alcohol-related behaviors, screens for depression and posttraumatic stress disorder, and self-report of attempts to quit, cut back, or change conditions of use, all repeated at follow-up. Motor vehicle records and medical records were also analyzed for changes from baseline to 1-year follow-up.

RESULTS

Among 7,807 PED patients screened, 1,202 were eligible; 853 enrolled (I, n = 283; AC, n = 284; MAC, n = 286), with a 12-month follow-up rate of 72%. At 12 months, more than half of enrollees in Reaching Adolescents for Prevention (RAP) attempted to cut back on drinking, and over a third tried to quit. A significantly larger proportion of the I group made efforts to quit drinking and to be careful about situations when drinking compared to AC enrollees, and there was a numerically but not significantly greater likelihood (p = 0.065) among the I group for efforts to cut back on drinking. At 3 months, the likelihood of the I group making attempts to cut back was almost triple that of ACs. For efforts to quit, it was double, and for trying to be careful about situations when drinking, there was a 72% increase in the odds ratio (OR) for the I group. Three-month results for attempts were sustained at 12 months for quit attempts and efforts to be careful. Consumption declined in both groups from baseline to 3 months to 12 months, but there were no significant between-group differences in alcohol-related consequences at 12 months or in alcohol-related risk behaviors. We found a pattern suggestive of assessment reactivity in only one variable at 12 months: the attempt to cut back (73.3% for the I group vs. 64.9% among the AC group and 54.8% among the MAC group).

CONCLUSIONS

Brief motivational intervention resulted in significant efforts to change behavior (quit drinking and be careful about situations while drinking) but did not alter between-group consumption or consequences.

Alcohol and injury in Poland: review and training recommendations

Background

Alcohol plays a significant role in accidents, injuries, and their outcomes. According to the World Health Organization (WHO), there are 76.3 million people with alcohol use disorders worldwide; in 2000, 1.8 million deaths and loss of 58.3 million disability-adjusted life years were attributed to alcohol.

Methods

Although the association between alcohol consumption and trauma-related morbidity and mortality is well-documented, particularly in the US, there is much less information on trauma and alcohol in Poland, a country undergoing unprecedented economic and cultural changes stemming from entry into the European Union (EU) in the midst of a global recession.

Results

Injury is the third leading cause of death in Poland. Rates for all injuries in Poland are higher than in the rest of the EU. Alcohol is one of the greatest risk factors for disease and injury among men and one of the top ten health and injury risk factors for women. In this paper we review the last 10 years of research on injury and alcohol in Poland.

Conclusion

Recommendations are provided for next steps with regard to training health care professionals in emergency medical settings to address this serious and growing problem.

A Dual-Focus Motivational Intervention to Reduce the Risk of Alcohol-Exposed Pregnancy

Project CHOICES developed an integrated behavioral intervention for prevention of prenatal alcohol exposure in women at high risk for alcohol-exposed pregnancies. Settings included primary care, university-hospital based obstetrical/gynecology practices, an urban jail, substance abuse treatment settings, and a media-recruited sample in three large cities. The intervention was based on motivational interviewing and targeted both adoption of effective contraception and reduction of alcohol use. Treatment included 4 manual-guided sessions delivered by mental health clinicians and 1 contraceptive counseling session delivered by a family planning clinician. This paper describes the rationale for treatment; the use of motivational interviewing and the transtheoretical model for a dual-focused approach to behavior change; the development of the Project CHOICES intervention; development of the study protocol and treatment manual; and selection, training, supervision, and monitoring of study counselors. Implications for future applications of the intervention are discussed.