A randomized pilot trial of a mobile delivered brief motivational interviewing and behavioral economic alcohol intervention for emerging adults

Grouping motivational interviewing is only effective for younger patients with alcohol dependence in the rehabilitation stage

Alcohol dependence (AD) is a risk factor for death and disability. Relapse prevention for AD has been exclusively dominated by psychotherapy intervention for many years. Our study aimed to investigate the efficacy of group motivational interviewing (MI) on the psychological craving for alcohol and depressive symptoms in AD patients in the rehabilitation phase, as well as the impact of age. The participants included 108 individuals with AD in the rehabilitation phase. All participants were assigned to the MI intervention group or the control group and were treated for 6 weeks. The severity of psychological craving for alcohol was assessed by the Penn Alcohol Craving Scale (PACS), and psychological status was evaluated by the Hamilton Depression Rating Scale (HAMD). We found that group MI significantly reduced the psychological craving for alcohol in patients with AD in the rehabilitation phase (p < 0.05). In addition, when patients were divided into two groups according to their ages, we found that group MI interventions tended to be effective only in younger patients with AD, but not in older patients. Our findings provide further evidence that the efficacy of group MI interventions was influenced by the age of patients with AD in the rehabilitation stage.

Women Empowered to Connect With Addiction Resources and Engage in Evidence-Based Treatment (WE-CARE)-an mHealth Application for the Universal Screening of Alcohol, Substance Use, Depression, and Anxiety: Usability and Feasibility Study

BACKGROUND

Women of childbearing age (aged 18-44 years) face multiple barriers to receiving screening and treatment for unhealthy alcohol and substance use, depression, and anxiety, including lack of screening in the primary care setting and lack of support in accessing care. The Women Empowered to Connect with Addiction Resources and Engage in Evidence-based Treatment (WE-CARE) mobile app was developed to test universal screening with women of childbearing age and linkage to care after an anonymous assessment.

OBJECTIVE

In this study, we aimed to investigate the feasibility and acceptability of providing anonymous screening instruments through mobile phones for alcohol and substance use, as well as depression and anxiety, for women of childbearing age.

METHODS

We used agile development principles based on previous formative research to test WE-CARE mobile health app with women of childbearing age (N=30) who resided in 1 of 6 counties in central Florida. WE-CARE included screening instruments (for alcohol, substance use, depression, and anxiety), a moderated discussion forum, educational microlearning videos, a frequently asked questions section, and resources for linkage to treatment. Individuals were recruited using flyers, academic listserves, and a commercial human subject recruiting company (Prolific). Upon completion of the screening instruments, women explored the educational and linkage to care features of the app and filled out a System Usability Scale to evaluate the mobile health app's usability and acceptability. Postpilot semistructured interviews (n=4) were conducted to further explore the women's reactions to the app.

RESULTS

A total of 77 women downloaded the application and 30 completed testing. Women of childbearing age gave the WE-CARE app an excellent System Usability Scale score of 86.7 (SD 12.43). Our results indicate elevated risk for substance use in 18 of the 30 (60%) participants, 9/18 (50%) also had an elevated risk for anxiety or depression, and 11/18 (61%) had an elevated risk for substance use, anxiety, or depression. Participants reported that WE-CARE was easy to navigate and use but they would have liked to see more screening questions and more educational content. Linkage to care was an issue; however, as none of the women identified as "at-risk" for substance use disorders contacted the free treatment clinic for further evaluation.

CONCLUSIONS

The mobile health app was highly rated for acceptability and usability, but participants were not receptive to seeking help at a treatment center after only a few brief encounters with the app. The linkage to care design features was likely insufficient to encourage them to seek treatment. The next version of WE-CARE will include normative scores for participants to self-evaluate their screening status compared with their age- and gender-matched peers and enhanced linkages to care features. Future development will focus on enhancing engagement to improve change behaviors and assess readiness for change.

Behavioral economic and wellness-based approaches for reducing alcohol use and consequences among diverse non-student emerging adults: study protocol for Project BLUE, a randomized controlled trial

BACKGROUND

Emerging adults (EAs) who are not 4-year college students nor graduates are at elevated risk for lifetime alcohol use disorder, comorbid drug use, and mental health symptoms, compared to college graduates. There is a need for tailored brief alcohol intervention (BAI) approaches to reduce alcohol risk and to facilitate healthy development in this high-risk population. Most BAIs include a single session focused on discussing risks associated with drinking and correcting normative beliefs about drinking rates. EAs may benefit from additional elements that enhance general wellness. The substance-free activity session (SFAS) aims to clarify life goals and values and increase goal-directed activities that provide alternatives to alcohol use, and the relaxation training (RT) session teaches relaxation and stress reduction skills.

METHODS

The present study is a randomized 3-group (BAI + SFAS vs. RT + SFAS vs. education control) trial with 525 EAs (175 per group; estimated 50% women and 50% African American) who report recent risky drinking and who are not students or graduates of 4-year colleges. Participants will have the option of completing the intervention sessions in person or via a secure video teleconference. Levels of drinking and alcohol-related problems will be evaluated at baseline and 1, 3, 6, and 12 months post-intervention. The primary hypothesis is that both BAI + SFAS and RT + SFAS participants will report significantly greater reductions in alcohol use and problems relative to education control participants, with no differences in outcomes between the two active treatment conditions.

DISCUSSION

The results of this study will inform alcohol prevention efforts for high-risk community dwelling emerging adults.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04776278.

Automated, tailored adaptive mobile messaging to reduce alcohol consumption in help-seeking adults: A randomized controlled trial

AIMS

To test differential outcomes between three 6-month text-messaging interventions to reduce at-risk drinking in help-seeking adults.

DESIGN

A three-arm single-blind randomized controlled trial with 1-, 3-, 6- and 12-month follow-ups.

SETTING

United States. A fully remote trial without human contact, with participants recruited primarily via social media outlets.

PARTICIPANTS

Seven hundred and twenty-three adults (mean = 39.9 years, standard deviation = 10.0; 62.5% female) seeking to reduce their drinking were allocated to 6 months of baseline 'tailored statically' messaging (TS; n = 240), 'tailored adaptive' messaging (TA; n = 239) or 'drink tracking' messaging (DT; n = 244).

INTERVENTIONS

TS consisted of daily text messages to reduce harmful drinking that were tailored to demographics and alcohol use. TA consisted of daily, tailored text messages that were also adapted based on goal achievement and proactive prompts. DT consisted of a weekly assessment for self-reported drinking over the past 7 days.

MEASUREMENTS

The primary outcome measure was weekly sum of standard drinks (SSD) at 6-month follow-up. Secondary outcome measures included drinks per drinking day (DDD), number of drinking days (NDD) per week and heavy drinking days (HDD) at 1-, 3-, 6- and 12-month follow-ups.

FINDINGS

At 6 months, compared with DT, TA resulted in significant SSD reductions of 16.2 (from 28.7 to 12.5) drinks [adjusted risk ratio (aRR) = 0.80, 95% confidence interval (CI) = 0.71, 0.91] using intent-to-treat analysis. TA also resulted in significant improvements in DDD (aRR = 0.84; 95% CI = 0.77-0.92) and drinking days per week (b = -0.39; 95% CI = -0.67, -0.10), but not HDD compared with DT at 6 months. TA was not significantly different from TS at any time-point, except DDD at 6 months. All groups made improvements in SSD at 12-month follow-up compared with baseline with an average reduction of 12.9 drinks per week across groups.

CONCLUSIONS

Automated tailored mobile messaging interventions are scalable solutions that can reduce weekly alcohol consumption in remote help-seeking drinkers over time.

Behavioral Economic and Wellness-based Approaches for Reducing Alcohol Use and Consequences Among Diverse Non-Student Emerging Adults: Study Protocol for Project BLUE, a Randomized Controlled Trial

Background

Emerging adults (EAs) who are not 4-year college students nor graduates are at elevated risk for lifetime alcohol use disorder, comorbid drug use, and mental health symptoms, compared to college graduates. There is a need for tailored brief alcohol intervention (BAI) approaches to reduce alcohol risk and to facilitate healthy development in this high-risk population. Most BAIs include a single session focused on discussing risks associated with drinking and correcting normative beliefs about drinking rates. EAs may benefit from additional elements that enhance general wellness. The Substance-Free Activity Session (SFAS) aims to clarify life goals and values and increase goal-directed activities that provide alternatives to alcohol use, and the Relaxation Training (RT) session teaches relaxation and stress reduction skills.

Methods

The present study is a randomized 3-group (BAI+SFAS vs. RT+SFAS vs. education control) trial with 525 EAs (175 per group; estimated 50% women & 50% African American) who report recent risky drinking and who are not students or graduates of 4-year colleges. Participants will have the option of completing the intervention sessions in person or via a secure video teleconference. Levels of drinking and alcohol-related problems will be evaluated at baseline and 1, 3, 6, and 12-months post-intervention. The primary hypothesis is that both BAI+SFAS and RT+SFAS participants will report significantly greater reductions in alcohol use and problems relative to education control participants, with no differences in outcomes between the two active treatment conditions.

Discussion

The results of this study will inform alcohol prevention efforts for high-risk community dwelling emerging adults.

ClinicalTrialsgov Identifier

NCT04776278.

Digital interventions for reducing alcohol use in general populations: An updated systematic review and meta-analysis

This article updates a 2017 review on the effectiveness of digital interventions for reducing alcohol use in the general population. An updated systematic search of the MEDLINE database was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria to identify randomized controlled trials (RCTs) published from January 2017 to June 2022 that evaluated the effectiveness of digital interventions compared with no interventions, minimal interventions, and face-to-face interventions aimed at reducing alcohol use in the general population and, that also reported changes in alcohol use (quantity, frequency, quantity per drinking day, heavy episodic drinking (HED), or alcohol use disorders identification test (AUDIT) scores). A secondary analysis was performed that analyzed data from RCTs conducted in students. The review was not preregistered. The search produced 2224 articles. A total of 80 studies were included in the review, 35 of which were published after the last systematic review. A total of 66, 20, 18, 26, and 9 studies assessed the impact of digital interventions on alcohol quantity, frequency, quantity per drinking day, HED, and AUDIT scores, respectively. Individuals randomized to the digital interventions drank 4.12 (95% confidence interval (CI): 2.88, 5.36) fewer grams of alcohol per day, had 0.17 (95% CI 0.06, 0.29) fewer drinking days per week, drank approximately 3.89 (95% CI: 0.40, 7.38) fewer grams of alcohol per drinking day, had 1.11 (95% CI: 0.32, 1.91) fewer HED occasions per month, and had an AUDIT score 3.04 points lower (95% CI: 2.23, 3.85) than individuals randomized to the control condition. Significant reductions in alcohol quantity, frequency, and HED, but not quantity per drinking day, were observed among students. Digital interventions show potential for reducing alcohol use in general populations and could be used widely at the population level to reduce alcohol-attributable harms.

Role of social context in addiction etiology and recovery

While social context has long been considered central to substance use disorder prevention and treatment and many drug-taking events occur in social settings, experimental research on social context has historically been limited. Recent years have seen an emergence of concerted preclinical and human laboratory research documenting the direct impact of social context on substance use, delineating behavioral and neurobiological mechanisms underlying social influence's role. We review this emerging preclinical and human laboratory literature from a theoretical lens that considers distinct stages of the addiction process including drug initiation/acquisition, escalation, and recovery. A key conclusion of existing research is that the impact of the social environment is critically moderated by the drug-taking behavior and drug use history of a social peer. Specifically, while drug-free social contexts can reduce the likelihood of drug use initiation and act as a competitive non-drug alternative preventing escalation, drug-using peers can equally facilitate initiation and escalation through peer modeling as a contingent reward of use. Likewise, social context may facilitate recovery or serve as a barrier that increases the chances of a return to regular use. We conclude by discussing evidence-based treatments and recovery support services that explicitly target social mechanisms or that have identified social context as a mechanism of change within treatment. Ultimately, new areas for research including the expansion of drug classes studied and novel human laboratory designs are needed to further translate emerging findings into clinical practice.

Do brief motivational interventions increase motivation for change in drinking among college students? A two-step meta-analysis of individual participant data

BACKGROUND

Brief motivational interventions (BMIs) are one of the most effective individually focused alcohol intervention strategies for college students. Despite the central theoretical role of motivation for change in BMIs, it is unclear whether BMIs increase motivation to change drinking behavior. We conducted a two-step meta-analysis of individual participant data (IPD) to examine whether BMIs increase motivation for change. N = 5903;59% women, 72% White) from Project INTEGRATE. The BMIs included individually delivered motivational interviewing with personalized feedback (MI + PF), stand-alone personalized feedback (PF), and group-based motivational interviewing (GMI).

METHODS

We included 15 trials of BMI (N = 5903;59% women, 72% White) from Project INTEGRATE. The BMIs included individually-delivered motivational interviewing with personalized feedback (MI + PF), stand-alone personalized feedback (PF), and group-based motivational interviewing (GMI). Different measures and responses used in the original trials were harmonized. Effect size estimates were derived from a model that adjusted for baseline motivation and demographic variables for each trial (step 1) and subsequently combined in a random-effects meta-analysis (step 2).

RESULTS

The overall intervention effect of BMIs on motivation for change was not statistically significant (standard mean difference [SMD]: 0.026, 95% CI: [-0.001, 0.053], p = 0.06, k = 19 comparisons). Of the three subtypes of BMIs, GMI, which tended to provide motivation-targeted content, had a statistically significant intervention effect on motivation, compared with controls (SMD: 0.055, 95% CI: [0.007, 0.103], p = 0.025, k = 5). By contrast, there was no evidence that MI + PF (SMD = 0.04, 95% CI: [-0.02, 0.10], k = 6, p = 0.20) nor PF increased motivation (SMD = 0.005, 95% CI: [-0.028, 0.039], k = 8, p = 0.75), compared with controls. Post hoc meta-regression analysis suggested that motivation sharply decreased each month within the first 3 months postintervention (b = -0.050, z = -2.80, p = 0.005 for k = 14).

CONCLUSIONS

Although BMIs provide motivational content and normative feedback and are assumed to motivate behavior change, the results do not wholly support the hypothesis that BMIs improve motivation for change. Changing motivation is difficult to assess during and following interventions, but it is still a theoretically important clinical endpoint. Further, the evidence cautiously suggests that changing motivation may be achievable, especially if motivation-targeted content components are provided.

A contextualized reinforcer pathology approach to addiction

Behavioural economic accounts of addiction conceptualize harmful drug use as an operant reinforcer pathology, emphasizing that a drug is consumed because of overvaluation of smaller immediate rewards relative to larger delayed rewards (delay discounting) and high drug reinforcing value (drug demand). These motivational processes are within-individual determinants of behaviour. A third element of learning theory posits that harmful drug use depends on the relative constraints on access to other available activities and commodities in the choice context (alternative reinforcers), reflecting the substantial influence of environmental factors. In this Perspective, we integrate alternative reinforcers into the contemporary behavioural economic account of harmful drug use - the contextualized reinforcer pathology model - and review empirical literature across the translational spectrum in support of this model. Furthermore, we consider how increases in drug-related mortality and health disparities in addiction can be understood and potentially ameliorated via a contextualized reinforcer pathology model in which lack of alternative reinforcement is a major risk factor for addiction.

Does abstaining from alcohol in high school moderate intervention effects for college students? Implications for tiered intervention strategies

Brief motivational intervention (BMI) and personalized feedback intervention (PFI) are individual-focused brief alcohol intervention approaches that have been proven efficacious for reducing alcohol use among college students and young adults. Although the efficacy of these two intervention approaches has been well established, little is known about the factors that may modify their effects on alcohol outcomes. In particular, high school drinking may be a risk factor for continued and heightened use of alcohol in college, and thus may influence the outcomes of BMI and PFI. The purpose of this study was to investigate whether high school drinking was associated with different intervention outcomes among students who received PFI compared to those who received BMI. We conducted moderation analyses examining 348 mandated students (60.1% male; 73.3% White; and 61.5% first-year student) who were randomly assigned to either a BMI or a PFI and whose alcohol consumption was assessed at 4-month and 15-month follow-ups. Results from marginalized zero-inflated Poisson models showed that high school drinking moderated the effects of PFI and BMI at the 4-month follow-up but not at the 15-month follow-up. Specifically, students who reported no drinking in their senior year of high school consumed a 49% higher mean number of drinks after receiving BMI than PFI at the 4-month follow-up. The results suggest that alcohol consumption in high school may be informative when screening and allocating students to appropriate alcohol interventions to meet their different needs.