Brief Interventions for Unhealthy Alcohol Use

1. Brief Interventions for Unhealthy Alcohol Use Matthew P. Martens, Ph.D. University of Missouri

2. A little bit about myself…

3. Purpose of this Presentation: • Review research on prevalence of harmful alcohol use, including a focus on college students • Discuss concept of “brief interventions” • Provide an example of content from a brief intervention • Review research on brief interventions

4. Prevalence of Harmful Alcohol Use • Almost 10% of the adult population will meet criteria for alcohol abuse or dependence in a given year • Those with alcohol use disorders are more likely to be diagnosed with mood and personality disorders • Women with alcohol use disorders are more likely to be diagnosed with a bulimia • Estimated costs of these disorders are over $300 million annually Grant et al., 2004a, Drug and Alcohol Dependence; 2004b; c, Archives of General Psychiatry; Dansky et al., 2000, International Journal of Eating Disorders ; Harwood, 1998, NIH Publication # 98-4327; Rice, 1999, Proceedings of the Association of American Physicians

5. Harmful Alcohol Use Among College Students • Almost 20% of college students will meet past-year diagnostic criteria for alcohol abuse or dependence • College students drink more than non-college attending peers • Approximately 1,800 deaths, 599,000 injuries, 646,000 assaults, and 97,000 sexual assaults related to alcohol use each year among college students Dawson et al., 2005, Drug and Alcohol Dependence; Hingson et al., 2009, Journal of Studies on Alcohol and Drugs

6. Somewhere around 40% of college students report “binge” drinking in the preceding two weeks • Has historically been defined as 5+ drinks for men and 5+ or 4+ drinks for women in one “sitting” • “Binge” drinkers more likely to experience problems as a result of alcohol use • Among students who used alcohol, as a result of their drinking… • 35% did something later regretted • 21% engaged in unplanned sexual activities • 7% got into trouble with police/authorities • 27% blacked out Johnston et al., 2009, NIH Publication # 09-7403; Weschsler et al., 2002, Journal of American College Health

7. As a result of other students’ drinking… • 29% of college students were insulted/humiliated • 15% had property damaged • 20% experienced an unwanted sexual advance • 9% were assaulted • Certain subgroups of college students drink more than others • Fraternity/Sorority members • Athletes Martens et al., 2006, Journal of Substance Abuse Treatment; Meilman et al., 1999, Journal of American College Health; Nelson & Weschlser, 2001; Medicine and Science in Sports and Exercise; Weschsler et al., 2002, Journal of American College Health

8. What are “Brief Interventions?” • Historically, alcohol treatment involved 12-step programs or some type of inpatient program • Intensive treatment may not be appropriate for all those experiencing alcohol-related risks • Unmotivated/non-treatment seeking individuals • Individuals experiencing relatively mild/moderate risks

9. Spectrum of Intervention Response None Mild Moderate Severe Thresholds for Action Specialized Treatment Brief Intervention Primary Prevention Slide courtesy of the Addictive Behaviors Research Center, University of Washington, adapted from the Institute of Medicine

10. Motivational Interviewing and Brief Interventions • Many brief interventions are delivered in a MI-based format • MI defined as:“A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25)

11. Key aspects of MI: • Recognizes ambivalence regarding changing behaviors • Compare this to more proscriptive approaches • Working collaboratively with a client • Helping clients verbalize their own reasons for change • Respecting client autonomy (e.g., a decision not to engage in change)

12. MI interventions involve: • Expressing empathy, or a genuine understanding of the client’s behaviors, attitudes, etc. • Developing discrepancy between current behavior and goals, aspirations, etc. • Key for eliciting change talk • Rolling with client resistance • Keep in mind that MI recognizes ambivalence about change as being normal • Supporting self-efficacy for change (e.g., helping interested clients set goals)

13. MI + Personalized Drinking Feedback • Well-studied intervention among college students • Core of the intervention involves delivering personalized feedback about one’s drinking behaviors in the context of a MI-based intervention • Feedback can help facilitate aspects of MI interventions, especially developing discrepancy • Most common model involves a single, 50 minute session Carey et al., 2006; Journal of Consulting and Clinical Psychology; Marlatt et al., 1998, Journal of Consulting and Clinical Psychology; Walters et al., 2009; Journal of Consulting and Clinical Psychology

14. Intervention may begin with brief orientation and/or decisional balance exercise • Core of the session involves covering personalized drinking feedback that is based on the client’s response to different questionnaires • Session may conclude with goal setting or other discussions regarding plans for behavior change • Feedback example:

15. Some researchers have examined the efficacy of just providing the personalized feedback (i.e., no one-on-one clinician contact) • Advantages involve ease of implementation and cost-effectiveness • Studies have also examined brief interventions in medical settings • Include components such as a brief meeting with a health care worker, brief physician advice, phone calls from nursing staff, and/or workbooks and personalized information • Some are as brief as 5-10 minutes Crawford et al., 2004; Lancet; Fleming et al., 1997; JAMA; Fleming et al., 2002; Alcoholism: Clinical and Experimental Research; Larimer et al., 2007, Journal of Consulting and Clinical Psychology; Martens et al., in press, Psychology of Addictive Behaviors; Murphy et al., 2004, Journal of Studies on Alcohol; Reiff-Hekking et al., 2005, Journal of General Internal Medicine

16. Research on Brief Interventions • Some studies have shown that briefer treatments are as effective as longer treatments • One well-known study found that four sessions of MI-based therapy yielded the same effects as 12 sessions of CBT or 12 sessions of 12-step therapy • Overall, meta analyses have showed that brief in-person interventions are effective at reducing alcohol use in a variety of populations Bertholet et al., 2005, Archives of Internal Medicine; Burke et al., 2003, Journal of Consulting and Clinical Psychology; Larimer & Cronce, 2009, Addictive Behaviors; Project Match Research Group, 1997, Journal of Studies on Alcohol

17. Example Studies • Project TrEAT • Adult patients asked to complete health questionnaire in their physician’s office (n = 774 in the trial) • Those who screened positive (14+ drinks/week for men; 11+drinks/week for women) eligible for the study • Control condition included a general health booklet • Treatment condition included booklet plus two 15 minute counseling sessions with physician and two 5 min phone calls with a nurse • Counseling session included a personalized workbook, review of adverse drinking effects, and drinking prescription from the physician Fleming et al., 1997, JAMA; 2002, Alcoholism: Clinical and Experimental Research

18. Treatment group reduced drinking from about 20 drinks/week to about 12 drinks per week at 6-month follow-up • Control group reduced drinking to about 15 drinks per week at 6-month follow-up • Differences were maintained at 48 month follow-up • Similar differences on other outcome variables (e.g., binge drinking) • Economic benefits associated with the intervention included greater medical savings in the treatment group and greater motor vehicle event savings • $712 in Medical Savings per patient • $7,171 in Motor Vehicle Event Savings per patient

19. Study of adolescents in an emergency room setting • Subjects were 94 older adolescents (18-19) who were “alcohol positive” when receiving ER treatment • Control condition was standard care • Handout on alcohol-related dangers • List of treatment services • Experimental condition was brief MI session + PDF Monti et al., 1999, Journal of Consulting and Clinical Psychology

20. At 6-month follow-up, those in the control condition: • Were four times as likely to report drinking and driving and experiencing an alcohol-related injury than those in the experimental group • Reported more alcohol-related problems • Reported greater drinking levels

21. “The BASICS Study” • Subjects were 348 entering first-year college student who were “high-risk” drinkers • Control group was assessment-only • Experimental group was single-session MI + PDF • Subjects in the experimental group reported less drinking and fewer alcohol-related problems at 2-year follow-up than those in the control group • Effects were modest: • 4.0 vs. 3.6 drinks per drinking occasion • 4.7 vs. 3.3 alcohol-related problems Marlatt et al., 1998, Journal of Consulting and Clinical Psychology

22. PDF-only intervention • Subjects were 1,488 college students • No drinking eligibility criteria • Control condition was no treatment • Experimental group received mailed PDF • At one-year follow-up • Experimental group reported less alcohol use than the control group • 4.8 vs. 5.6 drinks per week • No differences in alcohol-related problems Larimer et al., 2007, Journal of Consulting and Clinical Psychology

23. Project TEAM • In the PDF-standard condition participants received “typical” PDF information • In the PDF-targeted condition, participants received standard feedback plus feedback was designed to be especially salient for college athletes • The EO condition also included information specific to college athletes • Results provided some support for the PDF-targeted intervention, particularly in terms of impacting peak BAC Martens et al., in press, Psychology of Addictive Behaviors

24. Six-Month Peak BAC-Full Sample

25. One Month Peak BAC-Heavy Drinkers

26. Six Month Peak BAC-Heavy Drinkers

27. Concluding Thoughts • Brief interventions designed to decrease or prevent excessive alcohol use have been shown to be effective in multiple settings • Effects from these interventions are relatively modest, but… • They can provide “bang for your buck,” in terms of being relatively inexpensive and efficient • May have tremendous cost benefits in certain settings