Brief Alcohol Interventions for College Students and At-Risk Populations Jennifer Cadigan, M.A. Department of Educational, School, and Counseling Psychology University of Missouri Outline • Review research on prevalence of harmful alcohol use/risk factors, focus on college students • Discuss concept of “brief interventions” • Brief motivational interventions (BMI) • Personalized drinking feedback interventions • Provide an example of content from an intervention • Personalized feedback interventions for other at-risk groups Prevalence of Alcohol Use • 80% of college students consume alcohol (O’Malley & Johnson, 2002) • 20% of college students met criteria for alcohol abuse or dependence (Dawson et al., 2004) • Binge drinking (heavy episodic drinking) • Has historically been defined as 5+ drinks for men or 4+ drinks for women in one “sitting” • “Binge” drinkers more likely to experience problems as a result of alcohol use • 41% of men and 34% of women reported heavy drinking (binge drinking) within the past 2 weeks (White et al., 2006) Harmful Alcohol Use • Heavy alcohol use has been considered the primary public health concern among college students (Wechsler, Lee, Kuo & Lee, 2000) • Approximately: • 1,800 deaths • 599,000 injuries • 646,000 assaults • 97,000 sexual assaults related to alcohol use each year among college students (Hingson, Zha, & Weitzman, 2009) Alcohol-Related Problems • Heavy drinking - > more alcohol-related problems (Wechsler et al., 2000, 2002) • • • • • Among students who used alcohol… 35% did something later regretted 27% blacked out 7% trouble with police/authorities 21% unplanned sexual activity • physical injury • poor academic performance • felt sick • argument or fight • operating a car under the influence Alcohol-Related Problems • 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 Greenbaum et al., 2005 Biphasic Effect • Myth that more alcohol is better • Physiological phases • Euphoria; reduce inhibitions (occurs at low BACs and as BAC is initially rising) • Depressant-at high BACs (over .05) and when the BAC curve is descending (after you have finished drinking) • feel tired; slows thinking and reflexes • Alcohol is ultimately a depressant-slows heart-rate and breathing, and these effects are more prominent Slide courtesy http://www.luc.edu BAC • Measure of the amount of alcohol in bloodstream • As BAC , level of intoxication • Influenced by…. • alcohol quantity • • • • • speed of drinking gender- slower for females to process it than males weight food individual variations At-risk groups • College Students • Intercollegiate Athletes • Greek Students College Athletes • Consume more alcohol than those not participating in athletics (Leichliter et al., 1998) • More alcohol-related problems than nonathletes (Leichliter et al., 1998; Nelson & Wechsler, 2001) • arguments or fights, driving while intoxicated, police, hurt or injured while drinking %Binge Drinking 70 60 50 40 Athlete 30 Non-Athlete 20 10 0 Male Female Nelson &Wechsler, 2001; Wechsler et al., 1997 Alcohol Outcomes Non-athletes Athletes 7 Alcohol-Related Problems 2.0 Heavy Drinking 1.8 1.6 1.4 1.2 1.0 Non-athletes Athletes 6 5 4 3 Freshman Year Senior Year Freshman Year Senior Year Cadigan, Littlefield, Martens, & Sher, 2013 Alcohol Outcomes 2.0 Nonathlete Nonathlete 1.4 athlete 1.2 Stop athlete Alcohol-Related Problems Heavy Drinking 1.8 1.6 7 athlete 6 athlete 5 Nonathlete 4 Stop Start 1.0 Nonathlete Start 3 Freshman Year Senior Year Freshman Year Senior Year Cadigan, Littlefield, Martens, & Sher, 2013 Intercollegiate Athletes • Apparent risk factor for problem drinking- athletes show sharper increases in problem drinking • Need for prevention/ intervention efforts for athletes based on their current status (i.e., becoming an athlete vs. stopping) • Psychological and behavioral differences • Increased time constraints, isolated environment on campus, have a higher social status (Harvey, 1999; Parham, 1993) • Anxiety, pressure from teammates, athletic culture (Martens, 2012) Brief Motivational Interventions (BMI) The Need for 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 Harm Reduction Approach • Differ from zero-tolerance/abstinence based programs “emphasize the positive aspects of using alcohol” AND “lessen negative consequences of alcohol” (Marlatt, 1998) Moderation or abstinence goals Intervention Response Spectrum None Mild Moderate Thresholds for Action Severe Specialized Treatment Brief Intervention Primary Prevention Slide courtesy of the Addictive Behaviors Research Center, University of Washington, adapted from the Institute of Medicine Motivational Interviewing and Brief Interventions • Many brief interventions are delivered in a Motivational Interviewing (MI) based format • 1-2 sessions; 15-50 mins • MI defined as: “A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, p. 25) • MI promotes a nonconfrontational and collaborative discussion • Goal-directed • Key aspects of MI: • Recognizes ambivalence regarding changing behaviors • 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) • MI interventions involve: • Expressing empathy of the client’s behaviors, attitudes, etc. • Developing discrepancy between current behavior and goals • Supporting self-efficacy for change (e.g., helping interested clients set goals) • Open ended questions- “How does your alcohol use fit with your career goals?” • Affirmations- “You’ve tried very hard to cut down” • Summary- “What I’ve heard Is.....Is that right?” BMI Structure • 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 • Feedback example • Session may conclude with goal setting or other discussions regarding plans for behavior change • Decisional Balance Exercises • Ask the client to address both the positive and negative aspects of his/her behavior in question • Can directly get at some of the reasons for change in the early part of the session Facilitator: “I’m wondering if we can just start out with you explaining to me what it is you enjoy about drinking, as well as the things that you don’t enjoy about it.” BMI Structure • 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 • Feedback example • Session may conclude with goal setting or other discussions regarding plans for behavior change Personalized Feedback • Commonly used as a strategy for reducing alcohol use and related problems among college students (Carey et al., 2012) • Exact components of feedback can vary among interventions • Typically include: • social norms comparisons (e.g., how a student’s typical drinks per week compares to campus norms/age/gender norms, often expressed as a percentile rank) • feedback on alcohol use (e.g., self-reported BAC levels and consequences typically associated with such levels) • alcohol-related problems experienced over some time interval • calories consumed from alcohol Personalized Feedback Example pg. 1 Personalized Feedback Example pg. 2 Personalized Feedback Example pg. 3 Personalized Feedback Example pg. 4 Personalized Feedback Example pg. 5 Personalized Feedback Example pg. 6 Brief Interventions • Brief alcohol interventions that include personalized feedback about one’s alcohol-use and related-problems have been efficacious in reducing use and consequences (Carey, Scott-Sheldon, Elliott, Garey, & Carey, 2012) • Interventions aim to change alcohol use by developing a discrepancy between one’s actual and desired behaviors (Miller & Rollnick, 2002) • Personalized Feedback Interventions are considered a core component of alcohol interventions Targeted interventions • For whom? • Drinking norms for specific reference group • “Typical” College Student • • • • • Athletes Greek Demographic Group Age Gender Delivery Modality • Traditionally Personalized Feedback Interventions have been delivered: • in-person • typically include MI component • mail • computer • In-person and computer-based /mailed PFIs have resulted in a significant reduction of alcohol use when compared to control conditions (Larimer et al., 2007; Lewis et al., 2007; Neighbors et al. 2004) Research Findings • 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 + Personalized Drinking Feedback (PDF) Monti et al., 1999, Journal of Consulting and Clinical Psychology • At 6-month follow-up, those in the control condition: • Were 4x as likely to report drinking and driving and experiencing an alcohol-related injury than those in the MI + PDF group • Reported more alcohol-related problems • Reported greater drinking levels MI + Personalized Drinking Feedback Summary • MI can be effective at changing behaviors across a variety of domains • MI interventions can be delivered by a wide array of health professionals • MI interventions can be effectively combined with other behavioral approaches • “Very brief” MI-inspired approaches may also be effective at changing behavior Personalized Drinking Feedback (PDF) Interventions Computer/mailed PDF • Cost effective- don’t require a trained clinician • Ease of dissemination • Have been shown to be more effective than control conditions and/or as effective as in-person interventions in several clinical trials (e.g., Larimer et al., 2007; Neighbors et al. 2004) Personalized Drinking Feedback • Personalized drinking feedback-only (PDF) intervention targeted specifically toward college athletes (Martens et al., 2010) • No MI component (no clinician contact) • N = 263 • Randomized to one of three conditions: • PDF-targeted • PDF-standard • Education-only PDF Targeted PDF standard • Review of weekly drinking pattern • Comparison of personal drinking to norm for typical college athlete • Estimated BAC /risks associated for peak drinking over past 30 days, typical weekend drinking, and drinking the last time partied • Stated motivations for drinking • General alcohol-related problems • Calories per week from alcohol • Financial costs of alcohol • Use of protective behaviors • Review of weekly drinking pattern • Comparison of personal drinking to norm for typical college student • Estimated BAC and risks associated with it for peak drinking over past 30 days, typical weekend drinking, and drinking the last time partied • Stated motivations for drinking • General alcohol-related problems • Calories per week from alcohol • Financial costs of alcohol • Use of protective behaviors • Sport-specific alcohol-related problems • Possible impact of alcohol use on athletic performance • Possible impact of alcohol use on athletic injury Martens et al. (2010) Six-Month Peak BAC-Full Sample 0.12 0.1 0.08 PDF-Targeted 0.06 PDF-Standard EO 0.04 0.02 0 Baseline Six-Month Martens et al. (2010) Six Month Peak BAC-Heavy Drinkers 0.25 0.2 0.15 PDF-Targeted PDF-Standard 0.1 EO 0.05 0 Baseline Six-Month Martens et al. (2010) Personalized Drinking Feedback Interventions For Other At-Risk Populations OEF/OIF Veterans • Afghanistan: Operation Enduring Freedom (OEF) • Iraq: Operation Iraqi Freedom (OIF) • Veterans report higher levels of alcohol use than non-veterans (Wagner et al., 2007) • Rates of alcohol misuse among OEF/OIF veterans twice the rates of the general VA outpatient population (Calhoun et al., 2008) • At risk for PTSD/other mental health concerns • Harry S Truman VA Memorial Hospital, Columbia, MO • N = 325 • Randomized to one of two conditions: • computer delivered Personalized Drinking Feedback intervention in preventing hazardous alcohol use and alcohol-related problems among OEF/OIF veterans • Education-only Baseline 1 Month 6 Month • • • • Average age: 32 yrs old (range 20-54 yrs old) 93% Male 82% White; 9% African-American Occupation: 30% Students Branch 6% 5% 14% Army Marines 75% Air Force Navy • Content of PDF intervention included: • How one’s drinking compares to typical drinking of the same gender, same age adult in the United States • BAC • Alcohol-related problems • OEF/OIF veterans drinking norms • Mental health problems (i.e., depression and anxiety) and possible association with alcohol use • Cost • Calories Personalized Feedback Summary • Data collection from Project Transition ongoing… initial results promising • Personalized feedback alone is effective in drinking reduction in general population and student samples (Riper et al., 2009; Walters & Neighbors, 2005) • Both in-person and computer personalized feedback better than control conditions Future Directions • Emerging technology • Cell phones/apps • Ecological Momentary Assessment (EMA) • “real time” • Targeted interventions Concluding Thoughts • Brief interventions (MI + PDF; PDF only) 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 Acknowledgments • Matthew Martens, Ph.D. Questions? Additional Personalized Feedback Information • For students who endorse using both alcohol + other drugs