Brief Alcohol Interventions for College Students and At-Risk Populations

Jennifer Cadigan, M.A.

Department of Educational, School, and Counseling PsychologyUniversity 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 non-athletes (Leichliter et al., 1998; Nelson & Wechsler, 2001)• arguments or fights, driving while intoxicated,

police, hurt or injured while drinking

%Binge Drinking

Male Female0

10

20

30

40

50

60

70

AthleteNon-Athlete

Nelson &Wechsler, 2001; Wechsler et al., 1997

Alcohol Outcomes

Freshman Year

Senior Year1.0

1.2

1.4

1.6

1.8

2.0Non-athletes Athletes

Hea

vy D

rinki

ng

Freshman Year Senior Year3

4

5

6

7Non-athletes Athletes

Alco

hol-R

elat

ed P

robl

ems

Cadigan, Littlefield, Martens, & Sher, 2013

Alcohol Outcomes

Freshman Year Senior Year1.0

1.2

1.4

1.6

1.8

2.0

Stop Start

Hea

vy D

rinki

ng

Freshman Year

Senior Year3

4

5

6

7

Stop Start

Alco

hol-R

elat

ed P

robl

ems

Cadigan, Littlefield, Martens, & Sher, 2013

athleteathlete

athlete

athleteNon-athlete

Non-athlete

Non-athlete

Non-athlete

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

Specialized

Treatment

Primary

Prevention

Brief

Intervention

None

Mild

Moderate

SevereThresholds for Action

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)

• 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

Research Findings

• 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

Martens et al. (2010)

• Sport-specific alcohol-related problems

• Possible impact of alcohol use on athletic performance

• Possible impact of alcohol use on athletic injury

Six-Month Peak BAC-Full Sample

Baseline Six-Month0

0.02

0.04

0.06

0.08

0.1

0.12

PDF-TargetedPDF-StandardEO

Martens et al. (2010)

Six Month Peak BAC-Heavy Drinkers

Baseline Six-Month0

0.05

0.1

0.15

0.2

0.25

PDF-TargetedPDF-StandardEO

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

75%

14%

6% 5%

Branch

ArmyMarinesAir ForceNavy

• 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