A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an emergency department

We tested whether a brief motivational interview (MI) would reduce alcohol-related consequences and use among adolescents treated in an emergency department (ED) after an alcohol-related event. Patients aged 13 to 17 years (N = 152) with a positive blood alcohol concentration (BAC) by lab test or self-report were recruited in the ED and randomly assigned to receive either MI or standard care (SC). Both conditions resulted in reduced quantity of drinking during the 12-month follow-up, whereas alcohol-related negative consequences were relatively low and stayed low at follow-up. Adolescents who screened positive for problematic alcohol use at baseline reported significantly more improvement on 2 of 3 alcohol use outcomes (average number of drinking days per month and frequency of high-volume drinking) if they received MI compared with SC. We conclude that brief interventions are recommended for adolescents who present to an ED with an alcohol-related event and report preexisting problematic alcohol use.

What place does naltrexone have in the treatment of alcoholism?

Despite two recent negative trials, most controlled clinical studies have found that when naltrexone is added to substance abuse treatment or counselling, significantly less heavy drinking is done by the patients who are willing to take most of the prescribed naltrexone. Naltrexone also reduces urges to drink and makes any slips back into drinking less pleasant. Therefore, naltrexone can be a useful adjunct to substance abuse counselling or rehabilitation programmes, as one of many tools that clinicians and patients use. However, beneficial effects are limited in scope. Naltrexone mostly does not increase the chance of staying completely abstinent but rather reduces the intensity or frequency of any drinking that does occur. Many alcohol-dependent individuals are medically ineligible or are unwilling to take naltrexone, many who start naltrexone do not continue with it and many who comply with it do not benefit. Compliance is greater for individuals who experience fewer adverse effects and who have stronger beliefs in the benefits of naltrexone, suggesting that clinicians can increase compliance by helping patients to manage adverse effects and by bolstering patients' beliefs in the benefits of naltrexone. Alcohol-dependent individuals who are most likely to benefit from naltrexone seem to be those with close relatives who also had alcohol problems, or who have stronger urges to drink or who are more limited in cognitive abilities. Some individuals may benefit from a higher dose, particularly people with lower blood concentrations of the medication, and individuals who achieve good results may benefit from a longer course of treatment with naltrexone. In these ways, treatment can be targeted to increase the likelihood of beneficial outcomes with naltrexone.

Effects of tobacco deprivation on alcohol cue reactivity and drinking among young adults

Nicotine and alcohol may have common neurobiological mechanisms of reinforcement. Therefore, withholding one substance might result in compensatory increases in self-administration of the other. This laboratory study investigated the effects of brief tobacco deprivation on alcohol cue-elicited urges to drink, corresponding psychophysiological reactions, and alcohol consumption. Young adults (N=78) who were moderate to heavy smokers and drinkers were stratified and randomized to a 2 x 2 design. Participants were either deprived of tobacco for 5 h or not deprived and then exposed to in vivo alcohol or control beverage cues. Subsequently, participants engaged in a taste-rating task as an unobtrusive measure of alcohol consumption. Tobacco deprivation resulted in increased urge to smoke and decreased cardiovascular responses but did not increase alcohol urges or alcohol consumption. Results indicate that brief tobacco deprivation does not result in compensatory increases in alcohol consumption among young moderate to heavy drinkers.

Motivational enhancement and coping skills training for cocaine abusers: effects on substance use outcomes

AIMS

This clinical trial investigated effects of motivational enhancement treatment (MET) and group coping-skills training (CST) tailored for cocaine dependence. Effects of MET were hypothesized to be greater with CST and for less motivated patients.

DESIGN AND INTERVENTIONS

A 2 x 2 design investigated two individual sessions of MET compared to meditation-relaxation (MRT), followed by four group sessions of CST versus drug education (ED), as daily adjuncts to intensive treatment.

SETTING

The substance abuse program provided full-day treatment with a learning-theory and 12-Step orientation.

PARTICIPANTS

Cocaine-dependent patients were recruited.

MEASUREMENTS

Assessment included treatment retention; change in cocaine-related urge, self-efficacy, pros and cons, and motivation; substance use and problems during 12-month follow-up. Findings Of 165 patients, follow-up status is known for 90% (n = 149). Patients in MET with low initial motivation to change reported less cocaine and alcohol relapse and use days and fewer alcohol problems than MET patients with higher initial motivation. MET produced more employment improvement than MRT, with no other significant benefit for MET. Patients with higher motivation had more cocaine use and alcohol problems after MET than MRT. Group CST reduced cocaine and alcohol use during follow-up for women only and reduced alcohol relapse for men and women.

CONCLUSIONS

MET is more beneficial for patients with lower initial motivation than for patients with high initial motivation. CST reduced cocaine and alcohol use for women only and reduced alcohol relapses, in contrast to results with lengthier individual CST.

The Cocaine Effects Questionnaire for patient populations: development and psychometric properties

Outcome effect expectancies are considered a key determinant of behavior in social learning models of substance use. The present study reports the development and psychometric properties of the Cocaine Effects Questionnaire (CEQ-P), designed specifically for use with patients in treatment for substance abuse. Items generated from patients and treatment staff were Likert-rated for frequency by 178 patients in substance abuse intensive day treatment. Seven components were derived and reduced into a 33-item measure with good reliability. The components loaded on two higher order components: positive effects (five scales) and negative effects (two scales). The CEQ-P shows good construct and concurrent validity in comparison with measures of similar constructs and with cocaine use variables. Few gender or racial differences were significant. Greater pretreatment cocaine use was associated with expecting less frequent positive effects and more frequent social withdrawal, consistent with clinical reports of later stage cocaine use. Alternatively, greater urges to use correlated positively with expected positive effects, specifically with expecting enhanced well-being, pain reduction, and sexual enhancement from cocaine. Less cocaine use during the 3-months after intensive treatment was predicted by expecting more negative effects from cocaine pretreatment. The CEQ-P is likely to be useful for both clinical and research purposes. Treatment implications were discussed.

A cognitive-behavioral treatment for incarcerated women with substance abuse disorder and posttraumatic stress disorder: findings from a pilot study

Treatment for comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD) is of particular relevance for incarcerated women, whose rates of PTSD and SUD are considerably higher than women in the general population. Yet virtually no treatments have been developed or systematically evaluated that target concurrently the symptoms of PTSD and SUD in this underserved population. This preliminary study evaluates the initial efficacy of a cognitive-behavioral treatment, Seeking Safety, as an adjunct to treatment-as-usual in an uncontrolled pilot study of incarcerated women with current SUD and comorbid PTSD. Of the 17 incarcerated women with PTSD and SUD who received Seeking Safety treatment and had outcome data, results show that nine (53%) no longer met criteria for PTSD at the end of treatment; at a followup 3 months later, seven (46%) still no longer met criteria for PTSD. Additionally, there was a significant decrease in PTSD symptoms from intake to posttreatment, which was maintained at the 3-month followup assessment. Based on results from a diagnostic interview and results of urinalyses, six (35%) of the women reported the use of illegal substances within 3 months from release from prison. Measures of client satisfaction with treatment were high. Recidivism rate (return to prison) was 33% at a 3-month followup. Overall, our data suggest that Seeking Safety treatment appears to be appealing to incarcerated women with SUD and PTSD and that the treatment has the potential to be beneficial, especially for improving PTSD symptoms. However, these findings are tentative given that there was no control group.

Building Bridges: The Transdisciplinary Study of Craving From the Animal Laboratory to the Lamppost

This article represents the proceedings of a symposium at the 2003 Research Society on Alcoholism meeting in Ft. Lauderdale, Florida, organized and chaired by Peter M. Monti. The presentations and presenters were (1) Alcohol Seeking and Self-Administration in Rats: The Role of Serotonin Activity, by Cristine L. Czachowski; (2) Assessing Binge Drinking in Monkeys, by Kathleen A. Grant; (3) Craving and the Perception of Time, by Michael Sayette; (4) Ecological and Laboratory Assessment of Alcohol Urges and Drinking: Effects of Naltrexone, by Peter M. Monti; and (5) Discussion, by Damaris J. Rohsenow.

The Smoking Effects Questionnaire for adult populations. Development and psychometric properties

Outcome expectancies are central to a social learning model of smoking and of smoking cessation. The Smoking Effects Questionnaire (SEQ) was developed for use in general adult populations. Items were administered to 257 smokers and ex-smokers including worksite employees, hospital visitors, and clients entering smoking cessation treatment. Principal components analysis (PCA) found seven components with good reliability that were reduced into scales of four or five items each with internal consistencies above alpha=.80. The final measure has 33 items. The scales were divided by secondary factor analysis into three negative effect and four positive effect scales. The SEQ showed good construct and concurrent validity in comparison with measures of similar constructs and with other smoking variables. Women expected fewer negative physical effects and attributed more importance to positive stimulating effects from smoking but otherwise were comparable to men in expected effects of smoking. More dependent smokers ascribed more importance to negative physical effects and positive stimulating effects than did less dependent smokers but did not differ significantly on other expectancy domains. Both true/false scoring and importance ratings of effects produced mostly comparable results so that either scoring method could be used. Treatment implications were discussed. This brief scale is likely to be useful in a variety of research and clinical settings.

Alcohol use and related harm among older adolescents treated in an emergency department: the importance of alcohol status and college status

OBJECTIVE

Patients treated in an urban emergency department were studied to determine if college status, gender and having alcohol as a reason for medical treatment were related to alcohol use and related problem behaviors.

METHOD

Patients ages 18-19 years (N = 250; 55% men) who had or had not been drinking alcohol prior to the event that precipitated their medical treatment were assessed on their alcohol use, alcohol-related problems and drug use.

RESULTS

There were high levels of alcohol use, tobacco use and other drug use in the sample, regardless of the reason for medical treatment. Analyses consistently showed that patients treated for alcohol-related reasons had more severe drinking patterns and problems than patients who were alcohol negative. Patients not enrolled in college showed similar patterns of alcohol consumption as their college-attending peers, but bad more severe alcohol-related behaviors and problems. Few gender differences were found and no interactions were found between gender, alcohol status and college status.

CONCLUSIONS

Findings indicate that older adolescents who receive medical treatment for alcohol use are not inexperienced drinkers. Furthermore, in this convenience sample, college students did not appear to be at greater risk for substance use or problems. Findings underscore the potential usefulness of alcohol intervention programs for alcohol-involved medical patients, and the need to attend to the alcohol and drug use of nonstudent populations.

Naltrexone treatment for alcoholics: effect on cigarette smoking rates

Naltrexone (NTX), by its pharmacological action in the mesolimbic pathways, should decrease reinforcement from nicotine as well as from alcohol. By means of this mechanism, NTX could result in temporary increases in smoking followed by decreased smoking rates among alcoholics not motivated to quit smoking. The change from pretreatment in smoking rates of 73 recently abstinent alcoholics in a 12-week clinical trial of NTX vs. placebo during alcoholism treatment was compared during 8 of the 12 weeks. Only smokers compliant with NTX were included in the analyses. NTX was associated with decreased smoking at every time point, but the effect was significant at only one time point. When alcohol relapsers were excluded, NTX patients showed decreased smoking at every time point, but the effect was significant at only two time points, a reduction of about five cigarettes per day. When smoking stage of change was included in the analyses, NTX showed no significant main or interaction effects on smoking rate. Precontemplators showed significantly less change in smoking rate than all other patients at the first and last four time points. Therefore, NTX alone currently does not show promise for promoting smoking reduction among recently abstinent alcoholics who have not sought or been given smoking cessation treatment. Further research is needed on possible effects with smokers motivated to quit smoking and on other methods of promoting smoking cessation among alcoholics.

Perceived barriers to quitting smoking among alcohol dependent patients in treatment

Little is known about the perceived barriers to quitting smoking among alcohol abusers. In addition to the usual barriers perceived by smokers, alcohol dependent smokers may have a few barriers unique to their addictive lifestyle. The Barriers to Quitting Smoking in Substance Abuse Treatment (BQS-SAT) was administered to 96 alcohol dependent smokers in residential substance abuse treatment. The BQS-SAT is designed to assess perceived barriers to quitting smoking among alcohol abusers using eleven true-false items. One open-ended item was included to gather information about potential additional barriers. The majority of respondents reported withdrawal-related barriers such as expecting to feel irritable, anxious, restless, and about half expected intolerable urges to smoke if they were to quit smoking, as most smokers do. However, concerns about effects on sobriety and needing cigarettes to cope with feeling down were also endorsed by almost half of the patients. Total number of perceived barriers was significantly related to smoking history, expected effects from smoking, and smoking temptation but was not associated with severity of alcohol use or dependence on admission. Providing corrective feedback about these barriers could be useful when addressing smoking with patients who have alcohol abuse or dependence.

Potential biases in case detection of alcohol involvement among adolescents in an emergency department

OBJECTIVE

To determine the factors associated with physician decisions to test for alcohol involvement in adolescents treated in an emergency department (ED) and to examine patient and event characteristics associated with being identified as alcohol positive, either by testing or by clinical examination.

METHODS

Medical chart reviews were conducted for all adolescent patients (n = 9,660; age range, 13-19 y) treated over a 1-year period in a Level I regional trauma center/ED.

RESULTS

Among all 9,660 patients in the ED, 298 (3.1%) were identified as alcohol positive by test or clinical examination. Of the 9,660 patients, 464 (4.8%) were tested for alcohol, and 49% of these had alcohol-positive test results. Physicians were more likely to order alcohol tests when patients were male, older, injured, and treated during the overnight shift or on weekends. Testing was most common for suicide attempts, motor vehicle crashes, assaults, and intoxication. Patients being treated for an illness or for occupational or athletic injuries were rarely tested. A large proportion of alcohol-related treatment was for intoxicated, uninjured patients, whose profile was different (ie, younger, more often female, with higher blood alcohol concentrations, and admission distributed more evenly across ED shifts).

CONCLUSIONS

Case detection rates for alcohol involvement may be biased and inflated when based on physician decisions to test for alcohol use. Rates based on comprehensive chart reviews and clinical examination may be better estimates but are also subject to methodologic limitations. Universal screening would yield the most accurate estimates of alcohol prevalence and would provide more accurate guidance to physicians regarding when to test for alcohol use. Universal screening as a clinical standard would help to identify more adolescents who might benefit from additional alcohol use intervention.

Depressive symptoms and readiness to quit smoking among cigarette smokers in outpatient alcohol treatment

The authors examined whether length of alcohol abstinence and depressive symptoms were related to motivational readiness to consider smoking cessation among patients in alcohol treatment. Participants were adults (N = 253) enrolled in a smoking cessation trial. Controlling for gender, depressive symptoms, and nicotine dependence, hierarchical regression analysis of readiness scores revealed a significant interaction of days since last drink and depressive symptoms. It was found that a greater number of days since last drink was associated with greater readiness, but only among patients with low scores on the Center for Epidemiologic Studies Depression Scale (L. S. Radloff, 1977). The findings suggest that alcoholic smokers with low depressive symptoms are more receptive to quitting smoking after sustained alcohol abstinence.

Predictors of motivation to change after medical treatment for drinking-related events in adolescents

Characteristics associated with intention to change drinking were examined in 254 adolescents treated in an emergency department for alcohol. Younger age, living at home, lower baseline level of drinking and drinking problems, greater depression, having penalties for breaking family drinking rules, higher injury severity, being frightened, and being admitted to the hospital predicted greater intention to change drinking at the time of the event. Baseline characteristics related to being in the action stage of change 3 months later were younger age; lower drinking; having penalties for breaking family drinking rules; injury severity; and number of anticipated consequences, including being in trouble with parents. This study has implications for brief interventions that capitalize on potential teachable moments with problem-drinking adolescents.

Does alcohol use mediate the association between alcohol evaluations and alcohol-related problems in adolescents?

Alcohol use becomes more frequent during adolescence, with the percentage of youth who drink doubling from 8th grade to 12th grade. The escalation in drinking behavior during adolescence is often associated with increased problems and other risk behavior, such as drunk driving. In this study, adolescents (N = 557) were recruited from an emergency department to assess their alcohol use, positive and negative evaluations about alcohol, driving after drinking, and problems experienced from drinking. Analyses explored the mediational role of drinking behavior between adolescents' evaluations and problems from drinking and between evaluations and driving after drinking. The findings indicated that drinking behavior partially mediated the association between positive evaluations and problems experienced from drinking but did not mediate the association between evaluations and drunk driving.

Using acquired knowledge and new technologies in alcoholism treatment trials

This article represents the proceedings of a symposium held at the 2001 RSA meeting in Montreal, Canada. The organizer and chair was Barbara A. Flannery and the discussant was Raye Z. Litten. The presentations were (1) The use of biomarkers in alcohol-dependence treatment trials, by John P. Allen; (2) Strategies for enhancing patient compliance in clinical treatment trials, by Helen M. Pettinati; (3) The predictive utility of an alcohol-craving measure, by Barbara A. Flannery; (4) What should be the primary outcome measures in a clinical trial, by Damaris J. Rohsenow; (5) Innovative strategies for assessing functional outcomes in alcoholism treatment clinical trials, by Ron A. Cisler.

Response distortion in adolescents who smoke: a pilot study

A wide range of data are obtained with self-report. Information obtained from persons using substances is generally reliable and valid, however, many studies show that some proportion of self-reports regarding substance use are inaccurate. This study examines self-reported response distortion in adolescents who received a brief intervention to reduce their smoking. Findings indicate that age and ethnicity of respondent may influence reported response distortion. Factors that appear to influence under- and over-reporting include social desirability and fear of repercussion. Response distortion does not appear to affect rated usefulness of the intervention, nor does intervention type appear to influence whether respondents thought the researcher wanted them to report less use. Results point to the need for further research regarding adolescents and response distortion.

Naltrexone and cue exposure with coping and communication skills training for alcoholics: treatment process and 1-year outcomes

BACKGROUND

Promising treatments for alcoholics include naltrexone (NTX), cue exposure combined with urge-specific coping skills training (CET), and communication skills training (CST). This study investigated the effects of combining these elements as treatment adjuncts.

METHODS

A 2 x 2 design investigated the effects of CET combined with CST, as compared with an education and relaxation control treatment, during a 2-week partial hospital program (n = 165) followed by 12 weeks of NTX (50 mg/day) or placebo during aftercare (n = 128). Drinking outcomes were assessed at 3, 6, and 12 months after discharge from the partial hospital. Process measures included urge, self-efficacy (confidence about staying abstinent in risky situations), and self-reported coping skills. Medically eligible alcohol-dependent patients were recruited.

RESULTS

Among those compliant with medication on at least 70% of days, those who received NTX had significantly fewer heavy drinking days and fewer drinks on days that they drank than those receiving placebo during the medication phase but not during the subsequent 9 months. CET/CST-condition patients were significantly less likely to report a relapse day and reported fewer heavy drinking days at the 6- and 12-month follow-ups than patients in the control treatment. Interactions of medication with behavioral treatments were not significant. Process measures showed that NTX resulted in lower weekly urge ratings, and those in CET/CST used more of the prescribed coping skills after treatment, reported fewer cue-elicited urges, and reported more self-efficacy in a posttest role-play test. Drinking reductions at 3, 6, and 12 months correlated with more use of coping skills, lower urge, and higher self-efficacy.

CONCLUSIONS

The results suggest the probable value of keeping alcoholics on NTX for longer periods of time and the importance of increasing compliance with NTX. They also support the earlier promising effects of CET and CST as adjuncts to treatment programs for alcoholics by maintaining treatment gains over at least a year. The value of the urge-specific and general coping skills and of self-efficacy and urge constructs was demonstrated in their association with drinking outcomes.

Risks associated with alcohol-positive status among adolescents in the emergency department: a matched case-control study

OBJECTIVE

The purpose of this study was to examine alcohol use, alcohol-related problems, other risk-taking behaviors, and parental monitoring in adolescents who tested positive for alcohol in an emergency department.

STUDY DESIGN

A matched case-control design was implemented for adolescents presenting to a pediatric emergency department who were screened for alcohol use. An alcohol-positive sample (N = 150) was compared with a matched alcohol-negative sample (N = 150) for alcohol use, alcohol problems, depression, smoking, risk-taking behavior, and parental monitoring.

RESULTS

The alcohol-positive group reported significantly higher drinking frequency, drinking problems, prior alcohol-related injuries, and episodes of driving after drinking and riding with a drinking driver than the alcohol-negative adolescents. The same pattern was true for depressed mood, reckless behaviors, poor grades in school, and daily smoking. The parents of alcohol-positive teens reported their teens had come home intoxicated more often than parents of alcohol-negative teens. There were no differences between parent groups in monitoring of teens.

CONCLUSION

Adolescents who test positive for alcohol in an emergency department are a high-risk group who meet the criteria for indicated prevention. Screening for alcohol abuse is recommended.