Do risky friends change the efficacy of a primary care brief intervention for adolescent alcohol use?

Computer-Facilitated Screening and Brief Intervention for Alcohol Use Risk in Adolescent Patients of Pediatric Primary Care Offices: Protocol for a Cluster Randomized Controlled Trial

BACKGROUND

Alcohol and other substance use disorders usually begin with substance use in adolescence. Pediatric primary care offices, where most adolescents receive health care, are a promising venue for early identification of substance use and for brief intervention to prevent associated problems and the development of substance use disorder.

OBJECTIVE

This study tests the effects of a computer-facilitated screening and brief intervention (cSBI) system (the CRAFFT [Car, Relax, Alone, Forget, Family/Friends, Trouble] Interactive System [CRAFFT-IS]) on heavy episodic drinking, riding with a driver who is substance impaired, or driving while substance impaired among adolescents aged 14 to 17 years presenting for a well visit at pediatric primary care practices.

METHODS

We are conducting a cluster randomized controlled trial of the CRAFFT-IS versus usual care and recruiting up to 40 primary care clinicians at up to 20 pediatric primary care practices within the American Academy of Pediatrics (AAP) Pediatric Research in Office Settings network. Clinicians are randomized 1:1 within each practice to implement the CRAFFT-IS or usual care with a target sample size of 1300 adolescent patients aged 14 to 17 years. At study start, intervention clinicians complete web-based modules, trainer-led live sessions, and mock sessions to establish baseline competency with intervention counseling. Adolescents receive mailed recruitment materials that invite adolescents to complete an eligibility survey. Eligible and interested adolescents provide informed assent (parental permission requirement has been waived). Before their visit, enrolled adolescents seeing intervention clinicians complete a self-administered web-based CRAFFT screening questionnaire and view brief psychoeducational content illustrating substance use-associated health risks. During the visit, intervention clinicians access a computerized summary of the patient's screening results and a tailored counseling script to deliver a motivational interviewing-based brief intervention. All participants complete previsit, postvisit, and 12-month follow-up study assessments. Primary outcomes include past 90-day heavy episodic drinking and riding with a driver who is substance impaired at 3-, 6-, 9-, and 12-month follow-ups. Multiple logistic regression modeling with generalized estimating equations and mixed effects modeling will be used in outcomes analyses. Exploratory aims include examining other substance use outcomes (eg, cannabis and nicotine vaping), potential mediators of intervention effect (eg, self-efficacy not to drink), and effect moderation by baseline risk level and sociodemographic characteristics.

RESULTS

The AAP Institutional Review Board approved this study. The first practice and clinicians were enrolled in August 2022; as of July 2023, a total of 6 practices (23 clinicians) had enrolled. Recruitment is expected to continue until late 2024 or early 2025. Data collection will be completed in 2025 or 2026.

CONCLUSIONS

Findings from this study will inform the promotion of high-quality screening and brief intervention efforts in pediatric primary care with the aim of reducing alcohol-related morbidity and mortality during adolescence and beyond.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04450966; https://www.clinicaltrials.gov/study/NCT04450966.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55039.

Perceived Risk of Harm Mediates the Effects of Primary Care Alcohol Use Screening and Brief Advice in Adolescents

PURPOSE

A previous trial found lower alcohol use risk during follow-up among adolescent primary care patients receiving computer-facilitated Screening and provider Brief Advice (cSBA) compared to treatment-as-usual (TAU). We tested whether the effect was mediated by alcohol-related perceived risk of harm (PRoH).

METHODS

We analyzed data from the cSBA trial on 12- to 18-year-old patients at 9 New England practices (n = 2,096, 58% females). The trial used a quasi-experimental pre-post design with practices being their own controls (TAU followed by cSBA). Because prior alcohol experience could modify effects, we stratified analyses by baseline past 12-month drinking. Among baseline nondrinkers, we tested baseline to 3-month trajectories in PRoH of "trying alcohol" as an effect mediator for drinking at 3- and 12-month follow-up. Similarly, among those with prior drinking, we examined baseline to 3-month trajectories in PRoH of "weekly binge drinking" as an effect mediator for drinking and binge drinking. We used the Hayes product of coefficients mediation approach.

RESULTS

Among baseline nondrinkers (n = 1,449), cSBA had higher PRoH compared to TAU for "trying alcohol," and higher PRoH in turn was associated with lower follow-up drinking risk. PRoH mediated their cSBA effect at 12 months, but not 3 months. Among adolescents with prior drinking (n = 647), cSBA had higher PRoH for "weekly binge drinking," which was associated with lower drinking risk at both follow-ups, and lower binge drinking risk at 3 months. PRoH mediated their cSBA effect on drinking at both follow-ups, and binge drinking at 3 months.

CONCLUSION

A computer-facilitated primary care intervention enhanced adolescents' perceived alcohol risks which in turn was associated with lower drinking risk.

Trajectories of Religious Change From Adolescence to Adulthood, and Demographic, Environmental, and Psychiatric Correlates

Studies of religiosity and mental health largely characterize religiousness as stable over time. However, research shows that religiosity likely changes significantly with development. It is unclear whether associations of religiosity with mental health also change over the lifespan. Latent growth curves were created to quantify changes in multiple religious variables, identify associated psychosocial variables, and observe relationships between religiosity and mental health from adolescence to adulthood. Analyses used four waves of data from over 9000 subjects, from ages 12 to 34 years. Although religious service attendance decreased over time, the importance of religion increased and the frequency of prayer remained relatively stable. Baseline religiosity and changes over time were related to contextual variables including race, socioeconomic status, and peer substance use. Correlations with mental health varied over time. Religiosity should be conceptualized as multidimensional and dynamic; religion/health research should consider the impact of multiple psychosocial variables as well as bidirectional relationships with mental health.

Changes in Community Integration From Pre- to Post-incarceration: The Influence of Psychological and Criminal Justice Factors

Research on changes in community integration from pre- to postincarceration has primarily focused on employment and is mixed, showing both deterioration and improvement. Research is needed to examine change in other areas, as well as predictive individual-level factors. We assessed changes in jail inmates' (n = 334) employment, source of income, residential stability, marital status, and volunteerism from pre- to post-incarceration, and analyzed individual-level predictors of change. On average, more inmates improved than deteriorated in community integration, with education and low criminal thinking predicting the greatest improvement. Across multiple areas, inmates' community integration does not appear to deteriorate from pre- to post-incarceration. Apparent improvements may reflect that people become incarcerated during times of crisis, regressing to baseline by 1 year postrelease.

When and How Do Brief Alcohol Interventions in Primary Care Reduce Alcohol Use and Alcohol-Related Consequences among Adolescents?

OBJECTIVE

To systematically describe when and how brief alcohol interventions delivered to adolescents in primary care settings reduce alcohol use and alcohol-related consequences among adolescents, using realist review methodology.

STUDY DESIGN

Eleven electronic databases, gray literature, and reference screening were searched up to June 2016; 11 brief interventions published in 13 studies met inclusion criteria. Intervention design components (delivery context and intervention mechanisms) underlying brief alcohol interventions for adolescents were extracted and linked to alcohol use and related consequences.

RESULTS

Brief interventions had either an indicated context of delivery (provided to adolescent patients with low-to-moderate risk for alcohol problems) or universal context of delivery (provided to general adolescent patient population). Interventions that used motivational interviewing in an indicated delivery context had 2 potential mechanisms-eliciting and strengthening motivation to change and providing direction through interpretation. These interventions resulted in clinically significant reductions in alcohol use and associated consequences. Peer risk also was identified among universal and indicated brief interventions as a potential mechanism for changing alcohol-related outcomes among adolescents who received the intervention. None of the studies tested the processes by which interventions were expected to work.

CONCLUSIONS

The current evidence base suggests that both indicated and universal delivery of brief alcohol interventions to adolescents in primary care settings can result in clinically important changes in alcohol-related outcomes. Studies that test brief intervention processes are now necessary to better understand how brief interventions work with adolescents in primary care settings.

Peer Network Counseling with Urban Adolescents: A Randomized Controlled Trial with Moderate Substance Users

Close peer networks can affect adolescents' health behaviors by altering their social environments, and thus their risk for and protection against substance use involvement. We tested a 20 minute intervention named Peer Network Counseling that integrates motivational interviewing and peer network strategies with 119 urban adolescents who reported occasional or problem substance use. Adolescents presenting at primary care clinic were randomized to intervention or control conditions and followed for 6 months. Mixed-effect latent growth models were used to evaluate intervention effects on trajectories of alcohol and marijuana use, offers to use substances, and moderation models to test for interactions between intervention condition and peer network characteristics. A significant intervention effect was found for boys for offers to use alcohol from friends (p<.05), along with a trend significant effect for alcohol use (p<.08). Intervention was more effective in reducing marijuana use, vs. control, for participants with more peer social support (p<.001) and with more peer encouragement for prosocial behavior (school, clubs, sports, religious activities); however, intervention did not affect these network characteristics. Results provide support to continue this line of research to test brief interventions that activate protective peer network characteristics among at-risk adolescents, while also raising some interesting gender-based intervention questions for future research.

Putting the Screen in Screening: Technology-Based Alcohol Screening and Brief Interventions in Medical Settings

Alcohol is strongly linked to the leading causes of adolescent and adult mortality and health problems, making medical settings such as primary care and emergency departments important venues for addressing alcohol use. Extensive research evidence supports the effectiveness of alcohol screening and brief interventions (SBIs) in medical settings, but this valuable strategy remains underused, with medical staff citing lack of time and training as major implementation barriers. Technology-based tools may offer a way to improve efficiency and quality of SBI delivery in such settings. This review describes the latest research examining the feasibility and efficacy of computer- or other technology-based alcohol SBI tools in medical settings, as they relate to the following three patient populations: adults (18 years or older); pregnant women; and adolescents (17 years or younger).The small but growing evidence base generally shows strong feasibility and acceptability of technology-based SBI in medical settings. However, evidence for effectiveness in changing alcohol use is limited in this young field.