Adolescent alcohol misuse: methodological issues for enhancing treatment research

A sex- and gender-based analysis of alcohol treatment intervention research involving youth: A methodological systematic review

BACKGROUND

While there is widespread consensus that sex- and gender-related factors are important for how interventions are designed, implemented, and evaluated, it is not currently known how alcohol treatment research accounts for sex characteristics and/or gender identities and modalities. This methodological systematic review documents and assesses how sex characteristics, gender identities, and gender modalities are operationalized in alcohol treatment intervention research involving youth.

METHODS AND FINDINGS

We searched MEDLINE, Embase, Cochrane Central Registry of Controlled Trials, PsycINFO, CINAHL, LGBT Life, Google Scholar, Web of Science, and grey literature from 2008 to 2023. We included articles that reported genders and/or sexes of participants 30 years of age and under and screened participants using AUDIT, AUDIT-C, or a structured interview using DSM-IV criteria. We limited the inclusion to studies that enrolled participants in alcohol treatment interventions and used a quantitative study design. We provide a narrative overview of the findings. Of 8,019 studies screened for inclusion, 86 articles were included in the review. None of the studies defined, measured, and reported both sex and gender variables accurately. Only 2 studies reported including trans participants. Most of the studies used gender or sex measures as a covariate to control for the effects of sex or gender on the intervention but did not discuss the rationale for or implications of this procedure.

CONCLUSIONS

Our findings identify that the majority of alcohol treatment intervention research with youth conflate sex and gender factors, including terminologically, conceptually, and methodologically. Based on these findings, we recommend future research in this area define and account for a spectrum of gender modalities, identities, and/or sex characteristics throughout the research life cycle, including during study design, data collection, data analysis, and reporting. It is also imperative that sex and gender variables are used expansively to ensure that intersex and trans youth are meaningfully integrated.

TRIAL REGISTRATION

Registration: PROSPERO, registration number: CRD42019119408.

Binge drinking is associated with altered resting state functional connectivity of reward-salience and top down control networks

Binge drinking is characterized by bouts of high-intensity alcohol intake and is associated with an array of health-related harms. Even though the transition from occasional impulsive to addictive alcohol use is not well understood, neurobiological models of addiction suggest that repeated cycles of intoxication and withdrawal contribute to the development of addiction in part through dysregulation of neurofunctional networks. Research on the neural sequelae associated with binge drinking is scant but resting state functional connectivity (RSFC) studies of alcohol use disorders (AUD) indicate that the development and maintenance of long-term excessive drinking may be mediated by network-level disruptions. The present study examined RSFC in young adult binge (BD) and light (LD) drinkers with seeds representing the networks subserving reward (the nucleus accumbens and caudate nucleus), salience (anterior cingulate cortex, ACC), and executive control (inferior frontal cortex, IFC). BDs exhibited enhanced connectivity between the striatal reward areas and the orbitofrontal cortex and the ACC, which is consistent with AUD studies and may be indicative of alcohol-motivated appetitive behaviors. Conversely, BDs demonstrated lower connectivity between the IFC and hippocampus which was associated with higher craving. This may indicate impaired ability to suppress unwanted thoughts and a failure to employ memory of the harmful consequences of heavy drinking in prospective plans and intentions. The observed greater connectivity of the reward/salience network and the lower prefrontal-hippocampal connectivity were associated with hazardous drinking levels indicating that dysregulation of neurofunctional networks may underlie binge drinking patterns.

Goal commitment predicts cannabis use for adolescents in treatment

Background: Commitment to change is an innovative potential mediator and mechanism of behavior change (MOBC) that has not been examined in adolescents with cannabis use. The Adolescent Substance Abuse Goal Commitment (ASAGC) questionnaire is a reliable and valid 2-scale measure developed to assess the adolescent's commitment to either abstinence or harm reduction model for adolescents, which in addition to decrease in negative consequences includes consumption reduction as a stated treatment goal. The objective of this paper is to examine the ASAGC's ability to predict adolescent substance use treatment outcome. Methods: During Sessions 3 and 9 of a 10-week treatment program, therapists completed the ASAGC for 170 adolescents 13-18 years of age with alcohol use disorders, the majority of whom (82%) were diagnosed with co-occurring cannabis use disorder (CUD). Results: Logistic regression analyses assessing goal commitment regarding cannabis use at Session 3 indicated that commitment to both abstinence and harm reduction predicted cannabis use at Session 3. However, only commitment to abstinence predicted later cannabis use (assessed at Session 9 and during aftercare). When goal commitment at Session 9 was examined, only commitment to abstinence predicted cannabis use, concurrently and longitudinally. These results indicated that adolescents who had higher scores for commitment to abstinence were less likely to be positive for cannabis use. In contrast, harm reduction was not a significant predictor of cannabis use. Conclusions: Findings demonstrate that goal commitment consistently predicts cannabis use treatment outcome. Commitment to abstinence specifically is a salient predictor for concurrent and future cannabis use. Further prospective study is necessary to determine whether harm reduction may be an attainable goal for some youth given normative delayed neurodevelopmental processes of inhibitive behaviors.

Hypermethylation of Proopiomelanocortin and Period 2 Genes in Blood Are Associated with Greater Subjective and Behavioral Motivation for Alcohol in Humans

BACKGROUND

Epigenetic modifications of a gene have been shown to play a role in maintaining a long-lasting change in gene expression. We hypothesize that alcohol's modulating effect on DNA methylation on certain genes in blood is evident in binge and heavy alcohol drinkers and is associated with alcohol motivation.

METHODS

Methylation-specific polymerase chain reaction (PCR) assays were used to measure changes in gene methylation of period 2 (PER2) and proopiomelanocortin (POMC) genes in peripheral blood samples collected from nonsmoking moderate, nonbinging, binge, and heavy social drinkers who participated in a 3-day behavioral alcohol motivation experiment of imagery exposure to either stress, neutral, or alcohol-related cues, 1 per day, presented on consecutive days in counterbalanced order. Following imagery exposure on each day, subjects were exposed to discrete alcoholic beer cues followed by an alcohol taste test (ATT) to assess behavioral motivation. Quantitative real-time PCR was used to measure gene expression of PER2 and POMC gene levels in blood samples across samples.

RESULTS

In the sample of moderate, binge, and heavy drinkers, we found increased methylation of the PER2 and POMC DNA, reduced expression of these genes in the blood samples of the binge and heavy drinkers relative to the moderate, nonbinge drinkers. Increased PER2 and POMC DNA methylation was also significantly predictive of both increased levels of subjective alcohol craving immediately following imagery (p < 0.0001), and with presentation of the alcohol (2 beers) (p < 0.0001) prior to the ATT, as well as with alcohol amount consumed during the ATT (p < 0.003).

CONCLUSIONS

These data establish significant association between binge or heavy levels of alcohol drinking and elevated levels of methylation and reduced levels of expression of POMC and PER2 genes. Furthermore, elevated methylation of POMC and PER2 genes is associated with greater subjective and behavioral motivation for alcohol.

Goal commitment predicts treatment outcome for adolescents with alcohol use disorder

OBJECTIVE

Commitment to change is an innovative potential mediator and mechanism of behavior change (MOBC) that has not been examined in adolescents with substance use disorders (SUD). The Adolescent Substance Abuse Goal Commitment (ASAGC) questionnaire is a reliable and valid 2-scale measure developed to assess the adolescent's commitment to either abstinence or harm reduction (HR) that includes consumption reduction as a stated treatment goal. The objective of this study was to examine the ASAGC's ability to predict alcohol use treatment outcome.

METHOD

During sessions three and nine of a 10-week treatment program, therapists completed the ASAGC for 170 adolescents 13-18years of age with alcohol use disorder (AUD). Drinking behaviors were assessed during and after a continued-care phase until 12-month from study onset.

RESULTS

Analysis of Variance results indicated that adolescents who reported no alcohol use had significantly higher scores on the commitment to abstinence scale than adolescents who reported alcohol use. None of the ANOVA models were significant for commitment to HR. When treatment outcome was examined, commitment to abstinence consistently predicted number of drinking days, number of heavy drinking days, and the maximum number of drinks post-treatment. In contrast, commitment to HR did not predict any of the drinking outcomes. These results suggest that the more adolescents were committed to abstinence during treatment, the less they used and abused alcohol after treatment completion.

CONCLUSIONS

In addition to the ASAGC's ability to differentiate between commitment to abstinence and commitment to HR, study findings demonstrate that goal commitment consistently predicts AUD treatment outcome.

The effect of alcohol consumption on the adolescent brain: A systematic review of MRI and fMRI studies of alcohol-using youth

Background

A large proportion of adolescents drink alcohol, with many engaging in high-risk patterns of consumption, including binge drinking. Here, we systematically review and synthesize the existing empirical literature on how consuming alcohol affects the developing human brain in alcohol-using (AU) youth.

Methods

For this systematic review, we began by conducting a literature search using the PubMED database to identify all available peer-reviewed magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) studies of AU adolescents (aged 19 and under). All studies were screened against a strict set of criteria designed to constrain the impact of confounding factors, such as co-occurring psychiatric conditions.

Results

Twenty-one studies (10 MRI and 11 fMRI) met the criteria for inclusion. A synthesis of the MRI studies suggested that overall, AU youth showed regional differences in brain structure as compared with non-AU youth, with smaller grey matter volumes and lower white matter integrity in relevant brain areas. In terms of fMRI outcomes, despite equivalent task performance between AU and non-AU youth, AU youth showed a broad pattern of lower task-relevant activation, and greater task-irrelevant activation. In addition, a pattern of gender differences was observed for brain structure and function, with particularly striking effects among AU females.

Conclusions

Alcohol consumption during adolescence was associated with significant differences in structure and function in the developing human brain. However, this is a nascent field, with several limiting factors (including small sample sizes, cross-sectional designs, presence of confounding factors) within many of the reviewed studies, meaning that results should be interpreted in light of the preliminary state of the field. Future longitudinal and large-scale studies are critical to replicate the existing findings, and to provide a more comprehensive and conclusive picture of the effect of alcohol consumption on the developing brain.

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A large proportion of adolescents drink alcohol.

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Studies show how alcohol affects human adolescent brain development.

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This includes a systematic review of MRI and fMRI studies in alcohol-using youth.

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Changes in structure and function are observed in the brain in alcohol-using youth.

Smoking among undergraduate students in the area of health

The aim of this study was to evaluate the relationship between smoking and socio-demographic and behavioral factors among undergraduate students in the area of health at the State University of Paraíba, Brazil. An analytical cross-sectional study was conducted with a representative sample from each of the following courses: Dentistry, Nursing, Psychology, Pharmacy, Physical Therapy and Physical Education. A total of 492 students were interviewed using a structured questionnaire. The chi-square and Fisher's Exact tests were used for statistical analysis at a 5% level of significance. Smoking prevalence was 5.7% and stress was the main reason for starting the habit (36.8%). In the multivariate analysis by logistic regression, the variables of gender, religious persuasion, semester attended in the course, and alcohol consumption were significantly associated with smoking (p<0.05). Although other studies reported a strong relationship between university students and smoking, the prevalence of smokers was low. Most of the variables studied revealed a correlation with smoking. Since smoking and alcohol consumption are the two major human addictions, this study suggests a bidirectional relationship between these variables.

Consumo de álcool entre estudantes do ensino médio do município de Passos - MG

Este estudo identificou o padrão de consumo de álcool entre estudantes do ensino médio de Passos (MG) e sua associação com fatores socio-demográficos. Participaram 1.967 adolescentes de instituições públicas e privadas de ensino. Utilizou-se o questionário AUDIT. Realizou-se estatística descritiva, teste de qui-quadrado e regressão logística múltipla. A média de idade dos participantes foi de 15,84±1,23 anos. O primeiro contato com o álcool ocorreu aos 13,37±1,92 anos. Dos adolescentes, 30,96% eram abstêmios, 45,76% apresentaram comportamento de beber moderado, 16,47% de beber de risco, 3,51% de alto risco e 3,31% de possível dependência. Houve associação significativa entre o risco de beber e o sexo, relacionamento do adolescente com a mãe, trabalho, nível econômico e de escolaridade do chefe da família. Na análise multivariada observou-se maior risco para os adolescentes do sexo masculino, trabalhadores e com ausência de bom relacionamento com a mãe. Verificou-se que os adolescentes apresentaram contato precoce com bebidas alcoólicas e alta prevalência de comportamento de beber de risco.

Acceptability of the use of motivational interviewing to reduce underage drinking in a Native American community

Thirty-six Native American tribal leaders and members living on contiguous rural southwest California reservations were surveyed concerning their view of the acceptability of a motivational interviewing (MI) intervention with youth (aged 8-18 years) who are drinking and their families. The results suggest the following: (1) a substantial proportion of reservation youth would be willing to accept MI for behavior change; (2) relatively few are actually ready to change; (3) most reservation youth are in the precontemplation stage of change; and (4) MI may be well suited as an intervention to prevent underage drinking in that population. The study's limitations are noted.

Alcohol use by youth and adolescents: a pediatric concern

Alcohol use continues to be a major problem from preadolescence through young adulthood in the United States. Results of recent neuroscience research have substantiated the deleterious effects of alcohol on adolescent brain development and added even more evidence to support the call to prevent and reduce underaged drinking. Pediatricians should be knowledgeable about substance abuse to be able to recognize risk factors for alcohol and other substance abuse among youth, screen for use, provide appropriate brief interventions, and refer to treatment. The integration of alcohol use prevention programs in the community and our educational system from elementary school through college should be promoted by pediatricians and the health care community. Promotion of media responsibility to connect alcohol consumption with realistic consequences should be supported by pediatricians. Additional research into the prevention, screening and identification, brief intervention, and management and treatment of alcohol and other substance use by adolescents continues to be needed to improve evidence-based practices.

Integrated cognitive behaviour therapy for co-occurring substance misuse and major depression: lessons from a youth mental health service

OBJECTIVE

The aim of this paper is to describe a 20-week integrated cognitive behavioural therapy (CBT) program addressing co-occurring substance misuse and major depression in young people.

METHOD

Participants were aged between 15 and 25 years, met DSM-IV criteria for major depressive disorder and had at least weekly illicit drug use and/or weekly alcohol use exceeding the Australian national guidelines on alcohol.

RESULTS

Between December 2004 and January 2007, an integrated CBT program was offered to 60 young people with co-occurring depression and substance misuse who presented to a youth-specific mental health service. Young people attended for a median of 10.5 sessions.

CONCLUSIONS

We describe the components of a 20-week integrated CBT program for young people with co-occurring depression and comorbid substance misuse, as well as the challenges associated with providing such treatment. While integrated treatment approaches are recommended as best practice for this population, further evaluation is necessary to determine their effectiveness within routine clinical settings.

Profile of young people attending alcohol and other drug treatment services in Aotearoa, New Zealand: clinical file search

OBJECTIVE

The aim of the present study was to provide a profile of young people attending alcohol and other drug (AOD) treatment services in Aotearoa, New Zealand.

METHOD

Data were gathered from a clinical file search of 184 randomly selected young people aged 13-19 years who had attended one of eight youth AOD treatment services in New Zealand during 2003 or 2004. These services represented eight of the 11 youth-specific AOD services available to youth in New Zealand.

RESULTS

Young people who attend youth-specific AOD services in New Zealand present with a range of complex needs including substance use and mental health issues, criminality, family conflict and disengagement from school. A total of 62.0% were male, 56.4% had criminal convictions, 40.6% had spent some time in Child, Youth and Family Services care and 53.8% were reported to have a coexisting substance use and mental health disorder. Low rates of reporting of substance use and mental health diagnoses in treatment files suggest that substance use and mental health disorders among this population are likely to be higher than those reported.

CONCLUSIONS

This paper provides a unique profile of young people attending youth-specific AOD treatments in New Zealand. Such information is useful in informing treatment planning and funding and ensuring that service development occurs to specifically meet the complex needs of this patient group.

Predicting adolescent alcohol drinking patterns after major injury

BACKGROUND

Bedside alcohol counseling provided to injured adolescents during their acute medical care reduces subsequent alcohol consumption and reinjury. This counseling would be even more effective if extended beyond hospitalization to help injured youth return to normal functioning. To enhance this counseling, we first need to know the natural course of adolescent drinking during the year after injury, as well as the predictors of problem drinking during that year.

METHODS

Prospective cohort study that described the natural history of adolescent drinking during the year after traumatic injury and identified predictors of increased alcohol use. Randomly sampled injured adolescents 12 years to 18 years of age, admitted to the surgical services of a Level I trauma center were interviewed to assess alcohol consumption at baseline and 2 months, 5 months, and 12 months after injury admission.

RESULTS

Drinking increased steadily over the year, with this increase beginning in the months immediately after injury. Greater preinjury alcohol consumption, greater number of cumulative preinjury traumatic life experiences, and increasing age were independent positive predictors of increased drinking during the year after injury. Increased injury severity was a negative predictor such that the more severe the injury was, the less the adolescent drank during the year after injury.

CONCLUSIONS

This documented postinjury drinking pattern and its predictors can now identify for the purposes of extended counseling those adolescents most likely to drink heavily during the year after injury.

Substance use, education, employment, and criminal activity outcomes of adolescents in outpatient chemical dependency programs

Although the primary outcome of interest in clinical evaluations of addiction treatment programs is usually abstinence, participation in these programs can have a wide range of consequences. This study evaluated the effects of treatment initiation on substance use, school attendance, employment, and involvement in criminal activity at 12 months post-admission for 419 adolescents (aged 12 to 18) enrolled in chemical dependency recovery programs in a large managed care health plan. Instrumental variables estimation methods were used to account for unobserved selection into treatment by jointly modeling the likelihood of participation in treatment and the odds of attaining a certain outcome or level of an outcome. Treatment initiation significantly increased the likelihood of attending school, promoted abstinence, and decreased the probability of adolescent employment, but it did not significantly affect participation in criminal activity at the 12-month follow-up. These findings highlight the need to address selection in a non-experimental study and demonstrate the importance of considering multiple outcomes when assessing the effectiveness of adolescent treatment.

Systematic review identifies number of strategies important for retaining study participants

OBJECTIVE

Loss to follow-up threatens internal and external validity yet little research has examined ways to limit participant attrition. We conducted a systematic review of studies with a primary focus on strategies to retain participants in health care research.

STUDY DESIGN AND SETTINGS

We completed searches of PubMed, CINAHL, CENTRAL, Cochrane Methodology Register, and EMBASE (August 2005). We also examined reference lists of eligible articles and relevant reviews. A data-driven thematic analysis of the retention strategies identified common themes.

RESULTS

We retrieved 3,068 citations, 21 studies were eligible for inclusion. We abstracted 368 strategies and from these identified 12 themes. The studies reported a median of 17 strategies across a median of six themes. The most commonly reported strategies were systematic methods of participant contact and scheduling. Studies with retention rates lower than the mean rate (86%) reported fewer strategies. There was no difference in the number of different themes used.

CONCLUSION

Available evidence suggests that investigators should consider using a number of retention strategies across several themes to maximize the retention of participants. Further research, including explicit evaluation of the effectiveness of different strategies, is needed.

The psychological science of addiction

AIM

To discuss the contributions and future course of the psychological science of addiction.

BACKGROUND

The psychology of addiction includes a tremendous range of scientific activity, from the basic experimental laboratory through increasingly broad relational contexts, including patient-practitioner interactions, families, social networks, institutional settings, economics and culture. Some of the contributions discussed here include applications of behavioral principles, cognitive and behavioral neuroscience and the development and evaluation of addiction treatment. Psychology has at times been guilty of proliferating theories with relatively little pruning, and of overemphasizing intrapersonal explanations for human behavior. However, at its best, defined as the science of the individual in context, psychology is an integrated discipline using diverse methods well-suited to capture the multi-dimensional nature of addictive behavior.

CONCLUSIONS

Psychology has a unique ability to integrate basic experimental and applied clinical science and to apply the knowledge gained from multiple levels of analysis to the pragmatic goal of reducing the prevalence of addiction.

Primary alcohol versus primary drug use among adolescents: an examination of differences

Examination of differences between primary alcohol and drug abusing adolescents can provide valuable direction to intervention efforts, though little research in this area has been conducted. The current study compared primary alcohol and primary drug abusing runaway adolescents who were randomly assigned to family therapy or treatment as usual. Baseline differences, as well as response to treatment, were examined separately for alcohol and drug use and by gender. Although few baseline differences were found, hierarchical linear modeling indicated that alcohol and drug abusing male and female adolescents responded differently to therapy. Primary drug using males showed poorer alcohol use outcomes than did primary alcohol abusers. Specifically, alcohol use increased for primary drug using males receiving family therapy, while drug use decreased in all groups. Findings suggest that alcohol and drug use outcomes might be improved at treatment planning through consideration of client's gender and primary alcohol versus drug use.