Do brief measures of readiness to change predict alcohol consumption and consequences in primary care patients with unhealthy alcohol use?

Standardized Models for Identification and Intervention for Emergency Department Patients at Risk for Alcohol Use Disorder

Alcohol use disorder (AUD) is chronic, lasting a person's lifetime. An increase in driving under the influence of alcohol, as well as emergency department (ED) visits, has been reported. The Alcohol Use Disorder Identification Test Consumption (AUDIT-C) is utilized to assess hazardous drinking. The Screening, Brief Intervention, Referral to Treatment (SBIRT) model assists in early intervention and referral for treatment. The Transtheoretical Model standardized instrument assesses individual readiness to change. These tools may be used by nurses and nonphysicians in the ED to help reduce alcohol use and the consequences of its use.

Efficacy of alcohol reduction interventions among people with HIV as evaluated by self-report and a phosphatidylethanol (PEth) outcome: protocol for a systematic review and individual participant data meta-analysis

INTRODUCTION

Unhealthy alcohol use is associated with a range of adverse outcomes among people with HIV (PWH). Testing the efficacy and promoting the availability of effective interventions to address unhealthy alcohol use among PWH is thus a priority. Alcohol use outcomes in intervention studies are often measured by self-report alone, which can lead to spurious results due to information biases (eg, social desirability). Measuring alcohol outcomes objectively through biomarkers, such as phosphatidylethanol (PEth), in addition to self-report has potential to improve the validity of intervention studies. This protocol outlines the methods for a systematic review and individual participant data meta-analysis that will estimate the efficacy of interventions to reduce alcohol use as measured by a combined categorical self-report/PEth variable among PWH and compare these estimates to those generated when alcohol is measured by self-report or PEth alone.

METHODS AND ANALYSIS

We will include randomised controlled trials that: (A) tested an alcohol intervention (behavioural and/or pharmacological), (B) enrolled participants 15 years or older with HIV; (C) included both PEth and self-report measurements, (D) completed data collection by 31 August 2023. We will contact principal investigators of eligible studies to inquire about their willingness to contribute data. The primary outcome variable will be a combined self-report/PEth alcohol categorical variable. Secondary outcomes will include PEth alone, self-report alone and HIV viral suppression. We will use a two-step meta-analysis and random effects modelling to estimate pooled treatment effects; I2 will be calculated to evaluate heterogeneity. Secondary and sensitivity analyses will explore treatment effects in adjusted models and within subgroups. Funnel plots will be used to explore publication bias.

ETHICS AND DISSEMINATION

The study will be conducted with deidentified data from completed randomised controlled trials and will be considered exempt from additional ethical approval. Results will be disseminated through peer-reviewed publications and international scientific meetings.

PROSPERO REGISTRATION NUMBER

CRD42022373640.

Measuring Readiness to Change Substance Use, Alcohol Use, and Cannabis Use: An Experimental Manipulation of Cognitive Effort

Background: The Transtheoretical Model supports that readiness to change should predict actual substance-related behavior change. This relationship is surprisingly modest. Across several behavioral domains, individuals tend to have unrealistic expectations regarding the amount of effort and time required to successfully change one's behaviors, dubbed the False Hope Syndrome. Objectives: Based on False Hope Syndrome, we expect the standard method of measuring self-reported readiness to change is overestimated. To test this hypothesis, we experimentally manipulated level of cognitive effort prior to completing readiness to change measures. College students from a large southwestern university who reported using substances in the past 30 days (n = 345) were recruited from a psychology department participant pool and randomized to one of three conditions: 1) standard, low effort condition, 2) medium effort condition (selected likes/dislikes of substance use and negative consequences of changing one's use), and 3) high effort condition (also provided written responses to how they would handle difficult situations related to changing their substance use). We conducted one-way ANOVAs with Tukey post-hoc comparisons to examine differences on three measures of readiness to change: the University of Rhode Island Change Assessment (URICA) scale as well as readiness and motivation rulers. Results: Contrary to our hypothesis, all significant statistical tests supported higher cognitive effort conditions reporting higher readiness to change. Although effect sizes were modest, higher cognitive effort appeared to increase self-reported readiness to change substance use. Conclusions: Additional work is needed to test how self-reported readiness to change relates to actual behavior change when assessed under the different effort conditions.

A mobile-based pregaming drinking prevention intervention for college students: study protocol for a randomized controlled trial

BACKGROUND

Pregaming is a high-drink context popular among college students that often leads to elevated blood alcohol levels and negative consequences. Over 15 years of research studies have demonstrated that pregaming represents one of the riskiest known behaviors among college students, yet no pregaming-specific interventions have been developed to help prevent this behavior. General brief interventions for students do not reduce pregaming behavior and may not be appropriate, as they do not help students develop skills unique to the pregaming context that could help them drink less. We developed a brief, mobile-based intervention that is proposed to prevent heavy drinking during pregaming for college students, with the ultimate goal that behavioral reductions in this risky practice will ultimately affect global drinking and prevent consequences.

METHODS/DESIGN

The intervention, Pregaming Awareness in College Environments (PACE), was developed by combining two innovations to facilitate behavior change: (1) a mobile-based application that increases accessibility, is easy and engaging to use, and broadens the reach of the intervention content and (2) personalized pregaming-specific intervention content with harm reduction and cognitive behavioral skills proven to be mechanisms preventing and reducing heavy drinking among college students. After a develop and beta-test phase, we propose to test the efficacy of PACE in a preliminary randomized controlled trial with 500 college students who pregame at least once per week. Pregaming, general drinking, and alcohol-related consequences outcomes will be examined in the immediate (2 weeks post-intervention) and short-terms (six and 14-week post-intervention). We will also evaluate moderator effects for age, sex, and heaviness of drinking to allow for more refined information for a planned larger test of the intervention to follow this initial trial of PACE.

DISCUSSION

This pregaming intervention clinical trial, if found to be efficacious, will culminate with an easily-disseminated mobile-based intervention for college student drinkers. It has the potential to reach millions of college students, perhaps as a clinical tool used by college counseling centers as an adjunct to formal care or as a preventive tool for first-year students or other high-risk groups on campus.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT04016766.

Barriers and facilitators to changing drinking and receiving alcohol-related care: Interviews with Veterans Health Administration primary care patients who indicated interest but did not enroll in an alcohol care management intervention trial

Background: Most people with alcohol use disorder do not receive treatment, and primary care (PC)-based management of alcohol use disorder is a key strategy to close this gap. Understanding PC patients' perspectives on changing drinking and receiving alcohol-related care is important for this goal, particularly among those who decline alcohol-related care. This study examined perspectives on barriers and facilitators to changing drinking and receiving alcohol-related care among Veterans Health Administration (VA) PC patients who indicated interest but did not enroll in the Choosing Healthier drinking Options In primary CarE trial (CHOICE), which tested a PC-based alcohol care management intervention. Methods: VA PC patients with frequent heavy drinking who indicated interest in CHOICE but did not enroll were invited to participate. Twenty-seven patients completed in-person, semi-structured interviews. Interview transcripts were analyzed using iterative deductive and inductive content analysis. Results: Participants were mostly men (96%) and White (59%), and the mean age was 48. Seventy-four percent met criteria for alcohol use disorder, and the median number of past-week standard drinks was 41.5. Participants reported fewer alcohol-related problems, lower importance of/readiness to change drinking, and higher confidence in their ability to change than patients who enrolled in the CHOICE trial. Barriers fell into 5 domains: drinking fulfills need(s); reducing drinking or treatment is not needed; treatment is not effective/not acceptable; alcohol-related stigma; and practical barriers. Facilitators fell into 4 domains: reasons to change drinking; social support; treatment is acceptable/meets patients' needs; and practical facilitators. Participants discussed how Veteran identity and military experiences impacted drinking and willingness to receive care, which amplified multiple barriers/facilitators. Conclusions: This study identified barriers and facilitators to changing drinking and receiving alcohol-related care among VA PC patients who indicated interest but did not enroll in an alcohol care management trial. Findings can inform patient-centered interventions and support clinicians in engaging patients in care.

Evaluation of an online motivational interviewing training program for rehabilitation professionals: A pilot study

OBJECTIVE

To investigate the feasibility and effectiveness of an online motivational interviewing training program for rehabilitation professionals.

DESIGN

Pre-post design with two groups.

SETTING

Private rehabilitation hospital and an academic medical center.

SUBJECTS

Group 1 included 19 motivational interviewing-experienced rehabilitation professionals. Group 2 included 25 motivational interviewing-naïve rehabilitation professionals.

INTERVENTIONS

Group 1 was exposed to an online motivational training program and Group 2 was exposed to an online motivational training program and a live booster session.

MAIN MEASURES

Motivational interviewing communication skills were measured with an adapted Helpful Responses Questionnaire. Knowledge and attitudes were measured with an adapted Motivational Interviewing Knowledge and Attitudes Test. Confidence, importance, and feasibility for implementing motivational interviewing were measured using the Motivational Interviewing Rulers.

RESULTS

Group 1 showed improvement in communication skills (2.6/5-3.3/5; P < 0.05) and confidence (6.0/01-7.4/10; P < 0.01) after online training. Improvements seen in skills and confidence were maintained at three months. Group 2 showed improvement in skills (2.1/5-3.3/5; P < 0.001), knowledge (7.7/10-8.5/10; P < 0.01), confidence (6.4/10-7.5/10; P < 0.01), and importance (8.3/10-8.9/10; P < 0.05) after online training. At three-months post-booster, improvements in communication skills and knowledge were maintained.

CONCLUSIONS

Online training can be a cost and time effective approach to improve rehabilitation professionals' skills in motivational interviewing. Follow-up training activities are needed to maintain the level of knowledge and skill improvement.

Evidence based models of care for the treatment of alcohol use disorder in primary health care settings: a systematic review

Background

Pharmacological and behavioural treatments for alcohol use disorders (AUDs) are effective but the uptake is limited. Primary care could be a key setting for identification and continuous care for AUD due to accessibility, low cost and acceptability to patients.

We aimed to synthesise the literature regarding differential models of care for the management of AUD in primary health care settings.

Methods

We conducted a systematic review of articles published worldwide (1998-present) using the following databases; Medline, PsycINFO, Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials and Embase. The Grey Matters Tool guided the grey literature search. We selected randomised controlled trials evaluating the effectiveness of a primary care model in the management of AUD. Two researchers independently assessed and then reached agreement on the included studies. We used the Cochrane risk of bias tool 2.0 for the critical appraisal.

Results

Eleven studies (4186 participants) were included. We categorised the studies into ‘lower’ versus ‘higher’ intensity given the varying intensity of clinical care evaluated across the studies. Significant differences in treatment uptake were reported by most studies. The uptake of AUD medication was reported in 5 out of 6 studies that offered AUD medication. Three studies reported a significantly higher uptake of AUD medication in the intervention group. A significant reduction in alcohol use was reported in two out of the five studies with lower intensity of care, and three out of six studies with higher intensity of care.

Conclusion

Our results suggest that models of care in primary care settings can increase treatment uptake (e.g. psychosocial and/or pharmacotherapy) although results for alcohol-related outcomes were mixed. More research is required to determine which specific patient groups are suitable for AUD treatment in primary health care settings and to identify which models and components are most effective.

Trial Registration

PROSPERO: CRD42019120293.

Developing a clinical decision support for opioid use disorders: a NIDA center for the clinical trials network working group report

There is an urgent need for strategies to address the US epidemic of prescription opioid, heroin and fentanyl-related overdoses, misuse, addiction, and diversion. Evidence-based treatment such as medications for opioid use disorder (MOUD) are available but lack numbers of providers offering these services to meet the demands. Availability of electronic health record (EHR) systems has greatly increased and led to innovative quality improvement initiatives but this has not yet been optimized to address the opioid epidemic or to treat opioid use disorder (OUD). This report from a clinical decision support (CDS) working group convened by the NIDA Center for the Clinical Trials Network aims to converge electronic technology in the EHR with the urgent need to improve screening, identification, and treatment of OUD in primary care settings through the development of a CDS algorithm that could be implemented as a tool in the EHR. This aim is consistent with federal, state and local government and private sector efforts to improve access and quality of MOUD treatment for OUD, existing clinical quality and HEDIS measures for OUD or drug and alcohol use disorders, and with a recent draft grade B recommendation from the US Preventative Services Task Force (USPSTF) for screening for illicit drug use in adults when appropriate diagnosis, treatment and care services can be offered or referred. Through a face-to-face expert panel meeting and multiple follow-up conference calls, the working group drafted CDS algorithms for clinical care felt to be essential for screening, diagnosis, and management of OUD in primary care. The CDS algorithm was reviewed by addiction specialists and primary care providers and revised based on their input. A clinical decision support tool for OUD screening, assessment, and treatment within primary care systems may help improve healthcare delivery to help address the current epidemic of opioid misuse and overdose that has outpaced the capacity of specialized treatment settings. A semi-structured outline of clinical decision support for OUD was developed to facilitate implementation within the EHR. Further work for adaptation at specific sites and for testing is needed.

Comparisons as Predictors of People’s Beliefs About the Importance of Changing Their Health Behaviors

Abstract. The current study tested relative strengths of different comparison beliefs for predicting people’s self-assessments of whether they should increase their health-relevant behaviors (exercise, sleep, and fruit and vegetable consumption). Comparison beliefs relevant to three standards (perceived global, local, expert standards) were evaluated. Data were combined from three similar studies (total N = 744) that had a cross-sectional, within-subject design. Participants completed importance-of-change scales regarding the three health behaviors and reported comparison beliefs and absolute behavior frequencies/amounts. Results were consistent across the three behaviors. Comparison beliefs predicted ratings of importance of changing one’s behavior, even beyond what is predicted by reports of absolute behavior frequency. Expert comparisons were consistently most predictive above and beyond the absolute estimates and the other comparison standards. There was no evidence of a local dominance effect when examining local versus global comparisons. Comparison beliefs have unique utility for predicting people’s perceived importance of changing their heath behavior. The fact that expert comparisons were consistently most predictive (and local comparisons the least) may have implications for interventions designed for encouraging behavior change.

Effect of a Care Management Intervention on 12-Month Drinking Outcomes Among Patients With and Without DSM-IV Alcohol Dependence at Baseline

BACKGROUND

The CHOICE care management intervention did not improve drinking relative to usual care (UC) for patients with frequent heavy drinking at high risk of alcohol use disorders. Patients with alcohol dependence were hypothesized to benefit most. We conducted preplanned secondary analyses to test whether the CHOICE intervention improved drinking relative to UC among patients with and without baseline DSM-IV alcohol dependence.

METHODS

A total of 304 patients reporting frequent heavy drinking from 3 VA primary care clinics were randomized (stratified by DSM-IV alcohol dependence, sex, and site) to UC or the patient-centered, nurse-delivered, 12-month CHOICE care management intervention. Primary outcomes included percent heavy drinking days (%HDD) using 28-day timeline follow-back and a "good drinking outcome" (GDO)-abstaining or drinking below recommended limits and no alcohol-related symptoms on the Short Inventory of Problems at 12 months. Generalized estimating equation binomial regression models (clustered on provider) with interaction terms between dependence and intervention group were fit.

RESULTS

At baseline, 59% of intervention and UC patients had DSM-IV alcohol dependence. Mean drinking outcomes improved for all subgroups. For participants with dependence, 12-month outcomes did not differ for intervention versus UC patients (%HDD 37% versus 38%, p = 0.76 and GDO 16% versus 16%, p = 0.77). For participants without dependence, %HDD did not differ between intervention (41%) and UC (31%) patients (p = 0.12), but the proportion with GDO was significantly higher among UC participants (26% versus 13%, p = 0.046). Neither outcome was significantly modified by dependence (interaction p values 0.19 for %HDD and 0.10 for GDO).

CONCLUSIONS

Among participants with frequent heavy drinking, care management had no benefit relative to UC for patients with dependence, but UC may have had benefits for those without dependence.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01400581.

Motivation to Change and Treatment Participation Among Syringe Service Program Utilizers in Rural Kentucky

PURPOSE

Kentucky experiences a disproportionate burden of substance use disorder (SUD), particularly in rural areas of the state. Multiple factors increase vulnerability to SUD and limit access to services in rural communities. However, the recent implementation and expansion of syringe service programs (SSPs) in rural Kentucky may provide a leverage point to reach at-risk people who inject drugs (PWID).

METHODS

Data were collected as part of an ongoing NIDA-funded study designed to examine uptake of SSPs among PWID in Appalachian Kentucky. Using Respondent Driven Sampling (RDS), the study enrolled a sample of 186 PWID SSP attenders across 3 rural Appalachian Kentucky counties and conducted face-to-face interviews regarding health behaviors, injecting practices, SSP utilization, and treatment services. Using logistic regression analyses, we examined consistent SSP use, as well as importance and confidence to reduce substance use as predictors of current treatment participation.

FINDINGS

For the prior 6 months, 44.6% of the sample reported consistent SSP use. Consistent use of SSPs was associated with treatment participation in the unadjusted logistic regression models. Significant predictors of treatment participation in the adjusted model included high confidence to reduce substance use, and not reporting primary methamphetamine injection.

CONCLUSIONS

Rurally located SSPs may play an important role in supporting confidence and motivation to change substance use behaviors among PWID impacted by SUD. SSPs may be critical venues for integration and expansion of prevention, health promotion, and treatment linkage services for this underserved population.

An Examination of Motivation to Change and Neural Alcohol Cue Reactivity Following a Brief Intervention

Background: Brief interventions represent a promising psychological intervention targeting individuals with heavy alcohol use. Motivation to change represents an individual's openness to engage in a behavior change strategy and is thought to be a crucial component of brief interventions. Neuroimaging techniques provide a translational tool to investigate the neurobiological mechanisms underlying potential mediators of treatment response, including motivation to change. Therefore, this study aimed to examine the effect of a brief intervention on motivation to change drinking behavior and neural alcohol taste cue reactivity. Methods: Non-treatment-seeking heavy drinkers were randomized to receive a brief drinking intervention (n = 22) or an attention-matched control (n = 24). Three indices of motivation to change were assessed at baseline and after the intervention or control session: importance, confidence, and readiness. Immediately following the intervention or control session, participants also underwent an functional magnetic resonance imaging (fMRI) during which they completed an alcohol taste cues paradigm. Results: There was a significant effect of the brief intervention on increasing ratings of importance of changing drinking behavior, but not on ratings of confidence or readiness to change. Ratings of importance after the intervention or control session were associated with neural alcohol taste cue reactivity, but notably, this effect was only significant for participants who received the intervention. Individuals in the intervention condition showed a positive association between ratings of importance and activation in the precuneus, posterior cingulate, and insula. Conclusions: The brief drinking intervention was successful at improving one dimension of motivation to change among non-treatment-seeking heavy drinkers. The brief intervention moderated the relationship between ratings of importance and brain activation in circuitry associated with interoceptive awareness and self-reflection. Together, findings represent an initial step toward understanding the neurobiological mechanisms through which a brief intervention may improve motivation to change.

The relationship between in-session commitment language and daily self-reported commitment to reduce or abstain from drinking

BACKGROUND

Motivational interviewing is hypothesized to operate by enhancing a client's internal motivation to change. Past research operationalizes this process by measuring in-session statements for change (i.e., change talk), yet relationships between change talk and other measures of motivation have yet to be substantiated. This study tested whether in-session change talk predicted subsequent reports of commitment to abstain or moderate drinking assessed via ecological momentary assessment (EMA), and explored each of their contributions to drinking outcomes.

METHOD

Secondary data analysis was performed on data from 48 study participants who received therapy within a randomized controlled trial testing mechanisms of actions of MI. Multilevel models were used to test whether in-session commitment statements (strength, frequency, and slope of strength) made in two therapy sessions predicted subsequent daily reports of commitment to abstain or not drink heavily and drinking (21 days of data) in the weeks following each respective session.

RESULTS

A weak, negative relationship between in-session commitment and average daily commitment to abstain emerged. No relationship between in-session statements and average daily commitment to not drink heavily emerged. Only EMA commitment predicted drinking outcome. Post hoc analyses demonstrate a moderating impact of EMA commitment to abstain on in-session commitment strength: low pre-treatment commitment to abstain and increasing commitment strength across a session yielded the greatest drink reduction.

CONCLUSION

In-session change talk and EMA commitment may represent distinct aspects of motivation, yet their interaction appears important to treatment prognoses. Commitment to abstain may be important for treatment selection and successful drink reduction.

Motivation to reduce alcohol consumption and subsequent attempts at reduction and changes in consumption in increasing and higher-risk drinkers in England: a prospective population survey

AIMS

To assess how far motivation to reduce alcohol consumption in increasing and higher-risk drinkers in England predicts self-reported attempts to reduce alcohol consumption and changes in alcohol intake during the following 6 months.

METHODS

This study used self-reported data from 2928 higher-risk drinkers in the Alcohol Toolkit Study (ATS): a series of monthly cross-sectional household surveys of adults aged 16+ years of age in England. Alcohol consumption was measured in an initial survey and in a 6-month telephone follow-up interview using the Alcohol Use Disorders Identification Test (AUDIT)-C questionnaire. Motivation was measured in the initial survey using the Motivation to Reduce Alcohol Consumption (MRAC) scale. Attempts to reduce alcohol consumption during the past 6 months were recorded at follow-up. Data were analysed using repeated-measures difference-in-differences and logistic regression models.

RESULTS

Participants with higher initial motivation to reduce alcohol consumption were more likely to report that they had made an attempt to reduce consumption at follow-up [adjusted odds ratio (ORadj ) = 2.39, 95% confidence interval (CI) = 1.75-3.29]. There was an overall reduction in alcohol consumption between initial survey and follow-up (ORadj  = 0.72, 95% CI = 0.65-0.79), but there was insufficient evidence of an additional effect of motivation to reduce consumption on subsequent changes in alcohol consumption, with the difference-in-differences effect instead suggesting an average increase (ORadj  = 1.37, 95% CI = 1.00-1.88).

CONCLUSIONS

Increasing and higher-risk drinkers in England who report greater motivation to reduce their consumption are more likely to report making an attempt to reduce during the next 6 months, but this may not be associated with a reduction in alcohol consumption.

Homeless women's service use, barriers, and motivation for participating in substance use treatment

BACKGROUND

Homeless women are at high risk for substance use disorder (SUD), and are a growing proportion of the homeless population. However, homeless women experience barriers to engaging in substance use services.

OBJECTIVES

Among homeless women with SUD, to explore service use, motivation to change, service barriers, and willingness to have substance use and mental health problems addressed in primary health care.

METHODS

Women with SUD were sampled from 11 Health Care for the Homeless (HCH) primary care clinics in 9 states, yielding 241 with either an alcohol or drug use disorder who then completed questions about SUD services.

RESULTS

Over 60% of women with dual alcohol and drug use disorders used some type of SUD service in the past year, while 52% with a drug only disorder, and 44% with an alcohol only disorder used services. The most mentioned barrier to service use was depression, but cost, wait time, where to find treatment, and facilities located too far away, were also frequently noted. A large proportion across all groups indicated high motivation for treatment and willingness to discuss their SUD in a primary care setting.

CONCLUSION

There are continued barriers to SUD service use for homeless women despite high motivation for treatment, and willingness to be asked about SUD and mental health problems in primary care. HCH primary care sites should more systematically ask about SUD and mental health issues and address women's expressed need for support groups and alternative therapies to more holistically address their SUD needs.

Implementation of a Quality Improvement Initiative: Improved Congenital Muscular Torticollis Outcomes in a Large Hospital Setting

BACKGROUND

The American Physical Therapy Association (APTA) published a guideline for congenital muscular torticollis (CMT) in 2013. Our division adopted the guideline as the institutional practice standard and engaged in a quality improvement (QI) initiative to increase the percentage of patients who achieved resolution of CMT within 6 months of evaluation.

OBJECTIVE

The aims of this report are to describe the QI activities conducted to improve patient outcomes and discuss the results and implications for other institutions and patient populations.

DESIGN

This was a quality improvement study.

METHODS

In alignment with the Chronic Care Model and Model of Improvement, an aim and operationally defined key outcome and process measures were established. Interventions were tested using Plan-Do-Study-Act cycles. A CMT registry was established to store and manage data extracted from the electronic record over the course of testing. Statistical process control charts were used to monitor progress over time.

RESULTS

The QI initiative resulted in an increase in the percentage of patients who achieved full resolution of CMT within a 6-month episode of care from 42% to 61% over an 18-month period. Themes that emerged as key drivers of improvement included: (1) timely, optimal access to care, (2) effective audit and clinician feedback, and (3) accurate, timely documentation.

LIMITATIONS

The initiative took place at a single institution with a supportive culture and strong QI resources, which may limit direct translation of interventions and findings to other institutions and patient populations.

CONCLUSIONS

Improvement science methodologies provided the tools and structure to improve division-wide workflow and increase consistency in the implementation of the APTA CMT guideline. In doing so, significant CMT population outcome improvements were achieved.

Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial

BACKGROUND

Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample.

METHODS

The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs.

RESULTS

A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale.

CONCLUSION

The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

Psychosocial stressors and alcohol use, severity, and treatment receipt across human immunodeficiency virus (HIV) status in a nationally representative sample of US residents

BACKGROUND

Human immunodeficiency virus (HIV) is stigmatized and disproportionately impacts vulnerable populations. Thus, people living with HIV (PLWH) may have greater exposure to psychosocial stressors than those without HIV. Exposure to psychosocial stressors may increase alcohol use and serve as barriers to alcohol treatment receipt. The authors evaluate whether psychosocial stressors and alcohol use, symptom severity, and treatment receipt vary across HIV status in a general population sample of US residents and assess whether psychosocial stressors mediate identified associations.

METHODS

Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to assess associations between HIV status and psychosocial stressors (perceived stress, alcohol-related stigma, and perceived discrimination based on race/ethnicity, sexual orientation, or sex) and alcohol-related outcomes (any use, heavy drinking, symptom severity, and treatment receipt). For each outcome, regression models were fit and iteratively adjusted for sociodemographic characteristics and comorbidities. Indirect effects of HIV on alcohol-related outcomes through stressors were estimated to assess mediation when main effects were significant.

RESULTS

Among 34,653 NESARC Wave 2 respondents, 161 were PLWH. PLWH were more likely than those without HIV to experience discrimination and had higher levels of perceived stress than those without HIV (P values <.05), but the 2 groups did not differ regarding alcohol-related stigma. PLWH were less likely to use alcohol and had similar rates of heavy drinking relative to participants without HIV, but alcohol symptom severity and treatment receipt were greater among PLWH. Perceived stress but not discrimination mediated associations.

CONCLUSIONS

Findings from this first study of variation in psychosocial stressors and alcohol use, severity, and treatment receipt across HIV status further highlight PLWH as a population that is particularly vulnerable to experiences of psychosocial stress and certain adverse alcohol-related outcomes. Future longitudinal research is needed in a larger sample of PLWH to identify intervention targets.

Temporal patterns of alcohol consumption and attempts to reduce alcohol intake in England

BACKGROUND

The Alcohol Toolkit Study (ATS) is a monthly survey of approximately 1700 adults per month aged 16 years of age or more in England. We aimed to explore patterns of alcohol consumption and motivation to reduce alcohol use in England throughout the year.

METHODS

Data from 38,372 participants who answered questions about alcohol consumption (March 2014 to January 2016) were analysed using weighted regression using the R survey package. Questions assessed alcohol consumption (AUDIT-C) and attempts to reduce consumption.

RESULTS

Sixty-seven percent of participants reported using alcohol, with a small negative trend of about 2 % reduction over 12 months in the studied period (P < 0.01). These include ~25 % higher risk drinkers and ~10 % regular binge drinkers. About 20 % of higher risk drinkers indicated they were attempting to reduce their alcohol consumption. Attempts were lowest in December (-20 %; 95 % CI 0-35 %), but increases significantly in January (+41 %; 95 % CI 16-73 %) compared with other months (P < 0.001), indicating a small net gain; at least in attempts to reduce. However, there was no evidence that the increased motivation in January was accompanied by a reported decrease in consumption or binge drinking events. This could be an artefact of the use of AUDIT questions, but could also reflect a disconnect between attempting to reduce alcohol consumption and subsequent change; maybe as a result of lack of continuing support.

CONCLUSIONS

January is associated with moderate increased attempts to reduce alcohol consumption. However, we find little evidence of a change in alcohol consumption. In part, this may be due to temporal insensitivity of the AUDIT questions.

Readiness to Change Predicts Drinking: Findings from 12-Month Follow-Up of Alcohol Use Disorder Outpatients

AIM

To test whether measures of readiness to change (RTC) re-assessed every 3 months had predictive value for change in alcohol use over 12 months in a sample of adult outpatients with alcohol use disorder (AUD).

METHODS

Of the case, 78 outpatients were followed monthly over one year and averaged 9.0 interviews each (total observations = 704). Alcohol abstinence days and heavy drinking days were assessed monthly using a 30-day timeline follow-back procedure. RTC was assessed using 3 'readiness rulers' (importance, readiness, and confidence to change, measured on a 0-10 visual analog scale). The effect of RTC on alcohol use over time was tested every 3 months using negative binomial generalized estimating equations (GEE), controlling for gender, age, baseline alcohol dependence severity and AUD treatment status (ongoing vs. ceased).

RESULTS

GEE models showed highly significant effects of readiness and confidence to change on respective alcohol outcomes. Effects of importance to change were weaker.

CONCLUSION

As hypothesized, higher RTC scores were associated with improved alcohol use outcomes in this longitudinal study. The strongest effects were for confidence to change. Finding significant predictive validity prospectively is consistent with a theoretical view of RTC as a dynamic construct. Further research might clarify how AUD treatment could actually elicit or increase RTC.

Attachment Security and Self-compassion Priming Increase the Likelihood that First-time Engagers in Mindfulness Meditation Will Continue with Mindfulness Training

Mindfulness practice has many mental and physical health benefits but can be perceived as ‘difficult’ by some individuals. This perception can discourage compliance with mindfulness meditation training programs. The present research examined whether the activation of thoughts and feelings related to attachment security and self-compassion (through semantic priming) prior to a mindfulness meditation session might influence willingness to engage in future mindfulness training. We expected both of these primes to positively influence participants’ willingness to continue with mindfulness training. We primed 117 meditation-naïve individuals (84 female; mean age of 22.3 years, SD = 4.83) with either a self-compassion, attachment security, or a neutral control prime prior to an introductory mindfulness exercise and measured their post-session willingness to engage in further training. Both experimental primes resulted in higher willingness to engage in further mindfulness training relative to the control condition. The self-compassion prime did so indirectly by increasing state mindfulness, while the attachment security prime had a direct effect. This study supports theoretical links between self-compassion and mindfulness and reveals a causal role for these factors in promoting willingness to engage in mindfulness training. Our findings have implications for improving compliance with mindfulness intervention programs.

Development of a text message intervention aimed at reducing alcohol-related harm in patients admitted to hospital as a result of injury

Background

Screening for alcohol misuse and brief interventions (BIs) for harm in trauma care settings are known to reduce alcohol intake and injury recidivism, but are rarely implemented. We created the content for a mobile phone text message BI service to reduce harmful drinking among patients admitted to hospital following an injury who screen positive for hazardous alcohol use. The aim of this study was to pre-test and refine the text message content using a robust contextualisation process ahead of its formal evaluation in a randomised controlled trial.

Methods

Pre-testing was conducted in two phases. First, in-depth interviews were conducted with 14 trauma inpatients (16–60 years) at Auckland City Hospital and five key informants. Participants were interviewed face-to-face using a semi-structured interview guide. Topics explored included: opinions on text message ideas and wording, which messages did or did not work well and why, interactivity of the intervention, cultural relevance of messages, and tone of the content. In a second phase, consultation was undertaken with Māori (New Zealand’s indigenous population) and Pacific groups to explore the relevance and appropriateness of the text message content for Māori and Pacific audiences.

Results

Factors identified as important for ensuring the text message content was engaging, relevant, and useful for recipients were: reducing the complexity of message content and structure; increasing the interactive functionality of the text message programme; ensuring an empowering tone to text messages; and optimising the appropriateness and relevance of text messages for Māori and Pacific people. The final version of the intervention (named ‘YourCall^™’) had three pathways for people to choose between: 1) text messages in English with Te Reo (Māori language) words of welcome and encouragement, 2) text messages in Te Reo Māori, and 3) text messages in English (with an option to receive a greeting in Samoan, Tongan, Cook Island Māori, Niuean, Tokelauan, Tuvaluan, or Fijian).

Conclusions

We have developed a text message intervention underpinned by established BI evidence and behaviour change theory and refined based on feedback and consultation. The next step is evaluation of the intervention in a randomised-controlled trial.

Motivation and self-efficacy in the context of moderated drinking: global self-report and ecological momentary assessment

Despite ample research demonstrating the role of motivation and self-efficacy in predicting drinking in the context of abstinence, little research explicitly explores their role in the context of moderation, and none have utilized daily diary methods. The purpose of this study was to (a) explore the concordance between global self-report and daily diary composite measures of motivation and self-efficacy and (b) compare the ability of each in predicting drinking outcomes in the context of a study of brief AUD treatments focused on controlled drinking. Problem drinkers (N = 89) were assessed, provided feedback about their drinking, and randomly assigned to one of three conditions: two brief AUD treatments or a third group asked to change on their own. Global self-report (GSR) measures were administered at baseline and Week 8 (end of treatment). Daily diary composites (DDC) were created from data collected via an Interactive Voice Recording system during the week prior to baseline and the week prior to Week 8. Findings revealed some concordance between GSR and DDC at both baseline and Week 8, indicating the two methods capture some of the same construct; however, their respective relationships to drinking differed. DDC for both baseline and Week 8 significantly predicted Week 8 drinking outcomes, whereas only change in GSR significantly predicted drinking outcomes. Findings suggest that motivation and self-efficacy are important to moderated drinking, and that both GSR and daily diary methods are useful in understanding mechanisms of change in the context of moderation. Daily diary methods may provide significant advantages. Limitations and arenas for future research are discussed.

The Change Questionnaire predicts change in hazardous tobacco and alcohol use

INTRODUCTION

Assessing motivation for change is deemed an important step in the treatment process that allows further refinement of the intervention in motivational interviewing (MI) and brief MI (BMI) adaptations. During MI (and BMI) sessions, motivation for change is expressed by the client as "change talk", i.e. all statements inclined toward or away from change. We tested the predictive validity of the Change Questionnaire, a 12-item instrument assessing motivation to change, on hazardous tobacco and alcohol use.

METHODS

As part of the baseline measurements for a randomized controlled trial on multi-substance BMI at the Lausanne recruitment center (army conscription is mandatory in Switzerland for males at age 20, and thus provides a unique opportunity to address a non-clinical and largely representative sample of young men), 213 participants completed the questionnaire on tobacco and 95 on alcohol and were followed-up six months later. The overall Change Questionnaire score and its six subscales (Desire, Ability, Reasons, Need, Commitment, and Taking steps) were used as predictors of hazardous tobacco use (defined as daily smoking) and hazardous alcohol use (defined as more than one occasion with six standard drinks or more per month, and/or more than 21 standard drinks per week) in bivariate logistic regression models at follow-up.

RESULTS

Higher overall Change scores were significant predictors of decreased risk for hazardous tobacco (odds ratio [OR] = 0.83, p = 0.046) and alcohol (OR = 0.76, p = 0.03) use. Several sub-dimensions were associated with the outcomes in bivariate analyses. Using a principal components analysis to reduce the number of predictors for multivariate models, we obtained two components. 'Ability to change' was strongly related to change in hazardous tobacco use (OR = 0.54, p < 0.001), the second we interpreted as 'Other change language dimensions' and which was significantly related to change in hazardous alcohol use (OR = 0.81, p = 0.05).

CONCLUSIONS

The present findings lend initial support for the predictive validity of the Change Questionnaire on hazardous tobacco and alcohol use, making it an interesting and potentially useful tool for assessing motivation to change among young males.

Does experiencing homelessness affect women's motivation to change alcohol or drug use?

BACKGROUND AND OBJECTIVES

Homeless women are at high risk of drug and alcohol dependence and may receive less opportunity for treatment. Our objective was to examine the association between experiencing homelessness and motivation to change drug or alcohol use.

METHODS

Women (n = 154) participants in a study of substance dependence at an urban medical center (69 with some homeless days in the last 90 days; 85 continuously housed at baseline) completed six items rating motivation to change alcohol or drug use (ie, importance, readiness, and confidence) at baseline and in 3-, 6-, and 12-month follow-up interviews. Unadjusted and longitudinal analyses controlling for covariates (eg, demographics, insurance status, substance use consequences, mental health status, and participation in treatment) were conducted.

RESULTS

There were no significant differences between women experiencing homeless days versus continuously housed women in the odds of reporting high motivation to change alcohol or drug use, either in unadjusted baseline analyses or longitudinal analyses adjusted for covariates. Covariates that were significantly associated with high importance, readiness or confidence to change behavior were higher life time consequences of substance use, and participation in 12-step programs.

DISCUSSION AND CONCLUSIONS

The findings suggest that clinicians should not make assumptions that homeless women have low motivation to change their substance use.

SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS

The same opportunities for addiction treatment should be offered to homeless as to housed women.

Effectiveness of screening and brief alcohol intervention in primary care (SIPS trial): pragmatic cluster randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of different brief intervention strategies at reducing hazardous or harmful drinking in primary care. The hypothesis was that more intensive intervention would result in a greater reduction in hazardous or harmful drinking.

DESIGN

Pragmatic cluster randomised controlled trial.

SETTING

Primary care practices in the north east and south east of England and in London.

PARTICIPANTS

3562 patients aged 18 or more routinely presenting in primary care, of whom 2991 (84.0%) were eligible to enter the trial: 900 (30.1%) screened positive for hazardous or harmful drinking and 756 (84.0%) received a brief intervention. The sample was predominantly male (62%) and white (92%), and 34% were current smokers.

INTERVENTIONS

Practices were randomised to three interventions, each of which built on the previous one: a patient information leaflet control group, five minutes of structured brief advice, and 20 minutes of brief lifestyle counselling. Delivery of the patient leaflet and brief advice occurred directly after screening and brief lifestyle counselling in a subsequent consultation.

MAIN OUTCOME MEASURES

The primary outcome was patients' self reported hazardous or harmful drinking status as measured by the alcohol use disorders identification test (AUDIT) at six months. A negative AUDIT result (score <8) indicated non-hazardous or non-harmful drinking. Secondary outcomes were a negative AUDIT result at 12 months, experience of alcohol related problems (alcohol problems questionnaire), health utility (EQ-5D), service utilisation, and patients' motivation to change drinking behaviour (readiness to change) as measured by a modified readiness ruler.

RESULTS

Patient follow-up rates were 83% at six months (n=644) and 79% at 12 months (n=617). At both time points an intention to treat analysis found no significant differences in AUDIT negative status between the three interventions. Compared with the patient information leaflet group, the odds ratio of having a negative AUDIT result for brief advice was 0.85 (95% confidence interval 0.52 to 1.39) and for brief lifestyle counselling was 0.78 (0.48 to 1.25). A per protocol analysis confirmed these findings.

CONCLUSIONS

All patients received simple feedback on their screening outcome. Beyond this input, however, evidence that brief advice or brief lifestyle counselling provided important additional benefit in reducing hazardous or harmful drinking compared with the patient information leaflet was lacking.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN06145674.

Predictive value of readiness, importance, and confidence in ability to change drinking and smoking

Background

Visual analog scales (VAS) are sometimes used to assess change constructs that are often considered critical for change. Aims of Study: 1.) To determine the association of readiness to change, importance of changing and confidence in ability to change alcohol and tobacco use at baseline with the risk for drinking (more than 21 drinks per week/6 drinks or more on a single occasion more than once per month) and smoking (one or more cigarettes per day) six months later. 2.) To determine the association of readiness, importance and confidence with alcohol (number of drinks/week, number of binge drinking episodes/month) and tobacco (number of cigarettes/day) use at six months.

Methods

This is a secondary analysis of data from a multi-substance brief intervention randomized trial. A sample of 461 Swiss young men was analyzed as a prospective cohort. Participants were assessed at baseline and six months later on alcohol and tobacco use, and at baseline on readiness to change, importance of changing and confidence in ability to change constructs, using visual analog scales ranging from 1–10 for drinking and smoking behaviors. Regression models controlling for receipt of brief intervention were employed for each change construct. The lowest level (1–4) of each scale was the reference group that was compared to the medium (5–7) and high (8–10) levels.

Results

Among the 377 subjects reporting unhealthy alcohol use at baseline, mean (SD) readiness, importance and confidence to change drinking scores were 3.9 (3.0), 2.7 (2.2) and 7.2 (3.0), respectively. At follow-up, 108 (29%) reported no unhealthy alcohol use. Readiness was not associated with being risk-free at follow-up, but high importance (OR 2.94; 1.15, 7.50) and high confidence (OR 2.88; 1.46, 5.68) were. Among the 255 smokers at baseline, mean readiness, importance and confidence to change smoking scores were 4.6 (2.6), 5.3 (2.6) and 5.9 (2.7), respectively. At follow-up, 13% (33) reported no longer smoking. Neither readiness nor importance was associated with being a non-smoker, whereas high confidence (OR 3.29; 1.12, 9.62) was.

Conclusions

High confidence in ability to change was associated with favorable outcomes for both drinking and smoking, whereas high importance was associated only with a favorable drinking outcome. This study points to the value of confidence as an important predictor of successful change for both drinking and smoking, and shows the value of importance in predicting successful changes in alcohol use.

Trial registration number

ISRCTN78822107

The prevention access and risk taking in young people (PARTY) project protocol: a cluster randomised controlled trial of health risk screening and motivational interviewing for young people presenting to general practice

BACKGROUND

There are growing worldwide concerns about the ability of primary health care systems to manage the major burden of illness in young people. Over two thirds of premature adult deaths result from risks that manifest in adolescence, including injury, neuropsychiatric problems and consequences of risky behaviours. One policy response is to better reorientate primary health services towards prevention and early intervention. Currently, however, there is insufficient evidence to support this recommendation for young people. This paper describes the design and implementation of a trial testing an intervention to promote psychosocial risk screening of all young people attending general practice and to respond to identified risks using motivational interviewing.

MAIN OUTCOMES

clinicians' detection of risk-taking and emotional distress, young people's intention to change and reduction of risk taking.

SECONDARY OUTCOMES

pathways to care, trust in the clinician and likelihood of returning for future visits. The design of the economic and process evaluation are not detailed in this protocol.

METHODS

PARTY is a cluster randomised trial recruiting 42 general practices in Victoria, Australia. Baseline measures include: youth friendly practice characteristics; practice staff's self-perceived competency in young people's care and clinicians' detection and response to risk taking behaviours and emotional distress in 14-24 year olds, attending the practice. Practices are then stratified by a social disadvantage index and billing methods and randomised. Intervention practices receive: nine hours of training and tools; feedback of their baseline data and two practice visits over six weeks. Comparison practices receive a three hour seminar in youth friendly practice only. Six weeks post-intervention, 30 consecutive young people are interviewed post-consultation from each practice and followed-up for self-reported risk taking behaviour and emotional distress three and 12 months post consultation.

DISCUSSION

The PARTY trial is the first to examine the effectiveness and efficiency of a psychosocial risk screening and counselling intervention for young people attending primary care. It will provide important data on health risk profiles of young people attending general practice and on the effects of the intervention on engagement with primary care and health outcomes over 12 months.

TRIAL REGISTRATION

ISRCTN16059206.

Readiness to change, drinking, and negative consequences among Polish SBIRT patients

The aim of this study is to examine the longitudinal relationship of readiness to change, drinking pattern, amount of alcohol consumed, and alcohol-related negative consequences among at-risk and dependent drinkers enrolled in a Screening, Brief Intervention and Referral to Treatment (SBIRT) trial in an emergency department in southern Poland. The study examined 299 patients randomized to either an assessment or intervention condition and followed at 3 and 12 months after initial presentation. Patients indicating a readiness or were unsure of changing drinking behavior were significantly more likely to decrease the maximum number of drinks per occasion and the usual number of drinks in a sitting in the 3-months following study entry when compared to those that rated changing drinking behavior as unimportant. Readiness to change was not predictive of outcomes between the baseline and 12-month follow-up. Drinking outcomes and negative consequences by readiness and research condition were non-significant. This is the first Polish study utilizing SBIRT to enable patients to identify their hazardous drinking and reduce alcohol consumption. While some drinking outcomes improved with motivation, these improvements were not maintained at 12-months following SBIRT. Attention to additional constructs of readiness to change and drinking patterns may augment the effectiveness of SBIRT.

Comparison of the concurrent and predictive validity of three measures of readiness to change marijuana use in a clinical sample of adolescents

OBJECTIVE

The measurement of readiness to change has become common practice in alcohol and drug treatment of both adults and adolescents. Nevertheless, there is relatively little research on the validity of measures of readiness to change among treated adolescents. The purpose of this study was to compare three measures of readiness to change marijuana use commonly used in clinical research and practice with adolescents: the Readiness Ruler, the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES; Factors 1 and 2, Recognition and Taking Steps, respectively), and a staging algorithm.

METHOD

The participants were 174 adolescents presenting for intensive outpatient alcohol and drug treatment who reported current marijuana use at the initial assessment. Evidence for concurrent validity was assessed by computing simple correlations among readiness measures, and correlations of each readiness measure with marijuana involvement (percentage of days abstinent in the last 30 days, problem severity score, and marijuana abuse and dependence symptom count [based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria]) at both the initial/baseline assessment and at a 6-month follow-up assessment. Evidence for predictive validity was based on the results of multilevel regression models of the readiness measures in predicting frequency of marijuana use, symptoms, and problems at 6 months from the initial readiness assessment and then in predicting marijuana use, symptoms, and problems at 12 months from the readiness assessment at 6 months.

RESULTS

The results showed evidence for good concurrent and predictive validity for the ruler, the staging algorithm, and Taking Steps but poor evidence for the validity of Recognition. The ruler emerged as the measure with the most clinical utility when brevity and ease of administration are taken into account.

CONCLUSIONS

Research and clinical implications of the findings are discussed.

The role of demographic characteristics and readiness to change in 12-month outcome from two distinct brief interventions for impaired drivers

OBJECTIVES

This study tested specific intervention responsivity to brief intervention in driving while impaired by alcohol and/or drugs recidivists based upon their demographic, substance use, and initial readiness to change characteristics.

METHODS

A nonclinical community-based sample of 184 male and female recidivists was randomly assigned to receive one of two 30-minute interventions: brief motivational interviewing (n = 92) or an information-advice session (n = 92). Dependent variables were change at the 6- and 12-month follow-ups from baseline in percentage of risky drinking days and blood assay biomarkers of alcohol misuse. Independent variables were age, gender, education, past convictions for impaired driving, and baseline alcohol and drug misuse severity and readiness to change.

RESULTS

Recidivists who were younger, male, and exhibited more negative consequences and ambivalence towards their problem drinking improved more on alcohol-related outcomes, irrespective of intervention type.

CONCLUSIONS

The results do not convincingly indicate specific intervention responsivity based upon participant characteristics but provide preliminary guidance about which recidivists are most apt to benefit from these brief approaches.

A comparison of the concurrent and predictive validity of three measures of readiness to change alcohol use in a clinical sample of adolescents

The authors compared 3 measures of readiness to change alcohol use commonly used in clinical research and practice with adolescents: the Readiness Ruler, the SOCRATES (subscales of Recognition and Taking Steps), and a Staging Algorithm. The analysis sample consisted of 161 male and female adolescents presenting for intensive outpatient alcohol-abuse treatment who reported current alcohol use at the initial assessment. Evidence for concurrent validity was assessed by computing simple correlations of each readiness measure with the other 3 and of each readiness measure with drinking behavior (percentage of days abstinent [PDA] and drinks per drinking day [DDD], respectively, in the last 30 days) at the start of treatment and at the 6-month follow-up assessment. Evidence for predictive validity was based on percentage of independent variance accounted for by each of the readiness measures in predicting drinking behavior at 6 months from the start of treatment, and then in predicting drinking behavior at 12 months from the readiness assessment at 6 months. The results showed that all but Recognition had good concurrent validity, the Readiness Ruler score showed consistent evidence for predictive validity, and the Staging Algorithm showed good predictive validity for DDD at 6 and 12 months. For the 82 participants with an alcohol-use disorder diagnosis, the findings for the Ruler and Recognition were similar, but the Staging Algorithm had poorer prediction of DDD at 12 months, and Taking Steps was a better predictor of 6- and 12-month PDA and DDD. Research and clinical implications of the findings are discussed.

Comparative utility of a single-item versus multiple-item measure of self-efficacy in predicting relapse among young adults

Single-item measures of psychological experiences are often viewed as psychometrically suspect. The purpose of this study was to evaluate the validity and utility of a single-item measure of self-efficacy in a clinical sample of treatment-seeking young adults. Inpatient young adults (N = 303, age = 18-24, 26% female) were assessed at intake to residential treatment, end of treatment, and at 1, 3, and 6 months following discharge. The single-item measure of self-efficacy consistently correlated positively with a well-established 20-item measure of self-efficacy and negatively with temptation scores from the same scale, demonstrating convergent and discriminant validity. It also consistently predicted relapse to substance use at 1-, 3-, and 6-month assessments postdischarge, even after controlling for other predictors of relapse (e.g., controlled environment), whereas global or subscale scores of the 20-item scale did not. Based on these findings, we encourage the use of this single-item measure of self-efficacy in research and clinical practice.

Impact of motivational changes on drinking outcomes in pharmacobehavioral treatment for alcohol dependence

BACKGROUND

Psychological factors such as motivation to change and self-efficacy influence drinking outcomes in alcohol-dependent individuals who are enrolled in pharmacobehavioral studies. Previous results from our research clinic indicated that initial stage of change of heavy drinkers enrolled in a pharmacobehavioral trial was significantly associated with alcohol consumption. However, overall empirical findings regarding the consistency and extent of the connection between motivational factors and behavior are mixed. This may be in part because of the impact of changes in motivation over the course of treatment and/or characteristics of the individuals receiving the intervention. Our goal in the present study was to examine the extent to which levels of motivation and self-efficacy changed during the treatment phase of a pharmacobehavioral treatment trial, and the extent to which these variables affected drinking behavior in subsets of alcohol-dependent individuals.

METHODS

We conducted an exploratory evaluation of changes in motivation, temptation to drink, confidence to abstain, and drinking behavior over time during the treatment phase of a pharmacobehavioral study involving 321 alcohol-dependent individuals. We also examined the extent to which individual variables such as initial drinking severity, onset of alcohol dependence, and medication status influenced changes in motivation, self-efficacy, and drinking behavior.

RESULTS

Participants reported improvements in motivation to change, self-efficacy for change, and drinking behaviors over the course of treatment. As hypothesized, motivation to change and self-efficacy for change were related to specific dimensions of posttreatment drinking. Heavy drinkers reported more improvement in drinking behaviors than did nonheavy drinkers. Early-onset drinkers who were on medication reduced their drinking more than those on placebo, and these drinking changes appear to be partially mediated by reductions in temptation.

CONCLUSIONS

Reductions in drinking occur and are predicted by increased motivation to change, reduced temptation to drink, and increased confidence to abstain in this population of alcoholic-dependent individuals. Early and late onset and heavy drinkers and those taking medications displayed differential changes in drinking behavior, some of which were explained by the mediating effects of self-efficacy. This is a first step in understanding more about which alcoholic individuals respond best to treatment and what mechanisms may be involved in the changes in drinking and drinking-specific changes in frequency and intensity of drinking.

Severity of alcohol problems and readiness to change alcohol use in primary care

Screening measures for hazardous alcohol use that are efficient and can provide clinically relevant information are essential for primary care providers (PCPs). This study examined the clinical utility of the Alcohol Use Disorders Identification Test (AUDIT) and the AUDIT-Consumption (AUDIT-C) as predictors of readiness to change alcohol use in a primary care setting. In total, 114 veterans completed the AUDIT, readiness to change ruler, and an alcohol use disorders diagnostic interview. Two AUDIT-C scores were obtained; one administered during a primary care visit and one derived from the AUDIT. The AUDIT, both AUDIT-C scores, and number of dependence symptoms significantly predicted readiness to change independent of demographic variables. The AUDIT accounted for the greatest percentage of variance in readiness to change (19%). The AUDIT provides information about alcohol severity and readiness to change, which could be clinically useful for providers identifying patients for brief alcohol interventions.

A brief marijuana intervention for non-treatment-seeking young adult women

We randomized 332 women, 18-24 years old, who were not explicitly seeking treatment for their marijuana use to either a two-session motivationally focused intervention or an assessment-only condition. Assessed by timeline follow-back methodology, participants reported using marijuana 57% of days in the 3 months prior to study entry. Intervention effects on the likelihood of marijuana use were not statistically significant at 1 month (odds ratio [OR] = 0.77, p = .17), significant at 3 months (OR = 0.53, p = .01), and no longer significant at 6 months (OR = 0.74, p = .20). Among the 61% of participants endorsing any desire to quit using marijuana at baseline, significant intervention effects on the likelihood of marijuana use days were observed at 1 month (OR = 0.42, p = .03), 3 months (OR = 0.31, p = .02), and 6 months (OR = 0.35, p = .03). A two-session brief motivational intervention reduced marijuana use among young women not seeking treatment. Women with a desire to quit showed a greater and more durable response.

Persistence pays off: follow-up methods for difficult-to-track longitudinal samples

OBJECTIVE

Evolving privacy and confidentiality regulations make achieving high completion rates in longitudinal studies challenging. Periodically reviewing the methods researchers use to retain participants throughout the follow-up period is important. We review the effectiveness of methods to maximize completion rates in a 1-year longitudinal study of repeat driving-under-the-influence (DUI) offenders.

METHOD

During the course of 21 months, we attempted to follow-up with 704 participants of a licensed residential treatment facility for repeat DUI offenders. High rates of lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, substance-use disorders (97.6%) and nonsubstance- or nongambling-related psychiatric disorders (44.5%) among the sample made tracking participants difficult. To locate participants and complete follow-up interviews, we obtained baseline information, contacted collaterals, sent mailed reminders, searched Internet databases, and gave a monetary incentive for completing study interviews.

RESULTS

We located 608 participants with active telephone numbers (87.4%) and completed interviews with 488 (70.1% of the entire eligible sample and 80.3% of those with active telephone numbers), after an average (SD) of 8.6 (9.1) calls (median = 5.0). Increasing the number of calls continued to yield additional completions at 10, 20, and 30 calls; at approximately 40 telephone calls, the potential return for additional calls did not justify the added effort.

CONCLUSIONS

These results suggest that researchers need to (1) employ more than 10 telephone calls to adequately track difficult-to-follow substance-using populations, and (2) prepare for a subsample of participants who might require more extensive contact. These results highlight the importance of using empirical guidelines to plan estimates for the number of contacts needed to achieve an adequate follow-up completion rate.

Physical health and drinking among medical inpatients with unhealthy alcohol use: a prospective study

OBJECTIVE

Unhealthy alcohol use is common in medical inpatients, and hospitalization has been hypothesized to serve as a "teachable moment" that could motivate patients to decrease drinking, but studies of hospital-based brief interventions have often not found decreases. Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could inform refinement of hospital-based brief interventions by identifying an important foundation on which to build them. We tested associations between poor physical health and drinking after hospitalization and whether associations varied by alcohol dependence status and readiness to change.

METHODS

Participants were medical inpatients who screened positive for unhealthy alcohol use and consented to participate in a randomized trial of brief intervention (n = 341). Five measures of physical health were independent variables. Outcomes were abstinence and the number of heavy drinking days (HDDs) reported in the 30 days prior to interviews 3 months after hospitalization. Separate regression models were fit to evaluate each independent variable controlling for age, gender, randomization group, and baseline alcohol use. Interactions between each independent variable and alcohol dependence and readiness to change were tested. Stratified models were fit when significant interactions were identified.

RESULTS

Among all participants, measures of physical health were not significantly associated with either abstinence or number of HDDs at 3 months. Having an alcohol-attributable principal admitting diagnosis was significantly associated with fewer HDDs in patients who were nondependent [adjusted incidence rate ratio (aIRR) 0.10, 95% CI 0.03-0.32] or who had low alcohol problem perception (aIRR 0.36, 95% CI 0.13-0.99) at hospital admission. No significant association between alcohol-attributable principal admitting diagnosis and number of HDDs was identified for participants with alcohol dependence or high problem perception.

CONCLUSIONS

Among medical inpatients with nondependent unhealthy alcohol use and those who do not view their drinking as problematic, alcohol-attributable illness may catalyze decreased drinking. Brief interventions that highlight alcohol-related illness might be more successful.

Who is Ready to Change Illicit Drug Use Behavior: An Emergency Department Study

Objective

To identify emergency department patients who are ready to change their illicit drug use behavior.

Methods

A cross-sectional study of 198 Emergency Department patients at least 18 years old, seeking emergency department services, using at least one illicit drug, and scoring positive for alcohol problem based on CAGE score ≥ 1.

Results

Of the patients, 46% were “not ready” to change their drug behavior, 21% and 33% were “unsure” and “ready”, respectively. Our results identified that “Readiness to change alcohol behavior” [t (197) = 3.37, p ≤ 0.001], health insurance [t (197) = −3.011, p ≤ 0.003], number of drug use [t (197) = 2.88, p ≤ 0.004], and drug-related injury [t (197) = 1.98, p ≤ 0.049] were related to readiness to change illicit drug behavior.

Conclusion

Our results re-iterate the need for intervention programs that focus on screening and treatment for both drugs and alcohol.

Does readiness to change predict subsequent alcohol consumption in medical inpatients with unhealthy alcohol use?

We studied whether readiness to change predicts alcohol consumption (drinks per day) 3 months later in 267 medical inpatients with unhealthy alcohol use. We used 3 readiness to change measures: a 1 to 10 visual analog scale (VAS) and two factors of the Stages of Change Readiness and Treatment Eagerness Scale: Perception of Problems (PP) and Taking Action (TA). Subjects with the highest level of VAS-measured readiness consumed significantly fewer drinks 3 months later [Incidence rate ratio (IRR) and 95% confidence interval (CI): 0.57 (0.36, 0.91) highest vs. lowest tertile]. Greater PP was associated with more drinking [IRR (95%CI): 1.94 (1.02, 3.68) third vs. lowest quartile]. Greater TA scores were associated with less drinking [IRR (95%CI): 0.42 (0.23, 0.78) highest vs. lowest quartile]. Perception of Problems' association with more drinking may reflect severity rather than an aspect of readiness associated with ability to change; high levels of Taking Action appear to predict less drinking. Although assessing readiness to change may have clinical utility, assessing the patient's planned actions may have more predictive value for future improvement in alcohol consumption.

Computer versus in-person intervention for students violating campus alcohol policy

In this study, the authors evaluated the efficacy of a brief motivational intervention (BMI) and a computerized program for reducing drinking and related problems among college students sanctioned for alcohol violations. Referred students (N = 198, 46% women), stratified by gender, were randomly assigned to a BMI or to the Alcohol 101 Plus computer program. Data obtained at baseline, 1, 6, and 12 months were used to evaluate intervention efficacy. Planned analyses revealed 3 primary findings. First, women who received the BMI reduced drinking more than did women who received the computer intervention; in contrast, men's drinking reductions did not differ by condition. Second, readiness to change and hazardous drinking status predicted drinking reductions at 1 month postintervention, regardless of intervention. Third, by 1 year, drinking returned to presanction (baseline) levels, with no differences in recidivism between groups. Exploratory analyses revealed an overall mean reduction in drinking immediately after the sanction event and before taking part in an intervention. Furthermore, after the self-initiated reductions prompted by the sanction were accounted for, participation in the BMI but not the computer intervention was found to produce additional reduction in drinking and related consequences.

Factor structure of the SOCRATES questionnaire in hospitalized medical patients

The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES), a 19-item instrument developed to assess readiness to change alcohol use among individuals presenting for specialized alcohol treatment, has been used in various populations and settings. Its factor structure and concurrent validity has been described for specialized alcohol treatment settings and primary care. The purpose of this study was to determine the factor structure and concurrent validity of the SOCRATES among medical inpatients with unhealthy alcohol use not seeking help for specialized alcohol treatment. The subjects were 337 medical inpatients with unhealthy alcohol use, identified during their hospital stay. Most of them had alcohol dependence (76%). We performed an Alpha Factor Analysis (AFA) and Principal Component Analysis (PCA) of the 19 SOCRATES items, and forced 3 factors and 2 components, in order to replicate findings from Miller and Tonigan (Miller, W. R., & Tonigan, J. S., (1996). Assessing drinkers' motivations for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behavior, 10, 81-89.) and Maisto et al. (Maisto, S. A., Conigliaro, J., McNeil, M., Kraemer, K., O'Connor, M., & Kelley, M. E., (1999). Factor structure of the SOCRATES in a sample of primary care patients. Addictive Behavior, 24(6), 879-892.). Our analysis supported the view that the 2 component solution proposed by Maisto et al. (Maisto, S.A., Conigliaro, J., McNeil, M., Kraemer, K., O'Connor, M., & Kelley, M.E., (1999). Factor structure of the SOCRATES in a sample of primary care patients. Addictive Behavior, 24(6), 879-892.) is more appropriate for our data than the 3 factor solution proposed by Miller and Tonigan (Miller, W. R., & Tonigan, J. S., (1996). Assessing drinkers' motivations for change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of Addictive Behavior, 10, 81-89.). The first component measured Perception of Problems and was more strongly correlated with severity of alcohol-related consequences, presence of alcohol dependence, and alcohol consumption levels (average number of drinks per day and total number of binge drinking days over the past 30 days) compared to the second component measuring Taking Action. Our findings support the view that the SOCRATES is comprised of two important readiness constructs in general medical patients identified by screening.

Improvements in readiness to change and drinking in primary care patients with unhealthy alcohol use: a prospective study

BACKGROUND

The course of alcohol consumption and cognitive dimensions of behavior change (readiness to change, importance of changing and confidence in ability to change) in primary care patients are not well described. The objective of the study was to determine changes in readiness, importance and confidence after a primary care visit, and 6-month improvements in both drinking and cognitive dimensions of behavior change, in patients with unhealthy alcohol use.

METHODS

Prospective cohort study of patients with unhealthy alcohol use visiting primary care physicians, with repeated assessments of readiness, importance, and confidence (visual analogue scale (VAS), score range 1-10 points). Improvements 6 months later were defined as no unhealthy alcohol use or any increase in readiness, importance, or confidence. Regression models accounted for clustering by physician and adjusted for demographics, alcohol consumption and related problems, and discussion with the physician about alcohol.

RESULTS

From before to immediately after the primary care physician visit, patients (n = 173) had increases in readiness (mean +1.0 point), importance (+0.2), and confidence (+0.5) (all p < 0.002). In adjusted models, discussion with the physician about alcohol was associated with increased readiness (+0.8, p = 0.04). At 6 months, many participants had improvements in drinking or readiness (62%), drinking or importance (58%), or drinking or confidence (56%).

CONCLUSION

Readiness, importance and confidence improve in many patients with unhealthy alcohol use immediately after a primary care visit. Six months after a visit, most patients have improvements in either drinking or these cognitive dimensions of behavior change.

Development of a Readiness Ruler for use with alcohol brief interventions

BACKGROUND

A quick method of assessing readiness to change was needed for a major study of implementing screening and alcohol brief intervention in England. For this purpose, a Readiness Ruler that had been validated among a sample of male college students in the USA was adapted and applied to a sample of excessive drinkers in a general medical practice located in a deprived area of Gateshead, England.

METHODS

72 participants identified as excessive drinkers by health professionals completed a single-item Readiness Ruler, the 12-item Readiness to Change Questionnaire (RCQ) and the AUDIT questionnaire.

RESULTS

In terms of concurrent validity, the relationships between the Readiness Ruler, on the one hand, and either stage of change allocation or a dimensional score derived from the RCQ, on the other hand, were highly significant but weaker than expected. When patients who endorsed the "maintenance" point on the Readiness Ruler were excluded from the analysis, the above relationships were considerably strengthened for reasons that are discussed. On this basis and with another small change, a final Readiness Ruler was developed.

CONCLUSION

If the validity of the Readiness Ruler is confirmed in subsequent research, a quick and simple way of measuring readiness to change will be available for research or clinical work with alcohol brief interventions.

Issues related to implementing a smoking cessation clinical trial for cancer patients

Given high rates of smoking among cancer patients, smoking cessation treatment is crucial; yet limited data exist to guide integration of such trials into the oncologic context. In order to determine the feasibility of conducting smoking cessation clinical trials with cancer patients, screening and baseline data from a large randomized placebo-controlled pharmacotherapy trial were analyzed. Descriptive statistics and regression analyses were used to compare enrollees to decliners, describe program enrollees, and assess correlates of confidence in quitting smoking. Out of 14,514 screened patients, 263 (<2%) were eligible; 43 (16%) refused enrollment. Among the eligible patients, 220 (84%) enrolled. Enrollment barriers included smoking rate, medical history/contraindicated medication, lack of interest, and language. Compared to enrollees, decliners were more likely to have advanced cancer. The trial enrolled a sample of 67 (>30%) African Americans; participants had extensive smoking histories; many were highly nicotine dependent; and participants consumed about seven alcoholic beverages/week on average. Head and neck and breast cancer were the most common tumors. About 52 (25%) reported depressive symptoms. A higher level of confidence to quit smoking was related to lower depression and lower tumor stage. Integrating a smoking cessation clinical trial into the oncologic setting is challenging, yet feasible. Recruitment strategies are needed for patients with advanced disease and specific cancers. Once enrolled, addressing participant's depressive symptoms is critical for promoting cessation.

Methodological issues in alcohol screening and brief intervention research

The research literature on screening and brief intervention (SBI) for unhealthy alcohol use is large and diverse. More than 50 clinical trials and 9 systematic reviews have been published on SBI in a range of healthcare settings, and via a variety of delivery approaches, in general practice, hospital wards, emergency departments, addiction treatment centres, and more recently, via computers and the Internet. The aim of this paper was to discuss methodological issues which arise in the design, analysis, interpretation, and reporting of SBI trials. Principal among these are the challenge of detecting small effects, standards of analysis, reporting, and interpretation, the risks of bias arising from self-report of outcomes, and the need to ensure that results have the potential to be applied in practice to reduce the burden of disease and injury attributable to unhealthy alcohol use.