Brief motivational intervention for adolescents treated in emergency departments for acute alcohol intoxication - a randomized-controlled trial

Impact of the COVID-19 Pandemic on Youth Substance Use and Substance-Related Risk Factors and Outcomes: Implications for Prevention, Treatment, and Policy

Youth substance use and substance use disorders (SUD) are major public health issues associated with significant societal cost. The coronavirus SARS-CoV-2 (COVID-19) pandemic and pandemic-related lockdowns, school closures, and social distancing dramatically impacted the daily lives of young people worldwide, resulting in major disruptions to normal developmental trajectories and complex (and at times opposing effects) on different SUD risk and protective factors, which contributed to inconsistent outcomes. During the COVID-19 pandemic, substance use prevalence rates decreased in the general population of US youth, but increased for certain vulnerable subgroups. Additionally, overdose deaths related to fentanyl rose significantly among US youth.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Care of the Patients With Alcohol Intoxication in the Emergency Department of a Central Hospital: Nurses' Skills, Knowledge, and Attitudes

AIM

The aim of the study was to describe nurses' skills, knowledge of care, and attitudes toward the care of patients with alcohol intoxication in the emergency department.

METHOD

The data were collected using theme interviews in 2016. The study participants were nurses working in the emergency department (n = 6) that has a sobering unit. The data were analyzed using inductive content analysis.

RESULTS

On the basis of the interviewees' descriptions, five main categories were formed: the skills to discuss the use of alcohol on arrival, safety skills, teamwork skills, the skills to organize follow-up care, and nurses' attitudes and ethics in patients' care. Asking about the use of alcohol as well as the use of a screening tool varied. The interviewees emphasized the skills to anticipate the risk of violence as well as ensuring the safety of the working environment. Nurses' attitudes were seen as the ability to regulate negative emotions raised by the patient. Factors related to nurses' attitudes emerged in patients' behavioral disorders and commitment to treatment. Despite some negative feelings toward patients, nurses thought that it is important to ensure ethicality in patients' care.

CONCLUSIONS

The nurses' skills and knowledge of care and attitudes toward patients with alcohol intoxication varied. There is a need for additional training on issues relating to the treatment of patients with alcohol intoxication.

Trends of Hospitalization for Acute Alcohol Intoxication in Slovenian Children and Adolescents with and without Dual Disorder. Implications for a Correct Intervention

Background: Binge drinking and other forms of ethanol abuse are, when present, a serious problem in preteens and adolescents worldwide. Aim: The present study has analyzed the trend in alcohol-related intoxications requiring the hospitalization of children, adolescents and young adults aged less than 21 years in Slovenia in the 1999–2018 period. Methods: We performed a retrospective study on patients discharged after hospitalizations due to mental and behavioral disorders due to acute alcohol intoxication (MBDAAI) or hospitalizations due to the toxic effects of alcohol (TEA We considered three groups: children (aged 10–14), adolescents (aged 15–19) and young adults (20–21 years old). Hospitalization rates and time trends were analyzed using joinpoint regression to obtain the annually calculated age- and sex-specific rates and the annual percentage of change (APC). Results: Considering a total of 2912 MBDAAI-hospitalizations, 15–19-year-old subjects showed a significantly higher hospitalization rate compared to the immediately younger and older age groups and a significant increase in hospitalization rates in the period 1999–2011, followed by a significant decrease. Considering 1143 TEA-hospitalizations, we observed a continuous decrease in the hospitalization rates for children and young adults and, conversely, a continuous even if less than significant increase for adolescents aged 15–19. Conclusions: Alcohol consumption in Slovenian children and adolescents is a highly important health concern. Special attention to public health problem of severe alcohol abuse requiring hospitalization in children and adolescents is needed, especially with possible crisis of SARS-CoV-2/Covid-19 situation.

Five-Year Incidence of Hospital-Based Emergencies Related to Acute Recreational Intoxication in Minors

BACKGROUND

Alcohol or other drug (AOD) intoxication in minors is a public health challenge. We characterized underage patients admitted to an emergency department (ED) with acute, recreational AOD intoxication.

METHODS

We conducted a 5-year (2012 to 2016) analysis of minors admitted to the only hospital-based pediatric ED in an urban area. Episodes of AOD intoxication were selected using ICD-9-CM diagnostic codes. Sociodemographics, substance use and clinical characteristics, laboratory parameters, and discharge dispositions were collected through the revision of clinical charts.

RESULTS

A total of 266 admissions related to recreational AOD intoxication in 258 patients occurred during the study period. Among the 258 patients, 127 (49.2%) were men, median age 16 years [IQR: 15 to 17 years], and 234 (90.7%) of episodes were alcohol-related. At admission, 202/256 (78.9%) patients had a Glasgow Coma Scale ≥ 13 points, the median systolic and diastolic blood pressure was 109 mmHg (IQR: 101 to 118 mmHg) and 67 mmHg (IQR: 60 to 73 mmHg), respectively, and the median blood glucose level was 112 mg/dl (IQR: 99 to 127 mg/dl). Only 72/258 (27.9%) patients underwent urine screening (22/72 (30.5%) were positive for cannabis), and only 30/258 (11.6%) were tested for blood ethanol (median: 185 mg/dl, IQR: 163 to 240 mg/dl). There was a trend in admissions occurring early in the morning of weekend days, and 249 (96.5%) patients were discharged home the day of admission.

CONCLUSIONS

Though the severity of AOD intoxication seems to be mild to moderate, assessment of substance exposure is low and may underestimate polydrug use in underage populations.

Psychometric assessment of the marijuana adolescent problem inventory

Cannabis is one of the most commonly used psychoactive substances among adolescents in the United States. Adolescent cannabis use has multiple consequences including academic, health, and psychiatric problems. The Marijuana Adolescent Problem Inventory (MAPI) is a 23-item scale adapted from the Rutgers Alcohol Problem Index and used in the current literature to assess cannabis use problem severity. Psychometric testing for the MAPI has yet to be reported. The current investigation assessed the psychometric characteristics of the MAPI with cannabis-using adolescents (n=727) from school and outpatient settings who enrolled in five separate randomized clinical trials focused on treatment of substance use. Findings suggested that the MAPI is internally consistent and reliable. Factor structure analyses suggested that the MAPI measures one latent construct, with no differences in factor structure between the outpatient and school settings, supporting a one-factor model. External validity of the MAPI was also demonstrated as evidenced by significant relations with concurrent diagnosis of cannabis dependence and abuse, longitudinal frequency of cannabis use, and mean times used per day. Overall, this initial test of the psychometric characteristics of the MAPI suggests that it can be considered a reliable and valid measure of problems associated with cannabis use among adolescents. Future work is now needed to replicate these findings by testing the psychometric properties of the MAPI in more diverse samples and developing a short version to be used as a brief assessment tool.

Cross-sectional relationship of perceived familial protective factors with depressive symptoms in vulnerable youth

BACKGROUND

There are multiple negative consequences associated with heavy episodic drinking and close associations between substance abuse and depression, alcohol-intoxicated adolescents (AIA) represent a vulnerable group. We aim to add to the current literature by investigating the cross-sectional relationship of perceived familial protective factors with depressive symptoms in AIA in hospitals, with respect to sex. Depression is among the 10 leading causes of disabilities during childhood and adolescence, with girls being more vulnerable than boys. Considerable evidence reveals a strong association between depression and alcohol abuse. The family provides the possibility to positively influence depressive symptoms.

METHODS

We present cross-sectional data of a German multisite, epidemiological cohort study on AIA. By using youth's self-reports, we assessed sociodemographic data, as well as data on perceived familial protective factors and depressive symptoms using items of the Communities that Care Youth Survey instrument. We performed descriptive and multigroup analyses to evaluate the measurement invariance of the used instruments. Moreover, to investigate the relationships between the constructs, we used structural equation modelling.

RESULTS

The study sample comprised 342 AIA, with a mean age of 15.5 years (SD = 1.2; 48.1% girls). The final structural equation model achieved an acceptable model fit of χ2 (69, 342) = 110.056; p = .001; TLI = 0.97; CFI = 0.98; RMSEA = 0.046; SRMR = 0.042, and the rewards for prosocial involvement in the family context correlated significantly negatively with present depressive symptoms, (ß = - 0.540, p <  0.001). The effects were stronger in boys (ß = - 0.576, p <  0.001) than in girls (ß = - 0.519, p <  0.001).

CONCLUSION

In vulnerable youth in Germany, depressive symptoms are correlated to good experiences within the family. Future research should assess whether interventions that enhance parental support reduce the risk of depressive symptoms in AIA. Our findings highlight the need for family-based prevention programmes, particularly for AIA with an increased risk of depression.

Short- to Midterm Effectiveness of a Brief Motivational Intervention to Reduce Alcohol Use and Related Problems for Alcohol Intoxicated Children and Adolescents in Pediatric Emergency Departments: A Randomized Controlled Trial

OBJECTIVES

The proportion of children and adolescents receiving emergency care for acute alcohol intoxication (AAI) in Germany has sharply increased over the past years. Despite this, no randomized controlled trials (RCTs) have studied guideline- and evidence-based interventions to prevent future alcohol misuse within this population. The objective of our investigation was to evaluate the effectiveness of a brief motivational intervention (b-MI) to reduce drinking and associated problems within pediatric emergency departments (PED) in Hamburg, Germany.

METHODS

This stratified cluster-RCT compared a widely established but modified targeted b-MI and treatment as usual (TAU) for patients recruited and treated on Fridays, Saturdays, or Sundays from July 2011 to January 2014 for AAI in EDs of six pediatric hospitals in Hamburg, Germany. Patients under the age of 18 years and their caregivers were included in the study. Intervention was delivered by trained hospital-external staff. The intervention group (n = 141) received a single-session b-MI with a telephone booster after 6 weeks and a brief consultation for caregivers. All intervention material was manual-based. The TAU control group (n = 175) received youth-specific written information on alcohol use and contact information for community resources. Primary outcomes were changes in binge drinking frequency, number of alcoholic drinks on a typical occasion, and alcohol-related problems using the brief Rutgers Alcohol Problem Index. Outcomes were measured by research assistants not involved in intervention delivery. Baseline data were collected in person at the PED, and follow-up data were collected via telephone 3 and 6 months after baseline. Secondary outcome was postenrollment health service utilization. Analyses were based on linear mixed models and intent to treat.

RESULTS

A total of 86.1% (87.5%) of patients in the b-MI group and 82.4% (86.9%) in the TAU group provided valid outcome data after 3 (6) months, respectively. The differences between groups for all outcomes were statistically nonsignificant at both follow-ups (p > 0.05). After 3 months the mean change in binge drinking frequency was -1.36 (95% confidence interval [CI] = -1.81 to -0.91), a reduction of 62.1% in the b-MI group, and -1.29 (95% CI = -1.77 to -0.95), a reduction of 49.0% in the TAU group. The mean change in number of alcoholic drinks on a typical occasion was -2.24 (95% CI = -3.18 to -1.29), a reduction of 37.5% in the b-MI group, and -1.34 (95% CI = -2.54 to -0.14), a reduction of 26.4% in the TAU group. The mean change of alcohol-related problems was -6.72 (95% CI = -7.68 to -5.76), a reduction of 60.5% in the b-MI group, and -6.43 (95% CI = -7.37 to -5.49), a reduction of 58.3% in the TAU group. The differences in mean changes between groups were similar after 6 months for all outcomes.

CONCLUSION

This study provides new information on the effectiveness of b-MIs delivered at discharge of young AAI patients in emergency care. Both trial groups reduced alcohol use and related problems but the b-MI was not associated with significant effects. Although the intervention approach appears feasible, further considerations of improving the outcomes for this relevant target group are required.

Infant Strangulation from an Amber Teething Necklace

Amber teething necklaces supposedly provide analgesia for teething infants. Their use is becoming more widespread, despite lack of peer-reviewed evidence and warnings from Health Canada that they pose a strangulation and aspiration risk. To date, there have been no published reports of strangulation secondary to amber teething necklaces. In this report we present a case of non-fatal infant strangulation from the first time use of an amber teething necklace. We will also discuss the role of physicians as advocates in reporting similar cases and educating families. Finally, we will comment on the responsibility of all professionals and professional organizations that work with infants and toddlers to advocate for children by raising concerns and counselling parents.

Effectiveness of a Web-Based Screening and Fully Automated Brief Motivational Intervention for Adolescent Substance Use: A Randomized Controlled Trial

Background

Mid-to-late adolescence is a critical period for initiation of alcohol and drug problems, which can be reduced by targeted brief motivational interventions. Web-based brief interventions have advantages in terms of acceptability and accessibility and have shown significant reductions of substance use among college students. However, the evidence is sparse among adolescents with at-risk use of alcohol and other drugs.

Objective

This study evaluated the effectiveness of a targeted and fully automated Web-based brief motivational intervention with no face-to-face components on substance use among adolescents screened for at-risk substance use in four European countries.

Methods

In an open-access, purely Web-based randomized controlled trial, a convenience sample of adolescents aged 16-18 years from Sweden, Germany, Belgium, and the Czech Republic was recruited using online and offline methods and screened online for at-risk substance use using the CRAFFT (Car, Relax, Alone, Forget, Friends, Trouble) screening instrument. Participants were randomized to a single session brief motivational intervention group or an assessment-only control group but not blinded. Primary outcome was differences in past month drinking measured by a self-reported AUDIT-C-based index score for drinking frequency, quantity, and frequency of binge drinking with measures collected online at baseline and after 3 months. Secondary outcomes were the AUDIT-C-based separate drinking indicators, illegal drug use, and polydrug use. All outcome analyses were conducted with and without Expectation Maximization (EM) imputation of missing follow-up data.

Results

In total, 2673 adolescents were screened and 1449 (54.2%) participants were randomized to the intervention or control group. After 3 months, 211 adolescents (14.5%) provided follow-up data. Compared to the control group, results from linear mixed models revealed significant reductions in self-reported past-month drinking in favor of the intervention group in both the non-imputed (P=.010) and the EM-imputed sample (P=.022). Secondary analyses revealed a significant effect on drinking frequency (P=.037) and frequency of binge drinking (P=.044) in the non-imputation-based analyses and drinking quantity (P=.021) when missing data were imputed. Analyses for illegal drug use and polydrug use revealed no significant differences between the study groups (Ps>.05).

Conclusions

Although the study is limited by a large drop-out, significant between-group effects for alcohol use indicate that targeted brief motivational intervention in a fully automated Web-based format can be effective to reduce drinking and lessen existing substance use service barriers for at-risk drinking European adolescents.

Trial Registration

International Standard Randomized Controlled Trial Registry: ISRCTN95538913; http://www.isrctn.com/ISRCTN95538913 (Archived by WebCite at http://www.webcitation.org/6XkuUEwBx)

Alcohol and brief intervention for trauma victims

OBJECTIVE

to describe the causes and severities of trauma in patients who met the criteria for alcohol abuse or dependence according to Mini International Neuropsychiatric Interview, and to display the pattern of alcohol consumption and subsequent changes one year after trauma.

METHODS

a transversal and longitudinal quantitative study carried out between November 2012 and September 2013 in the ED. Medical and nursing students collected blood samples, applied the J section of the Mini International Neuropsychiatric Interview (MINI) and submitted alcohol abusers and dependents to BI. One year after admission, patients were contacted and asked about their patterns of alcohol use and their reasons for any changes.

RESULTS

from a sample of 507 patients admitted to the ED for trauma, 348 responded to MINI, 90 (25.9%) being abusers and 36 (10.3%) dependent on alcohol. Among the abusers, the most frequent cause of injury was motorcycle accident (35.6%) and among the dependents it was predominantly interpersonal violence (22.2%). Positive blood samples for alcohol were identified in 31.7% of the abusers and 53.1% of the dependents. One year after trauma, 66 abusers and 31 dependents were contacted, and it was ascertained that 36.4% of the abusers and 19.4% of the dependents had decreased alcohol consumption. The main reported reason for the reduction was the experienced trauma.

CONCLUSION

the motorcycle accident was the most common cause of injury. The detection of problematic alcohol use and implementation of BI are important strategies in the ED, however for alcohol abusers and dependents, BI was not the most reported reason for any changes in patterns of alcohol use.

Alcohol-related emergency department admissions among adolescents in the Ghent and Sint-Niklaas areas

Alcohol abuse is a major health concern. The aim of this retrospective study was to analyse the alcohol-related emergency department (ED) admissions among adolescents in all hospitals of distinct areas during a 1-year period. In each hospital, all ED patients with a blood alcohol concentration (BAC) of at least 0.5 g/l were surveyed in a standardised way. Of the 3918 included patients, only 146 (3.7%) were < 18  years. The male-to-female ratio was 1.5:1. There was a strong preponderance of weekend and night time admissions. Most of the patients were transported by ambulance (77% of 138 patients with information on this item). The main reason for ED admittance was depressed level of consciousness (64%), trauma (12%), vomiting and/or abdominal pain (12%), agitation or aggression (4%), syncope (4%) and psychological problems (4%). The context of the alcohol intoxication was related to some kind of festivity in 85%, mental problems in 14% and chronic abuse in 1%. Median BAC values (and range) were 2.08 g/l (0.73-3.70 g/l) for boys and 1.51 g/l (0.73-2.90 g/l) for girls. Most patients (87%) could be discharged home within 24  hours. Our study confirms that problematic alcohol use leading to ED admissions starts in adolescence. Although the numbers of cases below 18 years are low when compared to adults, the phenomenon is alarming as it is associated with substantial health problems. Therefore, Belgium urgently needs a global national alcohol plan, with youngsters being one of the target groups.