Moderators and mediators of two brief interventions for alcohol in the emergency department

Objective To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department. Methods Patients (18–24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1‐ and 3‐month booster sessions and 6‐ and 12‐month follow‐ups. Gender, alcohol status/severity group [ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+], attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self‐efficacy and alcohol treatment seeking. Results Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol‐related injury at follow‐up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found. Conclusions Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.     

The effect of brief interventions on alcohol consumption among heavy drinkers in a general hospital setting

AIMS: (i) To evaluate the effect of receiving one of two brief interventions in reducing alcohol consumption among general hospital patients compared with usual care. (ii) To assess whether a brief intervention of self-efficacy enhancement was superior to a self-help booklet in reducing alcohol consumption. DESIGN: A three-arm cluster randomized controlled trial. SETTING: Seven general medical, six general surgical, one dermatology and two otolaryngology wards of a large teaching hospital covering a large urban and rural area. PARTICIPANTS: A total of 215 of 789 in-patients aged 18-75 years, who screened positive for alcohol consumption in excess of national recommended limits according to a 7-day retrospective drinking diary. INTERVENTIONS: Participants were allocated to receive one of three interventions: (i) face-to-face self-efficacy enhancement; (ii) a self-help booklet; or (iii) usual care. MEASUREMENTS: The primary outcome measure was change in reported alcohol consumption at 6-month follow-up as measured by a 7-day retrospective drinking diary. Secondary outcomes were change in: number of alcohol drinking days in last week; the maximum units of alcohol consumed on any one day in last week; and Drinking Refusal Self-efficacy Expectancy Questionnaire score. FINDINGS: Compared to the usual care group the self-efficacy enhancement group (-10.1 units 95% CI -16.1 to -4.1) and the self-help booklet group (-10.0 units 95% CI -16.0 to -3.9) had greater reductions in self-reported weekly alcohol consumption. There was no evidence that self-efficacy enhancement was superior to the self-help booklet (P = 0.96). CONCLUSIONS: Brief interventions delivered in hospital offer simple means of helping heavy drinkers to reduce their alcohol consumption.     

Five-year outcomes of a brief alcohol intervention for adult in-patients with psychiatric disorders

Aims To compare 5 year outcomes (general hospital and mental health morbidity and mortality) among general hospital psychiatric in‐patients randomized to receive either an alcohol reduction motivational interview (MI) or information pack (IP), and compare these to matched controls. Design We recruited 120 patients aged 18–64 years who scored ≥8 on the Alcohol Use Disorders Identification Test (AUDIT). We selected matched controls from in‐patients not recruited but who reached the same AUDIT threshold. At 5 years, follow‐up data were collected via a state‐wide hospital record system. Findings There were no significant differences between the MI and IP groups in terms of ‘survival’ to their first alcohol‐related, other general hospital or mental health admission over 5 years. Matched controls had significantly more mental health in‐patient episodes (F[1,226] 4.4, P < 0.05) and greater length of hospital stay (F[1,226] 4.8, P < 0.05) than the combined MI‐IP group. Furthermore, the MI‐IP group had longer ‘survival’ times to both first general hospital (mean 583 versus 392 days) and mental health in‐patient (mean 788 versus 580 days) events. Collapsed across groups, dependent and harmful consumers had shorter ‘survival’ times than hazardous consumers (AUDIT classifications). Conclusions Alcohol interventions have medium‐term health benefits for those with mental health and alcohol use problems. Importantly, there were no differences in outcome between the intervention groups. The low cost of providing an IP makes it attractive as an alcohol intervention. The AUDIT provided an effective means of identifying those who are at risk of subsequent alcohol‐related admissions and may benefit from intervention.     

Brief alcohol interventions for mandated college students: comparison of face-to-face counseling and computer-delivered interventions

Aims College students who violate alcohol policies are often mandated to participate in alcohol‐related interventions. This study investigated (i) whether such interventions reduced drinking beyond the sanction alone, (ii) whether a brief motivational intervention (BMI) was more efficacious than two computer‐delivered interventions (CDIs) and (iii) whether intervention response differed by gender. Design Randomized controlled trial with four conditions [brief motivation interventions (BMI), Alcohol 101 Plus?, Alcohol Edu for Sanctions^®, delayed control] and four assessments (baseline, 1, 6 and 12 months). Setting Private residential university in the United States. Participants Students (n = 677; 64% male) who had violated campus alcohol policies and were sanctioned to participate in a risk reduction program. Measurements Consumption (drinks per heaviest and typical week, heavy drinking frequency, peak and typical blood alcohol concentration), alcohol problems and recidivism. Findings Piecewise latent growth models characterized short‐term (1‐month) and longer‐term (1–12 months) change. Female but not male students reduced drinking and problems in the control condition. Males reduced drinking and problems after all interventions relative to control, but did not maintain these gains. Females reduced drinking to a greater extent after a BMI than after either CDI, and maintained reductions relative to baseline across the follow‐up year. No differences in recidivism were found. Conclusions Male and female students responded differently to sanctions for alcohol violations and to risk reduction interventions. BMIs optimized outcomes for both genders. Male students improved after all interventions, but female students improved less after CDIs than after BMI. Intervention effects decayed over time, especially for males.     

A randomized trial of a brief alcohol intervention for needle exchangers (BRAINE)

Aims To test motivational interviewing (MI) as a brief intervention for reducing alcohol use among needle exchange clients. Design Randomized clinical trial. Setting Needle exchange program—Providence, Rhode Island, USA. Participants Between 2/98 and 10/99, we recruited 187 AUDIT‐positive (>8) active injection drug users. Intervention Those assigned to a brief motivational intervention (MI) condition received two 1‐hour therapist sessions following assessment visits, 1 month apart, focusing on alcohol use and HIV risk‐taking. Measurements Control and MI subjects received identical research assessments at baseline, 1 and 6 months following study enrollment. At 6 months, study outcomes included days of alcohol use measured using the time‐line follow‐back method. Findings Study retention was 96.8% at 6 months. Participants reported an average of 12.0 drinking days at baseline and 8.3 at 6 months. Significant reductions in drinking days were observed in both treatment conditions. We found significant treatment × baseline drinking day interaction effects. Tests for simple main effects were significant for subjects with above median (>9) baseline drinking day frequency, but not for those with below median baseline drinking frequency. Comparisons on dichotomous outcomes provided supporting evidence of treatment efficacy; those in MI were over two times more likely than controls to report reductions of 7 days or more (P < 0.05). Conclusions This study provides the first direct evidence that brief MI can decrease alcohol use among active injection drug users with drinking problems. Heavier drinkers seem best suited for this intervention, but the optimal intensity of treatments and which components of brief intervention are most effective deserve further study.     

Identification of behaviour change techniques to reduce excessive alcohol consumption

Background Interventions to reduce excessive alcohol consumption have a small but important effect, but a better understanding is needed of their ‘active ingredients’. Aims This study aimed to (i) develop a reliable taxonomy of behaviour change techniques (BCTs) used in interventions to reduce excessive alcohol consumption (not to treat alcohol dependence) and (ii) to assess whether use of specific BCTs in brief interventions might be associated with improved effectiveness. Methods A selection of guidance documents and treatment manuals, identified via expert consultation, were analysed into BCTs by two coders. The resulting taxonomy of BCTs was applied to the Cochrane Review of brief alcohol interventions, and the associations between the BCTs and effectiveness were investigated using meta‐regression. Findings Forty‐two BCTs were identified, 34 from guidance documents and an additional eight from treatment manuals, with average inter‐rater agreement of 80%. Analyses revealed that brief interventions that included the BCT ‘prompt self‐recording’ (P = 0.002) were associated with larger effect sizes. Conclusions It is possible to identify specific behaviour change techniques reliably in manuals and guidelines for interventions to reduce excessive alcohol consumption. In brief interventions, promoting self‐monitoring is associated with improved outcomes. More research is needed to identify other behaviour change techniques or groupings of behaviour change techniques that can produce optimal results in brief interventions and to extend the method to more intensive interventions and treatment of alcohol dependence.     

Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations

Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples ( n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples ( n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after >3–6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.     

Childhood predictors of drunkenness in late adolescence among males: a 10-year population-based follow-up study

AIMS: To study childhood precursors of drunkenness frequency among 18-year-old boys in a representative, nation-wide 10-year follow-up study. DESIGN: In 1989, a general population sample of 2,946 8-year-old boys was collected. Three different informant sources were used: parents, teachers and the boys themselves. The follow-up was 10 years later in 1999, when the boys were called up for their obligatory military service at age 18. Information about drunkenness frequency was obtained from 78.3% (n=2306) of the original sample. SETTING: Finland, nation-wide; in 1989 at schools, in 1999 at the obligatory military call-up. PARTICIPANTS: General population sample of Finnish boys born in 1981. MEASUREMENTS: At age 8, the Rutter A2 scale, Rutter B2 scale and Child Depression Inventory (CDI) were used. At age 18, self-reported drunkenness frequency during the previous 6 months was determined. FINDINGS: Of the subjects, 15.0% reported never being drunk from alcohol, 74.6% reported being occasionally drunk and 10.4% reported being drunk at least once a week during the previous 6 months. After adjusting for other variables, teacher's estimate of the child's problem behaviour at age 8 predicted frequent drunkenness in late adolescence. Hyperactive problems predicted both occasional and frequent drunkenness. Conduct problems at age 8 predicted only frequent drunkenness. High teacher-reported scores of emotional problems predicted lower occurrence of drunkenness-orientated alcohol use. CONCLUSIONS: The educational system has a potential role in detecting boys at risk of later risk-taking behaviours, such as frequent drunkenness. Early interventions in children with conduct problems and hyperactivity are called for.