1. Brief Alcohol Interventions for College Students and At-Risk Populations Jennifer Cadigan, M.A. Department of Educational, School, and Counseling Psychology University of Missouri

2. Outline Review research on prevalence of harmful alcohol use/risk factors, focus on college students Discuss concept of brief interventions Brief motivational interventions (BMI) Personalized drinking feedback interventions Provide an example of content from an intervention Personalized feedback interventions for other at-risk groups

3. Prevalence of Alcohol Use 80% of college students consume alcohol (OMalley & Johnson, 2002) 20% of college students met criteria for alcohol abuse or dependence (Dawson et al., 2004) Binge drinking (heavy episodic drinking) Has historically been defined as 5+ drinks for men or 4+ drinks for women in one sitting Binge drinkers more likely to experience problems as a result of alcohol use 41% of men and 34% of women reported heavy drinking (binge drinking) within the past 2 weeks (White et al., 2006)

4. Harmful Alcohol Use Heavy alcohol use has been considered the primary public health concern among college students (Wechsler, Lee, Kuo & Lee, 2000) Approximately: 1,800 deaths 599,000 injuries 646,000 assaults 97,000 sexual assaults related to alcohol use each year among college students (Hingson, Zha, & Weitzman, 2009)

5. Alcohol-Related Problems Heavy drinking - > more alcohol-related problems (Wechsler et al., 2000, 2002) Among students who used alcohol… 35% did something later regretted 27% blacked out 7% trouble with police/authorities 21% unplanned sexual activity physical injury poor academic performance felt sick argument or fight operating a car under the influence

6. Alcohol-Related Problems As a result of other students drinking… 29% of college students were insulted/humiliated 15% had property damaged 20% experienced an unwanted sexual advance 9% were assaulted

7. Greenbaum et al., 2005

8. Biphasic Effect Myth that more alcohol is better Physiological phases Euphoria; reduce inhibitions (occurs at low BACs and as BAC is initially rising) Depressant-at high BACs (over.05) and when the BAC curve is descending (after you have finished drinking) feel tired; slows thinking and reflexes Alcohol is ultimately a depressant-slows heart-rate and breathing, and these effects are more prominent

9. Slide courtesy http://www.luc.edu

10. BAC Measure of the amount of alcohol in bloodstream As BAC, level of intoxication Influenced by…. alcohol quantity speed of drinking gender- slower for females to process it than males weight food individual variations

11. At-risk groups College Students Intercollegiate Athletes Greek Students

12. College Athletes Consume more alcohol than those not participating in athletics (Leichliter et al., 1998) More alcohol-related problems than non- athletes (Leichliter et al., 1998; Nelson & Wechsler, 2001) arguments or fights, driving while intoxicated, police, hurt or injured while drinking

13. %Binge Drinking Nelson &Wechsler, 2001; Wechsler et al., 1997

14. Alcohol Outcomes Cadigan, Littlefield, Martens, & Sher, 2013

15. Alcohol Outcomes Cadigan, Littlefield, Martens, & Sher, 2013 athlete Non- athlete

16. Intercollegiate Athletes Apparent risk factor for problem drinking- athletes show sharper increases in problem drinking Need for prevention/ intervention efforts for athletes based on their current status (i.e., becoming an athlete vs. stopping) Psychological and behavioral differences Increased time constraints, isolated environment on campus, have a higher social status (Harvey, 1999; Parham, 1993) Anxiety, pressure from teammates, athletic culture (Martens, 2012)

17. Brief Motivational Interventions (BMI)

18. The Need for Interventions… Historically, alcohol treatment involved 12-step programs or some type of inpatient program Intensive treatment may not be appropriate for all those experiencing alcohol-related risks Unmotivated/non-treatment seeking individuals Individuals experiencing relatively mild/moderate risks

19. Harm Reduction Approach Differ from zero-tolerance/abstinence based programs emphasize the positive aspects of using alcohol AND lessen negative consequences of alcohol (Marlatt, 1998) Moderation or abstinence goals

20. Intervention Response Spectrum Specialized Treatment Primary Prevention Brief Intervention None Mild Moderate Severe Thresholds for Action Slide courtesy of the Addictive Behaviors Research Center, University of Washington, adapted from the Institute of Medicine

21. Motivational Interviewing and Brief Interventions Many brief interventions are delivered in a Motivational Interviewing (MI) based format 1-2 sessions; 15-50 mins MI defined as: A client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick, 2002, p. 25) MI promotes a nonconfrontational and collaborative discussion Goal-directed

22. Key aspects of MI: Recognizes ambivalence regarding changing behaviors Working collaboratively with a client Helping clients verbalize their own reasons for change Respecting client autonomy (e.g., a decision not to engage in change)

23. MI interventions involve: Expressing empathy of the clients behaviors, attitudes, etc. Developing discrepancy between current behavior and goals Supporting self-efficacy for change (e.g., helping interested clients set goals) Open ended questions- How does your alcohol use fit with your career goals? Affirmations- Youve tried very hard to cut down Summary- What Ive heard Is.....Is that right?

24. BMI Structure Intervention may begin with brief orientation and/or decisional balance exercise Core of the session involves covering personalized drinking feedback that is based on the clients response to different questionnaires Feedback example Session may conclude with goal setting or other discussions regarding plans for behavior change

25. Decisional Balance Exercises Ask the client to address both the positive and negative aspects of his/her behavior in question Can directly get at some of the reasons for change in the early part of the session Facilitator: Im wondering if we can just start out with you explaining to me what it is you enjoy about drinking, as well as the things that you dont enjoy about it.

26. BMI Structure Intervention may begin with brief orientation and/or decisional balance exercise Core of the session involves covering personalized drinking feedback that is based on the clients response to different questionnaires Feedback example Session may conclude with goal setting or other discussions regarding plans for behavior change

27. Personalized Feedback Commonly used as a strategy for reducing alcohol use and related problems among college students (Carey et al., 2012) Exact components of feedback can vary among interventions Typically include: social norms comparisons (e.g., how a students typical drinks per week compares to campus norms/age/gender norms, often expressed as a percentile rank) feedback on alcohol use (e.g., self-reported BAC levels and consequences typically associated with such levels) alcohol-related problems experienced over some time interval calories consumed from alcohol

28. Personalized Feedback Example pg. 1

29. Personalized Feedback Example pg. 2

30. Personalized Feedback Example pg. 3

31. Personalized Feedback Example pg. 4

32. Personalized Feedback Example pg. 5

33. Personalized Feedback Example pg. 6

34. Brief Interventions Brief alcohol interventions that include personalized feedback about ones alcohol-use and related-problems have been efficacious in reducing use and consequences (Carey, Scott-Sheldon, Elliott, Garey, & Carey, 2012) Interventions aim to change alcohol use by developing a discrepancy between ones actual and desired behaviors (Miller & Rollnick, 2002) Personalized Feedback Interventions are considered a core component of alcohol interventions

35. Targeted interventions For whom? Drinking norms for specific reference group Typical College Student Athletes Greek Demographic Group Age Gender

36. Delivery Modality Traditionally Personalized Feedback Interventions have been delivered: in-person typically include MI component mail computer In-person and computer-based /mailed PFIs have resulted in a significant reduction of alcohol use when compared to control conditions (Larimer et al., 2007; Lewis et al., 2007; Neighbors et al. 2004)

37. Study of adolescents in an emergency room setting Subjects were 94 older adolescents (18-19) who were alcohol positive when receiving ER treatment Control condition was standard care Handout on alcohol-related dangers List of treatment services Experimental condition was brief MI session + Personalized Drinking Feedback (PDF) Monti et al., 1999, Journal of Consulting and Clinical Psychology Research Findings

38. At 6-month follow-up, those in the control condition: Were 4x as likely to report drinking and driving and experiencing an alcohol-related injury than those in the MI + PDF group Reported more alcohol-related problems Reported greater drinking levels

39. MI + Personalized Drinking Feedback Summary MI can be effective at changing behaviors across a variety of domains MI interventions can be delivered by a wide array of health professionals MI interventions can be effectively combined with other behavioral approaches Very brief MI-inspired approaches may also be effective at changing behavior

40. Personalized Drinking Feedback (PDF) Interventions

41. Computer/mailed PDF Cost effective- dont require a trained clinician Ease of dissemination Have been shown to be more effective than control conditions and/or as effective as in-person interventions in several clinical trials (e.g., Larimer et al., 2007; Neighbors et al. 2004)

42. Personalized Drinking Feedback Personalized drinking feedback-only (PDF) intervention targeted specifically toward college athletes (Martens et al., 2010) No MI component (no clinician contact) N = 263 Randomized to one of three conditions: PDF-targeted PDF-standard Education-only

43. PDF TargetedPDF standard Review of weekly drinking pattern Comparison of personal drinking to norm for typical college athlete Estimated BAC /risks associated for peak drinking over past 30 days, typical weekend drinking, and drinking the last time partied Stated motivations for drinking General alcohol-related problems Calories per week from alcohol Financial costs of alcohol Use of protective behaviors Review of weekly drinking pattern Comparison of personal drinking to norm for typical college student Estimated BAC and risks associated with it for peak drinking over past 30 days, typical weekend drinking, and drinking the last time partied Stated motivations for drinking General alcohol-related problems Calories per week from alcohol Financial costs of alcohol Use of protective behaviors Martens et al. (2010) Sport-specific alcohol-related problems Possible impact of alcohol use on athletic performance Possible impact of alcohol use on athletic injury

44. Six-Month Peak BAC-Full Sample Martens et al. (2010)

45. Six Month Peak BAC-Heavy Drinkers Martens et al. (2010)

46. Personalized Drinking Feedback Interventions For Other At-Risk Populations

47. OEF/OIF Veterans Afghanistan: Operation Enduring Freedom (OEF) Iraq: Operation Iraqi Freedom (OIF) Veterans report higher levels of alcohol use than non-veterans (Wagner et al., 2007) Rates of alcohol misuse among OEF/OIF veterans twice the rates of the general VA outpatient population (Calhoun et al., 2008) At risk for PTSD/other mental health concerns

48. Harry S Truman VA Memorial Hospital, Columbia, MO N = 325 Randomized to one of two conditions: computer delivered Personalized Drinking Feedback intervention in preventing hazardous alcohol use and alcohol-related problems among OEF/OIF veterans Education-only Baseline1 Month6 Month

49. Average age: 32 yrs old (range 20-54 yrs old) 93% Male 82% White; 9% African-American Occupation: 30% Students

50. Content of PDF intervention included: How ones drinking compares to typical drinking of the same gender, same age adult in the United States BAC Alcohol-related problems OEF/OIF veterans drinking norms Mental health problems (i.e., depression and anxiety) and possible association with alcohol use Cost Calories

51. Personalized Feedback Summary Data collection from Project Transition ongoing… initial results promising Personalized feedback alone is effective in drinking reduction in general population and student samples (Riper et al., 2009; Walters & Neighbors, 2005) Both in-person and computer personalized feedback better than control conditions

52. Future Directions Emerging technology Cell phones/apps Ecological Momentary Assessment (EMA) real time Targeted interventions

53. Concluding Thoughts Brief interventions (MI + PDF; PDF only) designed to decrease or prevent excessive alcohol use have been shown to be effective in multiple settings Effects from these interventions are relatively modest, but… They can provide bang for your buck, in terms of being relatively inexpensive and efficient May have tremendous cost benefits in certain settings

54. Acknowledgments Matthew Martens, Ph.D.

55. Questions?

56. Additional Personalized Feedback Information For students who endorse using both alcohol + other drugs