Drinking norms, readiness to change, and gender as moderators of a combined alcohol intervention for first-year college students.

INTRODUCTION: Alcohol interventions targeting college students and their parents have been shown to be efficacious. Little research has examined moderators of intervention efficacy to help tailor interventions for subgroups of students. METHOD: This study is a secondary data analysis of readiness to change, drinking norms, and gender as moderators of an efficacious peer- and parent-based intervention (Turrisi et al., 2009). Students (n=680) were randomized to the combined peer and parent intervention (n=342) or assessment-only control (n=338). RESULTS: The combined intervention reduced peak blood alcohol content (BAC) compared to control. Gender and norms did not moderate the relationship between the intervention and drinking. Significant interactions were found between gender, precontemplation, and intervention. Students in the combined condition with higher precontemplation had lower weekly drinking compared to those with lower precontemplation. This pattern was also found among men for peak BAC and alcohol-related consequences but not among women, indicating a three-way interaction. CONCLUSION: Interventions may need to consider readiness to change and gender to optimize effectiveness.

Prevalence and Trends of Concurrent Opioid Analgesic and Benzodiazepine Use Among Veterans Affairs Patients with Post-traumatic Stress Disorder, 2003-2011.

BACKGROUND: Patients with post-traumatic stress disorder (PTSD) have complex and multiple symptoms, including anxiety, insomnia, and co-occurring pain, often treated with opioids and benzodiazepines. While concurrent use of these medications poses safety concerns, little is known about the trends of long-term concurrent use and the prevalence of high-risk conditions among those who are prescribed them. Study objectives were to examine the trends in annual prevalence of long-term concurrent opioid and benzodiazepine use among patients with PTSD and prevalence of high-risk conditions in concurrent users of these medications. DESIGN: Retrospective review of pharmacy records of the Veteran Affairs Northwest Integrated Network (VISN20). SUBJECTS: Patients (n = 66,210) with PTSD receiving care during 2003-2011. METHODS: Concurrent use was defined as overlapping opioid and benzodiazepine prescriptions for ≥90 consecutive days. Gender-specific logistic regressions estimated long-term concurrent use of these medications and tested for linear trends over 9-years. RESULTS: The trend in age-adjusted long-term concurrent opioid and benzodiazepine use over 9-years increased 52.7%, from 3.6% (95% confidence interval, 3.3-3.9%) to 5.5% (5.3-5.8%), in men and 79.5%, from 3.9% (3.0-5.0%) to 7.0% (6.2-7.9%), in women. In 2011, 17.1% of long-term concurrent users were prescribed morphine-equivalent daily doses of opioids ≥100 mg and 49.4% had a documented high-risk condition. CONCLUSION: Despite known risks associated with prescribing opioids and benzodiazepines concurrently, the adjusted prevalence of long-term concurrent use rose significantly among men and women with PTSD in VISN20 over a 9-year period. Common use of these medications among patients with high-risk conditions suggests comprehensive strategies are needed to identify and monitor patients at increased risk for adverse outcomes.

Adverse Childhood Experiences, Military Service, and Adult Health.

INTRODUCTION: Prevalence of adverse childhood experiences (ACE) and associations with adult health may vary by gender and military service. This study compares the gender-specific prevalence of ACE by military service and determines the associations of ACE with adult health risk factors and health-related quality of life (HRQOL). METHODS: This 2014 analysis used data from the 2011 and 2012 CDC Behavioral Risk Factor Surveillance System. Total ACE was operationalized as the number of reported ACE. Associations of total ACE with adult health risk factors were estimated using general linear models; associations with HRQOL were estimated using negative binomial regression. All analyses adjusted for age and race/ethnicity. RESULTS: Those with military service had more total ACE than civilians. Higher ACE was associated with poorer HRQOL among women (physical health, military service, relative risk [RR]=1.20, 95% CI=1.09, 1.33; civilians, RR=1.18, 95% CI=1.17, 1.20; mental health, military service, RR=1.21, 95% CI=1.12, 1.32; civilians, RR=1.25, 95% CI=1.23, 1.26). Among men, these associations were somewhat attenuated in those with military service relative to civilians (physical health, military service, RR=1.13, 95% CI=1.09, 1.18; civilians, RR=1.20, 95% CI=1.17, 1.24; mental health, military service, RR=1.21, 95% CI=1.16, 1.27; civilians, RR=1.30, 95% CI=1.27, 1.34). CONCLUSIONS: Relative to civilians, men and women with military service report more ACE, but associations of ACE with adult HRQOL are weaker among men with military service relative to civilians. There is a need to implement and disseminate evidence-based programs to prevent ACE and for research on the long-term health consequences of ACE in military populations.

Factors Underlying Quality Problems with Alcohol Screening Prompted by a Clinical Reminder in Primary Care: A Multi-site Qualitative Study.

BACKGROUND: Population-based alcohol screening is recommended in primary care, and increasingly incentivized by policies, yet is challenging to implement. The U.S. Veterans Health Administration (VA) achieved high rates of screening using a national performance measure and associated electronic clinical reminder to prompt and facilitate screening and document results. However, the sensitivity of alcohol screening for identifying unhealthy alcohol use is low in VA clinics. OBJECTIVE: We aimed to understand factors that might contribute to low sensitivity of alcohol screening. DESIGN: This was an observational, qualitative study. PARTICIPANTS: Participants included clinical staff responsible for conducting alcohol screening and nine independently managed primary care clinics of a single VA medical center in the Northwestern U.S. APPROACH: Four researchers observed clinical staff as they conducted alcohol screening. Observers took handwritten notes, which were transcribed and coded iteratively. Template analysis identified a priori and emergent themes. KEY RESULTS: We observed 72 instances of alcohol screening conducted by 31 participating staff. Observations confirmed known challenges to implementation of care using clinical reminders, including workflow and flexibility limitations. Three themes specific to alcohol screening emerged. First, most observed screening was conducted verbally, guided by the clinical reminder, although some variability in approaches to screening (e.g., paper-based or laminate-based screening) was observed. Second, specific verbal screening practices that might contribute to low sensitivity of clinical screening were identified, including conducting non-verbatim screening and making inferences, assumptions, and/or suggestions to input responses. Third, staff introduced and adapted screening questions to enhance patient comfort. CONCLUSIONS: This qualitative study in nine clinics found that implementation of alcohol screening facilitated by a clinical reminder resulted primarily in verbal screening in which questions were not asked vertbatim and were otherwise adapted. Non-verbal approaches to screening, or patient self-administration, may enhance validity and standardization of screening while simultaneously addressing limitations of the clinical reminder and issues related to perceived discomfort.

Take One for the Team? Influence of Team and Individual Sport Participation on High School Athlete Substance Use Patterns.

The current web-based survey investigated the association between team or individual sport participation (or both) and self-reported alcohol and tobacco use among high school athletes (N=1, 275) transitioning to college. Peak Blood Alcohol Concentration, weekly drinking, and alcohol-related problems were significantly lower among athletes in individual sports compared to other groups. Athletes competing in both team and individual sports reported greater lifetime tobacco use and combined alcohol/tobacco use compared to individual or team sports alone. Preventive strategies targeting HS athletes in general and those participating in team sports in particular may be useful in minimizing future alcohol use and related problems.

Clinical monitoring and high-risk conditions among patients with SUD newly prescribed opioids and benzodiazepines.

BACKGROUND: Opioid therapy alone or in combination with benzodiazepines poses safety concerns among patients with substance use disorders (SUD). Guidelines for opioid therapy recommend SUD treatment and enhanced monitoring, especially in patients with additional risk factors, but information on monitoring practices is sparse. This study estimated high-risk conditions - psychiatric comorbidity, suicide risk, and age <35 and ≥65 - and described clinical monitoring among patients with SUD who were newly prescribed opioids alone and concurrent with benzodiazepines long-term. METHODS: This study included VA Northwest Veterans Network patients with SUD who started opioids only (n=980) or benzodiazepines and opioids concurrently (n=353) long-term (≥90 days) in 2009-2010. Clinical characteristics, outpatient visits and urine drug screens (UDS) documented within 7-months after starting medications were extracted from VA data. RESULTS: Approximately 67% (95% CI: 64-70) of opioids only and 94% (92-97) of concurrent medications groups had ≥1 psychiatric diagnoses. Prevalences of suicide risk and age <35 and ≥65 were 7% (5-8), 6% (5-8) and 18% (15-20) among the opioids only group, and 20% (16-24), 8% (5-11) and 13% (9-16) among the concurrent medications group. Among patients prescribed opioids only and medications concurrently, 87% and 91% attended primary care, whereas 28% and 26% attended SUD specialty-care. Overall, 30% and 48% of opioids only and concurrent medications groups engaged in mental health or SUD care, and 35% and 39% completed UDS. CONCLUSIONS: Improvements in clinical monitoring are needed as many VA patients with SUD and comorbid risks who initiate opioid therapy do not receive sufficient mental health/SUD care or UDS monitoring.

Prevalence of clinically recognized alcohol and other substance use disorders among VA outpatients with unhealthy alcohol use identified by routine alcohol screening.

OBJECTIVE: The purpose of routine alcohol screening is to identify patients who may benefit from brief intervention, but patients who also have alcohol and other substance use disorders (AUD/SUD) likely require more intensive interventions. This study sought to determine the prevalence of clinically documented AUD/SUD among VA outpatients with unhealthy alcohol use identified by routine screening. METHODS: VA patients 18-90 years who screened positive for unhealthy alcohol use (AUDIT-C ≥3 women; ≥4 men) and were randomly selected for quality improvement standardized medical record review (6/06-6/10) were included. Gender-stratified prevalences of clinically documented AUD/SUD (diagnosis of AUD, SUD, or alcohol-specific medical conditions, or VA specialty addictions treatment on the date of or 365 days prior to screening) were estimated and compared across AUDIT-C risk groups, and then repeated across groups further stratified by age. RESULTS: Among 63,397 eligible patients with unhealthy alcohol use, 25% (n=2109) women and 28% (n=15,199) men had documented AUD/SUD (p<0.001). The prevalence of AUD/SUD increased with increasing AUDIT-C risk, ranging from 13% (95% CI 13-14%) to 82% (79-85%) for women and 12% (11-12%) to 69% (68-71%) for men in the lowest and highest AUDIT-C risk groups, respectively. Patterns were similar across age groups. CONCLUSIONS: One-quarter of all patients with unhealthy alcohol use, and a majority of those with the highest alcohol screening scores, had clinically recognized AUD/SUD. Healthcare systems implementing evidence-based alcohol-related care should be prepared to offer more intensive interventions and/or effective pharmacotherapies for these patients.

Follow-up care for alcohol misuse among OEF/OIF veterans with and without alcohol use disorders and posttraumatic stress disorder.

Little is known about follow-up care for alcohol misuse in the Veterans Affairs (VA) health care system among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans with and without alcohol use disorders (AUD) and/or posttraumatic stress disorder (PTSD). Using data from 4725 OEF/OIF VA outpatients with alcohol screening (2006-2010), we compared the prevalence of follow-up for alcohol misuse--brief intervention (BI) or referral to treatment--among patients with and without AUD and/or PTSD. Among 933 (19.7%) patients with alcohol misuse (AUDIT-C ≥5), 77.0% had AUD and/or PTSD. Rates of BI or referral for alcohol misuse were higher among patients with AUD (76.9%) and both AUD and PTSD (70.1%) compared to those with PTSD only (53.1%) and neither AUD nor PTSD (52.3%). Among OEF/OIF VA outpatients with alcohol misuse, those with AUD had higher rates of follow-up for alcohol misuse than those without, but PTSD was not associated with differential follow-up.

Characterizing high school students who play drinking games using latent class analysis.

Heavy alcohol use and its associated negative consequences continue to be an important health issue among adolescents. Of particular concern are risky drinking practices such as playing drinking games. Although retrospective accounts indicate that drinking game participation is common among high school students, it has yet to be assessed in current high school students. Utilizing data from high school students who reported current drinking game participation (n=178), we used latent class analysis to investigate the negative consequences resulting from gaming and examined underlying demographic and alcohol-related behavioral characteristics of students as a function of the resultant classes. Three classes of "gamers" emerged: (1) a "lower-risk" group who had a lower probability of endorsing negative consequences compared to the other groups, (2) a "higher-risk" group who reported that they experienced hangovers and difficulties limiting their drinking, got physically sick, and became rude, obnoxious, or insulting, and (3) a "sexual regret" group who reported that they experienced poor recall and unplanned sexual activity that they later regretted. Although the frequency of participating in drinking games did not differ between these three groups, results indicated that the "lower-risk" group consumed fewer drinks in a typical gaming session compared to the other two groups. The present findings suggest that drinking games are common among high school students, but that mere participation and frequency of play are not necessarily the best indicators of risk. Instead, examination of other constructs such as game-related alcohol consumption, consequences, or psychosocial variables such as impulsivity may be more useful.

Relationships among veteran status, gender, and key health indicators in a national young adult sample.

OBJECTIVE: Although many risk behaviors peak during young adulthood, little is known about health risk factors and access to care. This study assessed health indicators and health care access in a national sample of young adult veterans and civilians. METHODS: Data were from the 2010 Behavioral Risk Factor Surveillance System, a national telephone survey. Of 27,471 participants, ages 19-30 years, 2.2% were veterans (74.6% were male) and 97.7% were civilians (37.6% were male). Gender-stratified comparisons assessed health indicators and health care access by veteran status. Multivariate logistic regression was used to examine health indicators and health care access as a function of gender and veteran status. RESULTS: In the overall sample, women were more likely than men to have insurance, to have a regular physician, and to have had a routine checkup and yet were more likely to report financial barriers to care. Women also were more likely than men to report general medical and mental distress and higher lifetime anxiety and depressive disorders, whereas men were more likely to be overweight or obese and to report tobacco use and high-risk drinking. Adjusted analyses revealed a higher likelihood of general medical distress and higher rates of lifetime anxiety disorders among veterans compared with civilians, although there were no differences between veterans and civilians regarding health care utilization and hazardous drinking. CONCLUSIONS: Findings extend the literature on health care status and modifiable risk factors for young adults by identifying differences between men and women and between veterans and civilians. Interventions may need to be tailored on the bases of gender and veteran status because of several differences in mental health and general health needs.

Alcohol expectancies and risky drinking behaviors among high school athletes: "I'd rather keep my head in the game".

Research suggests that high school students who participate in sports may be at elevated risk for alcohol use compared to their non-athlete peers; however, reasons for this association are unclear. Alcohol expectancy theory posits that individuals who expect favorable outcomes to occur because of alcohol use are more likely to drink than those who do not endorse such beliefs. As such, the present study was designed to examine the associations of alcohol expectancy outcomes and valuations (i.e., beliefs about whether an outcome is good or bad), as well as alcohol expectancies related to sports functioning (e.g., alcohol's effects on one's ability to learn new plays and recover physically from sporting activities), with risky drinking among high school athletes. Participants were 219 in-season high school athletes (mean age = 15.6, range = 13-18) who completed anonymous self-report surveys. A structural equation model indicated that endorsement of positive alcohol expectancy outcomes and favorable evaluations of negative expectancy outcomes were associated with higher levels of risky drinking. Conversely, greater endorsement of negative athletic-functioning drinking expectancies was associated with lower levels of risky drinking. Future research considerations and implications for intervention efforts targeting high school athletes are discussed.

Perceived norms for thinness and muscularity among college students: what do men and women really want?

BACKGROUND: Perceived norms are related to health-related attitudes and behaviors, including body image. The current study examined body dissatisfaction and perceived norms for thinness and muscularity among male and female college students. METHOD: Participants included 842 undergraduate students (64.5% female) who completed an online survey assessing body image and other health-related attitudes and behaviors. A series of independent sample and paired sample t tests were conducted to document sex differences in body dissatisfaction and misperceptions of thinness and muscularity norms. RESULTS: Based on pictorial ratings, both males and females reported discrepancies between their ideal and actual figures. Females perceived other females as significantly thinner and less muscular than the actual norms. Males perceived other males as significantly heavier than their own figures, but the difference between men's self-reported muscularity and perceived norm was not significant. Both males and females misperceived opposite-sex attractiveness norms for thinness and muscularity. DISCUSSION: Results suggest the importance of evaluating same-sex and opposite-sex perceived norms of thinness and muscularity in the etiology of body dissatisfaction, and this research informs social norms interventions targeting misperceptions of body image norms among both males and females.

Substance use patterns among first-year college students: secondary effects of a combined alcohol intervention.

This study explored secondary effects of a multisite randomized alcohol prevention trial on tobacco, marijuana, and other illicit drug use among a sample of incoming college students who participated in high school athletics. Students (n = 1,275) completed a series of Web-administered measures at baseline during the summer before starting college and 10 months later. Students were randomized to one of four conditions: a parent-delivered intervention, a brief motivation enhancement intervention (Brief Alcohol Screening and Intervention for College Students [BASICS]), a condition combining the parent intervention and BASICS, and assessment-only control. A series of analyses of variance evaluating drug use outcomes at the 10-month follow-up assessment revealed significant reductions in marijuana use among students who received the combined intervention compared to the BASICS-only and control groups. No other significant differences between treatment conditions were found for tobacco or other illicit drug use. Our findings suggest the potential utility of targeting both alcohol and marijuana use when developing peer- and parent-based interventions for students transitioning to college. Clinical implications and future research directions are considered.

Development and preliminary validation of a comprehensive marijuana motives questionnaire.

OBJECTIVE: Relatively little research has evaluated motives for using marijuana based on users' self-reported reasons. This article details the construction and psychometric validation of a new marijuana motives questionnaire. METHOD: Participants included 346 marijuana-using college students who completed online assessments regarding their motives for, frequency of, and problems associated with their marijuana use. RESULTS: Exploratory and confirmatory factor analysis supported a 12-factor scale, including the following: (1) Enjoyment, (2) Conformity, (3) Coping, (4) Experimentation, (5) Boredom, (6) Alcohol, (7) Celebration, (8) Altered Perception, (9) Social Anxiety, (10) Relative Low Risk, (11) Sleep/Rest, and (12) Availability. Regression results indicated enjoyment, boredom, altered perception, relative low-risk, and sleep/rest were each uniquely associated with greater frequency of use. Experimentation and availability motives were associated with less use. After accounting for use, coping and sleep/rest were associated with significantly more consequences whereas enjoyment was associated with fewer consequences. Additional results comparing the scale to an existing marijuana motives measure indicated comparatively good convergent validity. CONCLUSIONS: Emerging adult college students may have several different reasons for using marijuana, which are uniquely related to use and negative consequences. Results are considered in terms of their implications for brief interventions.

Competitive anxiety in young athletes: differentiating somatic anxiety, worry, and concentration disruption.

The age-appropriate Sport Anxiety Scale-2 (SAS-2; Smith, Smoll, Cumming, & Grossbard, 2006) was used to assess levels of cognitive and somatic anxiety among male and female youth sport participants. Confirmatory factor analyses with a sample of 9-14 year old athletes (N=1038) supported the viability of a three-factor model of anxiety involving somatic anxiety, worry, and concentration disruption previously demonstrated in high school and college samples. Tests for factorial invariance revealed that the three-factor model was an equally good fit for 9-11 year olds and 12-14 year olds, and for both males and females. Gender and age were modestly related to anxiety scores. Worry about performing poorly was highest in girls and in older athletes, whereas boys reported higher levels of concentration disruption in competitive sport situations. Implications for emotional perception and for the study of competitive anxiety in young athletes are discussed.

Athletic identity, descriptive norms, and drinking among athletes transitioning to college.

College student-athletes are at risk for heavy alcohol consumption and related consequences. The present study evaluated the influence of college student and college athlete descriptive norms and levels of athletic identity on drinking and related consequences among incoming college students attending two universities (N=1119). Prior to the beginning of their first year of college, students indicating high school athletic participation completed assessments of athletic identity, alcohol consumption, drinking-related consequences, and normative perceptions of alcohol use. Estimations of drinking by college students and student-athletes were significantly greater than self-reported drinking. Athletic identity moderated associations among gender, perceived norms, drinking, and related consequences. Athlete-specific norms had a stronger effect on drinking among those reporting higher levels of athletic identity, and higher levels of athletic identity exclusively protected males from experiencing drinking-related consequences. Implications of the role of athletic identity in the development of social norms interventions targeted at high school athletes transitioning to college are discussed.

Normative Misperceptions and Marijuana Use Among Male and Female College Athletes.

This research assessed the frequency of marijuana use and perceptions of gender-specific marijuana use among intercollegiate athletes from two National Collegiate Athletic Association (NCAA) Division 1 universities. Normative data were gathered in a live setting. Male athletes reported significantly greater marijuana use than female athletes and the overall sample reported higher prevalence of use than national averages for college athletes and non-athletes. Gender-specific perceptions among male and female athletes exceeded actual self-reported use, and perceived marijuana use among male athletes was strongly associated with personal use. The findings demonstrate the salience of group-specific marijuana norms and present implications for normative feedback interventions among college athletes.

Body Image Concerns and Contingent Self-Esteem in Male and Female College Students.

Body dissatisfaction in females, and to a lesser extent males, is associated with low self-esteem, depression, and eating disorders. This research examined gender as a moderator of the association between contingent self-esteem and body image concerns, including weight and muscularity. Participants included 359 (59.1% female) heavy drinking first-year U.S. undergraduate students who completed a survey assessing health-related risk behaviors. Hierarchical multiple regression was used to examine relations among gender, contingent self-esteem, and body image. Females reported higher levels of contingent self-esteem and greater concerns about their weight, although males reported a greater drive for muscularity. The relationship between contingent self-esteem and weight concerns was stronger among females, and for males, greater contingent self-esteem was associated with a greater drive for muscularity.

Alcohol and risky sex in athletes and nonathletes: what roles do sex motives play?

OBJECTIVE: Studies indicate greater sexual risk-taking behaviors and alcohol use in student-athletes compared with nonathletes, particularly in college samples. Although research has documented an association between drinking and risky sex, studies have not examined the role of sex motives in predicting risky sex in athletes. The purpose of the current study was to extend previous research on athletes' risk-taking behaviors by examining incoming college student-athletes and nonathletes' alcohol consumption, risky sexual behavior, and sex motives. METHOD: Participants included 2,123 (58.9% female) incoming college students attending a northwest university, 221 of whom reported intercollegiate athletic participation during their upcoming year. Hierarchical multiple regression analyses were conducted to examine associations between sex motives and risky sexual behaviors using a cross-sectional design. RESULTS: Results indicated greater weekly alcohol consumption, frequency of drinking before or during sex, and number of sexual partners in athletes compared with nonathletes. Athletes also reported greater levels of enhancement motives for sex and lower levels of intimacy motives than nonathletes, although no differences were found for coping motives. Significant interactions indicated that, for athletes, greater levels of enhancement sex motives predicted a greater number of sexual partners and more frequent drinking before or during sex, and greater levels of intimacy motives predicted less frequent drinking before or during sex. CONCLUSIONS: Student-athletes are at risk for problematic outcomes associated with risky sex, including drinking before or during sex and having sex with multiple partners. Prevention efforts targeted at incoming college student-athletes should consider the role of sex motives.

How informative are parent reports of attention-deficit/hyperactivity disorder symptoms for assessing outcome in clinical trials of long-acting treatments? A pooled analysis of parents' and teachers' reports.

OBJECTIVE: The validity of parent reports of children's attention-deficit/hyperactivity disorder (ADHD) symptoms has been questioned, especially in clinical trials. Some advocate the exclusive use of teacher reports, maintaining that parent reports are not sensitive to changes in ADHD symptoms. This study compares the ability of parent and teacher reports to document change during clinical trials of long-acting treatments. METHODS: We conducted a literature search of Medline to identify any published clinical trials in pediatric ADHD that met the following criteria: 1) used a randomized design, 2) examined the efficacy of long-acting agents or standard formulations using 3-times-a-day dosing, and 3) used both parent and teacher reports of the same measure of ADHD symptoms as a study outcome. For each measurement of ADHD symptoms, we calculated effect sizes for parent and teacher reports. RESULTS: Three large, randomized, controlled clinical trials were identified (N = 1445 subjects). For every outcome for which teacher reports documented significant improvement, parent reports did also. Pooled analysis revealed a larger effect captured by the parent report relative to the teacher report. CONCLUSION: Results suggest that parent reports are at least as sensitive to detecting change in ADHD symptoms as teacher reports in clinical trials that assess the efficacy of long-acting agents. These results suggest that parent reports are informative for detecting change during treatment of children with ADHD.