Subtypes of Alcohol Dependence and 36-Year Mortality.

BACKGROUND: Chronic, heavy alcohol use is associated with multiple health problems, including premature death. Further, the clinical presentation of alcohol dependence may differentially affect and predict the long-term health consequences of affected individuals. Subtypes of alcohol dependence based upon treatment intake information can help identify homogenous groups of patients for treatment purposes, but have not been used to predict long-term outcomes. The current study examined mortality in a 36-year posttreatment interval among 4 subtypes of alcohol-dependent patients based upon their initial intake data. METHODS: Extensive baseline data were collected from n = 316 male and female patients receiving inpatient treatment for alcohol dependence between 1980 and 1982. Four alcohol dependent subtypes (Del Boca & Hesselbrock, Alcohol Health Res World, 20:56, 1996) derived from the baseline data were used to examine the 1-year posttreatment drinking status and the risk of death 36 years postdischarge. Public records were used to determine patient deaths in the 36 years since discharge. RESULTS: At the 36-year follow-up interval since discharge, 68.4% of the sample had died. The 4 subtypes were found to be associated with different rates of resumption of regular drinking in the first year posttreatment and a differential risk of mortality. An increased risk for returning to regular drinking (once a week or more) and early death were associated with subtypes defined, in part, by conduct problems and externalizing disorders. Regardless of subtype membership, women had the highest risk of death following treatment. CONCLUSIONS: This study demonstrates the clinical usefulness of subtypes of alcohol dependence for examining different alcohol use outcomes, including predicting mortality. The increased risks for returning to regular drinking once a week or more and early death posttreatment among subtypes associated with conduct problems and externalizing disorders suggest the need for continued monitoring and possible additional intervention postdischarge.

Screening, Brief Intervention and Referral to Treatment (SBIRT): rationale, program overview and cross-site evaluation.

AIMS: Since 2003, the US Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment (SAMHSA, CSAT) has awarded 32 Screening, Brief Intervention and Referral to Treatment (SBIRT) grants to states, territories and tribal organizations to enhance services for persons with, or at risk for, substance use disorders. The grants supported an expansion of the continuum of care to include screening, brief intervention, brief treatment and referral to treatment in general medical and community settings. This paper describes the SAMHSA SBIRT program in the context of the scientific research that motivated its development, as well as the two cross-site evaluations that are the subject of subsequent papers in this Supplement. METHODS: A narrative review of research evidence pertaining to SBIRT and of the cross-site evaluation design that made it possible to determine whether the SAMHSA SBIRT grant program achieved its intended aims. The 11 programs within the two cohorts of grant recipients that were the subject of the cross-site evaluations are described in terms of SBIRT service components, performance sites, providers, management structure/activities and patient/client characteristics. CONCLUSION: The US SAMHSA SBIRT program is an effective way to introduce a variety of new services that extend the continuum of care for substance-involved individuals, ranging from early intervention with non-dependent substance users to referral of more serious cases to specialized substance abuse treatment.

Development of the SBIRT checklist for observation in real-time (SCORe).

BACKGROUND AND AIMS: Screening, Brief Intervention and Referral to Treatment (SBIRT) programs have been implemented widely in medical settings, with little attention focused on how well providers adhere to evidence-based service delivery in everyday practice. The purposes of this paper were to: (1) introduce a flexible, relatively simple methodology, the SBIRT Checklist for Observation in Real-time (SCORe), to assess adherence to evidence-based practice and provide preliminary evidence supporting its criterion validity; and (2) illustrate the feasibility and potential utility of the SCORe by analyzing observations of providers within four large-scale SBIRT programs in the United States. METHODS: Eighteen potential adherence judges were trained to recognize SBIRT service elements presented in realistic taped portrayals constructed to serve as criterion coding standards. Across the four SBIRT programs, 76 providers were observed performing 388 services in three types of medical settings; emergency departments (n = 10), hospital out-patient/ambulatory clinics (n = 16) and hospital in-patient settings (n = 5). RESULTS: Across two exercises, trainees identified 81% of screening and 75% of brief intervention (BI) elements correctly; for the six FRAMES components (Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy), agreement ranged from 69% to 91%. Across programs, 56% of screening, 54% of brief intervention (BI) (81% of FRAMES) and 53% of referral to treatment elements were observed. Programs differed significantly in adherence [screening, P = 0.024; BI, P < 0.001; FRAMES, P < 0.001; referral to treatment (RT), P < 0.001]; medical setting differences were minimal. CONCLUSIONS: The Screening, Brief Intervention and Referral to Treatment Checklist for Observation in Real-time provides a flexible method for assessing adherence to evidence-based Screening, Brief Intervention and Referral to Treatment service protocols. Preliminary evidence supports the criterion validity, feasibility and potential utility of the Screening, Brief Intervention and Referral to Treatment Checklist for Observation in Real-time protocol.

Screening, Brief Intervention and Referral to Treatment: implications of SAMHSA's SBIRT initiative for substance abuse policy and practice.

AIMS: This paper describes the major findings and public health implications of a cross-site evaluation of a national Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program funded by the US Substance Abuse and Mental Health Services Administration (SAMHSA). METHODS: Eleven multi-site programs in two cohorts of SAMHSA grant recipients were each funded for 5 years to promote the adoption and sustained implementation of SBIRT. The SBIRT cross-site evaluation used a multi-method evaluation design to provide comprehensive information on the processes, outcomes and costs of SBIRT as implemented in a variety of medical and community settings. FINDINGS: SBIRT programs in the two evaluated SAMHSA cohorts screened more than 1 million patients/clients. SBIRT implementation was facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Although the quasi-experimental nature of the outcome evaluation does not permit causal inferences, pre-post differences were clinically meaningful and statistically significant for almost every measure of substance use. Greater intervention intensity was associated with larger decreases in substance use. Both brief intervention and brief treatment were associated with positive outcomes, but brief intervention was more cost-effective for most substances. Sixty-nine (67%) of the original performance sites adapted and redesigned SBIRT service delivery after initial grant funding ended. Four factors influenced SBIRT sustainability: presence of program champions, availability of funding, systemic change and effective management of SBIRT provider challenges. CONCLUSIONS: The US Substance Abuse and Mental Health Services Administration's Screening, Brief Intervention and Referral to Treatment (SBIRT) demonstration program was adapted successfully to the needs of early identification efforts for hazardous use of alcohol and illicit drugs. SBIRT is an innovative way to integrate the management of substance use disorders into primary care and general medicine. Screening, Brief Intervention and Referral to Treatment implementation was associated with improvements in treatment system equity, efficiency and economy.

Screening, brief intervention and referral to treatment (SBIRT): implementation barriers, facilitators and model migration.

AIMS: To identify barriers and facilitators associated with initial implementation of a US alcohol and other substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) grant program, and to identify modifications in program design that addressed implementation challenges. DESIGN: A mixed-method approach used quantitative and qualitative data, including SBIRT provider ratings of implementation barriers and facilitators, staff interview responses and program documentation. SETTING: Multiple sites within the first seven programs funded in a national demonstration program in the United States. PARTICIPANTS: One hundred and two SBIRT providers were surveyed; 221 SBIRT stakeholders and staff were interviewed. MEASUREMENTS: Mean ratings of barriers and facilitators were calculated using provider survey responses. An inductive content analysis of interview responses identified factors perceived to support and challenge implementation; program modifications that occurred over time were recorded. FINDINGS: Providers rated pre-selected implementation facilitators higher than barriers. Content analysis of interview responses revealed six themes: committed leaders; intra- and inter-organizational communication/collaboration; provider buy-in and model acceptance; contextual factors; quality assurance; and grant requirements. Over time, programs tended to: adopt more efficient 'pre-screen' item sets; screen for risk factors in addition to alcohol/substance use; use contracted specialists to deliver SBIRT services; conduct services in high-volume emergency department and trauma center settings; and implement on-site and telephonic treatment delivery. CONCLUSIONS: Screening, Brief Intervention and Referral to Treatment program implementation in the United States is facilitated by committed leadership and the use of substance use specialists, rather than medical generalists, to deliver services. Many implementation challenges can be addressed by an adequate start-up phase focused on comprehensive education and training, and on the development of intra- and inter-organizational communication and collaboration; opinion leader support; and practitioner and host site buy-in.

The SBIRT program matrix: a conceptual framework for program implementation and evaluation.

BACKGROUND AND AIMS: Screening, Brief Intervention and Referral to Treatment (SBIRT) is a comprehensive, integrated, public health approach to the delivery of services to those at risk for the adverse consequences of alcohol and other drug use, and for those with probable substance use disorders. Research on successful SBIRT implementation has lagged behind studies of efficacy and effectiveness. This paper (1) outlines a conceptual framework, the SBIRT Program Matrix, to guide implementation research and program evaluation and (2) specifies potential implementation outcomes. METHODS: Overview and narrative description of the SBIRT Program Matrix. RESULTS: The SBIRT Program Matrix has five components, each of which includes multiple elements: SBIRT services; performance sites; provider attributes; patient/client populations; and management structure and activities. Implementation outcomes include program adoption, acceptability, appropriateness, feasibility, fidelity, costs, penetration, sustainability, service provision and grant compliance. CONCLUSIONS: The Screening, Brief Intervention and Referral to Treatment Program Matrix provides a template for identifying, classifying and organizing the naturally occurring commonalities and variations within and across SBIRT programs, and for investigating which variables are associated with implementation success and, ultimately, with treatment outcomes and other impacts.

How many versus how much: 52 weeks of alcohol consumption in emerging adults.

In previous research using timeline follow-back methods to closely monitor drinking and related variables over the first year of college (9 months), we showed that drinking varied considerably over time in accord with academic requirements and holidays. In a new community sample (N = 576) of emerging adults (18- and 19-year-olds who reported having begun drinking prior to recruitment), we used similar methods to compare drinking patterns in college and noncollege individuals over a full calendar year (including summer). To reduce the extreme distortion in computations of average drinking over restricted time spans (i.e., 1 week) that arise because large numbers of even regular drinkers may not consume any alcohol, we analyzed data using recently developed two-part latent growth curve modeling. This modeling distinguished consumption levels from numbers of individuals drinking in a given period. Results showed that drinking levels and patterns generally did not differ between college and noncollege drinkers, and that both groups responded similarly to even those contexts that may have seemed unique to one (i.e., spring break). We also showed that computation of drinking amounts without accounting for "zero drinkers" could seriously distort estimates of mean drinking on some occasions; for example, mean consumption in the total sample appeared to increase on Thanksgiving, whereas actual average consumption for those who were drinking diminished.

Enhancing the validity and utility of randomized clinical trials in addictions treatment research: I. Treatment implementation and research design.

PURPOSE: This paper is the first in a series that examines methods for improving the validity and utility of randomized clinical trials (RCTs) in addictions treatment research. The specific foci of this article are treatment implementation and research design. SCOPE: We begin by considering the conditions under which the RCT provides an appropriate design choice. Sections that follow discuss methodological issues with respect to RCT structure and collaborative arrangements; treatment specification, delivery and cost; experimental design; and randomization/blinding procedures. We emphasize the importance of advance planning; treatment integrity and discriminability; treatment standardization; staff training and supervision; client compliance; maintenance of between-group equivalence across study conditions; and inclusion of appropriate comparison groups in study designs. CONCLUSIONS: Investigators are encouraged to maximize the internal validity of RCTs, but also to consider methods for enhancing external validity. The utility of addictions RCTs for advancing theory and improving clinical practice can be enhanced by investigating underlying mechanisms of action.

Enhancing the validity and utility of randomized clinical trials in addictions treatment research: III. Data processing and statistical analysis.

PURPOSE: This is the third paper in a series that reviews strategies for optimizing the validity and utility of randomized clinical trials (RCTs) in addictions treatment research. Whereas the two previous papers focused on design and implementation, here we address issues pertaining to data processing and statistical analysis. SCOPE: Recommendations for enhancing data quality and utility are offered in sections on data coding and entry; and data format, structure and management. We discuss the need for preliminary data analyses that examine statistical power; patterns of attrition; between-group equivalence; and treatment integrity and discriminability. We discuss tests of treatment efficacy, as well as ancillary analyses aimed at explicating treatment processes. CONCLUSIONS: Safeguards are necessary to protect data quality, and advance planning is needed to ensure that data formats are compatible with statistical objectives. In addition to treatment efficacy, statistical analyses should evaluate study internal and external validity, and investigate the change mechanisms that underlie treatment effects.

Enhancing the validity and utility of randomized clinical trials in addictions treatment research: II. Participant samples and assessment.

PURPOSE: This paper is the second in a series that describes strategies for optimizing the validity and utility of randomized clinical trials (RCTs) in addictions treatment research. Whereas the first paper focused on treatment implementation and research design, here we address issues pertaining to participant samples and assessment methods. SCOPE: With respect to participant samples, sections focus on the definition of study populations; informed consent; sample size and statistical power; recruitment and enrollment; sample retention; and participant tracking systems. Assessment topics include eligibility screening and baseline assessment; treatment-related variables; outcome measures; the frequency of follow-up evaluation; and assessment process. A final section highlights the importance of pilot testing. CONCLUSIONS: Sample recruitment and retention strategies are needed that safeguard both internal and external validity. Daily estimation assessment procedures are recommended because of their versatility for creating a range of outcome measures. Assessment batteries should include measures that permit the investigation of treatment processes and mechanisms of action.

Binge drinking and alcohol-related problems among community college students: implications for prevention policy.

Binge drinking and alcohol-related problems among students at traditional 4-year universities have been well documented. However, little is known about the frequency of their such behaviors and its consequences among community college students, who comprise roughly 44% of all undergraduate students in the United States. The present study examined binge drinking and alcohol-related problems in 762 (61% female) ethnically diverse (65% Caucasian, 20% Hispanic, 9% African American) community college students (mean age = 26.23, SD = 7.81). Based on gender-specific criteria, 25% engaged in binge drinking. As compared to nonbingers and current abstainers, bingers had higher rates of drinking-related problems. The implications of these findings for research and for prevention/intervention programs are discussed.

Variation in the drinking trajectories of freshmen college students.

F. K. Del Boca, J. Darkes, P. E. Greenbaum, and M. S. Goldman (2004) examined temporal variations in drinking during the freshmen college year and the relationship of several risk factors to these variations. Here, using the same data, the authors investigate whether a single growth curve adequately characterizes the variability in individual drinking trajectories. Latent growth mixture modeling identified 5 drinking trajectory classes: light-stable, light-stable plus high holiday, medium-increasing, highdecreasing, and heavy-stable. In multivariate predictor analyses, gender (i.e., more women) and lower alcohol expectancies distinguished the light-stable class from other trajectories; only expectancies differentiated the high-decreasing from the heavy-stable and medium-increasing classes. These findings allow for improved identification of individuals at risk for developing problematic trajectories and for development of interventions tailored to specific drinker classes.

Up close and personal: temporal variability in the drinking of individual college students during their first year.

Surveys have documented excessive drinking among college students and tracked annual changes in consumption over time. This study extended previous work by examining drinking changes during the freshman year, using latent growth curve (LGC) analysis to model individual change, and relating risk factors for heavy drinking to growth factors in the model. Retrospective monthly assessments of daily drinking were used to generate weekly estimates. Drinking varied considerably by week, apparently as a function of academic requirements and holidays. A 4-factor LGC model adequately fit the data. In univariate analyses, gender, race/ethnicity, alcohol expectancies, sensation seeking, residence, and data completeness predicted growth factors (ps <.05); gender, expectancies, residence, and data completeness remained significant when covariates were tested simultaneously. Substantive, methodological, and policy implications are discussed.

The validity of self-reports of alcohol consumption: state of the science and challenges for research.

AIMS: To review three topics pertaining to the validity of alcohol self-reports: factors that influence response accuracy; the relative merits of different self-report approaches; and the utility of using alternative measures to confirm verbal reports. FINDINGS: Response behavior is influenced by the interaction of social context factors, respondent characteristics, and task attributes. Although research has advanced our knowledge about self-report methods, many questions remain unanswered. In particular, there is a need to investigate how task demands interact with different patterns of drinking behavior to affect response accuracy. There is also a continuing need to use multiple data sources to examine the extent of self-report response bias, and to determine whether it varies as a function of respondent characteristics or assessment timing. CONCLUSION: Self-report methods offer a reliable and valid approach to measuring alcohol consumption. The accuracy of such methods, however, can be improved by research directed at understanding the processes involved in response behavior.

Advancing the expectancy concept via the interplay between theory and research.

Four papers from a 2001 Research Society on Alcoholism symposium on expectancy theory and research are summarized. The symposium contributors describe recent advances in expectancy theory and discuss their implications for assessment and for understanding the processes of development and change in the behavioral domain of alcohol use. First, findings are integrated across the diverse domains in which the expectancy concept has been applied. Second, the implications of expectancy theory for the measurement of expectancy structure and process are examined. Third, research and theory regarding alcohol expectancy development and change are presented, with an emphasis on the role of expectancies as mediators of known antecedents of drinking. Finally, an experimental procedure for investigating the causal role of expectancies is described, together with its implications for theory testing and prevention or intervention programming. Collectively, the symposium contributions demonstrate the utility of an integrated expectancy theory for the generation of innovative research operations and new insights regarding behavior development and change. Consistent with the notion of consilience, expectancy theory has demonstrated a convergence of findings across different levels of analysis, as well as across different operations, methods, and research designs.

Gender and Alcoholic Subtypes.

Although women generally have been subjects of alcohol research less often than men, gender can be used as a defining characteristic in subtyping schemes. Whether the sexes actually differ in aspects of their alcoholism, such as in etiology and degree of severity, however, is not known. Analyzing a sample of male and female alcoholics using several different statistical methods, the researchers found that men and women with either a severe or mild form of alcoholism differed little in their character profiles and etiologies. Women and men with moderately severe alcoholism, however, tended to differ with respect to co-occurring psychopathologies (e.g., depression or antisocial personality) and the degree to which they drank to relieve other conditions (e.g., boredom). These findings suggest that different forms of alcoholism treatment may be most effective for men and women with moderately severe alcoholism. However, as is the case with any subtyping scheme, this conclusion cannot be applied to the general population without further research.