Annals of Emergency Medicine
Volume 45, Issue 4 , Pages 430-432, April 2005

Preventing Alcohol Misuse Among Adolescents

  • Edward Bernstein, MD

      Affiliations

    • Corresponding Author InformationAddress for correspondence: Edward Bernstein, MD, Department of Emergency Medicine, Boston University School of Medicine, 815 Albany Street, Boston MA 02118; 617-414-3453, fax 617-630-9923
    • ,
  • Judith Bernstein, RNC, PhD

From the Department of Emergency Medicine, Boston University School of Medicine (E. Bernstein); the Department of Maternal and Child Health, Boston University School of Public Health (J. Bernstein); and the National Institute on Alcohol Abuse and Alcoholism Youth Alcohol Prevention Center, Boston University of Public Health (E. Bernstein, J. Bernstein), Boston, MA

published online 15 February 2005.

SEE RELATED ARTICLE, P. 420.

Article Outline

 

Comprehensive strategies to prevent underage drinking involve public policy changes, media campaigns, communities, schools, and clinical interventions in the emergency department (ED), as described by Maio et al1 in this issue of Annals. The authors focus our attention on adolescent alcohol misuse because many adolescents use the ED as their only source of health care and may return ill or injured if their drinking is not addressed.

Organizations representing ED practitioners highlight the importance of intervention with ED patients who are at-risk or dependent drinkers, and the National Institute for Alcohol Abuse and Alcoholism has given critical attention to promoting ED research in this field. 2, 3, 4 Adolescent binge drinking presents a major public health challenge. In 2002, 2 million youths aged between 12 and 20 years engaged in binge drinking (≥5 drinks per occasion) at least 5 times a month.5 According to the 2003 national Youth Risk Behavior Surveillance Survey, 28% of high school students consumed 5 or more drinks of alcohol in a row, within a couple of hours, in the past month. For 28%, drinking onset occurred before the age of 13 years; 12% had driven a car after drinking, and 30% had driven with a drinking driver in the past 30 days.6 Furthermore, youths who begin drinking early are more likely to develop alcohol dependence as adults. Those who begin at age 14 years are at least 3 times more likely to experience dependence (using Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria) than those who delay drinking to age 21 years.7 Early onset increases the likelihood of alcohol-related unintentional injuries8 and crash involvement after drinking,9 even after controlling for frequency of heavy drinking, alcohol dependence, and other factors related to age of onset.

Long-term learning deficits and serious health effects can occur when adolescents engage in high-risk drinking, even if they later revert to appropriate alcohol use.10 Along with hormonal changes, adolescents experience massive remodeling of neural connections in the brain, especially in the prefrontal and mesolimbic areas, as genetic, biological, cognitive, psychological, and sociocultural changes occur simultaneously.11 These structural events affect rule and spatial learning, memory, affective regulation, and goal-directed behavior, as well as contribute to and reinforce the effects of alcohol and other drugs of abuse. Adolescent social exploration and novelty seeking with peer groups may serve to promote learning of requisite skills for independent living, but may also have less desirable consequences. Research suggests that features of the adolescent brain may actually predispose adolescents to early and excessive alcohol use, altering brain growth and increasing the potential for rapid development of abuse/dependence disorders.12 One study analyzing magnetic resonance imaging scans among 17 year olds found that, compared with controls, those diagnosed with alcohol use disorders had a smaller volume in the hippocampus, a critical region for memory and new learning.13

What can ED providers do about adolescent drinking? There is much we can learn from the article by Maio et al.1 The authors implemented a universal intervention with a sample containing both drinkers and nondrinkers as a component of a broader community intervention strategy. This study was a carefully implemented, randomized controlled trial. It used valid and reliable instruments, delivered a brief standardized intervention, required no training or monitoring for adherence, and had a follow-up rate of 88%. The intervention, which consisted of an interactive computerized program, was developed with the help of a youth focus group and featured a simulated house party in which the subjects could choose a “party pal” from 5 cartoon characters and visit various rooms in the house. Through participation in the scenarios, participants could learn accurate information about alcohol misuse, improve their decisionmaking skills, and improve their ability to resist social pressure.14 Program content was derived from a school-based curriculum that had demonstrated sufficient power in previous studies to modify the trajectory of alcohol use among adolescents.

The authors report that 655 of 843 youths who were eligible completed the program. The intervention was acceptable to 94% of participants; 74% reported that it helped them to reflect on their alcohol use. However, at 1-year follow-up, no significant positive effects were demonstrated in the intervention group as a whole. Both the intervention and the control group reduced their binge drinking at 3 months, but at 12 months both had returned to baseline levels.

Among a subgroup of subjects who had previous drinking and driving experience, however, the intervention did reduce binge drinking episodes and the alcohol misuse index compared with controls.

What explains these findings? A number of questions come to mind. Could the strategy of a universal intervention for drinkers and nondrinkers alike account for these findings? Could the characteristics and size of the targeted group have contributed?

The authors' hypothesis was that the laptop intervention would reduce the age-related increase in alcohol misuse that one would normally expect to see in a control group. No other ED studies have attempted to provide a primary prevention-focused intervention for a universal or general population. It is possible this study lacked the power to answer this question. It certainly lacked the power to evaluate results year by year, in order to control for a maturational effect. Furthermore, it has been difficult to show any influence over time of curriculum-based or knowledge-based approaches on youth who have not yet begun to drink. In a systematic review of 27 studies of primary prevention in adolescents, only 3 demonstrated intervention effectiveness on all outcome measures, 6 demonstrated intervention effectiveness on some measures, and 18 showed no effect at all.15 It is therefore not surprising that the computerized intervention reported here, which included a majority of nondrinkers, was shown to be successful solely among drinking drivers (secondary prevention).

There are only 2 other randomized, controlled trials of alcohol interventions with adolescent ED patients,16, 17 and only 1 of these enrolled teens younger than 18 years. Among 152 13 to 17 year olds enrolled by Spirito et al,17 both groups experienced a reduced quantity of drinking at 12 months but no change in high-volume drinking or alcohol-related consequences. The mean for binge drinking episodes per month in the intervention group was 1.82 at baseline, 1.0 at 3 months, 2.12 at 6 months, and 1.66 at 12 months, versus the control group means of 2.56, 2.06, 2.56, and 3.11, respectively.

How does this outcome compare to the study by Maio et al?1 The laptop intervention group reported 1.2 binge drinking episodes per month at baseline, 0.9 at 3 months, and 1.4 at 12 months, versus 1.0, 0.8, and 1.2, respectively, for controls. The Spirito et al17 study enrolled a group whose visits were directly related to drinking, yet they did not show any change in binge drinking at 1 year. The studies by Brown University17 and Maio et al1 showed declines in binge drinking episodes at 3 months for both intervention and control groups. Maio et al1 attribute these declines to the teachable moment of the injury visit and interpret the return to baseline at 12 months as the natural maturation of the study population.

What are the implications for understanding the limited effect of the intervention? Both studies1, 17 found some significance for the intervention in a subgroup analysis with higher severity of baseline drinking. These findings could direct researchers to target or select a more severe population, rather than a universal audience of adolescents, and to power their study accordingly.

Could the findings be explained by the method of delivery, quality, intensity, or the duration or frequency of the intervention? Another area to consider is the effect of different types of intervention strategies on different subpopulations. Maio et al1 adapted a school-based strategy. We can ask whether school-based interventions that produce environmental change can translate to the ED. Also, the injured ED adolescent population may be not ready to make a connection between alcohol and their current or a future injury. Among 18 and 19 year olds studied by Spirito et al,17 enrollees with low motivation to change at baseline benefited most from a motivational approach. Assessing readiness to change and negotiating change may be a possible addition to the curriculum-based approach tested by Maio et al.1

Finally, because ED interventions by their very nature need to be brief and need to have a low impact on patient flow and resources, it stands to reason that such interventions may also have a brief impact. A booster session18 and referrals to pediatric or adolescent physicians could complement the ED effort. A kiosk in the ED waiting room might offer the interactive software, provide referrals, and suggest that patients talk with their physicians if these issues are relevant to them.

An ED intervention will have greatest impact if it is part of a comprehensive, community-based, public health approach. The redesigned Drug Abuse Warning Network (DAWN), which now collects data on underage drinking and referrals from 500 EDs, can provide objective outcome measures, so we can begin to see if what we do in the ED has the desired effect.

In conclusion, we congratulate the editors for publishing this rigorously conducted study, despite the fact that the intervention was only significant for a subgroup, and only 1 in 20 in the total sample received benefit. This innovative, interactive laptop intervention represents an attempt to use limited ED staff resources and time effectively to reduce the social and medical consequences of adolescent alcohol abuse. Preventive interventions are worth our effort if they reduce by even a small amount the number of times that we have to tell yet another family that a child died as a result of driving while intoxicated, alcohol poisoning, or a fight or fall related to alcohol. This past year, the National Institute for Alcohol Abuse and Alcoholism funded 20 ED investigators to conduct research on alcohol interventions. As National Institute for Alcohol Abuse and Alcoholism Director Dr. Ting-Kai Li aptly pointed out recently, “Hospital EDs offer a unique opportunity not available elsewhere for alcohol abuse screening, brief counseling and referral.”19

Back to Article Outline

References 

  1. Maio RF, Shope JT, Blow FC, et al. A randomized controlled trial of an emergency department–based interactive computer program to prevent alcohol misuse among injured adolescents. Ann Emerg Med. 2005;45:420–429
  2. In:  Bonnie RJ,  O'Connell ME editor. National Research Council and Institute of Medicine. Reducing Underage Drinking: A Collective Responsibility. Washington, DC: The National Academies Press; 2004;
  3. National Institute on Alcohol Abuse and Alcoholism Web site. NIAAA initiative on underage drinking. Available at: http://www.niaaa.nih.gov/about/underage.htm. Accessed November 2, 2004.
  4. Emergency Department Alcohol Education Project Web site. The ED physician and the problem drinker. Available at: http://www.ed.bmc.org/sbirt. Accessed November 10, 2004.
  5. Substance Abuse and Mental Health Services Administration . Results From the 2002 National Survey on Drug Use and Health: National Findings. NHSDA Series H-22, Pub. No. SMA 03-3836 Rockville, MD: Department of Health and Human Services; 2003;
  6. Grunbaum JA, Kann L, Kinchen S, et al. Youth Behavior Risk Surveillance—United States, 2003. MMWR. 2004;53:1–29
  7. Grant B. The impact of family history of alcoholism on the relationship between the age of onset of alcohol use and DSM-IV alcohol dependence. Alc Health Res World. 1998;22:144–147
  8. Hingson RW, Heeren T, Jamanka A, et al. Age of drinking onset and unintentional injury involvement after drinking. JAMA. 2000;284:1527–1533
  9. Hingson R, Heeren T, Levenson S, et al. Age of drinking onset, driving after drinking, and involvement in alcohol related motor-vehicle crashes. Accid Anal Prev. 2002;34:85–92
  10. Duncan CB. The natural history of alcohol abuse disorders. Addiction. 2004;99(Suppl 2):5–32
  11. Lerner R, Lerner J, DeStefanis I, et al. Understanding developmental systems in adolescence: implications for methodological strategies, data analytic approaches and training. J Adol Res. 2001;16:9–27
  12. Brown SA, Tapert SF. Adolescents and the trajectory of alcohol use: basics to clinical studies. Ann NY Acad Sci. 2003;1021:234–244
  13. Bellis MD, Clark DB, Beer SR, et al. Hippocampal volume in adolescent-onset alcohol use disorders. Am J Psychiatr. 2000;157:737–744
  14. Gregor MA, Shope JT, Blow FC, et al. Feasibility of using an interactive laptop program in the emergency department to prevent alcohol misuse among adolescents. Ann Emerg Med. 2003;42:276–284
  15. Minozzi S, Grilli R. The systematic review of studies on the efficacy of interventions for the primary prevention of alcohol abuse among adolescents. Epidemiol Prev. 1997;21:180–188
  16. O'Leary-Tevyaw T, Monti P. Motivational enhancement and other brief interventions for adolescent substance abuse: foundations, applications and evaluations. Addiction. 2004;99:63–81
  17. Spirito A, Monti P, Barnett NP, et al. A randomized clinical trial of brief motivational intervention for alcohol-positive adolescents treated in an emergency department. J Pediatr. 2004;145:396–402
  18. Longabaugh R, Woolard RF, Nirenberg TD, et al. Evaluating the effects of a brief motivational intervention for injured drinkers in the emergency department. J Consult Clin Psychol. 1999;67:989–994
  19. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. News release: Alcohol agencies announce academic emergency medicine department collaboration. Available at: http://www.niaaa.nih.gov/press/2004/NASD04-04.htm. Accessed January 18, 2005.

 Funding and support: The authors report that this study did not receive any outside funding or support.Reprints not available from the authors.

PII: S0196-0644(04)01745-7

doi:10.1016/j.annemergmed.2004.12.003

Refers to article:

  • A Randomized Controlled Trial of an Emergency Department–Based Interactive Computer Program to Prevent Alcohol Misuse Among Injured Adolescents , 15 February 2005

    Ronald F. Maio, Jean T. Shope, Frederic C. Blow, Mary Ann Gregor, Jennifer S. Zakrajsek, James E. Weber, Michele M. Nypaver
    Annals of Emergency Medicine April 2005 (Vol. 45, Issue 4, Pages 420-429)

Annals of Emergency Medicine
Volume 45, Issue 4 , Pages 430-432, April 2005

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