Drinking Among Young Adults

Screening, Brief Intervention, and Outcome

Peter M. Monti, Ph.D., Tracy O’Leary Tevyaw, Ph.D., and Brian Borsari, Ph.D.

Both college and noncollege populations face a high risk of becoming heavy drinkers and experiencing negative consequences of alcohol use. Because young people in these populations do not tend to identify themselves as having alcohol problems, they may be more readily identified through proactive screening in locations where they are likely to seek treatment related to alcohol problems, such as hospital emergency rooms, their college campuses, or workplaces. This article summarizes research on screening and brief interventions for alcohol use among young adults, particularly brief motivational interventions (BMIs). KEY WORDS: young adult; undergraduate student; heavy drinking; binge drinking; alcohol dependence; problematic AOD (alcohol and other drug) use; AOD effects and consequences; harm reduction; identification and screening for AOD use; intervention (persuasion to treatment); brief intervention; motivational interviewing; school­based intervention; prison­based prevention; emergency room; medical­facility­based prevention; drinking and driving education; workplace­based prevention; Employee Assistance Program

mple evidence demonstrates that at least once in the past month (Johnston PETER M. MONTI, PH.D., is a senior excessive alcohol use among et al. 2001), and 40 percent reported research career scientist at the Providence

A young people is a significant heavy episodic drinking (defined, for Veterans Affairs Medical Center and a cause for public concern (see table). men, as drinking five or more drinks professor of medical sciences and director Young adults in the 18–25 age group at least once in the past 2 weeks and, of the Center for Alcohol and Addiction consistently engage in high rates of for women, four or more drinks at least Studies, Brown University, both positions risky behaviors such as unprotected sex once in the last 2 weeks) (Wechsler and in Providence, Rhode Island. and substance use (Arnett 2000). The Nelson 2001). National Survey on Drug Use and Health Heavy drinking also is prevalent TRACY O’LEARY TEVYAW, PH.D., is an (Substance Abuse and Mental Health among young adults in the military. In assistant professor of psychiatry and human Services Administration [SAMHSA] a survey of 5,136 military personnel ages behavior, and BRIAN BORSARI, PH.D., 2003) revealed that young adults show 18 to 25, 2,763 (53.8 percent) reported is an assistant professor of community the highest prevalence of problem drink­ health, both at the Center for Alcohol ing. Specifically, 41 percent of young 1 The National Institute on Alcohol Abuse and Alcoholism and Addiction Studies, Brown University, adults reported drinking five or more (NIAAA) defines a standard drink as about 14 g of alcohol, Providence, Rhode Island. 1 per occasion at least once in the which corresponds to approximately 1.5 oz of 80­proof drinks distilled spirits, one glass of wine, or one 12­oz beer or past month (i.e., binge use), and 15 wine cooler. This research was supported by a VA percent reported drinking five or more Senior Career Research Scientist Award 2 These definitions of heavy drinking and binge drinking drinks per occasion on at least 5 differ­ differ from those provided by NIAAA, which defines binge to Peter M. Monti and by grants 1–RO1– ent days in the past month (i.e., heavy drinking as consumption of 4 or more drinks in about 2 AA–12319, 5–RO1–AA–09892, and 2 hours for women, and 5 or more drinks for men; heavy use). Among college students, approxi­ drinking is defined as more than 7 drinks per week for 2T32–AA–0745–19 from the National mately 67 percent reported using alcohol women and more than 14 drinks per week for men. Institute on Alcohol Abuse and Alcoholism.

236 Alcohol Research & Health Screening, Brief Intervention, and Outcome

a heavy­drinking episode in the past dependence (Jackson et al. 2001). (For adolescents who drank heavily during month, with 1,422 (28 percent) experi­ more discussion of this phenomenon, their teen years were significantly more encing at least one heavy­drinking episode see the article by O’Malley in this issue.) likely to be overweight and have high a week in the past month (Bray et al. Despite the fact that young adults’ blood pressure by the time they were 2003). Young adults often exhibit heavy alcohol use is in some sense develop­ 24 years old (Oesterle et al. 2004). Finally, drinking before entering the military; mentally normative, combating heavy repeated instances of heavy episodic for example, 1,506 of 2,002 Navy recruits alcohol use in this population is impor­ drinking among youth can have negative (89 percent under age 21) consumed tant for several reasons. The primary effects on the developing brain and brain alcohol in the past year, and one­third causes of illness and death among young function (Crews 2004; Caldwell et al. (519/1,506) of these recruits reported adults involve lifestyle and behavioral 2005; Monti et al. 2005) (see the article heavy episodic drinking as their typical factors, including excessive alcohol use by Tapert and colleagues in this issue). consumption pattern (Ames et al. 2002). (Schulenberg et al. 2001). Even one On college campuses, alcohol con­ Among young adults, 25 percent of episode of excessive drinking can have sumption consistently is linked to a variety males and 14 percent of females meet serious consequences that persist well of serious consequences. For example, (or at some time have met) the diagnostic beyond adolescence and young adult­ in 1998 and 2001, more than 500,000 criteria for alcohol dependence (SAMHSA hood, such as alcohol­related car crashes, students were injured in drinking­related 2003), as defined by the Diagnostic and unintended pregnancies, and physical incidents, more than 600,000 were Statistical Manual of Mental Disorders, fights leading to arrest or jail. Young assaulted by a fellow student who had Fourth Edition (DSM–IV) (American adults who engage in heavy episodic been drinking, and more than 1,600 Psychiatric Association 1994), with drinking are significantly more likely students died each year from injuries 13 percent of men and 6 percent of than those who do not drink heavily related to alcohol use (Hingson et al. women meeting diagnostic criteria for to get in trouble with police, damage 2005). alcohol dependence in the past 12 property, sustain injuries, drive after In addition, neighbors of colleges months (Grant et al. 2004). However, drinking, and engage in unplanned and who lived within 1 mile of campus were many young people “mature out” of or unprotected sexual activity (Wechsler 135 percent more likely to report second­ moderate excessive drinking; as they enter et al. 2000). Alcohol use can trigger hand effects of college student drinking, including vandalism, assault, and other their mid­twenties, their drinking no health problems even as early as adoles­ public disturbances (Wechsler et al. longer meets the criteria for abuse or cence and young adulthood. In one study, 2002b). Excessive alcohol use by col­ lege students is linked to risky sexual The Numbers Don’t Lie: The Need for Screening and Brief Intervention in the behavior (Wechsler et al. 2000). Among United States college women who reported being raped, 72 percent reported that the rape 27,386 Number of college students referred to school administration for occurred while they were intoxicated violating school alcohol policy in 2001 1 (Mohler­Kuo et al. 2004). Alcohol consumption also is associated with 99,109 Number of first­time hospital emergency department visits that were alcohol related in 2001 2 academic impairment, including miss­ ing classes, doing poorly on tests, and 6.2 million Number of full­time workers who are heavy alcohol users (five or getting behind in schoolwork (see more drinks on 5 or more days in the past month) 3 Perkins 2002 for a review). Despite these risks, college students usually accept 1,600 Number of college students who die each year from injuries 4 higher drinking levels than experts do related to alcohol use when defining a drinking problem in a 21.3% Percentage of driving under the influence (DUI) arrestees peer (Posavac 1993). They also tend to between the ages of 18 and 24 5 report feeling in control of their drinking even after acknowledging excessive alcohol 28% Percentage of parole violators under the influence of alcohol 6 use (Burrell 1992), and to dismiss the when committing a new offense need to reduce heavy drinking although 840,188 Number of State and Federal inmates in need of substance reporting alcohol tolerance and alcohol­ abuse treatment 6 related problems (Vik et al. 2000). When they need medical attention 1 Hoover 2003. for intoxication or injuries associated 2 Hingson 2004. with alcohol use, many college students 3 SAMHSA 2002. 4 Hingson et al. 2005. seek treatment off campus rather than 5 Bureau of Justice Statistics 1998. campus­based medical care (Colby et 6 Balenko 1998. al. 2000). As a result, college adminis­ trators may significantly underestimate

Vol. 28, No. 4, 2004/2005 237 the number of students who require Hospital Emergency Departments the AUDIT was a psychometrically sound screening instrument for detecting medical attention for alcohol­related A study of 18­ and 19­year­old patients harmful alcohol use in this population. incidents. In addition, if intoxicated who visited an ED for medical treatment In one large­scale screening of college students drive themselves to off­cam­ found that patients who were treated students conducted as part of the 1999 pus medical facilities or rely on friends for an alcohol­related event, such as a National Alcohol Screening Day, 13,053 who have been drinking to drive them, car crash, were significantly more likely students were screened at 499 campuses they may risk further injury and harm. to report more alcohol use and more A considerable number of students (Greenfield et al. 2003). Of these stu­ alcohol­related problems than patients dents, 4,005 (31 percent) reported scores appear to require, but do not seek, treated in the ED for events that did not medical treatment. A recent survey of that were indicative of hazardous drink­ involve alcohol (Barnett et al. 2003). ing. These findings support the idea more than 14,000 students revealed that This finding bolsters the notion that 6.3 percent met DSM–IV criteria for that college campuses can provide an EDs are a useful venue for identifying alcohol dependence at some time over important context in which to identify young people who may have alcohol young adults who are engaging in risky the past year, but only 6.2 percent of problems. Given the prevalence of alco­ alcohol use. Nevertheless, some evidence this 6.3 percent of students had sought hol use reported by young adults in the indicates that few college health clinics treatment for their drinking (Knight et armed forces, it also would be beneficial routinely screen for alcohol and other al. 2002). Some students may not seek for EDs on military installations or in drug use and abuse in students; Rickman medical help for illness or injuries related the surrounding communities to screen and Mackey (1995) found that only 37 to drinking, or for alcohol dependence, military personnel who present with percent of 277 college student health because of concerns regarding confi­ alcohol­related injuries. clinics conducted such screening. Given dentiality and administrative reprisals. For Emergency departments use different the wide reach that student health clinics example, in one survey of 215 students, methods to screen for alcohol use. One and counseling centers have on cam­ almost the entire sample reported hav­ study examining young adults admitted puses, more efforts to screen students in ing helped other students during or to a trauma center through an ED found these sites should yield valuable results. after an alcohol­related negative event, that 41 percent of the sample tested such as acute intoxication, passing out, positive for alcohol, and more than 22 College Judicial Review Programs and the like, and more frequently uti­ percent had blood alcohol concentrations lized off­campus medical help and local in the legally intoxicated range (Rivara Violations of campus alcohol policies police rather than on­campus resources et al. 1992). The same study showed lead to most of the judicial penalties (Colby et al. 2000). These findings sug­ that among patients who had been drink­ colleges impose on students (Freeman gest that most college student drinking ing, a substantial proportion had injuries 2001). From a prevention perspective, does not come to the attention of campus that stemmed from their alcohol use. the need to screen students for alcohol officials. Finally, in addition to a general However, research among young adults use and misuse before they commit who present to emergency rooms has lack of knowledge about the nature of alcohol­related infractions is obvious. found that blood alcohol levels alone are drinking and related problems among However, more and more researchers not sufficiently reliable or sensitive to are recognizing the advantages of young adults and among college students identify people with alcohol problems specifically, little is known about these screening students who are mandated (e.g., Gijsbergs et al. 1991). A more problems among young adults who do to attend alcohol education classes on comprehensive approach, using both campus as a penalty for violating college not attend college. screening instruments (Chung et al. 2002) alcohol policy. This group is an appro­ and self­reports of alcohol consumption priate target for alcohol screening because

Screening preceding the event that led to the ED they already have begun to experience visit (Monti et al. 1999), can be more adverse consequences as a result of their useful in identifying alcohol problems. drinking (that is, their referral to man­ Because young adults do not tend to dated education programs). In addi­ identify themselves as having alcohol College Campus Venues tion, the number of these “mandated problems, proactive screening should students” is large and growing. In one be conducted in locations where they College counseling centers and health survey of 199 schools, the number of are likely to present with alcohol­ clinics can be other important venues students required to attend alcohol related injuries or illness. Among 18­ to for alcohol screening among young adults. programs nearly doubled between 1993 24­year­olds, these environments may O’Hare and Sherrer (1999) examined and 2001 (i.e., from 1.8 percent to 3.5 include hospital emergency departments the validity and reliability of one screen­ percent of the schools’ student popula­ (EDs), college counseling centers, college­ ing measure, the Alcohol Use Disorders tions) (Wechsler et al. 2002a). Another sponsored judicial review programs for Identification Test (AUDIT), with col­ recent study, which surveyed 4,711 2­ alcohol­related infractions of campus lege students who had violated campus and 4­year schools, indicated that the policies, and worksites. alcohol policies. Their study found that number of mandated students increased

238 Alcohol Research & Health Screening, Brief Intervention, and Outcome

by 4.7 percent from 2000 to 2001 social worker), with each session ranging tained over time (as long as 4 years after (Hoover 2003). from 30 minutes to an hour. A recent treatment), even though BMIs took meta­analysis (Moyer et al. 2002) of 34 less time than the interventions with

On the Job studies found that people being treated which they were compared. for problems other than alcohol use BMIs are intended for people who The workplace is another promising (i.e., non­treatment­seeking participants) do not have detectable signs or symp­ venue for screening young adults for who received such brief interventions toms of a diagnosable disorder; as such, alcohol­related problems. Researchers consistently showed greater reductions they can be considered “indicated pre­ used the AUDIT as a workplace screen­ in alcohol use than did those assigned ventive interventions” (see Mrazek and ing measure in a large­scale study of to no­treatment control groups. Among Haggerty 1994). People who are expe­ 4,193 law enforcement personnel con­ people seeking treatment for alcohol riencing more severe problems (e.g., ducted in Australia (Davey et al. 2000). use, brief interventions and extended alcohol dependence) probably require Results indicated that participants treatments (consisting of five or more more intensive treatment. Many BMIs between ages 18 and 25 reported the sessions) were associated with similar have been effective in reducing alcohol highest average alcohol consumption reductions in alcohol use. Overall, the use among nondependent adult drinkers, rates, and had higher rates of alcohol­ findings indicate that brief interventions which suggests that they could be suc­ related problems and higher AUDIT can be an effective way to reduce drink­ cessfully implemented with young adults. scores, than other age groups in the ing, especially among non­treatment­ sample. Approximately one­third of the seeking people who do not have severe Nonstudents total sample was found to be at risk for drinking problems that would require hazardous alcohol consumption, further more intensive treatment. Although a significant percentage of underscoring the desirability of screen­ A brief intervention that includes young adults who are not college stu­ ing young adults in the workplace. motivational interviewing is called a dents engage in risky drinking and brief motivational intervention (BMI). experience its consequences, BMIs have BMI is a collaborative method that makes not yet been implemented extensively Brief Interventions use of reflective listening and empathy with this population. Several contexts as well as specific techniques (e.g., asking appear promising for administering Traditional alcohol education programs, key questions, anticipating the future) BMIs with young adults. which provide information about the to enable clients with alcohol­related risks of alcohol use, have been imple­ problems to explore and resolve their Emergency Departments. Hospital mented in a variety of ways (e.g., indi­ ambivalence about reducing their alcohol emergency departments are perhaps the vidual sessions, lectures, multisession use. This combination of reflective, places where young adults with drinking groups). However, these approaches have empathic listening and specific techniques problems are most commonly identified. not resulted in drinking reductions in for change is known as motivational A study of 250 18­ and 19­year­old either nonstudent or student populations interviewing (MI).3 Interventions that patients in an urban ED found that (Hingson et al. 1997; Wells­Parker et use MI and incorporate other compo­ nonstudents were at risk for alcohol al. 1995). Given the variety of drinking nents are known as “adaptations of use and problems, and that older ado­ patterns evident in the young adult motivational interviewing” (AMIs) lescents tended to be more experienced population and the minimal effect of (Burke et al. 2003). Brief motivational drinkers (Barnett et al. 2003). traditional alcohol education programs, interventions can be considered AMIs, Fortunately, several studies have more targeted, systematic approaches as they often involve giving the client shown BMIs to be effective interventions are needed to help young adults recognize individualized feedback regarding his with young adults who sought medical and reduce their hazardous drinking. or her drinking and the risks associated treatment in hospital emergency depart­ Young adults engaging in risky levels with it. ments. Monti and colleagues (1999) of alcohol use may respond more favor­ In a meta­analysis of the clinical impact randomly assigned 18­ and 19­year­old ably to brief, more intensive interventions of BMIs on alcohol and marijuana use, ED patients to receive either BMI or (Monti et al. 2001) than to traditional Burke and colleagues (2003) found standard care, which consisted of a longer­term treatments, which originally that 51 percent of clients who received handout on the hazards of drinking were designed for adults with longer BMIs reduced their substance use, and of driving after drinking. During histories of alcohol use and alcohol­related compared with 37 percent of those who the intervention, a treatment provider problems (e.g., Monti et al. 2002). The received assessment only or treatment precise definition of what constitutes a as usual. For alcohol use specifically, 3 Motivational interviewing is a client­centered counseling “brief intervention” has been the source BMIs showed large effects (average style to help clients change their behavior by enabling them to deal with their ambivalence about the change of some debate (Moyer et al. 2002). d = .82), with participants reducing their (Miller and Rollnick 2002). MI can be either directive Typically, brief interventions consist of alcohol use by 56 percent (from 36 to (e.g., when selectively eliciting and discussing possible change) or nondirective (e.g., when exploring ambiva­ one to four sessions with a trained inter­ 16 standard drinks per week) following lence and maintaining a neutral stance regarding the per­ ventionist (e.g., physician, psychologist, a BMI. BMI effects also were main­ son’s options).

Vol. 28, No. 4, 2004/2005 239 assessed the participant at bedside with the types of problems encountered, adults, enhancing standard treatment the help of a laptop computer that pro­ the format of EAP interventions varies with personalized feedback reduced vided immediate personalized feedback widely. Research indicates that when repeat DUI arrests by 35 percent on the participant’s drinking behavior. these programs focus on alcohol problems (Wells­Parker and Williams 2002). In addition to discussing this feedback, they can have positive results, enabling during the BMI the clinician and par­ participants to reduce their alcohol use, Prison and Parole Programs. Young ticipant focused on the participant’s especially when the EAP intervention adults make up a large proportion of perceptions of norms regarding alcohol includes strategies to prevent relapse the U.S. prison population: A 1996 use; perceptions of the pros and cons (Roman and Blum 2002). About 80 survey found that 34 percent of inmates of drinking, drinking and driving, and percent of workers who enter EAPs do were 24 years old or younger, and 75 other alcohol­related risk behaviors; so on their own initiative. Most are percent of State inmates and 31 and expectations about alcohol use. women and are in their late thirties or percent of Federal inmates require sub­ The clinician also provided educational early forties (French et al. 1997; Roman stance abuse treatment (Balenko 1998). material about drinking. Followup data and Blum 2002). Little is known about As in EAPs and DUI programs, most collected for 94 of the participants 6 the use of EAPs by younger adults, who young adults receiving substance abuse months after the intervention demon­ tend not to seek any kind of treatment. treatment in the prison system receive strated that the BMI group had signifi­ Because most young adults who are standard treatments, which might cantly fewer alcohol­related injuries, traffic not attending college are employed full include self­help groups, individual violations, and other alcohol­related time, EAPs are a promising context for and group counseling, therapeutic problems than the standard­care group. intervening with those who have devel­ communities, and methadone mainte­ A more recent study (Monti and oped problems with alcohol. EAPs may nance (Balenko 1998). Barnett 2005) added two booster sessions be particularly effective with this popu­ Research indicates that providing to the BMI and compared this treatment lation if these programs include proac­ substance abuse treatment during both with a feedback­only condition, which tive alcohol screenings to identify these incarceration and parole to those who consisted of patients receiving the same workers. The brief, nonconfrontational need it is associated with reductions in baseline assessment and computer­ nature of BMIs may make them ideally criminal activity, substance use, and generated personalized feedback sheet suited for early indicated interventions recidivism after release (e.g., Andrews as did patients receiving a BMI. With with young workers who have not yet et al. 1990). Younger parolees who use participants receiving feedback only, developed more serious alcohol problems. alcohol and other drugs also are at greater counselors briefly stated that the sheet risk of recidivism (Balenko 1998; Zanis provided information from the assessment, DUI Programs. Almost 35 percent of et al. 2003), and addressing the treatment but there was no further discussion. people arrested for driving under the needs of youthful offenders has been Two hundred and fifteen young adults influence (DUI) are younger than 25 recognized as one of the challenges fac­ were recruited into this trial. Results at years old (McCarty and Argeriou 1988), ing prison alcoholism programs (Valle 12 months show significant differences and 10 percent are under age 21 (Socie and Humphrey 2002). on several drinking variables such as et al. 1994). In addition, drivers younger Methodological issues (e.g., treatment number of drinking days and number than 21 years of age are at greater risk fidelity) have limited the conclusions of heavy­drinking days as well as on for repeat DUI arrests than older drivers that can be drawn from research imple­ average blood alcohol concentrations, (Socie et al. 1994). Because so many menting motivational interventions but no differences in alcohol­related people arrested for drinking and driving with incarcerated adults (see Ginsberg consequences such as alcohol­related are young, DUI treatment programs et al. 2002). However, several aspects of injuries and drinking and driving. are a promising context for implement­ BMIs recommend their use with young The results of these two studies show ing BMIs. However, standard programs adult offenders. Specifically, lack of that emergency departments afford a developed for DUI offenders, which motivation to change substance use has unique opportunity to provide effective range from group educational interven­ been recognized as a primary issue with BMIs to young adults who engage in tions to individual psychotherapy, require this population (De Leon et al. 2000; risky drinking. multiple sessions. A comprehensive Rosen et al. 2004). BMIs explicitly meta­analysis of 215 studies of DUI attempt to increase one’s motivation to Worksite Employee Assistance Programs programs revealed that standard inter­ reduce substance use. In addition, the (EAPs). These programs, which have ventions reduce repeat arrests by 8 to 9 warm, genuine, and empathetic style grown in number and use in the past percent (Wells­Parker et al. 1995), sug­ of motivational interviewing may be 25 years, provide counseling and treat­ gesting that DUI offenders can benefit more acceptable than a confrontational ment at the worksite to workers who from interventions aimed at changing approach for prisoners and parolees. are experiencing problems, including behaviors. In recent years, DUI programs Furthermore, providing prisoners and problems related to alcohol and other have increasingly targeted individual parolees with information in a non­ substance abuse (Roman and Blum 2002). client attributes and needs (Williams et judgmental setting and permitting them Given the variety of work settings and al. 2000). In one recent study of depressed to take an active role in the intervention

240 Alcohol Research & Health Screening, Brief Intervention, and Outcome

may facilitate reductions in the use of may be an appropriate and effective than did heavy drinkers in the other alcohol and other drugs. Indeed, pre­ treatment for college students taken to two groups. liminary research with incarcerated the ED for alcohol­related injuries. In a study of college fraternity mem­ young adults indicates that a brief bers, Larimer and colleagues (2001) motivational intervention enhanced College Campuses. Six published studies compared (a) a one­on­one BMI paired treatment engagement (Stein et al. 2005). have evaluated BMIs provided to college with a 1­hour group feedback session students who have drinking problems. provided to the whole fraternity with College Students Baer and colleagues (1992) found that (b) a 1­hour didactic presentation on alcohol consumption dropped by up to alcohol use, with no personalized feed­ Much more research has been devoted 40 percent among college students who back. At the 1­year followup, students to developing, implementing, and eval­ received 1 hour of feedback and advice who had received the BMI reported uating BMIs for college students than using motivational interviewing, similar greater reductions in average use and for nonstudents. In 1999, national con­ to those who participated in a 6­week self­reported typical peak blood alcohol cern regarding the widespread adverse skills training group. For both groups, content. No reductions in alcohol­ effects of heavy alcohol use on college these effects were maintained at the 2­ related consequences were observed. campuses led to the formation of the year followup. Finally, in a study of heavy­drinking Task Force on College Drinking, convened Marlatt and colleagues (1998) ran­ college students, Murphy and colleagues by the National Institute on Alcohol domly assigned incoming college stu­ (2004) provided personalized feedback Abuse and Alcoholism and consisting dents who reported binge drinking or with or without a motivational inter­ of educators, researchers, and students. problems with alcohol use to a brief viewing session. A 6­month followup (See the related sidebar by Robert Saltz, intervention (similar to the one used by revealed significant, small­to­moderate p. 249) In a review of the task force’s Baer et al. 1992) or an assessment­only reductions in alcohol use, but no dif­ findings, Larimer and Cronce (2002) condition. Four­year followup showed ferences between the groups and no found BMIs to be more effective at reduc­ that students in the brief intervention change in alcohol­related problems for ing alcohol use among college students group experienced significant reductions either group. than other interventions (e.g., education in drinking rates and problems associ­ Overall, this research indicates that programs). Therefore, BMIs delivered ated with alcohol, compared with their personalized feedback and motivational in one­on­one sessions continue to be own baseline levels and with students interviewing appear to influence changes developed and implemented for college in the assessment­only condition (Baer in drinking behaviors and, to a much students engaging in risky alcohol use. et al. 2001). This study produced a lesser extent, alcohol­related problems.

Emergency Departments. Hospital manual, Brief Alcohol Screening and emergency rooms are likely places for Intervention for College Students (BASICS), Mandated Students. Mandated stu­ identifying alcohol problems among describing the brief intervention these dents are students who have violated college students as well as nonstudents. researchers used (Dimeff et al. 1999). campus alcohol policies. Given that In a recent study, students presenting Borsari and Carey (2000) implemented these students are often the heavier to a hospital emergency room for both the BASICS approach at a Northeastern drinkers on campus, several projects alcohol and non­alcohol­related problems university; compared with an assess­ using BMIs with mandated students were screened for alcohol use. Students ment­only control group, BMI partici­ have been implemented in the past 5 who reported an AUDIT score of 6 or pants showed significant reductions in years. For example, Borsari and Carey greater were invited to receive a brief alcohol use at 6­week followup. (in press) randomly assigned mandated open­ended counseling session (5–25 Three more recent evaluations com­ students to receive either a 60­ to 90­ minutes). During the session, counselors pared BMIs with other active interven­ minute motivational interview (BMI) used motivational interviewing techniques tions. Murphy and colleagues (2001) or a 60­ to 90­minute alcohol educa­ to help students examine their alcohol compared a BMI (using the BASICS tion session in which the student was use and gave them a brochure address­ protocol) with an assessment­only provided information about alcohol ing alcohol­related risks and providing condition and an individualized educa­ and its effects. Following their referral a menu of strategies for reducing those tional intervention that consisted of incident, all eligible participants had risks. Three months later, these students watching a video detailing alcohol­ continued to binge drink (defined as demonstrated significant reductions in related risks. Although participants in having had two or more binge­drinking alcohol use, problems, and dependence the three conditions showed no overall episodes in the past month). At 3­ and symptoms, and more than 77 percent significant differences in alcohol use at 6­month followups, both treatment of participants viewed the BMI as the 3­ and 9­month followups, BMI groups demonstrated significant drink­ somewhat or very helpful (Helmkamp participants who drank 25 or more drinks ing reductions, with BMI students et al. 2003). Although limited by the per week (i.e., heavy drinkers) reduced reporting significantly fewer alcohol­ lack of a no­treatment control group, their weekly alcohol consumption and related problems than the alcohol edu­ findings of this study indicate that BMIs binge drinking by greater amounts cation students at the 6­month followup.

Vol. 28, No. 4, 2004/2005 241 Recently, adaptations of BMIs for as problem drinkers, which suggests that al. 2003)? Furthermore, does the inclu­ mandated students have been devel­ proactive screening approaches may be sion of significant others or peers (e.g., oped (see Barnett et al. 2004). For warranted. Several screening methods O’Leary et al. 2002; Tevyaw et al. 2005) example, BMIs incorporating booster recently have proven effective and deserve enhance the BMI session for the partic­ sessions have been compared with a further research attention. ipant? If so, what is the responsible 45-minute interactive computer pro­ Most interventions studied with mechanism? Addressing these and other gram (Alcohol 101 Plus) that provides young problem drinkers have incorpo­ research questions likely will improve the the student with information about the rated BMIs. Promising contexts in efficacy of BMIs in addressing alcohol effects of alcohol and the risks associated which to implement BMIs with non­ use and problems in young adults. ■ with excessive alcohol use (Century students include hospital EDs, EAPs, Council 2003). In addition, students in DUI programs, and prison- and parole- both conditions were randomly assigned based programs. Among college popu­ References to receive booster sessions 1 month after lations, where more research on BMIs the intervention. The booster sessions has been conducted, outcomes are American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, Fourth were a shorter version of the original impressive. Convincing results have been Edition. Washington, DC: APA, 1994. intervention, lasting 25 to 30 minutes. obtained for BMIs with students whose Reductions in alcohol use were evident alcohol problems were identified in AMES, G.M.; CUNRADI, C.B.; AND MOORE, R.S. Alcohol, tobacco, and drug use among young in both groups at a 3-month followup, emergency departments and with stu­ adults prior to entering the military. Prevention suggesting that both approaches may be dents from the general college popula­ Science 3:135–144, 2002. PMID: 12088138 valuable in reducing drinking in man­ tion who were identified as having AMRHEIN, P.C.; MILLER, W.R.; YAHNE, C.E.; ET dated students. In addition, students who drinking problems. In general, findings AL. Client commitment language during motiva­ received a BMI with a booster session suggest that personalized feedback and tional interviewing predicts drug use outcomes. were most likely to seek further assis­ motivational interviewing influence Journal of Consulting and Clinical Psychology 71: tance, suggesting that face-to-face con­ change in drinking variables and, to a 862–878, 2003. PMID: 14516235 tact in BMI may facilitate problem lesser degree, in alcohol-related prob­ ANDREWS, D.A.; ZINGER, I.; HOGE, R.D.; ET AL. recognition in mandated students. lems. Results with students mandated Does correctional treatment work? A clinically rele­ Another BMI adaptation involves to alcohol treatment demonstrate the vant and psychologically informed meta-analysis. the active participation of a peer of the effectiveness of BMIs in reducing heavy Criminology 28:369–404, 1990. mandated student in the intervention. episodes of alcohol use and alcohol- ARNETT, J.J. Emerging adulthood: A theory of This peer, selected by the mandated related problems. development from the late teens through the twen­ student, also receives personalized feed­ BMIs have been implemented in a ties. American Psychologist 55:469–480, 2000. back about his or her own alcohol use variety of contexts, with varying ranges of PMID: 10842426 and supports the student’s goals for alcohol use and problems, and with both BAER, J.S.; MARLATT, G.A.; KIVLAHAN, D.R.; ET reducing hazardous alcohol use (O’Leary treatment-seeking and non-treatment­ AL. An experimental test of three methods of alco­ hol risk reduction with young adults. Journal of et al. 2002). Although this study did seeking populations. The flexibility and Consulting and Clinical Psychology 64:974–979, 1992. not include a control condition, results effectiveness of BMIs make them a PMID: 1460160 indicated that students receiving peer- promising component of stepped care, BAER, J.S.; KIVLAHAN, D.R.; BLUME, A.W.; ET AL. enhanced BMIs reported reductions in in which people first are assigned to the Brief intervention for heavy-drinking college students: alcohol use similar to those reported by least restrictive, intrusive, and costly 4-year follow-up and natural history. American students receiving standard BMIs. treatment that has a good chance of Journal of Public Health 91:1310–1316, 2001. Taken together, these findings demon­ success and, if they do not respond to PMID: 11499124 strate the flexibility of BMIs and indi­ this initial level of treatment, are pro­ BALENKO, S. Behind Bars: Substance Abuse and cate that they are an effective option vided more intensive care (Borsari and America’s Prison Population. New York: National for campus alcohol programs intended Tevyaw 2005; Sobell and Sobell 2000). Center on Addiction and Substance Abuse at to reduce heavy episodic drinking in Thus, BMIs could address different Columbia University, 1998. mandated students. degrees of alcohol use and problems BARNETT, N.P.; MONTI, P.M.; SPIRITO, A.; ET AL. by serving as a stand-alone intervention Alcohol use and related harm among older adoles­ for people with less severe alcohol prob­ cents treated in an emergency department: The importance of alcohol status and college status. Conclusions lems or as an initial screening and Journal of Studies on Alcohol 64:342–349, 2003. intervention tool for people who will PMID: 12817822 Excessive alcohol use among young require more intensive treatment. adults is a major public health concern. Despite the promise of BMIs, further BARNETT, N.P.; FROMME, K.; O’LEARY TEVYAW, T.; ET AL. Brief alcohol interventions with man­ Although drinking among college stu­ research is needed to determine precisely dated or adjudicated students. Alcoholism: Clinical dents has received the most research how these interventions facilitate behav­ and Experimental Research 28:966–975, 2004. attention, it is a problem among non- ior change. For example, which inter­ PMID: 15218881 college students as well. Young adults in viewer and client in-session behaviors BORSARI, B., AND CAREY, K.B. Effects of a brief both groups rarely identify themselves are related to change (e.g., Amrhein et motivational intervention with college student

242 Alcohol Research & Health Screening, Brief Intervention, and Outcome

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