Event-specific drinking and the use of technology: Implications for clinicians

Clinical Translation

Event-specific drinking and the use of technology: Implications for clinicians

Jennifer M. Cadigan, Ph.D.¹ & Michael Bernstein, Ph.D.²

¹Department of Psychiatry and Behavioral Sciences, University of Washington

²School of Public Health, Center for Alcohol and Addiction Studies, Brown University

Manuscripts often include a section focused on “clinical implications” of the findings and although these implications are often well-intentioned, many times they are brief, lacking sufficient detail, and fail to fully describe how a clinician could utilize the findings in their own practice.  In this article, we focus on two recently published manuscripts that tested event-specific interventions using technology-based approaches (Bernstein et al., 2018; Cadigan et al., 2018). Our goal is to apply these findings to outline more comprehensive implications for clinicians to incorporate in their practice.

Bernstein et al. (2018) assigned 200 college students to a 21^st birthday text-message intervention or an assessment only control group. Participants in the text-message condition received two texts, one the day before and one the day of their 21^st birthday celebration. These messages focused on 21^st birthday specific personalized normative feedback and protective behavioral strategies. Counter to expectations, there was no direct intervention effect. However, perceived 21^st birthday drinking norms mediated treatment condition and 21^st birthday estimated blood alcohol concentration (eBAC). Furthermore, moderation analyses suggested that the intervention reduced eBAC among a small but very high-risk subset of participants (i.e. light weekly drinkers who intended to drink very heavily on their 21^st birthday).

Cadigan et al. (2018) developed a text-message intervention for reducing high-risk alcohol use and related-problems for heavy drinking college students when tailgating prior to football games. A total of 130 college students were assigned to a text-message personalized feedback intervention (TXT PFI) that included feedback on tailgating alcohol use or to a text-message control condition. Individuals in TXT PFI received a text-message the morning of a home football game with personalized content on their alcohol use, alcohol-related problems, and perceived drinking norms from the last time they tailgated. Participants who received the TXT PFI reported less alcohol use when tailgating than those in the control condition. One month later, those in TXT PFI continued to report lower peak eBAC and fewer alcohol-related problems during typical drinking occasions than the control condition. These findings suggest an event-specific intervention can be used to reduce both tailgating (event-specific) and typical drinking alcohol outcomes.

Both Bernstein et al. (2018) and Cadigan et al. (2018) focused on specific events associated with excessive alcohol use among college students. Research has identified certain events (e.g., 21^st birthdays, Spring Break, New Year’s Eve, sporting events) that are associated with extremely high risk drinking (Neighbors et al., 2011) and an escalation in alcohol use and alcohol-related consequences (Neighbors et al. 2007). Event-specific alcohol use can be conceptualized differently than other drinking (e.g., alcohol use on a generic Friday night), because the events can be anticipated (e.g., the event is known in advanced) and are time limited (e.g., last for the duration of the specific event) (Neighbors et al. 2011). Therefore, it is important for both researchers and clinicians to examine and intervene before these types of events.

Cognitive Behavioral Therapy (CBT) for Alcohol Use Disorder often include weekly assessments of high-risk drinking situations, in which the patient and clinician discuss possible situations where the patient would find it difficult to not drink (Epstein & McCrady, 2009). The clinician and patient then identify several ways in which the patient could handle the situation and not engage in alcohol use. Even for patients whose goal is reduction instead of abstinence, identifying known events that are associated with increased alcohol use, and associated negative consequences, remains important. We encourage clinicians to thoroughly assess for specific-events that serve as high-risk drinking occasions. Many of these high-risk drinking events are planned in advance and happen once a year (e.g., friend’s birthday party; their own birthday; 4^th of July). Other specific drinking events repeat throughout the year (e.g., tailgating at football games; a routine drinking event that holds significance to a friend group). We encourage clinicians to assess for alcohol use during specific events that are developmentally appropriate for the patient. For example, if the patient is a college student, are they planning on tailgating at a football game this weekend? If so, what alcohol-related negative consequences happened the last time they tailgated? What are their plans for Spring Break? What are they doing for New Year’s Eve?

After identifying known windows where the patient is likely to engage in high-risk drinking, the clinician and patient can problem solve ways to engage in low-risk drinking or abstinence, depending on the patient’s goals. Consistent with NIAAA guidelines, low-risk drinking is defined as no more than 3 drinks on a single day for woman, and no more than 4 drinks on a single day for men. The clinician could discuss protective behavioral strategies (PBS, Martens et al., 2005) the patient could utilize at the event before drinking (e.g., determine not to exceed a set number of drinks), while drinking (e.g., drink water while drinking alcohol), and to avoid serious harm (e.g., use a designated driver). The patient could then identify several PBS strategies to implement during the specific event. 

Technology-based approaches (e.g., use of websites, text-messages) can also be integrated with face-to-face sessions and can prove especially useful in terms of homework reminders and self-monitoring (Aguilera & Muench, 2012; Marsch et al., 2014). Aguilera and Muench (2012) offer several suggestions and examples of applications for mood monitoring. For example, patients could engage in self-monitoring by tracking their daily mood using a mood monitoring app or website. This information could then be discussed with the clinician at the next session. Technology-enhanced interventions have been utilized in CBT for the treatment of adolescent depression (Kobak et al., 2015) where between-session text-messaging was used to provide reminders of the session homework and for self-monitoring. The clinician then received a summary of the content from the text-messages, which was discussed with the patient at the next session. We also encourage clinicians to use technology to have patients track daily alcohol consumption and mood. Patients could use their phone to log daily alcohol consumption (in a “notes” document, for example) to improve accurate assessment of consumption, which could then be discussed with the clinician at the next session.

References

Aguilera, A., & Muench, F. (2012). There's an app for that: Information technology applications for cognitive behavioral practitioners. The Behavior Therapist, 35, 65-73.

Bernstein, M. H., Stein, L. A., Neighbors, C., Suffoletto, B., Carey, K. B., Ferszt, G., ... & Wood, M. D. (2018). A text message intervention to reduce 21st birthday alcohol consumption: Evaluation of a two-group randomized controlled trial. Psychology of Addictive Behaviors, 32, 149-161.

Cadigan, J. M., Martens, M. P., Dworkin, E. R., & Sher, K. J. (2018). The efficacy of an event-specific, text message, personalized drinking feedback intervention. Prevention Science. Advance online publication.

Epstein, E. E., & McCrady, B. S. (2009). Overcoming Alcohol Use Problems: A Cognitive-Behavioral Treatment Program. Oxford University Press.

Kobak, K. A., Mundt, J. C., & Kennard, B. (2015). Integrating technology into cognitive behavior therapy for adolescent depression: a pilot study. Annals of General Psychiatry, 14, 37.

Martens, M. P., Ferrier, A. G., Sheehy, M. J., Corbett, K., Anderson, D. A., & Simmons, A. (2005). Development of the protective behavioral strategies survey. Journal of Studies on Alcohol, 6, 698-705.

Marsch, L. A., Carroll, K. M., & Kiluk, B. D. (2013). Technology-based interventions for the treatment and recovery management of substance use disorders: a JSAT special issue. Journal of Substance Abuse Treatment, 46, 1-4.

Neighbors, C., Atkins, D. C., Lewis, M. A., Lee, C. M., Kaysen, D., Mittmann, A., ... & Rodriguez, L. M. (2011). Event-specific drinking among college students. Psychology of Addictive Behaviors, 25, 702-707.

Neighbors, C., Lee, C. M., Lewis, M. A., Fossos, N., & Walter, T. (2009). Internet-based personalized feedback to reduce 21st-birthday drinking: A randomized controlled trial of an event-specific prevention intervention. Journal of Consulting and Clinical Psychology, 77, 51–63.

Neighbors, C., Walters, S. T., Lee, C. M., Vader, A. M., Vehige, T., Szigethy, T., & DeJong, W. (2007). Event-specific prevention: Addressing college student drinking during known windows of risk. Addictive Behaviors, 32, 2667-2680.

Rutledge, P. C., Park, A., & Sher, K. J. (2008). 21st birthday drinking: Extremely extreme. Journal of Consulting and Clinical Psychology, 76, 511–516.