National Institute on Alcohol Abuse and Alcoholism’s College Alcohol Intervention Matrix Part 5 of 5

Jason Kilmer, Ph.D. and Toben Nelson Sc.D. Author

08/04/2017 Added

40 Plays

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Review of the National Institute on Alcohol Abuse and Alcoholism's College Alcohol Intervention Matrix (AIM) and practical application for professionals working in higher education to reduce high-risk drinking and associated harms.

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[00:00:03.470]I think we probably need to be developing
[00:00:07.100]some of those more effectively.
[00:00:10.550]I think a lot of the stuff I talk...
[00:00:17.110]Yes, on again.
[00:00:18.400]A lot of the stuff that I talk, I'm good.
[00:00:20.454](audience laughter)
[00:00:23.320]You're no boom mic operator.
[00:00:24.630]I try, though.
[00:00:25.890]A lot of the stuff that I talked about
[00:00:27.910]I think can be particularly effective with administrators.
[00:00:33.540]One of the things that we've been doing
[00:00:36.700]is borrowing a lot of the concepts
[00:00:40.460]and approaches from motivational interviewing
[00:00:43.640]to work with groups and to work and try
[00:00:47.650]to help advance a policy agenda.
[00:00:50.440]It doesn't fit directly in all cases.
[00:00:53.560]But I think some of those principles can be very effective.
[00:00:58.550]So, meeting people where they're at,
[00:01:03.921]and eliciting some change talk,
[00:01:07.530]trying to get to a common place,
[00:01:10.200]and asking, "Can I tell you more about
[00:01:14.717]"the approach that I'm taking
[00:01:16.047]"or a strategy I think might be useful?"
[00:01:19.440]I think really can be effective.
[00:01:22.230]And part of that is very simply relationship development,
[00:01:28.790]and understanding the self-interest
[00:01:31.355]of the people that you're talking to.
[00:01:34.600]So if you know where that person is coming from,
[00:01:37.400]and you can try and help align your strategies
[00:01:40.920]with where they're coming from and give them something
[00:01:45.250]to jump on board with you, you're not gonna totally align,
[00:01:49.240]but the extent that you can,
[00:01:51.640]or the extent that you can accentuate those alignments,
[00:01:55.660]I think the better chances you have for success.
[00:01:59.940]But the foundation for that is having a good relationship.
[00:02:04.360]And I'm kind of a jerk, so I understand
[00:02:06.490]that that's not my role. (laughs)
[00:02:11.250]Yeah, oh, go ahead.
[00:02:12.180]I was curious, Jason, about screen--
[00:02:14.730]Repeating the question
[00:02:15.660]for people listening remotely:
[00:02:16.700]what screening recommendations are there?
[00:02:19.150]You know, if it's for an assessment,
[00:02:21.370]there are a lot of tools that guide it.
[00:02:22.570]If it's literally a brief screening,
[00:02:24.410]arguably the most well-known and most well-studied
[00:02:27.890]screening instrument is the AUDIT,
[00:02:29.200]the Alcohol Use Disorders Identification Test.
[00:02:31.730]That comes from the World Health Organization
[00:02:33.310]and has particular value because
[00:02:35.740]of its value outside of North America.
[00:02:37.580]With the campuses that are increasingly seeing
[00:02:39.380]more international students, that's very useful.
[00:02:43.063]The other nice thing about the AUDIT
[00:02:44.730]is you can actually make referral recommendations
[00:02:50.600]and document why that was made.
[00:02:53.160]If you google AUDIT, A-U-D-I-T, and WHO, one of the first
[00:02:57.200]three things you get on Google is the AUDIT guide.
[00:02:59.930]In the AUDIT guide is a list of four zones.
[00:03:02.650]If it's this score, ah, best giving you simple advice.
[00:03:05.340]If it's this score, they probably need a brief intervention.
[00:03:07.600]If it's above this, you should refer them
[00:03:09.450]to a more thorough assessment than just the AUDIT.
[00:03:12.310]So for true screening, that's a great tool.
[00:03:14.467]And you can even justify next steps with it.
[00:03:16.940]If you're using it a counseling or health center,
[00:03:18.480]you're like, "Wow, that's 10 items."
[00:03:19.870]There's an AUDIT-C, which is only three items.
[00:03:22.520]And if people are like, "I don't have time
[00:03:23.353]"for three items," NIAAA has a single item.
[00:03:26.370]It just gets that binge idea.
[00:03:28.220]How many times within the last two weeks
[00:03:29.930]have you had five or more drinks for a man,
[00:03:31.750]four or more drinks for a woman.
[00:03:33.120]But I would think the AUDIT is a
[00:03:34.570]tool you could certainly do.
[00:03:36.330]If you're doing a formal assessment,
[00:03:37.921]I mean, there are so many tools.
[00:03:39.930]We use the Brief Drinker Profile,
[00:03:43.070]just because it's free and it's in the public domain.
[00:03:45.730]And it's been well-researched.
[00:03:48.060]It was developed by Bill Miller,
[00:03:49.530]father of motivational interviewing,
[00:03:51.020]and Alan Marlatt, who did relapse prevention
[00:03:53.820]in the work I showed you here.
[00:03:55.620]And again, just for a more
[00:03:57.010]thorough assessment, that's a nice tool.
[00:03:59.036]I don't know what you would add to--
[00:04:00.390]Yeah, actually some of the work that we've done
[00:04:03.430]as part of our college systems project
[00:04:06.850]working with Ken Winters on our campus
[00:04:09.780]actually went through and assessed the different
[00:04:13.470]brief screening tools and provide kind of
[00:04:17.482]a matrix of its own just of screening tools.
[00:04:20.712]And that's published, as well.
[00:04:24.430]What we found when we surveyed colleges were
[00:04:29.940]the majority of schools were using something
[00:04:32.430]that wasn't validated and had never
[00:04:37.760]been tested with college-level students.
[00:04:40.540]But the beauty of that is, there are actually
[00:04:42.270]several of them that are validated,
[00:04:45.000]that are tested with the college students,
[00:04:47.140]and, very importantly, are free.
[00:04:49.960]So we make some recommendations about what those are
[00:04:53.340]and advocate for schools and places that are interfacing
[00:04:57.680]with students to use those kinds of tools.
[00:05:00.730]The AUDIT is my particular favorite.
[00:05:03.933](man speaking faintly)
[00:05:05.190]Yeah, we've heard about those,
[00:05:06.120]and they use as part of their program eCHECKUP.
[00:05:09.257]And eCHECKUP is in CollegeAIM.
[00:05:12.330]They use a lot of other programs
[00:05:13.490]that were either outside of the scope of CollegeAIM review.
[00:05:16.260]One last thing is, I'm glad to hear you say the AUDIT,
[00:05:18.000]'cause I was like, "Uh-oh, what would you recommend?"
[00:05:20.020]The main thing I would say, though, is,
[00:05:21.250]when you're asking about drinks,
[00:05:22.850]again, you have to define what counts as a drink.
[00:05:25.160]I'm an author on a study where we did
[00:05:26.390]market intercept interviews on college campuses.
[00:05:29.090]And we said, "Tell us how much you've had
[00:05:30.827]"to drink in the last two weeks," and they fill it out.
[00:05:32.480]And then we trained the provider
[00:05:33.730]to act like they screwed up.
[00:05:34.870]They go, "Oh, sorry, I'm so stupid.
[00:05:37.467]"I was supposed to tell you,
[00:05:38.457]"a drink means this, this, this, or this.
[00:05:40.197]"Could you do it one more time?"
[00:05:41.920]And the estimates on how much
[00:05:42.810]they drink went up 30 seconds later.
[00:05:45.610]So, if you just say, "How many drinks have you had?"
[00:05:47.237]"Well, I only have two."
[00:05:48.070]Oh, okay, phew.
[00:05:49.380]Two what?
[00:05:50.420]And really do what you can to define that
[00:05:51.950]before completing a measure like that.
[00:05:53.400]That's important, too.
[00:05:55.130]What else in terms of questions or comments people have?
[00:05:57.900]Just slightly back
[00:05:58.733]to the environment, on that.
[00:06:02.300]That's a complicated question, of course.
[00:06:05.430]And it's one that, you know what, a lot of the issues
[00:06:09.340]we are dealing with on this topic,
[00:06:14.870]it kinda cuts both ways, right?
[00:06:17.260]So, if you have kind of unregulated,
[00:06:21.860]heavy use outside that's surreptitious,
[00:06:26.240]happening in a parking lot or maybe
[00:06:27.950]in a commercial establishment that's
[00:06:30.800]maybe not directly under control.
[00:06:33.650]If you wanna argue that bringing
[00:06:36.270]alcohol inside of a sports stadium
[00:06:41.017]is safer, that argument has been routinely made.
[00:06:46.300]I'm not sure I believe it, but there's some kernels
[00:06:48.880]of truth in there, I think, one of which is,
[00:06:53.140]if you're selling alcohol at $8 a cup,
[00:06:57.790]you have now some environmental
[00:07:01.240]economic availability control over that.
[00:07:06.280]So, I think you have to look at the broader mix.
[00:07:10.660]You also have to look at the motivations
[00:07:12.629]of the NCAA and vendors like Aramark.
[00:07:18.720]I mean, they want a piece of that pie, as well.
[00:07:22.360]So, how can you leverage that very
[00:07:26.810]complicated situation into prevention?
[00:07:30.890]I think it's an open question,
[00:07:32.310]and I think it's one that needs a lot more research.
[00:07:36.179]I mean, I can think of maybe a dozen studies
[00:07:38.730]that have looked at that broad issue.
[00:07:41.630]We need a lot more work in that area.
[00:07:45.510]NCAA has been very reluctant to engage
[00:07:50.920]with researchers like myself on these topics
[00:07:53.900]because they think we're gonna tell 'em
[00:07:56.320]not to do something that they're gonna make money at.
[00:07:59.560]So, that's one of the challenges.
[00:08:01.050]We have a challenge with our own athletic department
[00:08:04.990]in terms of even having a conversation about these issues.
[00:08:08.970]And your colleague to your right
[00:08:12.100]brought up the sponsorship issue.
[00:08:16.330]At our place, even though I have personal relationships
[00:08:19.230]with some of the folks in athletics,
[00:08:21.160]they do not wanna talk to me about any of this stuff.
[00:08:26.370]And so it's hard to even make progress.
[00:08:30.890]I can take two of those parts.
[00:08:33.134]And there are two-- Summarize those four
[00:08:34.630]questions I think I heard.
[00:08:35.800]Well first, thank you for the very nice feedback.
[00:08:37.390]And for those listening remotely,
[00:08:38.410]the two that I can mention, I mentioned that there's more
[00:08:41.270]research that needs to be done on cultural adaptations.
[00:08:43.740]And you asked about what research
[00:08:45.341]has looked at the impact of culture.
[00:08:48.250]I mean, everything from social norms and what is acceptable.
[00:08:51.550]Do we do things in bars here that we would never do
[00:08:54.170]in other cultures, other countries?
[00:08:55.660]And, I mean, we work on that one looking at
[00:08:58.220]students studying abroad, as well, as an example.
[00:09:00.820]The two main things that have been looked at is,
[00:09:03.500]looking at adaptations in any, and the thing
[00:09:05.730]that has been explored the most is norms.
[00:09:08.450]If you go, "You say this, but here's what
[00:09:10.857]"the typical person does," what if I don't
[00:09:12.850]identify with the typical person?
[00:09:15.420]And so it's getting a sense of,
[00:09:17.020]who in the referent group is gonna be most
[00:09:18.850]salient and relevant to anyone that you do research with?
[00:09:21.560]That research has been done to a degree,
[00:09:23.630]but so much more needs to be done.
[00:09:25.500]We find that a lotta times, it's still,
[00:09:28.180]looking at what the typical person does
[00:09:30.150]results in the biggest behavior change.
[00:09:32.170]But being thoughtful and sensitive about norms
[00:09:34.310]that are given, for example, becomes important, too.
[00:09:37.790]The other piece, well you mentioned, again,
[00:09:41.270]there are multiple pieces in there.
[00:09:43.180]The idea about causation, correlation.
[00:09:45.260]I think you're very right.
[00:09:46.410]There are things that generally will hang together.
[00:09:48.410]I showed you the information on,
[00:09:49.980]as drinking goes up, students saying they're tired
[00:09:52.330]all the time increases, and GPA goes down.
[00:09:54.970]I mean, what's interesting is, if you ask students,
[00:09:56.887]"What gets in the way of your academic success?"
[00:09:59.280]the top three answers from the National College
[00:10:00.980]Health Assessment aren't drinking or drug use.
[00:10:03.680]It's being stressed, being tired
[00:10:05.410]all the time, and being anxious.
[00:10:07.250]But what do we know about going to bed
[00:10:08.273]with a positive blood alcohol level?
[00:10:10.350]Throws off REM sleep, and the next day,
[00:10:12.360]increases in anxiety, increases in sleepiness,
[00:10:15.130]increases in sleepiness, increases in irritability.
[00:10:18.030]So even if it's not causal, but there's
[00:10:20.210]something correlational, it goes back to,
[00:10:22.200]what's important to the student?
[00:10:23.700]If a student says, "I don't wanna talk about my drinking.
[00:10:26.047]"I wanna talk about how to make my sleep better,"
[00:10:28.120]there's a backdoor conversation
[00:10:29.410]we can have about alcohol that will still get at sleep
[00:10:32.290]as the topic that's most important to the student.
[00:10:34.530]And the other ones are more environmental, in your realm.
[00:10:36.600]Yeah, I mean, a couple thing.
[00:10:38.360]I'll touch on the cultural question.
[00:10:41.260]And this comes up a lot.
[00:10:42.920]I used to have a slide on this
[00:10:44.130]in some of the talks that I give.
[00:10:46.860]The sort of hand-wringing about,
[00:10:48.980]oh, it's cultural, it's this big amorphous
[00:10:53.100]thing that we can't really do a good job
[00:10:55.660]of defining or doing anything about,
[00:10:58.550]and that kinda leads to sort of
[00:11:00.670]throwing up our hands and being frustrated.
[00:11:04.290]And I think that relates a little bit
[00:11:05.880]to your question about, what are these cultural influences?
[00:11:09.820]Culture, or cultural influences,
[00:11:13.230]tends to be kind of a catchall
[00:11:14.840]for this amorphous set of causes
[00:11:18.070]that are impacting on people's behavior
[00:11:21.950]and on their outcomes that we might care about.
[00:11:25.619]And I think we need to be very particular
[00:11:29.690]about how we're defining, what does culture mean?
[00:11:33.550]And what does culture mean very specifically for alcohol?
[00:11:39.100]Culture is routinely defined as,
[00:11:42.807]"Well, in this culture, it's this thing.
[00:11:45.817]"And in this culture, it's another thing."
[00:11:48.150]It's probably a whole range of different,
[00:11:51.570]very specific things, so we do need to be
[00:11:54.000]more specific about what we mean by culture.
[00:11:57.320]I also think culture is one of the things that,
[00:12:00.650]how we define what our community standards are,
[00:12:04.210]particularly as it relates to alcohol,
[00:12:06.710]what's acceptable and what's not acceptable,
[00:12:09.810]and there are certain things that are
[00:12:11.677]and are not acceptable as they vary by culture.
[00:12:14.990]So being more specific I think is
[00:12:17.780]my attempt at answering what that is.
[00:12:21.190]And then when we're more specific about what culture means,
[00:12:24.300]we can be more specific about what's influencing drinking.
[00:12:29.720]You brought up the drinking age.
[00:12:33.550]That's an area that's probably the most
[00:12:35.750]well-researched in our field.
[00:12:39.060]The evidence is crystal clear.
[00:12:42.470]Places that have lower drinking ages,
[00:12:44.950]more access to alcohol, more likely to drink.
[00:12:48.320]There's been changes in those drinking ages,
[00:12:51.510]both in the United States and in other countries.
[00:12:54.220]When we lower the drinking age,
[00:12:56.950]drinking goes up, particularly among those
[00:12:59.460]who are not quite of that age.
[00:13:02.190]So what's happened in the United States,
[00:13:05.540]as a specific example, when we had an 18 drinking age,
[00:13:10.360]lots of access for students who were in high school.
[00:13:13.630]15, 16, 17-year-olds were drinking heavily
[00:13:17.430]and accessing alcohol through social sources
[00:13:20.410]of people who were able to legally purchase.
[00:13:22.820]When that age goes up to 21,
[00:13:27.530]the high school students don't have as direct access
[00:13:30.610]to those social sources of alcohol
[00:13:32.600]because they know fewer people who are 21.
[00:13:35.900]So, that's made a gigantic impact,
[00:13:39.170]particularly on high-school drinking.
[00:13:41.430]The problem for the population that you're talking about,
[00:13:44.610]college students, is now we've moved that problem
[00:13:47.670]from a high-school problem into the college realm.
[00:13:51.660]And I know a lot of college administrators
[00:13:54.360]would like to say, "Well, let's redefine it
[00:13:57.447]"and make it a high-school problem again."
[00:13:59.950]And I think that would be an enormous,
[00:14:02.950]enormous error in doing that.
[00:14:06.570]And when we've seen New Zealand, in particular,
[00:14:11.600]reduce their drinking age, they've seen a whole host
[00:14:14.430]of negative consequences creep back down
[00:14:18.160]into those younger age groups.
[00:14:20.780]So, in my view, that would be a terrible idea.
[00:14:25.890]And that's been the consistent conclusions
[00:14:30.400]of researchers who've looked at that particular issue.
[00:14:34.150]On Sunday sales, it's a challenging issue.
[00:14:38.030]And it's very similar for
[00:14:42.810]hours of sale, as well.
[00:14:45.080]There's certainly the phenomenon that you described,
[00:14:47.930]which is, well, if we can't get alcohol
[00:14:50.230]on Sunday, there's this rush on Saturday
[00:14:53.690]before closing time to go get some.
[00:14:56.690]And that may not be there if
[00:14:59.810]there were Sunday sales available.
[00:15:01.610]But we know that when Sunday sales are available
[00:15:05.830]that there's a lot more overall consumption
[00:15:09.460]that's happening on those dates.
[00:15:12.540]And the reason the producers of alcohol
[00:15:15.560]want to open up Sunday sales is because
[00:15:18.540]they're gonna sell more alcohol,
[00:15:20.970]and people are gonna drink more alcohol and be more
[00:15:24.020]intoxicated and experience more problems as a result.
[00:15:29.100]So, I think the evidence is pretty clear
[00:15:31.790]on Sunday sales in particular.
[00:15:35.010]A resource that I can point you to
[00:15:36.540]is The Community Guide from the CDC.
[00:15:38.580]It goes through pretty carefully.
[00:15:41.840]There's a nice review article that you can download
[00:15:43.880]from their website, if you're interested
[00:15:45.800]in that topic a little bit more.
[00:15:47.820]And then I think the last topic,
[00:15:52.350]oh, now I'm blanking on what else you were,
[00:15:55.030]oh, the mediators and moderators.
[00:15:58.360]I think there's no question that we can
[00:16:02.490]be more specific and do better research
[00:16:05.930]to try and identify the specific causal mechanisms,
[00:16:10.530]physiologic and psychologic, that are happening
[00:16:13.190]from the relationship between consumption
[00:16:16.150]and the negative consequences that result.
[00:16:19.250]We certainly can do better.
[00:16:21.100]But as a general theme, from a population level,
[00:16:24.930]and I do epidemiologic research,
[00:16:28.310]it's very consistent that the more consumption there is,
[00:16:32.310]the more negative consequences of alcohol
[00:16:36.270]that we might care about from a public health perspective.
[00:16:42.070]There's more nuance that Jason can talk about there,
[00:16:45.410]some of which we understand, but a lot
[00:16:47.020]of which I would say we don't.
[00:16:50.088]With the time we have left,
[00:16:50.921]we have 17 minutes left, what else in terms
[00:16:52.930]of other questions, comments, or things that
[00:16:54.310]would be helpful to support your efforts with this?
[00:16:59.150]I'd say the short answer is,
[00:17:00.430]no, there's not a lot of research on that.
[00:17:03.070]You're right in characterizing
[00:17:04.650]the research that's been done.
[00:17:05.940]It's primarily focused on suppliers.
[00:17:10.303]And that's been a very effective strategy.
[00:17:13.900]I'm very sympathetic to the plight
[00:17:17.240]that you're bringing up, which is, how do you enforce that
[00:17:22.170]out in the neighborhoods at a house party?
[00:17:25.960]And I don't think there's been
[00:17:28.530]a lot of great research on that topic.
[00:17:30.950]What I would say is, we're sort of back to
[00:17:34.640]sort of classic deterrence theory.
[00:17:36.840]And I breezed over that slide in my presentation,
[00:17:42.530]but I'll come back and hit it now.
[00:17:46.090]The way that people sort of reflexively
[00:17:49.640]try to think about punishment or deterrence
[00:17:52.530]is to really ramp up the severity of the consequence.
[00:17:56.230]So, "Oh, we're gonna give him a really big fine,"
[00:17:57.990]or, "We're gonna throw him in jail for five days,"
[00:18:00.030]or something that is perceived as severe.
[00:18:03.680]And that goes over really well when you're passing a policy
[00:18:07.810]and when you are publicizing it
[00:18:09.750]or it's being written up in the newspaper.
[00:18:11.490]It's like, "Oh, that's a tough policy."
[00:18:15.590]The problem is, then you've got
[00:18:18.640]people who are trying to enforce that
[00:18:20.790]that may be backing off on enforcing it.
[00:18:24.570]And actually, having a severe punishment
[00:18:28.510]really undermines the two other really important
[00:18:31.140]components of deterrence theory, which is,
[00:18:35.010]the swiftness, how quickly that consequence happens,
[00:18:40.200]it doesn't have to be a real severe one,
[00:18:43.550]from the time that the discretion happens
[00:18:48.010]to the time where the consequence is administered,
[00:18:50.540]and the shorter that time period is, the better.
[00:18:53.580]And what happens in the judicial system oftentimes is,
[00:18:57.280]that period gets really, really long.
[00:18:59.610]So three years later, I get a consequence
[00:19:01.800]from something that happened long ago.
[00:19:04.660]And then the certainty of the consequence.
[00:19:10.850]So, is it every time that I violate this?
[00:19:16.190]Or is it only every once in a while, or sort of a randomness
[00:19:22.250]that if I have a transgression, I'm gonna get caught?
[00:19:27.010]And students have a very clear perception of,
[00:19:29.670]the likelihood of me getting caught is next to zero.
[00:19:34.180]So, that has no deterrent effect if there's a policy.
[00:19:39.280]And I think what I'm arguing is,
[00:19:42.720]having a severe penalty really undermines
[00:19:46.170]the certainty and the celerity of those punishments.
[00:19:49.870]So that's sort of falling back on theory
[00:19:53.100]when there's the absence of literature
[00:19:55.190]and empirical evidence on it, is where I'd go.
[00:20:01.438]Does that help? One more question,
[00:20:02.590]we were just told.
[00:20:04.360]What else, if anything?

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National Institute on Alcohol Abuse and Alcoholism’s College Alcohol Intervention Matrix Part 5 of 5

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