Addressing High-Risk Drinking on Campus: Examining the Impact of a Multi-Pronged

Approach including a Recent Hard Alcohol BanDARTMOUTH COLLEGE HEALTH SERVICE

BRIAN BOWDEN, MEd, LCMHC, VIRGINIA BRACK, MD, ANN BRACKEN, MD, PHD,BRYANT FORD, PHD, LAURI GALLIMORE, RN

NECHA NOVEMBER, 2016

Learners will be able to:

1. Describe the impact of high-risk drinking on the health and well-being of college students using national and institutional data

2. Describe evidence-based strategies to address high-risk drinking using the National Institute on Alcohol Abuse and Alcoholism (NIAAA) College Alcohol Intervention Matrix (AIM)

3. Learn how to use institutional data to examine the impact of policy and program interventions on alcohol use at your college or university

LEARNING OBJECTIVES

1. Review national and institutional initiatives to address high-risk drinking (HRD)2. Review data sources that may be helpful to generate information for your

campus3. Review CollegeAIM tool and how you can use at your own institution4. Dartmouth AOD team members will discuss people, places and processes

involved in addressing HRD at Dartmouth

OUTLINE

NCHIP LEARNING COLLABORATIVE SCHOOLS, 2011

National College Health Improvement Program

LEARNING COLLABORATIVE

1

• High-level engagement and leadership

2• Collective learning

3• Outcomes measurement

4• Data Sharing

5

THE IMPROVEMENT METHOD

Evidence Practice Outcomes

GeneralizableScience

Implementation Expertise

Design and test local changes

Continually measure, re-

design programs

Measure and share lessons

Disseminate findings

Dartmouth College Health Improvement Project (DCHIP) Campus Improvement Team

7

Individual Interventions

Started June 2011

Campus Environment

Winter 2012

Campus Systems

July 2012

WHAT DO WE KNOW ABOUT DARTMOUTH HIGH-RISK DRINKING?

High-risk Drinking Trends - Dartmouth Compared to National SampleThink back over the past two weeks. How many times, if any, have you had five or more

alcoholic drinks at a sitting?

4644

4137

49

43

40

33 3536

36

33

0

10

20

30

40

50

60

2005 2008 2010 2012 2014 2016/15Dartmouth NCHA

STUDENTS REPORT THAT ALCOHOL AFFECTS THEIR ACADEMICS

4%

3%

12%

11%

14%

9%

12%

24%

20%

31%

6%

6%

7%

8%

13%

13%

24%

27%

30%

37%

0% 5% 10% 15% 20% 25% 30% 35% 40%

ADHD

Alcohol use

Internet social network sites

Computer games/internet use

Relationship difficulty

Concern for troubled friend/familymember

Depression

Sleep difficulties

Anxiety

Stress

Within the last 12 months, the following affected your academic performance:(including received lower grade on exam or important project, or received lower grade course, or received incomplete or dropped

course)

2016 2014

ADVERSE EFFECTS OF HIGH-RISK DRINKING

0%

20%

40%

60%

80%

100%

201420122010200820052014201220102008200520142012201020082005201420122010200820052014201220102014201220102008200520142012201020082005201420122010201420122010

Did something later

regretted

Forgot where you were or

what you did

Physically injured

yourself

Had unprotected sex Thought might

have drinking

problem

Been involved in a fight Sex with my consent Been in trouble Sex without

others' consent

Binge Drinker Non-Binge Drinker

Sex without my consent

Adverse Events Experienced When Drinking Alcohol:

Dartmouth Students Who Binge/ High-risk Drink Compared to Those Who Do Not

NIAAA COLLEGE ALCOHOL INTERVENTION MATRIX (AIM)

Two basic types of strategies: Individual

Designed to change knowledge, attitudes and behaviors so students drink less, take fewer risks, and experience fewer harmful consequences• Cognitive behavioral skills, motivation and feedback and behavioral interventions

by health professionals

Environmental Designed to change the environment in which

student drinking occurs and reduce the availability of alcohol to reduce consumption and negative consequences

COLLEGEAIM

How do you start? Briefly assess the problems on your campus

– Greek system? Retail outlets? Subgroups that experience more harm?

– Consult with colleagues and key stakeholders

– Then use College AIM to rate your strategies

– Consider alternative evidence based strategies

USING COLLEGEAIM

INDIVIDUAL LEVEL STRATEGIES MATRIX

ENVIRONMENTAL LEVEL STRATEGIES MATRIX

COLLEGEAIM STRATEGY PLANNING WORKSHEET

FOR 2011-2012 ACADEMIC YEAR Screen 90% of all primary care clinical encounters at Dick’s

House

100% of students with an alcohol policy violation will complete the BASICS I program within 2 weeks of incident

Increase use of Good Sam (medical amnesty) to over 75% of all alcohol-related interactions with Dept. of Safety & Security

Conduct test cycles on 2 innovative strategies for addressing high-risk pre-gaming in the residence halls each term

Screen 95% of incoming class (prior to matriculation) for HRD and provide feedback

PAST AND FUTURE GOALS

WITHIN 3 YEARS

Eliminate Dartmouth-Hitchcock Medical Center Emergency Department visits for BAC >0.25, by eradicating this level of intoxication from our campus community.

ADDITIONAL ASPIRATIONAL AIM

18

INDIVIDUAL STRATEGIES AT DARTMOUTH

Strategy Effectiveness Cost BARRIERS Research

Screeningand Brief

Intervention

AlcoholEDU *** $$$ # ^^

BASICS *** $$ ## ^^^^

MedicationUse for Alcohol Disorder

Not rated in CollegeAIM because of difference in research population and wide variation in cost and barriers

Not rated in CollegeAIM because of difference in research population and wide variation in cost and barriers

Effectiveness Research Barriers

*** 75% or more ^^^^ 11+ studies ### higher

** 50 – 74% ^^^ 7 – 10 studies ##moderate

* 25 – 29% ^^ 4- 6 studies # lower

PRIMARY CARE SCREENING FOR HIGH RISK DRINKING

The USPSTF found adequate evidence that brief behavioral counseling interventions are effective in reducing heavy drinking episodes in adults engaging in risky or hazardous drinking.

These interventions reduce weekly alcohol consumption rates and increase adherence to recommended drinking limits.

Evidence for benefits of screening in adults (not adolescents)

BENEFITS OF SCREENING AND COUNSELING

Alcohol Use Disorders Identification Test (AUDIT, 10 items)

Abbreviated AUDIT-Consumption (AUDIT-C, 3 items)

Single-question screening (for example, the NIAAA recommends asking, “How many times in the past year have you had 5 [for men] or 4 [for women and all adults older than 65 years] or more drinks in a day?”)

22

THREE TOOLS RECOMMENDED BY THE USPSTF

Variation in interventions:

Content

cognitive behavioral strategies (eg. action plans, drinking diaries), motivational enhancement, stress management

Administration

face-to-face sessions, written self-help materials, web-based programs, telephone counseling.

Length

Frequency

USPSTF BEHAVIORAL COUNSELING INTERVENTIONS

23

Definitions: very brief single contact (≤5 minutes)

brief single contact (6 to 15 minutes)

brief multi-contact (each contact is 6 to 15 minutes)

extended multi-contact (≥1 contact, each >15 minutes)

Brief multi-contact behavioral counseling seems to have the best evidence of effectiveness; very brief behavioral counseling has limited effect

Evidence is lacking to determine the optimal interval for screening in adults

USPSTF DEFINITIONS OF INTERVENTION INTENSITY

Time (provider and student)

Resistance to the answering the question

Screening less intrusive than face-to-face ask

Interference with patient-provider relationship

No evidence for harm

Potential concerns: Anxiety, stigma

COSTS OF THE SCREENING?

25

26

DICK’S HOUSE: DARTMOUTH COLLEGE HEALTH SERVICE

PRIMARY CARE SCREENING PDSA

27

Started with small PDSA in July 2011 -modified our sign-in slip:

“In the past two weeks, have you had five or more drinks in one sitting?”

HOW ARE WE DOING WITH PRIMARY CARE SCREENING?

28

40%

50%

60%

70%

80%

90%

100%

Jul-

11

Au

g-1

1

Sep

-11

Oct

-11

No

v-1

1

Dec

-11

Jan

-12

Feb

-12

Mar

-12

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

Dec

-12

Jan

-13

Feb

-13

Mar

-13

Ap

r-1

3

May

-13

Jun

-13

Jul-

13

Au

g-1

3

Sep

-13

Oct

-13

No

v-1

3

Dec

-13

Jan

-14

Feb

-14

Mar

-14

Ap

r-1

4

May

-14

Jun

-14

Jul-

14

Au

g-1

4

Primary Care: % Students Screened (Students Screened/ Primary Care Visits)

Goal

Picture of new slip

ADDITIONAL SCREENING QUESTIONS

Blood Alcohol Concentration (BAC)

cards

By gender and weight

After drinking

– 1hr

– 3hrs

– 5hrs

Designed by our AOD coordinator, Caitlin Barthelmes, modeled after card from UVA

BRIEF INTERVENTION TOOL

ANOTHER BRIEF INTERVENTION TOOL

31

Developed a very simple NIH alcohol use message for providers to give to students who say “yes” to high-risk drinking

One card- back and front

*Designed by our AOD coordinator, Brian Bowden

Alcohol misuse screening and brief interventions

2015 - 2016

11,520 patient encounters included screening for alcohol misuse

8% screened positive for 5 or more drinks in a sitting in the last 2 weeks

73% screened negative

18% did not complete screen

Of those screening positive, 50% received intervention

Data Source: Dartmouth Point n Click EMR

ARE WE MAKING A DIFFERENCE? ACADEMIC YEAR 15-16

32

CAN WE CHANGE BEHAVIORS?

Do students remember being asked about HRD?

Do students report changes in behavior?

78% report being asked about alcohol use

17% report receiving helpful information

15% report making healthy changes in alcohol use

Data Source: Patient Satisfaction Survey 2016 (response rate for survey 19%): 433 respondents reported using Primary Care

33

DARTMOUTH COLLEGE HEALTH SERVICE INPATIENT DEPARTMENT

35

DARTMOUTH COLLEGE HEALTH SERVICE INPATIENT ROOMS

DICK’S HOUSE: DARTMOUTH COLLEGE HEALTH SERVICE

Inpatient Nursing and the AOD team

Email Invite

Online Survey

Email Scheduling

48 hrs.

10 days21 days

DOSS Report

JA

Outcome Letter

AOD

AOD

MANDATED BASICS

Old New

Online EChug

CHDAssessment

AOD

Months

JA

JA

Feedback Session

Online Programs: Maxient, BluSky

30 Minute Feedback

• Process Explanation

• Norms Perception

• Information gathering/giving

– Typical/Peak BAC

– Biphasic Response

– Detoxification time

– Calories

• Expectancy Challenge

• Consequence Awareness

• Continuum of Drinking

• Family Risk Factors

• Protective Strategies

• Goal impairment

• Readiness Ruler

• GOAL

1 Hour Feedback Session

• Building Rapport/Explanation

• Norms Perception

• Information gathering/giving

– Typical/Peak BAC

– Biphasic Response

– Detoxification time

– Calories

• Expectancy Challenge

• Consequence Awareness

• Continuum of Drinking

• Family Risk Factors

• Protective Strategies

• Goal impairment

• Readiness Ruler

• GOAL

http://www.dartmouth.edu/~healthed/basics/basicsmanual.pdf

RESULTS FROM BASICS AT DARTMOUTH

39

90 days

90 days180 days

7.9

7.7

8.1

4.0

3.5

3.4

3.6

3.53.8

0 2 4 6 8 10

Drinks

Avg. Alcohol Consumption for the Heaviest Drinking Episode in the Last Month for Mandated Students

60.0% response rate, N=186

47% response rate, N=114

36% response rate, N=75

Dartmouth College Office of Institutional Research (OIR). Hanover, NH.

(BASICS data for calendar year 2012, N=311 mandated alcohol incident)

Baseline 3 months

Baseline 3 months6 months

Baseline 3 months6 months 1 year

Email Invite

Online Survey

Feedback Session

Assoc. Athletic Director

Team

Year 1, n = 1000

AOD

Assoc. Athletic Director

Email Scheduling

Email Invite

Online Survey

Feedback Session

Team

AOD

Email Scheduling

Year 2+, n = 250

2 PT Graduate

Interns Evenings/Weekends

1 FT Graduate

Intern

PREVENTATIVE ATHLETES BASICS

2015 - 2016 Invitation Categories (n=939)

Preventative

Educational

Mandated

26%, 240

10%, 94

64% , 605

*Number of students invited from given class

**Percentage of class group that completed program

2016

2017

2018

2019

I

i

2015

91% completed**

71%

100%70%

2015 - 2016 Invitation/Completion Rate=939)

61%

Mental Health Role Review all admissions to IPD for intoxication Counseling referral

Routes• BASICS • Undergraduate Judicial Affairs• Self-referral• Dean’s Office

Substance abuse evaluation/Mental health intake at CHD Counseling options

1. Individual counseling2. Group counseling3. Medication management

44

MENTAL HEALTH: ROLE ON AOD TEAM

Mental Health Role Referral for Intensive Outpatient Program

Reason

Criteria

Types of treatment

Medical Leaves:

Reason

Criteria

Types of treatment

Mental Health: Role on AOD Team

45

ENVIRONMENTAL STRATEGIES AT DARTMOUTH

Effectiveness Research Barriers

*** 75% or more ^^^^ 11+ studies ### higher

** 50 – 74% ^^^ 7 – 10 studies ##moderate

* 25 – 29% ^^ 4- 6 studies # lower

Strategy Effectiveness Cost Barriers Research

Require alcohol-free programming ?? $$$ # ^^

Establish amnesty policies ? $ # ^^^

Implement beverage service training:sales to intoxicated, sales to underage

* $$$ # (college)## (local/state)

^^^

Implement party patrols ? $ ## ^^^

Implement bystander intervention ? $$ # 0

Implement campus wide social norms campaign

* $$ # ^^^^

Enforce drinking age/compliance checks *** $$ ## ^^^^

Implement safe rides ? $$$ ## ^^

Enact social host property laws ? $$$ ## 0

Enact social host provision laws ** $ ## ^^^

OTHER ENVIRONMENTAL STRATEGIES

48

▪Pre-matriculation education and screening

▪ BASICS▪ Primary Care Screening

*Care intoxicated student

▪ Referral to treatment assessment

▪ Recovery support

▪ Green Team ▪ Pre-gaming

interventions in residence halls

▪ Students initiated no FY

In Greek Houses 6 wks

▪ Safety and Security

walk-throughs▪ FY trips – no

alcohol*Responsible

Service Policies

▪ BASICS for Athletes, RAs, Greeks

▪ Motivational Interviewing trainings

▪ Increased Late night options

▪ Integration withAcademics

▪ Case Management*Community

CoalitionsGood Samaritan Policy

*Hard liquor ban

INDIVIDUAL

ENVIRONMENT

Moving Dartmouth Forward

– Moving Dartmouth Forward is an initiative aimed at eliminating high-risk behavior and increasing inclusivity while strengthening Dartmouth’s longstanding commitment to leadership in teaching and learning

PROMOTE SAFER AND HEALTHIER CAMPUS ENVIRONMENT

ALCOHOL INCIDENT AND HIGH BAC DATA

HARD ALCOHOL POLICY

HARD ALCOHOL POLICYViolation Type Incident Likely Conduct Response*Possession/Consumption or Public Intoxication

1st Incident College Probation, 4 Terms

2nd Incident 1 Term Suspension3rd Incident 2 Term Suspension

Providing Hard Alcohol to Others 1st Incident 1 Term Suspension

2nd Incident 2 Term Suspension

Organization Providing Hard Alcohol To Others**

1st Incident

1 Term Suspension followed by a specified period of time when alcohol may not be consumed or served at organizational events or on the premises.

2nd Incident 1 Year Suspension

3rd Incident Permanent Loss of Recognition

*All incidents involving a violation of Dartmouth's Alcohol or Other Drug policy include an educational and/or medical referral.

**Organization leaders and/or event coordinators will also be held accountable for violations of this policy and violations of the Social Event Management

Procedures.

NIAAA selects winners of its Wearable Alcohol Biosensor Challenge

In May, the NIAAA announced the winners of its Wearable Alcohol Biosensor Challenge, a competition to design a discreet device capable of measuring blood alcohol levels in near real-time. The winning prototype and recipient of the $200,000 first prize was submitted by BACtrack, a company known nationally for designing and selling portable breath alcohol testers for consumer and professional use. Their entry, the BACtrack Skyn, is worn on the wrist and offers continuous and non-invasive monitoring of a user’s BAC. Alcohol is detected using a fuel cell technology similar to that in devices used by law enforcement for roadside alcohol testing. The device connects via Bluetooth to a smartphone to store data.

WAVE OF THE FUTURE?

NEW IDEAS

How are you feeling ask your smart phone?Professor Andrew Campbell and a team of researchers have developed an APP to assess student health .

References Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care, Release Date: May 2013

– https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care

CollegeAIM—The College Alcohol Intervention Matrix– https://www.collegedrinkingprevention.gov/CollegeAIM/

Preventing Alcohol-Related Problems on College Campuses—Summary of the Final Report of the NIAAA Task Force on College Drinking– http://pubs.niaaa.nih.gov/publications/arh284/249-251.htm

REFERENCES