Trajectories of adolescent alcohol use after brief treatment in an Emergency Department.

OBJECTIVE: The primary aim of this study was to identify distinct classes of trajectories of adolescent substance use following a brief motivational interviewing (MI) intervention in an Emergency Department (ED). The secondary aim was to identify predictors of class membership. METHODS: Latent growth mixture modeling was used with 177 adolescents who participated in two randomized clinical trials evaluating MI for an alcohol-related event. RESULTS: Three classes were identified: (1) moderate use, decreasers consisting of 56.8% of participants; (2) heavy use, decreasers, consisting of 10.5% of participants, and (3) heavy use sustainers, consisting of 32.7% of participants. Hispanic ethnicity, parental monitoring, and days of high-volume drinking were significant predictors of class membership. Hispanic ethnic status and high levels of parental monitoring were associated with decreased likelihood of belonging to either of the two heavy use classes. More frequent high-volume drinking at baseline was associated with increased likelihood of belonging to the heavy use, sustainer class, and decreased likelihood of belonging to the heavy use, decreaser class. Across all three classes, being female and having frequent high-volume drinking at baseline were associated with worse response to the intervention. CONCLUSIONS: These findings have important implications for identifying adolescents who may benefit from different or additional intervention, and for anticipating and informing families of adolescents' potential drinking course following treatment.

Phase I and pharmacokinetic study of CT-322 (BMS-844203), a targeted Adnectin inhibitor of VEGFR-2 based on a domain of human fibronectin.

PURPOSE: To determine the maximum tolerated dose (MTD), safety, pharmacokinetics, pharmacodynamics, immunogenicity, and preliminary antitumor activity of CT-322 (BMS-844203), a VEGFR-2 inhibitor and the first human fibronectin domain-based targeted biologic (Adnectin) to enter clinical studies. EXPERIMENTAL DESIGN: Patients with advanced solid malignancies were treated with escalating doses of CT-322 intravenously (i.v.) weekly (qw), or biweekly (q2w). Plasma samples were assayed for CT-322 concentrations, plasma VEGF-A concentrations, and antidrug antibodies. RESULTS: Thirty-nine patients completed 105 cycles of 0.1 to 3.0 mg/kg CT-322 i.v. either qw or q2w. The most common treatment-emergent grade 1/2 toxicities were fatigue, nausea, proteinuria, vomiting, anorexia, and hypertension. Grade 3/4 toxicities were rare. Reversible proteinuria, retinal artery, and vein thrombosis, left ventricular dysfunction, and reversible posterior leukoencephalopathy syndrome were dose limiting at 3.0 mg/kg. The MTD was 2 mg/kg qw or q2w. CT-322 plasma concentrations increased dose proportionally. Plasma VEGF-A levels increased with dose and plateaued at 2 mg/kg qw. Anti-CT-322 antibodies developed without effects on pharmacokinetics, VEGF-A levels, or safety. Minor decreases in tumor measurements occurred in 4 of 34 evaluable patients and 24 patients had stable disease. CONCLUSIONS: CT-322 can be safely administered at 2 mg/kg i.v. qw or q2w and exhibits promising antitumor activity in patients with advanced solid tumors. The absence of severe toxicities at the MTD, demonstration of plasma drug concentrations active in preclinical models, and clinical pharmacodynamic evidence of VEGFR-2 inhibition warrant further development of CT-322 and suggest strong potential for Adnectin-based targeted biologics.

Alcohol use history differentiates adolescents treated in the emergency department after an alcohol-related incident.

OBJECTIVES: The current study compared 3 groups of adolescents identified in an emergency department (ED) following an alcohol-related event: (1) alcohol-positive adolescents scoring at or above the clinical cutoff on a measure of problematic drinking, the Adolescent Drinking Inventory (ADI) (n = 45); (2) alcohol-positive adolescents scoring below the clinical cutoff on the ADI (n = 68), and (3) alcohol-negative adolescents (n = 64). We examined whether these 3 groups of adolescents differed on measures of substance use as well as psychosocial factors. METHODS: Participants were recruited as part of a larger clinical trial. Alcohol-positive adolescents were recruited from a level I regional trauma center for treatment related to an alcohol-related incident. Alcohol-negative adolescents were recruited from the ED and the community. The data reported here were from the baseline adolescent and parent assessments. Before completing assessments, adolescents were required to pass a brief mental status examination. RESULTS: Adolescents in the alcohol-positive, high-ADI group reported significantly more substance use, peer substance use, and peer tolerance of substance use than adolescents in the alcohol-positive, low-ADI group followed by adolescents in the alcohol-negative group. Adolescents in the alcohol-positive, high-ADI group reported significantly less parental supervision than adolescents in the other 2 groups. CONCLUSIONS: These findings underscore that alcohol-positive adolescents being treated in an ED are a heterogeneous group with respect to substance use as well as parent and peer risk factors. Physicians need to consider relevant background factors when making individualized discharge recommendations.

Ethnic group differences in substance use, depression, peer relationships, and parenting among adolescents receiving brief alcohol counseling.

This study examined differences in substance use and related risk factors in a matched sample of Hispanic and White non-Hispanic adolescents receiving brief alcohol counseling. Findings revealed that the White non-Hispanic adolescents reported smoking a higher number of cigarettes per day. The Hispanic adolescents reported perceiving less acceptance from the neighborhood environment in which they live, whereas their parents reported monitoring their teens less than the parents' of White non-Hispanic adolescents. Consistent with the findings found in community samples, the overall findings of this study suggest that Hispanic and White non-Hispanic adolescents enrolled in this alcohol intervention have similar baseline characteristics.

Intolerance for Smoking Abstinence Questionnaire: psychometric properties and relationship to tobacco dependence and abstinence.

UNLABELLED: While smokers' ability to tolerate emotional or physical distress has been associated with length of smoking cessation, there is no measure of ability to tolerate smoking abstinence discomfort specifically, which may be more heuristic than a measure of tolerance of general emotional stress or physical discomfort. METHODS: Questionnaires completed by 300 smokers assessed inability to tolerate smoking abstinence discomfort (IDQ-S), general physical discomfort (IDQ-P), and general emotional discomfort (IDQ-E), so that shared variance among these measures could be assessed. RESULTS: The IDQ-S has three reliable components: withdrawal Intolerance, Lack of Cognitive Coping, and Pain Intolerance. The 14-item IDQ-P and 9-item IDQ-E each consist of one reliable component. Intercorrelations suggest only modest shared variance. Support for construct and discriminant validity was seen. Two scales of the IDQ-S showed excellent convergent validity, correlating with smoking use, dependence, motivation, and length of past smoking cessation, while IDQ-P and IDQ-E correlated with few indices of use or dependence and not with smoking cessation. CONCLUSIONS: The final 17-item IDQ-S with two scales is reliable and valid, and more heuristic than measures of general physical or emotional discomfort intolerance as a correlate of motivation and past success with smoking cessation.

The significance of marijuana use among alcohol-using adolescent emergency department patients.

OBJECTIVES: The objective was to determine if adolescents presenting to a pediatric emergency department (PED) for an alcohol-related event requiring medical care differ in terms of substance use, behavioral and mental health problems, peer relationships, and parental monitoring based on their history of marijuana use. METHODS: This was a cross-sectional comparison of adolescents 13-17 years old, with evidence of recent alcohol use, presenting to a PED with a self-reported history of marijuana use. Assessment tools included the Adolescent Drinking Inventory, Adolescent Drinking Questionnaire, Young Adult Drinking and Driving Questionnaire, Center for Epidemiologic Studies Depression Scale, Behavioral Assessment System for Children, and Peer Substance Use and Tolerance of Substance Use Scale. RESULTS: Compared to adolescents using alcohol only (AO), adolescents who use alcohol and marijuana (A+M) have higher rates of smoking (F = 23.62) and binge drinking (F = 11.56), consume more drinks per sitting (F = 9.03), have more externalizing behavior problems (F = 12.53), and report both greater peer tolerance of substance use (F = 12.99) and lower parental monitoring (F = 7.12). CONCLUSIONS: Adolescents who use A+M report greater substance use and more risk factors for substance abuse than AO-using adolescents. Screening for a history of marijuana use may be important when treating adolescents presenting with an alcohol-related event. A+M co-use may identify a high-risk population, which may have important implications for ED clinicians in the care of these patients, providing parental guidance, and planning follow-up care.

The effect of personal relevance on learning stroke symptoms/response.

The aim of this study was to test the effect of increasing the personal relevance of stroke symptom information on learning stroke symptoms/emergency response. A randomized pretest-posttest double-blind study design was used. A total of 173 community-dwelling adults participated. Treatment participants read the personally relevant statement, "Learn about stroke to save someone you love," completed the Stroke Action Test pretest, read the National Institute of Neurological Disorder and Stroke pamphlet titled Know Stroke. Know the Signs. Act in Time, and responded to the Stroke Action Test posttest. The control condition differed only in the omission of the personally relevant statement. The treatment group learned significantly more than the control group, F(1, 170) = 7.46, p < .007, eta2 = .02. The mean items learned by the treatment group was 8.3 (SD = 5.67) compared to the control group mean of 6.2 (SD = 5.76). Prefacing stroke prevention information with the statement, "Learn about stroke to save someone you love," could result in greater learning of stroke symptoms/response.

The Important People Drug and Alcohol interview: psychometric properties, predictive validity, and implications for treatment.

Research with the Important People instrument has shown that social support for abstinence is related to alcohol treatment outcomes, but less work has been done on the role of network support in drug treatment outcomes. A drug and alcohol version of the Important People instrument (IPDA) was developed and administered to 141 patients in residential treatment for cocaine dependence. Three components were found, all with acceptable internal consistency: (a) substance involvement of the network, (b) general/treatment support, and (c) support for abstinence. These components and three fundamental network characteristics (size of daily network, size of network, and importance of the most important people) were investigated as correlates of pretreatment and posttreatment alcohol and drug use. The general/treatment support component and network size were inversely related to pretreatment days using drugs, whereas network substance involvement positively correlated with pretreatment drinking frequency. Size of the daily network predicted less drinking, less drug use, and less problem severity during the 6 months after treatment, whereas general/treatment support and support for abstinence did not predict outcome. Network substance involvement decreased for patients who stayed abstinent but not for those who later relapsed. Results suggest that increasing the number of people the patient sees daily while replacing substance-involved with abstinent-supportive people may improve treatment outcomes. Treatment programs may use the IPDA to identify clients most likely to benefit from changes in their social networks.

Parental factors influence teen alcohol use after an emergency department visit.

OBJECTIVES: To determine if parental factors are significant predictors of short-term adolescent drinking after an alcohol-related emergency department (ED) visit. METHODS: Adolescents, 13 to 17 years, who either had evidence or reported usage of alcohol in the 6 hours before an ED visit, were eligible for this study. Alcohol use was assessed at baseline and at 3-month follow-up. Data on parental variables and parenting practices were collected at baseline. Linear regression models were created to determine the relationship between parental factors and follow-up drinking. RESULTS: Parental alcohol use, socioeconomic status, and monitoring practices were significant predictors of adolescent alcohol use at 3-month follow-up. CONCLUSIONS: Parental factors may significantly influence subsequent adolescent drinking after an ED visit. These factors should be assessed when treating alcohol-positive teens, and parents should be advised to closely monitor their teens.

Cocaine craving as a predictor of treatment attrition and outcomes after residential treatment for cocaine dependence.

OBJECTIVE: Whether craving (urge to use) actually predicts drug-use outcomes has had little investigation despite its central role in theories. Pretreatment predictors of within-treatment cocaine urges were investigated, and the urge reports were used as predictors of treatment attrition and outcome while controlling for correlated variables. In addition, urge to use in the patients' first relapse situations was compared with urge reports in the same patients' close-call situations without relapse. METHOD: Cocaine-dependent patients (N = 163) in residential treatment were assessed during the first week of treatment for pretreatment substance use and for urge to use cocaine in simulated high-risk situations. Substance use was assessed at follow-up with urine-confirmed self-reports (n = 119 at 3 months, n = 114 at 6 months). Mood and urge ratings just before relapse and in close calls without relapse were assessed. RESULTS: Urge to use cocaine was unrelated to demographics, other substance use, years used, or cocaine-use frequency in the past 6 months but was higher for those who spent more on cocaine before treatment or reported more negative cocaine consequences. Urge did not predict treatment attrition but significantly predicted the amount spent on cocaine during the first 3 months even after covarying the pretreatment amount spent on cocaine. Urge ratings, not mood, were higher just before a relapse than a close call. CONCLUSIONS: Urge to use cocaine predicts early drug-use outcomes and is not simply accounted for by the pretreatment quantity of cocaine use. Thus urge is a valid treatment target.

Utility of the AUDIT for screening adolescents for problematic alcohol use in the emergency department.

The emergency department is a setting conducive to screening adolescents for problematic alcohol use, who can then be targeted for further evaluation and intervention. This study examined the utility of the Alcohol Use Disorders Identification Test (AUDIT) as a screening measure for identifying young adolescents in an urban emergency department (ED). Adolescents (13-17 years old) who presented to the ED were screened as part of a larger study. A total of 859 adolescents, who denied alcohol use prior to their ED visit were administered the AUDIT. Of the 500 younger adolescents (13-15 years old), approximately 4% (n=22) were classified as AUDIT-positive using a cut-score of four or greater. Of the 359 older adolescents (16-17 years old), almost 19% (n=67) were classified as AUDIT-positive. The ability of shorter versions of the AUDIT to identify AUDIT-positive adolescents (as classified by the 10-item AUDIT using a cut-score of four or greater) was also explored. Since the adolescents in the current study were not alcohol-positive at the time of the ED visit, they would likely have been missed by biochemical alcohol screening alone. Screening procedures that employ the AUDIT may be most efficient when adapted for the specific adolescent age group (younger versus older), thus identifying the highest number of adolescents who should be targeted for intervention. Lowering the recommended adult cut-scores on the shorter versions of the AUDIT appears necessary to identify adolescents who may benefit from intervention or referral.

Validation of the timeline follow-back in the assessment of adolescent smoking.

The timeline follow-back instrument (TLFB) is a valid and reliable method of quantifying alcohol use patterns. The use of this instrument has been expanded to assess other behaviors, such as drug use, sexual behavior, binge eating, and panic attacks. Some evidence for the validity and reliability of this assessment instrument has emerged in the area of adult smoking. However, to date, there is no published evidence of its reliability and validity in the assessment of adolescent smoking. The purpose of this study is to present early evidence of the utility of the TLFB to collect information on adolescent smoking behavior. Through secondary data analysis of four studies on adolescent smokers, we examined the associations between the TLFB and measures of dependence, smoking history, respiratory symptoms, and saliva cotinine. Moreover, we examined the stability of the TLFB data across two 15-day time periods. Results provide preliminary evidence of the validity and reliability of the TLFB in the assessment of adolescent smoking. In particular, the TLFB instrument offered important data on the heterogeneity of adolescent smoking patterns beyond a global measure of cigarettes per day, and the reduction of digit bias. Implications of these findings for the assessment of adolescent smoking are discussed.

Potential biases in case detection of alcohol involvement among adolescents in an emergency department.

OBJECTIVE: To determine the factors associated with physician decisions to test for alcohol involvement in adolescents treated in an emergency department (ED) and to examine patient and event characteristics associated with being identified as alcohol positive, either by testing or by clinical examination. METHODS: Medical chart reviews were conducted for all adolescent patients (n = 9,660; age range, 13-19 y) treated over a 1-year period in a Level I regional trauma center/ED. RESULTS: Among all 9,660 patients in the ED, 298 (3.1%) were identified as alcohol positive by test or clinical examination. Of the 9,660 patients, 464 (4.8%) were tested for alcohol, and 49% of these had alcohol-positive test results. Physicians were more likely to order alcohol tests when patients were male, older, injured, and treated during the overnight shift or on weekends. Testing was most common for suicide attempts, motor vehicle crashes, assaults, and intoxication. Patients being treated for an illness or for occupational or athletic injuries were rarely tested. A large proportion of alcohol-related treatment was for intoxicated, uninjured patients, whose profile was different (ie, younger, more often female, with higher blood alcohol concentrations, and admission distributed more evenly across ED shifts). CONCLUSIONS: Case detection rates for alcohol involvement may be biased and inflated when based on physician decisions to test for alcohol use. Rates based on comprehensive chart reviews and clinical examination may be better estimates but are also subject to methodologic limitations. Universal screening would yield the most accurate estimates of alcohol prevalence and would provide more accurate guidance to physicians regarding when to test for alcohol use. Universal screening as a clinical standard would help to identify more adolescents who might benefit from additional alcohol use intervention.

Physician recruitment for a community-based smoking cessation intervention.

OBJECTIVE: Our goal was to describe a strategy to recruit a population-based sample of physicians into a trial to test an approach to disseminate physician-delivered smoking cessation interventions. STUDY DESIGN: The 3-phase population-based recruitment trial included: (1) a print-based promotional appeal, (2) in-person presentations with by the principal investigator (PI), and (3) follow-up calls by the PI and paid physician recruiters. Participation requirements were kept minimal to facilitate recruitment. POPULATION: All primary care physicians statewide were targeted; 3 counties were chosen as intervention areas and 2 counties as control areas. A subsample of physicians was targeted in the larger control areas through a matching process. OUTCOME MEASURED: We measured physician recruitment rate. RESULTS: Eighty-one percent (n=259) of all eligible physicians were successfully recruited into our study. CONCLUSIONS: The full multistep process was important in getting participation agreement. By using an intensive recruitment strategy and minimizing research demands, it is possible to recruit community-based primary care physicians for research projects that will help them enhance the preventive services they provide to their patients.