Tibor P. Palfai

Are Needs to Manage Uncertainty and Threat Associated With Political Conservatism or Ideological Extremity

Three studies are conducted to assess the uncertainty— threat model of political conservatism, which posits that psychological needs to manage uncertainty and threat are associated with political orientation. Results from structural equation models provide consistent support for the hypothesis that uncertainty avoidance (e.g., need for order, intolerance of ambiguity, and lack of openness to experience) and threat management (e.g., death anxiety, system threat, and perceptions of a dangerous world) each contributes independently to conservatism (vs. liberalism). No support is obtained for alternative models, which predict that uncertainty and threat management are associated with ideological extremism or extreme forms of conservatism only. Study 3 also reveals that resistance to change fully mediates the association between uncertainty avoidance and conservatism, whereas opposition to equality partially mediates the association between threat and conservatism. Implications for understanding the epistemic and existential bases of political orientation are discussed.

Alcohol-related motivational tendencies in hazardous drinkers: assessing implicit response tendencies using the modified-IAT.

This study examined the utility of an implicit measure of cognitive associations, the Implicit Association Test (IAT; ), to assess alcohol-related approach dispositions. Forty-seven hazardous drinkers completed a modified IAT procedure that assessed the relation between alcohol and behavioral categories (i.e., approach and avoid). Participants completed a series of individual difference measures before an alcohol cue exposure task in which they anticipated alcohol consumption. Results indicate that the modified IAT is associated with binge drinking episodes, perceived difficulty controlling alcohol use, and appetitive responses to alcohol cues. Findings are discussed in terms of the potential value of this measure to assess alcohol-related memory associations among those whose alcohol use puts them at risk for harm.

Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.

IMPORTANCE The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy. OBJECTIVE To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)-a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)-compared with no brief intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts. INTERVENTIONS Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by masters-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources. MAIN OUTCOMES AND MEASURES Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization. RESULTS At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity. CONCLUSIONS AND RELEVANCE Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00876941.

Brief intervention for medical inpatients with unhealthy alcohol use: a randomized, controlled trial

Context Brief interventions reduce alcohol use in outpatients who drink unhealthy amounts but are not alcohol-dependent. Their effect in medical inpatients is unknown. Contribution The authors screened all adult medical inpatients at an urban teaching hospital and randomly assigned 341 risky drinkers to a 30-minute motivational counseling intervention followed gy treatment planning or to usual care. By 3 months, the same proportion of patients from both groups had received alcohol assistance, and both groups had reduced their drinking to the same degree. Cautions Three quarters of the participants met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for alcohol dependence. Implications In this well-done study, brief intervention did not affect alcohol-related outcomes in persons who drank unhealthy amounts. The Editors Professional organizations recommend that clinicians screen their patients for unhealthy alcohol use (that is, the spectrum from drinking risky amounts to dependence) and conduct a brief intervention when indicated (1, 2). Despite this recommendation and the existence of brief, valid screening tools (35), patients with unhealthy alcohol use often are not identified and do not receive timely care. Although widely recommended, brief intervention has proven efficacy in decreasing alcohol consumption and related consequences only in unhealthy drinkers without alcohol dependence and in outpatient settings (6). Its efficacy among other populations (for example, persons with alcohol dependence) and in inpatient settings remains unclear (7). Evidence suggests, however, that medical inpatientsa group with a high prevalence of alcohol-related problemsmay benefit from brief intervention. Some studies have demonstrated the efficacy of brief intervention in settings similar to medical services in which alcohol-related problems are common and their related consequences are severe (8, 9). Further, brief interventions are well suited to medical services. Patients who otherwise might not seek care are accessible and have time for an intervention. Persons admitted because of an alcohol-related problem may recognize the link between drinking and hospitalization, thus providing a teachable moment (10). Also, busy staff might implement a brief intervention because of its brevity and flexibility. The unmet need for alcohol screening and intervention and opportunities for implementation underscore the importance of determining the efficacy of brief intervention in medical inpatients with unhealthy alcohol use. In addition, evaluating its effectiveness and practicality in real-world settings is critical to help clinicians make informed decisions when treating their patients (11). Therefore, we conducted a randomized, controlled trial to examine whether screening followed by brief intervention would improve alcohol-related outcomes in typical medical inpatients (that is, a racially diverse group with a range of unhealthy alcohol use, comorbid conditions, and readiness to change). We hypothesized that screening and brief intervention would lead to the following: receipt of alcohol assistance (for example, specialty treatment) among persons with alcohol dependence and, among all persons decreased alcohol consumption, alcohol-related problems, and health care utilization and improved readiness to change and health-related quality of life. Methods Patients As previously described, we recruited patients from the inpatient medical service of a large, urban teaching hospital (12). Trained research associates approached all patients who were age 18 years or older and whose physicians did not decline patient contact. Patients fluent in English or Spanish who gave verbal consent were asked to complete a screening interview to determine eligibility: currently (past month) drinking risky amounts (defined for eligibility as >14 standard drinks/wk or 5 drinks/occasion for men and >11 drinks/wk or 4 drinks/occasion for women and persons 66 years); 2 contacts to assist with follow-up; no plans to move from the area in the next year; and a Mini-Mental State Examination score of 21 or greater (13, 14). Research associates assessed demographic characteristics and administered the Alcohol Use Disorders Identification Test (AUDIT) (15) by interview. To better characterize current alcohol use, they assessed the average numbers of drinking-days per week and drinks consumed on a typical day, and the maximum number of drinks consumed per occasion (16, 17). For the first 7 months of the study, research associates asked these additional questions only to patients with an AUDIT score of 8 or greater (a recommended cutoff for screening) (18). For the remaining 22 months, research associates asked the additional questions to anyone who drank in the past 12 months to maximize identification of drinkers of risky amounts. Lastly, the research associates asked all patients who were drinking risky amounts to describe their readiness to change by using a visual analog scale ranging from 0 to 10 (19). Enrolled patients provided written informed consent and were compensated for each completed interview. The institutional review board at Boston University Medical Center approved this study. We secured additional privacy protection with a certificate of confidentiality from the National Institute on Alcohol Abuse and Alcoholism. Assessment at Enrollment Research associates interviewed patients before randomization to assess the characteristics shown in Table 1. One author reviewed the medical records to determine medical diagnoses (29). Diagnoses of alcohol use disorders were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (30), and were determined with the Composite International Diagnostic Interview (CIDI) Alcohol Module (31, 32). Table 1. Characteristics at Enrollment of All Study Patients and of the Subgroup with Alcohol Dependence* Randomization and Intervention An off-site data management group generated assignments to control and intervention groups by using a permuted block (size 8) randomization procedure stratified by AUDIT score (<12 vs. 12) and provided us the assignments in sealed opaque envelopes. We used the AUDIT score to stratify because we could not score the CIDI before randomization. After each baseline assessment, research associates opened an envelope and informed the patient of his or her assignment. Patients in the control group received usual care (that is, they were told the screening results and that they could discuss their drinking with their physicians). Specialists were available by referral. Systematic alcohol screening and brief intervention were not routine at this hospital. We assigned patients in the intervention group to a 30-minute session of brief motivational counseling (19, 33) conducted by counseling and clinical psychology doctoral students whom we trained and supervised. Sessions were audiotaped and included feedback, an open discussion, and construction of a change plan (Appendix). Outcomes and Measurements The first primary outcome was self-reported receipt of alcohol assistance in the past 3 months by patients with CIDI-determined alcohol dependence. This outcome was measured at the 3-month follow-up visit with a standardized interview based on the Treatment Services Review (34) and Form 90 (35). Assistance included residential treatment, outpatient treatment (for example, specialty counseling or therapy), medications, employee assistance programs, or mutual-help groups (for example, Alcoholics Anonymous). The other primary outcome was the change in the number of mean drinks per day in the past 30 days from enrollment to 12 months among all patients. We determined consumption with the Timeline Follow-back method (36). Five secondary consumption outcomes (past 30 days) included changes from enrollment to 12 months in the numbers of heavy drinking episodes (5 drinks/occasion for men and 4 drinks/occasion for women and for persons 66 y) and days abstinent; and the proportions of patients drinking risky amounts (>14 drinks/wk or 5 drinks/occasion for men and >7 drinks/wk or 4 drinks/occasion for women and persons 66 y) (37), having 1 or more heavy drinking episodes, and abstaining for all 30 days. Other secondary outcomes included the changes at 12 months in readiness to change (Taking Steps scale on the Stages of Change Readiness and Treatment Eagerness Scale) (38), alcohol problems (total score on the Short Inventory of Problems) (39), physical and mental health-related quality of life (Physical and Mental Component Summary scale scores on the Short-Form Health Survey) (40), and emergency department visits and days of medical hospitalization (both determined by a standardized interview based on the Treatment Services Review and Form 90) (34, 35). Follow-up Procedures Research associates conducted follow-up visits, which included reassessment of most domains covered at enrollment, usually in person and at 3 and 12 months (10% and 13%, respectively, by telephone; similar by randomized group). They performed alcohol breath tests at in-person follow-up visits (41). Although they were involved in the randomization assignment, research associates were not involved in the intervention. Further, 64% of patients at 3-month follow-up and 85% of patients at 12-month follow-up were interviewed by a different research associate than at baseline. Statistical Analysis We analyzed all patients in the groups to which they were randomly assigned. Reported P values are 2-tailed and are considered statistically significant if they were less than 0.05. We analyzed data with SAS/STAT software, versions 8.2 and 9.1.3 (SAS Institute, Inc., Cary, North Carolina). To describe the study sample and to compare groups, we used the chi-square test, Fisher exact test, 2-sample t test, and Wilcoxon rank-sum test, as appropriate. For the primary analyses, we used logistic and linear

Compelled to consume: The Implicit Association Test and automatic alcohol motivation.

The Implicit Association Test (IAT; A. G. Greenwald, D. E. McGhee, & J. L. K. Schwartz, 1998) has recently been used to assess the role of alcohol-affect associations in drinking behavior. The current study examined the validity of an alcohol IAT with 88 hazardous-drinking college students who completed measures of drinking behavior, an explicit measure of alcohol motivation, and an IAT that assessed alcohol-motivation associations. Regression analyses indicated that IAT scores correlated with binge drinking and cue reactivity, replicating T. P. Palfai and B. D. Ostafins (2003) results. Results also indicated convergent validity (the IAT was related to an explicit measure of alcohol motivation) and incremental validity (IAT scores were correlated with alcohol behavior after controlling for the explicit measure). Implications for understanding the self-regulation of drinking are discussed.

Effects of suppressing the urge to drink on the accessibility of alcohol outcome expectancies

Previous work has shown that attempts to deliberately suppress a given thought is associated with heightened accessibility of thought-related information both during and following suppression (Wegner, 1994, Psychological Review, 101, 34-52). This study examined whether attempts to suppress the urge for alcohol would similarly be associated with heightened accessibility of alcohol-related information. Heavy social drinkers were exposed to the sight and smell of their usual alcoholic beverage either under the instructions to suppress their urge to drink alcohol or without such instruction. Following this task, participants were asked to make timed judgements about the applicability of a series of alcohol outcome expectancies. Results supported the view that suppression increases the accessibility of information in memory. Those in the Suppression condition were faster to endorse alcohol outcome expectancies following the exposure to alcohol cues than those in the Control condition. Findings are discussed in terms of cognitive strategies for regulating alcohol use and patterns of restrained drinking.

Effects of nicotine deprivation on alcohol- related information processing and drinking behavior.

This study examined the influence of smoking cues and nicotine deprivation on responses to alcohol among hazardous drinkers. Fifty-six daily smoking, hazardous drinkers were exposed to either smoking cues or control cues after either 6 hr of nicotine deprivation or no deprivation. Urges to drink alcohol, alcohol-related cognitive processing, and alcohol consumption were assessed after cue exposure. Results indicated that nicotine deprivation increased urges to drink, the accessibility of alcohol outcome expectancies, and the volume of alcohol consumed. There was little influence of the smoking cue manipulation on these processes. Implications for understanding the mechanisms underlying alcohol-tobacco interactions are discussed.

Screening and Brief Intervention for Unhealthy Drug Use in Primary Care Settings: Randomized Clinical Trials Are Needed

The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.

Gender, alcohol consumption, and differing alcohol expectancy dimensions in college drinkers.

Examinations of gender differences in alcohol expectancies among college drinkers typically have used self-report measures to assess single expectancy dimensions and often have been confounded by drinking level. This study examined gender differences in alcohol expectancies using 2 assessment methods. College students (N = 88) completed self-report questionnaires, including expectancy likelihood and subjective evaluation endorsements of expectancies, and a computerized expectancy accessibility task. Expectancy accessibility and endorsement were modestly correlated, with higher alcohol consumption and female gender linked to greater accessibility and endorsement of social enhancement expectancies. Gender moderated the relation between consumption and sociability expectancy accessibility; among men, heavier drinking was associated with more rapid activation of expectancies. Findings suggest complexity in associations among these variables and underscore the need to capture the multidimensionality of the expectancy construct and its relationship to alcohol use.

Mapping the continuum of alcohol problems in college students: a Rasch model analysis.

The authors conducted Rasch model (G. Rasch, 1960) analyses of items from the Young Adult Alcohol Problems Screening Test (YAAPST; S. C. Hurlbut & K. J. Sher, 1992) to examine the relative severity and ordering of alcohol problems in 806 college students. Items appeared to measure a single dimension of alcohol problem severity, covering a broad range of the latent continuum. Items fit the Rasch model well, with less severe symptoms reliably preceding more severe symptoms in a potential progression toward increasing levels of problem severity. However, certain items did not index problem severity consistently across demographic subgroups. A shortened, alternative version of the YAAPST is proposed, and a norm table is provided that allows for a linking of total YAAPST scores to expected symptom expression.