Effect of motivational interviewing on reduction of alcohol use

Abstract

Background

Methadone-maintained (MM) clients who engage in excessive alcohol use are at high risk for HIV and hepatitis B virus (HBV) infection. Nurse-led hepatitis health promotion (HHP) may be one strategy to decrease alcohol use in this population.

Objective

To evaluate the impact of nurse-led HHP, delivered by nurses compared to motivational interviewing (MI), delivered by trained therapists in group sessions or one-on-one on reduction of alcohol use.

Methods

A three-arm randomized, controlled trial, conducted with 256 MM adults attending one of five MM outpatient clinics in the Los Angeles area. Within each site, moderate-to-heavy alcohol-using MM participants were randomized into one of three conditions: (1) nurse-led hepatitis health promotion group sessions (n = 87); (2) MI delivered in group sessions (MI-group; n = 79), or (3) MI delivered one-on-one sessions (MI-single, n = 90).

Results

Self-reported alcohol use was reduced from a median of 90 drinks/month at baseline to 60 drinks/month at 6-month follow-up. A Wilcoxon sign-rank test indicated a significant reduction in alcohol use in the total sample (p < .05). In multiple logistic regression analysis controlling for alcohol consumption at baseline and other covariates, no differences by condition were found.

Discussion

As compared to two programs delivered by MI specialists, a culturally-sensitive and easy to implement nurse-led HHP program produced similar reductions in alcohol use over 6 months. Employing nurse-led programs may allow cost savings for treatment programs as well as a greater integration of alcohol reduction counseling along with a more comprehensive focus on general health-related issues than previously conducted.

Introduction

Methadone-maintained (MM) clients have reported excessive alcohol use; in fact, nearly 50% of this population has reported chronic alcohol consumption (Maremmani et al., 2007). Alcohol abuse has been associated with major health problems, including hepatic cirrhosis and hepatocellular carcinoma (Srivastava et al., 2008). Alcohol-abusing MM clients suffer from psychological impairments, including anxiety and feelings of low moods, and poor social functioning (Senbanjo et al., 2007). Alcohol use and abuse are also correlated with chronic drug use (Backmund et al., 2003); both types of substance use place individuals at risk for HIV and hepatitis (Arasteh et al., 2008). Moreover, among MM clients who have hepatitis C (HCV), reduction and/or elimination of alcohol drinking is an important treatment goal as it would decrease demand on liver enzymes and perhaps slow HCV disease progression.

To date, no studies exist which assess the impact of brief alcohol reduction among patients enrolled in methadone maintenance programs. Currently, the most popular intervention which has shown an impact on reducing alcohol use is motivational interviewing (MI), a ‘client-oriented counseling style’ that seeks to help clients ‘explore and resolve ambivalence’ to change (Miller and Rollnick, 2002). MI has been found to be an effective strategy in reducing alcohol use and abuse among a variety of populations, when delivered by therapists one-on-one or the less evaluated group approach (Deas, 2008, Peterson et al., 2006).

The impact of intervention directed at reducing alcohol use by health care providers who traditionally provide care and support is nevertheless of interest. In particular, nurses can have a significant potential to change behavior when interacting with addicts who are enrolled in methadone maintenance programs, as these environments provide an excellent arena for developing health promoting behaviors among high risk populations. While no research has been conducted that has focused on reducing alcohol use among the methadone population to date, nurse-led interventions have resulted in reduction of alcohol use among general hospitalized patients (Tsai et al., 2009) and among postpartum women (Fleming et al., 2008). Lock et al. (2006) believes that as one of the key roles of the nurse is to promote health, and nurses have a lower cost of employment than physicians, nurses are ideally suited to deliver brief alcohol interventions.

To date, there have been no studies specifically looking at the comparative efficacy of nurse-led intervention, nor MI, delivered either individually or in a group setting among adults receiving MM. The present study evaluates the efficacy of nurse-led hepatitis health promotion (HHP) group sessions against the already established intervention MI. In addition, the study presents a unique opportunity to evaluate group MI compared to individual MI; the former of which possesses only a little, albeit growing, evidence for its efficacy compared to individual MI. Comparing these two MI interventions (group vs Individual) is also important because of the predominance of group therapy in substance abuse treatment and the fact that more studies are needed evaluating group therapy.

The comprehensive health seeking and coping paradigm (CHSCP; Nyamathi, 1989), originally adapted from Lazarus and Folkman's (1984) stress and coping paradigm and Schlotfeldt's (1981) health seeking paradigm, proposes that a number of factors impact health outcomes of vulnerable populations with health disparities (Nyamathi et al., 2003, Nyamathi et al., 2006, Nyamathi et al., 2008). These factors include socio-demographic characteristics, personal and psychosocial resources and health behaviors, cognitive appraisal, coping responses, nursing strategies, and health outcomes. In this study, variables of interest include socio-demographic factors (age, ethnicity, gender, education, recruitment site), personal (physical health status factors), psychosocial factors (depressive symptomotology, poor emotional well being, social support) resources, type of intervention (MI-group, vs MI-single, vs Nurse-led HHP programs) and behavior (alcohol use, injection and non-injection drug use, traded sex, multiple partners, HBV vaccination initiation).

Several studies have demonstrated that nurse-led interventions seeking to reduce alcohol consumption among high risk substance abusers are effective (Cummings et al., 2006, Fleming et al., 2008, Tsai et al., 2009). In a study a brief intervention delivered by nurses for problem drinkers in a Chinese hospitalized population, Tsai et al. (2009) revealed significant decreased alcohol scores at 12-month follow-up compared to a control group. Among a sample of 235 postpartum women screened as having an “at-risk” drinking problem, the findings of a brief intervention offered by obstetric nurses revealed a significant reduction in mean number of drinks in the past 30 days, and number of drinking days and heavy drinking days in the past 30 days (Fleming et al., 2008).

These findings support the need for widespread screening and brief intervention for populations at risk for poor maternal–child outcome. In yet another nurse-delivered cluster-randomized controlled trial (Lock et al., 2006), no differences were found between the intervention and control groups. The authors contend that the high drop-out rate of over 50% may have resulted in lack of positive findings. These findings highlight the fact that nurse-led interventions have high potential for reducing substance use among at-risk populations and would be worthy of testing in a methadone-maintained population as well.

Although MI has been applied to various areas of health behavior change, including obesity, HIV risk factor modification and eating disorders, the broadest application of this approach has been in the area of addiction (Hettema et al., 2005). MI has been effective for the reduction of alcohol use among adults attending community health centers in Idaho (Beckham, 2007) and has been shown to effectively reduce illicit drug use among homeless adolescents (Peterson et al., 2006). Among college students, several studies have shown the effectiveness of MI in the reduction of drinking (Deas, 2008), particularly heavy drinking (Juarez et al., 2006, LaBrie et al., 2007a). However, MI has not consistently resulted in measurable improvement (Hettema et al., 2005). For example, in a recent study of homeless adolescents, MI was not associated with a reduction of alcohol use (Baer et al., 2007).

Currently, there is a paucity of studies comparing outcomes when MI is delivered using individual versus group format for the management of alcohol abuse; moreover, the populations in which the studies have been conducted were quite disparate and mixed. Individually-delivered interventions using MI have been found most effective for the management of alcohol abuse among college students (Carey et al., 2007). However, brief, individual MI, delivered on a one-time basis to alcohol-abusing inpatients was not found to be associated with reductions in alcohol use (Saitz et al., 2007). Grenard et al. (2006) found that one-to-one sessions have been shown to be effective among adolescents and young adults engaged in drug-related behaviors. Group MI has also been shown to be effective in reducing alcohol use among both psychiatric inpatients with chemical dependence (Santa Ana et al., 2007) and female college students (LaBrie et al., 2007a). On the other hand, John et al. (2003) found no significant difference in amount of alcohol reduction when comparing individual to group MI among a group of alcohol-dependent inpatients.

The purpose of this trial was to evaluate the impact of a nurse-led hepatitis health promotion program in reducing alcohol use among participants receiving methadone maintenance, to an already established, empirically supported intervention (MI) and also to evaluate how the nursed-led HHP differs from either MI method.