Considerations on Recruitment and Sampling of Subjects & Measures

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A brief alcohol intervention for hazardously drinking incarcerated womenadd_2813 466..475

Michael D. Stein1,2, Celeste M. Caviness1, Bradley J. Anderson1, Meg Hebert1 & Jennifer G. Clarke2,3

Butler Hospital, Providence, RI, USA,1 Warren Alpert School of Medicine at Brown University, Providence, RI, USA2 and Memorial Hospital of Rhode Island, Pawtucket, RI, USA3

ABSTRACT

Objective To test the hypothesis that among hazardously drinking incarcerated women who are returning to the community, a brief alcohol intervention will result in less alcohol use at follow-up relative to standard of care. Methods Eligible participants endorsed hazardous alcohol consumption—four or more drinks at a time on at least 3 separate days in the previous 3 months or a score of 8 or above on the Alcohol Use Disorders Identification Test. Participants were randomized to either an assessment-only condition or to two brief motivationally focused sessions, the first delivered during incarceration, the second 1 month later after community re-entry. Participants recalled drinking behaviors at 3 and 6 months after the baseline interview using a 90-day time-line follow-back method. Results The 245 female participants averaged 34 years of age, and were 71% Caucasian. The mean percentage of alcohol use days in the 3 months prior to incarceration was 51.7% and heavy alcohol use days was 43.9%. Interven- tion effects on abstinent days were statistically significant at 3 months (odds ratio = 1.96, 95% confidence interval 1.17, 3.30); the percentage of days abstinent was 68% for those randomized to intervention and 57% for controls. At 6 months the effect of the intervention was attenuated and no longer statistically significant. Conclusions Among incarcerated women who reported hazardous drinking, a two-session brief alcohol intervention increased abstinent days at 3 months, but this effect decayed by 6 months. Study participants continued to drink heavily after return to the community. More intensive intervention pre-release and after re-entry may benefit hazardously drinking incarcerated women.

Keywords Alcohol, incarceration, women.

Correspondence to: Michael Stein, Brown University, Butler Hospital, General Medicine Research, 345 Blackstone Boulevard., Providence, RI 02906, USA. E-mail: [email protected] Submitted 13 May 2009; initial review completed 28 August 2009; final version accepted 15 September 2009

INTRODUCTION

There are approximately 200 000 female inmates in prisons and jails in the United States, and since 1995 the number of women in prisons has increased 53%, far sur- passing increases in the rate of incarceration of men [1]. Often returning to communities with few resources, the first weeks after release represent a time of vulnerability as released inmates encounter social and economic chal- lenges related to housing, employment and family. Crimi- nal activity, substance abuse and high-risk behaviors recur frequently in the days to weeks following release from jail and prison [2,3]. Alcohol use plays a significant, negative role in the lives of women who become incarcer-

ated, and a return to hazardous drinking has been asso- ciated with recidivism and health consequences [4]. Alcohol-associated sexual risk-taking leads to high rates of sexually transmitted infections, including human immunodeficiency virus (HIV) in this population [5,6].

Estimates of the prevalence of hazardous drinking among the incarcerated depend upon the type of correc- tional sample and measure of alcohol use. A life-time history of alcohol abuse has been reported in approxi- mately one-third of female offenders [7–9]. This rate is approximately five times that in a national sample of community-dwelling women [10]. Estimates of women under the influence of alcohol at the time of arrest suggest even higher rates [11–13].

RESEARCH REPORT doi:10.1111/j.1360-0443.2009.02813.x

Imprisonment is an enforced period of abstinence and could lead potentially to a persistent reduction in alcohol and other drug use. This period of abstinence may provide a ‘teachable moment’, as women recognize the possible link between drinking and incarceration, but it is not clear that incarcerated women want to change their drinking or are motivated to persist in reductions. Maintenance of abstinence may be difficult for incarcerated women returning to the communities where hazardous drinking began, and researchers have not attempted interventions to reduce alcohol consump- tion in this population. Brief interventions for alcohol use disorders have become popular over the past 15 years not only because they may be acceptable to non- treatment-seeking populations, but also because they can be administered by a wide variety of providers in a range of clinical settings, and offered less expensively than extended treatments.

Brief interventions have proven efficacy for decreasing alcohol consumption and alcohol-related problems when applied in out-patient clinical settings to hazardous and unhealthy drinkers [14,15]. In a meta-analytical review examining brief motivational interviewing (MI) interven- tions specifically, MI was found to be effective in reducing alcohol use among heavy drinkers [16]. In the few studies that include dependent drinkers, the magnitude of the MI effect size increases when drinkers are treatment-seeking [16]. In medical populations who are not seeking help voluntarily to reduce drinking, brief interventions for alcohol-dependent individuals have not generally been successful [17,18].

Incarcerated women who drink hazardously represent one population that can be identified opportunistically by screening and who may benefit from a brief intervention initiated during incarceration and reinforced after com- munity re-entry [19]. Incarcerated women who drink hazardously are accessible and, despite the rapid turnover of most jails, often have time for an intervention. An intervention that begins during incarceration and is rein- forced soon after return to the community, where alcohol is once again available, offers women two time-points to consider their alcohol consumption [20].

The unmet need for alcohol screening and the oppor- tunity for intervention among incarcerated women underscore the importance of determining the efficacy of brief interventions for this population. Therefore, we con- ducted a randomized trial to compare an assessment-only control condition to a two-session brief motivational intervention to reduce drinking frequency. The study design is such that interventionists provide the first session during incarceration, and the second session takes place in the community when participants are re-exposed to the availability of alcohol. Our alcohol use outcomes are related to the combined impact of these two

sessions. We also wanted to determine if our intervention impacted upon alcohol-related problems, mental health scores and alcohol treatment entry in women returning to the community after incarceration.

METHODS

Study site

In Rhode Island, all incarcerated people are housed on a single campus that operates as a unified, centralized and comprehensive state correctional system, the Rhode Island Department of Correction (RI DOC), encompass- ing jail, prison, rehabilitative services and community corrections (probation/parole).

Study design and procedure

All detained women over a 40-month period from Febru- ary 2004 to June 2007 were eligible for screening for a randomized clinical trial of a brief intervention to reduce alcohol use and HIV risk. The trial protocol was approved by the Miriam Hospital Institutional Review Board, the Office for Human Research Protection and the RI DOC’s Medical Research Advisory Group. The full details regard- ing the logistical planning for this trial have been pub- lished elsewhere [21].

Participants were eligible for the clinical trial of inter- est if they spoke English, had reliable contact information and endorsed having risky sexual behavior (unprotected sex on at least 3 separate days in the 3 months prior to incarceration) and hazardous alcohol consumption [four or more drinks at a time on at least 3 separate days in the previous 3 months or a score of 8 or above on the Alcohol Use Disorders Identification Test (AUDIT) [22], which was framed to the past year] [13]. As shown in Fig. 1, during the enrollment period on their first day of incarceration 1616 women were approached for screening and 201 refused. Of the 1415 women screened, 1133 were ineli- gible; 37 eligible women refused participation, leaving a final sample of 245 women (see [19] for details).

Schedule of the intervention

Following the baseline assessment which was completed on the first or second day of incarceration, participants were randomized to an intervention group receiving the motivational intervention or a control condition. Ran- domization and concealment were overseen by the study methodologist (B.J.A.) and research staff performing the assessments were blinded to the participant’s assigned condition. All women were scheduled for follow-up assessment at 1, 3 and 6 months following the baseline assessment, regardless of whether the participant was incarcerated.

Alcohol trial for incarcerated women 467

For each intervention group participant two indi- vidual intervention sessions were scheduled, each lasting 30–45 minutes. The initial MI session was conducted at the time of the baseline interview while the participant was incarcerated, immediately following the baseline assessment. The second MI session was scheduled for 1 month later, after the participant had been released, at a hospital-based research site in the community; the inter- vention session immediately followed the 1-month assess- ment. If the participant was still incarcerated at the time of the scheduled 1-month follow-up assessment the inter- view was completed, but the second MI session was delayed until she was (i) either released (and it was com- pleted in the community within weeks, but prior to the 3-month assessment); or (ii) if she had a prolonged incar- ceration, the second MI session was completed several days prior to the 3-month assessment.

Participants assigned to the control condition com- pleted baseline, 1-, 3- and 6-month assessment visits only. At the completion of the 1-month research assessment, participants in both conditions received the names and telephone numbers of local drug and alcohol treatment facilities, as well as their next interview date.

Manual development and therapist training

The manual for this study was adapted from the MI approach of Miller & Rollnick [23] and the Brief Alcohol Intervention in Needle Exchangers Study [24]. Training consisted of reviewing the five basic principles of motiva- tional interviewing including, (i) expressing empathy; (ii) developing discrepancy; (iii) avoiding argumentation; (iv) rolling with resistance; and (v) support self-efficacy [23].

All intervention sessions were audiotaped and tapes were reviewed in biweekly supervision sessions.

Initial MI session (during incarceration)

The goal of this first session was for the interventionist, using motivational interviewing techniques, to set goals regarding making a change in alcohol use behavior, and to explore strategies to deal with internal or external obstacles/barriers in achieving these goals. During this session interventionists discussed: the participant’s values and goals; pros and cons of alcohol use (using a decisional balance handout); thoughts about alcohol use and cutting back/quitting, feedback from the research assessment (highlighting cost of alcohol; reasons for drinking and negative consequences); thoughts about the usefulness of alcohol treatment, state of readiness to make changes; and generation of a change plan. Due to RI DOC regulations, participants were not allowed to keep any materials from the intervention session. Upon release, the feedback report and change plan handouts were enclosed in a mailing including payment for the baseline interview, community resources, condoms and the next appointment date.

Follow-up MI session

The follow-up session was based on the participant’s goal(s) and change plan from the initial MI session. For those participants with an alcohol change goal, follow-up sessions focused upon progress, assessment of barriers and developing concrete strategies for meeting new goals. Recovery strategies were also discussed, with an emphasis

1616 approached for screening

1415 (88%) screened 201 (12%) refused screening

1133 ineligible for randomized control trial

37 declined participation

245 enrolled Baseline assessment completed

within 48 hours of incarceration Randomization: intervention

group n=125

MI session 1 completed immediately following baseline

assessment Randomization: control group

n=120

Follow up assessments at 1-, 3-, and 6-months; MI session 2 completed following 1 month

assessment.

Follow up assessments at 1-, 3-, and 6-months

Figure 1 Study enrollment and protocol

468 Michael D. Stein et al.

on identifying high-risk situations for relapse and develop- ing effective strategies for coping in high-risk situations.

If the participant set a non-alcohol-related goal, ses- sions focused upon progress towards goals and barriers in achieving these goals. MI techniques were used to review the information from the first session in order to re-evaluate the possibility for setting an alcohol goal. Interventionists offered suggestions about interim steps which participants might consider prior to setting an abstinence goal.

Therapist integrity

The Motivational Interviewing Treatment Integrity Code version 2.0 (MITI) [25,26] was used both to train the four female study interventionists (three clinical psycholo- gists, one master’s level counselor) and to monitor the MI skills of the interventionists during biweekly supervision. The MITI version 2.0 allows for an assessment of thresh- old competence for individual therapists and a measure of integrity of MI interventions, has two global scores (‘empathy’ and ‘spirit’; score range 1–7) and seven behavior counts (e.g. ‘giving information’, ‘MI adher- ent’). Three raters trained in MI (inter-rater reliability >0.60) coded a random sample of 15% of the treatment sessions, coding 20-minute segments of each session. These segments were selected from the full sessions to reflect each portion of the intervention evenly. Sessions were double-coded frequently to prevent rater drift. Mean scores across the two global scales for the intervention sessions were 5.1 [standard deviation (SD) 0.81; empathy] and 4.6 (SD 0.85; spirit).

Measures

At the baseline assessment research staff, blinded to treat- ment group assignment, asked participants to recall 90 days prior to their incarceration using the time-line follow-back (TLFB) method [27]. Staff asked respondents to recall days they consumed alcohol and how many drinks on each day. They were then asked about vaginal or anal sex on each of these 90 days. Other measures included the Short-Index of Problems (SIP) [28] and a dichotomous indicator of treatment entry, coded 1 if the participant attended an Alcoholics Anonymous (AA) meeting, entered a medically supervised detoxification program, entered residential treatment or attended out- patient alcohol treatment in the last 90 days. Life-time diagnosis of DSM-IV alcohol dependence was measured using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) [29].

Statistical analysis

We present means, medians and percentages to describe the background characteristics and pre-baseline alcohol

use behaviors in this cohort. Pearson’s c2 tests and t-tests for differences in means were used to test the equivalence of intervention groups at baseline.

We use zero-inflated count regression models to test the effect of intervention on drinking outcomes [30]. These models estimate two equations simultaneously. The inflation part of the model uses a logit or probit response to estimate the probability of a zero response (that is, an abstinent day). The count part of the model uses a Poisson response, or a negative binomial, to estimate the quantity of alcohol use (drinks per drinking day). All models were estimated using Mplus version 5.1 [31]. The default standard errors are the robust sandwich estima- tors, adjusted here for within-subject clustering.

Our primary outcomes were (i) the probability of an abstinent day; and (ii) drinks per drinking day as reported using TLFB methodology on the baseline and 1-, 3- and 6-month follow-up interviews. We restricted our analyses to days when the participant was not incarcerated. Our analysis proceeded in three steps. We first examined the overdispersion parameter for the constant only zero- inflated negative binomial (ZINB). We then used the difference scaled c2 test to compare two models with alter- native parameterizations of time [32]. One operational- ized the effect of time as linear (coded 0, 1, 3, 6); the second treated time as unconstrained, with dummy indi- cators representing each of the three follow-up periods. Intervention effects were then estimated as the first-order treatment ¥ time interaction for the best-fitting zero- inflated count mode and time parameterization.

We report exponentiated coefficients giving the expected factor change on the odds of not drinking alcohol on a given day and the expected factor change on the expected number of drinks per drinking day; the later coefficients are sometimes referred to as incidence rate ratios (IRR). To facilitate interpretation we also present the model-estimated probabilities of not drinking alcohol (zero count) and the expected number of drinks per drinking day.

We conducted a secondary analysis to determine if the intervention had an effect on functional outcomes at the 3- and 6-month follow-up assessments. Models estimat- ing the effect on the SIP assumed normally distributed error; the effect on treatment entry was estimated as a logistic response with binomial error. Intervention effects were estimated as the first-order treatment ¥ time inter- action effect using generalized estimating equation (GEE) models.

RESULTS

Participants averaged 34.1 (� 8.9) years of age, and 71% were Caucasian (Table 1). On average, participants reported their alcohol consumption on 87.5 (� 7.6;

Alcohol trial for incarcerated women 469

median = 90) days prior to baseline. The mean percent- age days using any alcohol and heavy (�4 drinks) amounts of alcohol were 51.7 (� 33.6) and 43.9 (� 33.7), respectively. Participants averaged 12.4 (� 0.0) drinks per drinking day, their mean AUDIT score was 20.6 (� 10.1) and 220 (90%) met SCID criteria for a life-time diagnosis of alcohol dependence. Demographic characteristics and baseline alcohol use behaviors did not differ significantly between the intervention groups (Table 1).

One hundred and eighty-six (76%), 194 (79%) and 193 (79%) of the participants were located and com- pleted assessments at the 1-, 3- and 6-month follow-ups, respectively; 224 (91%) completed at least one follow-up (Table 1). Of those who completed assessments, 132, 174 and 180 participants had 1 or more days during which they were not incarcerated during the intervals assessed at the 1-, 3- and 6-month follow-ups. Follow-up rates were very similar in both intervention arms and there was no evidence of differential attrition.

Model selection and aggregate changes in alcohol use behaviors over time

The overdispersion parameter estimated for a constant- only negative binomial model was statistically significant (Z = -10.19, P < 0.001) indicating that the ZINB is pre- ferred to the zero inflated Poisson (ZIP) model. The model in which time was unconstrained fitted the data signifi-

cantly better than the linear time model (difference scaled c2 = 10.89, df = 2, P < 0.05). Coefficients indicated the expected odds of not using any alcohol were 1.48 [95% confidence interval (CI) 1.11, 1.98], 1.84 (95% CI 1.41, 2.39) and 1.96 (95% CI 1.49, 2.56) times lower on days observed at 1 month, 3 months and 6 months, respec- tively, than on days observed prior to baseline. Addition- ally, the expected number of drinks per drinking day was significantly lower at 3 months (P < 0.05) and 6 months (P < 0.01) than at baseline. Compared to baseline the expected number of drinks per day decreased by a factor of 0.81 (95% CI 0.67, 0.97) at 3 months and by a factor of 0.79 (95% CI 0.66, 0.95) at 6 months. Drinks per drinking day did not differ significantly between baseline and 1 month (IRR = 0.91, 95% CI 0.73, 1.10) among non-incarcerated women. Based on these analyses, the ZINB was used to test the effects of intervention with separate effects estimated for each of the three follow-up periods. Baseline assessment is the reference category in all estimated models.

Estimated intervention effects

One hundred and twenty-five women were assigned to the treatment arm. Of these, 70 (56%) received their second intervention session in the community, 23 (18%) received it while at the RI DOC due to prolonged incar- ceration and 32 (26%) did not receive a second interven- tion session. Table 2 gives the estimated effect of a brief

Table 1 Baseline characteristics by intervention (n = 245).

Total (n = 245)

Treatment (n = 125)

Control (n = 120) t (P =)

Mean age (years) 34.1 (� 8.9) 33.3 (� 9.4) 34.9 (� 8.3) 1.40 (0.162) Mean education (years) 10.4 (� 1.6) 10.3 (� 1.6) 10.5 (� 1.6) 1.18 (0.240)

Mean % alcohol days 51.7 (� 33.6) 54.2 (� 33.2) 49.3 (� 32.0) -1.17 (0.243) Mean % heavy days 43.9 (� 33.7) 44.9 (� 34.3) 42.7 (� 33.2) -0.50 (0.615)

Mean drinks/drink-day 12.4 (� 10.0) 12.5 (� 10.3) 12.4 (� 9.8) 0.04 (0.970) Mean AUDIT 20.6 (� 10.1) 20.8 (� 10.2) 20.4 (� 10.0) -0.33 (0.738)

c2 (P =) n (%) Ethnicity 1.21 (0.751)

Caucasian 175 (71.4%) 89 (71.2%) 86 (71.7%) African American 47 (19.2%) 26 (20.8%) 21 (17.5%) Hispanic 17 (6.9%) 8 (6.4%) 9 (7.5%) Other 6 (2.5%) 2 (1.6%) 4 (3.3%)

n (%) 1-month assessment 186 (75.9%) 96 (76.8%) 90 (75.0%) 0.11 (0.742) n (%) 3-month assessment 194 (79.2%) 99 (79.2%) 95 (79.2%) 0.00 (0.995) n (%) 6-month assessment 193 (78.8%) 99 (79.2%) 94 (78.3%) 0.03 (0.868) n (%) At least 1 FU 224 (91.4%) 114 (91.2%) 110 (91.7%) 0.02 (0.896) n (%) At risk 1 month 132 (53.9%) 67 (53.6%) 65 (54.2%) 0.01 (0.929) n (%) At risk 3 months 174 (71.0%) 86 (71.7%) 88 (70.4%) 0.05 (0.827) n (%) At risk 6 months 180 (73.5%) 92 (76.7%) 88 (70.0%) 1.23 (0.267) n (%) Any at risk 210 (85.7%) 107 (85.6%) 103 (85.8%) 0.00 (0.958)

AUDIT: Alcohol Use Disorders Identification Test; FU: follow-up.

470 Michael D. Stein et al.

intervention on alcohol use at each follow-up. A test of the treatment ¥ time interaction effect on the inflation part of the model indicates statistically significant between-group differences (difference scaled c2 = 8.20, df = 3, P < 0.05) in abstinent days. At 1 month, between- group differences are small and not statistically signifi- cant. Intervention effects on abstinent days are substantively larger and statistically significant at 3 months [odds ratio (OR) = 1.96, 95% CI 1.17, 3.30]. By 6 months the effect of intervention was somewhat attenu- ated and no longer statistically significant.

There was no evidence that the intervention reduced significantly the number of drinks on days when drinking was initiated. A test of the treatment ¥ time interaction effect on the count part of the model was not statistically significant (difference scaled c2 = 0.98, df = 3, P > 0.10) and an examination of the individual coefficients indi- cated the effects of intervention on the expected number of drinks on drinking days were trivially small at baseline, 3 and 6 months (Table 2). The effect at 1 month was substantively stronger (IRR = 0.81, 95% CI 0.63, 1.04), although not statistically significant (P > 0.05).

The probability of abstinence and the number of drinks per drinking day are presented in Fig. 2. Figure 2 highlights the first session of MI immediately following the baseline assessment, and the second session of MI was conducted following the 1-month assessment. The panels in Fig. 2 parallel directly the inflation and count parts of the ZINB model given in Table 2. At baseline, those randomized to intervention had a slightly lower probability of drinking on days in the prior 3 months; at 1 month the probability of an abstinent day in the two groups was nearly equal; and at 3 months the probability of an abstinent day was 0.68 for those randomized to intervention and 0.57 for controls. At 6 months, the sig- nificant intervention group effect was no longer present.

The second panel of Fig. 2 gives the expected number of drinks per drinking day for the ZINB model presented

in Table 2. At 1 month participants randomized to inter- vention consumed 9.8 drinks per drinking day, while con- trols were estimated to drink 12.2 drinks per drinking day (P > 0.10). At all other time-points between-group differ- ences in the number of drinks per drinking day were very small.

We performed two additional exploratory analyses. First, we found that neither site of the second MI session nor time between MI sessions one and two were associ- ated significantly with either drinking outcome. Secondly, we tested intervention effects comparing women who were and were not alcohol-dependent. At 3 months, the observed intervention effect was stronger among the 22 women who did not meet dependence criteria (IRR = 7.55; 95% CI 0.9–37.8) than among the 188 who did (IRR 1.69; 95% CI 1.0–2.9). At 1 and 6 months, the intervention effects were non-significant.

Functional outcomes

Intervention effects on alcohol treatment entry were small and not statistically significant at either the 3- or 6-month assessments (Table 3). Paralleling the primary outcome analysis, participants randomized to interven- tion reported fewer adverse alcohol consequences than controls on the SIP observed at 3 months (b = -4.96, 95% CI -8.91, 1.02, P < 0.05), but not at 6 months (b = -2.30, 95% CI -6.26, 1.65).

DISCUSSION

In this randomized clinical trial of incarcerated women who reported hazardous drinking prior to incarceration, we found that a two-session brief alcohol intervention increased abstinent days during the 3 months after the baseline assessment. The 24% decline in drinking days in the intervention group was associated with decreased SIP scores, suggesting the clinical meaningfulness of these findings.

Table 2 Zero-inflated negative binomial model estimating the effect of brief intervention on alcohol abstinence and number of drinks per drinking day (210 participants assessed for a total of 48 723 non-incarcerated person-days).

Inflation model OR (95% CI)a

Negative binomial IRR (95% CI)a

Intervention 0.79 (0.54, 1.15) 1.00 (0.78, 1.29) Month 1 1.34 (0.89, 2.02) 1.01 (0.78, 1.31) Month 3 1.33 (0.92, 1.91) 0.81 (0.63, 1.04) Month 6 1.63* (1.84, 2.72) 0.78 (0.61, 1.00) Intervention by month 1 1.22 (0.69, 2.17) 0.80 (0.53, 1.19) Intervention by month 3 1.96* (1.17, 3.30) 1.01 (0.70, 1.45) Intervention by month 6 1.44 (0.84, 2.49) 1.03 (0.72, 1.47)

*P < 0.05. aEstimated effect on the odds of not using alcohol. Confidence interval (CI) estimates and tests of significance were based on robust variance estimators adjusted for within-subject clustering. IRR: incidence rate ratios; OR: odds ratio.

Alcohol trial for incarcerated women 471

Using AUDIT and binge-drinking screeners to deter- mine study eligibility, we were surprised to find that 90% of our ‘hazardous drinkers’ were alcohol-dependent. These women drank extremely heavily, consuming on average 12 drinks on their drinking days. Many brief intervention studies exclude individuals with severe drinking problems. Indeed, brief intervention has proven efficacy in decreasing alcohol consumption and related consequences only in hazardous drinkers without alcohol dependence [14,17]. In one meta-analysis, brief interventions were no more effective than control condi- tions when people with severe alcohol problems were included, except for those people seeking treatment [15]. On hospital in-patient services, where patients also undergo enforced abstinence, several studies have dem- onstrated the efficacy of brief interventions on alcohol consumption [33,34], although not all have shown this

effect [18]. A systematic review of controlled studies enrolling hospital in-patients reported an association between brief intervention and decreased alcohol-related problems, but not alcohol consumption [17]. Our treat- ment effect is particularly promising, given that most of these women were alcohol-dependent (effects were supe- rior among the non-dependent), were not treatment- seeking and had not self-identified as problem drinkers.

As expected, both treatment arms decreased their drinking days and drinks per drinking day during the follow-up period. The period of enforced abstinence during incarceration and the research assessment itself could have motivated participants contemplating change to decrease alcohol consumption in both randomized groups. We found a significant intervention effect in days abstinent only at the 3-month assessment. We did not find an intervention effect at the 1-month follow-up,

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Figure 2 Expected probability of a zero- count and the expected drinks per drinking day by treatment group and assessment period estimated by zero-inflated negative binomial (ZINB). BL: baseline

472 Michael D. Stein et al.

which would have represented the effect of only the single intervention session performed during incarceration. The 3-month follow-up period represents the resultant change after two sessions, suggesting the importance of the second, post-release contact with participants. The significant treatment effect faded between the 3- and 6-month assessments, a finding which is consistent with the results of meta-analyses [16,35]. The optimal timing and number of community-based booster sessions remain open to further study, but suggest at least that in order to enhance the effectiveness of brief alcohol inter- ventions for this population ongoing monitoring of participants’ drinking will be important, particularly as most hazardously drinking women, including all those enrolled in this study, are not mandated to alcohol treat- ment programs upon community re-entry. We should note that the intervention group effect at 3 months was achieved mainly through moderation of ongoing alcohol use rather than cessation; only 18 (8.6%) women main- tained abstinence during the entire follow-up period. Rates of complete abstinence among those randomized to intervention (9.4%) did not differ significantly (c2 = 0.17, df = 1, P > 0.10) from controls (7.8%). In addition, there was no significant intervention effect on drinks per drink- ing day at any follow-up assessment. This suggests that while the intervention influenced initiation of drinking, once drinking began women were unable to constrain their consumption.

Our study had several strengths. We developed a screening and intervention protocol that was feasible and replicable across correctional settings. Furthermore, we did not restrict our eligibility criteria based on mental

health disorders or other drug use, and few eligible women refused to participate. Our study also had limita- tions. Participants could not be blinded, although they were generally interviewed at follow-up by research staff they had not met. Primary outcomes were self-reported but were assessed by trained staff using validated, stan- dardized procedures and techniques to aid recall and minimize bias. There was probably an assessment effect, reducing drinking generally, which may have limited group differences. Interventionists were trained clini- cians; jails and prisons will need to have staff with exper- tise in health behavior change dedicated to improving the drinking outcomes of women to apply these findings, but this intervention has broad potential applicability across US prison systems. Finally, this study included only incar- cerated women who drank hazardously and met hetero- sexual sex-risk criteria. Thus the generalizability of our findings to other populations of women, or to men, may be limited. Future analyses will examine the relationship of reduction in alcohol use to sexual risk-taking.

Although the proportion of abstinent days increased when compared to the period prior to incarceration, study participants continued to drink, and drink heavily, after their return to the community. Brief intervention was inadequate to produce consistent or prolonged absti- nence, and future studies must link released women with additional assistance to reduce consumption and related problems. Future interventions may also include the pro- vision of other known efficacious therapies such as medi- cations for dependent drinkers.

Among incarcerated women there is a high preva- lence of health problems including substance use, mental

Table 3 Generalized estimating equation models estimating the effect of brief intervention on the Short Inventory of Problems (SIP), the mental functioning component of the Short Form (SF)-12 and treatment entry.

SIPa Mental function SF-12a

Treatment entryb

b (95% CI)c

b (95% CI)

OR (95% CI)

Intervention 2.83 0.97 0.67 (-0.64, 6.31) (-1.84, 3.78) (0.35, 1.28)

Month 3 -5.10* 6.05** 3.02** (-7.87, -2.32) (3.09, 9.02) (1.82, 5,00)

Month 6 -7.46* 7.97** 3.84** (-10.18, -4.74) (5.25, 10.70) (2.42, 6.07)

Intervention by month 3 -4.96* -0.64 1.23 (-8.91, -1.02) (-4.73, 3.24) (0.59, 2.56)

Intervention by month 6 -2.30 -1.63 1.37 (-6.26, 1.65) (-5.49, 2.23) (0.67, 2.81)

Intercept 21.46 30.30

*P < 0.05, **P < 0.01. aThe effects on the Short-Inventory of Problems and the Mental Functioning Component of the SF-12 were estimated with an identity link and normally distributed error. bThe effects on treatment entry were estimated with a logit link and binomial error distribution. cTests of significance and confidence interval (CI) estimates were based on robust standard errors adjusted for within subject clustering. OR: odds ratio.

Alcohol trial for incarcerated women 473

health disorders and HIV. Socio-economic and psycho- logical factors affect drinking behavior and access to treatment. The high prevalence of hazardous drinking among incarcerated women and the absence of previous intervention studies drove the development and design of this brief intervention clinical trial. Our findings have important implications for the long-term reintegration and rehabilitation of this population. A brief intervention during incarceration, supplemented by a booster visit after return to the community, may catalyze change. Continued and more intensive interventions pre-release and after re-entry could benefit these women.

Clinical trial registration

Trial registered at clinicaltrials.gov; Clinical Trial #NCT00237003.

Declaration of interest

None.

Acknowledgements

This study was funded by the National Institute on Alcoholism and Alcohol Abuse AA 014495. Dr Stein is a recipient of a NIDA Mid-Career Award DA 000512.

References

1. Harrison P. M., Beck A. J. Prison and Jail Inmates at Midyear 2004 (Bureau of Justice Statistics, NCJ 208801). Washing- ton, DC: US Department of Justice; 2005.

2. Richie B. E., Freudenberg N., Page J. Reintegrating women leaving jail into urban communities: a description of a model program. J Urban Health 2001; 78: 290–303.

3. Binswanger I. A., Stern M. F., Deyo R. A., Heagerty P. J., Cheadle A., Elmore J. G. et al. Release from prison—a high risk of death for former inmates. N Eng J Med 2007; 356: 157–65.

4. Henderson D. J. Drug abuse and incarcerated women—a research review. J Subst Abuse Treat 1998; 15: 579–87.

5. Stein M. D., Anderson B. J., Caviness C. M., Rosengard C., Kiene S., Friedmann P. et al. The relationship of alcohol use and sexual risk-taking among hazardously-drinking incar- cerated women: an event level analysis. J Stud Alcohol Drugs 2009; 70: 508–15.

6. Willers D. M., Peiper J. F., Allsworth J. E., Stein M. D., Rose J. S., Clarke J. G. Prevalence and predictors of sexually trans- mitted infections among newly incarcerated females. Sex Trans Dis 2008; 35: 68–72.

7. Grella C. E., Greenwell L. Treatment needs and completion of community-based aftercare among substance-abusing women offenders. Women’s Health Issues 2007; 17: 244–55.

8. Jordan B. K., Schlenger W. E., Fairbank J. A., Caddell J. M. Prevalence of psychiatric disorders among incarcerated women. II. Convicted felons entering prison. Arch Gen Psy- chiatry 1996; 53: 513–9.

9. Teplin L. A., Abram K. M., McClelland G. M. Prevalence of psychiatric disorders among incarcerated women. I. Pretrial jail detainees. Arch Gen Psychiatry 1996; 53: 505–12.

10. Kessler R. C., Chui W. T., Demler O., Merikangas K. R., Walters E. E. Prevalence, severity and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 617–27.

11. El-Bassel N., Ivanoff A., Schilling R. F., Gilbert L., Chen D. R. Correlates of problem drinking among drug-using incarcer- ated women. Addict Behav 1995; 20: 359–69.

12. Greenfeld L. A., Snell T. L. Women Offenders (Bureau of Justice Statistics, NCJ 175688). Washington, DC: US Department of Justice; 1999.

13. Paasche-Orlow M. K., Clarke J. G., Hebert M. R., Ray M. K., Stein M. D. Educational attainment but not literacy is asso- ciated with HIV risk behavior among incarcerated women. J Women’s Health 2005; 14: 852–9.

14. Wilk A. I., Jensen N. M., Havighurst T. C. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Int Med 1997; 12: 274–83.

15. Moyer A., Finney J. W., Swearingen C. E., Vergun P. Brief interventions for alcohol problems: a meta-analytical review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 2002; 97: 279–92.

16. Vasilaki E. I., Hosier S. G., Cox W. M. The efficacy of motiva- tional interviewing as a brief intervention for excessive drinking: a meta-analytic review. Alcohol Alcohol 2006; 41: 328–35.

17. Emmen M. J., Schippers G. M., Bleijenberg G., Wollersheim H. Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review. BMJ 2004; 328: 318.

18. Saitz R., Palfai T. P., Cheng D. M., Horton N. J., Freedner N., Dukes K. et al. Brief intervention for medical inpatients with unhealthy alcohol use: a randomized controlled trial. Ann Intern Med 2007; 146: 167–76.

19. Caviness C. M., Hatgis C., Anderson B. J., Rosengard C., Kiene S. M., Friedmann P. D. et al. Three brief alcohol screens for detecting hazardous drinking in incarcerated women. J Stud Alcohol Drugs 2009; 70: 50–4.

20. Chandler R. K., Fletcher B. W., Volkow N. D. Treating drug abuse and addiction in the criminal justice system. Improv- ing public health and safety. JAMA 2009; 301: 183–90.

21. Hebert M. R., Clarke J. G., Caviness C. M., Ray M. K., Fried- mann P. D., Stein M. D. Feasibility of gaining access to women in jail for interventions. Women Health 2008; 47: 79–93.

22. Saunders J. B., Aasland O. G., Babor T. F., de la Fuente J. R., Grant M. Development of the Alcohol Use Disorders Identi- fication Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption— II. Addiction 1993; 88: 791–804.

23. Miller W. R., Rollnick S. Motivational Interviewing: Preparing People for Change. New York: Guilford Press; 2002.

24. Stein M., Charuvastra A., Maksad J., Anderson B. A ran- domized trial of a brief alcohol intervention for needle exchangers. Addiction 2002; 97: 691–700.

25. Moyers T., Martin T., Manual J., Miller W. The Motivational Interviewing Treatment Integrity (MITI) Code, version 2.0. 2005. Available at: http://casaa.unm.edu/codinginst.html (accessed 15 March 2005).

26. Moyers T., Martin T., Manual J., Hendrickson S., Miller W. Assessing competence in the use of motivational interview- ing. J Subst Abuse Treat 2005; 28: 19–26.

27. Sobell L. C., Sobell M. B. Timeline Followback User’s Guide: A Calendar Method for Assessing Alcohol and Drug Use. Toronto, ON: Addiction Research Foundation; 1996.

474 Michael D. Stein et al.

28. Miller W. R., Tonigan J. S., Longabaugh R. The Drinker Inven- tory of Consequences (DrInC): An Instrument for Assessing Adverse Consequences of Alcohol Abuse. Project MATCH Monograph Series, vol. 4. Rockville, MD: NIAA; 1995.

29. Spitzer R. L., Williams J. B. W., Gibbon M., First M. B. The structured clinical interview for DSM-III-R (SCID): I. History, rationale, and description. Arch Gen Psychiatry 1992; 49: 624–9.

30. Long J. S., Freeze J. Regression Models for Categorical Depen- dent Variables Using Stata, 2nd edn. College Station, TX: Stata Press; 2006.

31. Muthén L. K., Muthén B. O. Mplus Users Guide, 5th edn. Los Angeles, CA: Muthén & Muthén; 2007.

32. Satorra A., Bentler P. M. A scaled difference chi-square test statistic for moment structure analysis. Psychometrika 2001; 66: 507–14.

33. Blondell R. D., Looney S. W., Northington A. P., Lasch M. E., Rhodes S. B., McDaniels R. L. Can recovering alcoholics help hospitalized patients with alcohol problems? J Fam Pract 2001; 50: 447.

34. Hulse G. K., Tait R. J. Six-month outcomes associated with a brief alcohol intervention for adult in-patients with psychiatric disorders. Drug Alcohol Rev 2002; 21: 105–12.

35. Hettema J., Steele J., Miller W. R. Motivational interviewing. Annu Rev Clin Psychol 2005; 1: 91–111.

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