Prevention of Substance Use in Youth in Ukraine

Research Hypothesis

1. The rates and correlates of alcohol and other drug use, abuse and dependence, among
young adults age 18-25 presenting to a Psychoneurological Department in the Railway
Clinic Hospital in Kiev and Kyiv National Medical University will be high on the
prescreen survey and may not be related to self-identification of problems.

2. The quality of life of young people with alcohol and substance use problems can be low
compare to people without these problems. The quality of life can be improved after
Brief Motivational Interventions.

3. The rates of intentional and unintentional injury (e.g., motor vehicle, violence
related (fighting), sports injury, and other non-suicidal self-injury behavior) will be
higher among emerging adults with greater alcohol and other drug use.

4. The Brief Motivational Interventions will help young people with alcohol and substance
use problems and will be more effective for those with drinking motives that are social
enhancement/externalizing and for those with less depression, anxiety levels, sleep
disorders, impulsivity, sensation seeking, and aggression.

5. The Brief Motivational Interventions will help young people with alcohol and substance
use problems and will found to be effective in reducing primary outcomes (alcohol and
other drug use, as well as substance use related consequences) and secondary outcomes
(depression and anxiety levels, sleep disorders, aggression, and quality of life).

Background According to the World Health Organization (WHO), youth in the Ukraine have the
greatest level of alcohol consumption in the world, with typical age of initiation being 10
- 13 years old. When examining poisoning among youth in the Ukraine, 60% is caused by
alcohol 3. Although the legal drinking age in the Ukraine is 18 for wine and liquor, beer is
not legally classified as an alcoholic beverage and thus has no minimum drinking age. In
2011WHO ranked the Ukraine as 5th in the world in capita alcohol consumption. Recently,
attempts have been made to address these issues. For example, in 2010 legislation was passed
restricting access to low alcohol content beverages (e.g., beer) to youth, prohibiting
access in various settings (i.e., public transportation, education, playgrounds, etc.).

Young adults are a particularly interesting cohort to examine in Ukraine, as these youth
were raised following the downfall of the Soviet Union in 1991, during a socio-economic
downturn. For example, data from the Ukrainian Longitudinal Monitoring Survey shows about 4
in 10 males and 1 in 10 females drank alcohol in the last month. Despite these alarming
statistics, a paucity of data exists which examines correlates of alcohol use among young
adults in Ukraine. Consistent with problem behavior theory, a variety of studies from the
U.S. and Europe show that alcohol use and other problem behaviors tend to cluster during
adolescence and young adulthood, likely due to shared risk and protective factors, with some
researchers and clinicians viewing alcohol misuse as a self-harm behavior. Although
commonly, self-harm has the connotation of an intentional, self-inflicted, physical injury
or suicide attempt, substance use and eating disorders may be also considered non-suicidal
self-harm behavior. Further, some researchers assign the choice of involvement with HRO
(e.g., increased risk of injury including unintentional death) and the non-observance of
safety rules during work as self-harm behaviors. The boundaries between suicide and
non-suicidal self-harm behaviors are not always clearly defined, and in some cases behaviors
that usually fall outside the boundaries of self-harm may indeed represent self-harm if
performed with explicit intent to cause tissue damage. Self-harm is listed in the DSM-IV-TR
as a symptom of borderline personality disorder or it can be a comorbid disorder. The
motivations for self-harm vary, as it may be used to fulfill a number of different
functions. For example, it may function as a coping mechanism, which provides temporary
relief of intense feelings (e.g., anxiety, depression, stress, and emotional numbness), a
sense of failure or self-loathing, or other mental traits including low self-esteem.
Self-harm is most common during adolescence and young adulthood, usually first appearing
between the ages of 12 and 24.

Early intervention for emerging adults with risky drinking may be a more effective use of
resources than exclusive focus on treatment of those with alcohol use disorders (Nathan,
1988). A pilot study conducted in Ukraine survey emerging adults in an inpatient hospital
and found that most did not think they had an alcohol problem. Further, our data found that
common motives for alcohol use were related to coping with negative affect (e.g., stress,
anxiety) and social influences (e.g., because my friends use alcohol). These findings are
similar to that of American studies with college students, in which common motives for
drinking included: coping-anxiety, coping-depression, social, enhancement, and conformity
(Grant et al., 2007). In this regard, brief motivational interventions (BMIs) may be useful
to enhance desire to change behavior and address motives for use in order to reduce risk of
future alcohol problems. The need for early intervention may be particularly important for
young adults with alcohol use and co-morbid anxiety and/or depression.

In spite of the available literature data about the problem of alcohol consumption there is
the lack of information about efficacy of BMIs to reduce alcohol and other substance use
among emerging adults in Ukraine. Among emerging adults in the U.S., studies suggest BMI
approaches are promising among emerging adults.

In Europe, studies also showed the high efficacy of BMI in youth and adults. The goal of a
German study was to gain knowledge about the target group of medically referred alcohol
intoxicated adolescents and young adults, and to identify the utility of the administered
BMI. Namely, researchers tried to find out more about the age and gender structure of
participants, their alcohol and drug use history and their history of previous incidents of
acute alcohol intoxication, their risky substance use and symptoms of psychopathology. Also,
they assessed how many participants of the BMI took advantage of recommended further
counseling regarding their alcohol use. Third, it was examined in what characteristics the
group of "help accepters" differs from the group of "help avoiders" with regard to
socio-demographic characteristics and substance use patterns. Yet, this research faced
several limitations. First, the BMI was only semi-structured. It was uncontrolled stage-
1-design (there was not a control group); thus, researchers were not able to demonstrate the
efficacy of the BMI. It remains unclear, if the BMI initiated change motivation or had the
effect of motivational enhancement. The efficacy of the subsequent youth-specific counseling
services was not examined. Another European study illuminates the existing evidence
concerning the efficacy of brief motivational intervention [20]. Thus, there remain
unanswered questions around the effectiveness of brief alcohol intervention across different
settings, different population groups including emerging adults, about the optimal
intervention content, and the longevity of intervention effects.

In this regard, a recent U.S. study in primary care used the Composite International
Diagnostic Interview Alcohol Module to identify adults with alcohol problems in 3 randomized
controlled trials comparing BMI with no BMI. These were conducted in the USA in order to
identify key intervention components. This study examined 3 sets of audio-recorded BMIs (2
from null studies - no difference in drinking between BMI and no BMI groups; and 1 from a
positive study - less drinking in BMI group compared with no BMI group). The drinking
decreased among participants in all 3 studies. Intervention characteristics that are
considered as central to efficacious BMIs (such as changes in self- or other reports of
drinking quantity and/or frequency, drinking intensity and drinking within recommended
limits) were not strong predictors of drinking outcome. The quality of the BMI processes was
not predictive in these studies and may require attention to factors beyond constructs
typically examined. Therefore, more detailed analysis and prospective studies are necessary.
For example, the varying efficacy of BMI may depend on different factors such as drinking
motives, impulsivity, depression, anxiety, sleep disorders, and aggression.

Study Design Over a one year period, this Psychoneurological Department based study will use
a randomized controlled trial (RCT) design. Also, the Psychological Faculty of Kyiv National
Medical University. Eligible young adults will complete a screening survey. Given the fact
that we plan to include patients and students, we chose this subject pool for the study
because it combines the psychiatric ward and base of students at the university. Those with
risky drinking will be enrolled in the RCT and randomized to conditions and stratified by
patient/student and given either the brief motivational intervention or the control
brochure. A follow-up assessment will be conducted at 3 months.

Statistical Design

SPSS software version 18 will be used for data analysis. A regression model will be applied
according to the distribution of the data.

Inclusion Criteria:Adults ages 18-25 able to provide informed consent: 1) adults
presenting to the Railway Clinic Hospital for a medical problems except for exclusion
criteria below and, 2) students of KNMU ages 18-25. Additional inclusion criteria for the
RCT is:

- have prescreen survey results indicating alcohol and drug abuse risk or have
diagnosis of alcohol or substance use dependence according to ICD-10

- Between the ages of 18-25

- speaks and writes Ukrainian or Russian

- provide informed consent to participate

Exclusion Criteria: 1) Adults classified as "psychotic patients" (who need special
treatment and are not able to follow the requirements of the protocol); (2) adults deemed
unable to provide informed consent by hospital personnel or research staff (e.g.,
intoxication, mental incompetence) and (3) adults with suicide attempts in their history
or with suicidal thoughts in the past (because they present in high psychological distress
requiring intensive attention and intervention by staff); When we ask our patients about
suicidal thoughts and acts, and we will evaluate the suicidal risk for clinical referral
and because it is an important inclusion criteria. the patient has a high suicidal risk,
If we see that a participant has suicidal thoughts, suicidal attempts or suicidal risk
according to the results of the scales, we will we will exclude him/her from the study;
provide medical care, and phone numbers and addresses of help desk, but will not take
financial responsibility for that care. 4.) We will also exclude pregnant women.