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OCR for page 211
9 The Community Role: Identification,
Brief Intervention, and Referral
In responding to the fundamental questions raised in the first section of this report,
the committee has developed the premises on which its discussion of treatment for alcohol
problems is based. Among these is a definition of the target population of the treatment
enterprise that includes not only those who manifest the more severe sorts of alcohol
problems but those with less severe problems. Indeed, as noted in Chapter 1, the target
population for treatment comprises all who experience or who are likely to experience any
sort of problem arising in connection with their use of beverage alcohol. Another premise,
as noted in Chapter 2, is a definition of treatment that includes not only the therapeutic
activities of those who specialize exclusively in dealing with individuals manifesting alcohol
problems but any activity which has to do with the reduction of alcohol consumption and
its consequences in members of the target population.
Most of the balance of this report focuses on the management of more severe
alcohol problems in the specialized treatment sector. In this chapter, however, the focus
is upon the other end of the spectrum. Perhaps because of the historical development of
the field (see the Introduction and Summary), which reflects the natural tendency to divert
the lion's share of initial attention to the most obvious problems, less is known about
effective ways to deal with alcohol problems of lesser magnitude. A recent review has
described this effort as being "still in its early stages (Babor et al., 1987a). Nevertheless,
dealing with mild and moderate alcohol problems is of great importance even at present
and is likely to become even more important as further knowledge develops.
It is the view of the committee that the appropriate location for the effort directed at mild
and moderate problems lids not within the specu~lized treatment sector but within community
agencies that provide general services to various populafior~s. The specialized treatment sector
most appropriately addresses itself to substantial or severe alcohol problems; thus a
collaborative effort between community agencies and the specialized treatment sector is
required in order to have a significant positive impact upon the broad spectrum of alcohol
problems.
In this effort the role of community agencies in the treatment of alcohol problems
is threefold. First, it involves the identification of individuals with alcohol problems.
Second, it involves the provision of therapeutic attention in the form of brief intervention
to those with mild or moderate alcohol problems. Third, it involves the referral of those
with substantial or severe problems, or those for whom brief intervention does not suffice,
to the specialist sector for therapeutic attention. The reasons for this approach and the
manner in which it might be undertaken are the subjects of this chapter.
An Orientation to the Community Role in Treatment
To orient the reader the committee offers a simple diagram of its view of the
spectrum of interventions for alcohol problems (Figure 9-1) (Skinner, 1988~. The area
included within the triangle represents the general population. On the right the apex of
the triangle represents that proportion of the population with substantial or severe alcohol
problems, for whom specialized treatment is appropriate. (Dotted lines are used to indicate
that such categorical distinctions, although useful, are not to be considered as hard and fast
distinctions in the real world.)
211
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212 BROADENING TEIE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
On the left of the diagram the base of the triangle represents those persons in the
population who do not manifest alcohol problems. Primary prevention is shown as being
directed principally toward this segment of the population; it was defined in a recent review
as "policies or programs that affect whole (or substantial parts of) communities with the
ALCOHOL PROBLEMS
Primary
Mild
Moderate
~Intervention
Prevention
FIGURE 9-1 A spectrum of responses to alcohol problems. The triangle represents the population of the United
States, with the spectrum of alcohol problems experienced by the population shown along the upper side.
Responses to the problems are shown along the lower side (based on Skinner, 1988). In general, specialized
treatment is indicated for persons with substantial or severe alcohol problems; brief intervention is indicated for
persons with mild or moderate alcohol problems; and primary prevention is indicated for persons who have not
had alcohol problems but are at risk of developing them. The dotted lines extending the arrows suggest that both
primary prevention and brief intervention may have effects beyond their principle target populations. The
prevalence of categories of alcohol problems in the population is represented by the area of the triangle occupied;
most people have no alcohol problems, many people have a few alcohol problems, and some people have many
alcohol problems.
intention of reducing the incidence of problems experienced by individuals (Moskowitz,
1989:54~. The dotted portion of the primary prevention line indicates that, although
primary prevention activities are directed toward the population of individuals without
alcohol problems (represented by the solid portion of the line) and are designed to prevent
them from developing such problems, they nevertheless have important effects on
individuals who have already developed problems. Such programs tend to Operate
generally throughout the society . . . drinkers in many patterns of consumption are affected"
(Moore and Gerstein, 1981:53-54~.
For example, primary prevention measures that are taken to reduce the supply of
alcohol are principally intended to keep those without problems from developing them.
Yet such measures will also tend to reduce the consumption of other drinkers, including
drinkers with varying kinds of alcohol problems (cf. Popham et al., 1975~. Although
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THE COMMUNITY ROLE: IDENTIFICATION, BRIEF INTERVENTION, & REFERRAL 213
primary prevention is of great interest and concern, it has been extensively considered in
a recent report detailing a research agenda for this important area (IOM, 1989) and will
not receive major emphasis here.
The middle section of the triangle represents persons who exhibit mild or moderate
alcohol problems. "Brief intervention" is the term used (in Figure 9-1 and in this report)
to designate those activities that are employed to deal with this group; what these activities
might consist of will be discussed further below. The objective of brief intervention is to
reduce or eliminate the individual's alcohol consumption in a timely and efficient manner,
with the goal of preventing the consequences of that consumption. Other terms that are
generally synonymous include Secondary prevention" (to contrast with primary prevention
efforts directed at noncases and tertiary prevention efforts directed at severe cases), "early
intervention," and "prompt intervention."
Although directed toward persons who manifest mild or moderate alcohol problems,
brief intervention approaches also have some significance for those with more serious
problems (indicated by the dotted line for brief intervention in the diagram). Most persons
who experience substantial or severe alcohol problems neither seek nor receive formal
treatment for them. Current information suggests that, at minimum, this statement applies
in North America to four out of live such individuals (Hingson et al., 1982; McEvoy et al.,
1987), though figures from older studies have been even higher (Baekeland and Lundwall,
1977; Smart et al., 1980~. Similar findings have been reported outside of North America
in a variety of settings, suggesting that problems of the availability of service are not a
~ ~ A. _ ~ _ _ ._ _ _ ~ _ ~ ~ _ _ _ . ~ ~ _ ~
significant cause of the general failure of such individuals to seek treatment (see Appendix
C).
The principal reason for not seeking treatment even in the face of substantial or
severe alcohol problems seems to be a belief that such problems do not require assistance
and will take care of themselves (Hingson et al., 1982; McEvoy et al., 1987~. The persis-
tence of such a belief, together with additional factors including the denial of problems and
the stigma that an individual may perceive as being attached to his or her identification
as someone with alcohol problems and to the seeking of treatment, may result in the
continuing failure of many persons with substantial or severe alcohol problems to seek
specialized treatment. A broadly based program of brief intervention, appropriately
situated, can be viewed as in some measure responsive to this need.
Many of those who have substantial or severe alcohol problems but do not seek
treatment for them will nevertheless seek assistance for other problems of many kinds that
may be either related or unrelated to their consumption of alcohol. In this process they
will come into contact with a variety of health, social services, and other community
agencies. While ideally such persons upon being identified would accept referral to the
specialized treatment sector, some proportion in fact will not do so. The availability of
brief intervention within the community agency itself would assure that at least a degree
of therapeutic attention is provided to these individuals and to their problems.
In this introductory section, the committee has provided, through a diagram and
its accompanying text, an overview of what it believes might constitute the community role
in treatment. Details of this role and how it might be implemented are provided below.
First, however, the committee considers it necessary to indicate why the community role in
treatment is of fundamental importance in the overall response to alcohol problems.
A Paradox and Its Implications
Let us return to Figure 9-1 and examine an aspect of it that has not yet been fully
elaborated. As noted earlier, that portion of the population manifesting substantial or
severe alcohol problems is represented on the right by the apex of the triangle. On the
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214 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
left are those with no problems, and in the center, those with mild or moderate problems.
Simple inspection suggests that the number of persons in each category declines as one
moves from left to right in the diagram, with the smallest number of persons being in the
substantial or severe problems portion of the diagram. What the diagram suggests is that
most people have no alcohol problems, many people have some alcohol problems, and a
few people have many alcohol problems.
This suggestion has a substantial basis in empirical data. A national survey carried
out more than 20 years ago (in 1964-1965 and 1967) on a carefully drawn household
probability sample (Cahalan, 1970) looked in detail at specific alcohol problems. The
survey found, first, that during the 3 preceding years, 57 percent of the men and 79 percent
of the women in the study reported having none of the eleven actual or potential problems
specifically asked about in the survey questionnaire. Second, 43 percent of the men and
21 percent of the women reported having some degree of one or more of these problems.
Third, 28 percent of the men and 17 percent of the women had experienced a moderate
level of problems. Fourth, 15 percent of the men and 4 percent of the women had
experienced a high level of problems.
These data are consistent with the general shape of the diagram and are
substantiated by the most recent version of the same survey (Hilton, 1987), which was
again conducted on a nationwide sample. In this survey, however two kinds of "drinking
problems" were separately examined. One was "problematic drinking," which "consists of
a set of drinking behaviors and immediate sequelae of drinking which, although not
necessarily problematic in themselves, are thought to be indicative of alcohol dependence"
(cf. the discussion of the alcohol dependence syndrome in Chapter 2~. Examples included
the inability to cut down on drinking, memory loss or tremors after drinking, and morning
or binge drinking. The second kind of drinking problems surveyed was "tangible
consequences," that is, "specific problems that can arise because of drinking." Examples
included problems with one's spouse, problems on the job, problems with the police, and
health problems. The 1984 survey specifically asked about 13 items of "problematic
drinking and 32 "tangible consequences." All items of the earlier survey are included in
the later survey, but the list in the later survey is obviously considerably expanded.
In the committee's somewhat broader definition, all 45 of the items surveyed would
be considered to be indicative of alcohol problems. Although the two categories in the
survey are separately reported, both manifest the type of distribution indicated by Figure
9-1. Thus, 20 percent of current drinkers endorsed one or more "problematic drinking
items; 11 percent endorsed two or more; 7 percent, three or more; 4 percent, four or more;
3 percent, five or more, and 2 percent, six or more. Similarly, 21 percent endorsed one or
more "tangible consequences" items; 15 percent endorsed two or more; 10 percent, four or
more; 7 percent, six or more; 5 percent, 8 or more; 3 percent, 12 or more; and 1 percent,
16 or more (Hilton, 1987~.
These data indicate that the form of the diagram has held relatively constant over
the last two decades in terms of the nation as a whole. Some additional data reflect that
this tendency may hold for local samples as well. In a household probability sample of the
population in Contra Costa County, California, in 1987, a total of 1,980 persons was asked
to respond specifically to 10 "alcohol related problematic events," a combination of what
were called in the Hilton survey "problematic drinking and "tangible consequences items.
It was found that 96 percent of the respondents had experienced none of these
consequences in the last year; 3 percent had experienced one consequence; and 1 percent
had experienced two consequences (C. M. Weisner, Alcohol Research Group, University
of California, Berkeley, personal communication, May, 1989~.
A hazard of citing such data as the foregoing is that figures will be taken out of
context to calculate an exact number of persons with alcohol problems for the country at
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THE COMMUNITY ROLE: IDENTIFICATION, BRIEF INTERVENTION, & REFERRAL 215
large. The committee could preclude this error only by not citing the data, but it considers
the information to be relevant to this study. Perhaps the best course is to repeat a caution
voiced by one of the principal researchers in this field:
The problem distributions . . . are quite gradual. The gradient between
drinkers with few problems and those with many is such that the data
themselves never suggest a convenient, empirically derived dividing line
that can be used to separate problematic from nonproblematic drinkers.
Instead, analysts must rely on arbitrarily chosen cutpoints and prevalence
estimates will vary accordingly. Given this state of affairs, it must be
recognized that it is not possible to give a simple answer to the question
"What is the prevalence of problem drinking in the United States?" on the
basis of survey data. The answer depends heavily on the cutpoints that are
chosen. (Hilton, 1987:171)
Data on other parameters are also consistent with the diagram. For example, in
an examination of alcohol consumption based on seven national surveys, it was found that
35 percent of the population were abstainers, 32 percent light drinkers (up to three drinks
weekly), 22 percent moderate drinkers (up to two drinks daily), and only 11 percent were
heavy drinkers (more than two drinks daily). The authors observed: "lilt is remarkable
how much of the population either is completely abstinent or drinks very little. We
calculate that close to two-thirds of the adult population drinks three or fewer drinks per
week" (Moore and Gerstein, 1981:28~. They go on to comment on alcohol problems as
follows:
While chronic drinkers with high consumption both cause and suffer far
more than their numerical share of the adverse consequences of drinking,
their share of alcohol problems is still only a fraction typically less than
half-of the total. Alcohol problems occur throughout the drinking
population. They occur at lower rates but among much greater numbers
as one moves from the heaviest drinkers to more moderate drinkers.
(Moore and Gerstein, 1981:44; emphasis in the original)
Thus far, perhaps, there is nothing here that is counterintuitive. To put it simply,
people who drink a lot have many problems, but few people drink a lot. People who only
drink a little have fewer problems, but there are a great many people who drink a little.
Therefore, the total number of problems experienced by those who drink a little is likely
to be greater than the total number experienced by those who drink a lot, simply because
more people drink a little than a lot.
What does tend to be surprising is the logical implication of this distribution of
alcohol problems for intervention. If the alcohol problems experienced by the population are
to be reduced signif~cant0, the distribution of these problems in the population suggests that a
principal focus of intervention should be on persons with mild or moderate alcohol problems.
That such a focus may be advisable has been termed "the preventive paradox" (Kreitman,
1986~. What seems paradoxical is that the focus of efforts to reduce alcohol problems has
characteristically been only on those who manifested many of them, that is, on the heavy
drinkers who experience multiple consequences of their drinking. Those often labeled
"chronic alcoholics" are commonly seen as the source of the burden of alcohol problems,
and it is difficult and somewhat puzzling to be asked to shift one's gaze away from this
more troubled population, and to concentrate on a less apparent, albeit more familiar,
group.
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216 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
In health care generally, however, it is not exclusively the major problems that
must be dealt with, even though they may be the more immanently hazardous. It has been
said of dermatological conditions, for example, that although they may not immediately
threaten life, they may make it not worth living. Moreover, there is evidence from a field
related to the treatment of alcohol problems, that of smoking cessation, that effective brief
interventions can be mounted in a cost-effective manner (Cummings et al., 1989~.
Reference to the vignettes at the beginning of Chapter 2 may help to illustrate the
potential utility of identification, brief intervention, and referral in dealing with alcohol
problems of less than the greatest degree of severity or with those which arise from
relatively low levels of consumption.
George, a college freshman pledging a fraternity, becomes intoxicated and suffers
a broken pelvis as a consequence of an auto accident. Characteristically a low-level
consumer of alcohol, he is young (aged 19) and was drinking under the pressure of social
conformity; certainly he may "mature out" of his drinking, and it would be difficult to argue
that specialized treatment for alcohol problems is indicated. On the other hand, he may
not Mature out" of his present drinking pattern. An auto accident and a broken pelvis are
matters of no small concern; and even if George's overall level of consumption remains
low, another episode of intoxication could produce further serious trauma, especially if it
occurred while driving or boating. He is unlikely to be referred for court action with
respect to driving while intoxicated, but if this did happen the appropriateness and
effectiveness of the intervention could be questioned. Yet some level of attention, albeit
short of specialized treatment, would be prudent.
Sally, a young lady with a long-term speech impediment, has begun a pattern of
regular drinking because she feels alcohol reduces her disability in some way. Although she
initially disliked alcohol, she is beginning to find her drinking gratifying. Being both young
and female, she is (on a statistical basis) more likely than George to "mature out." Yet she
is already drinking regularly, drinking to cope with a problem, and under the influence of
alcohol while working. Again, although specialized treatment for alcohol problems does
not seem in order presently, some kind of helpful approach seems to be indicated. Should
this initial intervention prove to be ineffective, and should the problems persist or worsen,
referral for specialized treatment may indeed be indicated.
Gregory has a very low level of consumption: approximately two drinks in his
lifetime. Yet a consequence of his having taken those drinks, as well as other probable
factors, is that he is now in jail for murder. Although they may seem excessive, the
constellation of symptoms he exhibited has frequently been described (e.g., Banay, 1944;
May and Ebaugh, 1953; Marinacci, 1963; Bach-y-Rita et al., 1970; Skelton, 1970; Maletzly,
1976, 1978; Cold, 1979; Wolf, 1980~. Little is known of the precise etiology of what has
often been referred to as "pathological intoxication" (or, in the current American
nomenclature, Alcohol idiosyncratic intoxications) (American Psychiatric Association,
1987:128-129) or of its effective treatment.
Perhaps Gregory's experience will prove
sufficiently chastening that he will not drink again. In view of the potential consequences,
however, it may be better not to leave his treatment entirely to natural processes.
Finally, one may consider Elizabeth. An individual deeply imbedded in the
wine-growing culture, and consequently with a high level of alcohol intake, she nevertheless
experienced no apparent alcohol problems at all until the very moment of her acute
hemorrhage from the gastrointestinal tract. Certainly she would not have sought assis-
tance for problems that, from her point of view, she was not experiencing. Yet there is the
hope that someone might have done something to prevent matters from progressing to this
point. Excess mortality from cirrhosis of the liver, the presumptive antecedent cause of
Elizabeth's acute emergency, is high among those who, like her, are exposed to alcohol in
the course of their occupation (Plant, 1988~; a program of identification, brief intervention,
and referral for this group might be advisable.
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THE COMMUNI,IY ROLE: IDENTIFICATION, BRIEF INTERVENTION, & REFERRAL 217
None of these four individuals conforms to the stereotypical picture of the
alcoholic, nor could any of them be confidently said to exhibit the characteristics of alcohol
dependence. All, however, fall within the committee's definition of alcohol problems.
Although the level of alcohol consumption in three of these four cases was not high, each
individual nevertheless suffered significant consequences in connection with his or her
consumption. They are consequences that require address in and of themselves, regardless
of whether there may or may not be subsequent progression to more serious alcohol prob-
lems. The possibility of progression, although not high, is nevertheless not negligible;
furthermore, should brief intervention prove to be ineffective, referral for more extensive
intervention may be necessary.
These four cases well illustrate the complex interrelationships, outlined in Figure
9-2, among vulnerability factors, exposure to alcohol, modifying variables, and the
consequences of alcohol consumption (Babor et al., 1987b). One important feature of the
diagram is that it illustrates the possible independence of the consequences of alcohol
consumption from the development of alcohol dependence. Although one pathway
illustrates that the development of acute and long-term consequences of alcohol
consumption can be preceded or accompanied by the significant symptoms of alcohol use
that suggest alcohol dependence, there are other pathways that indicate the occurrence of
such consequences in the absence of these symptoms.
MODIFYING
VULNERABILITY EXPOSURE VARIABLES
r
PERSONAL
AN'rECENDENTS
AGE, SEX,
BODY MASS
GENEllC
VULNERABILITY,
PERSONALITY
SOCIAL
1~JTECENDENTS
AmTUDES
NORMS
CUSTOMS
RITUAIS
CONSEQUENCES
Or
1/
BAC
DRUGS
CONTm
SPEED OF
DRINKING
DRINKING
PATTERN
QUANTITY
FREQUENCY
V~BILITY
-
t
DIET
NUTRlllON
SMOKING
YEARS DRINKING
DEPENDENCE
~-
TOLERANCE
~ITHDRA'AL
| RELIEF DRINKING
ACUTE
CONSEQUENCES
ACCIDENTS
VIOLENCE
~ \
~ \
_ ~ \
\
\
\
\
_ \ ~
\
fir
LONG-TERM CONSEQUENCES
-
lIEDICAL' PSYCHOLOGICA1, AND
SOCIAL DISABILITIES
FIGURE 9-2 The complex interrelationships between vulnerability factors, exposure to alcohol, modifying variables,
and the consequences of alcohol consumption (Babor et al., 1987:395). The multiple pathways indicate that the
acute and long-term consequences of alcohol consumption may or may not be associated with dependence on
alcohol.
None of the individuals described in the four case vignettes would be likely to
appear in a specialized treatment program for alcohol problems. Rather, George would be
seen in the acute medical care inpatient system; Sally might be seen by a speech pathologist
or her general practitioner or both; and Gregory would be dealt with primarily by the
criminal justice system. If seen at all subsequent to acute treatment for the dramatic event
that initiated her difficulties, Elizabeth (absent the implementation of some special program
as discussed above) might possibly receive routine attention from occupational health
personnel, providing she was employed by a large enough company.
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218 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
It is unlikely that any of these individuals, with the possible exception of Elizabeth,
would have been referred as a first order of business to the specialist sector for treatment
of their alcohol problems. Because their problems are mild or moderate, such a referral
would not be strikingly appropriate. Indeed, the acceptance of an immediate referral to the
specialist sector by an individual manifesting mild or moderate problems might be
unfortunate, in terms of the potential adverse consequences of mislabeling and the
potentially inappropriate use of scarce treatment resources. Moreover, appropriate or not,
such a referral might not have been accepted. As a result, under the circumstances that
obtain at present, none of these individuals would receive any direct attention for their
alcohol problems. Such an outcome would be unfortunate indeed.
The implications of this analysis are clear. There is a need for a spectrum of
interventions that matches the spectrum of alcohol problems. It may be that, even prior to
brief intervention, some work will be required to persuade individuals that even a mild or
moderate problem exists; a stepwise progression into treatment interventions of graded
levels of intensity should be possible. At present, in the absence of the capability for such
a stepwise approach, an individual's denial that entry into, let us say, prolonged inpatient
treatment is required is tantamount to a denial that any problem exists.
Lee specu~lized treatment sector for alcoholproblems cannot be the sole locus oftreatment.
If significant inroads are to be made into the overall burden of alcohol problems, a
widespread, broad-based therapeutic approach must be taken within which gradations of
therapeutic attention are possible. For this vision of treatment to be realized, the
community and its resources must become a major part of the therapeutic system. How
that might be accomplished will be the subject of the balance of this chapter.
Identifying People with Alcohol Problems
The development of an effective role for community agencies in the treatment of
alcohol problems depends, first of all, upon the ability to identify persons with such
problems. A considerable amount of work has gone into developing methods to accomplish
this identification rapidly and effectively (see reviews by Kaplan et al., 1974; Morse and
Hurt, 1979; Saunders and Kershaw, 1980; Skinner et al., 1981; Bernadt et al., 1982, 1984;
Babor and Kadden, 1985; Babor et al., 1986, 1987a; NIAAA, 1987; Allen et al., 1988; Leigh
and Skinner, 1988; J. B. Saunders, 1988~. Two major methods of identifying cases in
populations have evolved. One is the use of questions or questionnaires. The other is the
laboratory examination of body fluids.
There is general agreement in the reviews noted above that currently available
laboratory examinations are significantly less useful than questionnaires in identifying new
cases. Laboratory examinations have comparatively low levels of sensitivity; that is, they
are likely miss a large number of actual cases. They tend to be more costly than are
questionnaire methods. They are also difficult to deploy in any but a medical setting,
which generally brings with it the necessary skill and the tradition of obtaining samples of
body fluids.
Medical care settings do, however, constitute a major potential source of otherwise
unrecognized individuals with alcohol problems (see below), and laboratory examinations
are often routinely done in such settings. It has been possible to develop methods for
using routine laboratory examinations to identify persons with problems (Beresford et al.,
1982~. Certainly the development of highly sensitive and specific laboratory means of
identifying individuals with alcohol problems would do much to enhance physicians' interest
in doing so (NIAAA, 1987~. Some initially promising new measures such as levels of
enzymes in blood platelets, carbohydrate-deficient transferrin, and various acetaldehyde ad
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IlIE COMMUNITY ROLE: IDENTIFICATION, BRIEF INTERVEN'IION, & REFERRAL 219
ducts await further investigation (Allen et al., 1988) but may possess more favorable
case-finding characteristics than the laboratory methods presently available.
Laboratory examinations may also prove useful for monitoring persons who are
receiving brief or other interventions and for providing feedback to treatment personnel
and to the individuals being treated regarding the success (or lack thereof) of the treatment
effort (Kristenson et al., 1983; Schuckit and Irwin, 1988~. Not necessarily a replacement
for questionnaires, laboratory examinations may be a useful supplement to them in the case
identification process, particularly in instances in which there is reason to suspect a high
level of denial of problems. Yet the choice of the appropriate supplementary test may be
a rather complex matter (Bernadt et al., 1984~. Manylaboratory tests involve delays and
expense; however, an accurate, inexpensive, and rapid method of measuring alcohol in body
fluids that could readily be used outside of medical settings, the alcohol dipstick, has been
developed (Kapur and Israel, 1985; Peachey and Kaput, 1986~.
The range of available question-based methods for identifying the presence of
alcohol problems is impressive. An NIAAA conference achieved consensus that case
finding should begin with a single question: nDo you drink now and then?" (NIAAA,
1987~. A study in an ambulatory care medical setting came up with two questions: "Have
you ever had a drinking problem?n and When was your last drink?n (the latter question
being scored as positive if the drink was within the 24 hours prior to the appointment)(Cyr
and Wartman, 1988~. The widely used CAGE questionnaire consists of four questions:
"Have you ever felt you ought to Cut down on your drinking? Have people Annoyed you
by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have
you ever had a drink first thing in the morning to steady your nerves or get rid of a
hangover (Eyeopener)?~ (Ewing, 1984~.
There are a number of multi-item questionnaires that are useful in case-finding; for
example, the Michigan Alcoholism Screening Test (MAST) (Seizer, 1971), the Reich
questionnaire (Reich et al., 1975) the Alcohol Dependence Scale (ADS) (Skinner and
Allen, 1982), and the Alcohol Use Disorders Identification Test (AUDIT) (J. B. Saunders
and Aasland, 1987; Babor et al., 1989~. The MacAndrew Scale, which contains no questions
having any direct alcohol-related content, was developed on an actuarial basis from the
Minnesota Multiphasic Personality Inventory (MMPI) to get around problems of denial
(MacAndrew, 1965~. Although it has gained some additional notice of late with the
development of increased concern about the validity of self-reports (see Chapter 101, a
critical review indicates that this particular scale may be fatally flawed (Gottesman and
Prescott, 1989~. Finally, there are case-finding packages, such as the Alcohol Clinical Index
(ACI) (Skinner et al., 1986; Skinner and Holt, 1987) which contain a number of different
components used together (clinical, laboratory, and questionnaire data).
Many of the instruments that are currently available for identifying alcohol
problems were developed specifically to identify severe alcohol problems. An exception is
the AUDIT; items for it were developed from a pool of questionnaires containing no
responses from persons with severe alcohol problems (their questionnaires were removed)
(J. B. Saunders and Aasland, 1987; Babor et al., 1989~. The AUDIT was also developed
on a cross-national basis, using large samples from six quite different countries. Its 10
items are simple and readily administered by nontechnical staff, or they can be
self-administered. The items cover alcohol consumption, symptoms of alcohol use, and
consequences of alcohol use, three areas of content that are desirable for the full
description of an alcohol problem (see Chapter 10~. Finally, as each of the 10 AUDIT
questions is scored on a 0-4 basis, the possible range of scores is 0-40, a potentially useful
feature in determining which individuals to retain for brief intervention in a general setting
and which to refer directly to specialized treatment settings. Initial indications are that the
instrument has highly satisfactory sensitivity and specificity (J. B. Saunders and Aasland,
1987; Babor et al., 1989~.
,
A
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220 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
Thus, a range of options is available for the identification of persons with alcohol
problems, from single questions to case-finding packages. There is a trade-off between the
accuracy of identification desired and the resources available to be expended. Although the
more elaborate instruments are generally more precise, their use entails a greater
commitment of resources. A possible compromise is to use a staged strategy, with simpler
measures deployed first, followed by more elaborate measures for those tentatively identified
as possible cases. These issues are discussed further in Chapter 10, which deals at greater
length with assessment, of which identification may be considered a subset.
Problem identification in many community settings (see below) might appropriately
be undertaken not for alcohol problems alone but for a range of ~lifestyle" problems that
include those related to alcohol, tobacco, caffeine, medications, nonmedical drugs, diet,
sleep, sexual functioning, and exercise (Babor et al., 1987a,b; cf. NIAAA, 1987; J. B.
Saunders and Aasland, 1987~. Not only is such broadly based inquiry more congruent
with the overall mission of many community settings (e.g., physician's offices or social
agencies) but "many patients may be willing to discuss their drinking within the broader
context of health behaviours, such as smoking, that are less threatening to talk about
initially" (Babor et al., 1987a:335~.
In one series of studies a lifestyle questionnaire was developed and administered
in three different formats while patients were waiting to see their primary care physician.
One format was a self-administered computerized version. The level of acceptance of the
lifestyle questionnaire in all three formats was very high, and there was evidence that its
administration significantly increased the patient's intention to raise questions regarding the
target areas in the questionnaire during the subsequent interview with the physician
(Skinner et al., 1985a,b).
Brief Intervention
Once persons with alcohol problems have been identified in a community setting,
the exercise of a triage function seems advisable. The committee believes that those
persons who are identified and who appear to have a substantial or severe alcohol problem
(see Chapter 3) should be referred to the specialist sector for treatment. However, those
with mild or moderate alcohol problems should be dealt with in the community agency
itself by staff who have been trained to deliver brief interventions.
Making the distinction between mild and moderate problems that require only brief
intervention on the one hand and substantial and severe problems that require specialized
treatment on the other is a function both of the screening instruments used and of the
judgment of those who use them. As noted above, some instruments (the AUDIT is an
example) provide a wide range of scores that would facilitate the making of such
distinctions. Further research and experience will help to sharpen the ability to provide
accurate triage of this kind; in particular the continued monitoring of outcomes in
individual cases will provide essential information. Irrespective of the triage classification,
those who do well following brief intervention need not be referred on, whereas those who
do not do well will need additional attention or referral, or both. This type of feedback
between intervention and outcome is also important in the specialized treatment sector (see
Chapter 13~.
Because referral has been an option since the redevelopment of the specialized
treatment sector following Prohibition (see Chapter 1), what has facilitated the possibility
of an effective community agency role in the treatment of alcohol problems has been the
development of effective brief interventions. That anything short of the most heroic efforts
might be a reasonable way of dealing with alcohol problems will seem to some quite
contrary to experience and common sense. How can such major, serious problems be
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THE COMMUNITY ROLE: IDENTIFICATION, BRIEF INTERVENTION, & REFERRAL 221
amenable to a brief and straightforward approach? At first glance, it seems unlikely.
However, as has been reviewed in Chapter 6 of this report, a significant proportion of such
problems will resolve without any formal treatment (so-called Spontaneous remissions).
Given this well-established fact, it is perhaps less surprising that some sort of formal inter-
vention, even a brief one, might add in a significant way to the proportion of positive
results.
Not every individual with an alcohol problem, of course, can be helped by a brief
intervention. Many persons (as already noted) will require more prolonged and intensive
treatment to achieve a good outcome. Yet it seems clear (see below) that some individuals
will be helped. Many would otherwise receive no assistance at p11 for their problems,
either refusing a referral outright or, in a pattern that is all too familiar, accepting the
referral but failing to see it through. A well-thought-out and effective brief intervention
delivered on the spot and immediately following identification of the problem avoids these
difficulties. Even if the intervention is ineffective in an individual case, little will have been
lost, and possibly the individual may as a consequence of the attempt and its failure be
motivated to undertake a more extensive approach to his or her problems.
In recent years a number of controlled studies have demonstrated the efficacy of
brief interventions in the treatment of alcohol problems. The committee views this as a
highly significant development and will review these studies in some detail below, partly
because it senses a high level of ambient skepticism about brief interventions. The review
will also serve to describe in some detail the interventions that have been studied. Because
the area of smoking cessation is closely related to that of brief intervention for alcohol
problems, one of the more important studies in this area will be reviewed as well.
Efficacy of Brief Interventions
The Edwards and Orford study of advice vs. treatment Interest in brief interventions
for alcohol problems was stimulated by an important British study (Edwards et al., 1977~.
A hundred married men who were admitted consecutively to an outpatient clinic for
treatment of alcohol problems were randomly assigned, following a careful initial
assessment, to one of two treatment conditions. One group was offered a multiplicity of
services including an anti-alcohol drug, an introduction to Alcoholics Anonymous, and
regular outpatient care, with admission to a 6-week inpatient unit if that seemed advisable.
The other group was given a single session of advice, conjointly with their wives, by a
professional team that directed them toward abstinence, a good work record for the
husband, and mutual effort in improving the marital relationship.
One year later there were no significant differences in outcome between the two
groups, and a two-year follow-up (Orford et al., 1976) yielded similar results. That is, for
the group as a whole, a single brief session of advice appeared to be as effective as much
more extensive treatment. There was evidence of a matching effect, in that those with
more severe problems tended to do better with the more extensive treatment program and
those with less severe problems tended to do better with the single conjoint session of
advice (Orford et al., 1976; see also Glaser, 1980~. One of the conclusions of the original
paper was that "we should look much more closely at the efficacy of less intensive treatment
methods than have previously been thought adequate" (Edwards et al., 1977:1027~.
Following their own advice, the principal authors published a paper on "a plain treatment
for alcoholism" (Edwards and Orford, 1977~.
Me Mating study Another influential study has been reported from Sweden
(Kristenson et al., 1983~. As part of an exercise in preventive medicine, all of the male
residents of Malmo born between 1926 and 1933 were invited to attend a health screening
program at the city's general hospital. Those with high serum levels of gamma glutamyl
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THE COMMUNITY ROLE: IDENTIFICATION, BRIEF INTERVENTION, & REFERRAL 231
may be willing to grant that alcohol consumption is a problem for them also will not
accept referral, for a variety of reasons. For these people the delivery of brief intervention
in the medical setting may offer the only opportunity for effective assistance; as noted
above, there is considerable evidence that brief interventions can be effective. Even if the
intervention is unsuccessful, it is possible that the experience will contribute to an eventual
decision to seek more formal help.
These recommendations are consistent with those of the forthcoming Guide to
Clinical P~remive Services, to be issued by the U.S. Preventive Services Task Force. Section
47 of this report addresses "Screening for Alcohol and Other Drug Abuse. A Clinical
intervention" is recommended as follows:
Clinicians should routinely ask all adults and adolescents to describe their
use of alcohol and other drugs . . . Certain questionnaires may be useful
to clinicians in assessing important alcohol use patterns . . . All persons
who use alcohol should be informed of the health and injury risks
associated with consumption and should be encouraged to limit
consumption . . . Many patients may benefit from referrals to appropriate
consultants and community programs specializing in the treatment of
alcohol and other drug dependencies. (U.S. Preventive Services Task
Force, 1989:186~.
Health care settings are not the only venues to be considered for a
community-based program of identification, referral, and brief intervention. Socu~l assistance
agencies are also a possibility. Less is known about the prevalence of alcohol problems
among those seeking social services. However, the ECA study did find that, for black,
white, and hispanic women, and for black and white men, the current prevalence of serious
alcohol problems was higher for those receiving welfare assistance than for those not
receiving welfare assistance (Helzer and Burnham, in press). It has been suggested
(Murray, 1977) that vagrants, prisoners, and those cited for legal offenses connected with
drinking are other groups likely to be seen in social service settings that may include a high
proportion of persons with alcohol problems.
Family service agencies often see individuals whose problems are the result of or
are aggravated by alcohol consumption. The same is true of welfare agencies and of
agencies that provide assistance for persons with various kinds of handicaps. For example,
a survey of all of California's county social services departments found that, on average, 23
percent of individuals on the general assistance caseload were public inebriates (Spieglman
and Smith, 1985~. Alcohol problems may be manifested by the designated client but also
frequently by other members of the family, a traditional focus of family and other social
agency concerns.
Alcohol problems are quite significant in the homeless population (IOM, 198%; see
also pages 386-388 of this report). Again, referral for formal alcohol treatment will be
effective only for a portion of the individuals identified by social agencies, and an onsite
identification and intervention capability in social agencies would add an important
dimension to overall management. There are exhortations to this effect in the social work
literature (Raspa, 1965; Ehline and Tighe, 1977; Deakins, 1983~.
Educational settings must also be considered, and are especially important in
instances in which students are in residence (e.g., in boarding schools and colleges). In
such settings students are away from their parents, and their parents' social support
systems, and must depend to a greater degree on the resources and guidance of the
institutions they are attending. Recently a number of serious incidents relating to the use
of alcohol on college campuses in the United States have risen to general attention, and
the time may be propitious for identification and brief intervention efforts in these and
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232 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
other educational settings. Many such settings have health services whose personnel have
been trained to help persons with alcohol problems, but other educational personnel may
appropriately be involved in such efforts as well (see the discussion on personnel below).
Health and especially alcohol problems have long been a matter of concern in
occupational settings. Indeed, many such settings have developed employee assistance
programs (EAPs) that are designed to deal with a broad spectrum of problems (see Section
IV). However, although the identification of persons with alcohol problems has been much
stressed in such programs, the therapeutic focus has been primarily on referral rather than
on intervention. Referral may, indeed, be appropriate in some instances, but an onsite
capability for dealing with at least some proportion of employee alcohol problems would
be a logical extension of occupational health and employee assistance programs.
Finally, consideration should be given as well to the cr~minaljustice system and the
settings it potentially offers for a community agency program. The association between
crime and alcohol is complex but significant (cf. Collins, 1981~. Alcohol is associated in
some way with many activities that come before the courts. Driving while intoxicated
(DWI) is an example (see also pages 381-385~. Some proportion of persons who drive
while intoxicated have severe alcohol problems, but many others do not (Donovan et al.,
1983; Vingilis, 1983; Wilson and Jonah, 1985; Perrine, 1986~. Yet there is evidence that
the specialized treatment sector for alcohol problems is being flooded with DWI and other
offenders (Fillmore and Kelso, 1987; State of Connecticut, 1988~. In 1986-1987, for
example, the state of Connecticut experienced a 400% increase in DWI referrals to alcohol
treatment services (State of Connecticut, 1988~.
There is scant evidence that an approach such as that recommended in this chapter
has been successful in the criminal justice system. On the other hand, there are particular
features of the system that would facilitate an approach based on identification, brief
intervention, and referral. Persons who enter the criminal justice system are often
extensively evaluated in a variety of ways, and it would not be discordant to make the
identification of alcohol problems a part of such evaluations. Given the authority of the
courts, compliance with intervention and follow-up regimes may prove less of a problem
in this system than elsewhere; as noted in Chapter 6, not all persons will respond favorably
to such coercion, but some will. Finally, those who enter the correctional system constitute
a target population that is at least readily available for interventions of various kinds.
Although the importance of alcohol problems in all of these settings is
considerable, it does not follow that the settings will necessarily be receptive to mounting
intervention programs. It may be necessary over time to foster a climate of institutional
change with respect to alcohol problems. Employee assistance programs have done signal
work in industry in this regard, and similar approaches in some school settings (i.e., student
assistance programs) have also been effective. Medical settings are not inherently well
disposed toward dealing with alcohol problems (Sparks, 1976~. The development of
specialized consultation teams may be quite helpful in this regard (Lewis and Gordon,
1983; Williams et al., 1985; Glaser, 1988~. Institutional change in training settings may be
of equal or greater importance in the long run; as noted earlier, one medical school (Johns
Hopkins) has made a thorough understanding of alcohol problems the principal goal of its
educational efforts (Holder, 1985; Moore et al., 1989~. The importance of this example
can hardly be overestimated.
To recapitulate: there are a number of settings other than those for the
specialized treatment of alcohol problems in which persons with such problems are likely
to appear. If these individuals can be effectively identified, a proportion will be
appropriate for and will accept referral to specialized treatment programs. But many
persons, perhaps most, either will have problems that are not sufficiently severe to require
specialized treatment, or, even if their problems are severe, will not accept a referral. For
these persons a brief intervention mounted within the setting in which they are identified
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THE COMMUNITY ROLE: IDENTIFICATION, BRIEF INTERVENTION, & REFERRAL 233
is probably the only alternative to receiving no assistance at all for their alcohol problems.
Even if the brief intervention should be unsuccessful it may serve the purpose of engaging
the attention and interest of the individual, who may consequently be more willing to
accept referral to the specialist sector. The settings noted in this section as ones in which
such a program might be effectively mounted include primary, specialized, and emergency
medical services; social agencies; educational institutions; occupational settings; and the
criminal justice system. A process of institutional change may be required to foster
intervention programs of the kind proposed.
Personnel
Within the settings that have been indicated in the previous discussion, which
personnel should be given the responsibility for identification and brief intervention? The
simplest answer is that this responsibility should be given to those personnel who already
deal with the target populations of the setting. It is a sensible response and leads to a
recommendation for an extensive program of on-thejob training.
Yet it is also quite a limited response. The personnel in a given setting are in
constant flux. As some leave and others take their places, the new staff will have to be
trained, or the capability to perform the community role in treatment will rapidly decline.
On-thejob training, however, is a difficult effort to sustain over the long haul.
Alcohol problems have been a part of human history from the beginning. They
are not going to go away. Thus, a long-range plan for training various kinds of personnel
to identify and deal with alcohol problems must be developed. Such a plan would involve
the development of a capability for identification and brief intervention during the training
of personnel likely to be active in he target settings. But who are these personnel?
In the medical setting, one thinks immediately of physwu~r~s. There have been
important and effective efforts in recent years to educate physicians about alcohol problems
during their period of training (Lewis et al., 1987~. Johns Hopkins Medical School in
particular has set an important example (see above and Holden, 1985; Moore et al., 1989~.
Special mention may be made of the career teacher program sponsored jointly by the
National Institutes on Drug Abuse and on Alcoholism and Alcohol Abuse, which singled
out junior faculty members at medical schools for specialized development in this area.
Although the program has now been discontinued, it was felt to be highly effective
(Pokorny and Solomon, 1983; see Chapter 4~. Certainly, physicians would be a critical
target population for training of this kind. The encouragement of physician involvement
in a multiplicity of ways in dealing with alcohol problems has come from the highest levels
of the government and of the profession (Bowen and Sammons, 1988~.
Yet physicians are not the only possible target for such training in the medical
setting. plumes represent another important potential resource. There are 220 schools of
nursing in the United States, and they admit approximately 14,000 students annually.
Enlisting this manpower would constitute a major addition to the personnel pool for
treatment based in community agencies. The suitability of nurses for the proposed tasks
is attested to by their having implemented them in whole or in part in three of the major
trials that have been reported to date: the Malmo study, the Edinburgh study, and the
New Zealand referral study (Kristensen et al., 1983; Chick et al., 1984; Elvy et al., 1988~.
To take a leaf from past experience, a career teacher program in nursing might be
an excellent vehicle through which to achieve the desired competency in this important
group. Nurses often work regularly in some settings viewed as important to this effort,
such as social agencies, educational and occupational settings, and the criminal justice
system. Physicians as well may work in such settings, but unlike nurses they are more
often on a consultative or minor part-time basis. Finally, there has been a movement in
_ ~ . . .
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234 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
the United States and elsewhere toward the provision of primary health care by nurse
practitioners (Spitzer et al., 1974), making their involvement all the more critical.
Social workers are a significant personnel target group in terms of social agency
settings; like nurses, they tend to work in multiple settings and in important, full-time roles
in those agencies. Social workers have a long and growing tradition of providing
therapeutic services. Psychologists are another potential target group; they often play a
major evaluative role in educational and criminal justice settings, developing and
administering assessment instruments. Theories developed by psychologists have been of
particular relevance to the development of brief intervention techniques (cf. Babor et al.,
1987a).
Although there are some physicians, nurses, social workers, and psychologists in
educational settings, there may be other personnel here to be considered. Teachers play a
large role in some approaches to primary prevention and might play a role in secondary
prevention as well. They spend a great deal of time with students on a regular basis and
may be in a good position to identify those who are in difficulty. They are accustomed to
imparting large bodies of complex information to their students; brief intervention
approaches have a large informational component and may be well within their capabili-
ties. Guidance and counseling personnel and supervisory personnel in the systems deployed in
large organized living arrangements (e.g., dormitories, and fraternity and sorority houses)
may be considered as well.
Occupational services employees in occupational settings for example, RAP
personnel-and parole, probation, arid corrections o~`cers in criminal justice settings may be
additional candidates. An increasingly important group that bears consideration, and that
is not particularly connected with any one of the target settings but could and perhaps
should be, is alcoholism counselors. Their training and orientation have traditionally been
toward the specialized treatment sector, but this seems more a matter of custom than
necessity. Alcoholism counselors might welcome the opportunity to expand their role into
this aspect of the field and might bring some unique perspectives and abilities to it.
To recapitulate: on-thejob training will be required in the short run to equip
existing personnel within relevant settings to identify and provide brief interventions to
persons with alcohol problems. In the long run, however, such capabilities will be most
efficiently imparted to relevant personnel during the course of their training. It should be
stressed that, to be effective, such training must be broad; it cannot be oriented exclusively
toward the more severe problems, as has frequently been the case in the past, but must be
oriented toward the entire spectrum of alcohol problems. Among the groups that may be
targeted for such training are physicians; nurses; social workers; psychologists; teachers;
occupational services employees; parole, probation, and corrections officials; and alcoholism
counselors.
Effects and Costs
The successful deployment of a capability for widespread identification of persons
with alcohol problems and of brief intervention for those problems, as outlined above, is
intended to reduce the overall burden of alcohol problems to the individual and to society
at large. There is reason to believe that this desirable result would follow. However, there
would be little point in introducing such a major innovation in care unless provisions were
made for a careful determination of whether the desired result did in fact occur.
Some may entertain the hope that the costs accruing to the specialized treatment
of substantial or severe alcohol problems could be greatly reduced through such a program.
This seems a possible but not a necessary consequence. The widespread availability of brief
intervention would remove from the specialist treatment pool those individuals who would
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THE COMMUNITY ROLE: IDENTIFICATION, BRIEF INTERVENTION, & REFERRAL 235
respond to less extensive kinds of treatment. However, the systematic identification of
individuals with alcohol problems in the many settings in which this would take place might
result in a significantly increased level of referrals to specialized treatment overall. The net
result in this instance would probably be an overall increase in the cost of treatment for
alcohol problems. As is discussed further in Chapter 20, the great likelihood is that the
overall costs of treatment would continue to be far less than the cost to society of alcohol
problems.
An initial financial investment of some magnitude in the development of a
comprehensive system of identification and brief intervention would seem to be
unavoidable. Further study of these processes, the development and dissemination of
appropriate packages of identification and intervention materials, the training of
appropriate personnel, and the evaluation of the effort require it. However, once the
system is in place, and, one would hope, working well, existing funding mechanisms should
be able to cover the provision of services, which will have become part of standard practice.
At the same time the overall financial benefits from the reduction of the alcohol problem
burden (e.g., reduced collisions, reduced accidents, reduced domestic violence) may begin
to be felt. There is evidence that the provision of preventive services of the kind
contemplated is at least as cost-effective as many accepted prevention practices (Cummings
et al., 1989)
A further comment seems in order regarding the financial implications of brief
therapy. Unlike brief intervention (one or two sessions), it is difficult to see how brief
therapy (six or eight sessions) can be construed as a part of standard practice, at least for
reimbursement purposes. Moreover, although some physicians may be trained in brief
therapy, the committee can see no necessary requirement of medical training as a part of
its delivery and anticipates that it may be provided for the most part by practitioners other
than physicians. In the current climate of health insurance, reimbursement of
nonphysicians would very largely not be possible. The committee urges strongly that a
f nancial mechanism be developed to furul brief therapy outside of, as well as within, the context
of funding for medical or medicalb-superv~sed services.
Conclusions and Recommendations
The committee recommends a broader and more comprehensive nationwide effort to
establish a strong community role in dealing with mild to moderate alcohol problems, to
complement the exhorts of the specialized treatment sector in dealing with substantial and severe
alcohol problems. The goal of this effort is to reduce or eliminate the consumption of
alcohol by persons experiencing problems, with the object of reducing the overall burden
of problems. The role of community agencies in treatment would involve (1) identifying
in a variety of human service settings those persons with alcohol problems, (2) referring
those who are appropriate to specialized treatment, and (3) dealing with the rest by
providing brief intervention or brief therapy.
To carry out this program, it would be necessary to designate a strong leadership
capability in this area. The most appropriate approaches to these activities need to be
defined and developed. A major training effort, directed at a variety of human services
professionals and their supporting institutions, would need to be mounted, as well as an
evaluation effort capable of determining both the outcome of the community role in
treatment and its costs. Methods of financing those components of the program not
underwritten by existing mechanisms (e.g., planning, materials development, further re-
search, feasibility studies, training, and the provision of brief therapy) would also have to
be developed.
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236 BROADENING THE BASE OF TREATMENT FOR ALCOHOL PROBLEMS
The committee recognizes that these recommendations constitute a major and (at
least initially) a costly proposal, but it also recognizes the appalling magnitude of the cost
of alcohol problems to society. For the reasons developed in this chapter, the committee
believes that the further development of the community component of treatment offers a
significant possibility of ultimately containing these costs.
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Representative terms from entire chapter:
alcohol consumption
