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C International Review of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse M. Grant and E. B. Ritson This review is concerned with trends in treatment policy for alcohol problems from an international perspective. It reflects opinions and data from a range of different cultures and states of socioeconomic development. lo, However, it makes no claim to be a comprehensive account of all worldwide experiences or a statement of World Health Organization (WHO) policy. Much of the evidence discussed below was obtained from investigators in nine countries who were participants in a WHO multicenter cross-national study on the effectiveness of brief interventions. Each center was asked to prepare a short report on its current national policy and future plans concerning the treatment of alcohol problems. They were asked to address this topic under the following headings: (1) What types of alcohol problems are most common in your country? (2) What types of treatment responses are offered to these problems? (3) What are the criteria for admission to these different types of treatment? (4) Are some treatment services also offered for special population groups (e.g., adolescents, women) and if so on what basis? (5) What information is available regarding the outcome of treatment for alcohol problems in your country? (6) How are treatment services financed, and how does the cost structure impact on patients, private institutions (e.g., insurance companies), and the public purse? (7) What important issues are currently being discussed in your country with respect to the future of alcohol treatment services? The countries involved were Australia, Bulgaria, Costa Rica, Kenya, Mexico, Norway, the United Kingdom, the USSR and Zimbabwe. The United States also participated in the study but for obvious reasons was not concerned in this particular enquiry. The opinions expressed therefore come from a reasonable geographic spread of countries with a diversity of political systems and economies. There have been a number of cross-national studies of alcohol policies during the past decade, and WHO has played a major role in promoting or participating in many of them. The value of cross-national research was the subject of a publication in the annals of the New York Academy of Sciences (Babor, 1986~. This report reviewed the findings of a large number of cross-national studies and international initiatives. A major WHO study entitled The Community Response to Alcohol-Related Problems (Rootman and Moser, 1984; Ritson, 1985) was concerned with the need to provide services that were more responsive to the pattern of alcohol-related problems existing in the population. Communities within three countries (Mexico, the United Kingdom, and Zambia) were studied. The investigation consisted of a general population survey on drink An edited version of the report submitted to the IOM Committee for the Study of Treatment and Rehabilitation Services for Alcoholism and Alcohol Abuse, August, 1988. Marcus Grant is a Senior Scientist with the Division of Mental Health, World Health Organization (WHO), Geneva, Switzerland. E. Bruce Ritson is a Consultant Psychiatrist with the Department of Psychiatry, University of Edinborough, Scotland and serves as a consultant to the WHO Collaborative Study on the Identification and Treatment of Persons with Harmful Alcohol Consumption. Investigators who contributed to this review are S. W. Acuda, Nairobi, Kenya; M. Boyadjieva, Pleven, Bulgaria; C. Campillo-Serrano, Mexico City, Mexico; R. Hodgson, Cardiff, UK; N. N. Ivanets, Moscow, USSR; M. Machona, Harare, Zimbabwe; S. Montero, San Jose, Costa Rica; J. B. Saunders, Camperdown, Australia; and A. Skutle, Bergen, Norway. 550

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APPENDIX C 551 ing patterns and the problems arising from alcohol. Enquiries were also made of a wide range of different agencies who were concerned with care giving or social control. They were asked about their experience of alcohol problems among their clients and their views about the management of alcohol problems in the community. When these views were considered alongside the opinions of specialist service providers, it was clear that the majority of alcohol problems never reaches specialist attention. This finding has been shown on many previous occasions and seems to be true even in the presence of an elaborate network of treatment agencies. The WHO project also showed that many different first-echelon services devote a great deal of time to working with the consequences of intoxication or habitual excessive drinking and yet rarely attempt to focus on their clients' drinking behavior in a constructive way. These generalists, whether social workers, primary health care workers, casualty staff, or law enforcement officers, were often reluctant to become involved in this work either because they did not see it as part of their job or more often because they felt that they lacked skills in working with "problem drinkers" and regarded this as a task for "specialists." Thus, primary-level workers are encountering clients with alcohol problems often at an early stage in their drinking careers. Such workers seem to be ideally situated to intervene in a simple and nonstigmatizing way, and yet in many countries there is an obvious reluctance to take on this task. In some countries, quite elaborate specialist services exist for the more severely damaged problem drinkers, whereas in others there is no possibility of developing these services even if it were seen as desirable. The WHO European Regional Office (WHO EURO) organized a series of meetings concerned with the merits of intervention at the primary level and with the relationship between primary level and specialist treatment (WHO, 1986, 1987~. Participants came from a wide range of European countries, and among the conclusions reached was the view that, . . . in addition to major efforts aimed at the prevention of alcohol-related problems, there is an outstanding need for the recognition of incipient alcohol problems and for intervention starting at an early stage. Such tasks can be undertaken only with the collaboration of personnel in PHC [primary health care] services. Their willingness and ability to assume such functions, however, is generally impeded by their lack of training for such work and by the inadequacy of the available assessment and intervention techniques for use within the PHC setting. (WHO, 1986) Mobilizing PHC services toward the early recognition and management of alcohol problems is a widely agreed upon goal in many countries, but there are also many barriers to achieving it. The community response project referred to above is being continued in modified form within the European section of WHO. It is too early to comment on its findings, but there is good evidence of the feasibility of innovative community action that is extremely cost-effective and that removes the necessity for transfering many problem drinkers to treatment facilities that are remote and of unproven value. It is also clear that there are very evident barriers to change the reluctance of PHC workers to be involved in a task they regard as difficult and of limited effectiveness. The evidence in favor of simple intervention is accumulating, and techniques are being developed (Babor et al., 1986~. The WHO project concerned with the evaluation of simple interventions, whose participants provided much of the data that follow, has been employing an instrument that seems effective in detecting alcohol problems at an early stage and in a wide range of different cultures (Saunders and Aasland, 1987~. The project has moved on to examine in a variety of settings the potential of simple interventions for modifying damaging drinking habits. In summary, there are clear trends toward a new perspective in responding to alcohol problems, which can be found in a number of international reports and

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552 APPENDIX C collaborative studies. It should be pointed out that almost all of these reports make it clear that primary prevention should be given greatest priority. This report focuses on treatment, but this narrow focus must not obscure the fact that developments in this area must be seen as part of a broader national alcohol policy. What follows is a short review of the extent of alcohol problems in the nine countries that participated in the enquiry. This will be followed by a review of their treatment policies. Unless otherwise stated, throughout this text, quotations ascribed to particular countries have been derived from the country reports. Types of Alcohol Problems Experienced Before reviewing the extent of the problems reported, it is important to remember that these data are very susceptible to cultural variation. The following brief overviews of the most common alcohol problems encountered in five rather different countries illustrate both similarities and differences. Kenya The whole range of alcohol problems occurs in Kenya, and these problems can be classified as physical, psychological, and social problems. lithe physical problems that are frequently seen can be acute, subacute or chronic. lithe acute problems that normally present in emergency rooms include gastritis, intoxication, hypoglycemic coma, injuries and pancreatitis. The subacute and chronic problems include malnutrition, gastric ulcers and liver disease, and dementia. The psychological complications of prolonged heavy alcohol abuse generally present in mental hospitals and psychiatric clinics, and also at the casualty departments of general hospitals and police stations. By far the commonest is alcohol psychosis. This condition may include delirium tremens, alcoholic paranoia, hallucinosis, blackouts, and "mania apotu.~ A recent study has shown that 21 percent of consecutive admissions into a mental hospital in Nairobi had alcohol psychosis. The other psychological presentations, which are more often detected among outpatients, are depression (occasionally with a suicide attempt), anxiety, chronic insomnia, and other nonspecific physical complaints (e.g., poor general health, weakness). Infrequently, patients may present with one or more features of the alcohol dependence syndrome such as inability to abstain despite awareness that harm is being done and uncontrollable intoxication lasting several days. The social problems attendant upon chronic alcohol abuse are equally common though only a few come to the attention of psychiatrists. These range from domestic problems, including violence, to problems at work and economic hardships. A recent investigation into the drinking history of factory workers in Nairobi who had retired prematurely on medical grounds showed that chronic alcohol abuse seemed to be the commonest cause of retirement. A systematic study of such employees initiated by the Ministry of Labour is now in progress. Mexico Alcohol consumption has a strong impact on the health of the population in Mexico. For the last two decades, mortality rate from hepatic cirrhosis has varied from 20 to 23 per 100,000 inhabitants. These rates are among the highest in Latin America. Hepatic cirrhosis is one of the first ten causes of mortality in the population over 20 years of age in both sexes. Among males from 25 to 44 years of age, it ranks first. It has been estimated by Jellinek's formula that the rate of alcoholism in the population over 20 years

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APPENDIX C 553 of age is 5.37 per 1,000 inhabitants. Thus, the total number of alcoholics in the country is 1.7 million. Alcohol-related problems are reflected in various aspects of everyday life. The biggest proportion of these problems is of a psychosocial nature and is associated with acute intoxication. For example, 5 percent of suicides in Mexico are committed under the effects of alcohol. (In a sample of 80 autopsies, alcohol was present in the blood of 28 percent of the people that died by suicide.) It has also been calculated that on the highways in Mexico, 4 percent of the drivers are drunk. In Mexico City this rate increases to 15 percent. With relative frequency, the medical services cover problems of the acute type. Eleven percent of all the cases that were seen in the emergency services in five hospitals in Mexico City were identified as being intoxicated with alcohol, and 22 percent of the cases in similar services had positive alcohol levels. It is estimated that 28 percent of the patients in general hospitals suffer from alcohol-related pathology. During surveys for minor psychiatric disorders with self-evaluation questionnaires, it was estimated that 8 percent of the patients in family medicine services also have drinking problems. Alcohol-related problems in the legal, family, and labor areas are also prevalent. Alcohol has been associated with 19 percent of the nation's cases of child abuse. The percentage of jail sentences resulting from the effects of alcohol was 18 percent and 24 percent, in 1975 and 1981, respectively. It is calculated that alcohol is involved in most cases of work absence. Gender is the sociodemographic variable that shows the greatest differences. In Mexico, males drink much more than females. Different studies have shown that the rates of abstinence vary between 15 percent and 20 percent in men. Ten percent of men drink heavily and have problems with their consumption. The period when heavy drinking is most common is between 30 and 50 years of age; younger or older people drink less. Young drinkers, however, have many more problems than do older drinkers. Social class differences are not crucial, and in rural areas rates of drinking are higher. The rates of abstinence among females vary from 50 to 60 percent. Three percent of women consume alcohol in a problematic way. There are almost no differences among age groups or among the social classes. Females in rural areas drink slightly more than females elsewhere. The typical consumption pattern is infrequent drinking circumscribed to special occasions such as parties, celebrations, or weekends. On each occasion, however, large quantities are often ingested, and drinking may last for several hours with high degrees of resulting intoxication. Quite often, drinking takes place at the drinker's home, and females are usually excluded. Yet, in spite of the fact that drinking is not frequent, that the rate of consumption per capita is low, and that a high proportion of the population is nondrinkers, alcohol-related problems are numerous because of the way alcohol is consumed. England and Wales The average health district in England and Wales serves about 250,000 adults, and, using 1984 government data, it has been estimated that the prevalence of alcohol-related problems in such a district will be as follows: Drinking heavily: 22,000 Based on a rate of 90 adults per 1,000 drinking more than 35 units a week (men) or 20 units a week (women)

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554 APPENDW C Admit to problems: 7,500 30 adults per 1,000 admitting to problems in a household survey Known to agencies: 1,250 5 adults per 1,000 known to at least one agency to have problems associated with drinking Admitted to psychiatric hospitals: 125 0.5 adults per 1,000 admitted to psychiatric hospital units with an alcohol related diagnosis The majority of these problem drinkers will be male. A recent survey showed that more than 90 percent of women drink less than 15 units a week, and 70 percent drink less than 5 units. However, indices of harm are rising faster among women than among men. Between 1979 and 1984 in the United Kingdom, women's deaths from liver disease and cirrhosis rose by 9 percent compared with a 1 percent fall for men. There has also been a large increase in the number of women seeking alcohol counseling services. The 18-24 age group has the highest proportion of heavy drinkers (i.e., 37 percent, compared with 22 percent among the 25-35 age group). In addition, there has been a marked rise In Coca figures for teenage Drunkenness, from 1,852 in 1964 to 4,805 in 1976. Between 1950 and 1978 deaths from alcoholic cirrhosis of the liver in England and Wales increased by 61 percent. United Kingdom studies have shown that alcohol intoxication is involved in 60 percent of parasuicides, 54 percent of fire fatalities, 50 percent of homicides, 42 percent of patients admitted with serious head injuries, 30 percent of deaths through drowning, and 30 percent of all domestic accidents. It has also been estimated that, in England and Wales, alcohol intoxication is implicated in the deaths of more than 500 young people each year, which is about 10 percent of all deaths in persons under 15. It is salutary to compare the absence of media coverage of these tragedies with the extensive coverage of deaths of young people from solvent abuse (about 25 per annum). Between 1950 and 1977 the number of proven offenses of drunkenness in England and Wales increased by 100 percent. In one recent investigation it was found that alcohol usage was associated with assaults in 78 percent of cases; it was linked with breaches of the peace in 80 percent of cases and with criminal damage arrests in 88 percent of cases. Furthermore, 93 percent of people arrested between the hours of 10:00 p.m. and 2:00 a.m. were intoxicated. In the United Kingdom, a 1974 study carried out by the Transport and Road Research Laboratory showed that one in three drivers killed in road accidents had blood alcohol levels above the statutory limit. On Saturday night, this figure rose to 71 percent. Australia The comparative prevalence of various alcohol problems may be gauged from mortality data, morbidity data as judged by hospital admissions, and surveys of the general population and specific target groups. The two most common causes of alcohol-related deaths are trauma as a result of road accidents (approximately 1,600 deaths per annum) and chronic liver disease (approximately 1,000 deaths per annum). Dependence and withdrawal syndromes are common reasons for hospitalization; in New South Wales they account for 150 to 200 admissions per 100,000 population per year, compared with 20 to 30 per 100,000 for chronic liver diseases. Between 10 and 30 percent of patients admitted to general or psychiatric hospitals have an alcohol-related problem. In general, Australia

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APPENDS C 555 experiences the whole gamut of alcohol-related disorders including trauma and other acute sequelae, chronic physical and neuropsychiatric complications, dependence and withdrawal, and psychosocial problems, including industrial losses. The cost to the national economy has been estimated to exceed a A$2,500 million per annum. Union of Soviet Socialist Republics (USSR) The following brief comment from the USSR not only shows the overall extent of alcoholism but points out the enormous regional variation in patterns of problems that must be taken into account in most countries. Epidemiological research reveals that levels of alcoholism prevalence in different regions of the country differ considerably. The highest level is registered in the Russian, Ukrainian, Byelorussian, Latvian and Moldavian Soviet Socialist Republics. The lowest ones-both in the past and nowadays -are registered in the Georgian, Azerbeijan and Armenian SSRs: 7-16 times lower as compared to the average country level. But in general the contingent of alcoholics who are on the books is rather large and at present it accounts for more than 4.5 million persons and treatment of alcoholism is still one of the most urgent problems. The five descriptions given above inevitably reflect the different resources, attitudes, and preoccupations of the countries concerned, but they also reveal many similarities. The problems may be broken down into those that are medical, social, or psychological. They may be consequences of intoxication or injudicious drinking, which result, for instance, in accidents, assaults, criminal damage, or overdose, or they may be those that are the end stage of many years of habitual drinking such as alcoholic cirrhosis, delirium tremens, or "alcoholism." Treatment Responses Most of the countries had some form of specialist treatment for alcohol problems, although in some cases it was almost exclusively embedded within the general wards of a psychiatric hospital. For example, in Kenya, recognition of the extent of the problem has been coupled with the realization that, apart from a few overburdened psychiatrists, no other profession is "offering treatment seriously" and that Treatment is currently being carried out mainly either in psychiatric hospitals or general medical hospitals on either an inpatient or outpatient basis depending on the mode and severity of presentation. In either setting, treatment unfortunately stops with detoxification, usually Benzodiazepine cover, vitamin supplement and treatment of any coexisting physical illness." Epically, these institutional services are augmented by various community-based, often voluntary groups. Again quoting from the Kenya experience: Various voluntary and religious groups have also started some forms of counselling services. But their efforts have been curtailed by lack of knowledge and skills in counselling alcoholics or drug dependent persons. On many occasions they have requested psychiatrists to assist in training their personnel in this respect. Of all these voluntary groups, it is the Alcoholics Anonymous group which is most active in Kenya, especially in the Nairobi city. Both psychiatrists and other counsellors frequently refer

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556 APPENDIX C clients to the group. The AA meetings are announced daily in both national newspapers. It seems they have two daily meetings: one for the upper socio-economic group (in English) and the other for the working class (in Swahili). Finally there are various traditional healers and herbalists who claim that they cure all psychiatric illnesses including alcohol problems. Their claims however cannot be verified as they do not permit other therapists to witness or even to know their clients. The way in which services have developed in a variety of countries is probably best illustrated by the following series of discussions from the reports received. Australia A range of hospital, community-based, and private-sector treatments is available. Hospital treatment is provided for persons with trauma and acute physical sequelae, chronic physical complications (e.g., cirrhosis), and chronic neuropsychiatric disorders (e.g., Wernicke-Korsakoff syndrome). There is a shortage of long-stay facilities in some states. There have also been moves to place such patients in community hostels. Increasingly, patients who are intoxicated or in withdrawal are admitted to specially built detoxification units for alcohol dependence. Inpatient treatment is currently less favored. Many outpatient drug and alcohol services are now located in general hospitals, a development which has taken place over the past 5-7 years. Community or health clinics tend to cater to problem drinkers who have minor or major psychosocial problems. There is an emphasis on assessment and referral to drug and alcohol agencies. Many of these agencies are community based and offer counseling, behavior modification, or psychotherapy. Self-help groups are well established. They include Alcoholics Anonymous, which was introduced into Australia in 1955, Al-Anon, A1- Ateen, and Adult Children of Alcoholics. Private medical practitioners may also undertake the management of alcohol problems, although probably to a lesser extent than in other Western countries. Involvement by psychiatrists, general physicians, and others varies considerably from state to state. There is considerable interest in early intervention programs, but there are few service units offering early intervention. Norway Traditionally, the treatment of alcohol and drug problems in Norway has been organized independently from ordinary health care services. Special institutions for people with alcohol problems have existed since the beginning of the century, and specific laws regulate these activities. Originally, only alcohol problems were considered, but during the 1950s the legislation was amended to include problems related to the use of drugs. Since 1969 the Directorate for the Prevention of Alcohol and Drug Problems has been responsible for the development of treatment services for persons with alcohol problems, as well as for primary prevention efforts. The directorate reports to the Ministry of Health and Social Affairs. There has been a gradual increase in the number of institutions, and today, there are more than 70 treatment facilities. There is at least one institution for each of the 19 counties, and the total number of beds is approximately 3,000. The treatment centers vary with regard to which groups of patients they serve and which programs they offer. The treatment system is based on idea that the various groups of problem drinkers have different service needs that may range from intensive inpatient

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APPENDIX C 557 treatment programs to sheltered homes. Yet the relatively broad differentiation of institutions that has existed in the past seems to be gradually disappearing, yielding a new financial structure distinguishing between emergency institutions (e.g., detoxification centers), institutions for treatment and rehabilitation, and institutions for permanent residence. In addition, Norway appears to have an increasing number of outpatient facilities for people with alcohol and drug problems. They are usually linked to one of the inpatient treatment services and offer outpatient treatment to the general population as well as offering follow-up to some treated inpatients. England and Wales The principle of community-based, multidisciplinary teams has now been embraced by Health and Social Services within mental health generally and within alcohol services in particular. During the last 10 years there has been a steep rise in the number of community alcohol teams because they appear to be the most cost-effective way of providing the type of service outlined in the previous section. There are now 14 community alcohol teams throughout England and Wales with others being planned and negotiated. These teams are usually based in a building away from the hospital environment; most teams include community psychiatric nurses, a psychologist, a social worker, counselors, and an administrator/clerk. Some teams also have the support of a psychiatrist, usually on a consultant basis. The team is involved in consultation, education, and prevention (e.g., drinking and driving), as well as counseling and skills training. There are 64 services that fall into the category of advisory and counseling services, 20 of which are within Greater London. They are often called either councils on alcoholism or alcohol advisory services. The size of these projects varies. For example, the North East Council on Addictions employs 46 staff, but most councils employ from 2 to 6 staff. Local councils are accountable to an executive committee that usually includes representatives from Health, Social Services, and Probation. Recently, a number of councils established formal links with community alcohol teams. Another recent trend is to combine an alcohol and drug service. Local councils on alcoholism carry out a range of tasks that, to some extent, overlap with the functions of an alcohol team. The most important functions are (a) providing advice and counseling to people with drinking problems; (b) informing the public and the media about alcohol misuse; (c) providing education and training, particularly to primary care workers; (d) acting as a coordinating body on alcohol misuse within their areas; and (e) initiating and developing strategies to prevent alcohol misuse locally. There are 256 day centers that provide services primarily for people with drinking problems. They make up 10.5 percent of alcohol services and employ 340 people (12 percent of the alcohol problems work force). Of these, 141 (41.5 percent) are full-time, 127 (34 percent) are part-time and 72 (21.1 percent) are volunteers. Day services are offered mostly in inner cities and tend to fall into two types. Most are nonstatutory and provide food, shelter, and low-level support on request, dealing mainly with welfare rights, claims and accommodation problems. A few offer individual counseling, group psychotherapy, drama therapy, and relaxation groups. There are 248 alcohol agencies in England and Wales, and, of these, 81 (32.7 percent) are residential hostel projects. They provide a total of 1,487 beds and employ 499 staff (a quarter of whom are part-time) with 129 volunteers. Seventeen of these projects provide day support for a further 293 people. More than half of the projects provide 12 or fewer beds. Most projects are registered with their local authorities, 28 percent are registered housing associations, and a further 24 percent are linked with a housing association.

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558 APPENDW C Residential projects allow people to spend time in an alcohol-free environment in which they can learn to break their dependence on drinking and develop alternative ways of living. The length of stay ranges from three months to a year or more. The projects have tended to attract problem drinkers who are homeless (or without a secure home base), single, unemployed, and male. This pattern is beginning to change in some areas, however, and home-based people are coming in for shorter periods. Most residential projects are in the inner cities, although there are some in small towns. Some are linked closely to an existing community-based service; for instance, the Hastings hostel in Leicester receives its referrals through the local community alcohol team. Ideally, residential projects should be part of an integrated network of services so they can be used more flexibly. Including them in such a network, however, would entail a reexamination of their objectives, as well as a less rigid form of funding. In particular, it would involve determining whether residential alcohol services were primarily aimed at helping homeless people who have a drinking problem or helping drinkers who need a temporary home away from their normal environment. Alcohol treatment units (ATUs) are the major National Health Services treatment institutions for people with drinking problems. Set up in the 1960s, there are now 30 such units, and they provide varying services. Initially, they were supposed to provide services to an entire region, but it soon became clear that this expectation was unrealistic, and many now restrict their services to the surrounding community. Most ATUs require total abstinence from inpatients. Some use group work exclusively; others employ individual counseling. A few emphasize occupational therapy, and many encourage the involvement of Alcoholics Anonymous. ATUs are now shifting their focus from institutional psychiatry to community psychiatry and are developing many links with community agencies. Many areas plan to close their ATUs that operate as separate units within hospitals and move them into the community. Help for coping with withdrawal symptoms and the other immediate physical consequences of giving up alcohol may be provided either in a general or in a psychiatric hospital ward. Detoxification may also be linked to a period in an alcohol treatment unit. One recent development has been the growth of home detoxification in which the individual is helped to cope with withdrawal at home under the supervision of a general practitioner and a community psychiatric nurse. This procedure is best carried out with support from a close relative or friend. Many alcohol agencies find it difficult to persuade hospitals to accept individuals for detoxification, especially since the closure of many psychiatric and other types of hospitals. The largest and best known UK self-help group is Alcoholics Anonymous (AA), which has approximately 1,350 groups throughout England and Wales and 25 regional contact points. Each group is self-supporting and autonomous, although they all subscribe to the basic philosophy of AA and follow the 12 steps laid down in the AA Wig Book. AA sees itself as a "fellowship of men and women who share their experiences, strength and hope with each other so that they may solve their common problem and help others . . .. ~. . . to recover from alcoholism." The primary goals of AA members are To stay sober and help the alcoholics to achieve sobrietyn. One of the basic tenets of belief in AA is that alcoholism is a disease, for which the only cure is total abstinence. A recent innovation in the alcohol field is the development of Drinkwatchers groups. These groups are intended for people who have not yet developed serious problems of alcohol dependence but who want to do something about their present level and pattern of drinking before it gets too serious. Some people may attend only one meeting of the group. However, at that meeting, they will receive a copy of the Drinkwatchers manual, which suggests ways of cutting down, and for some people this may be all the help they need to resolve their problem.

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APPENDIX C 559 The number of private clinics that cater to people with alcohol problems has grown from 6 in 1982 to at least 15, with more on the way. Private clinics usually operate on a residential basis and offer programs lasting two or three months. Most subscribe to the "disease" model of alcoholism and have close links with Alcoholics Anonymous. Some of the recently established clinics subscribe to the Minnesota model of treatment, and several cater to people with both drug and alcohol problems. Norway and a number of other countries have emphasized the importance of a national plan and of government initiative in stimulating fresh thinking about the organization of services. Mexico, the USSR, and Zimbabwe provide further examples. Mexico Before 1982 there were a number of different institutions that dealt with health policies, and there was little coordination of their efforts. There was a lack of appropriate distribution of responsibility among the agencies, and there was also strong centralization: most of the responsibility for health measures belonged to the federal government. Since 1982 the Ministry of Health has assumed greater responsibility and has established the rules for health policies at a national level. As a result, the total population receives more legal protection owing to that fact that the right to such services has been raised to a constitutional level. The roles of each health institution are specified, and actions are now regulated by a legal framework. The general policy is harmonized and unified by the General Health Law and also by the introduction of the National Health System. One of the intents of the new system is for each state to share the responsibility of arranging policies and administrating funds. Alcohol treatment in Mexico has benefited from the above-mentioned changes. The Health Ministry considers alcohol problems to be a priority. A National Antialcoholic Council was installed in 1985 and is coordinated by the Health Ministry. It includes representatives of social, governmental, and private sectors, and its purpose is to develop preventive actions at legal, educational, and assistance levels. The National Antialocoholic Council has elaborated a national program that contemplates treatment measures as a priority issue. Unit now, only a few programs in this field are being undertaken. The changes that have occurred in the alcohol field in Mexico now permit coordination of the different institutions, as well as the sharing of responsibilities at various governmental levels: federal, state, and district. There are three basic systems of care for a population of about 75 million people. The first system assists individuals in the lower socioeconomic levels (about 24 million people), offering virtually free services. It is administered by the Ministry of Health (SSA), the National and State Family Integration System (DIF), the municipal services, state boards, the Mexican Institute of Social Security (IMSS) and city hospitals. The second system which assists a population of a higher socioeconomic level (approximately 32.8 million people), is a social security program financed by employers and employees with regular jobs. It includes the Institute of Social Security and Services for Government Employees (ISSSTE) and the IMSS for the rest of the working class. The third system embraces private institutions and practitioners and covers the higher socioeconomic levels (approximately 7 million people). It is also important to point out that, for various reasons, approximately 14 million Mexicans do not have access to health facilities. As can be seen, the Mexican government provides most of the available medical assistance programs, but in general they are crowded and insufficient to assist the whole population. ~ ~ ~ _ problems. Rather, such services are integrated with other treatment programs, most often in the form of acute detoxification centers. AS a result. there are few (specialty) treatment programs for alcolhol

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560 APPENDIX C Despite the small number of programs in this area, Mexican government health authorities and the professionals related to this field are conscious of the need to establish others because they recognize the magnitude and extension of the problems created by high rates of alcohol consumption. Alcohol problems already represent a substantial burden for the country's health services, and it is evident that, in the future, this burden will increase, mainly as a result of the pyramidal structure of the population, which is wider at the base. As was mentioned earlier, the group of greatest morbidity is between 35 to 50 years of age. In the near future, however, the larger younger population will be in this age range, and, consequently, there will be a larger number of drinkers who will require medical assistance. It is generally accepted in Mexico that alcohol-related problems should be treated by medical personnel, even though drinkers are ashamed to recognize the problem and ask for help. Priests are among the agents who are trusted by drinkers and who are often sought out for help. The personnel who work in agencies that handle alcohol-related problems (policemen, doctors, nurses), clearly understand that these problems are frequent, but they consider themselves untrained in handling alcohol problems and lack the time to deal with them. Nonetheless, they report that they would like to have more knowledge on this topic and that they would be willing to undertake special training. USSR The impact of a recent national campaign in the USSR related to alcohol problems has been substantial, not only for preventive strategies but also for treatment services. For the past two and a half years since the start of this campaign, the number of specialist doctors/narcologists has increased by 45 percent, and the number of beds in narcological departments has risen by 25 percent. In addition, while outpatient facilities have more than doubled. The following extract outlines the current organizational structure of alcohol treatment services in the USSR: In the USSR there are different organizational forms of treatment of alcoholics: outpatient, inpatient, one-halfway settings. Treatment may be voluntary and involuntary. To choose the most adequate form one should consider a number of clinico-social characteristics: severity of patient's clinical state, whether there is a desire for treatment, social behaviours, etc. A specialized narcological service organized in the USSR in 1976 is just the organizational structure in charge of treatment of alcoholics. Its basic unit is [the] narcological dispensary assigned to some definite area (city district, city, province). A dispensary structure usually includes [facilities] . of divisional psychiatrist-narcologists, narcological [facilities] for young people, narcological consulting rooms and medical attendants' narcological posts at industrial and other enterprises, room of alcohol dizziness detection by experts, anonymous treatment rooms, rooms of anti-alcohol propaganda and preventive medical aid, specialized rooms of neuropathologist, psychologists, physicians, inpatient departments (including those organized at industrial and other enterprises); organizational- methodical advisory departments, medical offices and auxiliary subunits (clinicodiagnostic laboratory, room of functional diagnosis and others). Inpatient departments may exist as a separate narcological hospital. In the departments of this type treatment is free of charge. Alongside with these

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568 APPENDIX C for admission to general or psychiatric hospitals in Kenya and Mexico. In some circumstances, the ability to pay or the possession of health insurance is an important consideration, as revealed in the following examples from Zimbabwe: In Zimbabwe everybody has the right for treatment provided the person is seen to be ill and in need of such treatment. While this is mostly so with Government institutions, it may not be so for private ones, where one gets treatment on payment. Although governmental institutions also require able patients to pay for their treatment, those without money receive free treatment. There is a further criterion for rural clinics, where feeding of patients is a problem. If such patients are to be inpatients, then somebody must accompany them, who would cook and feed them. Violent patients with alcohol related problems who are a danger to themselves or to others are ordered by law to get treatment, whether they like it or not. Such patients may be kept in secluded institutions until their situation has improved. The reply from Costa Rica illustrates the way in which criteria are deduced from physical state, degree of dependence, and social need as well as more subjective concerns such as motivation: In the case of the Unit of Detoxification which LAFA offers, the main condition is that they are not chronic nor deteriorated patients-mental patients [who] are hospitalized for the first time there and who are under intoxication levels and are not [capable] of stopping. In general hospitals, where alcoholic patients who are intoxicated are hospitalized, it is because they present medical emergencies or physical complications which can not be treated ambulatory. In case of withdrawal symptoms and mental compromise they are hospitalized at the neuropsychiatric hospital. In other community private services, the main criteria is that the patient wants to stop drinking further on they will receive rehabilitation programs. The rehabilitation centre for alcoholics where patients remain for 2-3 months is mainly for chronic alcoholics. They are first disintoxicated and later on they are submitted to the centre's program of rehabilitation through occupational therapy and a multi-disciplinary approach. In Norway the degree of dependence and damage experienced by the person is taken as a guide to the kind of treatment he or she is offered: The treatment programme usually offered to alcohol clients [is] a combination of a medical and psychological examination followed by an individually tailored treatment and/or group therapy. The majority of treatment centres allow the clients to choose [their] treatment goal-abstinence [or] controlled drinking.

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APPENDIX C 569 During the last couple of years some new treatment programmes have developed in order to meet uncovered client needs. These have for instance been secondary prevention programmes recruiting people with a stable living situation revealing mild to moderate dependence symptoms. At first these programmes were part of research programmes, but were later integrated into the services of some of the out-patient units. These secondary prevention studies have revealed relatively positive outcomes, and have to some extent contributed to a more positive attitude among health and social professionals towards persons with alcohol problems. Where they exist, the community alcohol teams described in England and Wales take responsibility for placing clients appropriately among the agencies available in the area. Considering the multiplicity of treatment approaches available in some communities, it is surprising that so little progress has been made in tailoring the programs that are offered to the needs of the patients. Some centers appear to use motivation and social stability as criteria for particular types of treatment; in a few centers, the degree of dependence (based on symptom measures and questionnaire assessment) is used as a guide to allocate clients to controlled drinking programs. In general, attempts at matching continue to be based on very subjective or crude assessments. Treatment Services for Special Populations Most countries recognize the special needs of certain groups, particularly women, but very few are in a position to provide differentiated services of that kind. Norway is an exception: There are special programmes for women and families. The traditional treatment programmes have primarily been a service for the men not paying enough attention to the needs of the women. Many women developed alcohol problems due to a heavy burden, having a job and being [mainly] responsible for raising children. The stigmatizing effect is much larger for female problem drinkers than it is for males. As a result women feel more guilt about their drinking and prefer less stigmatizing strategies to ~cope" with their drinking problem. Extensive use of psychopharmaca and psychiatric treatment [has] been a more common treatment approach among female problem drinkers compared to men drinkers. The special treatment programmes for women within some of the Norwegian treatment centres are efforts at meeting their particular needs. Some centers stress their growing concern about alcohol problems among adolescents and the way in which such problems are often linked to other forms of drug abuse. The Australian comment is particularly apposite: Treatment services specifically for adolescents barely exist and there is considerable debate about the most effective type of service. Formal detoxification is infrequently required for persons under 18 years. A more

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570 APPENDW C important requirement is accommodation for adolescents who have become estranged from their families. Polydrug and alcohol use is the predominant pattern, rather than abuse of alcohol exclusively. There is considerable emphasis on presentation of alcohol intoxication among adolescents in national media campaigns and community drug education campaigns. In their reports, Costa Rica and Australia both describe several facilities designed specifically for women. Costa Rica also provides a counseling service for the children of alcoholics and in common with some other countries organizes support groups for the relatives of problem drinkers. This function is also provided in many areas by self-help from Al-Anon and Al-Ateen. A voluntary organization in England and Wales recently prepared a report on treatment services and their consideration of treatment provision for specialist groups is summarized below. Wonton All the advisory and counselling agencies offer their services equally to women and men, but most residential services are for men only. Only three agencies offer a specific service for women problem drinkers; one of these is privately run; two of the three are residential. 67 agencies (23 percent of the total) advertise women-only groups. Women often prefer female counsellors and groups. ~D r Younger People 109 agencies (38 percent) operate a minimum age criterion. 61 of these are residential. 85 (29 percent) set minimum age of 18 or above. 56 percent of all residential agencies exclude people under 18. 19 agencies (6.5 percent) advertise young drinkers' groups. There are a small but growing number of projects aimed at young people and seeking to influence their drinking behaviour through non-alcohol cocktail clubs, temperance youth clubs, programmer for young drunken drivers and some group work by probation officers. Black and Ethnic Minorities The 6.6 percent of the population of England and Wales who belong to black and minority ethnic communities have two (0.7 percent of the total) agencies advertising a specifically appropriate response, both of them in London. The common experience is that referrals (including self referrals) from black and ethnic minority communities are rare, as are alcohol agencies which have any links with services which help those communities. It is possible that most people from black and minority ethnic communities experiencing alcohol-related problems are being received into general and acute mental health care as a result of disturbed behaviour and the relevance of the alcohol relationship is ignored. Lesbian and Gay People There is no specialist provision for lesbian and gay problem drinkers outside London. In London there are three AA groups which, although open, welcome lesbian and gay people: The Women's Alcohol Centre runs a group for lesbian and gay people with London Friend, Accept and the Alcohol Counselling Service based at Brixton. Services for lesbian and gay communities appear to depend on the presence of openly lesbian and gay workers. Homeless The overwhelming majority of agencies, including residential, offer a service to homeless people, three of these are Alcohol Advisory

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APPENDIX C 571 Services. There is a range of specialist services for single homeless people, some operated within the alcohol field, and many run by a variety of statutory and voluntary agencies. They include day centres, drop-in services and various housing projects. Many residential projects within the alcohol sector cater for single homeless people with drinking problems. Relatives, Friends awl Children of People with Drinking Problems The only organization specifically set up for relatives and friends of people with drinking problems is Al-Anon. It has around 750 groups in the UK and Eire. It aims to bring partners and relatives together to provide mutual support and to share their common problems. However, it does not purport to teach any particular skills for coping with their drinking partners. Most counselling services encourage relatives and friends to attend either on their own or with the person who has the drink problem. However, their statistics would suggest that not many of the former attend. Al-Ateen is the only organization specifically for children. Al-Ateen has around 150 groups in the UK and Eire. Most other services have little, if any, contact with children. Many studies have suggested that the treatment of problem drinking is more effective if family members can be involved. However, most services in England and Wales are organized in a way that concentrates on the drinker and not on families. Contacting the children of problem drinkers is difficult. One strategy is to develop links with the childcare organization. Information Regarding the Outcome of Treatment Services Very few countries reported outcome evaluation studies, although several had changed their treatment priorities in response to research conducted elsewhere (e.g., the evaluation reviews of Emrick [1974] and Miller and Hester [19863~. The work of Edwards and his team (1977) seems to have been a particularly influential approach. In addition, Norway has recently completed studies on the benefits of early intervention. Few reports of systematic monitoring were received, however. Costa Rica quoted a follow-up of 3,000 men treated in a rehabilitation center: the researcher found that relapse was particularly common among younger patients (Miguez, 1983~. Indeed, the move toward simpler interventions for alcohol problems, given at an early stage and often located in primary-level agencies, has been supported by a number of reports (Kristenson [1983] in Sweden; Chick et al. [1985] and Heather et al. [1987] both from Scotland; and Elvy et al. fl988] from New Zealand). Thus, relatively few countries have conducted evaluation studies and, as the review by Miller and Hester (1986) points out, even fewer have been sufficiently well designed to draw reliable conclusions. Nonetheless, those with convincing methodologies do seem to have had some effect on decisions about the patterns of services in many countries and are quoted in support of the move toward simpler and more accessible intervention. The current WHO project studying the effectiveness of simple intervention should soon add a significant new dimension to this evidence. ~, . . . .

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572 APPENDW C How Are Treatment Services Financed? Very little appears to be known in the various countries about the costs of treatment for alcohol problems. Kenya described a typical dilemma: Virtually nothing is known about the cost of treatment for alcohol problems in the country. Many patients are admitted, treated and discharged without the doctors being aware that the cause of the illness was alcohol. But even in cases where an accurate diagnosis is made, the clinicians are reluctant to enter a diagnosis of alcohol dependence because of stigma and the implication of such diagnosis on the patient's employment and future. The Kenya Government continues to provide free medical services to all its citizens including in-patient treatment in government institutions. Consequently all government health facilities are chronically congested and usually short of essential supplies such as drugs and laboratory materials. Health personnel at government hospitals or health centres usually have no more than five minutes per patient. Consequently disorders that usually require a bit more probing into for an accurate diagnosis, such as alcohol dependence are largely missed. For people who want to avoid the over-crowding in government hospitals or clinics and employees in the private sector, there are numerous private hospitals. Usually their health insurance policies cover all medical treatment including alcohol dependence, but the diagnosis of "alcoholism" is hardly ever entered in the case notes or on the sick sheet. Even in these settings the cost of treatment for alcohol problems remain unknown. Many countries have a balance between services that are free to the user, those that must be paid for, and it is often difficult to cost these services. Fee-for-service and insurance-based services are costed with more clarity, but very few useful data were forthcoming. Two estimates of the cost to society of alcohol problems were received from England and Wales and Australia, but they do not address the issue of the cost- effectiveness or cost-benefit of special treatments. Consequently, the question of treatment costs of alcohol problems appears to be a much underresearched area. The paragraphs below briefly discuss the England/Wales and Australia estimates. England and Wales A recent attempt to quantify the cost to society of alcohol problems in the United Kingdom concluded that a low estimate of the social cost of alcohol use (using 1983 prices) is 1,614 million pounds. This figure includes costs to industry, costs to the National Health Service, and the social costs of drink-related offenses. It excludes the cost to society of family stress and the burden placed on probation and social services. Days lost from work because of alcohol-induced sickness are estimated at 8 million to 15 million days per year in the United Kingdom and 20 percent of male admissions to a general medical ward are also estimated to be related to alcohol use. Australia The costs of excessive alcohol consumption to the individual, his or her family members, the local community, and society as a whole are extremely difficult to quantify,

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APPENDS C 573 either in human or financial terms. An econometric analysis undertaken by federal government economists concluded that the financial cost in 1980 was at least $2,500 million, constituting $454 million from health care, $501 million from welfare payments, $454 million from the costs of emergency services because of road accidents, and $898 million in losses to industry because of absenteeism, accidents, and reduced efficiency. The Future of Alcohol Treatment Services Almost all of the countries had or were about to formulate plans for the future of their treatment services. As already described, some countries (e.g., Mexico, the USSR) found that a central plan had proved a help to the development and status of treatment services. Prevention of alcohol problems through reduction in per capita consumption by controlling availability has been a major theme in recent national resolutions in Bulgaria and the USSR. Australia has a national health policy on alcohol. The overall objective of the policy is "minimization of the harm associated with the use of alcohol." The policy comprises six components that are regarded as interdependent: (1) controls; (2) education; (3) treatment; (4) the non-governmental sector; (5) research; and (6) administrative arrangements. Essential to that policy is a clearly defined structure for communication and administrative purposes that would encompass national, state, regional and local government areas as well as the voluntary sector. The policy also calls for the formation of a specific subcommittee on alcohol to report to the Ministerial Council on Drug Strategy. In England and Wales a ministerial group, the Wakeham Committee, has been created to promote preventive and treatment policies. As already mentioned in relation to Zimbabwe, several countries now recognize the importance of an intersectoral approach to planning alcohol policies. It is also important that such policies are given ministerial backing and can establish a proper means of monitoring developments including costing and effectiveness. Turning to more detailed plans regarding future trends in service delivery, there is an evident preference among the countries for the development of community-based projects and, as mentioned, the promotion of interventions at the primary level. In some countries this policy stems from the realization that very little treatment exists at present and that the creation of a costly specialized service would be totally inappropriate. The development will require new training initiatives, as explained in the following report from Kenya: It is important to reiterate that the existence of alcohol problems in the country has been recognized although accurate or actual figures are still lacking. The question now being asked more often is what should be done to curtail the problem. Two main approaches are being debated. There are those advocating preventive measures and those demanding the creation of treatment facilities and the production of manpower to man the facilities. Recent attempts at prevention by suppression of production, distribution and consumption of traditional alcoholic beverages have not made any impact on consumption of illicit alcoholic beverages. Consequently there have been repeated calls for the training not only of health personnel but other professionals as well to enable them to recognize and deal with al

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574 APPENDS C cohol problems wherever they may present. Most training curricula and syllabus for health personnel now include something on alcohol and other drugs. Kenya has recently initiated pilot primary health care projects in at least three districts in the country. The future plan is to integrate alcohol and drug problems into the system so that alcohol problems can be treated as a primary health care problem. The curriculum for the training of primary health care workers is being finalized and it has a strong section on alcohol problems. Costa Rica envisages a greater emphasis on community workers (promotores) facilitating the development of alternative activities, providing education, and possibly acting as change agents to help those who are beginning to drink in a damaging way. Costa Rica is also planning to study the prevalence of alcohol problems in casualty departments and to use the data obtained as a stimulus to more widespread recognition and treatment of alcohol problems in general hospitals. The USSR regards its research into classification as leading to better matching of patients with treatment approaches: A rise of efficacy of alcoholic therapy in the near future can be achieved on the basis of deep knowledge of the disease pathogenesis and ever growing differentiation of therapeutic activities with consideration of the disease clinical picture peculiarities, premorbid structure of [the] patient's character and [the] influence of [the] micro-environment. Thus, it is possible to mark out several peculiarities of treatment of alcoholics in the USSR. In the first place, alcohol patients are treated by special narcological services, organized according to territorial principles. Secondly therapy is conducted in accordance with results of the alcoholism pathogenesis study. Thirdly psychotropic agents, applied differentially, depending on clinical peculiarities of the disease play an important role in the therapy of alcohol patients. The USSR is unusual among the countries considered, in that it gives a great deal of attention to pharmacological and physical treatments, which received little mention by other countries except with respect to medical detoxification. Some countries (e.g., Australia, England and Wales, Norway) are making a conscious effort to shift their existing services toward briefer community-based treatment. For example, in Norway it seems that this process is quite advanced: The county responsibility for the planning and administration of the treatment services will probably lead to a reduction of the number of inpatient treatment services, and a corresponding increase in the outpatient treatment capacity. Hopefully, the new "trend" within the alcohol treatment area will continue, characterized by a more differentiated treatment system, meeting various client needs. The ultimate goal must be to integrate some of the public responsibilities for these problems as fully as possible with the general health and social services. Only then will it be possible to undertake realistic secondary preventive measures and interventions. There have been relatively few treatment evaluation studies or prospective studies in Norway. It will be valuable to reinforce the efforts at doing treatment evaluation studies, and to reduce the gap

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APPENDIX C 575 between research and clinical practice: how to implement our new knowledge about treatment programmes in the most cost-effective way. There are many challenges to be met in the future. The increased competence and level of knowledge among the health and social professionals in Norway have created a new optimism and positive attitudes towards clients with alcohol problems. This new optimism is a good basis for carrying on with the positive development we have seen the last couple of years. In England and Wales changes of this kind are also occurring. The following issues and problems were preoccupying those concerned with alcohol services: Joint working and joint planning: Most services involve health, social services and voluntary organizations. There is a great deal of debate about how to work together and plan together. Joint planning groups are usually given responsibility for both mental health and alcohol services and these groups are being given more power. A survey carried out in 1985 showed that only 18 percent of District Health Authorities had specific planning teams on alcohol and/or drug abuse. Social services: Most social services departments give very low priority to alcohol-related problems in spite of the evidence that many of their clients experience such problems. Probation: The response from the probation service depends upon the enthusiasm of local teams rather than central policy but there is an increasing interest within the National Association of Probation Officers. Changes in the management of the National Health Service are placing much more emphasis on information and service evaluation. 6. 8. There is a trend towards minimal interventions especially within District General Hospitals. Services for drug abusers have been developing at quite a pace as a result of government commitment. No official government backing has yet been given to the development of alcohol services. Should alcohol treatment units be closed and the resources used to develop or consolidate community services? Should the alcohol treatment service be managed by a particular profession?

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576 comments: APPENDIX C Conclusion This selective review of treatment trends points to the following conclusions and In most countries, alcohol-related disabilities are viewed as a major and costly problem with diverse manifestations. Alcohol problems are now seen as a much broader concept than "alcoholism" or alcohol dependence, although this changed perspective is not always reflected in the organization of treatment services. There is a trend toward the early recognition of hazardous drinking patterns and toward responding with simple interventions at this early stage. Low-cost interventions delivered at the primary level seem to be as beneficial as many more intensive treatments, but additional properly designed evaluation studies are required for treatments of all kinds including self-help groups. Very few programs have been properly evaluated from a cost-effective or cost-benefit viewpoint. Effective categorization of patients' needs and the matching of patients with programs remain underdeveloped and underresearched. The balance between specialist and nonspecialist services needs careful consideration as do the needs of both during a time of transition toward more community-based services. Some countries are examining the potential role of new kinds of change agents, such as promotores, pharmacists, or even the drinker's own family. Detoxification in the community or in the patient's own home is commonplace in some areas. The trend toward community management is placing new demands on primary-level workers who often feel ill equipped for this task. Their training needs require urgent consideration. National alcohol policies do seem to have provided a stimulus to new developments in many countries. The treatment component of such plans needs to be integrated within a broader preventive strategy and entails ministerial support and intersectoral collaboration. In several countries all forms of substance abuse are considered together, both in terms of planning and of service delivery.

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APPENDS C 577 The enquiry produced disappointingly little information about the various strategies for funding services and their implications for cost and quality. This area needs further research. In some countries there is a tendency to continue with established programs in an uncritical way and refuse to be influenced by research findings from other centers. Improved communication between and within countries would facilitate innovation, but it is also important to recognize the barriers to change and to provide support to services while they are experiencing the change process. REFERENCES Babor, T. F., ed. 1986. Alcohol and culture. Annals of the New York Academy of Sciences 472:1-239. Babor, T. F., E. B. Ritson, and R. J. Hodgson. 1986. Alcohol-related problems in the primary health care setting: A review of early intervention strategies. British Journal of Addiction 81:2346. Chick, J., G. Lloyd, and E. Crombie. 1985. Counselling problem drinkers in medical wards: A controlled study. British Medical Journal 290:965-967. Edwards, G., J. Orford, S. Egert, S. Guthrie, A. Hawker, C. Hensman, M. Micheson, E. Oppenheimer, and C. Taylor. 1977. Alcoholism: A controlled trial of "treatment" and advice. Journal of Studies on Alcohol 38:1004- 1031. Elvy, G. A., J. E. Wells, and K A. Baud. 1988. Attempted referral as intervention for problem drinking in the general hospital. British Journal of Addiction 83:83-89. Emrick, C. D. 1974. A review of psychologically oriented treatments of alcoholism. Quarterly Journal of Studies on Alcohol 35:523-549. Heather, N., P. D. Campion, R. G. Neville, and D. McCabe. 1987. Evaluation of a controlled drinking minimal intervention for problem drinkers in general practice. Journal of the Royal College of General Practitioners 37:358-363. Kristenson, H. 1983. Studies on Alcohol-related Disabilities in Medical Intervention Programmes in Middle-aged Males. Skurup, Sweden: Lindbergs Blankett. Miller, W. R., and R. K Hester. 1986. The effectiveness of alcoholism treatment: What research reveals. Pp.121- 174 in Treating Addictive Behaviours: Processes of Change, W. R. Miller and N. Heather, eds. New York: Plenum Press. Miguez, L. 1983. El paciente aloholico en Costa Rica: Caracteristicas y resultados. Acta Psiquiat. Psicoliga America Latina 29:7-20. Ritson, E. B. 1985. Community Response to Alcohol-Related Problems. Geneva: World Health Organization. Rootman, I., and J. Moser. 1984. Community Response to Alcohol-related Problems. Washington, D.C.: U.S. Department of Health and Human Senaces. Saunders, J., and O. G. Aasland. 1987. WHO Collaborative Project on Identification and Treatment of Persons with Harmful Alcohol Consumption. Report on Phase I: Development of Screening Instrument. Geneva: World Health Organization. World Health Organization (WHO). 1984. Management of Alcohol-related Problems in General Practice. Geneva: World Health Organization.

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578 APPENDIX C World Health Organization (WHO). 1986. Treatment and Rehabilitation Programs in Alcohol Abuse: Report of a Meeting in Helsinki, November 1985. Copenhagen: WHO, Regional Office for Europe. World Health Organization (WHO). 1987. The Respective Roles of Primary Health Care and Specialized Services: The Development and Implementation of Programs for Problem Drinkers. Report of a Meeting in Oslo, August 1986. Copenhagen: WHO, Regional Office for Europe.