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10 EARLY IDENTIFICATION AND TREATMENT Since 1980, increased attention has been given to the identification and treatment of individuals early in their development of alcohol problems. Indeed, people who are unlikely to meet the diagnostic criteria for alcohol dependence actually experience the largest proportion of society's alcohol problems (Moore and Gerstein, 1981~. Like many other health problems, alcohol problems may be treated more easily and successfully if they are detected early. ~ , . ~ one growth or employee assistance programs, student assistance programs, and health maintenance organizations has increased access to populations within which early identification and intervention are feasible. This identification effort represents an overlap of "treatment" with Secondary prevention" of alcohol problems. To implement a public health approach to the secondary prevention of alcohol-related problems, programs are now under way in several countries to link a new generation of screening technologies to low-cost early intervention strategies (Babor, Ritson, and Hodgson, 1986~. Part of the impetus for these programs comes from a broader public health concern with the relationship between life-style-related behavioral risk factors and disease prevalence (IOM, 1982~. Because life-style risk factors such as heavy or intensive drinking are often amenable to behavioral interventions, a number of innovative clinical trials, demonstration projects, and early intervention programs have been initiated. An underlying assumption of such efforts is that regular drinking and frequent alcohol intoxication increase substantially the risk of social, medical, and psychological problems (Babor, Kranzler, and Lauerman, 1987~. Promising research opportunities in this domain are noted as questions to be investigated. CONTROLLED TRIALS AND PROGRAM EVALUATIONS r ~-o---o During the 1970s there were a number of research reports evaluating the effectiveness of behavioral treatments for problem drinkers who were recruited from the community rather than from traditional treatment settings (Miller, 1983~. In general, the early studies of less dependent problem drinkers were encouraging, with success rates at the one-year follow-up point averaging between 60 and 70 percent (Miller and Hester, 1980~. The broad-spectrum treatment methods used in some of these early studies, however, were time-consuming, sometimes requiring as much as 45 hours per client. Studies reported in the 1980s have tended to employ less time-consuming approaches that can be grouped under the heading of behavioral self-control training (see Chapter 9~. Such an approach typically includes specific behavioral goal setting, self-monitoring, modulation of the rate of consumption, functional analysis of drinking behavior, self-reinforcement training, and the learning of alternative behavioral competencies to substitute for previous functions of drinking (Miller and Munoz, 1982~. , , One unexpected finding that emerged from the research of Miller and his colleagues was that a self-help manual may be as effective as self-control training provided by a therapist (Miller and Taylor, 1980; Miller, Taylor, and West, 1980; Miller, Gribskov, and Mortell, 1981~. Subsequently, several research teams have systematically investigated the effectiveness of minimal treatment interventions using self-help manuals, simple advice, and -215

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brief time-limited counseling (Babor, Ritson, and Hodgson, 1986~. The effectiveness of manual-based self-help approaches has been supported in several recent controlled trials (Buck and Miller, 1981; Heather, 1986; Heather et al., 1986~. These findings suggest that low-cost interventions based on a manual or brief counseling may be appropriate and effective as a first attempt to intervene with the large number of people who drink heavily but show little or no dependence on alcohol. The results of several other studies support this conclusion. Kristenson and his colleagues in Malmo, Sweden, studied a group of 529 middle-aged men who had been identified as at-risk drinkers during a general community-wide health screening project (Kristenson, Trell, and Hood, 1982; Kristenson et al., 1983~. Men with an elevated liver enzyme (gamma-glutamyl transpeptidase, or GGT) were randomly allocated either to a brief counseling group or to a control group. Although the GOT scores of both groups decreased significantly over the sex-year follow-up period, the group given the brief intervention showed greater reductions in absenteeism, sick days, and days hospitalized. A related Scottish study was conducted at the Royal Edinburgh Infirmary to assess the impact of brief counseling and a self-help manual on socially stable problem drinkers who had been identified in a general hospital (Chick, Lloyd, and Crombie, 1985~. Screening was conducted by a trained nurse using a 10-minute interview covering drinking habits, medical history, and social background. Although both the counseled and the control group reported significantly less alcohol consumption at the one-year follow-up point, the group that was given a single brief intervention showed fewer alcohol-related problems, greater reductions in GOT values, and better performance on a global outcome measure. Elvy and colleagues (1988) similarly reported a significant impact of a brief referral intervention with alcohol-impaired patients treated on orthopedic and surgical wards. - . ~.. . . . Perhaps the most ambitious program of early intervention with heavy drinkers was initiated in France as part of a national policy to deal with alcohol problems in specialized outpatient clinics rather than in primary care settings and hospitals. Beginning in 1970, the French Health Ministry established a system of outpatient clinics as part of a national program to prevent alcohol problems. These clinics respond to the needs of habitual excessive drinkers who do not have serious psychological problems (LeGo, 1977~. More them 140 Centers of Nutritional Hygiene have now been established, reaching every major city in France. Although a randomized clinical trial has not been conducted, two critical reviews (Babor et al., 1983; Chick, 1984) concur that this program merits careful attention because of its low cost (relative to inpatient treatment), widespread accessibility, and apparent effectiveness in reaching large numbers of problem drinkers. BRIEF INTERVENTIONS AND TREATMENT RESEARCH Current data indicate that brief interventions are superior to no treatment or to waiting list status. lithe assumption is made that some proportion of those on a waiting list would respond favorably to a brief intervention and not require treatment. leaving a subpopulation that was more in need of therapeutic assistance. The apparent effectiveness of certain brief interventions also suggests a more feasible alternative to no-treatment controls in experimental designs. Justification for the use of an alcoholism treatment method could be based on its ability to exceed the effectiveness of a well-implemented brief intervention. The use of research-supported brief intervention comparison groups can avert some of the ethical concerns regarding refusal of treatment to control groups. -216

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Alternatively, a brief intervention can be used to remove from a clinical population those individuals who respond to simpler strategies. Such a design provides a reasonable analogue to a pr~ure sometimes used in drug research, whereby Placebo responders are first removed from a population before the specific effect of a drug is tested. Although a true placebo therapy is difficult if not impossible to achieve, those individuals who respond to brief intervention can be successfully treated and then removed from the sample, leaving a subpopulation that is not responsive to minimal intervention. Such a subpopulation may be particularly useful in evaluating the true specific impact of particular treatment interventions. A variety of brief intervention strategies have emerged in recent efforts to encourage behavior change in at-risk drinkers (Hodgson and Miller, 1982; Miller and Munoz, 1982; Skinner and Holt, 1983; Miller, 1985; Babor, Ritson, and Hodgson, 1986; Berg and Skutle, 1986; Heather, 1986; Heather, Whitton, and Robertson, 1986~. As evaluation research and program planning become more sophisticated, it is important to develop a more systematic understanding of the common processes that underlie effective brief interventions. It appears at present that the more promising approaches use a combination of intervention strategies that address various aspects of problems and resistance (Miller, 1985; Miller and Sanchez, in press). The following questions represent opportunities for research on brief interventions: What brief intervention procedures effectively reduce the probability and severity of future alcohol abuse? How much reduction in drinking and related problems can be accomplished through brief interventions? How do brief intervention procedures compare, in absolute impact, with more intensive treatment alternatives? What kinds of drinkers respond best to brief intervention programs? Do persons who fail to respond to brief intervention show more receptiveness to further treatment? Do they achieve more favorable outcomes when treated subsequently with more intensive approaches? Are there identifiable pretreatment characteristics (e.g., family history, sociopathology, depression) that are prognostic of poor response to brief interventions and that justify more intensive initial treatment? What are the key ingredients of an effective brief intervention strategy? Are there unique contributions of screening, assessment, feedback, and advice elements of brief intervention programs? RESEARCH ON INTERVENTIONS WITH PREGNANT WOMEN Interest in brief and early intervention has also increased because of concerns regarding the effects of alcohol on the fetus when pregnant women drink (see the discussion of this problem in Chapter 2~. Research on the prevention of fetal alcohol effects has developed during the last 15 years following the reports of Jones and Smith (1973) and Jones and colleagues (1973~. These authors reported on eight children born to alcoholic mothers, all of whom displayed a similar pattern of craniofacial, limb, and cardiovascular defects that were associated with growth deficiency and developmental delay. They called this constellation of abnormalities the fetal alcohol syndrome (FAS). In 1980, minimal criteria were established for the diagnosis of FAS (Rosett and Weiner, 1985~. -217

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Prevention of FAS and of less serious but possibly significant fetal effects of maternal drinking has focused heavily on reductions in alcohol intake by pregnant women. Prevention has taken the form of educational activities, social support, and efforts to identify problem drinkers among pregnant women. As with the findings from studies of early intervention with problem drinkers, there are some grounds for optimism regarding the prevention of adverse fetal alcohol effects. live programs have reported successful impacts--one at Boston City Hospital (Rosett et al., 1983) and tl~e other in Sweden (Larsson, 1983~. Each program systematically evaluated all pregnant women who attended the prenatal clinic, checking for excessive alcohol intake by means of interviews and questionnaires. The women in the study by Rosett and colleagues (1983) were told that they had a better chance of having a healthy baby if they abstained from alcohol use during pregnancy. Supportive therapy with a psychiatrist or counselor was provided one to four times a month in conjunction with prenatal visits. Treatment stressed a positive approach to reducing heavy drinking while avoiding the induction of guilt. About two-thirds of the women who participated in at least three sessions appeared to have stopped heavy drinking before the third trimester. The five cases of FAS diagnosed in this population were all associated with women who continued to drink heavily. Larsson (1983) implemented a similar program with 464 women at four maternal health centers in Stockholm. Alcohol abuse was identified in 4 percent of these women, according to criteria established by Rosett and coworkers (1983~. Rosett's counseling intervention was offered to all women (not only those identified as problem drinkers) who attended the centers. Reduction in alcohol use was observed for all women classified as excessive drinkers, and for 78 percent of those diagnosed as showing alcohol abuse. More infants from mothers classified as excessive drinkers or abusers (33 percent) were placed in the intensive care nursery than were infants born to mothers who were social drinkers (12 percent). The two babies born to mothers who continued to drink heavily exhibited significant growth retardation, and one was diagnosed as having FAS. The following questions represent opportunities for research on intervention to prevent fetal~alcohol effects: women? What interventions are effective in suppressing drinking behavior among pregnant Do drinking-focused interventions with pregnant women yield significant reductions in risk for their infants? Is it warranted and effective to include family members or significant others in interventions designed to reduce alcohol-related fetal risk? RESEARCH ON NONABSTINENCE OUTCOMES AND GOALS lithe development of the prevention and early intervention efforts discussed in this chapter implies that the reduction of alcohol consumption to low-risk levels is a worthwhile goal within certain contexts and populations. Achieving this goal necessitates a more careful examination of nonabstinence outcomes and goals in addressing alcohol problems. The occurrence of moderate and problem-free drinking outcomes following treatment is a complex, emotionally charged, and highly controversial issue within the alcohol treatment -218

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community (Miller, 1983~. Total abstinence from alcohol and other drugs of abuse has been the consensus goal of most treatment personnel. Nevertheless, it has become normative in the 1980s for outcome studies to report alcohol consumption and its sequelae among individuals who continue to drink after treatment. A majority of studies likewise now employs such data to classify various proportions of nonabstinent outcomes as Improved, Controlled, Moderate, or Symptomatic." An important research development in the 1980s has been the emergence of new data regarding the long-term stability of nonabstinent outcomes. Many of the studies relevant to this issue are epidemiological or natural history studies rather than treatment outcome studies. Helzer and colleagues (1985), for example, evaluated 5- to 7-year outcomes among alcoholics who received unspecified treatment at medical and psychiatric facilities. They reported that 15 percent were totally abstinent for at least the 3 years prior to the interview, 1.6 percent sustained moderate drinking for that period, 4.2 percent were mostly abstinent with occasional moderate alcohol consumption, 12 percent were drinking heavily but without evidence of problems, and 66 percent continued heavy drinking with alcohol-related problems. A 15- to 32-year prospective study (Nordstrom and Berglund, 1987) reported that, among 55 alcoholics evidencing good social adjustment (by Swedish public health records), 11 (20 percent) were abstainers, 21 (38 percent) were drinking without problems, and 23 (40 percent) showed continuing evidence of alcohol abuse. Alford (1980) studied 56 (of 68) alcoholics who completed inpatient treatment based on Alcoholics Anonymous and were discharged with staff approval. At the 2-year follow-up point, 15 percent were reported to have sustained moderate drinking for the previous year, and 51 percent were reported to have been Essentially abstinent" (no more than two slips) during the same period. Two older reports of moderation outcomes were subjected to independent retrospective follow-ups at 10 years (Pendery, Maltzman, and West, 1982) and 29 to 34 years (Edwards, 1985~. Both provided evidence that questioned the stability of controlled drinking outcomes in the cases studied. New data likewise have appeared regarding long-term outcomes following treatments with a goal of moderation. Research teams have reported long-range outcome data for behavioral self-control training programs after two years (Miller and Baca, 1983; Sanchez-Craig et al., 1984), five to six years (Foy, Nunn, and Rychtarik, 1984), and five to eight years (Miller, Leckman, and Tinkcom, 1988~. These studies reported that between 10 and 37 percent of individuals who were treated in a program with a goal of moderation sustained moderate drinking at long-term follow-up intervals. All of the controlled studies thus far in which problem drinkers have been allocated at random to abstinence versus moderation goal conditions have reported no differences in outcome based on the assigned goal (Sanchez-Craig, 1980; Stimmel et al., 1983; Sanchez-Craig et al., 1984; Orford and Keddie, 1986b; Graber and Miller, 1988~. The verification of self-reports of moderation is a concern that has been addressed thus far through the use of collateral reports, serum chemistries, and neuropsychological assessment (e.g., Babor, Kranzler and Lauerman, 1989~. More aggressive verification procedures (e.g., daily breath or urine testing) have not been used in studies to document either moderation or abstinence goals. In some outcome studies, treated individuals who showed stable abstinence and those who evidenced stable, problem-free drinking outcomes have constituted groups of roughly equal size (Booth, Dale, and Ansari, 1984; Helzer et al., 1985; Rychtarik et al., 1987~; in other studies, however, either abstainers (Taylor et al., 1985; Chapman and Huygens, 1988; Miller, Leckman, and Tinkcom, 1988) or moderate drinkers (Bernadou et al., 1981, cited by Babor -219

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et al., 1983; Gottheil et al., 1982; Nordstrom and Berglund, 1987) have been more numerous. In any event, the assessment of a full spectrum of alcohol use outcomes following treatment (from abstinence through moderation to excessive drinking) is now clearly accepted in practice as an important element of alcoholism treatment evaluation (Gottheil et al., 1982~. With the recognition that some individuals do sustain moderate and problem-free drinking after treatment, another important question has been the focus of a number of studies: What differentiates these people either from those who sustain abstinence or from those who remain unremitted? This question has been addressed within programs that emphasize a goal of abstinence (Finney and Moos, 1981; Polich, Armor, and Braiker, 1981; Edwards et al., 1983) and in treatment programs with a goal of moderation (Maisto, Sobell, and Sobell, 1980; Miller and Baca, 1983; Miller, Leckman, and Tinkcom, 1988~. Although findings have not been wholly consistent (Elal-Lawrence, Slade, and Dewey, 1987a,b), U.S. studies generally indicate stable moderation to be most likely for those with less severe alcohol problems and dependence, whereas those with more severe problems are most likely to suaver in abstinence. Several European studies, however, have reported no relationship between the severity of dependence and different outcome patterns (Orford and Keddie, 1986a,b; Nordstrom and Berglund, 1987~. Peele (1987) has speculated that this discrepancy may be attributable to cross-cultural differences in beliefs about alcoholism. Two studies (Booth, Dale, and Ansari, 1984; Miller, Leckman, and Tinkcom, 1988) reported individual goal preference to be predictive of outcome (abstinence versus moderation). Other investigators have pointed to a relationship between outcome type and the individual's beliefs about alcoholism (Pfrang and Schenk, 1985; Orford and Keddie, 1986b), although Watson and coworkers (1984) found no such relationship. Ogborne (1987) reported that alcohol abusers who self-select a moderation goal resemble the profile of optimal responders to this treatment approach. The general picture is one of a continuum of severity of alcohol problems, with moderation being most feasible toward the lower end, abstinence most vital toward the upper end, and a large gray area in between. Contraindications for specific treatment goals remain an important area for future research (cf. Miller and Caddy, 1977~. The following questions represent opportunities for research on abstinence outcomes and goals: What are the characteristics of individuals who sustain moderate and problem-free drinking over extended spans of time after treatment? How do they differ from those who successfully sustain abstinence or who fail to show improvement? Are there significant differences between stable abstainers and stable moderate drinkers on other important outcome dimensions (e.g., neuropsychological functioning, physical health, family and social adjustment)? With less dependent problem drinkers, what are the positive or negative effects of openly negotiating the treatment goal, as compared with permitting only a goal of total abstention? What treatment or prevention procedures are effective in establishing stable, moderate, and problem-free drinking outcomes among less dependent problem drinkers? -220

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SCREENING, RECRUITMENT, AND IMPLEMENTATION Although the concepts of brief intervention and secondary prevention are attracting widespread interest, the development of effective, inexpensive, early interventions is still in the beginning stages. Programs to date have been experimental or demonstration projects. Some have not been evaluated with sufficient rigor to provide more than a suggestion of their e~cac~r. The only major long-term clinical trial to date (Kristenson et al., 1983) produced highly encouraging results on the ability of early intervention to reduce alcohol-related morbidity and mortality. Other program evaluations have indicated that modest but reliable effects on drinking behavior and related problems can follow from brief interventions, especially among less severe problem drinkers. Before these findings can be applied to the design of large-scale secondary prevention programs, however, further research is needed to claritr the behavioral processes that underlie the effectiveness of such programs and the barriers that may limit widespread initiation of early intervention. Specific research needs include further exploration of screening, recruitment, and implementation processes. Screening Screening is designed to differentiate among apparently well people' separating those who probably have the condition of interest from those who probably do not. It is equally applicable either to conditions that are categorical entities (i.e., conditions that are present versus not present) or to conditions that exist on a continuous scale of severity. The latter requires an operational threshold for a "case," that is, the point on the continuum at which treatment becomes preferable to no treatment. Implicit in the concept of screening is the assumption that the health and well-being of the individual will benefit significantly from early detection of the condition. Screening is thus conceptually different from "detection" or Case finding, although these terms are sometimes used interchangeably. The aim of case finding is to identify active cases that have already developed a diagnosable disorder. A variety of assessment procedures have been developed in recent years to facilitate the early identification of persons with harmful or potentially harmful alcohol consumption. Job performance criteria are used in industry, blood alcohol concentrations are employed in the courts, biochemical tests and brief questionnaires are used in health settings, and population surveys are conducted in the community. Although most of these procedures have been developed to identify active cases of alcohol dependence or "alcoholism,. many are useful for early identification as well. These procedures include self-report instruments like the Michigan Alcohol Screening Test (MAST) and the CAGE questions, objective blood tests like those for GOT and mean corpuscular volume (MCV), and clinical examinations (Babor and Kadden, 1985~. Because verbal report methods such as the MAST and CAGE can be falsified easily by defensive individuals, there has been strong interest in the development of biological markers that reflect recent heavy drinking or the early onset of physical consequences. Measures of GOT and MCV have been used for both screening and confirmatory diagnosis, but their values are affected by substances other than alcohol, as well as by physical conditions that are not related to drinking; furthermore, they are not invariably elevated in heavy drinkers. Serum transferrin and new immunological tests that have been developed to measure acetaldehyde bound to hemoglobin show promise as more specific markers of heavy drinking, but further research is needed to confirm their -221

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usefulness in routine screening. The use of such markers could identity problem drinkers during visits to physicians and thus point out those who might benefit from some level of intervention. The ideal marker would be one that is even more accurate and able to identify gradations of recent alcohol use. Such a precise indicator is not yet available. As markers are found that indicate genetic vulnerability to alcohol abuse (see Chapter 3 and also IOM, 1987), they might also become part of a screening program. Because screening procedures based on biological, clinical, and verbal report methods all have limitations that affect their sensitivity and specificity, there has been renewed interest in the use of screening procedures that combine these domains. Two such combined screening approaches are the World Health Organization's Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol Clinical Index (Saunders and Aasland, 1987; Skinner et al., 1986~. Although these new screening tests have not been sufficiently studied, the use of combined procedures presently offers substantial promise for early identification. The choice of an optimal screening procedure will depend on the resources available, the goals of the screening and intervention, and the nature of the drinking problems within the target population. One assumption implicit in many screening procedures has been that there is a distinct clinical entity called alcoholism that is either present or absent and can be detected at early stages of development. Although alcohol dependence follows a predictable course in many individuals, evidence of the progressive nature of alcohol-related problems is not compelling when all types of problem drinkers are considered as a heterogeneous group (Babor, Kranzlerj and Kadden, 1986~. Many problem drinkers appear to mature out of their harmful drinking practices. Early identification should, therefore, assume the less ambitious and more practical task of identifying specific types of alcohol problems within specific groups of problem drinkers, without making undue assumptions about etiology and natural history. This approach suggests the need for screening procedures that are capable of identifying a broad range of alcohol problem dimensions rather than the simple presence or absence of an assumed syndrome. Such dimensions include quantity and frequency of consumption, severity of alcohol dependence, number and intensity of alcohol-related social and health problems, and extent of family history and childhood risk factors for alcohol problems (Babor, Kranzler, and Lauerman, 1989~. The following questions represent opportunities for research questions on screening: Which of the many available biochemical, clinical, and self-report screening procedures are best suited to the identification of alcohol problems in primary care clinics, through community surveys, or in employment and criminal justice settings? What are the optimal combinations of such measures? Are there biological or biochemical markers, or sets of markers, with sufficient sensitivity and specificity to identify adults and adolescents at risk for future alcohol-related health problems? What are the relative validity and cost-effectiveness of verbal report screening methods (interviews, questionnaires, computer-assisted tests) compared with clinical and laboratory procedures? How can the accuracy of such measures be improved? Under what conditions are verbal report methods most or least accurate for the purpose of early identification? Can childhood factors that indicate enhanced risk of later alcohol problems (see Chapter 3) provide useful information when incorporated into routine screening tests? . -222

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Recruitment Once individuals at risk have been identified, how can they be engaged in an intervention that is intended to reduce risk? The motivation for, and the involvement of, problem drinkers in the change process pose major challenges (Miller, 1985~. The results of the Kristenson et al. (1983) study are encouraging, perhaps because this research group took full advantage of the prestige and resources of the Swedish national health service. The use of coercive recruitment methods by the courts, schools, and industry poses special ethical dilemmas that need to be considered, along with the possibility that "constructive coercion" may yield significant benefits. One procedure that has been found to attract large numbers of heavy drinkers who are likely to be motivated to change is recruitment through the media (Berg and Skutle, 1986; Heather, Whitton, and Robertson, 1986~. The success of media recruitment is apt to be affected by the nature and duration of the interventions that are offered. Programs that require only a brief counseling session and the use of a self-help home study manual may reach a wider (literate) audience than programs that demand regular participation in a series of counseling or educational sessions. The goals of the intervention are likely to affect recruitment as well (Miller, 1987~. Almost all of the successful programs reviewed in this chapter recognized the need for flexibility in setting personal goals, with moderation rather than abstinence being the preferred initial option for most individuals. Another common characteristic of early intervention programs to date has been a careful avoidance of labeling. The terms alcoholic and alcoholism are Reemphasized in favor of less stigmatizing concepts: heavy drinking, hazardous alcohol use, personal risk, and alcohol-related problems (Miller, 1983~. Recent reports have suggested that the information collected during screening can be used as feedback to motivate an individual's engagement in change programs (Kristenson et al., 1983; Miller, 1985; Miller and Sanchez, in press). Miller, Sovereign, and Krege (1988) reported modest decreases in alcohol use and increased helpseeking among a population of problem drinkers given a "drinker's checkup" that involved feedback regarding personal impairment related to alcohol use. The following questions represent opportunities for research on recruitment: What kinds of recruitment approaches (e.g., voluntary versus coercive; media solicitation versus initiation by a health worker) provide the best chances for engaging high-risk drinkers in an early intervention program? What are the characteristics of personnel and procedures that are most optimal for engaging heavy drinkers in intervention programs? How can screening information (e.g., lab tests, alcohol consumption estimates, clinical examination findings) be used to increase an individual's motivation for, and engagement in, efforts to change? How can public attitudes toward health habits and life-style behavioral risk factors be mobilized to engage more drinkers in intervention programs? Is there a positive relationship among health beliefs, perceptions of risk, fear of harm, and motivation for change? -223

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Implementation Even when effective screening, recruitment, and intervention strategies have been defined, there remain a number of logistical, technical, and professional issues that must be addressed before promising findings are likely to be applied in clinical practice and public health settings (Miller, 1987~. More research attention should be devoted to the evaluation of low-cost, rapid, reliable screening procedures that can be used routinely by primary care practitioners in a variety of health settings. No matter how sophisticated a biochemical test or how reliable a self-report questionnaire, neither may be implemented in routine clinical practice if they lack face validity, ease of use, or affordability. Research is needed to identify common barriers to effective screening that may arise once such technologies have been developed. One of the reasons alcohol-related problems are ignored or underdiagnosed in primary care settings is that nurses and physicians do not feel responsible for--or competent to intervene in--a situation in which a drinking problem has been identified (Clement, 1986~. With the development of screening and early intervention procedures that are effective and easy to use, this reluctance no longer seems warranted. Hero areas worthy of research include the training of health care professionals in screening and brief intervention and the development of continuing education materials for health professionals and other groups such as employee assistance program personnel and school counselors. In addition, the reimbursement policies for early intervention should be examined to determine their effect on the delivery of this kind of preventive health service. The Kristenson study indicated that early intervention may have significant long-term effects on morbidity and mortality, which would suggest that remuneration for such services could be highly cost-effective in health care delivery systems. The following questions represent opportunities for research on program implementation: What are the principal barriers to implementation of effective screening, recruitment, and intervention strategies once they have been identified? ~ What methods are optimally effective in disseminating and implementing effective brief intervention strategies? What are the effects on long-term health care costs of implementing brief interventions for alcohol-related problems? Does reimbursement for such services have a tangible effect on their implementation and consequently on long-term outcomes? REFERENCES Alford, G. Alcoholics Anonymous: An empirical study. Addict. Behav. 5:359-370, 1980. Babor, T. F., and R. Kadden. Screening for alcohol problems: Conceptual issues and practical considerations. Pp. 1-30 in N. C. Chang and H. M. Chao, eds. Early Identification of Alcohol Abuse. NIAAA Research Monograph No. 17. DHHS Publ. No. (ADM)85-1258. Rockville, MD: NIAAA, 1985. Babor, T. F., H. R. Kranzler, and R. M. Kadden. Issues in the definition and diagnosis of alcoholism: Implications for a reformulation. Progress in Neuropsychopharmacology -224

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