Broadening the Base of Treatment for Alcohol Problems (1990) / Chapter Skim
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Chapter 9--The community role
Chapter 9--The community role
Pages 211-241
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From page 211... ...
It is the view of the committee that the appropriate location for the effort directed at mild and moderate problems lids not within the specu~lized treatment sector but within community agencies that provide general services to various populafior~s. The specialized treatment sector most appropriately addresses itself to substantial or severe alcohol problems; thus a collaborative effort between community agencies and the specialized treatment sector is required in order to have a significant positive impact upon the broad spectrum of alcohol problems.
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From page 212... ...
. In general, specialized treatment is indicated for persons with substantial or severe alcohol problems; brief intervention is indicated for persons with mild or moderate alcohol problems; and primary prevention is indicated for persons who have not had alcohol problems but are at risk of developing them.
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From page 213... ...
While ideally such persons upon being identified would accept referral to the specialized treatment sector, some proportion in fact will not do so. The availability of brief intervention within the community agency itself would assure that at least a degree of therapeutic attention is provided to these individuals and to their problems.
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From page 214... ...
Some additional data reflect that this tendency may hold for local samples as well. In a household probability sample of the population in Contra Costa County, California, in 1987, a total of 1,980 persons was asked to respond specifically to 10 "alcohol related problematic events," a combination of what were called in the Hilton survey "problematic drinking and "tangible consequences items.
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From page 215... ...
Data on other parameters are also consistent with the diagram. For example, in an examination of alcohol consumption based on seven national surveys, it was found that 35 percent of the population were abstainers, 32 percent light drinkers (up to three drinks weekly)
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From page 216... ...
Should this initial intervention prove to be ineffective, and should the problems persist or worsen, referral for specialized treatment may indeed be indicated. Gregory has a very low level of consumption: approximately two drinks in his lifetime.
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From page 217... ...
Although one pathway illustrates that the development of acute and long-term consequences of alcohol consumption can be preceded or accompanied by the significant symptoms of alcohol use that suggest alcohol dependence, there are other pathways that indicate the occurrence of such consequences in the absence of these symptoms. MODIFYING VULNERABILITY EXPOSURE VARIABLES r PERSONAL AN'rECENDENTS AGE, SEX, BODY MASS GENEllC VULNERABILITY, PERSONALITY SOCIAL 1~JTECENDENTS AmTUDES NORMS CUSTOMS RITUAIS CONSEQUENCES Or 1/ BAC DRUGS CONTm SPEED OF DRINKING DRINKING PATTERN QUANTITY FREQUENCY V~BILITY t DIET NUTRlllON SMOKING YEARS DRINKING DEPENDENCE ~TOLERANCE ~ITHDRA'AL | RELIEF DRINKING ACUTE CONSEQUENCES ACCIDENTS VIOLENCE ~ \ ~ \ _ ~ \ \ \ \ \ _ \ ~ \ fir LONG-TERM CONSEQUENCES lIEDICAL' PSYCHOLOGICA1, AND SOCIAL DISABILITIES FIGURE 9-2 The complex interrelationships between vulnerability factors, exposure to alcohol, modifying variables, and the consequences of alcohol consumption (Babor et al., 1987:395)
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From page 218... ...
Lee specu~lized treatment sector for alcoholproblems cannot be the sole locus oftreatment. If significant inroads are to be made into the overall burden of alcohol problems, a widespread, broad-based therapeutic approach must be taken within which gradations of therapeutic attention are possible.
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From page 219... ...
The items cover alcohol consumption, symptoms of alcohol use, and consequences of alcohol use, three areas of content that are desirable for the full description of an alcohol problem (see Chapter 10~. Finally, as each of the 10 AUDIT questions is scored on a 0-4 basis, the possible range of scores is 0-40, a potentially useful feature in determining which individuals to retain for brief intervention in a general setting and which to refer directly to specialized treatment settings.
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From page 220... ...
However, those with mild or moderate alcohol problems should be dealt with in the community agency itself by staff who have been trained to deliver brief interventions. Making the distinction between mild and moderate problems that require only brief intervention on the one hand and substantial and severe problems that require specialized treatment on the other is a function both of the screening instruments used and of the judgment of those who use them.
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From page 221... ...
In recent years a number of controlled studies have demonstrated the efficacy of brief interventions in the treatment of alcohol problems. The committee views this as a highly significant development and will review these studies in some detail below, partly because it senses a high level of ambient skepticism about brief interventions.
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From page 222... ...
204~. The authors comment that "in focusing on the GGT value, which can be completely normalized when alcohol consumption is ceased, the patient perceives a direct advantage of restricting his drinking habits, which cannot be accomplished by the questionnaires" (p.
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From page 223... ...
After an initial assessment that covered the pattern and amount of their alcohol consumption, evidence of alcohol- related problems, and symptoms of dependence, patients were provided with a histogram "to illustrate how their weekly consumption compared with that of the general population." They were advised about the potential harmful effects of their current level of consumption, which was reinforced by the distribution of an information pamphlet entitled That's the Limit. Specific limits for safe drinking were also prescribed, and each patient was given a drinking diary that bore on its cover the likeness of a prescription emblazoned with the words Cut Down on your Drinking!
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From page 224... ...
The largest changes in reported alcohol consumption took place in the first six months of the trial. Both men and women in the treatment condition showed highly significant reductions in alcohol consumption in comparison with the controls at that point.
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From page 225... ...
It might constitute a logical "next step" in the event that brief intervention is not successful and specialized treatment is not acceptable. In settings with a large staff complement and a high proportion of individuals with alcohol problems in the target population, a small number of staff could be trained in a brief therapy and could deliver it on a referral basis to
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From page 226... ...
The target population might be those whose problems were somewhat more severe, or who had failed to improve following brief intervention, or who had refused referral for specialized treatment. Brief therapy is thus a further significant addition to the therapeutic armamentarium.
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From page 227... ...
Because his college infirmary staff had been among those trained to identify alcohol problems and to briefly intervene when they were present, all persons seen there were routinely given a lifestyle questionnaire. The recent change in George's alcohol consumption was detected, and an alert attending physician perceived the potential dangers.
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From page 228... ...
Referral The final element in the community role is referral, which in this instance means referral of individuals to the specialized treatment sector for alcohol problems. One advantage of the committee's vision of a treatment system in the specialized sector (see Chapters 1 and 13)
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From page 229... ...
In another study, 46 percent of 400 casualty cases had positive breathalyzer readings when evening, and particularly weekend evening, admissions were sampled (Holt et al., 1980~. A recent study of emergency rooms in San Francisco and the surrounding county area showed a significant and positive association between injuries, high breathalyzer readings, self-reported alcohol consumption, and more frequent heavy drinking (the city sample reported a 21 percent rate of binge drinking in the past year, and the county sample an 8 percent rate, compared with a rate of 1 percent in the general population)
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From page 230... ...
Yet significant adverse consequences, sometimes referred to as fetal alcohol effects (FAE) , may occur at lower levels of maternal alcohol consumption (Little, 1977; Hanson et al., 1978; Harlap and Shiono, 1980; Sokol et al., 1980; Streissguth et al., 1980; Rosett et al., 1983~.
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From page 231... ...
that vagrants, prisoners, and those cited for legal offenses connected with drinking are other groups likely to be seen in social service settings that may include a high proportion of persons with alcohol problems. Family service agencies often see individuals whose problems are the result of or are aggravated by alcohol consumption.
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From page 232... ...
Yet there is evidence that the specialized treatment sector for alcohol problems is being flooded with DWI and other offenders (Fillmore and Kelso, 1987; State of Connecticut, 1988~. In 1986-1987, for example, the state of Connecticut experienced a 400% increase in DWI referrals to alcohol treatment services (State of Connecticut, 1988~.
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From page 233... ...
Johns Hopkins Medical School in particular has set an important example (see above and Holden, 1985; Moore et al., 1989~. Special mention may be made of the career teacher program sponsored jointly by the National Institutes on Drug Abuse and on Alcoholism and Alcohol Abuse, which singled out junior faculty members at medical schools for specialized development in this area.
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From page 234... ...
Some may entertain the hope that the costs accruing to the specialized treatment of substantial or severe alcohol problems could be greatly reduced through such a program. This seems a possible but not a necessary consequence.
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From page 235... ...
The committee urges strongly that a f nancial mechanism be developed to furul brief therapy outside of, as well as within, the context of funding for medical or medicalb-superv~sed services. Conclusions and Recommendations The committee recommends a broader and more comprehensive nationwide effort to establish a strong community role in dealing with mild to moderate alcohol problems, to complement the exhorts of the specialized treatment sector in dealing with substantial and severe alcohol problems.
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From page 236... ...
Pp. 1-30 in Early Identification of Alcohol Abuse, N
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From page 237... ...
1978. The effects of moderate alcohol consumption during pregnancy on fetal growth and morphogenesis.
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From page 238... ...
1986. Alcohol consumption and the preventive paradox.
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From page 239... ...
1977. Screening and early detection instruments for disabilities related to alcohol consumption.
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From page 240... ...
1987. WHO Collaborative Project on Identification and Treatment of Persons with Harmful Alcohol Consumption: Report on Phase I Development of a Sereening Instrument.
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From page 241... ...
1988. Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption.
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