Toward more responsive and effective intervention systems for alcohol‐related problems

In a landmark volume, an international team of scholars made a case for 'Broadening the base of treatment for alcohol problems'. Institute of Medicine (IOM) 1990. Among other general goals, it called for expanding the continuum of care beyond short-term, abstinence-oriented treatments, creating more services for non-dependent problem drinkers and designing more responsive and better coordinated intervention systems. Building upon these themes in light of the past decade's scientific and clinical progress, this editorial attempts to: (1) translate the above goals into conceptual guidelines and discrete applications that will contribute to the development of more responsive, accessible and complete systems of care; and (2) discuss new directions in applied intervention research that will inform changes in service delivery systems. The scope of this editorial is limited in two respects. Firstly, it expresses an idealized vision of the future of alcohol intervention rather than dwelling on the significant economic, cultural, political, religious and other barriers to attaining it. Secondly, although a few outstanding cross-cultural, comparative studies of addiction treatment systems have been conducted in recent years (e.g. Klingemann et al. 1992; Klingemann Porter et al. 1999), the lack of current and complete data on many societies leaves all commentators at times unduly influenced by their own nation's experience, in this case that of the United States. As context, we preface our proposals for intervention and research with two empirically supported assertions: (1) alcohol problems are best characterized as environmentally responsive behavioral health problems; (2) current systems of care for alcohol problems are often unresponsive to the fact that the affected population is diverse on every dimension relevant to intervention (e.g. problems, resources, treatment preferences, goals, motivations and behavior change pathways). These arguments will be familiar to many readers, but merit adumbration because alcohol intervention systems in many countries have developed without heed to them (Porter et al. 1999), even when they were accepted by the local community of scholars. Alcohol problems are environmentally responsive behavioral health problems. Over the latter half of the 20th century, many nations moved from a moral to a medical view of alcohol problems, often by embracing some variant of the disease model (Klingemann et al. 1992; Blomqvist 1998). Such medicalization helped move alcohol problems into the purview of professional health care and applied science, but the limitations of understanding substance abuse solely as a biomedical disorder have been recognized for some time (Curran et al. 1987; Pattison et al. 1977). Viewing alcohol problems as environmentally responsive behavioral health problems retains the valuable, hard-won alliance with medical services and research, while shifting assumptions about aetiology and behavior change in directions that are better supported empirically. Specifically, it places greater emphasis on extra-therapeutic, environmental forces that shape alcohol misuse. It further recognizes that alcohol problems are unlike acute medical disorders (e.g. infections, broken bones), for which short-term medical treatments can produce lasting improvements without significant changes in patients' behavior or environment. Thus, behavior is inherent in the health problem of substance abuse, rather than merely being a modifier of disease course—as, for example, medication compliance is for the course of HIV/AIDS. This viewpoint is supported by experimental demonstrations that environmental contingencies affect drinking even among severely dependent individuals (e.g. Bigelow et al. 1975), by naturalistic research showing the powerful influence of enduring environmental features (e.g. family, work, love relationships) on the long-term course of alcohol abuse (Bacon 1973; Öjesjö 1981; Edwards 1989; Moos et al. 1990) and by studies of how economic, legal and policy factors affect alcohol use and misuse (Bruun et al. 1975; Room 1987). Perhaps ironically, additional support comes from genetic research, which indicates that large proportions of the variance in the aetiology and course of alcohol dependence are explained by behavioral and environmental factors (McLellan et al. 2000). Taken together, these findings demonstrate the 'embedded-ness' of alcohol problems within the surrounding environmental context and argue for greater concern with such forces in intervention systems. This supports conceptual and practical connections across a continuum of interventions that span individual clinical treatments, mutual help and other community-based interventions, and economic and policy initiatives aimed at reducing alcohol-related problems. Alcohol intervention systems are often unresponsive to the full range of problems, resources, treatment preferences, goals, motivations and behavior-change pathways within the affected population. In most of the 77 countries recently surveyed by the World Health Organization (WHO), the alcohol treatment system is tailored to serve highly dependent drinkers (Porter et al. 1999). Although such individuals certainly merit attention, treatment systems targeted solely at them are not responsive, appealing or effective across the population with alcohol-related problems because it is quite diverse on every dimension relevant to intervention. Several lines of research support this contention. Epidemiological studies show that only a small proportion of persons with problems seeks specialist alcohol treatment services (Marlatt et al. 1997). Utilization rates are particularly low among non-dependent problem drinkers, which is unfortunate given that they compose the majority of persons with problems and are responsible for the bulk of alcohol-related harm (Bruun et al. 1975; Institute of Medicine 1990). Contrary to some clinical lore, lack of help-seeking cannot uniformly be attributed to denial or to a lack of motivation to reduce problem behavior, because many individuals with problems of all severities eventually reduce or cease problem drinking in the absence of intervention (see Klingemann et al. 2002, for an international review of evidence). Along the same lines, every developed nation has voluntary mutual help associations for alcohol problems e.g. Alcoholics Anonymous (AA), Croix D'Or; see Room 1998; Mäkeläet al. 1996. Given the significant effort that persons with problems expend to create mutual help organizations, even when professional services exist, it seems clear that problem drinkers desire a broader range of alternatives than most current systems provide. Diversity among people with alcohol problems is also evident in the patterning, time course and outcomes of behavior change efforts (Weisner 1991; Schmidt Tucker Klingemann et al. 2002) and in motivations and preferences for services (Klingemann et al. 1992; Weisner in comorbid presentation with mental health problems such as depression and anxiety; Weisner see Curran et al. 1987). Doing so should help reduce the stigma that makes alcohol services unappealing to many of those in need and contributes to professional reticence to screen for and treat alcohol problems. To the extent that opinion leaders can create a mind-set that alcohol services are an integral part of health care, intervention opportunities should increase and the stigma of alcohol treatment should be reduced. The preceding suggestions for changes in practice follow from research findings. We next consider changes in research that follow from our proposed changes in practice. Firstly, the methods and standards applied in alcohol treatment evaluations should be modified; they are not detailed enough in some respects, are overly stringent in others and embody assumptions and values about outcomes that deserve re-consideration. Treatment research for example the proportion of patients who are or moderate drinkers at some after treatment (e.g. in the preceding a month do not well environmentally behavioral health problems that have a chronic course (McLellan et al. 2000). dependent like drinking are better in a more the the common practice of into full with no relapses and that single treatment episodes can be to and resolve an alcohol problem as if it were an or a broken This alcohol treatments to a than interventions for other chronic health problems that have a substantial behavioral component (e.g. where of current health treatment is valued in relation to continued likely in the absence of interventions (McLellan et al. 2000). A more of the effectiveness of alcohol treatment should include of the of intervention episodes the natural course of drinking problems of similar would also be by of the environment et al. 1990) and by the of goals and for clinical in light of it. Given that drinking patterns are influenced by enduring natural such as economic family, work and mutual help groups, these must be in studies because the of interventions will on and with viewpoint also supports a of what the methods are for the best A clinical conducted with a idealized treatment no choice of treatment and no of or access is a powerful for but often from a scope of utility (Tucker 1999; Humphreys & Weisner 2000). should be as one of several to clinical science, rather than as the best or treatment A broader scientific with our would include more naturalistic studies of the through which individuals to seek help how they between of care and what factors within treatment systems influence the of individuals that they and serve (e.g. scope of services, Such an would also include evaluations of treatment as typically to and research on how supported interventions can be into practice settings. who a research so to systems would have to be of the political context of research and how this may influence the use of their For example, findings that mutual help groups are effective for some problem drinkers may be applied by healthcare to and by treatment professionals to their This must include of and of intervention systems (e.g. waiting which significant but have not been of to This will to that research (e.g. or research on is often of less utility than research on what systems of care, healthcare policies and and the environmental contingencies that affect the behavior of all not only the From the of view of the clinical the between and are and from the of view of potential these may be We suspect that to enter treatment are more by waiting social and even available than by such deserve greater scientific We have that intervention systems the array of available services. 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