Alcohol screening and brief intervention: dissemination strategies for medical practice and public health.

This paper introduces the concept of risky drinking and considers the potential of alcohol screening and brief intervention (SBI) to reduce alcohol-related problems in medical practice and in organized systems of health care. The research evidence behind this approach is reviewed. Potential strategies for the dissemination of SBI to systems of health care are then discussed within the context of a public health model of clinical preventive services. There is an emerging consensus that SBI should be promoted in general healthcare settings, but further research is needed to determine the best ways to achieve widespread dissemination. In an attempt to provide an integrative model that is relevant to SBI, dissemination strategies are discussed for three target groups: (1) individual patients and practitioners; (2) health care settings and health systems; and (3) the communities and the general population. Dissemination strategies are considered from the fields of social change, social science, commercial marketing and education in terms of their potential for translating SBI innovations into routine clinical practice. One overarching strategy implicit in the approaches reviewed in this article is to embed alcohol SBI in the more general context of preventive health services, the utility of which is becoming increasingly recognized as a critical supplement to more traditional clinical medicine.

Talk is cheap: measuring drinking outcomes in clinical trials.

OBJECTIVE: To evaluate the correspondence among measures of self-reported drinking, standard biological indicators and the reports of collateral informants, and to identify patient characteristics associated with observed discrepancies among these three sources of research data. METHOD: Using data collected from a large-scale clinical trial of treatment matching with alcoholics (N = 1,726), these three alternative outcome measures were compared at the time of admission to treatment and at 12 months after the end of treatment. RESULTS: Patient self-reports and collateral reports agreed most (97.1%) at treatment admission when heavy drinking was unlikely to be denied. In contrast, liver function tests were relatively insensitive, with positive serum gamma-glutamyl transpeptidase (GGTP) values obtained from only 39.7% of those who admitted to heavy drinking. At 15-month follow-up the correspondence between client self-report and collateral report decreased to 84.7%, but agreement with blood chemistry values increased to 51.6%. When discrepancies occurred, they still indicated that the client' s self-report is more sensitive to the amount of drinking than the biochemical measures. Patients who presented discrepant results tended to have more severe drinking problems, more previous treatments, higher levels of pretreatment drinking and significantly greater levels of cognitive impairment, all of which could potentially interfere with accurate recall. CONCLUSIONS: In clinical trials using self-selected research volunteers, biochemical tests and collateral informant reports do not add sufficiently to self-report measurement accuracy to warrant their routine use. Resources devoted to collecting these alternative sources of outcome data might be better invested in interview procedures designed to increase the validity of self-report information.

Managing alcohol problems and risky drinking.

While overall alcohol consumption and alcohol-related automobile deaths have declined, rates of alcohol dependence, liver cirrhosis, and alcohol-related problems remain high among adults, and binge drinking continues as a major health risk for high school and college students. Some individual-level downstream interventions have been evaluated with sufficient rigor to recommend widespread dissemination, and widened availability of new pharmacotherapies could further increase effectiveness. Midstream population-based programs, such as screening and brief interventions in hospitals and managed care organizations, may have greater public health impact than tertiary treatment because of early identification and low cost. Upstream programs and policies that place limits on alcohol availability (e.g., higher legal purchasing age) have the greatest potential to reduce morbidity and mortality at the least cost to society.

Ethical, scientific and clinical issues in ethanol administration research involving alcoholics as human subjects.

Research involving the administration of ethanol to human subjects has been conducted with some regularity since the 1960s. The purpose of this paper is to provide a broader discussion of the ethical and clinical issues pertaining to the administration of ethanol to subjects with a history of alcohol dependence and to assess the potential benefits and risks of ethanol administration research. Three kinds of investigation are reviewed: (1) basic scientific research on alcohol dependence and related disabilities; (2) clinical research that involves ethanol administration as part of the treatment; and (3) studies that have evaluated the short- and long-term effects of ethanol administration on the health and wellbeing of alcoholic research participants. It is concluded that ethanol administration research has not only contributed to the fund of knowledge about basic mechanisms of alcohol dependence; it has also advanced the scientific understanding of treatment. Moreover there is no compelling evidence that participation in ethanol administration research per se has adverse effects on alcoholic research subjects. In the interests of developing a practical approach to the ethical dilemmas posed by ethanol administration research, an ethical review process is suggested that takes into account the principles of respect for people, beneficence, and justice by tailoring the risk/benefit analysis to four types of research subjects: alcoholics recruited directly from the community, subjects recruited from residential treatment settings, recovering alcoholics, and alcoholics in outpatient treatment.

Test-retest reliability of the alcohol and drug use disorder sections of the schedules for clinical assessment in neuropsychiatry (SCAN).

This report presents the results of a test-retest reliability study of the alcohol and drug dependence, as well as harmful use/abuse were investigated in Ankara, Turkey and Farmington, Connecticut (US). Reliabilities for the past year, prior to past year, and lifetime diagnosis of alcohol and drug use disorders were evaluated using ICD-IO, DSM-III-R and DSM-IV criteria. The results indicate that SCAN alcohol and drug diagnosis have good to excellent levels of reliability for dependence across different substances, different diagnostic systems, and different cultural groups. Diagnostic classification of alcohol and drug abuse/harmful use was considerably less reliable. Implications of the findings are discussed.

Alcohol screening and brief intervention: where research meets practice.

Numerous studies have consistently shown that quick screening instruments can identify people whose drinking is likely to present health risks and that low-cost, brief interventions are effective in reducing drinking among many such at-risk drinkers. This article describes the results of a one-year policy analysis that explored how alcohol screening and brief intervention (SBI) can be moved to widespread clinical applications in the United States. It introduces the concept of risky drinking and considers the potential of this new technology to reduce it. The research evidence behind this approach is reviewed, and a description of current programs in this and other countries beginning to apply SBI is provided. Economic issues attendant to applications are identified and discussed. The potential for applications in health care is analyzed and summary conclusions from market research are set forth. Recommendations are offered for immediate action.

Alcohol and drug abuse among Connecticut youth: implications for adolescent medicine and public health.

In 1995, a statewide survey of alcohol and other drug use was conducted in a random sample of approximately 4,000 7th to 12th graders in public schools in Connecticut. The survey, part of a statewide substance abuse treatment needs assessment, showed that use of tobacco, alcohol, and marijuana was widespread and increasing, particularly among younger students. Connecticut's students reported higher rates of substance use compared to their peers nationwide. Substance use differed according to age, gender, ethnic background, and community type. It was estimated that almost 1-in-10 senior high school students should receive a diagnostic evaluation for substance abuse, with half likely to need a treatment referral. Most of these adolescents had not received treatment for their substance abuse. Primary-care physicians can play a key role in reducing adolescent substance abuse through prevention messages, screening for drug use, brief interventions, and timely referrals to appropriate intervention services.

Estimating measurement error in alcohol dependence symptomatology: findings from a multisite study.

Inter-rater test-retest reliability of alcohol diagnoses and symptom ratings, made by means of a modified version of the Structured Clinical Interview for DSM-III-R (SCID), were evaluated in the context of a multisite clinical trial of alcoholism treatment. Reliability coefficients for the subject's 'worst period' and the 'current period' were compared. The results show that with proper training, reliable diagnostic classification can be achieved across multiple sites. Symptom reliabilities for the current period were higher than the worst period. Respondents with higher discrepancies between test and retest tended to drink more on each drinking occasion, reported more medical detoxifications, changed residence more often, had lower occupational status and were rated by the interviewer as less attentive, motivated and intelligent. Methods to monitor and improve the reliability of diagnostic interviews in addiction research, particularly in multisite studies, are discussed in relation to the findings.

Validity of the longitudinal, expert, all data procedure for psychiatric diagnosis in patients with psychoactive substance use disorders.

The longitudinal, expert, all data (LEAD) procedure has been employed as a criterion for the assessment of the procedural validity of diagnostic instruments. This study evaluated the procedure's concurrent, discriminant and predictive validity. Interview and questionnaire data obtained from 100 individuals in a substance abuse treatment program were used to assess current and lifetime substance use disorders and common comorbid disorders. An experienced, doctoral-level clinician formulated LEAD diagnoses for each patient, based on an initial interview, ongoing clinical contact and the results of the research assessment and all available clinical records. LEAD-derived substance use diagnoses showed good concurrent, discriminant and predictive validity. The validity of comorbid diagnoses obtained using the LEAD procedure was generally fair to good. Comparison with diagnoses based only on the clinician's unstructured initial interview showed that the availability of additional data enhanced diagnostic validity. Diagnoses derived by a research technician using the Structured Clinical Interview for DSM-III-R showed validity comparable to that of LEAD diagnoses. To enhance its diagnostic validity, applications of the LEAD standard should include a structured interview. Other variations in the application of the LEAD standard, including a longer evaluation period, may also enhance its performance as a diagnostic criterion measure.