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PREVENTION AND TREATMENT OF ALCOHOL PROBLEMS:
RESEARCH OPPORTUNITIES
Report of a Study by a Committee of the
INSTITUTE OF MEDICINE
Division of Mental Health and Behavioral Medicine
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NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils of
the National Academy of Sciences, the National Academy of Engineering, and the Institute
of Medicine. The members of the committee responsible for the report were chosen for
their special competencies and with regard for appropriate balance.
This report has been reviewed by a group other than the authors according to procedures
approved by a Report Review Committee consisting of members of the National Academy
of Sciences, the National Academy of Engineering, and the Institute of Medicine.
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to
enlist distinguished members of the appropriate professions in the examination of policy
matters pertaining to the health of the public. In this, the Institute acts under both the
Academy's 1863 congressional charter responsibility to be an adviser to the federal
government and its own initiative in identifying issues of medical care, research, and
education.
The work on which this publication is based was performed pursuant to Contract No.
ADM 281-87-0003 with the National Institute on Alcohol Abuse and Alcoholism of the
Department of Health and Human Services. Additional support for this study was provided
by The Pew Charitable Trusts and by the National Research Council Fund.
2101 Constitution Avenue, N.W.
Washington, D.C. 20418
(202) 334-2328
Publication IOM-89-13
Library of Congress catalog Card No. 89-63865
International Standard Book Number 0-309-04182-1
Additional copies of this report are available from:
National Academy Press
2101 Constitution Avenue, NW
Washington, DC 20418
S071
Printed in the United States of America
First Printing, February1990
Second Printing, September 1990
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INSTITUTE OF MEDICINE
Division of Mental Health and Behavioral Medicine
Committee to Identify Research Opportunities
in the Prevention and Treatment of
Alcohol-Related Problems
iSteering Committee]
ROGER EMIL MEYER, Co-Chair, Professor and Chair, University of Connecticut Health
Center, Farmington, Connnecticut.
ROBERT F. MURRAY, JR., Co-Chair, Professor of Pediatrics, Medicine, Oncology, and
Genetics, Howard University School of Medicine, Washington, D.C.
THOMAS F. BABOR, Professor of Psychology, University of Connecticut Health Center,
Farmington, Connecticut.
JOHN W. FARQUHAR, Professor of Medicine, Director, Stanford Center for Research
in Disease Prevention, Stanford University, Stanford, California.
MERWYN R. GREENLICK, Vice President Kaiser Foundation Hospitals, and Director,
Health Care Research, Portland, Oregon.
JOHN E. HELZER, Department of Psychiatry, Washington University School of Medicine,
St. Louis, Missouri. (Currently, Professor and Chair of Psychiatry, University of
Vermont School of Medicine, Burlington, Vermont.)
HAROLD D. HOLDER, Director, Prevention Research Center, Berkeley, California.
SHEPPARD G. KELLAM, Professor and Chairman, Department of Mental Hygiene,
Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland.
TING-KAI LI, Professor of Medicine and Biochemistry, Department of Medicine, Indiana
University Medical Center, Indianapolis, Indiana.
GEORGE E. WOODY, Chief, Substance Abuse Treatment Unit, Philadelphia V.A.
Medical Center and Clinical Professor of Psychiatry, University of Pennsylvania,
Philadelphia, Pennsylvania.
Study Staff
Study Director: Alice H. Fraenkel
Division Director: Fredric Solomon
Research Assistants: Jay Sternberg, Karen Goldberg
Editor: Leah Mazade
Secretaries: Angela Parlor, Katherine B. Edsall, Elizabeth Kitsinger, Elaine Lawson
. . .
111
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INSTITUTE OF MEDICINE
Division of Mental Health and Behavioral Medicine
Panel on Opportunities for Research on Prevention
of Alcohol Problems
ROBERT F. MURRAY, JR., Chair, Professor of Pediatrics, Medicine, Oncology, and
Genetics, Howard University School of Medicine, Washington, D.C.
DAVID B. ABRAMS, Director, Division of Behavioral
Providence, Rhode Island.
Medicine, Miriam Hospital,
JOHN W. FARQUHAR, Professor of Medicine and Director, Stanford Center for
Research in Disease Prevention, Stanford University, Stanford, California.
BRADLEY S. GREENBERG, Professor and Chairman, Department of
Telecommunications, Michigan State University, East Lansing, Michigan.
RALPH HINGSON, Professor and Chief, Social and Behavioral Sciences, School of Public
Health, Boston University, Boston, Massachusetts.
HAROLD D. HOLDER, Director, Prevention Research Center, Berkeley, California.
SHEPPARD G. KELLAM, Professor and Chairman, Department of Mental Hygiene, Johns
Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland.
TING-KAI LI, Professor of Medicine and Biochemistry, Department of Medicine, Indiana
University Medical Center, Indianapolis, Indiana.
1V
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INSTITUTE OF MEDICINE
Division of Mental Health and Behavioral Medicine
Panel on Opportunities for Research on
Treatment of Alcohol Problems
ROGER EMIL MEYER, Chair, Professor and Chair, University of Connecticut Health
Center, Farmington, Connnecticut.
THOMAS F. BABOR, Professor of Psychology, University of Connecticut Health Center,
Farmington, Connecticut.
RICHARD K FULLER, Assistant Chief of Gastroenterology Service, Cleveland V.N
Medical Center, Cleveland, Ohio.
MERWYN R. GREENLICK, Vice President, Kaiser Foundation Hospitals, and Director,
Health Care Research, Portland, Oregon.
JOHN E. HELZER, Department of Psychiatry, Washington University School of Medicine,
St. Louis, Missouri. (Currently, Professor of Psychiatry, University of Vermont School
of Medicine, Burlington, Vermont.)
BARBARA S. McCRADY, Associate Professor of Psychology and Clinical Director,
Center for Alcohol Studies, Piscataway, New Jersey.
THOMAS McLEI~LAN, Research Professor, Department of
V.N Medical Center, Philadelphia, Pennsylvania.
Psychiatry, Philadelphia
WILLIAM R. MILLER, Professor of Psychology and Psychiatry, and Director of Clinical
Training, Department of Psychology, University of New Mexico, Albuquerque, New
Mexico.
GEORGE~E. WOODY, Chief, Substance Abuse Treatment Unit, Philadelphia V.A.
Medical Center and Clinical Professor of Psychiatry, University of Pennsylvania,
Philadelphia, Pennsylvania.
v
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PREFACE
Problems related to the use of alcohol continue to exact a dreadful toll on individuals and
societies. In the United States, alcohol use is involved in nearly 100,000 deaths every year
and plays a major role in numerous medical and social problems from liver disease to
homelessness. The National Institute on Alcohol Abuse and Alcoholism (NIAAA), has
been given responsibility by Congress for fostering biomedical and behavioral research on
alcohol problems. In 1986, NIAAA asked the Institute of Medicine (IOM) to undertake a
study to assess the current state of knowledge about alcohol-related problems and identify
important and promising avenues for research.
NIAAA identified three broad areas of research progress and needs for IOM to review:
(1) causes and consequences of the misuse of alcohol, (2) prevention, and (3) treatment.
An IOM committee completed the first phase of this study in 1987 with the release of the
report Causes and Consequences of Alcohol Problems: An Agenda for Research. The
present report, which deals with research in the prevention and treatment of alcohol-related
problems, was prepared by a different committee; it represents the second and final phase
of that effort. Together, the two reports comprise an update of the 1980 IOM study, also
commissioned by NIAAA, Alcoholism Alcohol Abuse and Related Problems:
Opportunities for Research. Additional support for this study was provided by the Pew
Charitable Trusts.
In some cases, the material in this volume updates or amplifies topics that were reviewed
in Causes and Consequences of Alcohol Problems. For instance, Chapter 2 on
epidemiology does not aim at comprehensiveness but rather at enhancing, with recent
research results and in some cases more extensive coverage, some of the information that
appeared in the earlier report. One example is the information that has become available
recently on the role of alcohol in injuries; this report is able to treat that subject more
fully than was possible in 1987. In those areas of research that have seen little change,
however, the committee refers the reader to discussions in the earlier volume.
Throughout their deliberations, committee members maintained the view that alcohol
problems constitute a continuum ranging from occasional misuse by social drinkers to
chronic misuse by individuals suffering from alcohol dependence syndrome. The adoption
of such a perspective introduces the issue of terminology to describe the various points
along the continuum. This thorny problem often arises in any attempt to write about the
alcohol field; it is dealt with in various ways (e.g., see IOM, 1987, pp.l6-18~. Except when
discussing particular studies (in which the terminology used by researchers is retained), the
committee employs three general levels of reference in this report to distinguish areas
along the continuum of alcohol problems. The first level, the least severe in the
committee's scheme, consists of alcohol-related problems, which may involve undesirable
health, personal, or societal consequences. This terminology appears most conspicuously
in Part I, the prevention section of the report. The second level is heavy drinking; this
category constitutes a more severe level of problems arising from the injudicious or risly
use of alcohol but stops short of dependence or addiction. The third level of reference
comprises the most severe alcohol problems, which may be described by the term
alcoholism or, more often, alcohol dependence. This report reviews a wide range of
research efforts whose targets of interest represent a myriad of points along the continuum
and are described in terms of these levels of problem severity.
V1
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Such a broad perspective and scope prompt mention of three limitations that should be
understood to govern the committee's presentation. First, the research cited in the report
is illustrative of recent progress but is not intended to be comprehensive or exhaustive.
Second, this is not a policy document. Although the committee's presentation of the
current state of research into alcohol-related problems might be used to inform
policymaking, its focus, as established by NIAAA's mandate and IOM's subsequent charge,
is to identify promising avenues of research. The committee thus did not consider the
formulation of policy recommendations based on research results to be properly part of its
task nor could it have done so, given the constraints of time and other resources. Some
may find the report disappointing in this respect. For a thorough discussion of policy in
the field of alcohol-related problems, the committee would refer the reader to the National
Research Council report Alcohol and Public Policy: Beyond the Shadow of Prohibition
(Moore and Gerstein, 1981) and to the forthcoming IOM report Broadening the Base of
Treatment for Alcohol Problems (in press).
Third, the committee limited its scope of work in that it made no attempt to rank its
recommendations. Given the large number of areas of research and the multiple
perspectives of multiple disciplines involved in the study of alcohol-related problems, it
would not be useful to try to prioritize recommendations across so many different
approaches to prevention and treatment. The field is still relatively new; there has often
been little substantive or replicative evaluation of many of the approaches, and it is too
soon to draw conclusions about the most promising areas of research. Consequently, the
committee has refrained from any system of prioritization of its recommendations and
instead identifies what it considers to be the most promising approaches within each of the
areas under discussion.
Following the framework of its charge, the committee's report is divided into three parts.
Part I examines prevention research, taking as its conceptual framework a public health
model of alcohol-related problems. The model proposes three interacting elements: the
"agents (alcohol); the "host" or individual (traits that affect an individual's susceptibility or
vulnerability to problem outcomes); and the "environment" (a multifaceted concept involving
such varied milieus as the broad legal environment--minimum drinking age laws or zoning
decisions to exclude bars from neighborhoods--and the normative environment--general
attitudes and beliefs regarding alcohol--as well as the ~micro" environments of family and
peer groups). The committee examines current prevention research using the interactive
points of the model as an organizing framework and also moves beyond it to identify work
in other disciplines that holds promise for application to alcohol-related problems. Part
II of the report delineates the research picture for the treatment of alcohol-related
problems and opportunities for advancement in this area. Part III, the shortest section,
briefly discusses funding mechanisms and the necessary infrastructure to carry out
prevention and treatment research on alcohol-related problems.
The steering committee was greatly assisted in its efforts by the IOM staff, under the
leadership of Alice Fraenkel, who served as study director, and Fredric Solomon who
provided overall supervision of the project. Its deliberations were enriched by the
contributions of several consultants and, especially, by two panels--one on prevention
research and one on treatment research. The committee itself, however, is responsible for
the final report.
vii
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REFERENCES
Institute of Medicine. Alcoholism, Alcohol Abuse and Related Problems:
for Research. Washington, DC:- National Academy Press, 1980.
Opportunities
Institute of Medicine. Causes and Consequences of Alcohol Problems: An Agenda for
Research. Washington, DC: National Academy Press, 1987.
Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems.
Washington, DC: National Academy Press, in press.
Moore, M and D. Gerstein, eds. Beyond the Shadow of Prohibition. M. Moore and D.
Gerstein, eds. Washington, DC: National Academy Press, 1981.
. · .
vail
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CONTENTS
Committee and Staff, iii
Panels, iv
Preface, vi
Summary, 1
Introduction
Part I: Research.. Opportunities in the.Prevention of
Alcohol-Related Problems
Chapter 1 A PUBLIC HEALTH PERSPECTIVE ON THE PREVENTION OF
ALCOHOL PROBLEMS 23
A Public Health Model of Alcohol-Related Problems, 24
Prevention Research from a Public Health Perspective, 26
A Systems Approach, 27
Chapter 2 EPIDEMIOLOGY OF ALCOHOL-RELATED PROBLEMS . . . 31
Injuries, 31
Crime, 38
Suicide, 38
Child Abuse, 39
Sexually Transmitted Diseases, 40
Early Sexual Activity and Adolescent Pregnancy, 40
Fetal Alcohol Syndrome and Fetal Alcohol Effects, 40
Chapter 3 INDIVIDUAL-ENVIRONMENT INTERACTIONS:
INDIVIDUL
FOCUS ON THE
.. 47
Life-Course Development, Vulnerability, and Prevention Research 47
Social Learning Models, 57
Genetic Determinants of Risk, 66
Conclusion, 66
Chapter 4 INDIVIDUAL-ENVIRONMENT INTERACTIONS: FOCUS ON THE
ENVIRONMENT. ~ .~. ~ c ~ ~ .~. ~ eve ~ ~ ~ en ~ ~ ~ ~ ~ 75
Environmental Controls on the Availability of Alcoholic Beverages, 75
Environmental Influences on Individual Drinking Behavior, 81
Factors That Affect the Risk or Severity of the Negative Consequences
of Drinking, 96
IX
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Chapter 5 COMMUNITY APPROACHES AND PERSPECTIVES FROM OTHER
HEALTH FIELDS . ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ 109
Limitations of Alcohol Prevention Research, 110
Community-Based Cardiovascular Disease Prevention Studies, 111
Results from Primary Prevention Programs in Other Health Fields, 116
Summary of Lessons Learned from Other Fields, 120
Implications for Alcohol Problem Prevention, 121
Chapter 6 METHODOLOGICAL ISSUES IN ALCOHOL PREVENTION
RESEARCH: CONCLUSIONS AND RECOMMENDATIONS 127
Research Design for Future Alcohol Prevention Research Programs, 128
Direction and Design of Future Alcohol Prevention Research Programs:
Conclusions and Recommendations, 131
Part II: Research Opportunities in the Treatment of
Alcohol-Related Problems
Introduction
Chapter 7 THE SOCIAL AND HISTORICAL
TREATMENT RESEARCH
CONTEXT OF ALCOHOL
................ . 141
Federal Involvement in Alcohol Treatment, 141
Emerging Trends in Treatment Services, 142
Demography, Epidemiology, and the Delivery of Treatment Services, 143
Popular Trends in Treatment and Referral, 145
Chapter 8 ISSUES OF ASSESSMENT, METHODOLOGY, AND RESEARCH
DESIGN ·~*~ee.~. 149
Recent Developments in Conceptualization, 149
Advances in Assessment Technology, 150
Assessment of Treatment Process, Quality, and Outcome, 1S8
Growing Sophistication in Methodological Approaches, lS9
x
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Chapter 9 TREATMENT MODALITIES: PROCESS AND OUTCOME . 169
Outcome Research on Specific Treatment Approaches, 169
Research on Traditional Treatment Programs, 185
Research on the Intensity and Duration of Treatment, 188
Research on Aftercare, 189
Treatment Process Research, 190
Conclusions, 195
Chapter 10
EARLY IDENTIFICATION AND TREATMENT 215
Controlled Trials and Program Evaluations, 215
Brief Interventions and Treatment Research, 216
Research on Interventions with Pregnant Women, 217
Research on Nonabstinence Outcomes and Goals, 218
Screening, Recruitment, and Implementation, 221
Chapter 11 PATIENT-TREATMENT MATCHING AND OUTCOME
IMPROVEMENT IN ALCOHOL REHABILITATION 213
Advances in Patient-Treatment Matching Research, 1978-1988, 231
Research on Patient-Treatment Matching: Perspectives and
Opportunities, 237
Patient-Treatment Matching:
Recommendations, 241
Some Conclusions and Research
Chapter 12 ADVANCES IN THE TREATMENT OF OTHER PSYCHOACTIVE
SUBSTANCE-USE DISORDERS: IMPLICATIONS FOR RESEARCH
ON TREATMENT OF ALCOHOL PROBLEMS 247
Smoking, 247
Other Drug Dependencies, 255
Conclusions, 260
Chapter 13 THE HEALTH CONSEQUENCES OF ALCOHOL ABUSE:
OPPORTUNITIES FOR TREATMENT RESEARCH 267
Intoxication, 267
Alcohol Withdrawal, 268
Nervous System Effects, 275
Cardiovascular Effects, 278
Liver Effects, 281
Other Health Consequences of Alcohol Abuse, 283
xi
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Chapter 14 TREATMENT COSTS, BENEFITS, AND COST OFFSETS: PUBLIC
POLICY CONSIDERATIONS 289
Treatment Effectiveness, Benefits, and Efficiency, 289
Methodological Approaches to Policy Analysis, 290
The Cost Offset Effect, 292
Managed Care and Preferred Provider Research Issues, 296
Other Insurance Issues, 296
Other Cost-Related Research Areas, 299
Cost, Insurance, and Public Policy Research Needs Specific to
Adolescents, 299
Other Public Policy Research Needs, 301
Part III: Support for Scientific Progress in the
Prevention and Treatment of Alcohol Related Problems
Introduction
Chapter 15 SUPPORTING THE SCIENTIFIC INFRASTRUCTURE FOR
PREVENTION RESEARCH 309
Mechanisms of Support for Prevention Research, 310
Infrastructure Needs, 310
Community Initiatives, 311
Cooperative Studies, 311
Chapter 16 SUPPORTING THE SCIENTIFIC INFRASTRUCTURE FOR
TREATMENT RESEARCH 313
Acknowledgments, 323
Index, 325
. .
X11
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Chapter 9 TREATMENT MODALITIES: PROCESS AND OUTCOME . 169
Outcome Research on Specific Treatment Approaches, 169
Research on Traditional Treatment Programs, 185
Research on the Intensity and' Duration of Treatment, 188
Research on Aftercare, 189
Treatment Process Research, 190
Conclusions, 195
Chapter 10 EARLY 'IDENTIFICATION AND TREATMENT 215
Controlled Trials and Program Evaluations, 215
Brief Interventions and Treatment Research, 216
Research on Interventions with Pregnant Women, 217
Research on Nonabstinence Outcomes and Goals, 218
Screening, Recruitment, and Implementation, 221
Chapter 11 PATIENT-TREATMENT MATCHING AND OUTCOME
IMPROVEMENT IN ALCOHOL REHABILITATION 231
Advances in Patient-Treatment Matching Research, 1978-1988, 231
Advances in Treatment Measurement, 235
Research on Patient-Treatment Matching: Perspectives and
Opportunities, 237
Patient-Treatment Matching: Some Conclusions and Research
Recommendations, 241
Chapter 12 ADVANCES IN THE TREATMENT OF OTHER PSYCHOACTIVE
SUBSTANCE-USE DISORDERS: IMPLICATIONS FOR RESEARCH
ON TREATMENT OF ALCOHOL PROBLEMS 247
Smoking, 247
Other Drug Dependencies, 255
Conclusions, 260
Chapter 13 THE HEALTH CONSEQUENCES OF ALCOHOL ABUSE:
OPPORTUNITIES FOR TREATMENT RESEARCH 267
Intoxication, 267
Alcohol Withdrawal, 268
NeIvous System Effects, 27S
Cardiovascular Effects, 278
Liver Effects, 280
Other Health Consequences of Alcohol Abuse, 282
. . .
x~
%
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Chapter 14 TREATMENT COSTS, BENEFITS, AND COST ONSETS: PUBLIC
POLICY CONSIDERATIONS 289
Treatment Effectiveness, Benefits, and Efficiency, 289
Methodological Approaches to Polipy Analysm, 290
The Cost Offset Effect, 292
Managed Care and Preferred Provider Research Issues, 296
Other Insurance Issues, 296
Other Cost-Related Research Areas, 299
Cost, Insurance, and Public Policy Research Needs Specific to
Adolescents, 299
Other Public Policy Research Needs, 301
Part III: Support for Scientific Progress in the
Prevention and Treatment of Alcohol Related Problems
. .
Introduction, 308
Chapter 15 SUPPORTING THE SCIENTIFIC
PREVENTION RESEARCH
Chapter 16 SUPPORTING THE SCIENTIFIC
TREATMENT RESEARCH
Acknowledgments, 323
Index, 32S
xiv
INFRASTRUCI~URE FOR
........................ 309
INFRASTRUCTURE FOR
................ , 313
