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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