Interview #1:

'Targeting the At-Risk Drinker'

John C. Higgins-Biddle, PhD, is an assistant professor in the department of community medicine at the University of Connecticut School of Medicine, Farmington. He is co-director of Cutting Back™, a national program sponsored by the Robert Wood Johnson Foundation to test whether screening and brief interventions for "at-risk" drinkers can be used in primary care practices.

Q: What is meant by "at-risk" drinking?

A: At-risk drinking is a pattern of regular or occasional alcohol consumption that is hazardous or harmful to one’s self or others. The U.S. Department of Agriculture nutrition guidelines have established that high risk or harm increases substantially for men if they consume more than two drinks a day and for women if they drink more than one. The National Institute on Alcohol Abuse and Alcoholism goes a step farther and recommends that people 65 and older, regardless of their gender, have no more than one drink a day.[2] It is important to say that there are situations and conditions in which people should not consume alcohol at all. People who are alcohol-dependent, who are pregnant or considering getting pregnant or taking certain medications should not drink, nor should people who are driving or operating machinery.

Q: How does at-risk drinking differ from alcohol dependence?

A: The vast majority of at-risk drinkers drink too much occasionally, and that may include people who do it only once a year at New Year's or St. Patrick's Day as well as people who do it on a regular weekly basis or several days a week. People who are alcohol-dependent (often called "alcoholics"), in contrast, have a diagnosable disorder. They have a cluster of three or more symptoms in the past year that might include increasing tolerance to a given dose of alcohol, withdrawal symptoms, drinking more than initially planned and continued use despite medical, social or work-related problems. Only 5 percent of the population are alcohol-dependent, while 20 percent are at-risk drinkers. Approximately 35 percent of Americans drink within recommended limits, and 40 percent do not drink or drink so infrequently they can be considered abstainers.

We need a lot more research, but I think ultimately we are going to find that the bulk of the harm associated with alcohol in our society is not caused only by people who are alcoholics. There are about four times as many at-risk drinkers as there are alcoholics. It's simply a matter of the statistics that the at-risk drinkers are going to produce more harm.

Q: What potential harm do drinkers face?

A: More than 100,000 people die every year in this country because of alcohol-related events, and most of them are not people with cirrhosis of the liver. The risks include short-term conditions or injuries that are related to intoxication and long-term medical problems that result from regular excessive use. People who drink excessively are at higher risk of a wide range of problems related to the liver, pancreas and gastrointestinal tract. They also are at greater risk for a variety of cancers, including breast, head and neck. Excessive drinking exacerbates hypertension and is a factor in certain kinds of strokes. It’s obviously a big factor in injury and deaths from motor vehicle crashes and falls. In addition to these medical problems -- which largely relate to the individual who consumes the alcohol -- there are a whole range of alcohol-related problems that affect other people, including spousal abuse, sexual abuse, rape and other forms of violence.

The other issue to remember here is that we are talking about degrees of risk. People who consume excessive amounts of alcohol only once a year are likely to have a lower risk of doing harm to themselves than people who do it on a daily basis. On the other hand, a person who drinks excessively once or twice a year still has a higher risk of falling down the stairs or hitting a bridge abutment than someone who doesn’t.

Q: Attention historically has focused on treating people who are alcohol-dependent. What effect has that had?

A: By focusing primarily on treatment of people who are alcohol-dependent, we have not only ignored the problems related to at-risk drinking, we have also missed important opportunities to prevent people from becoming alcohol-dependent. Not all at-risk drinkers will become dependent, but many will. Some at-risk drinkers, on the other hand, are diverted into intensive alcohol treatment programs while there are less expensive options that can reduce the potential harm they face and reduce their risk of becoming alcohol-dependent.

Q: How do programs for at-risk drinkers differ from those for people who are alcohol-dependent?

A: In this country, the consensus is that abstinence is the key for people who are alcohol-dependent, and treatments modeled on the Alcoholics Anonymous 12-step program have been very effective. For at-risk drinkers, more than 40 clinical trials here and abroad have shown that they can be identified relatively easily using a variety of screening questionnaires, and they can be persuaded by brief advice from their doctor or other health care provider to reduce their alcohol consumption significantly.

Not everyone will respond to this advice, but a significant proportion will and reduce their drinking enough to make a difference. If one approaches the phenomenon of at-risk drinking from the perspective of the whole population, then performing brief interventions with those people who are at-risk drinkers will over time have a significant effect on reducing the problem in that population. And because brief intervention is relatively inexpensive, it may be a cost-effective approach to dealing with the problem of at-risk drinking within the entire population.

It is also important to emphasize that we are not talking about people who are alcohol-dependent. At-risk drinkers are in control of their behavior. However, there's no research to my knowledge that shows a brief intervention is going to cure an alcoholic.

Q: You are currently testing a large national screening and brief intervention program called Cutting Back™. With all the previous trials, what makes this one different?

A: We’ve had a large number of very well-controlled trials to determine the efficacy of this approach. Now we are trying to determine whether it can actually be implemented effectively in primary care practices within the managed care environment.

Within five sites in Wisconsin, Colorado, New Mexico, Michigan and New Hampshire, more than 45,000 patients were screened and almost 12 percent were positive for at-risk drinking. We are now just beginning to analyze our results, but in one site patients who received interventions reduced their weekly drinking by 40 percent compared to a 12 percent reduction among those who did not receive an intervention. Moreover, a lower percentage (13 percent) of those receiving interventions increased their drinking than those who did not (24 percent). These modest but statistically significant results suggest that screening and brief interventions are likely to provide meaningful reductions over time in alcohol consumption and related problems among primary care and HMO populations.

Interview #2:

'Screening and Brief Intervention'

Michael F. Fleming, MD, is professor of family medicine and director of the Center for Addiction Research and Education at the University of Wisconsin Medical School, Madison. Dr. Fleming has led several large trials of screening and brief interventions for at-risk drinkers and regularly trains physicians and other health care providers in the technique.

Q: What is the basic idea behind screening and brief intervention?

A: Routine screening is done to identify patients who have potential problems. Screening for at-risk drinkers is not all that different from screening people for high blood pressure, diabetes or breast cancer. Brief intervention is an office-based counseling technique where you try to persuade patients to change their behavior.

Q: With diabetes or hypertension there are objective physiologic measures. Are there similar tests for at-risk drinking?

A: There are certain lab tests that can suggest patients are using alcohol excessively. But in our screening of at-risk drinkers we ask questions about the quantity and frequency that people drink to see if they drink too much -- men who drink more than two drinks a day, women who drink more than one drink a day, people who binge-drink a couple of times a week. One or two drinks a day is probably safe for most people and may have some cardioprotective effects. Three or four drinks a day leads to some pretty significant health problems.

Q: Suppose I came to your office and told you I don't drink during the week, but on weekends I down a six-pack on Friday and Saturday nights. How does the brief intervention work?

A: In the first part of the intervention, I would tell you that you are drinking above recommended limits based on health risks and you are drinking more than most people do. Then I’d give you a clear recommendation about stopping drinking or cutting down. The advice would be personalized so that if you are having stomach troubles or are feeling depressed, we’d review how alcohol may be contributing to these or other conditions. Then we would negotiate an amount to cut down to, and I might write out a "prescription" or you might sign a contract agreeing to that goal. We would then follow-up in a couple of weeks either in person or on the phone to see how well you have done. It's pretty simple behavioral modification.

Q: You’ve studied the effectiveness of screening and brief intervention in a number of trials. What have you found?

A: In one trial, called Project TrEAT (Trial for Early Alcohol Treatment), my colleagues and I followed 774 patients ages 18 to 65 who had screened positive for at-risk drinking.[7] About half of the patients received the brief intervention, including counseling sessions and follow-up phone calls. A control group received a booklet reviewing general health information. A year later we found that the intervention group had reduced its drinking significantly, from an average of 19.1 drinks a week to 11.4. The control group also reduced its drinking, but less dramatically, from 18.9 drinks a week to 15.4. Binge drinking also decreased by more than 45 percent in the intervention group and 21 percent in the control group.[8]

Q: Managed care companies frequently want to know not only if an intervention is effective but whether it is cost effective? Was this project cost effective?

A: In Project TrEAT, at a cost of about $80,000, we demonstrated savings of nearly $425,000 in reduced crime, motor vehicle accidents and hospital and emergency room use -- a savings of more than $56,000 for every $10,000 invested in the intervention.[9]

Q: Is it necessary that a physician provide the intervention or can a nurse practitioner or other health care provider do it?

A: I guess we're not sure. We think it should be a person that has a relationship with the patient. That seems to make a difference. I think nurse practitioners and lay people can do this if they are well trained. But typically it should be somebody in the physician's office with whom the patient is already familiar.

Q: What are the biggest obstacles toward implementing screening and brief intervention in general practice?

A: That's a really complicated question. Lack of training is one. Many physicians don't have the skills, and they're not comfortable addressing people’s alcohol use. There's a perception that most people with alcohol problems don't change. Reimbursement is also a problem. Plans don’t pay for preventive counseling, or they pay at reduced rates. Doctors' offices are also getting pretty busy and in the typical seven-to-eight minute visit it can be hard to squeeze in screening for alcohol, diet, exercise and breast or prostate cancer. Physicians tend to do things they're comfortable with and things they feel they can make a difference with, and alcohol counseling doesn't tend to be high on the list of things to do.

Q: What steps can be taken to encourage more doctors to do this?

A: Training in medical school and residency programs would be a start so that doctors have the skills and are comfortable doing it. There needs to be more of a culture within medicine and an expectation that when you go to your doctor's office, he or she is going to ask you about alcohol and take your blood pressure. People in emergency rooms and trauma centers need to be held accountable if they don't do alcohol screening. And as peer review committees, accreditation organizations and consumer groups start to see this as a measure of quality health care, health plans and doctors will respond to the pressure as everyone else does.

What is a Drink?

One standard drink is defined [5] as:

* 12 ounces of beer

* 5 ounces of wine

* 1.5 ounces of 80-proof distilled spirits.

All contain approximately 0.5 ounces of pure alcohol.

Physicians Fail to Screen for At-Risk Drinking:

Although numerous studies demonstrate that doctors are key to identifying at-risk and alcohol-dependent patients, evidence suggests that most physicians don’t talk with their patients about alcohol and substance abuse. Less than one third (32.8 percent) of primary care physicians carefully screen their patients for alcohol and substance abuse regularly, according to a May 2000 national survey of nearly 650 physicians conducted by the National Center on Addiction and Substance Abuse at Columbia University. Two in five (40.7 percent) physicians find it difficult to discuss alcohol abuse with their patients and a majority (57.7 percent) say they do not discuss alcohol or substance use because they believe patients lie about it. More than one third (35.1 percent) say they do not do so because of time.[14]

Policy Alternatives:

Although many efforts to curb alcohol consumption focus on the individual, a number of public policy approaches can be effective tools to reduce at-risk and underage drinking, says George Hacker, director of the Alcohol Policies Project of the Center for Science in the Public Interest, a Washington, DC, advocacy group. Among them:

Increase alcohol excise taxes. Hacker says that substantial evidence in the research literature demonstrates that raising the price of alcoholic beverages through higher state and federal excise taxes can reduce a variety of alcohol-related problems, including fatal and nonfatal motor vehicle crashes, cirrhosis of the liver and crime.[3] But federal excise taxes on beer and wine have been increased only once in the past 50 years and taxes on distilled spirits just twice. As a result, prices for alcoholic beverages have trailed the Consumer Price Index for all products and have trailed nonalcoholic beverages even more dramatically. One researcher estimated that if the federal excise tax on beer were indexed to inflation since 1951, more than 1,000 motor vehicle deaths among 18 to 20 year olds would be prevented each year.[11]

Restrict youth-oriented alcohol advertising and promotion. The alcohol beverage industry spends $1.2 billion a year on broadcast and other advertising and perhaps another billion through sponsorships, discounts and other marketing efforts, Hacker says. Much of that advertising is youth-oriented with, for example, recent ads featuring members of the U.S. women’s Olympic soccer team and professional women basketball players. In its 10th Special Report to the U.S. Congress on Alcohol and Health, the National Institute on Alcohol Abuse and Alcoholism concluded that "children and adolescents who view, or are made aware of, alcohol advertisements hold more favorable beliefs about drinking, intend to drink more frequently as adults and are more likely to be drinkers than are other young people."[1] Efforts should be similar to those directed at tobacco, Hacker says: ban billboard advertisements; restrict alcohol commercials to times of day that are not likely to have a large youth audience; ban sponsorships of music, sports and other youth oriented events; and ban the use of alcohol by cartoon and other characters that largely appeal to young people.

Prohibit misleading health claims for alcohol. In light of increasing evidence that moderate drinking may reduce the risk of cardiovascular disease in some people, the alcohol industry has been promoting alcohol consumption as a healthy activity, frequently by making misleading claims, Hacker says. For example, while the wine industry touts the low rate of cardiovascular disease in France, where wine consumption exceeds that of other developed countries, the industry fails to note that nearly 25 percent of all premature deaths in France have been attributed to alcohol, Hacker says.

The federal Bureau of Alcohol, Tobacco and Firearms (ATF) is reviewing a proposal to amend rules that now allow winemakers and others to include "directional" health statements on alcoholic beverage labels. Some current wine labels urge consumers to talk with their physician about the health effects of alcohol consumption or send for a government pamphlet. Aside from implicitly endorsing the generic message that drinking is healthy, the concept of "moderate [drinking] has no meaning" to consumers. According to a study conducted for the federal Substance Abuse and Mental Health Services Administration,[6] people’s view of moderate consumption varied from one or two drinks a month to a bottle of wine a night. The more that people drank on a regular basis, the greater the number of drinks they viewed as moderate. Heavy drinkers said consuming six drinks on one occasion was moderate drinking -- a level viewed by most researchers as "binge-drinking."

A ruling by ATF is expected in the next few months, Hacker says.

Strengthen the federal government’s focus on alcohol as a major youth drug problem. The White House Office of National Drug Control Policy spends approximately $200 million a year on a five-year national youth anti-drug campaign. The campaign targets use of marijuana, cocaine, heroin and amphetamines. But public health advocates say the campaign is missing an important opportunity to address underage drinking, which involves a far greater proportion of adolescents. For example, while 51 percent of 12th graders have used alcohol in the past 30 days, 23 percent have used marijuana, 2.6 percent have used cocaine, 2.0 percent have used inhalants, and 0.5 percent have used heroin.[15] ONDCP reportedly has resisted the inclusion of alcohol for fear of "diluting" the campaign. But some communications researchers assert that alcohol can easily be inserted into current ads and that would only strengthen the message. For example, in ads with the tagline, "Another missed opportunity to talk with your child about marijuana," the message could easily read: "Another missed opportunity to talk with your child about alcohol and other drugs."[4]

Curbing Binge-Drinking on Campus:

Perhaps no group of at-risk drinkers has received more attention in recent years than the nation’s college students. Almost half (44 percent) of all students are binge-drinkers -- men who consume more than five drinks in a row at least once in the previous two weeks and women who consume more than four, according to Henry Wechsler, PhD, principal investigator of the ongoing College Alcohol Study at the Harvard School of Public Health.[19]

Although headlines have focused on a few tragic deaths from alcohol poisoning, Wechsler and his colleagues have documented binge-drinking’s widespread consequences -- both for those who binge drink and those who do not. Frequent binge-drinkers, for example, are 4-to-15 times more likely than those who do not binge drink to experience problems related to drinking, including: missing class, arguing with friends, getting hurt or injured or getting in trouble with campus or local police. And problems are not limited to drinkers. Students at schools with high rates of binge drinking who do not binge drink are three times more likely to experience at least one problem related to another student’s drinking than students who attend schools with lower binge-drinking rates. These problems include having their study or sleep interrupted; being pushed, hit or assaulted and experiencing unwanted sexual advances or assaults. Overall, the incidence of physical assaults, damage to school property, and sexual assault or date rape are highest at schools with the highest proportions of binge-drinkers, Wechsler and his colleagues have found.[20]

While many colleges and universities have begun efforts to curb binge-drinking, most have done "the easy things," he says. In a survey of 734 college administrators, he found that schools commonly have launched educational interventions targeted at individual students and their behavior.[18] Schools are less likely to take a more comprehensive and long-term approach to the problem.

"However, some schools are working with the community, which is really the key," Wechsler says. That is the premise of a national program supported by the Robert Wood Johnson Foundation called, "A Matter of Degree." Campus/community coalitions at 10 universities nationwide are implementing a range of strategies both on and off-campus to curb at-risk drinking, says Richard Yoast, PhD, director of the American Medical Association’s Office of Alcohol and Other Drug Abuse, which administers the program.

"The core idea is to manage the environment and make drinking less the norm, less socially acceptable," Yoast says. "General strategies include reducing the availability of alcohol, making university and community standards and laws clear and enforcing them, and helping students to develop alternative activities to drinking." For example,

* At the University of Delaware, the University of Vermont, and The University of Wisconsin, university and community coalitions have become involved in the alcohol licensing process to curb the opening of new taverns, which frequently ring college campuses.

* The University of Iowa closed its campus pub and the University of Colorado has banned beer sales at its football stadium.

* The student newspaper at Louisiana State no longer accepts advertising that promotes high-risk drinking, such as 25-cent beers or all-you-can-drink for $5.

* The University of Iowa is building more recreational facilities, and a parents’ group at the University of Wisconsin has raised funds to keep the student union open later.

While it is too soon to evaluate the outcome of the project (a formal evaluation by Wechsler is underway), Yoast says there are already signs at some schools that secondary effects, such as arrests and vandalism are declining. In cities like Burlington, VT, and Bethlehem, PA, traditional "town and gown" tensions have lessened, he says.

Steps to the Collaborative Reduction of Health Behavior Risks:

Successfully reducing health behavior risks such as smoking, physical inactivity, obesity and alcohol and substance abuse is a process that may be best achieved through the collaborative engagement of providers and patients. These simple steps, drawn from research on the collaborative management of chronic illness, provide one framework for providers and patients to work together to help patients improve their chances of staying healthy.

1) Ask: Providers provide a context for helping patients reduce health risks by asking patients about their lives and the regular activities in which they engage. Asking about health-threatening and health-promoting behaviors helps providers and patients establish a common starting point in addressing potential health risks.

2) Advise: Based on the information patients share with them, providers can help patients recognize how and why specific behaviors may threaten their health and advise them about steps that can be taken to change health-threatening behaviors.

3) Arrange: Armed with knowledge about programs and services that are appropriate to patients’ needs, priorities and preferences, providers can play a key role in helping patients reduce health risks through referrals to appropriate sources of supplementary health behavior change intervention and support.

4) Assist: Providers can help catalyze successful behavior change by targeting their assistance and interventions to patients’ specific circumstances. Arranging regular telephone contacts by office staff, for example, may help one patient’s efforts to change a lifelong habit, while another patient may do best with face-to-face visits with a provider that occur at less frequent intervals.

5) Anticipate: Successfully reducing health behavior risks involves a lifelong process of behavior change and monitoring. A critical step in this process is anticipating points at which re-evaluation of behavior change efforts and subsequent course corrections may be necessary. Planned follow-up by providers is one way to help ensure that needed course corrections take place.

The Research:

1. 10th Special Report to the U.S. Congress on Alcohol and Health. (2000). National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD. http://silk.nih.gov/silk/niaaa1/publication/10report/10-order.htm.
   
2. Alcohol and aging. (1998). Alcohol Alert No. 40. National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD. http://silk.nih.gov/silk/niaaa1/publication/aa40.htm.
   
3. Chaloupka FJ, Grossman M, Safer H. (1998). The effects of price on the consequences of alcohol use and abuse, in Recent Developments in Alcoholism, Vol. 14. New York: Plenum Press.
   
4. DeJong W. (2000). The drug czar’s anti-drug media campaign: Continuing concerns. Journal of Health Communication, 5:77-82.
   
5. Dietary Guidelines for Americans, 2000. U.S. Department of Agriculture, Washington, DC. http://warp.nal.usda.gov/fnic/dga.
   
6. Eigen LD, Kellerman K, DeJong W, Hairston B, Eng-Kohn B. (January 30, 1998). The effect of wine labels on public perception. Main findings. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention, Rockville, MD.
   
7. Fleming MF, Barry KL, Manwell LB, Johnson K, London R. (1997). Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. Journal of the American Medical Association, 277(13):1039-45.
   
8. Fleming MF, Manwell LB, Barry KL, Adams W, Stauffacher EA. (1999). Brief physician advice for alcohol problems in older adults: A randomized community-based trial. Journal of Family Practice, 48(5):378-84.
   
9. Fleming MF, Mundt MP, French MT, Manwell LB, et al. (2000). Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Medical Care, 38(1):7-18.
   
10. Grant BF, Dawson DA. (1997). Age at onset of alcohol use and its association with DSM-IV alcohol abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse, 9:103-10.
    
11. Grossman M. (1989). Health benefits of increases in alcohol and cigarette taxes. British Journal of Addiction, 84:1193-204.
    
12. Higgins-Biddle JC, Babor TF, Mullahy J, Daniels J, McRee B. (1997). Alcohol screening and brief intervention: Where research meets practice. Connecticut Medicine, 61(9):565-75.
    
13. McGinnis JM, Foege WH. (1993). Actual causes of death in the United States. Journal of the American Medical Association, 270(18):2207-12.
    
14. Missed opportunity: The CASA National Survey of Primary Care Physicians and Patients. (2000). The National Center on Addiction and Substance Abuse at Columbia University, New York, NY. www.casacolumbia.org.
    
15. Monitoring the Future Study. (2000). High School and Youth Trends. NIDA Infofax 13565. National Institute on Drug Abuse, Baltimore, MD. www.nida.nih.gov/DrugPages/MTF.html.
    
16. Ockene JK, Adams A, Hurley TG, Wheeler EV, Hebert JR. (October 1999). Brief physician- and nurse practitioner-delivered counseling for high-risk drinkers: Does it work? Archives of Internal Medicine, 159(18):2198-205.
    
17. Ponicki W, Holder HD, Gruenewald PJ, Romelsjo A. (1997). Altering alcohol price by ethanol content: Results from a Swedish tax policy in 1992. Addiction, 92(7):859-70.
    
18. Wechsler H, Kelley K, Weitzman ER, San Giovanni JP, Seibring M. (2000). What colleges are doing about student binge drinking: A survey of college administrators. Journal of American College Health, 48(10):219-26.
    
19. Wechsler H, Lee JE, Kuo M, Lee H. (2000). College binge drinking in the 1990s: A continuing problem. Journal of American College Health, 48(10):199-210.
    
20. Wechsler H, Moeykens B, Davenport A, Castillo S, Hansen J. (1995). The adverse impact of heavy episodic drinkers on other college students. Journal of Studies on Alcohol, 56(6):628-34.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research, Academy of Psychosomatic Medicine, American Academy of Nursing, Association for Applied Psychophysiology and Biofeedback, American College of Neuropsychopharmacology, American Psychiatric Association, American Psychological Association, American Psychological Association-Division 38, American Psychological Society, American Psychosomatic Society, American Sociological Association, American Society of Psychiatric Oncology, College on Problems of Drug Dependence, Institute for the Advancement of Social Work Research, International Psycho-Oncology Society, International Society for Traumatic Stress Studies, Society of Behavioral Medicine, Society for Developmental and Behavioral Pediatrics, Society for Public Health Education, Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health is an independent nonprofit organization that promotes greater recognition of how psychological, social, behavioral, economic, and environmental factors influence health and illness. The Center advocates the highest quality research and communicates it to the medical community and the public. The fundamental aim of the Center is to translate into policy and practice the growing body of evidence that can lead to the improvement and maintenance of the health of individuals and the public. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding. Funding for this series was provided by the Robert Wood Johnson Foundation.

For Information Contact:
Ira R. Allen
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Center for the Advancement of Health
2000 Florida Ave., NW, Suite 210
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p. 202.387.2829 / f. 202.387-2857
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