CHAPTER ONE:  HEALTH PROMOTION PROGRAMS

Health Promotion Programs in Canada

Health promotion programs cover a wide range of goals (health enhancement, risk avoidance and risk reduction), targets (person, environment and drug) and strategies (influence, control, competence development and environmental design).  These programs also rest on a variety of theoretical foundations and may be implemented in a range of settings or systems within the community.

            The approach to health promotion has broadened in recent years.  For example, school-based programs once limited to health education now include a stronger theoretical base emphasizing peer influences, resistance to persuasion, beliefs about risks and consequences, social learning and self-efficacy (Gliksman and Smythe 1989).  The emerging themes are comprehensiveness, community participation and the integration of efforts among key community stakeholders (Shain et al. 1990).

            Gliskman and Venesoen (1990) recently completed a review of alcohol- and drug-specific health promotion activities in Ontario.  The diversity of approaches they observed probably mirrors the situation across the country.  While most programs (78%) sought to "provide education and promote awareness" of alcohol and other drug abuse,  there was a wide variety of other objectives, such as providing information on risks and consequences, improving life skills and improving parenting skills.

            The most frequently identified target group was youth and children (50%), followed by the general public (25%) and parents (5.5%). The most common target area was the "person" with 64% of the programs trying to change knowledge, attitudes, intentions, behaviors and/or skills of individuals.  Twenty per cent of the programs focused on making the environment safer or more supportive of individual changes. A further 16% of programs were aimed at the drug itself (e.g., making it safer).

            Most programs were implemented in elementary schools (40%), secondary schools (35%), or in the general community (56%).[3]  Other avenues included the family, post-secondary schools, workplace, corrections and the implementation of social controls through legislation.  The principal strategy being used was one of "influence" (62%).  These programs tried to change knowledge or attitudes of the individual, as opposed to "competence development" (39%), environmental change (15.5%) or control strategies to reduce the supply or demand for alcohol or other drugs (11%).

 

School Programs

Health promotion programs aimed at youth tend to be concentrated within the school system.  Young people who are not in school, such as those who are "on the streets," are much harder to reach.  The knowledge/attitudes/behavior model most widely used in schools assumes that increased knowledge about the consequences of alcohol and other drug abuse will change attitudes and in turn, lead to changes in behavior.

            Other theoretical models used in school-based programs are the values/decision-making model and the social competency model (Moskowitz 1989). The values/decision-making approach focuses on the individual's self-examination of their needs or values and the roles that alcohol and other drug use serves in fulfilling these needs.  The social competency model teaches students communication and social skills to resist social influences that promote alcohol or other drug use.

            A common finding for school-based education programs internationally is that they do increase knowledge (Gliksman and Smythe 1989).  However, relatively few programs influence attitudes, and even fewer influence behavior (Williams et al. 1985).

            Some evaluations of school-based programs have found reductions in alcohol and other drug use, but typically over the short-term (Schaps et al. 1982; Moskowitz et al. 1984b).

            These mixed findings are also evident in Canadian evaluations of school-based programs.  One such program, which was implemented in two primary schools in Quebec and evaluated by Crete and Grignon (1983), typifies the Canadian experience.  The program was multifaceted and included giving questionnaires to 4th, 5th and 6th graders; holding an information session with parents to give them the results of the questionnaire and to tell them about the prevention program; group work by 6th graders on drug-related topics; and presentations of the results of the research to parents and other students.  The process and outcome evaluation data showed mixed results.  While the program was cited as having "gone well," comparisons with students who had not participated in the program indicated no significant difference in knowledge or attitudes.

            Evaluations of educational theatre programs indicate results similar to those of other types of school programs.  Some evaluations show short-term gain in knowledge, attitudes and/or behavior but no evidence of longer-term changes.  Desbiens and Mercier (cited by Chamberland 1989) evaluated a play called "Captain Cosmos," which was directed at children in primary schools in the Montreal area. This program was based on the American "Dare" program with its "Just Say No" slogan.  No change in attitude towards drugs and alcohol, or in the intention to consume them, were found in either the comparison or intervention groups.  However, in Alberta, an evaluation of a performance called "Zeke and the Indoor Plants" showed a significant impact on student knowledge about the themes of the program (Atwood et al. 1987).

            In summary, Canadian evaluation studies of school-based prevention programs, as well as international studies, have generated mixed results. And so, the question remains: what is the best way to design and deliver school-based programs?  Moskowitz concludes his recent review of alcohol prevention programs by stating that, to be effective, educational programs may require a change in community norms and values regarding alcohol and other drug use, much like that which has occurred over the last decade with smoking.  To reinforce the messages received in school, such school-based programs and policies should also be supported by the community, and be consistent with other interventions such as parenting programs, mass media campaigns and policy initiatives.  This integrated approach would seem to be the most prudent strategy at the present time, given the limited evidence from evaluation studies concerning the effectiveness of school educational programs that operate in isolation.


University/College Programs

Health promotion programs aimed at university and college students are usually based on similar theoretical models of health behavior and elements of all three approaches described in the previous section are frequently employed: knowledge/attitudes/behavior, values/decision-making and social competency.  One important difference, however, is that the university and college programs are often more comprehensive, for example, using various print and electronic media as well as policy changes concerning the availability of alcohol.


            Goodstadt and Caleekal-John (1984) reviewed 14 U.S. evaluations of alcohol education programs on college campuses, seven of which used a comparison group and assessed changes in self-reported, alcohol-related behavior over time.  Although they found that five of the seven reported fewer alcohol problems at post-test, the nature of the evaluations made it difficult to be certain of the reasons.  Moskowitz (1989) raised concerns about the equivalence of the experimental and comparison groups in these studies, especially since members of the experimental group were usually volunteers.

            The most comprehensive university-based health promotion program to be evaluated in Canada was implemented at the University of Western Ontario in London, Ontario.  The program, Campus Alcohol Policies and Education (CAPE), sought to prevent: drinking to drunkenness; maintaining a high average daily consumption; drinking and driving; and drinking prior to or during academic activities (Hart 1986).  Although it targeted first-year students, the program was expected to have an impact on the entire university community over the long term.  The program comprised an extensive education campaign that included mass media, small group, and individual communication strategies; and a set of campus alcohol policies to guide the sale and use of alcohol in outlets on campus, including training bartenders to avoid serving intoxicated patrons, making food and non-alcoholic drinks more available, promoting "light" beers, and establishing a differential price structure depending on alcohol content.


             Initial data on program effectiveness were not encouraging (Gliksman, Hart et al. 1989; Gliksman 1990).  However, a second intervention that reduced the length of the mass media campaign, and only implemented policies on which there was unanimous agreement, appeared to have more success.  Using a more complex evaluation design, Gliksman, Hart et al. (1989) concluded that significant positive changes occurred in the knowledge about, and attitudes towards, alcohol of the first-year students receiving the program, compared to students at another university who did not.  Results also suggested that the program moderated or halted the typical sharp increase in alcohol consumption by first-year students over the course of the year.

             As with the school-based programs, some university- and college-based programs have brought about short-term changes in knowledge and attitudes, and perhaps behavior, but evidence of long-term impact is lacking.

Mass Media Programs

Mass media campaigns, like most educational health promotion programs, have been based primarily on the knowledge/attitude/behavior model.  Moskowitz (1989) examined six of the best designed evaluations of mass media campaigns conducted between 1971 and 1982.  Two of the six were Canadian studies of the effects of anti-drinking and driving campaigns (Pierce et al. 1975; Vingilis et al. 1979).  Both campaigns produced gains in knowledge, and one was associated with several small positive changes in self-reported behavior (Pierce et al. 1975).  After reviewing results from all six programs Moskowitz (1989) concluded that, as with school-based educational programs, mass media campaigns alone are not likely to produce significant and lasting changes in alcohol or other drug use.

            Such programs may, however, be helpful in increasing public support for other types of health promotion efforts, such as taxation policies or restrictions on advertising.  An evaluation of the Community Action Project in New Zealand (Casswell and Gilmore 1989) illustrated how a mass media campaign predisposed the public to support restrictions on the availability of alcohol.

            In addition to the Canadian studies cited by Moskowitz (1989),  Health and Welfare Canada (1988) has evaluated its three English and three French national public awareness and information campaigns aimed at youth and young adults:  "Really me"/"Les drogues . . . pas besoin!" (Action on Drug Abuse Program); "Play It Smart"/"Moi, j'ai toute ma tete!" (Long-term National Program on Impaired Driving); and "Break Free"/"Pour une génération de non-fumeurs" (National Program to Reduce Tobacco Use).  A high percentage of individuals in the target groups in each tracking study, including those at risk, were aware of the campaign and most felt that the ads were interesting and credible.  Survey respondents were also asked whether they believed that they, or others, were likely to change their behavior regarding using alcohol and other drugs, drinking and driving, and smoking as a result of the campaign.  The majority responded positively to these measures of behavioral intention.

            Over the 1980s, the Alberta Alcohol and Drug Abuse Commission (AADAC) devoted considerable resources to mass media campaigns aimed at adolescents, and to a lesser extent, their parents.  The campaigns have included television, radio and print messages, as well as Zoot Capri, a magazine for adolescents featuring articles of general interest and specific themes related to alcohol and other drug prevention. A multifaceted approach has been employed for the evaluation of these programs and some aspects of these evaluations have focused on behavioral outcomes.

            One study evaluated the impact of AADAC's primary prevention campaign for adolescents over a four-year period (Thompson 1986a).  Evaluation data gathered through interviews with Alberta teens and their parents showed that components of the media campaign were highly successful in increasing awareness of substance abuse for adolescents and their parents compared to Manitoba, where campaigns similar to AADAC's were not implemented.  Furthermore, both frequency of drinking occasions and total quantity consumed by Alberta teens showed a significant decline between 1981 and 1985.  There was also a trend toward a delay in the onset of drinking.  In sharp contrast, opposite trends appeared in Manitoba.  Many of these findings were replicated in a subsequent household survey comparing Alberta and Manitoba teens (Thompson et al. 1987).

            The most recent follow-up study in the AADAC evaluation showed a departure from the positive trends for several indicators found in the earlier studies.  For example, although the percentage of Alberta teenage drinkers had declined steadily from 55% in 1981 to 43% in 1987, the prevalence of drinking had dropped much faster in Manitoba between 1986 to 1987.  Similarly, data on the age at which teens started drinking and the total quantity of alcohol consumed showed that Alberta teens were starting to drink at younger ages than their Manitoba counterparts.  The study suggested that the withdrawal of radio and television commercials in 1986 (in order to focus attention on Zoot Capri) was largely responsible for the negative findings.  It was also suggested that the electronic mass media may be necessary, in addition to print media, to focus and reinforce AADAC's prevention goals.

            The results of these Canadian studies of mass media campaigns are generally consistent with those cited in the international literature: mass media campaigns may influence knowledge about alcohol and other drugs but are unlikely to create long-standing behavioral change by themselves.  These campaigns seem to have the greatest impact in areas that are already salient in the minds of the target audience (e.g., drinking and driving).

 

Family-Based Prevention Programs

Family-based prevention programs represent another alternative within the spectrum of alcohol and other drug health promotion programs.  Some family-based programs aim to change parents' knowledge of, and attitudes towards, alcohol and other drugs.  Other programs focus on improving parenting skills generally.

            Many programs aimed at parents have been based on the "persuasion approach," whereby information is provided to parents in an attempt to modify beliefs and attitudes.  A second approach is based on "behavioral" or "social learning" theory.  It is based on the belief that a child's behavior can be shaped through the judicious use of reward and punishment, and by having parents serve as positive role models for their children.

            While there is a fair amount of research on these two approaches to prevention, there is very little research on their actual effectiveness.  For example, a review of parental education programs published by Health and Welfare Canada (1984) identified 12 programs to help parents deal with their children in general and 10 programs that focused specifically on alcohol and other drugs.  Of the 22 programs, only 6 had any kind of formal evaluation.

            Evaluations of family-based prevention programs both in Canada and the U.S. have provided little evidence of long-term effects on alcohol and other drug use among the children.  Some results for parents are positive with improvements noted in parental confidence, self-esteem, knowledge and attitudes.  However, the extent to which parents manifest changes in their behavior at home has not been investigated.  The results for children are less positive with either negligible behavioral changes or, in some cases, increased levels of substance use being found.  In addition, family prevention programs have had problems recruiting and maintaining parental participation.

            Although family-based prevention programs may be used to augment other programs, such as school-based prevention programs, the objectives of the programs need to be clearly stated and outcomes evaluated in light of these objectives.  There is currently insufficient evidence to conclude that they contribute to prevention efforts or to warrant choosing one type of program over another.

 

Community Programs

In community-based health promotion programs, the whole community is targeted.  A "community" may be defined in many different ways -- geographically, culturally or  organizationally (Perry 1986; Pederson et al. 1990).  Although there has been a keen interest in community-based health promotion programs, few such programs have been conducted or evaluated that focus specifically on alcohol or other drugs.

            Recently, a symposium was held in Scarborough, Ontario, and summarized the international experiences with community action projects for the prevention of alcohol and other drug problems (Giesbrecht et al. 1990).  Several Canadian studies were included in this symposium.  One example discussed was a program in Thunder Bay, Ontario, which involved the development and adoption of a policy regulating the licensing of alcohol in municipally owned parks and recreation facilities.  An extensive marketing campaign involving, for example, news items, public service announcements, paid advertisements, pamphlets and posters was also implemented to influence people to voluntarily comply with the regulations in the policy (see Douglas (1990) for an overview of the project).  The results of the evaluation showed that the campaign increased the intention of the residents to comply with the policy.  In addition, compared to a comparison community there were significant changes in residents' attitudes toward legal controls on drinking, tolerance of underage drinking, and support for the use of alcohol in recreational facilities (Gliksman et al. 1990).

            Evaluation of these community-based prevention programs has generally produced results similar to those for educational programs:  evidence of knowledge and attitude, and perhaps short-term behavioral change.

 

Server Intervention Programs

Over the past 15 years, it has become increasingly common for individuals to be sued for the conduct of their intoxicated patrons, guests or colleagues.  Consequently, in the past five years, hospitality organizations, government agencies, and alcohol producers have endorsed or developed server training programs.  A number of states in the U.S. and the provincial governments of Ontario and British Columbia are instituting mandatory training programs for all serving staff in licensed establishments.  At the federal level, the Health Promotion Directorate of Health and Welfare Canada, with support from the National Steering Committee on Impaired Driving, supported a national conference on server training in March, 1989.

            Preliminary evidence from the U.S. and Canada indicates that server training programs are effective in reducing intoxication.  Four evaluation studies have been conducted to date -- three in the U.S. and one in Canada.  One of the U.S. studies assessed the impact of the "TIPS" program (Training for Intervention Procedures by Servers) in two bars in a rural university town (Russ and Geller 1987; Geller et al. 1987).  Training involved approximately six hours of videotaped vignettes, leader-facilitated discussions, and server role-play segments.  Using actors posing as patrons, the study found that trained servers were less likely to serve patrons to the point of intoxication or beyond, and that the amount of gratuities did not suffer as a result.

            The only Canadian evaluation of a server intervention program was conducted in Thunder Bay, Ontario, in 1988 (Gliksman and Single 1988) using a pre-test and post-test design.  Observations were collected in eight taverns before and after the serving staff in four of the taverns were given the server training course offered by the Addiction Research Foundation.  Professional actors posing as patrons enacted seven "scenarios" involving behaviors covered in the training course such as ordering doubles, frequent ordering of drinks, drinking to intoxication and arriving intoxicated.  The study found significant positive changes in knowledge and attitudes by the trained serving staff.  Most importantly, the observation of their reactions to the actors' behavior revealed significant positive changes in dealing with patrons who were intoxicated, troublesome, seeking an excessive number of drinks, or apparently underage.

            While further studies are required to assess the benefits of server training programs over longer periods of time, the available data suggest server intervention programs can make an important contribution to the prevention of alcohol problems, especially drinking and driving.

 

Alcohol Control Policies

Governments adopt laws and regulations designed to influence alcohol and other drug consumption and to prevent related problems.  These policies control the physical, economic, and social availability of alcohol (Moskowitz 1989). Because of the extensive contribution of Canadian evaluation studies on the effects of alcohol control policies, both international and Canadian examples are discussed together in the following section.

            Policies Controlling the Physical Availability of Alcohol

Although the evidence is limited, controls on hours of operation of alcohol outlets have been found to be related to consumption patterns and alcohol problems in a number of settings.  Popham (1982) found arrests for public drunkenness to be correlated with hours of tavern operation in Toronto.  A study by Ollson and Wikstron (1982) in Sweden of the effect of Saturday outlet closures found that there was an overall decline in sales and in public drunkenness; a Saturday and Sunday decline in public disturbances and crimes of violence; and a 30% to 46% decline in domestic violence on Saturdays.  Overall, however, there are relatively little data concerning the impact of either extending or contracting the days and hours when alcohol is normally available for sale.

            Not surprisingly, complete prohibition on the sale of alcohol results in very low rates of alcohol consumption and alcohol problems (Popham 1956).  On a less dramatic scale, the evidence suggests lower rates of alcohol consumption will result when there are fewer outlets for the sale of alcohol.  Using structural equation modelling, Rush et al. (1986a), and Gliksman and Rush (1986) investigated the relationship between alcohol availability, consumption, and alcohol-related morbidity and mortality using data from Ontario's 49 counties.

            The findings were consistent and typical of the results from other studies.  There was a high, positive correlation between retail availability of alcohol and per capita consumption of alcohol, and between consumption and the level of alcohol-related morbidity.

            Another aspect of physical availability that has received attention in Canada is the selling of alcohol in corner stores.  A study of the impact of introducing limited wine sales in grocery stores in Quebec revealed no significant impact on wine sales or total alcohol sales (Smart 1986).  Proposed reasons for the lack of impact included depressed economic circumstances, the relative unpopularity of wine compared to other beverages, and the long-term trend toward lower alcohol consumption throughout Canada.  Macdonald (1986) assessed the impact of increased availability of wine in grocery stores on consumption in four states where a policy change to allow this option had recently taken place.  During the years after the policy change, in three of the four states, wine consumption increased significantly.

            The findings regarding the impact of the legal drinking age are relatively unequivocal.  The lower the drinking age, the lower the age at which adolescents first use alcohol, the higher the consumption of alcohol, and the higher the incidence of alcohol-related problems, including alcohol-related car accidents among teenagers (Smart 1977, Single et al. 1981).

            There is far less evidence as to whether raising the drinking age reduces consumption.  In general, while researchers have found that increasing the drinking age is sometimes associated with decreased rates of alcohol-related traffic injuries and fatalities among teenagers, the effects have generally been found to be minimal (Wagenaar 1986; Wagenaar and Maybee 1986).

            Policies Controlling the Economic Availability of Alcohol

Economic availability is concerned with the real price of alcoholic beverages in relation to disposable income and the cost of other beverages.  Cook (1981), and Cook and Tauchen (1982) found that relatively small increases in the price of distilled spirits due to an increase in state taxes led to significantly less consumption.  From a methodological point of view, Cook's research (1981) is among the strongest studies on this topic.  He compared the consumption of spirits before and after tax increases in 39 states to consumption within several states that had no tax increases.  The states with the tax increases had a significant decrease in consumption, as well as a decline in automobile and liver cirrhosis fatalities.

            A recent paper on taxation and alcohol policy prepared for Health and Welfare Canada by Johnson et al. (1990) includes a review of Canadian studies on the importance of price on alcohol consumption.  They conclude that a 10% increase in beer prices causes a short-run drop in demand of 3%.  For wine and spirits, the same increase causes an 8% decrease.

            Many researchers measure the potential impact of tax changes through simulation studies, a number of which are reviewed by Johnson et al. (1990).  These studies invariably show that increasing taxes and price would result in a decline in consumption as well as a decline in alcohol-related problems such as cirrhosis and traffic fatalities.

            The general public resists increases in government taxes.  However, increases in alcohol and tobacco taxes receive a higher level of approval than other levies such as property taxes, income taxes and general sales taxes (Johnson et al. 1990).  Data from the National Alcohol and Drug Survey (Health and Welfare Canada 1990) show that 46% of the Canadian adult population believe taxes on alcohol should stay the same, 27% believe they should be increased, and 18% believe they should be reduced.

            Policies Controlling the Social Availability of Alcohol

Social availability is concerned with the promotion of alcoholic beverages at the point of purchase, within the community and in the mass media.  Besides promoting beverages through advertising, the alcoholic beverage industry sponsors recreational and sports activities.  Accurate representation of the products (e.g., listing of ingredients, product warning labels) is also considered an aspect of social availability.  Misrepresentation of the product is another important consideration; for example, associating drinking with inappropriate activities such as sports and recreational activities or driving.

            In studies of alcohol advertising bans, none have found decreases in consumption attributable to the bans.  However, the bans have generally been partial or of short duration.  British Columbia banned the advertising of alcoholic beverages and tobacco from September 1, 1971 to October 31, 1972.  To assess the effects of the ban, Ontario was chosen as a comparison site.  Smart and Cutler (1976) analyzed yearly and monthly consumption of beer, wine and spirits and found no major effects of the ban on consumption.  They suggest several reasons for the ban's lack of success:  relatively short duration; lack of popular support; lack of support from the mass media; the fact that it was not total, since national and out-of-province advertisements could not be stopped; and uncertainty about the future of the ban with a change in government.

            Given the lack of evidence for the effectiveness of advertising, the amount of money invested in it, and by the breweries in particular, is striking.  It has been estimated that Canadian breweries spent approximately $375 million in 1988 on all promotional efforts, with $104 million being spent on purchased media (McMullen and Associates 1989).  Distilleries and wineries are estimated to spend $60 million and $10 million respectively.  According to McMullen and Associates (1989), alcohol producers are taking a "leap of faith" in their expenditure on promotion.  While they may suspect that some expenditures are wasted, as long as the competition is putting money into promotion they cannot afford not to do so.

            The warning messages on alcoholic beverages are another derivative of policies controlling social availability.  Much of the existing literature on alcohol warning labels consists of reports and reactions to legislative action (Single et al. 1989). The U.S. government commissioned a survey of public opinion regarding warning labels on alcoholic beverages and found strong support.  Data from the National Alcohol and Drug Survey (Health and Welfare Canada 1990) showed strong public support (74% approval) for warning labels in Canada.

            Engs (1989) used the health belief model to consider whether warning labels are likely to change behavior.  She concluded that warning labels might be effective, when combined into a comprehensive health promotion program, but that a warning approach alone was unlikely to have a major impact on consumption.  Smart (1988b) reviewed American studies on the effectiveness of warning messages on other products.  He concluded that warning labels on alcoholic beverages could be designed to be effective and that consumption could be reduced by 4% to 10%.

            Formal Social Control Policies Regulating Behavior

Societies adopt bodies of laws and policies that regulate the individual's use or possession of alcohol or other drugs.  These formal social controls also prohibit individuals from engaging in certain activities such as operating a motor vehicle while consuming alcohol or while under the influence.  Typically, such laws also prohibit serving alcohol to minors or intoxicated persons.

            Studies of the effectiveness of enforcement programs have shown mixed results.  Some have shown that laws defining levels of intoxication as well as sobriety check points can result in at least short-term reductions in motor vehicle crash rates (Vingilis et al. 1980; U.S. Department of Health and Human Services 1987).  To be most effective, the enforcement needs to be coupled with extensive media coverage.  In fact, media coverage may be even more important than the extent of road checks or police charging activity.


                                                        CHAPTER TWO: EARLY

                                                   INTERVENTION PROGRAMS

Early intervention programs represent a second major category of community alcohol and other drug programs.  Early interventions attempt to identify people who are just beginning to experience problems related to alcohol or other drug use.  As well, early intervention programs include strategies directed at alleviating the alcohol- and other drug-related problems and reducing the use of alcohol or other drugs.

            This chapter narrows its focus on early intervention programs for individuals arrested for drinking and driving, programs for individuals in the workforce, and programs in the health and social service setting.  Programs for "high risk" populations -- children raised in a home with serious substance abuse problems ("children of alcoholics"); youth in Native communities; women who are single mothers living on low income and/or depressed; women who are pregnant (hence the risk of fetal alcohol syndrome), etc. -- are discussed only briefly as there are, as yet, few evaluation studies in this area.

 

Programs for Impaired Drivers

Using education and rehabilitation as alternatives to court-imposed legal sanctions for driving while impaired (DWI) has become increasingly popular in many countries, including Canada, since the 1960s (Makela et al. 1981).

            The evaluations of international programs in this area are not sufficiently strong methodologically to draw definitive conclusions about program effectiveness (Nichols et al. 1978; Foon 1988).  For example, in the review by Nichols et al. (1978) more optimistic results came from the most poorly controlled studies.

            Well-conducted studies carried out after Nichol's review in 1978 provided mixed results and questions remain about the consistency and durability of any positive behavioral outcomes (Foon 1988).

            Among Canadian evaluations, Chamberland (1989) reports on a process evaluation of a program in Quebec for drinking drivers who have been convicted at least twice of the offense.  Subjects were put into one of three "streams," depending on the number of times they had been arrested for impaired driving, with longer and more intensive programs for those with more arrests.  Treatment included individual and group counselling.  Participants were required to follow certain rules to remain in the program: sobriety, punctuality, and participation in the program activities.  The evaluation results showed that, of 35 participants who started the program in 1984-85, 31 finished it, and 24 "succeeded" in following the rules.  Program participants were also generally satisfied with the program.  What is not known is whether the program had any effect on the drinking/driving behavior of offenders.

            In Alberta, AADAC has implemented and evaluated two educational programs aimed at impaired drivers:  the IMPACT program and the Alberta Impaired Drivers Course (AIDC).  IMPACT is a province-wide program based on an adult education model of prevention.  Results indicated that elements of the IMPACT program were generally delivered uniformly across all program locations, that the small groups were conducive to providing a supportive environment for discussion, and that participants' perceptions of the program were generally positive.

            There was also some evidence that impaired driving offenders who were recidivists benefited from the IMPACT program (Huebert 1990).  Similarly, Jeune et al. (1988) found in a short-term and long-term post-treatment follow-up of IMPACT participants, increased awareness about the role that alcohol and/or other drugs could play in their lives, as well as improved attitudes towards impaired driving.  The majority of respondents also reported a decrease in alcohol consumption since attending the IMPACT program.

            The Alberta Impaired Drivers' Course (AIDC) is a one-day course attended by first-time offenders attempting to have their driving privileges reinstated.  The program is primarily educational in focus and aims to provide clients with information and the opportunity to assess their drinking behavior.  Results of the program's evaluation showed significant post-treatment changes in attitudes towards impaired driving.  Huebert (1990) found a low recidivism rate of approximately 12% among AIDC program completers.

            Although the process evaluations of IMPACT and AIDC provided helpful data for making program improvements, all the studies relied heavily on self-reports in their follow-up analyses.  Some studies suffered from poor response rates to post-treatment follow-up interviews.  Finally, none of the studies used a comparison group.

Programs in the Workplace

Most workplace programs for alcohol and other drug problems fall into two broad categories:  Employee Assistance Programs (EAPs) and "wellness" health promotion programs.  The majority are EAPs and are oriented more towards the treatment of alcoholism than prevention or early intervention (Roman 1981; Nathan 1984).  Much lip-service has been paid to the potential of EAPs as a form of early intervention but there is little evidence to support this view (Shain and Groeneveld 1980).

            Evaluations of EAPs have been made difficult by widely varying objectives and implementation strategies (Jerrell and Rightmyer 1982).  In addition, most studies have not used comparison groups.  These, and other factors, account for the absence of research evidence in support of EAPs generally, and their contribution to early intervention specifically (Jerrell and Rightmyer 1982; Walker and Shain 1983; Nathan 1984).

            Worksite health promotion or "wellness" programs offered by large corporations may have a component to help identify heavy drinking and provide intervention when needed.  However, wellness programs usually take a very broad lifestyle approach, and many do not even include alcohol as a risk factor for health (Weinstein 1986).  There is considerable research support for the effectiveness of wellness programs in reducing some risk factors for health, and some dimensions of health (e.g., Blair et al. 1984; Baun et al. 1986; Bibeau et al. 1988).  No strong evidence is available from the international literature to demonstrate the impact of these wellness programs on alcohol use or related problems.

            These observations from the published international literature mirror much of the situation in Canada.  Canadian studies have documented some positive effects of worksite wellness programs.  For example, Cox et al. (1981) showed that participants in an employee fitness program improved on several measures of fitness as well as absenteeism and employee turnover.  However, few Canadian evaluations have focused specifically on alcohol consumption or the detection and management of employees with alcohol-related problems.

            One of the most comprehensive evaluations of a Canadian Employee Assistance Program was reported by Groenveld et al. (1984).  As part of that evaluation a group of alcohol abusers that had been referred to treatment were compared to a group of non-alcohol abusing employees matched on the basis of age and seniority.  Substantial improvements were noted for program participants on costs related to health care services, disciplinary events and absenteeism.  Self-reported alcohol consumption declined as well.  This evaluation provides some evidence of effectiveness of an EAP, though the nature of the evaluation precludes definitive answers.

Programs in Health Care and Social Service Settings

One of the most significant trends in the delivery of alcohol and other drug services over the past decade is the development of early intervention programs in settings where professionals routinely interact with people with alcohol and other drug problems (e.g., Martin 1990).  The strongest emphasis in this work has been placed on physicians and other health care professionals (Skinner 1990).  There is ample evidence that physicians often fail to encourage their patients to address their drinking problems (Hingson et al. 1982, Cleary et al. 1988).  Many other professionals such as primary health care workers, social workers and psychiatrists could make better use of the techniques available for identifying and managing the people they routinely encounter with alcohol- and other drug-related problems (e.g., Ehline and Tighe 1977, Jacobson and Lindsay 1980).

            Strategies for Detection

Much research has been directed toward finding simple and accurate screening procedures for the early detection of alcohol and other drug problems.  Four main areas of investigation have been ongoing in the area of alcohol abuse:  laboratory tests with biochemical markers of alcohol consumption; questionnaires/interviews based largely on psychosocial indicators of alcohol problems; clinical indices of consequences of excessive alcohol use; and combinations of these techniques.

            The most frequently used biochemical markers of alcohol consumption are serum gamma-glutamyl transpeptidase (GGT) levels and mean erythrocyte cell volume (MCV).  Although these and many other biochemical markers have been studied (see Babor et al. (1986) and Saunders and Conigrave (1990) for recent reviews), the general conclusion to date is that they have not been shown to be sensitive enough for identifying early stage problem drinking (Bush et al. 1987).

            Questionnaires asking about alcohol-related problems and consequences have a long history of helping professionals make a diagnosis of alcoholism or alcohol dependence.  The best known of these questionnaires are the CAGE (Mayfield et al. 1974) and the Michigan Alcoholism Screening Test (MAST) (Selzer 1971).  The CAGE questionnaire[4] has received considerable attention with the most recent results showing very high sensitivity (i.e., Can it accurately identify people with drinking problems?) and specificity (i.e., Can it accurately rule out people without drinking problems?) (e.g., King 1986; Bush et al. 1987; Beresford et al. 1990).  For example, Beresford et al. (1990) found that the CAGE identified 76% of positive cases and ruled out 94% of negative cases -- by far outperforming biochemical indices.

            A wide variety of other psychosocial, problem-oriented screening questionnaires have been developed.  One recent and significant contribution has come from a World Health Organization (WHO) collaborative study on early intervention (Babor and Grant 1989); the Alcohol Use Disorders Identification Test (AUDIT) identifies people at a hazardous level of alcohol consumption or related problems (Saunders et al., in press).  Results from initial studies showed a sensitivity of 92% and specificity of 94%.

            In summary, no one method has emerged as the most accurate and reliable for early detection in heterogenous populations.  However, most agree that incorporating brief interviews or questionnaires such as the CAGE or AUDIT into routine daily practice is the recommended approach at the present time (e.g., Saunders and Conigrave 1990).

            Canadian researchers have made significant contributions to the development of tools and techniques for detecting early stage problem drinkers.  The work of Skinner and colleagues in Toronto has been the most notable.  They have developed a "Computerized Lifestyle Assessment," which includes a component that screens for heavy alcohol consumption and related problems (Skinner et al. 1985a; 1985b; 1987).  A "Trauma Scale" has also been developed, and it may be used in conjunction with biochemical markers (Skinner et al. 1984).  The most comprehensive approach is the "Alcohol Clinical Index," which combines clinical signs and symptoms with items from a medical history (Skinner et al. 1986).

            Within Canada, as in other parts of the world, there has been little evaluation of the dissemination and/or implementation of these screening procedures in various field settings. One such evaluation did take place in Alberta.  In conjunction with the Alberta Medical Association, AADAC developed an information kit to help physicians to diagnose and treat substance abuse (Brown et al. 1990).

            Three months after receiving the kit, two-thirds of the 103 physicians selected for the study had read it, and the majority had found the material to be somewhat or very useful.  Staff also indicated more appropriate physician referrals and increased satisfaction with communication.

 

            Strategies for Intervention

Counselling strategies for problem drinkers who are identified in early intervention programs generally try to match treatments to the specific strengths and problem areas of the individual patient (Glaser 1980; Institute of Medicine 1990a).  One of the criteria for matching clients to treatment is the severity of the problem.  For example, one important study showed that patients with few symptoms of alcohol dependence derived the most benefit from brief counselling with a goal of reduced consumption, whereas patients who were physically dependent did better with more intensive treatment and a goal of complete abstention (Orford et al. 1976).

            Kristenson et al. (1983) in Malmo, Sweden, studied a large group of healthy middle-aged men who had been identified as heavy drinkers as part of a general health screening project.  The sample was randomly divided into an intervention and control group.  Members of the control group were informed by letter that their test had indicated an impaired liver, were advised to cut back on their use of alcohol, and asked to come in for new liver tests in two years.  The intervention group was given a detailed physical examination, a comprehensive interview about their use of alcohol and related problems, advice on moderating their drinking, and several follow-up appointments and contacts to monitor progress.  Over a five-year follow-up period, GGT levels in both groups improved.  However, the intervention group had significantly lower rates of sick absenteeism, hospitalization and mortality than the control patients.  This was one of the first demonstrations that a simple intervention with regular feedback could have a major effect on drinking habits and overall health.  This general finding has been confirmed in several subsequent projects in various medical settings (Chick et al. 1985, Wallace et al. 1988).

            These results have shown the potential for very low-cost intervention with problem drinkers identified in health care settings. The reductions in alcohol consumption and related problems may be modest, but the time and costs involved are even more modest (Babor 1990).

Programs For "High Risk" Populations

A number of subgroups in the population are at particularly high risk for the development of alcohol- and other drug-related problems.  The groups most commonly included in this discussion are women or young people with various types of problems or in various living conditions (see, for example, Dupont 1989).

            With the increased interest in women's issues and women's health over the past few decades, a number of prevention programs directed at women in general and specific high-risk groups of women have been developed.  For a variety of reasons, most early intervention efforts targeted at women have focused on pregnant women.  There are reasons to be optimistic about the potential effectiveness of programs aimed at reducing fetal alcohol syndrome (Ferrence 1984).

            There appears to be good evidence that children of alcoholics are at a greater risk of developing alcohol problems, both for genetic and psychosocial reasons (Goodwin 1984).  Programs are new, however, and there is little evaluation research to prove their effectiveness  (Russell et al. 1985).

            The CASPAR program in Massachusetts is one of the best documented programs for children of alcoholics operating within a school setting[5] (DiCicco et al. 1984).  For children in grades two through six, groups with 8 to 12 participants meet during school hours weekly for 10 weeks.  For older children in grades 7 to 12, groups meet after school at CASPAR's facility, a private residence off school grounds.  Although preliminary data on program effectiveness need to be examined in more detail with better-controlled studies they do at least show the potential for reaching children of alcoholics with non-stigmatizing alcohol education groups.

            In Ontario, Marshman (1990) is currently conducting an evaluation of the cost-effectiveness of a personal skills development intervention aimed at secondary students at high risk for substance abuse.  The study of the HYPER program (High Risk Youth Power Enhancing Regimen) is also of particular interest in that it is a comprehensive evaluation of the innovative and comprehensive health promotion approach of Ken Low in Alberta (Low 1986,1990).  It is also one of the few economic evaluations of health promotion programs in Canada or elsewhere.


                 CHAPTER THREE:  TREATMENT/REHABILITATION PROGRAMS

 

Treatment/Rehabilitation Programs in Canada

Rush and Ogborne (in press) recently reviewed the history of alcohol and other drug treatment service development in Canada as well as current trends and issues across the country.  They found considerable diversity across the provinces and territories in factors such as the administration and funding of services and the availability of programs for special target populations.  They also noted several similarities in the delivery of programs.  For example, while alcohol remains the predominant drug of abuse among clients, the majority of treatment programs identify themselves as "substance abuse services" with a broad mandate for the treatment of "chemical dependence" or "addiction."

            There has been a shift away from using hospital beds designated specifically for the treatment of alcohol and other drug problems towards more non-medical treatment settings.  There is also an increasing reliance on outpatient care.  Indeed, it is generally recognized that treatment must be available in a range of community settings along a full continuum of care -- detoxification, outpatient, day/evening treatment, and short- and long-term residential facilities.  Increased importance is being placed on comprehensive assessment to match clients to the appropriate program(s) and to develop very individualized treatment plans.

            Many treatment programs are broadening their focus to provide more assistance to the family members of people with alcohol and other drug problems.  With native services, in particular, the consideration of alcohol and other drug abuse as a cross-generation problem is having a major influence on the design and delivery of culture-based programs.

            Several major reviews have been completed recently of the international literature on the effectiveness of treatment for alcohol and other drug problems (e.g., Miller and Hester 1980, 1986a, 1986b; Institute of Medicine 1990a, 1990b).  One of the most noteworthy overviews of the treatment literature was prepared by the Advisory Committee on Drug Treatment, which reported to the Minister responsible for the Provincial Anti-Drug Strategy in Ontario (Martin 1990). 

 

General Issues

As noted by Heather and Tebbutt (1989), the fact that the question of whether treatment "works" has been seriously debated over the last two decades reflects the state of uncertainty in the field.  Confidence in the effectiveness of treatment was reduced in the 1970s by a major review of research studies showing relatively poor outcomes from treatment (Emrick 1975).  Major reviews by Baekeland (1977) and Ogborne (1978) highlighted the importance of client characteristics as determinants of treatment outcome.  In one major study (Orford and Edwards 1977) clients were asked what they regarded as the most significant factor contributing to their recovery.  Such things as changes in their life situation (e.g., work, housing) or marital relationship were rated as being more important than the actual treatment experience in inpatient or outpatient programs, Alcoholics Anonymous or other helping agencies.

            One response of treatment providers and researchers was to call for better quality in the delivery of treatment.  Another response was to call for better quality-controlled evaluations.  A broader perspective concerning the goals of treatment also emerged which called for a wider range of criteria to measure improvement and program effectiveness.  For example, Martin (1990) recently summarized three perspectives on the goals of alcohol and other drug treatment - recovery, harm reduction or care.  A counselling program for intravenous drug users may be "ineffective" in achieving recovery or enduring abstinence from drugs, but "effective" in reducing the harm associated with this type of drug use.  Finally, one of the most significant developments in the past decade has been the "matching hypothesis" which suggests the failure in the past to show significant benefits of treatment may be explained, at least in part, by the failure of treatment programs to individually match clients to a treatment plan (Glaser 1980; Miller and Hester 1986b).

            When summing up the literature on treatment effectiveness, the most recent reviews have concluded with a qualified "yes" to the question of whether treatment "works."   The question, however, is now typically expanded to ask "which kinds of individuals, with what kinds of problems, are likely to respond to what kinds of treatments, by achieving what kinds of goals, when delivered by which kinds of practitioners?" (Institute of Medicine 1990a).  While the answer to this considerably more complex question is still being developed, it is clear that the appropriate and specific treatment for alcohol and other drug problems can significantly improve the outcome for the client.  A recent review by the Addiction Research Foundation (1990) concludes that, on average, 50-65% of individuals receiving treatment show improvement at follow-up.

            Recent economic analyses suggest further that the cost of providing treatment for alcohol abuse is more than offset by the savings associated with reduced health care use (e.g., Luckey 1987; Holder 1987).  Reviews of drug treatment programs such as methadone maintenance programs, therapeutic communities and outpatient counselling services also show the significant economic return on the investment in treatment (Institute of Medicine,1990b).

            The weight of the research evidence has shifted from pessimism to cautious optimism.  Within this new-found optimism, however, the search continues for effective treatment methods for specific subpopulations, as well as for more general applications appropriate for a wide cross-section of clients.

 

Treatment Modalities

            Pharmacotherapy

Any treatment that involves the administration of a drug treating alcohol or other drug problems is called pharmacotherapy.  Miller and Hester (1986a) reviewed three major alternative strategies for pharmacotherapy for the treatment of alcohol problems -- antidipsotropic drugs, psychotropic medications and hallucinogens.

            Antidipsotropics are a class of drugs that cause an adverse physical reaction when consumed in conjunction with alcohol.  Disulfiram (trade name: Antabuse) is the most popular antidipsotropic used in the treatment of alcohol problems.  Several recent controlled trials of disulfiram have failed to show benefits related to its use (Institute of Medicine 1990a).  This lack of strong outcome data, coupled with the side effects that accompany regular use, indicate that disulfiram should not be used as a routine adjunct to treatment.

            Psychotropic drugs have been used to treat alcohol problems by influencing mental states and treating underlying psychopathologies such as anxiety or depression that are presumably causing the excessive drinking.  However, no psychotropic medication has yet been shown in controlled evaluation studies to change drinking behavior and, given the potential risk of abuse, their use should be discouraged (Heather and Tebbutt 1989).  An exception is the use of diazepam (Valium) as an aid in the withdrawal of severe alcohol intoxication (see section below on Detoxification Methods).

            During the late 1950s through to the early 1970s, the use of lysergic acid diethylamide (LSD) for the treatment of alcoholism enjoyed a flurry of popularity.  All recent reviews of this literature recommend that LSD and other hallucinogenic drugs no longer be used for treating alcohol problems (e.g., Miller and Hester 1986a).

            Methadone is the most common treatment for opiate (heroin) addiction.  It is a synthetic drug, which substitutes for other opiates and thereby prevents the onset of withdrawal.  Methadone remains the treatment of choice for opiate dependence on the basis of encouraging results from evaluation studies (Martin 1990; Institute of Medicine 1990b; Heather and Tebbutt 1989).

            A wide variety of other drugs have been investigated as potential therapeutic agents for the treatment of drug problems (e.g., Heather and Tebbutt 1989).  Some of these other drug therapies do show promise.  In general, however, these pharmacotherapies are not yet sufficiently supported by controlled evaluation studies to warrant general application.

            Counselling and Psychotherapy

Some authors view any form of treatment with a psychological orientation as qualifying as a form of "psychotherapy" (e.g., Emrick 1982). Such a definition is clearly too broad to be much use.  In the major literature reviews by Miller and Hester (1980, 1986a) and Heather and Tebbutt (1989), it is argued that most psychotherapy for alcohol problems is derived from the psychoanalytic model.  In this model, alcohol or other drug problems are seen as a symptom of an underlying conflict (e.g., oral fixation, latent homosexuality) and it is the conflict rather than the symptom that should be treated.  This differs from "counselling," which tends to be more directive, supportive, reality-centred, focused on the short-term, and oriented toward problem solving and behavioral changes.  Unfortunately, the tendency for evaluation studies not to provide the details of the content and procedures of the psychotherapy or counselling make it difficult to summarize or compare studies in terms of relative effectiveness.

            In a comprehensive review of literature on psychotherapy, Miller and Hester (1986a) drew these conclusions:

                                   the majority of studies found no differences between those receiving versus not receiving psychotherapy;

 

                                   in several studies the existing differences favoured those not receiving counselling or psychotherapy; and

 

                                   studies that reported an advantage for psychotherapy relative to controls did not use random assignment, lacked adequate outcome measures of drinking or showed minimal differences at best.

 

            The possibility still remains that people with certain types of alcohol or other drug problems may benefit from this kind of treatment, specifically those with particular types of psychopathology.  However, on the basis of available data, psychotherapy is not to be recommended for general use, especially given the complexity of the treatment, the need for highly trained counsellors and the duration and cost of treatment.

            Alcohol and Other Drug Education

One of the most common features of alcohol and other drug treatment programs is an educational component.  This usually involves lectures, films, readings and/or discussions about alcohol, drugs, alcoholism and drug addiction.  For example, Stalonas et al. (1979) compared three alternative methods of education (videotape, live lectures or reading written presentations) and found that participants in all three groups returned to baseline levels of knowledge at follow-up.  The study did not include a no-education control group.

            Controlled evaluations have not provided strong support for the effectiveness of alcohol and other drug education in changing drinking or drug-taking behaviors and related problems.  The widespread adoption of the educational approach to treatment is thus highly questionable in light of this very limited research evidence.

            Confrontation

There is almost universal acceptance that it is therapeutic for people with alcohol and other drug problems to be confronted with the reality of their problems.  Although the literature contains an exhaustive description of different methods of confrontation, Miller and Hester (1986a) were unable to find one controlled evaluation study of confrontational counselling with people with alcohol problems.  There is some evidence that a hostile-confrontational style of leadership in group therapy may produce more negative outcomes than other styles of leadership (Lieberman et al. 1973).  Legitimate concerns may be raised, for example, about the potential of this approach for precipitating drop-out and lowering self-esteem.

            Marital and Family Therapy

Alcohol and other drug problems influence, and are influenced by, the individual's family situation.  Treatment programs that provide marital and family therapy use a variety of approaches, typically within a family systems perspective (e.g., Steinglass 1979).  Some treatments involve meetings with the entire nuclear family, while others involve only the couple, only the spouse, or all family members except the substance abusers.  Family therapy is widely recommended for young people with drug problems (Coleman and Davis 1978), using either a systems or behavioral approach (Bry 1988).

            Behavior Therapy

There are a number of specific behavior therapy methods that have been used to treat alcohol and other drug problems.

Aversive therapy:   This approach to treatment attempts to suppress drinking behavior by creating an aversion or distaste for alcohol.  It is based on classical conditioning procedures in which alcohol is repeatedly paired with unpleasant experiences.  It is not the same as using antidipsotropic drugs, such as disulfiram, which is based on the suppression of drinking by the fear of immediate unpleasant consequences.

            In aversive therapy for the treatment of alcohol problems, conditioned stimuli are the sights, smells and tastes of alcoholic beverages, and the unconditioned stimuli have been nausea-producing drugs (chemical aversion therapy), electric shock (electrical aversion therapy), or visualized unpleasant experiences (covert sensitization therapy).  If the conditioning is successful, the individual shows an automatic negative response when later exposed to alcohol alone.

            In their comprehensive review of the literature published since the 1940s, Miller and Hester (1986a) found mixed results with the weight of the evidence suggesting a small but consistent increase in abstinence rates at six-month follow-up.

BAC Discrimination Training:  Blood alcohol concentration (BAC) is frequently used as a measure of level of intoxication.  Information regarding the relationships among alcohol consumption, BAC and behavioral effects has been a component of many treatment programs for problem drinkers.  However, the practical value of including the training in the treatment of alcohol problems has not been conclusively established and further research is needed to determine whether certain types of alcoholics and problem drinkers can benefit from this approach.

Contingency Management:  A contingency management treatment program attempts to change the environmental consequences that are helping to shape and maintain problem drinking or other drug-taking behavior.

            Miller and Hester (1980) reviewed several studies conducted in tightly controlled experimental situations that showed the drinking behavior of even seriously dependent problem drinkers can be modified. For example, a series of studies conducted by Bigelow and colleagues (e.g., reference check Miller and Hester 1980) showed that problem drinkers will reduce their consumption of alcohol if they are punished for drinking by being isolated from social contact.

            The manipulation of environmental contingencies has also been used to increase compliance with a treatment program.  Bigelow et al. (1976) for example, found that a financial program of contingency management increased compliance with a disulfiram regime.

            The outcome studies on CRA are among the most methodologically sound and the most encouraging in the treatment literature.  A study comparing standard hospital treatment to the enhanced CRA showed significantly different outcomes favouring the CRA program (Azrin 1976).  Another study, this one with outpatient clients only, and as an adjunct to disulfiram also showed encouraging results (Azrin et al. 1982).  Research to date suggests that this approach makes a valuable contribution to the treatment of alcohol problems, and it deserves further implementation and evaluation.

Broad-spectrum Treatment:  In broad-spectrum treatment, each client's particular problems are assessed and then a range of interventions are made available to assist in dealing with these problems.  Interventions typically include skills training (e.g., social skills, problem-solving skills), stress management and relaxation training.

            People experiencing problems with alcohol often appear to be deficient in social skills.  Research has indicated that social skills training is of benefit in the treatment of alcohol problems.  This training can include assertiveness training, group training with skills practice sessions, and cognitive restructuring.  Most research has been conducted on assertiveness training with consistently positive findings as in a Canadian study by Freedberg and Johnston (1978a).

            Another common component of the broad spectrum approach is stress management since stress has often been hypothesized as an antecedent of drinking and relapse.  Both relaxation therapy and systematic desensitization have been subjected to controlled evaluations with problem drinkers.  Evaluation studies of relaxation training have tended to use only physiological measures of relaxation, rather than measuring effects on drinking behavior.

Behavioral Self-Control Training:  Behavioral self-control training (BSCT) is often referred to as self-management training.  Although the training may vary from setting to setting, it usually includes an educational component designed to assist individuals in attaining a controlled level of drinking.  It is offered on an outpatient basis and is amenable to a variety of formats including individual, group and/or bibliotherapy.

            A series of controlled evaluations by Miller and colleagues provides very positive evidence for the effectiveness of this approach for early stage problem drinkers (Miller 1978; Miller and Taylor 1980; Miller, Taylor and West 1980; Miller, Gribskov and Mortell 1980; Miller and Baca 1983).  Comprehensive reviews of this literature, and a wide range of studies by other researchers around the world have documented the consistent and very conclusive evidence regarding the BSCT approach.

Motivational Interviewing:  This relatively new behavioral approach to treatment is based on one of the simplest yet most influential models of behavior change that has been applied to the alcohol and other drug field.  At its most basic level, the model of change developed by Prochaska and di Clemente (1986) describes four stages of change that people must progress through in order to change addictive behavior -- precontemplation, contemplation, action and maintenance.  Motivational interviewing is a term used by Miller (1983) to describe an approach that emphasizes motivating the client to move through the precontemplation and contemplation stages.  The approach focuses on individual responsibility for change, contrasts current behavior with its negative consequences (i.e., cognitive dissonance) and uses empathic listening and feedback from objective assessments to change behavior on the basis of this cognitive dissonance.

            Self-Help Groups

Programs such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), provide community-based support for people with alcohol and other drug problems.  Similar support also exists for the families of these individuals (e.g., Al-Anon and Alateen).  AA is the most well-established and widespread self-help group having chapters in over 90 countries and over half a million active members.  It is also an integral part of many alcohol treatment programs.  Although many anecdotal reports attest to the effectiveness of AA, its efficacy has not been established through controlled evaluation studies.  Some feel that the characteristics of AA preclude its scientific evaluation (Bebbington 1976).  Other researchers recognize the difficulties, but are more optimistic about the potential for good evaluation studies (Bradley 1988).

            There have been three controlled studies of AA.  Brandsma et al. (1980) recruited subjects primarily from the court system and randomly assigned them to either AA, insight therapy, professionally delivered rational behavior therapy, self-help rational behavior therapy, or a control group which could make their own arrangements for treatment in the community.  Of the four treatment groups, (1) AA showed the highest drop-out rate (68% vs. 57% for the other groups); and (2) subjects in the AA group appeared to show the least improvement of the treated groups, showing fewer, if any, significant differences from the control group.

            Although, the results of this and other studies provide no scientific evidence for the effectiveness of AA, they also point to the need to more closely study the kinds of individuals for whom AA may be particularly effective.  In their review, Miller and Hester (1986a) suggest that AA may work best for individuals who have higher levels of authoritarianism, higher affiliative and dependency needs, greater severity of alcohol-related problems, and lower levels of education and psychopathology.  It may also be the case that the most successful use of AA is as continuing care following professional treatment (Bradley 1988).  Given their widespread availability and the fact that there is no cost to the individual or government, the use of AA, and similar self-help groups should be encouraged.

 

Treatment Context and Duration

"Common sense" would suggest that the most effective treatment programs are those that are longer and more intensive.  Yet after reviewing 12 controlled evaluations, Miller and Hester (1986a) found not a single study showing inpatient treatment to be superior to nonresidential alternatives.  They note that these studies were of high quality, using either random assignment or careful matching, generally including extended follow-up, and a sample of problem drinkers who would otherwise have been routinely admitted for inpatient care.  Not only did those undergoing outpatient treatment do as well as those undergoing inpatient treatment--they often did significantly better.  Canadian studies have also confirmed this general finding (Annis and Liban 1979, McLachlan and Stein 1982).

            There has been only one controlled study comparing short-term residential treatment to outpatient treatment for individuals with drug problems (Wilkinson and Martin 1983; cited in Martin 1990).  Again, no differences were observed in outcome between the residential and outpatient options at one- and two-year follow-up.

            The debate on whether the effectiveness of treatment is related to the duration of the intervention has also been studied.  Four controlled studies comparing the outcomes of short and long inpatient stays showed that shorter stays were at least as effective as longer stays (Miller and Hester 1986a).  For example, Mosher et al. (1975) randomly assigned alcoholics to either a short (nine day) or a long (30 day) inpatient stay, combined with detoxification and outpatient aftercare.  Follow-up data at three and six months on drinking, other drug use, work status and anxiety revealed no significant differences in outcome between the two conditions.

Detoxification Programs:   Detoxification refers to the process by which individuals who are dependent on alcohol or other drugs recover from intoxication in a supervised manner so that withdrawal symptoms are minimised (Heather and Tebbutt 1989).

            In many countries, and especially in the U.S., the standard approach to detoxification has been to use medication, such as diazepam and chlormethiazole for alcohol withdrawal, and cloridine or methadone for opiate withdrawal.  The social, non-medicated model was part of a movement to decriminalize public drunkenness that resulted in incarceration, in favour of a more humane, rehabilitative approach to the skid-row problem (O'Briant 1974/75; O'Briant et al. 1976/77).  Largely on the basis of Canadian research in the 1970s into the effectiveness of the social detoxification model (Annis 1979), this approach has gained acceptance around the world.  Research into this model has consistently shown that withdrawal symptoms can be relieved by providing a safe, non-stimulating environment with support provided by trained staff, usually non-medical professionals or lay persons (DenHartog 1982).  Thus, these specialized, non-medical detoxification facilities have been shown to be as effective, and certainly more cost-effective (Sparadeo et al. 1982), than medically oriented inpatient units.  The research evidence, however, still points to the need for a medicated approach in some instances of severe withdrawal, and most countries now have a mix of medical and non-medical inpatient detoxification facilities (DenHartog 1982).

            Home detoxification is similar to an outpatient model in that the individual continues to reside at his or her normal residence, but with daily or spaced contact with a helping professional at home.  For both the medicated and non-medicated approaches, family members and significant others typically provide support during the home detoxification process.  The home detoxification model has only a short history and, therefore, has not been evaluated very frequently.  A program in Exeter, England, is the best known in the international literature and has been the subject of a comprehensive evaluation by Stockwell and colleagues (Stockwell et al. 1986; Stockwell et al. 1990; Stockwell 1989).  Results of these studies have shown home-based detoxification to be as safe and effective as inpatient care, even for the severely dependent problem drinker.

            Sausser et al. (1982) stress that perhaps the most important criteria for outpatient (or home) detoxification is the support system that exists for the client, including not only the family, but also A.A., other self-help groups and/or treatment services.

Long-term Residential Programs:   In addition to inpatient detoxification centres and traditional, treatment-oriented short-term residential facilities, other residential alcohol and other drug programs exist that are more long-term in nature.

            Very little research has addressed the effectiveness of these long-term residential facilities.  In Miller and Hester's (1980) overview of the literature, the results were not particularly encouraging.  However, as noted by Martin (1990), these programs serve individuals who are less likely to achieve the most favourable outcomes, and evaluation of the programs must adopt criteria for successful outcome that may fall short of the ideal.

            Another type of long-term residential program is the therapeutic community (TC).  The TC relies on principles of mutual self-help, an emphasis on work, the use of peers as role models and staff as rational authority (Heather and Tebbutt 1989).  Most reviews of the effectiveness of the TC approach conclude by noting that despite the lack of solid evidence about program effectiveness, there is reasonably good evidence that the approach is more cost-effective than the other major alternative for this population, namely incarceration (Institute of Medicine 1990b).

 

Assessment and Matching of Clients to Treatment

It is now widely recognized that, given the diversity of the population seeking treatment, not all types of interventions or programs will necessarily be effective for all types of individuals in need of assistance.  Individuals need to be assessed, then receive the kind of treatment that best suits their needs.

            Heather and Tebbutt (1989) and Institute of Medicine (1990a, 1990b) provide very comprehensive and practical discussions of assessment strategies and techniques.  In general, assessment should focus on the quantity, frequency and pattern of past and present alcohol and other drug use, the level of dependence and the nature and extent of alcohol and other drug-related problems (e.g., health, social, intrapersonal).  Assessment should also focus on the client's level of motivation for change.  There is an emerging consensus as well that the client's expressed needs and requests for assistance are an important part of the assessment process and the effective matching to treatment.  Finally, assessment should take into account the individual's social context and involve family members and significant others where appropriate.

            Researchers at the ARF in Ontario have contributed significantly to the development of assessment protocols and instruments.  Skinner and colleagues have developed or evaluated the psychometric properties of several instruments including the Alcohol Dependence Scale (Skinner and Allen 1982; Horn et al. 1984); the Michigan Alcoholism Screening Test (Skinner 1979) and the Drug Abuse Screening Test (Skinner 1982a).  Annis (1982) has developed the Inventory of Drinking Situations, an assessment protocol closely tied to relapse prevention procedures.

            Although it seems to be a very common-sense assertion that individuals with varying needs and characteristics will respond more positively to different kinds of interventions this is actually a very complex area of research from a conceptual and methodological point of view.  (For a thorough review of the relevant issues and findings, see Institute of Medicine (1990a), Marlatt (1988), and Miller and Hester (1986b), Finney and Moos (1986), Glaser (1980), and Skinner (1982b).)

 

Relapse Prevention and Continuity of Care

The effectiveness of treatment increases when services are provided to deal with difficulties that commonly arise after formal treatment ends.

Relapse Prevention:  This approach builds on the work of Prochaska and di Clemente (1986) and their model of change in the addictive behaviors.  Relapse prevention acknowledges the difficulty in maintaining changes in behavior and seeks to counteract the negative emotional states, interpersonal conflict and social pressure that precipitates relapse.  The work of Marlatt and colleagues (e.g., Marlatt and Gordon 1980; Marlatt and George 1984) has been particularly influential in this area.  Clients are assessed to identify high-risk situations and are taught skills to deal with these situations.

            Relapse prevention techniques appear to offer the promise of dealing with the difficulties of long-term changes in addictive behavior.  Nevertheless, more research is required to determine their value.

Continuity of Care:  It should be obvious from the wide range of treatment interventions and programs considered in this and other reviews, that an individual seeking treatment for an alcohol or other drug problem is faced with a rather complex array of services.  There is an implicit assumption in the field that the treatment provided to an individual will be more effective (or at least more efficiently delivered) if all the services the client is involved in are coordinated.  The term "continuity of care" reflects this assumption (Martin 1990).

            The term "aftercare" has been traditionally used to describe care that continues after a formal period of treatment ends, typically a period of short-term residential treatment.  "Case management" is a much broader term than aftercare (Johnson and Rubin 1983), with the core components for mental health services (including alcohol and other drug services) being defined as:

                        assessment of current strengths, weaknesses and needs;

 

                        planning to identify services appropriate to the particular needs of the client;

 

                        linking clients to needed services and ensuring that these linkages are maintained;

 

                        continuous monitoring and evaluation of progress; and

 

                        interceding on behalf of the client (advocacy) to ensure that the treatment system responds equitably and effectively to client needs.

 

 

          The development and evaluation of case management in the alcohol and other drug field has lagged behind that in the mental health field.  In particular, there is considerable controversy concerning several issues, including whether or not the case manager should provide therapy, and the various roles the case manager should assume with the client.

          In Canada, Pearlman (1984a, 1984b, 1984c) reported on an evaluation of case management as part of a research project concerned with a broader system of treatment services.  Pearlman reported that case management did not reduce drop-out, but did increase participation in treatment following intake and assessment (Pearlman 1984a).

          More evaluation studies are needed to determine the benefits of various types of continuing care and case management services for different populations.  As exemplified by the work of Graham and colleagues, this will require more innovative approaches to the evaluation design and the measurement of outcome than has been the case in most of the published literature in this area.


                                                 CHAPTER FOUR:  NEXT STEPS

The overall focus of this report has been on the evaluation of alcohol and other drug programs across the full range of community programs in three broad areas: health promotion, early intervention and treatment/rehabilitation. It has consolidated the significant findings from a massive literature on the effectiveness of these programs and has highlighted important Canadian contributions to this literature along the way.

          This literature review has brought to the fore the considerable variability in the type, quality and findings of evaluation studies undertaken in Canada and in the broader international context.  For example, many studies suffer from inadequate explanation of how the program was implemented, despite the importance of knowing this type of information to correctly interpret program results. The reliability from other studies could have been improved considerably if the researchers had used control groups with which to compare results.  A third common problem, particularly for treatment programs, is the lack of long-term follow-up. What impact has a particular program had on its "graduates"  one or two years down the road?[6]

 

These are just some of the questions that arise when discussing evaluation studies for alcohol and other drug problems.  While the evaluation literature reviewed in this report has indeed provided guidance on what kinds of programs are working and what kinds of programs are not, the review has also pointed to the need for better standards of evaluation and methodologies to improve the value of evaluation research findings. What follows are some lessons learned from this review that could improve the quality of future evaluation efforts:

-        more process-oriented evaluation that documents how programs are implemented and how well they were received;

 

-        cost-effectiveness studies of various program approaches;

 

-        studies aimed at determining the most effective means of disseminating new knowledge gained from research into prevention and treatment programs;

 

-        funding to develop dependable evaluation research;

 

-        training for program managers and policy-makers in evaluation techniques as well as for candidates for evaluation positions;

 

-        determining practical evaluation measures;

 

-        adopting evaluation practices before the actual evaluation studies take place to ensure these practices will fully meet program objectives.

 

These steps, and others in the same spirit, would go some measure toward improving the number and quality of program evaluations undertaken within health promotion, early intervention and treatment/rehabilitation programs in the Canadian alcohol and other drug field.


 

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[add new Eliany entry here]

 

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[3]Since programs being surveyed could identify more than one target, system or strategy these percentages exceed 100%.

[4]CAGE is an acronym for the four questions of the instrument:  Need to Cut down on drinking?  Annoyed by criticism about your drinking?  Guilty about drinking?  Need a morning drink or Eye-opener?

 

[5]CASPAR is the acronym for Cambridge and Somerville Program for Alcoholism Rehabilitation.  The organization provides a range of treatment services.  The program for children of alcoholics is offered by CASPAR's Alcohol Education Program and is partly delivered in local schools, as well as on-site at CASPAR's facility.

[6]           For a detailed description of methodological issues, please refer to the technical report, The Effectiveness of Prevention and Treatment Programs for Alcohol and Other Drugs Problems: Towards an Integrated Assessment of Canadian Evaluation Studies, Health and Welfare Canada, 1991.