based on the perception that whereas no single prevention approach is likely to make an impact by itself, a package of mutually supporting strategies may achieve synergistic effects. Accordingly, these projects usually contain a mix of individually or environmentally focused strategies. Studies of communitywide interventions are difficult to conduct due to their size and complexity as well as methodological compromises that are inherent in working in real-world settings. Several investigations that are currently under way promise to provide results from which we may draw some tentative conclusions about prevention effectiveness at this level.

Chapter 13: Screening and Brief Intervention

Screening for alcohol problems involves the use of easily administered, inexpensive procedures to identify people who are at risk for alcoholism or those who may be developing alcohol problems. The goal of these procedures is early identification and thus prevention through early intervention. Screening programs to identify individuals with risk factors for alcohol problems are well accepted. On the other hand, screening of asymptomatic persons is less well established, although some study findings suggest that routine screening should be conducted for all people seeking medical treatment.

The most commonly used screening instruments focus on quantity and frequency of recent and lifetime use. These tools can be administered in a variety of ways, including with paper and pencil questionnaires, in interviews, or via computer. Some general screening tests that are used currently in clinical practice are the CAGE, the Michigan Alcoholism Screening Test and various modifications, and the Alcohol Use Disorder Identification Test. Although researchers have developed special instruments that target drinking problems among pregnant women and adolescents, further research is needed to develop tools that screen for alcohol problems among nonpregnant women, Hispanics, African Americans, Native Americans, older adults, the chronically mentally ill, and people with sensory disabilities.

Brief interventions are time-limited, directed prevention strategies that focus on reducing alcohol use in the nondependent drinker. Brief intervention procedures for alcohol use are timelimited therapeutic strategies. The goal of these approaches is prevention, that is, changing the

behavior of individuals who are experiencing adverse effects of drinking but who are not physically dependent on alcohol.

These clinically based interventions include assessment and direct feedback, contracting and goal setting, brief counseling, behavioral modification techniques, and the use of written materials such as self-help manuals. Several studies have shown that such forms of intervention are successful with problem drinkers who have not developed physical dependence. However, little information is available about the long-term effectiveness of these procedures. Additional research is needed to examine the effectiveness of individual components of brief interventions as well as the responses of different populations to intervention strategies.

Section V-Treatment of Alcoholism and Related Problems

Chapter 14: Diagnosis and
Treatment of Alcoholism

Specialized interventions are often required to arrest drinking; to alleviate the physiological, psychological, and social consequences of alcoholism; and to help patients maintain long-term sobriety. These interventions are delivered either singly or in various combinations, in diverse treatment settings, and for varying lengths of time and at varying levels of intensity.

Patients in alcoholism treatment comprise diverse populations. To meet the needs of these varied groups, researchers are conducting studies in several domains: patient factors, treatment factors, and the efficiency with which treatment services reach persons in need of such services.

Accurate diagnosis is the first step in determining which interventions are best for which patients. Toward this goal, researchers are working to increase the compatibility and validity of diagnostic systems for alcoholism. New diagnostic instruments have been developed in coordination with changes in the diagnostic systems, and strategies for improving the accuracy of patient assessment have been explored. Research attention has been focused on identifying new laboratory tests of alcohol consumption and improving the sensitivity and specificity of existing markers of consumption.

Psychological and behavioral interventions are the most commonly used treatments for

alcoholism; yet, they have traditionally been difficult to evaluate. Researchers recently have been using increasingly sophisticated study designs such as controlled clinical trials in an attempt to define the active elements of psychologicalbehavioral treatments. To date, findings on aftercare and relapse prevention have suggested the importance of long-term adherence and commitment to aftercare protocols. Cue-exposure interventions and behavioral skills training programs have shown promise for lessening the probability of relapse.

Psychological and behavioral interventions are the most commonly used treatments for alcoholism; yet, they have traditionally been difficult to evaluate.

During the past decade, findings from several studies have pointed to potential dangers associated with unmedicated treatment of alcohol withdrawal. The use of medication protocols based on withdrawal symptom scores is improving the effectiveness of withdrawal management. Various pharmacological agents, some of which have seen widespread use in other health care areas, have shown promise for reducing the likelihood of relapse, self-reports of alcohol craving, and psychological distress to alcoholics.

In various areas of health services research, special populations have been defined as groups

with unique biological and sociocultural characteristics that require culturally sensitive interventions; as groups that, because traditional treatment programs have addressed their needs inadequately, require improved access to treatment services; or both. In alcoholism treatment research, these definitions typically apply to older adults, women, and ethnic minorities. Evidence that specialized services can improve treatment outcomes among special populations remains sparse. Newly developed populationspecific assessment instruments should provide new information for monitoring treatment outcomes among special population groups.

Research on patient-treatment matching is directed toward identifying improved treatments for individual patients and patient subgroups at a reduced expenditure of limited treatment resources. Future research should continue to focus on defining specific patient and treatment characteristics that can interact to yield successful long-term results.

Conclusion

The Eighth Special Report to the U.S. Congress on Alcohol and Health summarizes the current state of alcohol research and presents the progress that has been made in unraveling the mysteries of alcohol abuse and alcoholism since the publication of the Seventh Special Report 3 years ago. These research advances will lay the foundation for future studies probing the causes, treatment, and prevention of alcohol use problems.

1

Introduction

N

ot everyone chooses to drink alcohol, and of those who do, most have little or no trouble limiting their intake to amounts that produce no serious health or social consequences. In contrast to drinking habits that produce few adverse outcomes, alcohol abuse refers to patterns of problem drinking that have resulted in detrimental effects on health, social problems, or both. Indeed, alcohol can have serious and debilitating effects on both the physical health and the social well-being of problem drinkers. Alcohol dependence, often called alcoholism, refers to a disease characterized by abnormal alcohol-seeking behavior that leads to impaired control over drinking. Although alcoholics and alcohol abusers experience many of the same harmful effects of drinking, the critical difference between the two is the physical dependence displayed by alcoholics and their impaired ability to regulate their consumption of alcohol.

Numerous adverse consequences can arise from alcohol consumption, and these outcomes are costly both in human and monetary terms. For example, alcohol-specific medical conditions (such as alcoholic liver disease) can cause illness and death; alcohol can also contribute to other diseases, causing these conditions to worsen, and may in many cases lead to early death. In addition, alcohol-related injuries and accidents can be serious or fatal, and alcohol use can lead to the development of significant marital and job

problems. Adverse effects of alcohol consumption are not limited to alcohol abusers and alcoholics, because some outcomes may result from a single bout of drinking as well as from chronic alcohol misuse. Thus, alcohol use is not a riskfree activity. Those who drink even occasionally may place themselves at risk for an adverse event, such as a traffic accident. Further, everyone, even those who abstain, may be adversely affected by someone else's drinking.

Clearly, global terms such as alcoholism fail to communicate an accurate description of the broad range of behaviors and consequences associated with alcohol use. Thus, research providing insight into the many problems associated with drinking is needed to clarify the nature and extent of alcohol use and problems arising from it. To evaluate the spectrum of alcohol's impact on society, it is necessary to use both indirect and direct measures to assess the full range of alcohol's effects. Such research is especially valuable in informing prevention and treatment efforts. This chapter will provide basic information about alcohol consumption patterns in the United States and review recent research on the extent of adverse health and social consequences of drinking, including alcohol abuse and alcohol dependence.

Data estimating the extent of alcohol consumption, adverse consequences of drinking, and alcohol abuse or dependence are drawn from U.S. vital statistics and national surveys. Table 1 provides an overview of some of the