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Alcohol and Public Policy Group: Alcohol: No ordinary commodity – a summary of the second edition

This article summarizes the contents of Alcohol: No Ordinary Commodity (2nd edn). The first part of the book describes why alcohol is not an ordinary commodity, and reviews epidemiological data that establish alcohol as a major contributor to the global burden of disease, disability and death in high, middle and low income countries. This section also documents how international beer and spirits production has recently been consolidated by a small number of global corporations that are expanding their operations in Eastern Europe, Asia, Africa, and Latin America. In the second part of the book, the scientific evidence for strategies and interventions that can prevent or minimize alcohol-related harm is critically reviewed in seven key areas: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drink-driving countermeasures, restrictions on marketing, education and persuasion strategies, and treatment and early intervention services. Finally, the book addresses the policy making process at the local, national, and international levels and provides ratings of the effectiveness of strategies and interventions from a public health perspective. Overall, the strongest, most cost-effective strategies include taxation that increases prices, restrictions on the physical availability of alcohol, drink-driving countermeasures, brief interventions with at risk drinkers, and treatment of drinkers with alcohol dependence.

The alcohol industry and public interest science

AIMS

This report argues that the growing involvement of the alcohol industry in scientific research needs to be acknowledged and addressed. It suggests a set of principles to guide ethical decision-making in the future.

METHODS

We review relevant issues with regard to relationships between the alcohol industry and the international academic community, especially alcohol research scientists. The guiding principles proposed are modelled after expert committee statements, and describe the responsibilities of governmental agencies, the alcohol industry, journal editors and the academic community. These are followed by recommendations designed to inform individuals and institutions about current 'best practices' that are consistent with the principles.

FINDINGS AND CONCLUSIONS

Growing evidence from the tobacco, pharmaceutical and medical fields suggests that financial interests of researchers may compromise their professional judgement and lead to research results that are biased in favour of commercial interests. It is recommended that the integrity of alcohol science is best served if all financial relationships with the alcoholic beverage industry are avoided. In cases where research funding, consulting, writing assignments and other activities are initiated, institutions, individuals and the alcoholic beverage industry itself are urged to follow appropriate guidelines that will increase the transparency and ethicality of such relationships.

A common standard for conflict of interest disclosure in addiction journals

This paper presents a common standard for conflict of interest disclosure. The common standard was drafted by the authors, following consultation with a multi-disciplinary group of journal editors, publishers, bioethicists and other academics. It is presented here for the benefit of authors, editorial managers, journal editors and peer reviewers to stimulate discussion and to provide guidance to authors in reporting real, apparent and potential conflicts of interest. It is particularly relevant to addiction specialty journals because of the potential conflicts of interest associated with funding from the alcohol, tobacco, pharmaceutical and gambling industries. Following an appropriate period of vetting the common standard within the scientific community, it is recommended that journal editors adopt journal policies and reporting procedures that are consistent across journals.

Alcohol research and the alcoholic beverage industry: issues, concerns and conflicts of interest

AIMS

Using terms of justification such as 'corporate social responsibility' and 'partnerships with the public health community', the alcoholic beverage industry (mainly large producers, trade associations and 'social aspects' organizations) funds a variety of scientific activities that involve or overlap with the work of independent scientists. The aim of this paper is to evaluate the ethical, professional and scientific challenges that have emerged from industry involvement in alcohol science.

METHOD

Source material came from an extensive review of organizational websites, newspaper articles, journal papers, letters to the editor, editorials, books, book chapters and unpublished documents.

RESULTS

Industry involvement in alcohol science was identified in seven areas: (i) sponsorship of research funding organizations; (ii) direct financing of university-based scientists and centers; (iii) studies conducted through contract research organizations; (iv) research conducted by trade organizations and social aspects/public relations organizations; (v) efforts to influence public perceptions of research, research findings and alcohol policies; (vi) publication of scientific documents and support of scientific journals; and (vii) sponsorship of scientific conferences and presentations at conferences.

CONCLUSION

While industry involvement in research activities is increasing, it constitutes currently a rather small direct investment in scientific research, one that is unlikely to contribute to alcohol science, lead to scientific breakthroughs or reduce the burden of alcohol-related illness. At best, the scientific activities funded by the alcoholic beverage industry provide financial support and small consulting fees for basic and behavioral scientists engaged in alcohol research; at worst, the industry's scientific activities confuse public discussion of health issues and policy options, raise questions about the objectivity of industry-supported alcohol scientists and provide industry with a convenient way to demonstrate 'corporate responsibility' in its attempts to avoid taxation and regulation.

Treatment for persons with substance use disorders: mediators, moderators, and the need for a new research approach

This article describes two major studies (i.e. Project MATCH and the US Department of Veterans Affair Effectiveness Study) of mediators and moderators of drinking behavior change following treatment, and considers alternatives to the dominant paradigm that has guided treatment research for more than two decades. Both studies were designed to test the "Technology Model" of therapeutic change, which postulates that patient attributes and treatment process elements, respectively, constitute mediators and moderators of change in drinking and drug use following treatment. The studies show that matching to therapeutic orientation is not an essential ingredient to substantially enhanced outcomes, as previously believed. They also indicate that the mediational mechanisms underlying several of the most popular therapies are different than what is suggested by their proponents. The inability of the Technology Model to explain, much less improve, the effectiveness of addiction treatment suggests the need for a new paradigm. It may be more fruitful to look for matching in larger populations at the level of communities or treatment systems, where a wider range of settings and therapeutic interventions can be evaluated.

Validation of the Alcohol, Smoking And Substance Involvement Screening Test (ASSIST)

AIM

The concurrent, construct and discriminative validity of the World Health Organization's Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were examined in a multi-site international study.

PARTICIPANTS

One thousand and 47 participants, recruited from drug treatment (n = 350) and primary health care (PHC) settings (n = 697), were administered a battery of instruments.

MEASUREMENTS

Measures included the ASSIST; the Addiction Severity Index-Lite (ASI-Lite); the Severity of Dependence Scale (SDS); the MINI International Neuropsychiatric Interview (MINI-Plus); the Rating of Injection Site Condition (RISC); the Drug Abuse Screening Test (DAST); the Alcohol Use Disorders Identification Test (AUDIT); the Revised Fagerstrom Tolerance Questionnaire (RTQ); and the Maudsley Addiction Profile (MAP).

FINDINGS

Concurrent validity was demonstrated by significant correlations between ASSIST scores and scores from the ASI-Lite (r = 0.76-0.88), SDS (r = 0.59), AUDIT (r = 0.82) and RTQ (r = 0.78); and significantly greater ASSIST scores for those with MINI-Plus diagnoses of abuse or dependence (P < 0.001). Construct validity was established by significant correlations between ASSIST scores and measures of risk factors for the development of drug and alcohol problems (r = 0.48-0.76). Discriminative validity was established by the capacity of the ASSIST to discriminate between substance use, abuse and dependence. Receiver operating characteristic (ROC) analysis was used to establish cut-off scores with suitable specificities (50-96%) and sensitivities (54-97%) for most substances.

CONCLUSIONS

The findings demonstrated that the ASSIST is a valid screening test for identifying psychoactive substance use in individuals who use a number of substances and have varying degrees of substance use.

Alcohol and drug treatment systems in public health perspective: mediators and moderators of population effects

This article describes a public health approach to the study of service systems for people with substance use disorders. Such an approach is broadly conceived to include the consideration not only of specialized services for alcohol and drug dependence, but also of medical care and social welfare services that interact with and complement specialized drug and alcohol services. After describing a conceptual model of the substance abuse service system, we discuss how systems of care may contribute to population health and social welfare by reducing the societal burden of substance use disorders. The article then summarizes key systems issues pertaining to mediators and moderators of effective treatment systems. The potential benefits of systems thinking in relation to the management of substance use disorders are described. It is suggested that systems concepts and research may help to improve access, efficiency, economy, continuity of care, and effectiveness, thereby improving the population impact of treatment services.

Tackling alcohol misuse in the UK

Higher alcohol taxes and restricting availability are more likely to succeed than partnerships with industry

The Effect of Screening and Brief Intervention for Risky Drinking on Health Care Utilization in Managed Care Organizations

OBJECTIVE

We sought to estimate the effect of screening and brief intervention (SBI) for risky alcohol use on the health care utilization of risky drinkers in 4 managed care organizations.

RESEARCH DESIGN

A quasi-experimental group design was implemented in which 12 participating primary care clinics randomly were assigned to 1 of 3 study conditions. In one condition, physicians, physician assistants, and nurse practitioners delivered the brief intervention. In another condition, midlevel professionals (usually nurses) performed the brief intervention. In the third condition, SBI was not performed. Using administrative claims data, we estimated the effect of SBI on individual-level annual days of total and inpatient health care utilization; annual outpatient visits; annual emergency room visits; and annual visits related to alcohol, drug, or mental health conditions. Negative binomial regression models were used to control for other factors that may affect health care utilization.

RESULTS

Across all categories of care, the pre- to postintervention change in average health care utilization among risky drinkers in the intervention clinics was not significantly different from that of risky drinkers in the comparison clinics.

CONCLUSIONS

Our findings suggest that there is no effect of SBI on the health care utilization of risky drinkers in the year following the intervention. Although SBI does not appear to reduce health care utilization, previous studies find that it significantly reduces the alcohol consumption of risky drinkers. Because these reductions presumably improve patients' overall health and well-being, managed care organizations may still find it beneficial to implement SBI on a broad scale.

BRIEF INTERVENTIONS FOR AT-RISK DRINKING: PATIENT OUTCOMES AND COST-EFFECTIVENESS IN MANAGED CARE ORGANIZATIONS

AIMS

Evaluate effectiveness and costs of brief interventions for patients screening positive for at-risk drinking in managed health care organizations (MCOs).

METHODS

A pre-post, quasi-experimental, multi-site evaluation conducted at 15 clinic sites within five MCO settings. At-risk drinkers (N = 1329) received either: (i) brief intervention delivered by licensed practitioners; or (ii) brief intervention delivered by mid-level professional specialists (nurses); or (iii) usual care (comparison condition). Clinics were randomly assigned to three study conditions. Data were collected on the cost of screening and brief intervention. Follow-up interviews were conducted at 3 and 12 months.

RESULTS

Participants in all three study conditions were drinking significantly less at 3-month follow-up, but the decline was significantly greater in the two intervention groups than in the control group. There were no significant differences between the two intervention conditions. Of the patients in the intervention conditions 60% reduced their alcohol consumption by > or =1 drink per week, compared with 53% of those in the control condition. No differences were found on a measure of the quality of life. Differential reductions in weekly alcohol consumption between intervention and control groups were significant at 12-month follow-up. Average incremental costs of the interventions were 4.16 US dollar per patient using licensed practitioners and 2.82 US dollar using mid-level specialists.

CONCLUSION

Alcohol screening and brief intervention when implemented in managed care organizations produces modest, statistically significant reductions in at-risk drinking. Interventions delivered to a common protocol by mid-level specialists are as effective as those delivered by licensed practitioners at about two-thirds the cost.