Alcoholism: beliefs and attitudes among Canadian alcoholism treatment practitioners

Drug and alcohol treatment providers' views about the disease model of addiction and its impact on clinical practice: A systematic review

ISSUES

Addiction treatment providers' views about the disease model of addiction (DMA), and their contemporary views about the brain disease model of addiction (BDMA), remain an understudied area. We systematically reviewed treatment providers' attitudes about the DMA/BDMA, examined factors associated with positive or negative attitudes and assessed their views on the potential clinical impact of both models.

APPROACH

Pubmed, EMBASE, PsycINFO, CINAHL Plus and Sociological Abstracts were systematically searched. Original papers on treatment providers' views about the DMA/BDMA and its clinical impact were included. Studies focussing on tobacco, behavioural addictions or non-Western populations were excluded.

KEY FINDINGS

The 34 included studies were predominantly quantitative and conducted in the USA. Among mixed findings of treatment providers' support for the DMA, strong validity studies indicated treatment providers supported the disease concept and moral, free-will or social models simultaneously. Support for the DMA was positively associated with treatment providers' age, year of qualification, certification status, religious beliefs, being in recovery and Alcoholics Anonymous attendance. Greater education was negatively associated with DMA support. Treatment providers identified potential positive (e.g. reduced stigma) and negative (e.g. increased sense of helplessness) impacts of the DMA on client behaviour.

IMPLICATIONS/CONCLUSION

The review suggests treatment providers may endorse disease and other models while strategically deploying the DMA for presumed therapeutic benefits. Varying DMA support across workforces indicated service users may experience multiple and potentially contradictory explanations of addiction. Future policy development will benefit by considering how treatment providers adopt disease concepts in practice.

Treatment Professionals' Basic Beliefs About Alcohol Use Disorders: The Impact of Different Cultural Contexts

BACKGROUND

The treatment of alcohol abusers in different cultural contexts does not depend only on the methods used but also on the ways in which treatment providers perceive the problem and relate to their clients.

OBJECTIVES

This study compares treatment professionals' basic beliefs about alcohol use disorders in two culturally different European countries to find out to what extent these ideas are shaped by the respondents' socio-cultural context, profession, and other background variables.

METHODS

Similar postal surveys were conducted among professionals working in specialized addiction treatment units in Finland (n = 520) and France (n = 472). The data were analyzed by descriptive statistical methods and logistic regression analysis.

RESULTS

Consistent cultural differences were found in almost all the questions asked and they remained significant even after controlling for the other background factors. The French professionals emphasized the addictiveness of alcohol more than their Finnish colleagues. They also believed less in the chances of recovery and attributed more responsibility for the problem to external factors, while the Finns emphasized individual responsibility. Profession, gender and some other background variables also modified beliefs about specific questions.

CONCLUSIONS

Cultural factors shape the ways in which alcohol use disorders are perceived more pervasively than the other background variables. The French professionals' low trust in treatment and the Finnish professionals' lack of concern for the addiction potential of alcohol and stronger tendency to regard the person as responsible for the problem could be seen as potential impediments to effective ways of helping alcohol abusers in these countries.

Attitudes about addiction: a national study of addiction educators

The following study, funded by the National Institute of Drug Abuse (NIDA), utilized the Addiction Belief Inventory (ABI; Luke, Ribisl, Walton, & Davidson, 2002) to examine addiction attitudes in a national sample of U.S. college/university faculty teaching addiction-specific courses (n=215). Results suggest that addiction educators view substance abuse as a coping mechanism rather than a moral failure, and are ambivalent about calling substance abuse or addiction a disease. Most do not support individual efficacy toward recovery, the ability to control use, or social use after treatment. Modifiers of addiction educator attitudes include level of college education; teaching experience; licensure/certification, and whether the educator is an addiction researcher. Study implications, limitations, and directions for future research are discussed.

Counselor attitudes toward pharmacotherapies for alcohol dependence

OBJECTIVE

Addiction treatment counselors play a central role in the dissemination of information about new treatment techniques to alcohol-dependent patients and are key in the implementation of new treatment technologies. Building on previous research, this study examines counselors' perceptions of the effectiveness and acceptability of pharmacotherapies for the treatment of alcohol dependence.

METHOD

Mail questionnaires were received from 1,140 counselors employed in a nationally representative sample of public-sector addiction treatment programs in 2006. Counselors answered a series of questions about three U.S. Food and Drug Administration (FDA)-approved medications used in the treatment of alcohol dependence (disulfiram [Antabuse], tablet naltrexone [Revia], and acamprosate [Campral]), indicating their extent of familiarity with the medication, its perceived effectiveness in the treatment of alcohol dependence, and its acceptability for use with alcohol-dependent patients.

RESULTS

The extent of diffusion of these pharmacotherapies was associated with time since FDA approval. Counselors reported receiving little or no pharmacotherapy-specific training. Multivariate models showed that the receipt of medication-specific training as well as indirect observation of the medication's use in the treatment program were significantly associated with diffusion of information about these pharmacotherapies and counselors' perceptions of the effectiveness and acceptability of the medications for use in addiction treatment.

CONCLUSIONS

When exposed to information about medications to treat alcohol dependence, counseling staff appear quite receptive. More efforts are needed to disseminate information about alcohol pharmacotherapies to front-line addiction treatment staff.

Improving acceptance of naltrexone in community addiction treatment centers: a pilot study

Alcoholism pharmacotherapies are underused in community addiction treatment settings, in part because individuals who practice in these settings--nonmedical addiction counselors and administrators--lack knowledge about and confidence in the value of adjunctive alcohol pharmacotherapies. We developed and tested an intervention to improve knowledge and attitudes about naltrexone. A team of researchers, physicians, addiction treatment counselors, and administrators collaborated to develop a naltrexone educational intervention designed for nonmedical addiction professionals. The intervention was compared with a control condition in a pilot study with 6 addiction treatment agencies (3 agencies per group). Participants (counselors and administrators, N = 84) were assessed before and 6 months after the intervention. Results revealed that the intervention significantly improved naltrexone knowledge, and participants who received the intervention reported greater satisfaction with the education they received, as well as greater use of the information. The effect of the intervention on attitudes about naltrexone was encouraging but did not to reach statistical significance. This study is the first reported attempt to develop and test an intervention specifically to improve acceptance of adjunctive medications for alcoholism among nonmedical addiction professionals.

[Psychometric characteristics of questionnaires designed to assess the knowledge, perceptions and practices of health care professionals with regards to alcoholic patients]

Failure of the French health care services to diagnose and manage problem drinkers has been established on many occasions. This results from a relative lack of knowledge of the basics of alcoholism and the low level of involvement of health care professionals in the management of these patients. In response to this inadequacy, the French Public Health Ministry promoted the development of managed care and coordination of care for these patients. Teams in charge of coordinating care for problem drinkers have been implanted in 96 French hospitals since 1996. These teams aim to provide support to health care providers caring for problem drinkers. For this purpose, they have delivered continuing medical education designed to prepare health care providers to identify and manage these patients in various settings. However, no formal assessment of the impact of these interventions on the knowledge, perceptions, and practices of health care professionals has been planned. The assessment of these interventions can rely on qualitative methods such as observation, focus groups, or individual interviews. However, qualitative methods require specific skills, are time-consuming, and cannot be implemented on a large scale. In contrast, quantitative methods using survey questionnaires or standardized instruments appear to be more appropriate for large scale or repeated evaluations. However, the accuracy of ratings provided by these instruments can be affected by many methodological factors, including the quality of the instrument in terms of validity, reliability, and sensitivity to changes. The aim of this paper is to describe the properties of French and English language questionnaires designed to assess the knowledge, perceptions, and practices of health care professionals with regards to alcoholic patients.

METHODS

The instruments were retrieved by searching the Medline, Pascal, and Sudoc computerized bibliographic databases from January 1964 to December 2002. The following medical Subject Headings (MeSH) and text words were used: "*alcoholism/psychology/therapy", "questionnaire", "healthy care surveys", "attitude of health personnel", and "*knowledge/attitude/practice". In addition, the table of contents of the French journals devoted to alcoholism that were not indexed in electronic bibliographic databases were examined (Alcoologie et addictologie, Alcoologie). The bibliographies of relevant articles were also examined for additional citations. Finally, a phone survey of 34 professionals caring for alcoholic patients located in French university hospitals was carried out to retrieve unpublished questionnaires. Two authors independently extracted data from each study using a standard date abstract form. Disagreements were resolved through consensus. They extracted information on the development process and properties of validity, reliability, and sensitivity to changes. Validity is a concept concerned with the extent to which an instrument actually measures what it is supposed to measure. It is assessed through different facets (content, construct, criterion, discriminant, and predictive validity). Reliability reflects the amount of error inherent in any measurement. Sensitivity to change corresponds to the property of an instrument to identify small but clinically significant changes in attitude or practice.

RESULTS

A total of 57 relevant publications involving 39 original instruments were identified. Eighty questionnaires were not available, despite the solicitation of their developers. Overall, the study included 21 instruments. Of these, 20 were English-language questionnaires and one was in French. The conceptual frameword was specified for only two questionnaires: "the Addiction Belief Scale" and "the Alcohol and Alcohol Problems Perception Questionnaire". The number of items ranged from 9 to 122. Items were derived from qualitative surveys in only two cases. In the other cases, they were derived from the literature, expert panels, or form unknown sources. The internal construct validity of eight questionnaires was assessed using principal component analysis, factor analysis, or cluster analysis. We considered that external construct validity was analyzed by testing empirical hypotheses derived from the literature for 15 of the instruments studied. Predictive validity cas evidenced for only one questionnaire. Internal consistency was documented for seven instruments, using Cronbach's coefficient. Test-retest or inter-rater reliability was assessed for none of the instruments. The sensitivity to change of two instruments was analyzed. The response rate to the instruments ranged from 46% to 93%.

DISCUSSION

The main finding of this study is that properties of validity, reliability, and sensitivity of questionnaires designed to assess the knowledge, perceptions, and practices of health care professionals with regards to alcoholic patients are neglected. Moreover, these questionnaires generally lack a theoretical background. Hence, the interpretation of responses to these questionnaires may be misleading. The present study has several limitations. The search strategy could be criticized for searching only a small number of databases, and selecting French and English language questionnaires. However, given the large range of journals included, it was unlikely that the strategy has limited the generality of the results. In addition, we identified no additional relevant articles by contacting professionals working with alcoholic patients in French university hospitals. Articles reporting instruments designed to assess the knowledge, perceptions, and practices of health care professionals with regards to alcoholic patients are incomplete. Journals should require minimum evidence of validity, reliability, and sensitivity when reporting results of surveys, development of questionnaires or standardized instruments.

CONCLUSION

The psychometric characteristics of French language questionnaires were given very little attention. In order to evaluate the effectiveness of their continuing medical education programs, the teams that train French medical staff caring for alcoholic patients should either develop a standardized survey questionnaire following a strict methodology or translate an English language instrument, which would also require a cross-cultural validation.