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NAT 6/08 - THL

NAT 6/08 - THL

Commentary Taking stock:

Commentary Taking stock: Twenty-five years of translational research on alcohol screening and brief intervention 578 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 25. 2008 . 6 thoMas F. BaBor The papers collected in this special volume of NAT tell a story about the prevention of alcohol problems that is greater than the sum of its parts. Those parts include three basic elements: 1) the modern conceptual history of alcohol-related problems; 2) clinical research on the efficacy and effectiveness of brief interventions with hazardous and harmful drinkers; and 3) local, regional and national efforts to translate research findings into programmatic initiatives aimed at the secondary prevention of alcohol-related problems in health care settings throughout the world. Refining concepts There was a time when academics who studied alcohol would lament the predominant focus of alcohol studies on the disease concept of alcoholism. It was argued that too little attention was devoted to the broader spectrum of alcohol problems that are manifested in the general population. After a period of acrimonious debate about the feasibility of controlled drinking therapies for alcoholics, the field shifted its attention in the 1980’s to a new secondary prevention approach that applied many of the controversial controlled drinking concepts to problem drinkers who had not developed severe alcohol dependence. This shift in focus was facilitated by the development of new concepts, such as hazardous and harmful drinking, and a refinement of the traditional dependence concept from a medical “disease” to a psychiatric and behavioral “disorder”. Once it became evident that not all alcohol problems were the manifestation of a clinical syndrome called alcoholism, the stage was set for

a more nuanced approach that focused on people who drank too much or too often. Psychometric and clinical research In 1982 the World Health Organization (WHO), which for 30 years had been articulating a global approach to alcohol problems from a public health perspective, began a long-term applied research project to develop an international screening test and to evaluate how persons identified as hazardous and harmful drinkers responded to brief clinical interventions in primary health care settings. That project, as described in an article by Aasland et al., produced the AUDIT screening test, which is now widely used throughout the world, in part because of an impressive science base that now includes more than 700 scientific papers. The same kind of international collaboration among clinicians, scientists and public health administrators that lead to the development of the AUDIT was then applied to a 10-nation study to test the effectiveness of brief interventions (WHO Brief Intervention Study Group 1996). Combined with similar researchto-practice efforts in other countries, the WHO study showed that brief interventions could produce clinically meaningful changes in patients’ drinking behavior with only a small investment of time and resources. Translating research to practice As indicated by the papers in this volume, the WHO program on alcohol screening and brief intervention was part of a broader social movement that has now matured to the point where national implementa- tion programs are being disseminated and evaluated in a variety of different countries. Although the challenges are formidable, the fact that so many programs are operating in so many countries is in itself testimony to the power of an idea whose time has come. In the Nordic countries, the story is dominated by attempts to integrate early intervention for alcohol problems into the traditional primary health care system, which is built around the general practitioner (GP) as the primary agent of curative medical services. Reports from Sweden (Spak and Andersson), Denmark (Barford), Norway (Aasland and Johannesen), and Finland (Seppä and Kuokkanen) suggest that GPs may not be the most appropriate vehicle for delivering early intervention with at-risk drinkers, especially under conditions where resources are shrinking, training is inadequate, patients are defensive, and public attitudes still do not consider excessive drinking as a legitimate health issue. But as several of these papers show (Holmquist et al.; Nilsen et al.), there are many other ways to reach high risk drinkers, through other parts of the health care system (e.g., occupational medicine clinics) and through new technologies (e.g., internet health programs). In contrast to the somewhat pessimistic views from the Nordic countries, the papers from Latin America are more sanguine about the prospects for alcohol screening and brief intervention as a public health initiative directed at large population areas in the developing world. In countries like Brazil, the health care system is organized around high volume clinics where most care is delivered by nurses and community health agents, rather than GPs. Demonstration programs implemented in Sao Paulo, Cu- NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 579

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