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NAT 6/08 - THL

NAT 6/08 - THL

The long and winding

The long and winding road to widespread implementation of screening and brief intervention for alcohol problems subsequent multinational wHO project of brief intervention, as well as in several other similar projects. Many of these projects have proven quite efficient, but screening and brief intervention for alcohol problems is still not standard procedure in primary health care. The paper discusses some of the reasons why. KEywORDS Alcohol, screening, brief intervention, primary health care, history, wHO, AUDIT 470 NORDIC STUDIES ON ALCOHOL AND DRUGS VOL. 25. 2008 . 6 systems were reluctant to acknowledge this. In many countries, special institutions, often prison-like, were built for the severely dependent. The effect of this type of treatment, often lasting for months or even years, was hard to document scientifically. However, several steps were taken during the 1970s towards a preventive strategy that involved delivery of alcohol interventions in general health care settings. In his book The Hidden Alcoholic in General Practice, Wilkins (1974) described a study from the UK where some pre-determined risk criteria (certain somatic or psychiatric diseases or symptoms, certain occupations, and a number of social problems known to be alcohol related) were combined with data from a specially developed patient questionnaire to identify patients with possible alcoholism. Wilkins’ results suggested that “the problem of alcoholism in the community as a whole is probably far greater than hitherto suspected, the wider social and economic implications of this being indicated, and that it is possible for general practitioners, by spending about 15 minutes per week interviewing selected patients, to improve considerably their detection of the hidden alcoholic and thus increase the chance of being able to help him and those around him” (Wilkins 1974; back cover). An important contribution to the pursuit of new intervention models was made by Edwards et al. (1977). They showed that there were no significant differences after one year between one group of alcoholics who received one brief session of counselling and a control group with several months of intensive in and outpatient treatment. The outcome variables included dinking behaviour, as well as social adjustment variables, e.g. sick leave periods and marital situation. In 1979 Russell et al. published an interesting article on the effect of general practitioners’ advice for smoking cessation. Russell conducted a controlled study with interventions of various intensity, and found that after one year, more than 3% of the smoking patients who had only been subjected to one brief advice session remained non-smokers. “If all the GPs in the UK participated the yield would exceed half a million ex-smokers a year,” he observed. “This target could not be matched by increasing the existing 50 or so special withdrawal clinics to 10 000” (Russell et al. 1979, 231). Russell’s and his colleagues’ observation coincided with

the work of English epidemiologist Geoffrey Rose (1926–1993), who described the so-called prevention paradox in 1979. This principle suggests that alcohol-related problems in a population come more from moderate drinkers than from heavy drinkers because there are so many more moderate drinkers, even though these drinkers are individually at lower risk of adverse outcomes than heavier drinkers. A major implication of the prevention paradox is that there may be substantial benefits to public health, e.g. if health care providers implement secondary prevention interventions to reduce alcohol risk and harm in the population, but there will be relatively small health gains to specific individuals (Rose 1981). The WHO project on Identification and Management of Alcohol- Related Problems In November 1979, a WHO Expert Com- mittee on “Problems Related to Alcohol Consumption” met in Geneva. The purpose was to consider what could be done about alcohol problems on a broad scale. The meeting proved to be an important turning point in the WHO’s re-orientation towards a population strategy to the alcohol problem. It was noted in a 1980 document of the meeting, “In the past, most programmes concerning alcohol problems focused on the individual drinker, particularly the heavy drinker, including the person who had become dependent on alcohol. In recent years, however, attention has increasingly turned to the consequences of drinking for the community, for society in general” (WHO 1980, 7). There was an urgent call for the development of strategies The long and winding road to widespread implementation of screening and brief intervention for alcohol problems that could be applied in primary health care settings with a minimum of time and resources (WHO 1980). In early 1981, Jan Ording, a Swedish government official (originally from Norway), at the time director of the Alcohol program at WHO Headquarters in Geneva, invited UK psychologist Ray Hodgson and Norwegian physician Olaf G. Aasland to an informal one-day meeting in Geneva. They were each given an office, pencil and paper, and the assignment to come up with first drafts of two international collaborative projects, one on screening (Aasland) and one on brief intervention (Hodgson). The instruction was to develop standardized methods that were simple enough to be implemented in primary health care systems worldwide. Subsequently, international experts were brought together and research groups were formed in Oslo, Norway (screening) and Farmington, USA (brief intervention). This was the beginning of the “WHO Collaborative Project on Identification and Treatment of Persons with Harmful Alcohol Consumption” (Saunders & Aasland 1987), later renamed “Project on Identification and Management of Alcohol-Related Problems” (Babor & Grant 1992). In 1983, an expert committee produced a report that received much positive attention, Problems Related to Alcohol Consumption (WHO 1983). The report introduced the concepts of hazardous and harmful drinking. Hazardous drinkers have an elevated risk (physical, psychical and social harm) from alcohol consumption that exceeds daily, weekly, or per-occasion thresholds, whereas harmful drinkers are already experiencing physical, social or psychological harm due to NORDIC STUDIES ON ALCOHOL AND DRUGS V O L . 25. 2008 . 6 471

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