Assessing bias in community-based prevalence estimates: towards an unduplicated count of problem drinkers and drug users

General population survey estimates of the overall prevalence of problem drinking and drug use in a community are biased by the exclusion of non-household populations. Estimates based on compiling prevalences in community institutions may also be biased due to over-counting of users of more than one institution. This paper examines prevalence estimates derived from probability samples of problem drinkers in the general population and within alcohol treatment, drug treatment, mental health, criminal justice and welfare agencies in a single US county. Data sets are merged and weighted to reflect a community sample of institutions, and a 1 7% subset of cases is identified within the institutional samples that are not living in housing units typically included in general population sampling frames. The difference in prevalences of problem drinking in the household and non-household populations is found to be large: 11% and 48%, respectively. Even greater differences are found between estimates of unprescribed weekly drug use (6% and 47%, respectively) and combined problem drinking and weekly drug use (2% and 27%, respectively). This suggests that confining samples to the household population can systematically under-represent the prevalence of problem drinking and drug use. A second source of bias in prevalences is characteristic of studies using records from multiple institutions. When duplication of service use in the five agency samples is considered, it becomes apparent that prevalences may be biased upward due to over-counting of multiple service users.     

Integrating Public Health and Public Safety in the Criminal Justice System: An Overview of Behavioral Health Services,including Alcohol/Other Drug Disorders

Mental illness and alcohol and other drug disorders account for more disability than any other medical problem. One of the systems most affected by these disorders in the United States is the criminal justice system. This article provides an overview of the problem of behavioral health disorders in the justice system in addition to innovative programs that are contributing to a more humane and, potentially, cost-effective system of care in correctional and community settings.     

Twenty-one-year trends and correlates of pressure to change drinking

Background: The vast majority of individuals with alcohol problems in the United States and elsewhere do not seek help. One policy response has been to encourage institutions such as criminal justice and social welfare systems to mandate treatment for individuals with alcohol problems (Addiction, 1997; 92 :1133). However, informal pressures to drink less from family and friends are far more common than institutional pressures mandating treatment (Addiction, 1996; 91 :643). The prevalence and correlates of these informal pressures have been minimally studied. Methods: This analysis used data from 5 Alcohol Research Group National Alcohol Surveys (NAS) collected at approximately 5‐year intervals over a 21‐year period (1984 to 2005, pooled N = 16,241) to describe the patterns of pressure that drinkers received during the past year from spouse, family, friends, physicians, police, and the workplace. Results: The overall trend of pressure combining all 6 sources across all 5 NAS data sets indicated a decline. Frequent heavy drinking and alcohol‐related harms also declined, and both were strong predictors of receiving pressure. Trends among different sources varied. In multivariate regression models, pressure from friends showed an increase. Pressure from spouse and family showed a relatively flat trajectory, with the exception of a spike in pressure from family in 1990. Conclusions: The trajectory of decreasing of pressure over time is most likely the result of decreases in heavy drinking and alcohol‐related harm. Pressure was generally targeted toward higher risk drinkers, such as heavy drinkers and those reporting alcohol‐related harm. However, demographic findings suggest that the social context of drinking might also be a determinant of receiving pressure. Additional studies should identify when pressure is associated with decreased drinking and increased help seeking.     

Associations Between Injection Risk and Community Disadvantage Among Suburban Injection Drug Users in Southwestern Connecticut,USA

Increases in drug abuse, injection, and opioid overdoses in suburban communities led us to study injectors residing in suburban communities in southwestern Connecticut, US. We sought to understand the influence of residence on risk and injection-associated diseases. Injectors were recruited by respondent-driven sampling and interviewed about sociodemographics, somatic and mental health, injection risk, and interactions with healthcare, harm reduction, substance abuse treatment, and criminal justice systems. HIV, hepatitis B and C (HBV and HCV) serological testing was also conducted. Our sample was consistent in geographic distribution and age to the general population and to the patterns of heroin-associated overdose deaths in the suburban towns. High rates of interaction with drug abuse treatment and criminal justice systems contrasted with scant use of harm reduction services. The only factors associated with both dependent variables—residence in less disadvantaged census tracts and more injection risk—were younger age and injecting in one’s own residence. This contrasts with the common association among urban injectors of injection-associated risk behaviors and residence in disadvantaged communities. Poor social support and moderate/severe depression were associated with risky injection practices (but not residence in specific classes of census tracts), suggesting that a region-wide dual diagnosis approach to the expansion of harm reduction services could be effective at reducing the negative consequences of injection drug use.     

Factors associated with probation officers' use of criminal justice coercion to mandate alcohol treatment

Alcohol problems are widespread among individuals in county criminal justice probation systems. However, it is unclear why only a small fraction of these problem drinkers receive treatment. In this study, self-administered questionnaires were mailed to 145 probation officers in nine California counties to identify factors that predicted probation officers' use of coercion to mandate alcohol treatment. The questionnaire measured characteristics of probation officers, characteristics of their caseloads, and perceptions about their departments. Principle components analysis combined some of the items into six factor-based scales. Multiple regression analyses identified two significant predictors of use of coercion into treatment: a belief that treatment was effective and a belief that one's peers in the department were using coercion frequently. Implications for increasing treatment entry of probationers with drinking problems include educating probation officers about the effectiveness of substance abuse treatment in general and about coerced treatment in particular. Probation departments are encouraged to develop management styles that facilitate shared normative beliefs about assessing and managing alcohol problems among probationers.     

An Industrial Alcohol Policy: The Characteristics of Worker Success

Characteristics associated with success of problem drinkers in workplace treatment settings remain obscure. The development of interventions in such settings tend to rely on generalizations from non-workplace treatment settings and untested assumptions. The present study seeks to ascertain the characteristics of success in a workplace setting. A company with an alcohol policy provided records of all individuals referred for treatment over a 4 year period (N = 48). Analysis of the data indicated that older, longer service employees were likely to be more successful in this company. It was also evident that self-referral was associated with ‘poor’ outcome. The significance of this result is discussed in relation to prognostic factors in the industrial setting and the relevance to future development of industrial alcohol policies.     

Strategies to enhance linkages between care for HIV/AIDS in jail and community settings

The policies of mass incarceration and the expansion of the criminal justice system in the USA over the last 40 years have weighed heavily on individuals and communities impacted by drug use and HIV disease. Though less than ideal, jails provide a unique opportunity to diagnose, treat and implement effective interventions. The role of jails in HIV detection, treatment, and continuity of care, however, has yet to be systematically examined. This paper reviews the service strategies and contexts for 10 demonstration sites funded to develop innovative methods for providing care and treatment to HIV-infected individuals in jail settings who are returning to their communities. The sites have implemented varied intervention strategies; each set in unique policy and service system contexts. Collaboration among agencies and between systems to implement these interventions is viewed as particularly challenging undertakings. We anticipate the sites will collectively serve 700-1000 individuals across the duration of the initiative. In this paper, we review the service contexts and strategies developed by the 10 sites. The individual and multi-site evaluations aim to provide new data on testing, treatment, and community linkages from jails that will further develop our knowledge base on effective intervention strategies in these settings.     

An Industrial Alcohol Policy: The Characteristics of Worker Success

Characteristics associated with success of problem drinkers m workplace treatment settings remain obscure. The development of interventions in such settings tend to rely on generalizations from non-workplace treatment settings and untested assumptions. The present study seeks to ascertain the characteristics of success in a workplace setting. A company with an alcohol policy provided records of all individuals referred for treatment over α 4 year period (N = 48). Analysis of the data indicated that older, longer service employees were likely to be more successful in this company. It was also evident that self-referral was associated with ‘poor’ outcome. The significance of this result is discussed in relation to prognostic factors in the industrial setting and the relevance to future development of industrial alcohol policies.     

Factors Associated with Probation Officers' Use of Criminal Justice Coercion to Mandate Alcohol Treatment

Alcohol problems are widespread among individuals in county criminal justice probation systems. However, it is unclear why only a small fraction of these problem drinkers receive treatment. In this study, self‐administered questionnaires were mailed to 145 probation officers in nine California counties to identify factors that predicted probation officers' use of coercion to mandate alcohol treatment. The questionnaire measured characteristics of probation officers, characteristics of their caseloads, and perceptions about their departments. Principle components analysis combined some of the items into six factor‐based scales. Multiple regression analyses identified two significant predictors of use of coercion into treatment: a belief that treatment was effective and a belief that one's peers in the department were using coercion frequently. Implications for increasing treatment entry of probationers with drinking problems include educating probation officers about the effectiveness of substance abuse treatment in general and about coerced treatment in particular. Probation departments are encouraged to develop management styles that facilitate shared normative beliefs about assessing and managing alcohol problems among probationers.     

Ethnic disparities in clinical severity and services for alcohol problems: results from the National Alcohol Survey

BACKGROUND: This study reports lifetime estimates of the extent of unmet need for alcohol services across the 3 largest ethnic groups in America, and examines factors that may contribute to ethnic differences in service use. Prior studies report mixed findings as to the existence of ethnic disparities in alcohol services, with some suggesting that minorities are over-represented in treatment settings. METHODS: Drawing on the most recent National Alcohol Surveys, we compare rates and factors associated with the lifetime service use for alcohol problems among Whites, Blacks, and Hispanics who meet lifetime criteria for alcohol abuse or dependence. RESULTS: While bivariate analyses revealed few ethnic differences in service use, there were significant differences by ethnicity in multivariate models that included alcohol problem severity and its interactions with ethnicity. At higher levels of problem severity, both Hispanics and Blacks were less likely to have utilized services than comparable Whites. Hispanics, on the whole, reported higher-severity alcohol problems than Whites. Yet, they were less likely to have received specialty treatment and multiple types of alcohol services, and were more likely to cite economic and logistical barriers as reasons for not obtaining care. CONCLUSIONS: Future efforts to study ethnic disparities in alcohol services should utilize analytic approaches that address potential confounding between ethnicity and other factors in service use, such as alcohol problem severity. Our findings suggest that Hispanics and Blacks with higher-severity alcohol problems may utilize services at lower rates than comparable Whites, and that, particularly for Hispanics, this may in part be attributable to financial and logistical barriers to care.     

The role of problem drinking in psychiatric admissions

Although problem drinkers are over-represented in psychiatric treatment populations throughout the United States, it is unclear whether this is primarily due to difficulties in differentially diagnosing alcohol and mental problems and to high rates of comorbidity, or to factors unique to help-seeking for alcohol problems. This article examines the role that alcohol problems play in treatment entry to inpatient and outpatient mental health agencies, considering the potential roles of a drinking problem both as a condition perceived by the sufferer to require a psychiatrist's help, and as a source of social disruption that activates others to encourage mental health treatment. Analysis focuses on comparing samples of newly admitted patients in a community mental health system and untreated individuals with high levels of psychiatric symptoms living in the same community. Experiencing the adverse social consequences of a drinking problem, holding the belief that drinking has caused one's psychological problems, and having prior experiences in mental health treatment for a drinking problem are factors found to be positively associated with psychiatric admissions, while heavier drinking and dependence symptoms are not. Further analysis of events precipitating psychiatric admission suggests that an important role for the mental health system vis à vis alcohol problems is to contain social disruptions attributable to problem drinking in the community. Alcohol-related psychiatric admissions are found to have more frequently involved public disruptions, to have elicited police or court referrals, and to have more often resulted in the client's going to a locked hospital ward, as opposed to a mental health outpatient clinic.     

Factors associated with adolescent utilization of alcohol treatment services

OBJECTIVE: This study examined factors associated with adolescents' use of alcohol treatment services. METHOD: Data on adolescents (aged 12-17) from the 1994 National Household Survey on Drug Abuse (NHSDA, N = 4,698), a large representative sample of the U.S. population, were used in this study. Information obtained from the survey included adolescent alcohol use, drinking patterns, alcohol abuse/dependent problems, and service use for alcohol-related problems. In addition, socio- demographics, health insurance, mental and behavioral problems, and other drug use were also included in the analysis. RESULTS: The findings indicate that many adolescents with alcohol problems did not receive treatment. White adolescents were more likely to receive alcohol treatment services than nonwhites. Among alcohol-related problems, alcohol causing problems at home, school, or other settings predicted entry into alcohol treatment. Drug use and poor health status were also associated with receiving alcohol treatment services. CONCLUSIONS: This study calls for an improved service delivery system to meet service needs of adolescents with alcohol-related problems, especially among minorities, and those with alcohol-related problems but without yet experiencing significant negative social consequences.     

Life-time problem drinking and psychiatric co-morbidity among Ontario women 1

Women problem drinkers in the community, aged 15-64 years, with and without life-time psychiatric co-morbidity were compared to examine the association of this co-morbidity with alcohol consumption patterns, course and chronicity of problem drinking, treatment service utilization and other substance use and misuse. The women problem drinkers were also compared with non-problem drinkers on substance use patterns and utilization of services. The study employs data from the Mental Health Supplement to the Ontario Health Survey, a province-wide household population study. The University of Michigan Composite International Diagnostic Interview (UM-CIDI) was administered by trained lay interviewers and subsequently World Health Organization computer algorithms were used to generate DSM-III-R diagnoses based on the interview responses. Multiple logistic regression analysis indicated that psychiatric co-morbidity was associated with less education, earlier onset of problem drinking and one indicator of binge drinking. Co-morbidity also greatly increased the chances of women problem drinkers having sought mental health treatment. Women problem drinkers were significantly younger (about 7 years) than other women in the general population, perhaps an indicator of an increased mortality rate.     

Functioning, life context, and help-seeking among late-onset problem drinkers: comparisons with nonproblem and early-onset problem drinkers

We compared the functioning and life contexts of late-middle-aged adults classified as late-onset problem drinkers (n=229), early-onset problem drinkers (n=475), and nonproblem drinkers (n=609). Compared with nonproblem drinkers, late-onset problem drinkers consumed more alcohol and functioned more poorly; they also reported more negative life events and chronic stressors, fewer social resources, and more use of avoidance coping. However, late-onset problem drinkers consumed less alcohol, had fewer drinking problems, functioned better, and had more benign life contexts than did early-onset problem drinkers. We found no evidence of an association between age-related loss events and the onset of late-life drinking problems. Very few problem drinkers sought help specifically for their alcohol abuse, but about 25% did seek treatment from mental health practitioners. Problem drinkers who were functioning more poorly and who reported more life stressors and fewer social resources were more likely to seek help.     

Ageing, families and welfare systems: Comparative perspectives

Some convergence between countries may be observed in total welfare spending during the later decades, but while levels are becoming more similar, the profiles are still very different. Some welfare states are high on transfers, others on services, and among services--some give priority to institutions, others invest more heavily in community (home) care. Discussed in this article is how different family cultures are reflected in welfare systems, and conversely--how welfare systems in turn may influence families. The article argues that home care services tend to have lower priority in countries with familistic policies, and higher priority where social policies are individualistic. What model is the more sustainable for the future, given the social and demographic changes to be expected?     

Ageing, families and welfare systems: Comparative perspectives

Some convergence between countries may be observed in total welfare spending during the later decades, but while levels are becoming more similar, the profiles are still very different. Some welfare states are high on transfers, others on services, and among services – some give priority to institutions, others invest more heavily in community (home) care. Discussed in this article is how different family cultures are reflected in welfare systems, and conversely – how welfare systems in turn may influence families. The article argues that home care services tend to have lower priority in countries with familistic policies, and higher priority where social policies are individualistic. What model is the more sustainable for the future, given the social and demographic changes to be expected?     

Mandated AA attendance for recidivist drinking drivers: policy issues

Mandates for recidivist drinking drivers to attend AA meetings raise concerns about whether AA referral practices could have an adverse impact on both alcohol problems and traffic safety, whether routine and unregulated referrals to AA may prove detrimental to AA as an organization, and over ethical issues and possible loss of civil liberties. Similar issues arise in criminal justice and other agencies' handling of a variety of situations beyond the DUI arena. As a result institutions mandating involvement in mutual aid programs such as AA, and a variety of treatment settings, should adopt cautious referral practices, support rigorous research and create and evaluate targeted programs and integrated services.     

Factors associated with adolescent utilization of alcohol treatment services

Objective: This study examined factors associated with adolescents' use of alcohol treatment services.

Method: Data on adolescents (aged 12–17) from the 1994 National Household Survey on Drug Abuse (NHSDA, N=4698), a large representative sample of the U.S. population, were used in this study. Information obtained from the survey included adolescent alcohol use, drinking patterns, alcohol abuse/dependent problems, and service use for alcohol-related problems. In addition, socio-demographics, health insurance, mental and behavioral problems, and other drug use were also included in the analysis.

Results: The findings indicate that many adolescents with alcohol problems did not receive treatment. White adolescents were more likely to receive alcohol treatment services than nonwhites. Among alcohol-related problems, alcohol causing problems at home, school, or other settings predicted entry into alcohol treatment. Drug use and poor health status were also associated with receiving alcohol treatment services.

Conclusions: This study calls for an improved service delivery system to meet service needs of adolescents with alcohol-related problems, especially among minorities, and those with alcohol-related problems but without yet experiencing significant negative social consequences.     

Drinking problems and self-reported criminal behavior, arrests and convictions: 1990 US alcohol and 1989 county surveys

Use of general population surveys in addition to institutional samples is critical to disentangling the relationship between criminal behavior and alcohol problems or use of illicit drugs. Local area studies can be useful but generalizability of their results is seldom studied. Data from recent US national (n = 2058) and county (n = 3069) general population surveys are used to examine the role of alcohol problem and drug use history in predicting self-reported criminal behavior, arrest and conviction within a logistic regression framework. In the national and county surveys controlling for age, gender, income, marital status, employment, education, race and drug use, lifetime drinking problems significantly predicted current criminal behavior (odds ratios 1.3 and 1.5, respectively) with slightly stronger relationships noted in equivalent models predicting arrest (odds ratios 1.7 and 1.8) and conviction (odds ratios 1.7 and 1.6). Relationships between alcohol, drugs and criminal behavior/justice variables are discussed. Parallels between US and county results suggest that findings from intensive, articulated analyses of community-level population and institutional surveys may be cautiously generalized beyond their geographic locus.