Missed opportunities in addressing drinking behavior in medical and mental health services

BACKGROUND: Epidemiological and clinical literature point to the importance of screening for alcohol problems in medical and psychiatric settings. However, little is known about which problem drinkers seek help from those services or about the characteristics of those who have their drinking addressed. METHODS: We interviewed a probability sample of adult dependent and problem drinkers in the general population (n = 672) and consecutive admissions to chemical dependency programs in a northern California county (n = 926). We reinterviewed them 1 year later and measured medical and mental health visits and whether their drinking was addressed during the visit. RESULTS: Almost two-thirds of problem drinkers had a medical visit, and approximately one-third had a mental health visit, yet drinking was not often discussed, especially during medical visits. Many of those more likely to have a visit were not more likely to have their drinking addressed. Women and individuals older than 40 years had more medical and mental health visits [odds ratio (OR), 1.71; p < 0.001 and OR, 1.55; p < 0.001, respectively, for women; OR, 1.57; p < 0.05 and OR, 1.64; p < 0.05, respectively, for age >/=40 years], but were not more likely to have their drinking addressed in either setting, and women were less likely than men to have their drinking addressed in mental health settings (OR, 0.62; p < 0.05). Those with higher alcohol severity and those who had attended chemical dependency treatment during the previous year were more likely to have their drinking addressed in each setting. Insurance status predicted medical, but not mental health, visits and was not related to having drinking addressed in either setting. CONCLUSIONS: Drinking behavior was not routinely addressed by medical and mental health practitioners for dependent and problem-drinking men and women who presented in public and private medical and mental health settings.     

Studies on natural recovery from alcohol dependence: sample selection bias by media solicitation?

Abstract Aims. To assess the selection bias of recruiting participants in studies on natural recovery from alcohol dependence through media solicitation. Design. Two samples with different recruitment strategies are compared. Setting. Media solicitation and general population. Participants. Sample 1 consists of 176 alcohol-dependent individuals remitted without formal help and recruited through media solicatation, sample 2 consists of 32 natural remitters derived from a representative general population study with a sample size of 4075 respondents and a response rate of 70.2%. Measurements. Several triggering mechanisms and maintenance factors of remission were assessed in a personal interview using standardized questionnaires. Findings. Results of logistic regression analyses show that media-solicited subjects were more often abstinent in the last 12 months, were more severely dependent, were less satisfied with eight life domains prior to remission and showed higher scores in a coping behaviour measure. Besides these major differences from the multivariate analysis, media subjects revealed more health problems prior to remission, experienced more social pressure to change drinking behaviour, and showed differences in reasons for not seeking help. Conclusions. Media solicitation leads to a sample selection bias in research on natural recovery from alcohol dependence. When measures to foster self-change are derived from such studies, findings from representative samples have to be considered.     

Patterns of drinking in the UK Armed Forces

AIMS: To examine patterns of drinking in the UK Armed Forces, how they vary according to gender and other demographics, and to make comparisons with the general population. DESIGN: Large cross-sectional postal questionnaire study (response rate 60%). SETTING: United Kingdom. PARTICIPANTS: A random representative sample of the regular UK Armed Forces who were in service in March 2003 (n = 8686; 7937 men, 749 women). Comparisons were made with the general population of Great Britain. MEASUREMENTS: Alcohol consumption was assessed using the Alcohol Use Disorders Identification Test (AUDIT). FINDINGS: Sixty-seven per cent of men and 49% of women in the UK Armed Forces had an AUDIT score of 8+ (defined as hazardous drinking), compared to 38% of men and 16% of women in the general population. In both sexes, for all ages, the military have a higher prevalence of hazardous drinking. Binge drinking was associated with being younger, being in the Army, being single, being a smoker and being white. Among military men, heavy drinking (AUDIT score 16+) was associated with holding a lower rank, being younger, being single, being in the Naval Service or Army, being deployed to Iraq, not having children, being a smoker, having a combat role and having a parent with a drink or drug problem. CONCLUSIONS: Excessive alcohol consumption is more common in the UK Armed Forces than in the general population. There are certain socio-demographic characteristics associated with heavy drinking within the military; for example, young age, being single and being a smoker, which may allow the targeting of preventive interventions.     

Factors influencing remission from alcohol dependence without formal help in a representative population sample

Aims. To analyse factors related to remission without formal help by using a representative sample and standardized instruments.
Design. Two groups of untreated alcohol-dependent subjects were compared.
Setting. General population survey.
Participants. Thirty-two subjects fully remitted without formal help (NFH) and 26 current alcohol-dependent individuals (CAD) according to DSM-IV drawn from a representative general population sample in northern Germany (response rate: 70.2%, n = 4075).
Measurements. Data focusing on the 2 years prior to remission from NFH were compared with past-year data from CAD. Groups were compared on variables found to be associated with remission without formal help in previous research.
Findings. Logistic regression analysis revealed that individuals remitted from alcohol-dependence without formal help reported a higher non-physiological severity of alcohol dependence, less social pressure to quit drinking and more incidents of driving while intoxicated. Furthermore, they tended to report more satisfaction with work and financial situation and were more likely to live in a stable partnership.
Conclusions. Findings support the concept of psychosocial resources as important enabling factors in remission from alcohol dependence without formal help. Implications for brief interventions are discussed.     

A comparison of general self-efficacy and drinking refusal self-efficacy in predicting drinking behavior

A number of studies have suggested that task specific self-efficacy has more influence over behavior than general self-efficacy. However, little research has compared the impact of task-specific self-efficacy beliefs to the impact of general self-efficacy in predicting alcohol consumption. This study aimed to compare the contribution of general self-efficacy and drinking refusal self-efficacy (a form of task-specific self-efficacy) to volume and frequency of alcohol consumption. Regression analyses were performed in samples of community (n = 298) and clinical (n = 296) drinkers. Overall, drinking refusal self-efficacy was found to be a significant predictor of alcohol consumption in the community sample, while general self-efficacy was found to be a significant predictor of drinking in the clinical sample. These differences highlight the differential roles of general and task specific self-efficacy in governing drinking behavior and suggest future directions for prevention and treatment of alcohol problems.     

Changing society, changing drinking: solitary drinking as a non-pathological behaviour

This study describes solitary drinking as it appears in a general population. The data are derived from a telephone survey carried out in April 1993 an a representative sample of 2015 adult drinkers from the Montreal metropolitan area. Thirty-one percent of the respondents (n = 633) reported drinking without being in the company of other people. First, solitary drinking is described according to drinking contexts and drinking patterns. Secondly, a comparison of solitary drinkers with Those who did not report this behaviour is presented according to socio-demographic characteristics, social representations of drinking and overall drinking patterns. Finally, a logistic regression analysis is performed to identify the main characteristics of the drinkers associated with solitary drinking. The results show that solitary drinking occurs mainly at home, at the end of the day, to accompany a meal, to mark a transition between work and leisure or to accompany a rest time. The quantity involved in solitary drinking is generally moderate. The results also show that solitary drinking is associated with gender, living alone, employment status, tension-reduction and harmful representations of drinking. However, the main predictor of solitary drinking is overall drinking frequency, indicating the constituent place of alcohol in solitary drinkers' life-style.     

Rates and predictors of relapse after natural and treated remission from alcohol use disorders

AIMS: This study examined the rates and predictors of 3-year remission, and subsequent 16-year relapse, among initially untreated individuals with alcohol use disorders who did not obtain help or who participated in treatment and/or Alcoholics Anonymous in the first year after recognizing their need for help. DESIGN AND MEASURES: A sample of individuals (n = 461) who initiated help-seeking was surveyed at baseline and 1 year, 3 years, 8 years and 16 years later. Participants provided information on their life history of drinking, alcohol-related functioning and life context and coping. FINDINGS: Compared to individuals who obtained help, those who did not were less likely to achieve 3-year remission and subsequently were more likely to relapse. Less alcohol consumption and fewer drinking problems, more self-efficacy and less reliance on avoidance coping at baseline predicted 3-year remission; this was especially true of individuals who remitted without help. Among individuals who were remitted at 3 years, those who consumed more alcohol but were less likely to see their drinking as a significant problem, had less self-efficacy, and relied more on avoidance coping, were more likely to relapse by 16 years. These findings held for individuals who initially obtained help and for those who did not. CONCLUSIONS: Natural remission may be followed by a high likelihood of relapse; thus, preventive interventions may be indicated to forestall future alcohol problems among individuals who cut down temporarily on drinking on their own.     

Changes in substance use associated with emergency room and primary care services utilization in the United States general population: 1995-2000

OBJECTIVE: The purpose of this study was to compare changes in the prevalence of heavy problem drinking and drug use among those obtaining emergency room (ER), primary care, and other health care services between 1995 and 2000 in the U.S. general population. METHOD: Data analyzed are from the Alcohol Research Group's 1995 (n = 4925) and 2000 (n = 7612) National Alcohol Surveys. Data for the 1995 survey was based on face-to-face interviews in respondents' homes in the 48 contiguous states, while the 2000 interview was a random-digit dialing computer-assisted telephone interview of the household population in all 50 states. RESULTS: Those reporting any health services utilization were less likely to report heavy drinking, two or more alcohol problems, and symptoms of alcohol dependence during the previous year in 2000 compared with 1995, but heavy or problem drinking was not predictive of health services utilization at either time. Controlling for demographic characteristics and health insurance coverage, illicit drug users were almost twice as likely [odds ratio (OR) = 1.85] compared with nonusers, to report ER utilization, and one and a half times more likely (OR = 1.55) to report primary care utilization during the past year in the 2000 survey, but drug use was not significantly predictive of health services utilization in 1995. CONCLUSIONS: These data suggest that while those alcohol-involved individuals were no more likely than others to use ER and primary care services in either 1995 or 2000, those drug-involved individuals were more likely to do so in 2000, perhaps related to the fact that these individuals may be incurring more health problems associated with their drug use that require medical attention. While identification and intervention with problem drinkers in clinical settings has received a great deal of attention, drug users may be overrepresented in health service settings, and such settings also may provide a window of opportunity for screening and intervention for a reduction in drug-related problems.     

Association of age at first drink with current alcohol drinking variables in a national general population sample

BACKGROUND: Age at first drink has been found to be associated with alcohol problems in adulthood, but little is known regarding the relationship of age at first drink and current alcohol intake variables. This study was designed to determine the relationship of age at first drink to traditional drinking variables as well as novel current drinking variables assessed for the first time in a national general population sample. METHOD: Data on age of first drink, pathological drinking (DSM-IV alcohol abuse or dependence) and alcohol intake on typical drinking occasions were collected on a national general population sample of 2631 subjects by means of computerized telephone interviewing. Variables assessed for the first time in a national survey included the duration of the typical drinking episode and the predicted peak blood alcohol levels achieved during those episodes. RESULTS: Data from 2276 subjects who reported an age at first drink were used in this study. Men and lifetime pathological drinkers reported an earlier age at first drink than did, respectively, women or lifetime nonpathological drinkers. There were significant regression coefficients between age at first drink and several current drinking measures. The largest coefficients were usually found within younger age groups. CONCLUSIONS: Age at first drink may be a useful predictive variable for some current drinking measures, including predicted peak blood alcohol levels as well as lifetime alcohol pathology. Further support was provided for the "convergence" hypothesis that the drinking habits of women have become more like those of men.     

The validity of the CAGE scale to screen for heavy drinking and drinking problems in a general population survey

Background. The CAGE scale is a short test developed in the 1970s to screen for alcoholism or covert drinking problems. The reliability and validity of the scale has been demonstrated in the majority of studies conducted in clinical settings, but the validity of the scale in general population surveys has not yet been shown conclusively. Aims. The goal of this study was to assess the criterion validity of the CAGE scale in a general population survey. Method. Data from a large general health survey conducted in 1992 in the province of Quebec (Canada) (N=23 564) were used to define various measures of heavy drinking and drinking problems and to calculate, for male and female drinkers separately, standard measures of sensitivity, specificity and positive predictive value at different cutoff scores on the CAGE. Findings. With respect to both male and female drinkers, with all operational definitions of heavy drinking and useful cutoff scores on the CAGE, the scale was shown to be unable to discriminate between heavy drinkers and non-heavy drinkers. Prevalence of drinking problems among CAGE positive drinkers was also very low. Conclusion. These results do not support the use of the CAGE as a screening tool for heavy drinking and drinking problems in a general population survey or as a tool to estimate the prevalence of drinking problems in the population.     

Performance of Screening Instruments for Identifying Alcohol Dependence in the General Population, Compared with Clinical Populations

Screening instruments for problem drinking have been developed in clinical populations, and little is known of their performance in the general population. Sensitivity and specificity of the CAGE and the TWEAK for ICD-10 and/or DSM-IV criteria for alcohol dependence are compared among those sampled from the southern region in the 1995 National Alcohol Survey ( n = 776). and from emergency room (ER) (n = 1327) and primary care clinic ( n = 767) samples in Jackson, MS. Sensitivity of the CAGE was higher in both the ER (85%) and primary care (82%) samples than in the general population (75%), although differences were not significant, and this held for males and females alike. Sensitivity of the TWEAK was lower in the general population sample (83%) than in the ER sample (89%), but higher than in the primary care sample (75%). In the general population, sensitivity of both screeners was better (although not significantly so) among those making an ER or primary care visit during the last year than among those not doing so, with the largest difference found for the CAGE (85% vs. 65%, respectively). In a merged sample of the three sites, the interaction of site by screening instrument was not a significant predictor of alcohol dependence for either the CAGE or TWEAK. Data suggest that screening instruments may not perform as well in the general population as in some clinical populations, with more variation apparent across groups for some screeners than for others. Although further analysis is necessary to explore this issue further, attention should be given to selection of the best instrument for use in a given population.     

Alcohol and casualties: comparison of county-wide emergency room data with the county general population

A representative sample of patients in hospital emergency rooms (ERs) in a Northern California county (n = 3731) were compared with a household probability sample of those living in the same county (n = 2101). The injured in the ER sample were more likely to be black and under 30 than those in the general population sample who reported an injury during the last year which was treated in the ER. ER injured were more likely to be abstainers than injured in the general population and among drinkers, they were also more likely to report social consequences of drinking, but were no more likely to report experiences associated with alcohol dependence. Similar differences were found between the injured and the non-injured in the two samples, with the injured more likely to be male, younger, never married and to report heavy drinking, drunkenness, social consequences of drinking and alcohol dependence experiences. The data suggest that associations of alcohol and injury found in representative samples of the ER population may be generalizable to the injured in the general population from which these patients come, with differences which do exist most likely attributable to characteristics associated with emergency room usage.     

College attendance and its effect on drinking behaviors in a longitudinal study of adolescents

BACKGROUND: While college attendance has been shown to be associated with increased drinking behaviors, there are no studies to our knowledge that have examined whether college attendance moderates genetic influences for drinking. We first tested for changes in alcohol consumption in adolescents who did and did not subsequently attend college, and then tested for variation of the genetic and environmental determinants of drinking in these 2 groups. METHODS: Participants eligible for this study were selected from 2 samples from the National Longitudinal Study of Adolescent Health (Add Health), a national probability sample (n=7,083) and a sample of sibling pairs (n=855 pairs). Participants were assessed for measures of drinking behaviors as adolescents (wave I) and reinterviewed at 1 (wave II) and 6 years (wave III) following the initial survey. Changes in binge drinking and average quantity of alcohol consumed in the past year were estimated among 4 groups (2-year college students, 4-year college students, college withdrawers, noncollege participants) in sequential cohorts which spanned the ages of 13 to 24 across the 3 Add Health waves. Gene by environment interactions were then tested at wave III using biometrical models in the genetically informative pairs. RESULTS: Participants who did not attend college reported more binge drinking and consumed greater quantities of alcohol as adolescents than participants who subsequently attended college. However, the college students not only surpassed their noncollege peers in alcohol use as young adults, but also exhibited a greater genetic influence on quantity of alcohol consumed per drinking episode. CONCLUSIONS: Exposure to a college environment acts as an environmental moderator, supporting the hypothesis that the magnitude of genetic influence on certain aspects of alcohol consumption is greater in environments where drinking behaviors are more likely to be promoted.     

Beliefs about the cardiovascular benefits of drinking wine in the adult population of Ontario

AIMS: to explore beliefs about the cardiovascular benefits of drinking wine in the Ontario population. DESIGN: secondary analysis of data from a provincial survey of adults. PARTICIPANTS: Ontarians aged 18 or older (n = 606) from Ontario living in households and participating in a telephone survey. MEASURES: responses to questions concerning beliefs that wine drinking may reduce the risk of heart disease. Self-reports of age, gender, quantity and frequency of wine drinking, drinking problems, and existence of a diagnosis of heart disease. Findings: a majority of respondents believed that wine drinking reduces heart disease. Almost all (87.6%) said that drinking one or two drinks a day would reduce heart disease. Belief in the health benefits of wine drinking was more common among men, more frequent drinkers, and wine drinkers. CONCLUSIONS: beliefs in the health benefits of wine drinking is common amongst Ontario adults and is consistent with many recommendations by health authorities. The study should be replicated with larger samples in a variety of countries with different drinking patterns.     

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.     

Abstinence, reasons for not drinking, and life satisfaction.

This study examines the reasons given for not drinking by abstinent alcoholics with varying lengths of sobriety. A Reasons for Not Drinking Scale is tested, as well as the Purpose in Life Questionnaire and Life Satisfaction Scale. Subjects are 60 males from a VA population. Results show that subjects with less education and those treated in a detoxification setting are more likely to endorse negative reasons for not drinking. Individuals with short and long abstinence have a higher level of life "dissatisfaction" than those with moderate periods of abstinence. The study suggests that purpose in life, life satisfaction, and reasons for not drinking are important measures of progress in treatment and movement through phases of recovery.     

Women ending marriage to a problem drinking partner decrease their own risk for problem drinking

Aims Marital dissolution is associated with increased risk of problematic drinking. However, marriage to a problem drinker also increases this risk, and ending this type of relationship may actually decrease risk of problematic drinking. This study tested whether women ending their marriage to a problem drinker exhibited improvements in drinking. Design National Epidemiologic Survey on Alcohol and Related Conditions, a two‐wave nationally representative survey of the US adult population. Setting In‐person interviews conducted in US households. Participants Females married or living as if married at wave 1 at least 18 years of age. Measurements Socio‐demographics, drinking frequency, drinking quantity, alcohol use disorders, problem drinking, partner problem drinking and relationship dissolution. Findings Ending marriage to a non‐problem drinker predicted increased frequency of drinking [risk ratio (RR) = 1.55; 95% confidence interval (CI) = 1.43, 1.67], heavier drinking (RR = 1.30; 95% CI = 1.71, 1.45), more problematic drinking (RR = 2.45; 95% CI = 2.17, 2.77) and a greater likelihood of use disorder diagnosis [odds ratio (OR) = 2.2; 95% CI = 1.67, 2.91]. Ending a relationship with a problem drinker predicted less frequent drinking (RR = 0.94; 95% CI = 0.90, 0.98), less heavy drinking (RR = 0.84; 95% CI = 0.78, 0.90) and fewer alcohol‐related problems (RR = 0.77; 95% CI = 0.62, 0.95). Conclusions Ending a marriage with a husband who drinks problematically may decrease risk of alcohol‐related problems among women, substantiating the need for alcohol treatments to address a problem drinking partner.     

Changes in Substance Use Associated with Emergency Room and Primary Care Services Utilization in the United States General Population: 1995–2000

Objective: The purpose of this study was to compare changes in the prevalence of heavy problem drinking and drug use among those obtaining emergency room (ER), primary care, and other health care services between 1995 and 2000 in the U.S. general population. Method: Data analyzed are from the Alcohol Research Group's 1995 (n = 4925) and 2000 (n = 7612) National Alcohol Surveys. Data for the 1995 survey was based on face‐to‐face interviews in respondents' homes in the 48 contiguous states, while the 2000 interview was a random‐digit dialing computer‐assisted telephone interview of the household population in all 50 states. Results: Those reporting any health services utilization were less likely to report heavy drinking, two or more alcohol problems, and symptoms of alcohol dependence during the previous year in 2000 compared with 1995, but heavy or problem drinking was not predictive of health services utilization at either time. Controlling for demographic characteristics and health insurance coverage, illicit drug users were almost twice as likely [odds ratio (OR) = 1.85] compared with nonusers, to report ER utilization, and one and a half times more likely (OR = 1.55) to report primary care utilization during the past year in the 2000 survey, but drug use was not significantly predictive of health services utilization in 1995. Conclusions: These data suggest that while those alcohol‐involved individuals were no more likely than others to use ER and primary care services in either 1995 or 2000, those drug‐involved individuals were more likely to do so in 2000, perhaps related to the fact that these individuals may be incurring more health problems associated with their drug use that require medical attention. While identification and intervention with problem drinkers in clinical settings has received a great deal of attention, drug users may be overrepresented in health service settings, and such settings also may provide a window of opportunity for screening and intervention for a reduction in drug‐related problems.     

Drinking Patterns and Problems: A Comparison of ER Patients in an HMO and in the General Population

The purpose of this study was to compare drinking patterns and alcohol-related problems and associations of these variables with casualties in an emergency room (ER) population and in the general population from which these patients come. A probability sample of patients seen in all three health maintenance organization (HMO) hospital ERs in one U.S. county (N = 986) and a household probability sample of those living in the same county who reported belonging to the HMO (N = 735) were interviewed. The ER sample was more likely to report consequences related to drinking, less likely to report feeling they should cut down on their drinking, and more likely to report greater use of the ER than the general population sample. Similar associations were found between injured and noninjured in the two samples. These data lend support for the generalizability of findings of associations of alcohol and casualties obtained from ER studies to the larger general population.     

A latent class analysis of DSM-IV alcohol use disorder criteria and binge drinking in undergraduates

Background: Adolescent and adult samples have shown that the Diagnostic and Statistical Manual of Mental Disorders‐IV (DSM‐IV) abuse and dependence criteria lie on a continuum of alcohol problem severity, but information on criteria functioning in college students is lacking. Prior factor analyses in a college sample ( Beseler et al., 2010 ) indicated that a 2‐factor solution fit the data better than a single‐factor solution after a binge drinking criterion was included. The second dimension may indicate a clustering of criteria related to excessive alcohol use in this college sample. Methods: The present study was an analysis of data from an anonymous, online survey of undergraduates (N = 361) that included items pertaining to the DSM‐IV alcohol use disorder (AUD) diagnostic criteria and binge drinking. Latent class analysis (LCA) was used to determine whether the criteria best fit a categorical model, with and without a binge drinking criterion. Results: In an LCA including the AUD criteria only, a 3‐class solution was the best fit. Binge drinking worsened the fit of the models. The largest class (class 1, n = 217) primarily endorsed tolerance (18.4%); none were alcohol dependent. The middle class (class 2, n = 114) endorsed primarily tolerance (81.6%) and drinking more than intended (74.6%); 34.2% met criteria for dependence. The smallest class (class 3, n = 30) endorsed all criteria with high probabilities (30 to 100%); all met criteria for dependence. Alcohol consumption patterns did not differ significantly between classes 2 and 3. Class 3 was characterized by higher levels on several variables thought to predict risk of alcohol‐related problems (e.g., enhancement motives for drinking, impulsivity, and aggression). Conclusions: Two classes of heavy‐drinking college students were identified, one of which appeared to be at higher risk than the other. The highest risk group may be less likely to “mature out” of high‐risk drinking after college.