Health Services Research (OnlineEarly Articles). 17 August 2007

Racial Disparities in Completion Rates from Publicly Funded Alcohol Treatment: Economic Resources Explain More Than Demographics and Addiction Severity

• Jerry O. Jacobson¹ E-mail: jerry.jacobson@cdc.hhs.gov
• ¹Central America and Panama, Centers for Disease Control and Prevention, Universidad del Valle, 18 Av. 11-37, VH III, Edificio GAP, Zona 15, CP 01015, Ciudad de Guatemala, Guatemala, ^*,
• Paul L. Robinson²
• ²University of Medicine and Science, Lynwood, CA, , and
• Ricky N. Bluthenthal³
• ³RAND Corporation, Santa Monica, CA

• ¹Central America and Panama, Centers for Disease Control and Prevention, Universidad del Valle, 18 Av. 11-37, VH III, Edificio GAP, Zona 15, CP 01015, Ciudad de Guatemala, Guatemala, ²University of Medicine and Science, Lynwood, CA, ³RAND Corporation, Santa Monica, CA

Abstract

Objectives.

To assess racial and ethnic differences in rates of completion from publicly funded alcohol treatment programs, and to estimate the extent to which any identified racial differences in completion rates are related to differences in patient characteristics.

Data Sources.

Administrative intake and discharge records from all publicly funded outpatient and residential alcohol treatment recovery programs in Los Angeles County (LAC) during 1998–2000. Study participants (N=10,591) are African American, Hispanic, and white patients discharged from these programs, ages 18 or older, who reported alcohol as their primary substance abuse problem.

Study Design.

Bivariate tests identified racial and ethnic differences in rates of treatment completion and patient characteristics. Logistic regression models assessed the contribution of differences in patient characteristics to differences in completion.

Principal Findings.

Significantly lower completion rates by African Americans (17.5 percent) relative to whites (26.7 percent) (odds ratio [OR]=0.58, 95 percent confidence interval [CI]: 0.50–0.68) are partially explained (40 percent) by differences in patient characteristics in outpatient care (adjusted OR=0.75, 95 percent CI: 0.63–0.90), mostly by indicators of economic resources (i.e., employment, homelessness, and Medi-Cal beneficiary). In residential care, only 7 percent of differences in completion (30.7 versus 46.1 percent) could be explained by the patient-level measures available (OR=0.52, 95 percent CI: 0.45–0.59; AOR=0.55, 95 percent CI: 0.47–0.65). Differences in completion rates between Hispanic and white patients were not detected.

Conclusions.

Large differences in rates of outpatient and residential alcohol treatment completion between African American and white patients at publicly funded programs in LAC, the nation's second largest, publicly funded alcohol and drug treatment system, are partially because of economic differences among patients, but remain largely unexplained. These racial disparities merit additional investigation and the attention of health professionals.

Health Services Research (OnlineEarly Articles). 19 Sep 2006

The Effects of Health Sector Market Factors and Vulnerable Group Membership on Access to Alcohol, Drug, and Mental Health Care

• Susan E. Stockdale^{1 e-mail:} sstockdale@mednet.ucla.edu
• ¹UCLA Semel Institute Health Services Research Center, 10920 Wilshire Blvd., Ste 300 Los Angeles, CA 90024, ^*,
• Lingqi Tang²
• ²UCLA Semel Institute Health Services Research Center, Los Angeles, CA, ,
• Lily Zhang²
• ²UCLA Semel Institute Health Services Research Center, Los Angeles, CA, ,
• Thomas R. Belin³
• ³Department of Biostatistics, UCLA School of Public Health, Los Angeles, CA, and
• Kenneth B. Wells²
• ²UCLA Semel Institute Health Services Research Center, Los Angeles, CA,

• ¹UCLA Semel Institute Health Services Research Center, 10920 Wilshire Blvd., Ste 300 Los Angeles, CA 90024,
• ²UCLA Semel Institute Health Services Research Center, Los Angeles, CA,
  
• ³Department of Biostatistics, UCLA School of Public Health, Los Angeles, CA

Abstract

Objective.

This study adapts Andersen's Behavioral Model to determine if health sector market conditions affect vulnerable subgroups' use of alcohol, drug, and mental health services (ADM) differently than the general population, focusing specifically on community-level predisposing and enabling characteristics.

Data Sources.

Wave 2 data (2000–2001) from the Health Care for Communities study, supplemented with cases from wave 1 (1997–1998), were merged with area characteristics taken from Census, Area Resource File (ARF), and other data sources.

Study Design.

The study used four-level hierarchical logistic regression to examine access to ADM care from any provider and specialty ADM access. Interactions between community-level predisposing and enabling vulnerability characteristics with individual race/ethnicity, age, income category, and insurance type were explored.

Principal Findings.

Nonwhites, the poor, uninsured, and elderly had lower likelihoods of service use, but interactions between race/ethnicity, income, age and insurance status with community-level vulnerability factors were not statistically significant for any service use.

For ADM specialty care, those with Medicare, Medicaid, private fully managed, and private partially managed insurance, the likelihood of utilization was higher in areas with higher HMO penetration.

However, for those with other insurance or no insurance plan, the likelihood of utilization was lower in areas with higher HMO penetration.

Conclusions.

Community-level enabling factors explain part of the effect of disadvantaged status but, with the exception of the effect of HMO penetration on the relationship between insurance and specialty care use, do not modify any of the residual individual-level effects of disadvantage.

Interventions targeting both structural and individual levels may be necessary to address the problem of health disparities.

More research with longitudinal data is necessary to sort out the causal direction of social context and ADM access outcomes, and whether policy interventions to change health sector market conditions can shift ADM treatment utilization.

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Health Services Research (OnlineEarly Articles). 31 August 2006

Primary Care Quality and Addiction Severity: A Prospective Cohort Study

• Theresa W. Kim¹ e-mail theresa.kim@bmc.org
  

• ¹Clinical Addiction Research and Education (CARE) Unit, Section General Internal Medicine, 91 E. Concord Street, Suite 200, Boston University Medical Center, Boston, MA 02118, ^*,
• 
  
• Jeffrey H. Samet^2,3
• ²Clinical Addiction Research and Education (CARE) Unit, Boston University Medical Center, Boston, MA, ³Department of Social and Behavioral Sciences, Boston University School of Public Health, ,
• 
  
• Debbie M. Cheng^2,4
• ²Clinical Addiction Research and Education (CARE) Unit, Boston University Medical Center, Boston, MA, ⁴Department of Biostatistics, Boston University School of Public Health, ,
• 
  
• Michael R. Winter⁵
• ⁵Data Coordinating Center, Boston, MA, ,
• 
  
• Dana Gelb Safran⁶
• ⁶The Health Institute, Institute for Clinical Research and Health Policy Studies, Boston, MA, and
• 
  
• Richard Saitz²
• ²Clinical Addiction Research and Education (CARE) Unit, Boston University Medical Center, Boston, MA,

• ¹Clinical Addiction Research and Education (CARE) Unit, Section General Internal Medicine, 91 E. Concord Street, Suite 200, Boston University Medical Center, Boston, MA 02118, ²Clinical Addiction Research and Education (CARE) Unit, Boston University Medical Center, Boston, MA, ³Department of Social and Behavioral Sciences, Boston University School of Public Health, ⁴Department of Biostatistics, Boston University School of Public Health, ⁵Data Coordinating Center, Boston, MA, ⁶The Health Institute, Institute for Clinical Research and Health Policy Studies, Boston, MA

Abstract

Background.

Alcohol and drug use disorders are chronic diseases that require ongoing management of physical, psychiatric, and social consequences. While specific addiction-focused interventions in primary care are efficacious, the influence of overall primary care quality (PCQ) on addiction outcomes has not been studied. The aim of this study was to prospectively examine if higher PCQ is associated with lower addiction severity among patients with substance use disorders.

Study Population.

Subjects with alcohol, cocaine, and/or heroin use disorders who initiated primary care after being discharged from an urban residential detoxification program.

Measurements.

We used the Primary Care Assessment Survey (PCAS), a well-validated, patient-completed survey that measures defining attributes of primary care named by the Institute of Medicine. Nine summary scales cover two broad areas of PCQ: the patient–physician relationship (communication, interpersonal treatment, thoroughness of the physical exam, whole-person knowledge, preventive counseling, and trust) and structural/organizational features of care (organizational access, financial access, and visit-based continuity). Each of the three addiction outcomes (alcohol addiction severity (ASI-alc), drug addiction severity (ASI-drug), and any drug or heavy alcohol use) were derived from the Addiction Severity Index and assessed 6–18 months after PCAS administration. Separate longitudinal regression models included a single PCAS scale as the main predictor variable as well as variables known to be associated with addiction outcomes.

Main Results.

Eight of the nine PCAS scales were associated with lower alcohol addiction severity at follow-up (p≤.05).

Two measures of relationship quality (communication and whole- person knowledge of the patient) were associated with the largest decreases in ASI-alc (−0.06).

More whole-person knowledge, organizational access, and visit-based continuity predicted lower drug addiction severity (ASI-drug: −0.02).

Two PCAS scales (trust and whole-person knowledge of the patient) were associated with lower likelihood of subsequent substance use (adjusted odds ratio, [AOR]=0.76, 95 percent confidence interval [95% CI]=0.60, 0.96 and AOR=0.66, 95 percent CI=0.52, 0.85, respectively).

Conclusion.

Core features of PCQ, particularly those reflecting the quality of the physician–patient relationship, were associated with positive addiction outcomes. Our findings suggest that the provision of patient-centered, comprehensive care from a primary care clinician may be an important treatment component for substance use disorders.

Psychology of Addictive Behaviors. 2006 Dec Vol 20(4) 453-462

The Development and Initial Evaluation of the Survey of Readiness for Alcoholics Anonymous Participation.

Kingree, J. B.; E-mail: jking10@sph.emory.edu Simpson, Alpha; Thompson, Martie; McCrady, Barbara; Tonigan, J. Scott; Lautenschlager, Gary

Kingree, J. B.: Department of Public Health Sciences, Clemson University, Clemson, SC, US

Simpson, Alpha: Department of Public Health Sciences, Clemson University, Clemson, SC, US

Thompson, Martie: Department of Public Health Sciences, Clemson University, Clemson, SC, US

McCrady, Barbara: Department of Psychology, Rutgers University, NJ, US

Tonigan, J. Scott: Department of Psychology, University of New Mexico, Albuquerque, NM, US

Lautenschlager, Gary: Department of Psychology, University of Georgia, Athens, GA, US


Abstract

This article presents 5 studies related to the development and initial evaluation of the Survey of Readiness for Alcoholics Anonymous Participation (SYRAAP).

The SYRAAP is a brief, multidimensional, self-administered instrument that assesses beliefs associated with Alcoholics Anonymous (AA) participation.

Study 1 generated 239 candidate items for potential inclusion in the instrument.

Study 2 assessed the content validity of these items according to 3 criteria and identified a subset of 60 with the highest values on the criteria for further consideration.

Study 3 produced a shorter version of the SYRAAP and evaluated its structure, internal reliability, and validity.

Study 4 reevaluated the structure and internal reliability of the SYRAAP and yielded findings that were generally consistent with those from Study 3.

Study 5 established stability reliability for the instrument.

The collective findings indicated the SYRAAP can reliably and validly assess individual-level beliefs associated with AA participation.

The potential use of the SYRAAP for researchers and clinicians, along with limitations of the work presented here, are discussed.

Alcohol treatment news: future of therpeutics; problem drinking in opiate addicts; increasing self-efficacy; impact of domestic abuse on treatment experience

Therapeutics for alcoholism: what's the future?

• As with other addictions, human alcoholism is characterised as a chronically relapsing condition. Consequently, the therapeutic goal is the development of clinically effective, safe drugs that promote high adherence rates and prevent relapse. These products can then be used in conjunction with psychosocial approaches.
• In this review, preclinical studies are highlighted that indicate the mechanism of action of currently used anti-craving medications or demonstrate the potential of novel pharmacological agents for the treatment of alcohol use disorders.
• While current pharmacological strategies are far from ideal, there are a number of candidate molecules that may ultimately be developed into therapeutic agents. In addition, prescribing clinicians should also consider strategies such as combinations of various drugs to aid in the regulation of aberrant alcohol consumption.

Lawrence AJ. Therapeutics for alcoholism: what's the future? Drug Alcohol Rev 2007;26:3 - 8 Drug and Alcohol Review email: a.lawrence@hfi.unimelb.edu.au

Problem drinking in relation to treatment outcome among opiate addicts in methadone maintenance treatment

• This study analyzed indicators of alcohol-related problems in opiate addicts before, during, and after leaving methadone maintenance treatment (MMT), in relation to illicit drug use and retention in treatment.
• The results of the present study indicate that drinking problems among patients undergoing MMT is associated with an increased risk of relapse into illicit drug use and with discharge from treatment.
• Concurrent treatment of alcohol-related problems, including systematic monitoring of alcohol use, therefore should be recommended to reduce the risk for relapse into illicit drug use and improve overall treatment outcome in MMT.

Stenbacka M, Beck O, Leifman A, Romelsjö A, Helander A. Problem drinking in relation to treatment outcome among opiate addicts in methadone maintenance treatment. Drug Alcohol Rev 2007;26:55 - 63 Drug and Alcohol Review email: marlene.stenbacka@cspo.sll.se

How do we increase problem drinkers' self-efficacy? A nurse-led brief intervention putting theory into practice

• The work undertaken aimed to develop an alcohol-related brief intervention based on the theoretical concepts of the self-efficacy construct. The brief intervention was to be administered by general nurses in a general hospital setting for patients who were identified as potential problem drinkers.
• Using the theoretical concepts of the self-efficacy construct a single session nurse administered minimal intervention was developed. The brief intervention comprised of nine stages.
• The development of a nurse-administered intervention with a sound theoretical basis demonstrates the ability to link theory to practice. The intervention was implemented within a general hospital setting following identification of potential problem drinkers.

A. S. Holloway, H. E. Watson, G. Starr How do we increase problem drinkers' self-efficacy? A nurse-led brief intervention putting theory into practice Journal of Substance Use, Volume 11, Issue 6 December 2006, pages 375 - 386 Journal of Substance Use

Safety first? The impact of domestic abuse on women's treatment experience

• This paper presents the findings of an exploratory study designed to investigate what is known about women's experiences of domestic abuse and their impact on treatment outcomes.
• Aims: To explore whether domestic abuse has an impact on women's access to treatment, retention, relapse, or increase in their substance use.
• Findings: Practice-based evidence suggests women's engagement with and retention in treatment is negatively affected by domestic abuse. Literature-based evidence is equivocal and limited in scope, quality and quantity.
• Conclusions: While further research is required to substantiate the practice-based evidence, it appears that treatment service providers are failing to recognize and address the issue of domestic abuse among their service users, leaving women and their children at risk.

Sarah Galvani Safety first? The impact of domestic abuse on women's treatment experience, Journal of Substance Use, Volume 11, Issue 6 December 2006, pages 395 - 407 Journal of Substance Use

Contributor: Libby Ranzetta Alcohol Policy UK February 17, 2007

Alcohol research news: identifying drunkenness in the NTE; alcohol and violence

Identifying drunkenness in the night-time economy

• Background: Prohibiting the sale of alcohol to intoxicated patrons by licensees and their staff requires definitions of drunkenness.
• Aims: To assess the relationship between blood alcohol concentration (BAC) and indicators used in field sobriety tests putatively associated with intoxication.
• Design, participants, setting, material and methods: A random sample of 314 female and 579 male city centre drinkers. Surveyors scored respondents' and non-respondents' gait, eyes and speech for signs of drunkenness as well as their drunkenness on a 10-point Likert scale. Breath analysis was used to determine respondents' BAC.
• Findings: Combinations of slurred speech, staggering gait and glazed eyes significantly predicted levels of BAC with a staggering gait indicating highest levels of intoxication.
• Conclusions: Subjective ratings of drunkenness by trained observers corresponded with BAC. Transition BACs denoting observable behaviour change associated with intoxication have been identified. Observations of gait, combined with assessment of slurred speech should be the basis of estimates of drunkenness.

Nick Perham, Simon C. Moore, Jonathan Shepherd, Bryany Cusens (2007) Identifying drunkenness in the night-time economy Addiction 102 (3), 377–380. Hear more about this research from Simon Moore on a forthcoming Alcohol Policy UK podcast

Alcohol and violence: use of possible confounders in a time-series analysis

• Aims: To assess the aggregate association between alcohol consumption and violence, while controlling for potential confounders.
• Design and measurements: The data comprise aggregate time-series for Norway in the period 1880–2003 and 1911–2003 on criminal violence rates and per capita alcohol consumption. Possible confounders comprise annual rates of unemployment, divorce, marriage, total fertility rate, gross national product, public assistance/social care and the proportion of the population aged between 15 and 25. Autoregressive integrated moving average (ARIMA) analyses were performed on differenced data. Both semilogarithmic and linear models were estimated.
• Findings: Alcohol consumption was associated significantly with violence, and an increase in alcohol consumption of 1 litre per year per inhabitant predicted a change of approximately 8% in the violence rate. The parameter estimate for the alcohol variable remained unaltered after including the covariates both in the semilogarithmic and the linear models. Of the seven covariates included in the models, only divorce was associated significantly with violence rate.
• Conclusions: The results suggest that alcohol consumption has an independent effect on violence rates when other factors are controlled for. The results support the assumption of a causal effect of alcohol consumption on violence, and it appears that alcohol consumption is an important factor when we wish to explain changes in violence rates over time.

Elin K. Bye, Alcohol and violence: use of possible confounders in a time-series analysis, Addiction, Vol. 102 Issue 3 Page 369

Contributor: Libby Ranzetta Alcohol Policy UK February 17, 2007

J. Stud. Alcohol Drugs 68: 208-219, 2007

Environmental Policies to Reduce College Drinking: An Update of Research Findings

Traci L. Toomey, Email: toomey@epi.umn.edu

Kathleen M. Lenk,

Alexander C. Wagenaar

Objective: We provide an overview of environmental strategies that may reduce college drinking.

The identified environmental strategies fall into three categories: (1) reducing alcohol use and related problems among underage college students, (2) reducing risky alcohol use and related problems among all college students, and (3) de-emphasizing the role of alcohol and creating positive expectations on campus.

At the time of our 2002 review, few studies had assessed environmental policies and strategies in the context of college student alcohol use and related problems.

The present article summarizes recent research on the effects of environmental policies and strategies affecting college students.

Method: We updated our previous literature searches to identify peer-reviewed research studies evaluating the effects of environmental strategies on college and general populations.

Results: We identified 110 new studies addressing environmental strategies published between 1999 and 2006. Thirty-six of these studies focused on the college population.

The extant research indicates that many environmental strategies are promising for reducing alcohol-related problems among the general population.

Several recent studies suggest that these strategies, particularly combined strategies, also may be effective in decreasing alcohol-related problems among college populations.

Conclusions: Further research is needed to continue expanding our understanding of environmental strategies to identify the most effective individual and combined strategies.

J. Stud. Alcohol Drugs 68: 197-207, 2007)

The Sacramento Neighborhood Alcohol Prevention Project: Outcomes From a Community Prevention Trial

Andrew J. Treno, email: andrew@prev.org

Paul J. Gruenewald,

Juliet P. Lee,

Lillian G. Remer

Objective: This article reports the results of the Sacramento Neighborhood Alcohol Prevention Project (SNAPP). SNAPP set as its goal the reduction of alcohol access, drinking, and related problems in two low-income, predominantly ethnic minority neighborhoods, focusing on individuals between the ages 15 and 29, an age group identified with high rates of alcohol-involved problems.

Method: Two neighborhoods in Sacramento were selected to be the intervention sites because they were economically and ethnically diverse and had high rates of crime and other drinking-related problems.

The quasi-experimental design of the study took a phased approach to program implementation and statistical examination of outcome data. Outcome-related data were collected in the intervention sites as well as in the Sacramento community at large.

Five project interventions included a mobilization component to support the overall project, a community awareness component, a responsible beverage-service component, an underage-access law enforcement component, and an intoxicated-patron law enforcement component.

Archival data were collected to measure and evaluate study outcomes and to provide background and demographic information for the study.

Results: Overall, we found significant (p < .05) reductions in assaults as reported by police, aggregate emergency medical services (EMS) outcomes, EMS assaults, and EMS motor vehicle accidents.

Conclusions: Results from the Sacramento Neighborhood Alcohol Prevention Project demonstrate the effectiveness of neighborhood-based interventions in the reduction of alcohol-related problems such as assaults, motor vehicle crashes, and sale of alcohol to minors

SAMHSA Newsletter

2007 – Volume 15
	Jan/Feb 2007 Vol 15, No 1

View HTML | Download PDF (size: 1.00MB)

Inside This Issue

Older Adults . . . Treatment: What Works Best?

A Peer Perspective

Technical Assistance Center

Terry L. Cline Welcomed as SAMHSA Administrator

Seclusion and Restraint: Final Rule on Patients Rights

Buprenorphine: Patient Limits Increase

Communities That Care

Prevention Planning Tool Available

Strategic Prevention Framework

Regional Centers Support Communities That Care

Funding Opportunities

2007 Recovery Month Web Site Launched

Addiction Counseling Competencies Updated

Mental Health Resources Help Build Bridges

NSAATS: Who Is in Treatment for Both Alcohol and Drugs?

Substance Use in Metropolitan Areas

New Science to Service Awards

Superheroes Carry Prevention Message

SAMHSA News Information

Welcome

RADAR, a project of the Alcohol and other Drugs Council of Australia, aims to promote awareness of alcohol, tobacco and other drugs research in Australia.

The register contains up-to-date records of current and recently completed research projects with details of published research. There is also information about researchers, their organisations and research funding bodies.

We urge you to contribute your research records to this database by using the interactive form or contact us for assistance.

© Alcohol and other Drugs Council of Australia 2004

Funded by Australian Government Department of Health and Ageing.

Source: Alcohol and Drug History Society Posted by Matthew McKean on February 16, 2007

J. Stud. Alcohol Drugs 68: 173-181, 2007)
Stages and Sequences of Initiation and Regular Substance Use in a Longitudinal Cohort of Black and White Male Adolescents

Helene R. White, emailto: hewhite@rci.rutgers.edu

Nicole Jarrett,

Elvia Y. Valencia,

Rolf Loeber,

Evelyn Wei

Objective: This study examined whether developmental sequences and stages of substance-use initiation and regular use differed and, if so, whether they varied for black and white adolescent males.

Method: The analyses were based on a cohort of inner-city boys in the Pittsburgh public schools, who had been followed prospectively from ages 7 to 19 across 18 data waves (N 412).

Results: Blacks were most likely to end initiation of any use and regular use with marijuana, whereas alcohol and tobacco were the most common end stage drugs for whites.

Whites were also more likely than blacks to initiate and to become regular users of hard drugs.

For both races, the typical developmental sequence for substance-use initiation and regular use was alcohol and/or tobacco, then marijuana, and then hard drugs. However, blacks were more likely to deviate from this sequence than were whites.

Participants who initiated any substance use faced a high probability of becoming a regular user of at least one substance.

Conclusions: There were differences in the sequences and stages of substance-use initiation and regular use by race. Further research is needed to identify the antecedents of escalation to regular use and progression of regular use across substances and to delineate the cultural and environmental factors that affect substance-use progression.

Shame & Guilt Ernest Kurtz

Ernest Kurtz, Shame & Guilt, second edition, revised and updated, February 2007, 53 pp. Soon to appear in print. Click here to read online (the file is 108 Kbytes and may take time to download on a dial-up connection). Originally published as Shame and Guilt: Characteristics of the Dependency Cycle (A Historical Perspective for Professionals). Center City, Minnesota: Hazelden; 1981. Particularly in its new and revised version this little book, though short, is one of the best and most insightful works ever written on the sense of shame -- feeling bad about our lives and what we perceive as our failures -- that inner pain which haunts so many alcoholics and addicts and so many other human beings. And from his deep wisdom and accumulated experience, Kurtz also tells us how the twelve step program can be used to heal that sense of worthlessness and fear of abandonment, and restore us to lives that are happy, joyous, and free.

By the author of Not-God: A History of Alcoholics Anonymous, originally published in 1979 and still the classic work on the subject.

Kurtz, who holds a Ph.D. from Harvard, is one of the top people from A.A.'s second generation of authors (the generation following Bill W., Richmond Walker, Ed Webster, and Father Ralph Pfau).

His book on the spiritual life is equally well known and has also been an enduring best seller through the years: Ernest Kurtz and Katherine Ketcham, The Spirituality of Imperfection: Modern Wisdom from Classic Stories.

Some of the most important of his many articles and essays can be found in Ernest Kurtz, The Collected Ernie Kurtz (Wheeling, West Virginia: Bishop of Books, 1999).

Source: AAHistoryLovers February 14, 2007

Addiction (OnlineEarly Articles). 07 Feb 2007

RESEARCH REPORT

Alcohol and the preventive paradox: serious harms and drinking patterns

• Kari Poikolainen¹
• ¹Finnish Foundation for Alcohol Studies, Helsinki, Finland and Kari Poikolainen, Finnish Foundation for Alcohol Studies, PO Box 220, FIN-00531, Helsinki, Finland. E-mail: kari.poikolainen@stakes.fi ,

• Tapio Paljärvi^1,2
• ¹Finnish Foundation for Alcohol Studies, Helsinki, Finland and ²Alcohol and Drug Research Group, STAKES, Helsinki, Finland &

• Pia Mäkelä²
• ²Alcohol and Drug Research Group, STAKES, Helsinki, Finland

• ¹Finnish Foundation for Alcohol Studies, Helsinki, Finland and ²Alcohol and Drug Research Group, STAKES, Helsinki, Finland

Kari Poikolainen, Finnish Foundation for Alcohol Studies, PO Box 220, FIN-00531, Helsinki, Finland. E-mail: kari.poikolainen@stakes.fi

ABSTRACT

Aims The preventive paradox prevails if the majority of alcohol problems accrue to the lesser-drinking majority of population, not to heavy drinkers. Evidence for the paradox has been criticized for being based on self-report. The aim was to examine whether the paradox also applies to deaths and hospital admissions.

Design Data from four surveys representing the Finnish population aged 15–69 years in 1969, 1976, 1984 and 1992 were pooled; those from1969, 1976 and 1984 (n = 6726) to study alcohol-related hospital admissions and alcohol-related deaths, and those from 1984 and 1992 (n = 5558) to study self-reported problems. The former data were linked with register data on hospital admission and death up to the end of 2002.

Methods Comparisons were made separately for men and women (1) between the 10% of population with the highest average alcohol consumption and the remaining 90% of drinkers and (2) between those who reported and those who did not report drinking to intoxication.

Results A total of 3025 men and 2693 women were available for the study of self-reported problems and 2945 men and 2615 women for deaths and hospital admissions. Seventy per cent of all self-reported problems, 70% of alcohol-related hospitalizations, 64% of alcohol-related deaths and 64% of the premature life-years lost before the age of 65 occurred among the 90% of men consuming less. The respective figures for women were 64%, 60%, 93% and 98%. Drinking five or more drinks per occasion was related to more harm than not drinking that much.

Conclusions In men, the 'prevention paradox' appears to apply to a broadly similar degree to hospitalizations and deaths as self-report alcohol-related problems; in women the phenomenon was apparent to a greater degree for deaths than for other markers of harm.

Progress report on public-health problems caused by harmful use of alcohol



C. PUBLIC-HEALTH PROBLEMS CAUSED BY HARMFUL USE OF ALCOHOL

18. In order to implement resolution WHA58.26, the Secretariat strengthened its capacity and has implemented a range of activities at the global and regional levels. It has given priority to a comprehensive assessment of public-health problems caused by harmful use of alcohol, reviewing evidence and making recommendations for policies and interventions, reinforcing global and regional systems of information about alcohol, and collaborating with relevant stakeholders.

19. Regional activities have been intensified through assessments of public-health problems caused by harmful use of alcohol and design of appropriate regional responses and programmes. Technical consultations were organized in the African (Brazzaville, May 2006), Eastern Mediterranean (Cairo, June 2006) and Western Pacific regions (Manila, March 2006). Resolutions on the subject were adopted by the regional committees for South-East Asia and for the Eastern Mediterranean. A Regional Strategy to Reduce Alcohol-Related Harm was endorsed by the Regional Committee for theWestern Pacific.1

20. The Secretariat has updated the estimated global burden of disease attributable to alcohol and prevalence of alcohol-use disorders. The methods used for the estimations, the new figures on theburden attributable to alcohol, and data-collection procedures and their improvement were discussed at a meeting of a technical advisory group on alcohol epidemiology (Geneva, 13–15 September 2006).
1 Resolution WPR/RC57.R5.

21. The process of drawing up recommendations on policies and interventions to reduce alcoholrelated harm included a series of technical consultations and a web-based survey of the view and
opinions of academic institutions, professional associations, nongovernmental organizations and representatives of the alcoholic-beverage industry and trade and agricultural sectors. The WHO Expert Committee on Problems Related to Alcohol Consumption (Geneva, 10–13 October 2006) reviewed available evidence and made technical recommendations. Further consultations are needed to draft
global recommendations and construct an appropriate framework for global activities to reduce alcohol-related harm that accommodates regional examples such as the European Alcohol Action Plan
2000-2005, the Framework for Alcohol Policy in the WHO European Region and the Regional Strategy to Reduce Alcohol-Related Harm in the Western Pacific Region.

22. In order to enhance the global information system on alcohol consumption and its health and social consequences, the Secretariat has revised and expanded the Global Alcohol Database, and
transferred most of it to a web site. Global monitoring of both harmful use of alcohol and national policy responses need to be strengthened through the establishment or better functioning of regional information systems and effective linking with country-based monitoring and surveillance activities.

The technical tool to support data collection and analysis, the International Guide for Monitoring Alcohol Consumption and Related Harm,1 is being revised. Work on the development of a composite
indicator for monitoring harmful use of alcohol at national and subnational levels is in progress.

23. Collaboration with nongovernmental organizations was enhanced through a global consultation (Geneva, 24–25 April 2006) and by facilitating networking between such organizations and professional associations working directly with alcohol-related problems or in associated areas.

24. An open global consultation with representatives of the alcoholic-beverage industry in order to exchange views on appropriate corporate initiatives was organized in WHO headquarters (Geneva,
8 March 2006). A similar consultation was held in the Western Pacific Region (Manila, 8 June 2006).

Further interaction with representatives of the industry and the agricultural and trade sectors is being planned in the context of their potential contribution to reducing alcohol-related harm as commercial
producers, distributors and marketers of alcoholic beverages.

Source:
EXECUTIVE BOARD EB120/35
120th Session 7 December 2006
Provisional agenda item 9.2
Implementation of resolutions: progress reports
Report by the Secretariat
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Teenage drinkers face alcohol test

• 14 February 2007
• Andy Coghlan

Big Brother has arrived at a high school in New Jersey. Determined to stop their students consuming alcohol at weekends, staff at Pequannock Township High School in Morris county are to start using a controversial test that can detect if students have been drinking up to a week earlier.

The test measures urine concentrations of an ethanol breakdown product called ethyl glucuronide (EtG). "We plan to use this new test as part of our comprehensive testing programme to keep our kids safe from the dangers of drugs and alcohol," says Larrie Reynolds, superintendent of Pequannock High School. "About four to eight kids will be tested every day." In New Jersey drinking alcohol is illegal under the age of 21.

Drinking is a growing problem in US schools. "As many as half of our kids are doing this," says Reynolds. An estimated 1700 US high-school students died from alcohol poisoning or related accidents in 2005 alone.

However, the EtG test poses a problem. It is so sensitive that even total abstainers can sometimes test positive. Alcohol absorbed from soaps, mouthwashes or contaminated vinegars or by drinking a sip of communion wine can be enough.

“The EtG test poses a problem. It is so sensitive that even total abstainers can sometimes test positive”

Despite this, the test's popularity is growing, and around a dozen commercial versions are now available. Estimates by the US Department of Health and Human Services (DHHS) suggest that as many as 20,000 tests are being performed each month, mainly among medical staff - including 9000 physicians - pledged to abstinence following the discovery that they have a drink problem. Law firms and the military have started using it on their staff too. Greg Skipper, medical director of the Alabama Physician Health Program, says the test has been invaluable for monitoring doctors in recovery from alcoholism. "It enables them to comply, stay sober and keep their jobs," he says.

Skipper is, however, critical of health boards and agencies in some states that he says have been automatically sacking people who fail the EtG test without using other tests to confirm its findings. In the three to four years that the test has been commercially available in the US, more than 100 nurses in recovery from alcoholism have complained of losing their jobs after testing positive despite, they say, not drinking. Blood tests for a second metabolite such as phosphatidyl ethanol would be far less likely to give a false positive, as this substance appears only after large amounts of alcohol have been consumed, but these tests are more expensive.

In 2006, Skipper helped compile an advisory document for the DHHS which stated that "legal or disciplinary action based solely on a positive EtG test is inappropriate". Since the advisory was published, Skipper says there has been a fall in the number of complaints of unfair dismissal posted on a website he set up (http://www.ethylglucuronide.com/).

Using the EtG test alone, the risk of false positives remains, particularly in hospital wards, where nurses and doctors routinely use soaps containing ethanol. "In intensive care units, nurses and doctors apply it every 5 minutes," Skipper says. He has shown that the test could give a positive result in ward staff who have simply breathed vapour in. Even bystanders can test positive.

Both Skipper and the test's creator, Friedrich Wurst of the psychiatric clinic at the University of Basel, Switzerland, say that there is not yet an agreed threshold concentration that can be used to separate people who have been drinking from those exposed to alcohol from other sources. Below 1000 nanograms of EtG per millilitre of urine is probably "innocent", and above 5000 booze is almost certainly to blame. In between there is a "question zone", Skipper says.

Skipper backs use of the tests by schools if they accept its limitations. "Schools must have a system for dealing with positives, managed by a medical review officer, and not automatically expel the child," he says.

From issue 2591 of New Scientist magazine, 14 February 2007, page 14

Contributor: Don Phillips

Conference Report
Highlights of the 17th Annual Meeting of the American Academy of Addiction Psychiatry

December 7-10, 2006;

St. Petersburg, Florida

Posted 02/06/2007

Bryan K. Tolliver, MD, PhD

Performance Monitoring for Addiction Psychiatrists

The American Academy of Addiction Psychiatry (AAAP), an organization founded in 1985 to promote research, education, and improved clinical practice in addiction psychiatry, convened its 17th Annual Meeting in St. Petersburg, Florida, on December 7-10, 2006. Among a number of topics of interest to addiction professionals was the issue of optimizing pharmacotherapy for alcohol dependence, which was explored in several presentations.

On Friday, December 8, Mark Willenbring, MD,^[1] of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), Bethesda, Maryland, presented a draft of a self-audit instrument developed by the AAAP Evidence-based Practice Committee that is designed to help members assess their own medical practices. The first audit tool to be developed by the Committee, this instrument was designed to monitor performance in providing pharmacotherapy for alcohol dependence, as such treatment was considered to be a core area of addiction psychiatry supported by a substantial evidence base for the use of US Food and Drug Administration-approved medications. As yet unnamed, the instrument is expected to take approximately 10 minutes to use, and is recommended for a sample of 10-20 charts per physician per year. It will be available both in paper form and on the AAAP Web site, as will a site for each physician to input his or her own anonymous results for the formation of a database providing normative data from all physicians who use the audit. Though initially planned for AAAP members, the audit instrument may be made available to the American Society for Addiction Medicine and the APA Council on Addiction Psychiatry in the future.

Initial experiences with the self-audit instrument in both the academic medical center and private practice settings were presented. Daniel Hall-Flavin, MD,^[2] of the Mayo Clinic Department of Psychiatry, Rochester, Minnesota, discussed the results of a retrospective chart review of acamprosate treatment using the instrument in both residential and intensive outpatient programs. A surprising initial finding of this review was the low rate of prescribing of the medication (15%), even among patients considered appropriate candidates. Over the 18-month course of developing the database using the audit instrument, however, Dr. Hall-Flavin noted that the rate of prescribing more than doubled, to 37%. This experience was echoed by Syed Pirzada Sattar, MD,^[3] who reported the results of his application of the audit instrument to monitor his private practice. With increased practice in using the instrument, he found that the time to complete the audit fell to approximately 4 minutes per chart, and that documentation of treatment rationale and potential risks and side effects improved considerably. Perhaps of greatest importance, the rate of certain medication prescriptions for alcohol dependence increased.

According to the panel discussants, pharmacotherapy for alcohol dependence continues to be grossly underutilized for a variety of reasons, including therapeutic nihilism, patient resistance, or lack of access to physicians experienced in providing the treatment. As described by Drs. Hall-Flavin and Sattar, however, even addiction psychiatrists may underuse these treatments or use them inconsistently. Interventions that improve a clinician's awareness of his or her own prescription patterns thus have the potential to enhance patient care significantly. The self-audit instrument developed by the AAAP Evidence-based Practice Committee appears to be feasible in diverse settings and is likely to optimize pharmacotherapy for alcoholism, both in terms of standardization of treatments and improved prescription rates. According to Dr. Willenbring, the Evidence-based Practice Committee plans to identify additional areas for performance monitoring annually.

Empirical Research on 12-Step Programs

Several well-known researchers participated in Symposium III, "Twelve Step Programs: Empirical Research and Potential Clinical Applications," organized collaboratively with support from the NIAAA and the National Institute on Drug Abuse (NIDA) and chaired by Dr. Marc Galanter of New York University School of Medicine.

Dr. Willenbring^[4] of the NIAAA began the symposium with an introduction that emphasized the demonstrated success of 12-step programs and the importance of understanding how these programs are successful. He noted that more people recover from alcoholism outside of medical treatment than in treatment. In a study based on the 1992 National Longitudinal Alcohol Epidemiologic Survey, 87.3% of respondents with an alcohol use disorder never perceived an unmet need for treatment.^[5] Yet participation in Alcoholics Anonymous (AA) is widespread, and multiple studies have reported a strong correlation between participation in AA and abstinence from alcohol.^[6-8] Although AA and other 12-step programs have existed for decades, they have received little systematic study until relatively recently. As an attempt to understand the social context of addiction recovery, the NIAAA has introduced the Mechanisms of Behavioral Change initiative, designed to study systems from "the genome to the sociome," according to Dr. Willenbring. [See http://grants.nih.gov/grants/guide/rfa-files/RFA-AA-07-005.html for the relevant Funding Opportunity Announcement from the National Institutes of Health.]

Scott Tonigan, PhD,^[9] of the University of New Mexico, Albuquerque, described the recent expansion of empirical research on processes of 12-step programs following the completion of Project MATCH,^[10] the multicenter trial of different psychotherapies in alcoholics with distinct patient characteristics, almost 10 years ago. According to Dr. Tonigan, this work demonstrated that 12-step facilitation therapy, a manual-guided psychotherapy designed to familiarize patients with AA philosophy and encourage AA participation, was more effective than either cognitive behavioral therapy or motivational enhancement therapy in promoting abstinence from alcohol regardless of the clinical subtype of the patient. As presented by Dr. Tonigan, 24% of outpatients who received 12-step facilitation therapy were abstinent from alcohol, compared with 15% of those who received cognitive behavioral therapy and 14% of those who received motivational enhancement therapy at 1 year following treatment.^[9] Elucidating the mechanisms that contributed to the increased abstinence in the 12-step facilitation group has been the subject of much subsequent work since the completion of Project MATCH.

Dr. Tonigan and colleagues have studied at least 3 hypothesized mechanisms by which 12-step facilitation may have increased abstinence rates in Project MATCH: (1) increased attendance and involvement in AA, (2) insistence on complete abstinence, and (3) emphasis on spirituality in 12-step program philosophy.^[9,11-13] According to Dr. Tonigan, research to date has found that only one of these mechanisms, namely increased involvement in AA, was predictive of higher rates of abstinence from alcohol at 1 year after treatment.^[9] Though AA attendance increased in all 3 treatment arms of Project MATCH, attendance in AA was highest in the 12-step facilitation group. Involvement and engagement in AA ( sponsoring, helping other AA members) was highest . in this group^[9] and was associated with lower likelihood of relapse, independent of the number of AA meetings attended.^[13] Consonant with this finding, follow-up analyses of Project MATCH participants have demonstrated that 10-year abstinence rates are predicted by current, but not prior, AA attendance, according to Dr. Tonigan.^[9]

Other hypothesized mechanisms of behavioral change in 12-step programs have not received empirical support. Initial adherence to complete abstinence, a key feature of 12-step facilitation therapy, has predicted delayed relapse to both the first drink and to heavy drinking, but not abstinence, at 1 year posttreatment, according to Dr. Tonigan.^[9] Emphasis on spirituality in 12-step programs, although suggested by some cross-sectional studies to be associated with improved drinking outcomes, does not predict long-term abstinence in prospective longitudinal analyses of Project MATCH participants.^[12] This result is in agreement with data presented later in the symposium by Jon Morgenstern, PhD,^[14] of Columbia University, New York City, who summarized research including but not limited to Project MATCH. While affiliation with AA was correlated with positive drinking outcomes in multiple studies, adherence to the emphasis on spirituality in 12-step programs was not predictive of long-term abstinence rates in the literature as a whole. The panel discussants noted, however, that because spirituality may serve as a shared ideology that can maintain affiliation with AA, it is important to recognize the spiritual orientation of any individual patient when encouraging AA participation.

Relevance of Craving Concepts to the Treatment of Alcoholism

In the last session of the meeting devoted to treatments for alcohol dependence, Larissa Loukianova, MD, PhD, and Dr. Hall-Flavin, both of the Mayo Clinic, presented Workshop C-5, "Understanding Craving: Toward Identification of Treatment Targets in Alcoholism."

Dr. Loukianova^[15] began the workshop with a comprehensive review of the neurobiology of craving, from the level of cellular events within a single neuron to complex cortical-subcortical circuits in the normal and alcohol-dependent mammalian brain. She noted that although alcoholism is a complex heterogeneous phenotype that is unlikely to respond to a single treatment, a pathologically high motivation to use alcohol is common among all alcoholics. Recent advances in the neuroscience of reward and motivation present multiple potential therapeutic strategies.

Though difficult to operationalize, craving may be defined as the conscious experience of the desire to use alcohol or other drugs of abuse. The frequent experience of craving as a conflict between conscious resistance to using a substance and the loss of conscious control over drug-seeking behavior has suggested the involvement of neural circuits that include both cortical and subcortical brain regions. Data from addiction studies in animals have implicated dopamine, gamma-aminobutyric acid, and glutamate neurotransmission of the mesocorticolimbic and corticostriatal pathways in assigning incentive motivational salience to previously neutral cues, a process thought to be common to self-administration of virtually all abused substances.^[16] This literature contrasts with earlier, more simplistic concepts of dopamine as the "pleasure chemical" released in the nucleus accumbens (ventral striatum) by all drugs of abuse. Instead, more recent investigations have demonstrated a role for specific frontal-subcortical circuits known to be important in motivation, executive function, and impulse control. Our understanding of these circuits in humans is informed by studies of naturally occurring and traumatic lesions and, more recently, by the results of neuroimaging research.^[17]

Dr. Loukianova reviewed neuroimaging evidence for involvement of 3 cortical regions and their connections to limbic structures in cue-induced cravings for alcohol and other drugs of abuse. These regions include the anterior cingulate cortex, the orbitofrontal cortex, and the dorsolateral prefrontal cortex. The anterior cingulate may be subdivided into ventral and dorsal regions, associated with affective and cognitive components of motivational salience, respectively. Similarly, lateral and medial subdivisions of the orbitofrontal cortex appear to mediate social and object recognition aspects of motivation. Both of these cortical regions are active in response to incentive-salient events and are influenced by the predictability of a reward such as alcohol or other addictive drugs.^[16,17] Consistent evidence from human neuroimaging studies suggests that both the anterior cingulate and orbitofrontal cortex show reduced activity in the drug-free state in human addicts, but are hyperactive in response to alcohol- or other drug-related cues in a manner that correlates with the intensity of subjective craving in addicted human volunteers.^[16-18] The dorsolateral prefrontal cortex, which is associated with executive function, also appears to be dysregulated in human addicts, which may contribute to alcohol- or drug-dependent individuals' inability to resist compulsive drug-seeking in the face of serious adverse consequences. Though still on the horizon, each of these pathways may offer targets for addiction pharmacotherapy as our understanding of their complex neurocircuitry and their roles in drug and alcohol craving unfold.

Finally, Dr. Hall-Flavin discussed current concepts of subtypes of craving and their relevance to existing anticraving therapeutic strategies.^[19] In the case of alcoholism, the speaker distinguished reinforcement craving from withdrawal craving despite the absence of good instruments for differentiating these in the clinical population. Reinforcement craving was defined as the subjective experience of increased alcohol-seeking immediately following exposure to alcohol, and may be reduced by currently approved medications such as oral or depot naltrexone.^[19-21] Opioid antagonists may thus prevent progression or relapse by reducing the acute reinforcing properties of alcohol after an initial re-exposure. By contrast, withdrawal craving is the subjective experience of increased alcohol-seeking after some period of abstinence from the drug, ostensibly related to the desire to relieve the aversive properties of withdrawal. This phenomenon may be reduced by acamprosate.^[20,22-24]

A key question that remains is: Can we predict whether certain patients will respond preferentially to one of these treatment strategies? Dr. Hall-Flavin hypothesized that patients early in the course of alcoholism may be best treated with medications aimed at reinforcement craving, whereas those in later stages of the illness may respond better to medications that reduce withdrawal craving. However, there is currently little empirical evidence to support this hypothesis, he said. Additional considerations that remain unresolved at this time are whether alcoholic subtype, genetic constitution, or psychiatric comorbidities may influence responsiveness to different classes of anticraving medications.

Contributor: Don Phillips

Journal of Abnormal Psychology. 2006 Nov Vol 115(4) 807-814

Item Response Theory Analysis of Diagnostic Criteria for Alcohol and Cannabis Use Disorders in Adolescents: Implications for DSM-V.





Martin, Christopher S.: Western Psychiatric Institute and Clinic, Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, US
email: martincs@upmc.edu

Chung, Tammy: Western Psychiatric Institute and Clinic, Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, US

Kirisci, Levent: Department of Pharmaceutical Sciences,, School of Medicine, University of Pittsburgh, Pittsburgh, PA, US

Langenbucher, James W.: Center of Alcohol Studies, Rutgers University, NJ, US

Abstract
Item response theory (IRT) has advantages over classical test theory in evaluating diagnostic criteria.

In this study, the authors used IRT to characterize the psychometric properties of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994) alcohol and cannabis use disorder symptoms among 472 clinical adolescents.

For both substances, DSM-IV symptoms fit a model specifying a unidimensional latent trait of problem severity.

Threshold (severity) parameters did not distinguish abuse and dependence symptoms.

Abuse symptoms of legal problems and hazardous use, and dependence symptoms of tolerance, unsuccessful attempts to quit, and physical-psychological problems, showed relatively poor discrimination of problem severity.

There were gender differences in thresholds for hazardous use, legal problems, and physical-psychological problems.

The results illustrate limitations of DSM-IV criteria for alcohol and cannabis use disorders when applied to adolescents. The development process for the fifth edition (DSM-V) should be informed by statistical models such as those used in this study.

IMPAIRED CONTROL AND UNDERGRADUATE PROBLEM DRINKING

Alcohol and Alcoholism Advance Access published on January 1, 2007,
Alcohol Alcohol. 42: 42-48.

IMPAIRED CONTROL AND UNDERGRADUATE PROBLEM DRINKING

ROBERT F. LEEMAN^1,*,
MIRIAM FENTON² and
JOSEPH R. VOLPICELLI²

¹ Department of Psychology, University of Pennsylvania 3720 Walnut Street, Philadelphia, PA 19104
² Institute of Addiction Medicine, University of Pennsylvania School of Medicine 40 W. Evergreen Avenue, Suite 106, Philadelphia, PA 19118, USA

^*Author to whom correspondence should be addressed at: Department of Psychiatry, Yale University School of Medicine CMHC, 34 Park Street, Room S-200 New Haven, CT 06519, USA. Tel.: +1 203 974 7373; Fax: +1 203 974 7606; E-mail: robert.leeman@yale.edu

	Abstract

Aims: Impaired control, one of the hallmarks of addiction, is also one of the earliest dependence symptoms to develop. Thus impaired control is particularly relevant to undergraduates and other young adults with relatively brief drinking histories. The main goal of this study was to determine whether impaired control predicted heavy episodic drinking and alcohol-related problems cross-sectionally in an undergraduate sample after controlling for gender, family history of alcohol and drug problems, and several other established predictor variables from the undergraduate alcohol literature.

Methods: A sample of first-year undergraduates (n = 312) completed Part 2 of the Impaired Control Scale (ICS) and other measures related to alcohol use as part of a larger study on problem drinking in undergraduates.

Results: Scores on Part 2 of the ICS predicted heavy episodic drinking and alcohol-related problems cross-sectionally even after controlling for all other predictor variables. Notably, impaired control was a stronger predictor of alcohol-related problems than overall weekly alcohol consumption. Part 2 of the ICS was found to be a reliable and valid measure for use with undergraduates.

Conclusions: These findings support the notion that impaired control is one of the earliest dependence symptoms to develop. The ICS is an effective tool for identifying young adults at risk for problem drinking.