Community Response

The response of the community to addiction problems is spread out over many different organizations. The Health, Social and Criminal Justice sectors all have roles in the treatment of substance abusing individuals. Tam et al (1996) reported on the Community Epidemiology Laboratory (CEL) project, which had as one of its functions to determine which community services bear the greatest burden in managing alcohol problems. When looking at problem drinkers who had entered drug treatment, 87% had an encounter with the criminal justice system within the last 12 months. 36% had an encounter with the welfare system and 19% with mental health services. Problem drinkers in alcohol treatment also had high rates of encounters with criminal justice, 65%, welfare, 52% and mental health, 33%. The image of the criminal justice and welfare system as referral agencies for alcohol treatment is tempered somewhat by the fact that 60% of problem drinkers had made no contact with alcohol, drug or mental health services in the last year. 45% reported having had no contact in their lifetime.

The authors also point out that the demographic characteristics of problem drinkers who have made contact with an alcohol/drug treatment program and problem drinkers found only on criminal justice or welfare case loads are different. Men, between the ages of 18-24 are more likely to only have contact with the criminal justice and welfare systems, where as people who have had an encounter with an alcohol/drug treatment program are more likely to be unemployed with a lower income. Also, the problem drinkers in the treatment programs had a heavier percentage of alcohol consumption than the criminal justice/welfare only population. The authors suggest developing interventions for the criminal justice/welfare only group that focus on “early intervention” and treating mild or moderate problem drinking instead of alcohol dependence.

Friedmann et al (2003) also investigated community referral sources, specifically looking at “treatment naïve” clients. The study identified “treatment naïve” clients as those entering treatment within the past 30 days with no prior treatment for substance abuse. The results also point to a large percentage of clients being referred from the criminal justice system. Data collected from the year 2000, show 45.9% of those entering outpatient substance abuse treatment for the first time were referred from the criminal justice system. This is far and away the largest proportion of referrals, followed by mental health agencies (7.8%), hospitals (7.0%), social service agencies (4.8%) and employee assistance programs (4.1%). These results support the claims of Tam et al (1996) that intervention within the criminal justice system should be tailored for individuals earlier in their addiction career. The authors suggest that this study deemphasizes the role of medical services in referrals of treatment naïve clients, though they do stress the importance of the mental health system as a referral source for treatment-experienced clients.

What then is the role of medical services in providing outreach and referrals for their clients? Are the numbers skewed because there are less problem drinkers or substance abusers who regularly visit doctors in a primary care setting? Leshner (1999) reports that more than two-thirds of people with addiction see a primary care or urgent care physician every 6 months. Mitka (1998) reported that brief interventions by physicians reduced alcohol consumption by 20%. He suggests that many physicians are only screening for alcoholics (5% of the population), when attention should also be paid to problem or at-risk drinkers (15 – 20% of the population).

There is a tremendous amount of published research examining the efficacy of brief interventions (BI’s) targeting alcohol use in health care settings. Several meta-analytic studies have been produced attempting to analyze and summarize the available literature (Wilk et al, 1997; Poikolainen, K., 1999; Moyer et al, 2002; Ballesteros et al, 2004) These articles report generally favorable results for the ability of BI’s to decrease alcohol consumption among problem drinkers. But the focus of this report is not on the ability of BI’s to impact consumption but the ability of BI’s to reduce waiting times and no-shows to treatment while increasing retention. Bien et al, (1993) produced a meta-analytic study that also reviewed literature examining the affects of BI’s on alcohol consumption. But they also reviewed a number of studies that specifically looked at the ability of BI’s to increase the number of referrals to and retention in specialist treatment agencies.

They found 12 articles that specifically researched the ability of BI’s to facilitate referrals and increase retention. The earliest published research was done by Chafetz in the sixties (Chafetz, 1961; Chafetz et al, 1962; Chafetz et al, 1964, Chafetz, 1968). Chafetz designed a BI to be used in emergency medical care settings to motivate alcoholics to seek treatment. After medical care a specially trained counselor would meet with the patient to discuss their drinking behavior. The counselor was trained to use an emphatic counseling style, “to communicate respect, understanding and caring.” The results were dramatic as 65% of those receiving the BI kept a subsequent appointment for specialist treatment compared to 5% in the control group. He replicated the study and found the results to be similar, 78% to 6%. Demone (1963) replicated the study in a correctional setting and also found the results to be similar.

Koumans & Muller (1965) performed a study in which a single hand written letter from the counselor, expressing caring and encouraging further treatment, resulted in a return rate of 51% compared to 31% who didn’t receive any follow-up. Koumans, Muller & Miller (1967) performed a similar studying using a follow-up phone call instead of a letter and found a return rate of 44% compared to 8%. The authors also mention several articles that found comparable effects of letters and phone calls on subjects’ rate of return for treatment (Intagliata, 1976; Nirenberg, Sobell & Sobell, 1980; Panepinto & Higgins, 1969; Wedel, 1965).

One article which did not show BI’s as being a successful referral procedure was reported by Kuchipudi et al (1990). The study’s subjects were individuals who had “alcohol-related gastrointestinal disease, were actively drinking, had not received treatment for alcohol problems within the past 8 weeks, and had previously been unsuccessfully counseled to stop drinking because of their medical problems.” The authors suggest that one reason there was no difference between the intervention and control group was that the population studied had already rejected a previous referral attempt and this may be an indicator of unresponsiveness to subsequent attempts.

Primary care has been shown to be an important opportunity for engaging problem drinkers. And increasing the number of referrals from primary care is an important opportunity and role of outreach by treatment agencies. But in a study by Weisner et al (2003) the number of problem drinking patients screened by the medical and mental health services was rather low. 65% of those identified as problem drinkers had a medical visit at the 1-year follow-up. 24% of that group had their drinking assessed at the appointment. 33% of the group had a mental health visit at the 1-year follow-up. Of that group, 65% had their drinking assessed during the visit. The authors feel that this was a missed opportunity at intervention since only 40% of problem drinkers who had a medical or a mental health visit had their drinking addressed. This study also examined differences between those diagnosed as problem drinkers and those diagnosed as alcohol dependent. Patients who were alcohol dependent had the same rate of a medical visit (65% to 66%) as problem drinkers. They did have a higher rate of mental health visits. (44% to 28%). A higher proportion of alcohol dependent patients did have their drinking addressed in each setting (38% in the medical visit and 77% in the mental health visit). Women also had a higher percentage of having both a medical and mental health visit, but were still less likely to have their drinking addressed in both settings. The authors conclude that many problem drinkers never enter treatment, so being able to screen for drug abuse in the medical and mental health settings would greatly increase the number of individuals who have access to an intervention and are referred to specialty care.

Arndt et al (2002) examined the proportion of patients at a physical examination who received some sort of assessment or discussion about alcohol use compared with other health risks, in this case healthy eating. This study selected 23,349 adults who reported a routine physical examination during the past three years. The authors found that 16.1% of those surveyed had a health care worker initiate a discussion about alcohol use. In contrast, 44.6% of patients reported having a discussion about healthy eating. The results do indicate that among heavy or binge drinkers, the rate at which drinking was discussed was higher (27.8%). According to the article, 97% of general practitioners surveyed thought that members of their profession should inquire about alcohol use. But the results presented here indicate that physicians do not routinely attempt to screen for alcohol abuse.

Friedmann et al (2000) surveyed 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology and psychiatry. Of the 853 respondents, 88% reported that they usually or always ask new outpatients about alcohol use. With patients who drink, 47% regularly inquire about alcohol intake but only 13% use formal alcohol screening tools. With diagnosed problem drinkers, 82% routinely offer some form of intervention. The authors feel that at the minimum all primary care physicians and psychiatrists should screen for these disorders and offer referral to addiction treatment. To encourage greater physician involvement with alcohol use disorders, strategies should include the dissemination of brief interventions, focus on improving the confidence physicians feel with managing these problems, improving their familiarity with expert recommendations and to dispel concerns about patients’ sensitivity around substance abuse issues.

Roche & Freeman (2004) reviewed the available literature to try to determine the main reasons for the lack of use of BI’s by primary care physicians. They discovered that some physicians felt that it was not a legitimate part of their work to screen for alcohol and other drug use. The physicians own attitudes toward patients with substance abuse issues sometimes acted as a barrier to screening. Doctors surveyed felt that patients with alcohol and other drug abuse problems could be “difficult, aggressive, demanding, manipulative, deceitful, unmotivated and unwilling to change and such attitudes are often given as reasons for not responding to clients with alcohol and other drug related issues.” Some physicians felt that there was nothing that they could do to help a person with these issues or they felt a lack of confidence in their ability to intervene in these situations.

The question of how to motivate doctors to change behavior and begin early interventions has been addressed in a few articles. Anderson et al (2003) reviewed the current literature on engaging physicians in alcohol screening and came to several conclusions. The authors reviewed fifteen programs that attempted to influence physician behavior and found that the most promising were alcohol specific that combined both education and ongoing office-based support. Overall, they found an absolute increase in providers’ screening and advice behavior of between 8% and 18% over the results of the comparison groups.

McCormick et al (1999) performed a randomized controlled trial of marketing techniques to 369 New Zealand general practitioners. They compared three marketing techniques (direct mail, telemarketing and personal marketing) to determine the most cost effective approach to convince these doctors to use an early intervention alcohol-screening tool developed by the World Health Organization. They defined success as the doctor agreeing to receive the screening package. What they found was that although personal marketing had a slightly higher success rate as far as physicians deciding to use the product, 81% as compared to 74% for telemarketing and 51% for direct mail, the overall cost was much higher than the other methods. Direct marketing cost $20.36 per doctor, $10.00 for direct mail and only $3.97 for telemarketing. Telemarketing was the most effective strategy to encourage doctors to receive the early intervention screening package.

The literature regarding the efficacy of BI’s with drugs besides alcohol is rather sparse. Saunders et al (1995) looked at the effects of a brief motivational intervention on drug users attending a methadone clinic. On the third day of their treatment subjects were asked to take part in a voluntary research assessment and intervention. The intervention lasted approximately one hour and followed motivational interviewing principles designed by Miller (1983, 1985) for problem drinkers. A control group received a one hour educational intervention presenting them with facts about drug use. Among many results discussed the authors did show that the intervention group remained engaged in treatment longer than the control group. There was an attrition rate of 49% for the control group compared to 30% for the intervention group.

The previous work cited has focused exclusively on the adult population. Scott et al (2004) looked at referral rates of adolescents with substance abuse diagnoses to a substance abuse or mental health treatment facility. The authors refer to previous work that reported that only 4% - 7% of adolescents who are diagnosed with a substance abuse or mental health problem are actually referred to treatment (Costello et al, 1988; Costello & Janiszewski, 1990). The focus of the study was to compare the characteristics of adolescents diagnosed with a substance abuse disorder who are referred to substance abuse or mental health treatment compared to those not referred. The study did not try to predict treatment entry. Overall, 16% of adolescents with substance abuse disorders were referred by their physician to substance abuse treatment, while 30% were referred to mental health treatment. The study based its findings on chart documented referrals. The authors suggest that one reason mental health referrals occurred twice as often as substance abuse referrals was because physicians may prefer verbal referrals for substance abuse treatment instead of written referrals because of a perceived or real stigma associated with drug abuse treatment.

The role of family or concerned others (CO’s) needs to be addressed when discussing community response to alcohol or other drug abuse. The external motivation generated by CO’s has been documented as a positive influence on getting substance abusers to enter treatment. Marlowe et al (2001) reported that the predominant influence on 415 substance abusers entering treatment was family pressure. The best methods for family members or CO’s to engage substance abusers in treatment was the subject of a study by Stanton (2004). He reviewed “19 outcome studies, involving 1, 501 cases, within 10 different clinical approaches to getting alcohol or drug abusers to engage in treatment or self-help.” All of the methods were divided into one of two categories: Dual-Purpose or Engagement Primary. Dual-Purpose approaches to treatment entry focuses on getting the substance abuser into treatment as well as help the CO cope more effectively with the substance abuser. Engagement-Primary methods are focused solely on getting the substance abuser into treatment. Any benefits felt by the CO are purely incidental.

The Dual-Purpose method determined to have the most success in engaging adults with substance use disorder or alcohol use disorder was the Community Reinforcement and Family Training (CRAFT) approach. Engagement rate was 71% and 64% respectively. CRAFT is an enhanced version of Community Reinforcement Training which involves counseling the CO in how to deal with the substance abuser in a non confrontational way while encouraging sobriety and treatment. The CRAFT approach uses up to 12 sessions during a maximum of 6 months working with and counseling relatives or spouses/partners of substance abusers. CO’s are trained to take advantage of times when the internal motivation of substance abusers is high and immediately schedule them for a rapid intake into treatment.

The most effective Engagement-Primary approaches to treatment entry are broken into several subsets. When working with adolescents with substance use disorder the Intensive Parent and Youth Attendance method is cited as the most effective. When a CO of an adolescent calls a treatment center they are read a standardized program orientation which describes and promotes the program while outlining its advantages. Reminder phone calls are then placed to both the CO and the substance abuser 2-3 days prior to intake in which empathy is expressed regarding any concerns they have and positive aspects of treatment are reinforced. Studies which reviewed this approach reported an engagement rate of 89%.

For adults with substance use or alcohol use disorder the authors report the most effective family oriented intervention is A Relational Intervention Sequence for Engagement (ARISE). The focus of this method is to increase the chances of engaging the client at the earliest possible level of intervention while minimizing the amount of professional time and energy required. From the first contact from a CO, counselor’s convey the message that they can’t do this alone and attempts to get as many significant others, relatives, friends, co-workers and so on of the substance abuser involved in the process. The method can involve six sessions but the hope is to have the substance abuser engaged as quickly as possible. Stanton reports engagement rates of 87% for drug abuse and 77% for alcohol abuse. The ARISE method is also the most cost-effective.

And finally, Stanton reports on a program geared towards mothers with substance use disorder. The Engaging Mom’s Program (EMP) has had great success by tailoring a method to focus on drug abusing mothers. EMP uses individual and family engagement sessions which emphasize “respect, compassion and the strengthening of bonds between the mother and her family of origin, her partner and her children. This program has an engagement rate of 88%.

The response of the community outside of specialist services has been shown to have a great impact on facilitating substance abusers into treatment. Many of the most successful are also the most cost effective. This presents itself as a great opportunity for specialist services to look outside their walls for assistance in increasing referrals. By educating the criminal justice and medical systems as well as concerned family members and others, facilities will be able to increase the amount of substance and alcohol abusers engaged in treatment.