Measuring College Student Drinking

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Substance Abuse�

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EDITOR-IN-CHIEFMARC GALANTER, M.D.

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ADMINISTRATION

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Association forMedical Education and Research

in Substance Abuse

AMERSA 2005-2006 EXECUTIVE COMMITTEE

PresidentRichard Saitz, M.D., M.P.H.Boston University School of MedicineBoston, Massachusetts

SecretaryKimber P. Richter, Ph.D., M.P.H.University of Kansas Medical CenterKansas City, Kansas

Immediate Past PresidentMaryann Amodeo, M.S.W., Ph.D.Boston UniversityBoston, Massachusetts

Members-at-LargeEdward J. Callahan, Ph.D.University of California, DavisSacramento, California

John Da Silva, D.M.D., M.P.H., Sc.M.Harvard School of Dental MedicineBoston, Massachusetts

Diana M. DiNitto, Ph.D., A.C.S.W.University of Texas at AustinAustin, Texas

Katherine McQueen, M.D.Baylor College of MedicineHouston, Texas

Vice-PresidentPeter Friedmann, M.D., M.P.H.Brown Medical SchoolRhode Island HospitalProvidence, Rhode Island

TreasurerSusan A. Storti, Ph.D., R.N.Brown University–ATTC/NEProvidence, Rhode Island

Editor-in-Chief, Substance AbuseMarc Galanter, M.D.New York University School of MedicineNew York, New York

Emeritus DirectorDavid C. Lewis, M.D.Brown UniversityProvidence, Rhode Island

Co-DirectorIsabel VieiraAMERSA National OfficeProvidence, Rhode Island

Substance Abuse is an international interdisciplinary forum for the publication of original empirical researchpapers and reviews in the field of addiction and substance abuse. Topics covered include clinical and preclinicalresearch, education, health-service delivery, and policy. Substance Abuse provides an authoritative and broad-based view of recent developments in the field of interest to medical educators, researchers, clinicians, andstudents.

The Association for Medical Education and Research in Substance Abuse (AMERSA) is an organization ofmedical educators, clinical researchers, and other health professionals in the field of alcohol and drug abuse thatprovides: a scholarly interdisciplinary forum, Substance Abuse, for the exchange of information on techniquesand content of substance abuse teaching; a network of educators and researchers in the field of substance abuse;and a voice in support of academic programs in universities and professional schools for substance abuse educa-tion and research. Membership is open not only to all persons holding faculty appointments at schools of medi-cine, osteopathy, public health, social work, nursing, pharmacy, and physician assistants and/or those engaged insubstance abuse research or education in these fields, but also to students, residents, nonprofit organizations, andcorporations. For membership information and application, contact the AMERSA National Office, 125 WhippleStreet, Suite 300, Providence, RI 02908.

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Indexing, Abstracting &Website/Internet CoverageSubstance Abuse

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Abstracting, Website/Indexing Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Year When Coverage Began

• Abstracts on Hygiene and Communicable Diseases (CAB ABSTRACTS, CABI)<http://www.cabi.org> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

• ATForum.com > (Bibliographic Access) <http://www.pain-topix.com> . . . . . . . . . . . . . . . . . 2006

• British Library Inside (The British Library)<http://www.bl.uk/services/current/inside.html> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

• (CAB ABSTRACTS, CABI) Available in print, diskettes updated weekly, and onINTERNET. Providing full bibliographic listings, author affiliation, augmentedkeyword searching. <http://www.cabi.org/> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Cabell’s Directory of Publishing Opportunities in Psychology > (Bibliographic Access)<http://www.cabells.com>. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

• CINAHL (Cumulative Index to Nursing & Allied Health Literature) (EBSCO)<http://www.cinahl.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1995

• Criminal Justice Abstracts (Sage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• DH-Data (available via DataStar and in the HMIC [Health Management InformationConsortium] CD ROM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005

• EAP Abstracts Plus <http://www.eaptechnology.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• EBSCOhost Electronic Journals Service (EJS) <http://ejournals.ebsco.com> . . . . . . . . . . . 2004

• Elsevier Eflow-I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

• Elsevier Scopus <http://www.info.scopus.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005

• EMBASE.com (The Power of EMBASE + MEDLINE Combined)<http://www.embase.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2003

• EMBASE/Excerpta Medica Secondary Publishing Division. Included in newsletters,review journals, major reference works, magazines & abstract journals<http://www.elsevier.nl> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2003

• EMCare (Elsevier) <http://www.elsevier.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

• Family Index Database <http://www.familyscholar.com>. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Google <http://www.google.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Google Scholar <http://scholar.google.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Haworth Document Delivery Center <http://www.HaworthPress.com/journals/dds.asp> . . . 2004

(continued)

• Human Resources Abstracts (Sage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• (IBR) International Bibliography of Book Reviews on the Humanities and SocialSciences (Thomson) <http://www.saur.de> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

• Links@Ovid (via CrossRef targeted DOI links) <http://www.ovid.com> . . . . . . . . . . . . . . . . 2005

• MEDLINE (National Library of Medicine) <http://www.nlm.nih.gov> . . . . . . . . . . . . . . . . . 2002

• Mental Health Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1995

• National Center for Chronic Disease Prevention & Health Promotion (NCCDPHP)<http://chid.nih.gov> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Occupational Therapy Index/AMED Database . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Ovid Linksolver (Open URL link resolver via CrossRef targeted DOI links)<http://www.linksolver.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005

• Project MAINSTREAM <http://www.projectmainstream.net> . . . . . . . . . . . . . . . . . . . . . . . . 2005

• Psychological Abstracts (PsycINFO) <http://www.apa.org> . . . . . . . . . . . . . . . . . . . . . . . . . . 1995

• PubMed <http://www.ncbi.nlm.nih.gov/pubmed/>. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2002

• Referativnyi Zhurnal (Abstracts Journal of the All-Russian Institute of of Scientificand Technical Information-in Russian) <http://www.viniti.ru>. . . . . . . . . . . . . . . . . . . . . 2006

• SafetyLit <http://www.safetylit.org> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Sage Family Studies Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

• Scopus (See instead Elsevier Scopus) <http://www.info.scopus.com> . . . . . . . . . . . . . . . . . . 2005

• Social Work Abstracts (NASW) <http://www.silverplatter.com/catalog/swab.htm> . . . . . . . . 1997

• SwetsWise <http://www.swets.com> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2005

• Tropical Diseases Bulletin (CAB ABSTRACTS, CABI) <http://www.cabi.org> . . . . . . . . . . 2006

• Ulrich’s Periodicals Directory: International Periodicals Information Since 1932 >(Bibliographic Access) <http://www.Bowkerlink.com>. . . . . . . . . . . . . . . . . . . . . . . . . . . . 2006

• Violence and Abuse Abstracts (Sage) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1997

• zetoc (The British Library) <http://www.bl.uk> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2004

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FORTHCOMING

SUBSTANCE ABUSE

Educational Half Day: An Innovative Way to Incorporate Substance Abuse Curriculuminto Residency Training

Teaching Internal Medicine Resident Physicians About Alcoholics Anonymous: A PilotStudy of an Educational Intervention

Training HIV Physicians to Prescribe Buprenorphine for Opioid Dependence

Technology-Based Training in Cognitive Behavioral Therapy for Substance AbuseCounselors

Assessment of Alcohol and Other Drug Use Behaviors in Health Professions Students

Evaluation of a Combined Online and in Person Training in the Use of Buprenorphine

Duration of Non-Methadone Outpatient Treatment: Results from a National Survey

Book Review

ABOUT THE EDITOR

Marc Galanter, MD, is Professor of Psychiatry at NYU, Founding Director of the Division ofAlcoholism and Drug Abuse at NYU and Bellevue Hospital, and Director of the NYU Fellow-ship Training Program in Addiction Psychiatry. He is also Division Director at NYU’s WorldHealth Organization Collaborating Center, and Director of its national Center for Medical Fel-lowships in Alcoholism and Drug Abuse. In addition to 267 articles, chapters, and books, he isEditor of the “Textbook of Substance Abuse Treatment.”

He attended Albert Einstein College of Medicine where he did his residency in psychiatry.After that he was Clinical Associate at the National Institute of Mental Health, and then an NIHCareer Teacher. He later served as President of the Association for Medical Education and Re-search in Substance Abuse (AMERSA) (1976-7), the American Academy of Addiction Psychi-atry (1991-2), and the American Society of Addiction Medicine (1999-2001).

Dr. Galanter’s research and teaching interests have focused on addiction treatment, spirituality,and improving treatment systems. His current NIH and foundation-funded studies address fam-ily therapy for substance abuse, pharmacologic treatment for narcotic addiction, and self-helpmodalities. His Center at NYU has prepared curricula for 46 teaching hospitals and affiliatedmedical schools.

Among his awards are the Gold Achievement Award for innovation in clinical care and theSeymour Vestermark Award for Psychiatric Education, both from the American PsychiatricAssociation, and the McGovern Award for medical teaching from AMERSA.

CONTENTS

EDITORIAL

Buprenorphine for Heroin Addicts: The Issue of Illicit Opioid Abuse During Maintenance 1Elizabeth Cho, MDHelen Dermatis, PhDMarc Galanter, MD

LETTER TO THE EDITOR

Increasing Psychiatric Morbidity and Mortality Rates Among ‘Ozu’ Addictsin Ika Land, Nigeria 5

I. Onyesom, PhDA. Naiho, MSc

REGULAR ARTICLES

On Blending Practice and Research: The Search for Commonalities in Substance AbuseTreatment 9

Scott Kellogg, PhDMary Jeanne Kreek, MD

There has been a growing interest in the substance abuse treatment field in bringing together the treatment and re-search communities. While dialogues about logistical and philosophical issues are important, the development ofshared core concepts could potentially be quite helpful in facilitating communication and creating common treat-ment and research goals. It is the contention of this paper that all psychosocial and, potentially, pharmacologicaltreatments ideally address, in part or in full, three aspects of the self–the capacity to regulate emotional and behav-ioral expression, the ability to engage in future-oriented, goal-directed behavior, and the development of nonaddictand/or recovery-oriented identities. Examples from the research and treatment literature are provided.

KEYWORDS. Addiction treatment, psychotherapy integration, self-psychology

Tooth Retention, Tooth Loss and Use of Dental Care Among Long-Term NarcoticsAbusers 25

Jing Fan, MD, MSYih-Ing Hser, PhDDiane Herbeck, MA

This study examined tooth retention, tooth loss and use of dental care among aging male narcotics abusers beingfollowed-up for more than 33 years. The cohort of 581 male narcotics addicts admitted to California Civil Addict

Volume 27Numbers 1/22006

Program in 1962-1964 was tracked until 1996-1997. As of 1997, 284 (48.9%) were confirmed to be dead. A total of108 surviving participants completed the oral examination and survey of use of dental services. African Americanaddicts showed the least number of remaining teeth; and African Americans and Hispanics were less likely to uti-lize dental services compare to Whites. Factors significantly related to tooth retention were abusers’ age (p =0.0006), ethnicity (p = 0.01), income (p < 0.0001), smoking status (p = 0.03), and dental visits during the 12months prior to the survey (p < 0.0001). These findings suggest that settings such as prisons and drug treatmentprograms that include dental care referral and follow-up would be expected to enhance oral and general healthamong narcotics-addicted individuals.

KEYWORDS. Narcotic, addiction, tooth loss, dental care

Measuring College Student Drinking: Illustrating the Feasibility of a CompositeDrinking Scale 33

Jiun-Hau Huang, ScDWilliam DeJong, PhDShari Kessel Schneider, MSPHLaura Gomberg Towvim, MSPH

This study explored the feasibility of a Composite Drinking Scale (CDS) designed to capture fully the phenomenonof problem drinking among college students while allowing easy public understanding. A survey conducted at 32four-year U.S. colleges included four consumption measures: 30-day frequency; average number of drinks perweek; number of drinks usually consumed when partying; and greatest number of drinks in one sitting in the pasttwo weeks. Responses were normalized and added to create a continuous distribution, which was then subdividedinto quartiles (CDS/Q1-Q4). The CDS is an easily understood scoring system, but compared to the simplistic“binge drinking” measure, it captures a broader range of relative risks and more clearly establishes the quadraticrelationship between consumption and alcohol-related problems. Development of the CDS will require further ex-ploring the best set of questions to include, establishing U.S. norms for the general population, and then transform-ing those scores to a simple measurement yardstick whose meaning can be easily communicated to the public.

KEYWORDS. Alcohol consumption, measurement, psychometric properties, college, student

Racial/Ethnic Differences in the Protective Effects of Self-Management Skillson Adolescent Substance Use 47

Kenneth W. Griffin, PhD, MPHGilbert J. Botvin, PhDLawrence M. Scheier, PhD

A variety of cognitive and behavioral self-management skills have been posited as protective in terms of adolescentsubstance use. This study examined whether these skills measured in the 7th grade served a protective function in9th grade substance use across ethnically diverse samples of adolescents. Participants consisted of Black (n = 461)and Hispanic (n = 320) urban youth and White suburban youth (n = 757). Structural equation modeling indicatedthat a second order Self-Management Skills latent factor consisting of first order latent factors of Decision-Making,Self-Regulation, and Self-Reinforcement skills was protective for adolescent substance use across racial/ethnicsubgroups. However, Self-Management Skills were more strongly protective for suburban White youth and lessprotective for urban minority youth. These findings are consistent with previous research showing that predictivepower of risk and protective factors derived from psychosocial theories varies widely across racial/ethnic sub-groups of youth and is weaker among racial/ethnic minority youth compared to White youth. An important next stepis to broaden the focus of etiology research from individual-level determinants to studying adolescent substanceuse behavior in the context of the cultural background and primary social settings of young people, such as family,school, and community environments.

KEYWORDS. Adolescence, substance use, race, protective factors

Initiating Tobacco Curricula in Dental Hygiene Education: A Descriptive Report 53Linda D. Boyd, RDH, RD, EdDKay Fun, RDH, MPATheresa E. Madden, DDS, MS, PhD

Two hours of tobacco instructions were incorporated into the baccalaureate dental hygiene curricula in a univer-sity in the Northwestern United States. Prior to graduation, all senior students were invited to complete anony-

mously a questionnaire surveying attitudes and clinical skills in providing tobacco services to their clinic patients.Twenty students (67%) responded but no data was collected on the non-respondents. Eighteen (90%) reportedpracticing some of the “5 A’s,” and a few reported sustained adherence to all “5 A’s.” Moderately successful clini-cal outcomes parallelled students’ moderate self-rating of their knowledge/skills. When asked to identify barriersto sustained and ongoing full adherence, most students cited “patient resistance/disinterest,” and their own “lackof knowledge or confidence in the skills.” Our preliminary findings suggest that additional content and trainingtime may be required for dental hygiene graduates to feel highly confident and knowledgeable, and for them to sus-tain comprehensive tobacco services once in practice.

KEYWORDS. Dental hygiene, tobacco cessation, prevention, oral health, oral cancer, periodontitis, dental educa-tion

Initial Steps Taken by Nine Primary Care Practices to Implement Alcohol ScreeningGuidelines with Hypertensive Patients: The AA-TRIP Project 61

Peter M. Miller, PhDRuth Stockdell, RN, MSNLynne Nemeth, PhD, RNChris Feifer, DrPHRuth G. Jenkins, PhDPaul J. Nietert, PhDAndrea Wessell, PharmDHeather Liszka, MD, MSCRSteven Ornstein, MD

Many medical conditions are caused or exacerbated by heavy drinking, necessitating alcohol screening and dis-cussion in primary care practices. This is particularly true of hypertension, the most common primary diagnosis inthe United States, which has been linked to the regular consumption of 3 or more standard alcoholic beverages aday.

The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed toimprove detection and management of alcohol problems in primary care patients with hypertension. Medical pro-viders are being trained using the Practice Partner Research Network’s–Translating Research into Practice(PPRNet-TRIP) quality improvement model. This includes a multi-method intervention (electronic medical re-cords, on-site academic detailing, practice feedback reports and annual network meetings) to help practices in-crease adherence to clinical guidelines.

Qualitative analyses of initial steps taken by nine primary care practices toward the routine implementation ofalcohol screening guidelines are presented. Organizational factors and provider and patient characteristics all in-fluenced the method and consistency of alcohol screening and intervention. Perceived time constraints, patient sen-sitivity to questions about alcohol, and possible stigma associated with a diagnosis of alcoholism were alsorelevant barriers requiring problem solving.

KEYWORDS. Alcohol screening, brief intervention, primary care, hypertension

EDITORIAL

Buprenorphine for Heroin Addicts:The Issue of Illicit Opioid Abuse During Maintenance

Elizabeth Cho, MDHelen Dermatis, PhDMarc Galanter, MD

ANTICIPATED VALUEOF BUPRENORPHINE MAINTENANCE

FOR OPIATE DEPENDENCE

Buprenorphine was approved for the treat-ment of opiate dependence under the Drug Ad-diction Treatment Act 2000. In combinationwith psychosocial support it can address theneeds of opiate addicts who are unable or un-willing to access treatment in current metha-done maintenance treatment programs, eitherdue to lack of openings or limited geographicalaccess (1) or negative attitudes towards metha-done maintenance treatment (2,3). It is, how-

ever, important to review the applicability ofcurrent research findings to situations that canbe anticipated once this medication is widelyavailable. One issue of importance is whetherbuprenorphine maintained patients will use il-licitopiateswhile in treatment.Thiscanbecon-sidered in light of current findings on bupren-orphineandmethadonemaintenance,aswellasattitudes towards and anticipated use of bu-prenorphine itself in the general community.

There are only 180,000 methadone slotsavailable for an estimated 980,000 heroin ad-dicts in the U.S. (4). Buprenorphine, like meth-adone, can benefit patients due to (a) its effec-

Elizabeth Cho (E-mail: [email protected]), Helen Dermatis (E-mail: [email protected]), and Marc Galanter(E-mail: [email protected]) are all affiliated with the Division of Alcoholism and Drug Abuse, New York Uni-versity School of Medicine, 550 First Avenue, NB20N29, New York, NY 10016.

The authors are on the faculty of the Division of Alcoholism and Drug Abuse, Department of Psychiatry, NewYork University School of Medicine and Bellevue Hospital Center.

Address correspondence to: Helen Dermatis, PhD, New York University Medical Center, Division of Alcohol-ism and Drug Abuse, 550 First Avenue, New York, NY 10016 (E-mail: [email protected]).

Substance Abuse, Vol. 27(1/2) 2006Available online at http://suba.haworthpress.com

© 2006 by The Haworth Press, Inc. All rights reserved.doi:10.1300/J465v27n01_01 1

tiveness at decreasing opiate use, (b) safetyprofile, and (c) ability to reduce medical prob-lems associated with use (5-9). Additionally,buprenorphine in combination with naloxonedecreases diversion potential, thereby provid-ing increased access to opiate medicationmanagement as an office-based treatment andultimately increases flexibility of patients topursue lifestyle choices (job, school, travel).An office-based treatmentcanalso facilitate in-dividualized care plans to enhance retentionand satisfaction, leading to decreases in mor-bidityandmortalityassociatedwithopiateuse.

Since 1996, physicians in France have beenauthorized to prescribe buprenorphine for opi-ate dependence, in order to allow patientsgreater access to replacement therapy. Opiatesubstitution treatment was documented to haveincreased by over 95% from 1995 to 1999, with80%ofopioid-abusing individualsbeing treatedwith buprenorphine (10). Any physicians, in-cluding ones without specialized training, canprescribe buprenorphine like other medica-tions. Pharmacy supervision and dispensing isavailable if necessary. In assessing diversionand abuse potential of the drug, two studiesfrom different regions of France report that nomore than 20% of patients receiving buprenor-phine obtained excessive buprenorphine frommultiple providers (11,12).

We reviewed eight studies involving bu-prenorphinefor the treatmentofopioiddepend-ence (5-9,13-15). The studies all had informa-tion on safety and efficacy of buprenorphineand identified sociodemographic characteris-tics which may differentiate persons with opi-ate dependence who prefer or respond better tobuprenorphine treatment. Three studies com-pared buprenorphine to placebo and five stud-ies compared buprenorphine to methadone. Allstudies reviewed were randomized and dou-ble-blind (for a period of time) except for thatconducted by Strain et al. (6). All studies wereclinic-based with the exception of Fudala et al.(8) where visits took place in an office separatefrom the clinic where methadone/LAAM wasadministered in an attempt to simulatean actualpractice situation. All studies showed bupren-orphine to be effective and safe compared tomethadone or placebo except for one study (7)which showed high dose methadone signifi-

cantly more effective than buprenorphine (8mg).

We conducted an 18 week buprenorphinetrial with a community based sample of 66 sub-jects responding to local newspaper advertise-ments or referred from NYU facilities wantingtreatment for heroin dependence (16). To par-ticipate, subjects had to be 21 years or older,meet requirements for heroin dependence byDSM-IV criteria, have no serious medical ill-ness or history of psychosis. Subjects were notto have been involved in buprenorphine ormethadone maintenance treatment within 3months prior to admission. Importantly, wefound that secondary opiate abuse was lowerwhen a manualized psychosocial treatment,Network Therapy, was applied, compared withmedication management alone.

A review of this work indicates that illicitopioid abuse for heroin addicts will continue tobeaproblemofsomedimensionduringmainte-nance. This represents an important issue withregard to rehabilitation and addicts’ eventualdiscontinuation from maintenance, but may beaddressed with psychosocial counseling tai-lored to achieving diminished concomitantopioid abuse.

REFERENCES

1. Clark HW. Office-based practice and opioid-usedisorders. N Engl J Med 2003; 349:928-930.

2. Rosenblum A, Magura S, Joseph H. Ambiva-lence towards methadone treatment among intravenousdrug users. J Psychoactive Drugs 1991; 23:21-27.

3. Zule WA, Desmond DP. Attitudes toward metha-done maintenance: Implications for HIV prevention. JPsychoactive Drugs 1998; 30:89-97.

4. Office of National Drug Control Policy. NationalDrug Control Strategy, 2000. Washington, DC: Govern-ment Printing Office; 2000.

5. Johnson RE, Chutuape AM, Strain EC, WalshSL, Stitzer ML, Bigelow GE. A comparison of levo-methadyl acetate, buprenorphine, and methadone foropioid dependence. N Engl J Med 2000; 343:1290-1297.

6. Strain EC, Stitzer ML, Liebson IA, Bigelow GE.Buprenorphine versus methadone in the treatment ofopioid dependence: Self-reports, urinalysis, and addic-tion severity index. J Clin Psychopharmacol 1996; 16:58-67.

7. Ling W, Wesson DR, Charuvastra C, Klett CJ. Acontrolled trial comparing buprenorphine and metha-done maintenance in opioid dependence. Arch Gen Psy-chiatry 1996; 53:401-407.

2 SUBSTANCE ABUSE

8. Fudala PJ, Bridge TP, Herbert S, Williford WO,Chiang CN, Jones K, Collins J, Raisch D, Casadonte P,Goldsmith RJ, Ling W, Malkerneker U, McNicholas L,Renner J, Stine S, Tusel D. Office-based treatment ofopiate addiction with a sublingual-tablet formulation ofbuprenorphine and naloxone. N Engl J Med 2003; 349:949-958.

9. Mattick RP, Ali R, White JM, O’Brien S, WolkS, Danz C. Buprenorphine versus methadone mainte-nance therapy: A randomized double-blind trial with405 opioid-dependent patients. Addiction 2003; 98:441-452.

10. Auriacombe M, Fatseas M, Dubernet, J, DaulouedeJP, Tignol J. French field experience with buprenor-phine. The American Journal on Addictions 2004; 13:S17-S28.

11. Vignau J, Duhamel A, Catteau J, Lega G, Pho AH,Grailles I, Beauvillain J, Petit P, Beauvillain P, ParquetPJ. Practice-based buprenorphine maintenance treatment(BMT): How do French healthcare providers managethe opiate-addicted patient? Journal of Substance AbuseTreatment 2001; 21:135-144.

12. Thirion X, Lapierre V, Micallef J, Ronfle E,Masut A, Pradel V, Coudert C, Mabriez JC, Sanmarco

JL. Buprenorphine prescription by general practitionersin a French region. Drug and Alcohol Dependence 2002;65:197-204.

13. Johnson RE, Eissenberg T, Stitzer ML, StrainEC, Liebson IA, Bigelow GE. A placebo controlledclinical trial of buprenorphine as a treatment for opioiddependence. Drug Alcohol Depend 1995; 40:17-25.

14. Schottenfeld RS, Pakes JR, Kosten TR. Prognos-tic factors in buprenorphine versus methadone main-tained patients. J Nerv Ment Dis 1998; 186:35-43.

15. Ling W, Charuvastra C, Collins JF, Batki S,Brown LS, Kintaudi P, Wesson DR, McNicholas L,Tusel DJ, Malkerneker U, Renner JA, Santos E, CasadonteP, Fye C, Stine S, Wang RIH, Segal D. Buprenorphinemaintenance treatment of opiate dependence: A multi-center, randomized clinical trial. Addiction 1998; 93:475-486.

16. Galanter M, Dermatis H, Glickman L, MaslanskyR, Sellers MB, Neumann E, Rahman-Dujarric C. Net-work therapy: Decreased secondary opioid use duringbuprenorphine maintenance. J Subst Abuse Treat 2004;26:313-318.

Editorial 3

LETTER TO THE EDITOR

Increasing Psychiatric Morbidity and Mortality RatesAmong ‘Ozu’ Addicts in Ika Land, Nigeria

I. Onyesom, PhDA. Naiho, MSc

Between November 2003-February 2005,we conductedasurvey on theproblemsof ‘ozu’consumption in Ika, a community in DeltaState, Nigeria, and we wish to present and dis-cuss the major findings of the project in yourjournal outlet.

Ika is a smallprovince inDeltaStateof Nige-ria. Indigenes presently occupy two of thetwenty-five local government areas in the state.The Ika communities are situated in the north-ern part of the state, covering a total land massof about 1150 km2 and an approximate popula-tion of 259,850 (1991 cenus). The socio-cul-tural activities of the Ika people centre aroundthe use of ‘ozu,’ commonly regarded as a ‘so-cial lubricant.’ Thus, any social ceremony isusually climaxed by the presentation and con-sumption of ‘ozu.’ ‘Ozu’ is an alcoholic liquorlocally produced from palm juice, and is gener-ally loved and enjoyed by the Ika people. Therelationship between the Ika culture and ‘ozu’consumption is well known. The demand for‘ozu’ in Ika is so strong that unlicensed com-mercial brewers make livelihood from sales,

and there are no laws regulating production andavailability.Problemsof ‘ozu’ intoxicationanddependencearecommoninIka,andtherearenostrong concerns to rehabilitate sufferers whoare mainly men between the ages of 20 and 50years–the work force.

It is on this note that we attempted to reportthe psychiatric morbidity and mortality ratesamong ‘ozu’ consumers in Ika land. One of ourfindings shows that ‘ozu’ is bestowed with thepotential of inducing intoxication and depend-ence. ‘Ozu’containsethanoland if ‘ozu’ is con-sumed at a fairy high amount, ethanol builds upin the system and begins to interfere noticeablywith brain function. This interference mani-fests as slurred speech, blurred vision, sluggishmovement,andweakenedbehavioral restraintsand inhibitions–all common symptoms of in-toxication. Speech, vision, coordination, thoughtand behavior are all connected with an incredi-bly complex series of chemical reactions in thebrain’s neurons, or key cells. The presence ofethanol modifies these reactions, suppressingor enhancing the role of certain neurotrans-

I. Onyesom is affiliated with the Department of Medical Biochemistry and A. Naiho is affiliated with the Depart-ment of Physiology, Delta University, Abraka, Delta State, Nigeria.

Address correspondence to: I. Onyesom, Delta University, P.O. Box 144, Abraka, Delta State, Nigeria (E-mail:[email protected]).



mitters. This culminates in altered informationin the brain, preventing it from functioning nor-mally,hence theassociatedsymptomsof intox-ication. Ethanol, the chemical compound pres-ent inmostalcoholicdrinks including‘ozu,’ isaneurotoxin. Therefore, someone who drinks‘ozu’ suffers from a form of poisoning. Withprolonged exposure to ‘ozu,’ brain chemistryadapts to counter the poisonous effect of etha-nol and tomaintainnormalnerve function.Thisleads to tolerance, and dependence occurswhen the brain has adapted so much to the pres-ence of ‘ozu’ that it cannot operate properlywithout it. The body thus, craves ‘ozu’ to main-tain the chemical balance. Ethanol dependencehas been linked to acetaldehyde-induced alter-ations in the metabolism of biogenic amines(1,2). Acetaldehyde is the first metabolite ofethanol.

The information we gathered during the in-vestigationshowthat ‘ozu’ intoxicationandde-pendence elicit physical violence which wasobserved to be increasing over the past fiveyears in Ika communities. The major acts of vi-olenceassociatedwith ‘ozu’ include: fightings,domestic violence, robberies, road and domes-tic accidents, suicide attempts and sex-relatedcrimes. Our study reveals that these violent actsare increasing, hence, the elders in council ap-proved the operations of local anti-crime squadsto monitor crime waves. In the US, it is esti-mated that 50% of all murders, serious assaults,rapes, robberies, and incidents of domestic vio-lence are impacted by alcohol abuse (3). In Ika,it is commonly believed that drinking ‘ozu’ en-hances courage and alleviates fear and appre-hension in the face of danger. Although ‘ozu’may have a salutary effect in promoting cour-age and aggression in certain life-threateningsituations, in most instances, ‘ozu’-related ag-gression is destructive to the aggressor as wellas to the victims. ‘Ozu’-related violence in Ikaland exacts an enormous toll, study suggests.Beyond the issues of physical violence aremany other problems that affect the family of‘ozu’ addicts. Financial insecurity, loss of job,medicalcosts,excessivespendingon‘ozu,’andgeneral impractical attitudes toward money arecommon. We observe that many families iso-late themselves from society because of shameand ridicule, and social lives are ruined for chil-dren and adults even if there is no physicalabuse or violence in the home.

Evidence available from the research indi-cate that psychiatric morbidity is increasingamong ‘ozu’ consumers in Ika communities.Psychiatric illnesses ranging from anxiety anddepression (frequently related to financial,work or family problems) to paranoia, andcases of dementia are common and growingamong ‘ozu’ imbibers. Drinking ethanol over along period of time destroys millions of braincells, which cannot be repaired or replaced.Ethanol can permanently damage the biochem-ical system responsible for maintaining thestructure of the nerve cells by impairing themanufacture and transport of nucleic acids thatare crucial for maintenance of the protein struc-tures of nerve cells. Since certain types ofnucleic acids have also been implicated in theprocess of memory storage, ethanol-relatedchanges in memory function have been linkedto adverse effects of alcohol on brain cell nu-cleic acids. The spectrum of memory disordersassociated with ethanol abuse range from briefepisodes of forgetting to severe amnestic syn-dromes accompanied by structural changes inthe brain. It has been reported that about 4,000people in the US suffer from Wernicke-Korsakoff syndrome, a condition combiningsymptoms of palsy and neuritis (3).

Our survey shows that the leading cause ofdeath among ‘ozu’ consumers is liver diseases.Faty liver, alcoholic hepatitis, cirrhosis, andliver cancer develop in sequence over a periodof years. We discover that the risk of alcoholichepatitis and cirrhosis developing increases inproportion to the amount of ‘ozu’ consumedand the number of years of high consumption.The liver is responsible for oxidizing ethanol(4), and continual heavy drinking of ‘ozu’ cancause irreparable damage to the organ. Whenthe liver is forced to oxidize large amounts ofethanol, a condition known as cirrhosis or scar-ring of the liver, results and can be deadly. Cir-rhosis may occur after repeated episodes of al-coholic (or viral) hepatitis or it may developinsidiously with little or no warning. Cirrhoticpatients may not be aware until they developjaundice or other signs of severely impairedliver function. Loss of appetite, abdominalpain, weakness and debility may increase in se-verity as cirrhosis progresses. One of the mostserious symptoms of cirrhosis is severe en-largement of esophageal veins which may lead

6 SUBSTANCE ABUSE

to spontaneous venous bleeding and death fol-lowing liver failure. Cirrhosis of the liver withits complication is one of the leading causes ofdeath among adult males in the United King-dom (3), and in Nigeria, it has been observedthat alcohol-induced psychiatric disorder isaccompanied by liver dysfunction (5).

We have been able to identify the majorgrowing problems associated with ‘ozu’ con-sumption in Ika land. Regrettably, the aware-ness of such sizeable problems has not beendocumented, and so, there has been no seriousexamination of methods of preventing theproblems from growing. Research on how bestthe problems could be solved should be con-ducted in order to save promising youngalcoholics from abrupt death.

REFERENCES

1. Davis VE and Walsh MJ. (1970). Alcohol, aminesand alkaloids. Science (Washington, DC) 167:1005-1007.

2. Editorial (1972). Alcohol addiction, a bio-chemi-cal approach. Lancet 1:24-25.

3. Leung M. (2002). Alcohol. American MedicalStudent Association, (800) 767-2266.

4. Lieber CS. (1994). Metabolic consequences ofethanol. Endocrinology. 4 (2):127-139.

5. Onyesom I and Chukwuka-Offor HC. (1999). ANinvestigation into the major health risks associated withthe permissive sociocultural use of alcohol among theinhabitants of the Edo-Delta region of Nigeria. J. MedLab Sci. 8:122-127.

Letter to the Editor 7

REGULAR ARTICLES

On Blending Practice and Research:The Search for Commonalitiesin Substance Abuse Treatment

Scott Kellogg, PhDMary Jeanne Kreek, MD

ABSTRACT. There has been a growing interest in the substance abuse treatment field in bringingtogether the treatment and research communities. While dialogues about logistical and philosophi-cal issues are important, the development of shared core concepts could potentially be quite help-ful in facilitating communication and creating common treatment and research goals. It is thecontention of this paper that all psychosocial and, potentially, pharmacological treatments ideallyaddress, in part or in full, three aspects of the self–the capacity to regulate emotional and behav-ioral expression, the ability to engage in future-oriented, goal-directed behavior, and the develop-ment of nonaddict and/or recovery-oriented identities. Examples from the research and treatmentliterature are provided. [Article copies available for a fee from The Haworth Document Delivery Service:1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Addiction treatment, psychotherapy integration, self-psychology

INTRODUCTION

The issue of integrating research and prac-tice in the field of substance abuse is clearly onthe rise. The National Institute on Drug AbuseClinical Trials Network has been a major forcein this movement, but other local and regional

efforts such as the Addiction TechnologyTransfer Centers also represent collaborativeefforts to improve the quality of substanceabuse treatment and science. To date, therehave also been five major NIDA-sponsored“BlendingConferences”–inLos Angeles, NewYork, Denver, Detroit, and Miami–that have

Scott Kellogg and Mary Jeanne Kreek (Head of Laboratory) are affiliated with the Laboratory of the Biology ofthe Addictive Diseases, The Rockefeller University, New York, NY.

Address correspondence to: Scott Kellogg, Department of Psychology, New York University, 6 WashingtonPlace, Room 302, New York, NY 10003 (E-mail: [email protected]).

This work was supported by NIDA grant P60-DA05130. The authors would like to thank John Rotrosen and K.Steven LaForge for their helpful suggestions.



sought to connect the research and treatmentcommunities and to create ongoing forums andpartnerships.

There are many issues facing those who areinterested in this integration of science andpractice. Discussions typically include suchtopicsasfunding, thepragmaticsof implement-ing research in treatment settings, the differ-ences between the clinical and research worlds,the needs of both subcultures, and ways ofbuilding mutually affirming and lasting rela-tionships. One area that has perhaps been giveninsufficientattentionis thesearchfor, andclari-fication of, any conceptual common groundthatcouldservenotonlyasabridgebetweenthetwo groups, but also as a unifying force for thevarious initiatives within each group. The elu-cidation of these core treatment componentscould help in the development of synergistic al-liances across all of these divides. This paperwill address this gap.

Obviously all parties involved share a con-cernabout thewell-beingofpatients, andall areworking to reduce or eliminate substanceabuse. Going beyond that, there are severalconstructs that could serve as the common de-nominator of all treatment interventions. It is ahypothesis of this paper that most therapeuticinterventions are, directly or indirectly, at-tempting to address problems that are centrallyrelated to the psychology of the self, and theseattributes of the self could serve as unifyingconcepts for research and treatment.

“THE THREE SELVES”

The pragmatic model being proposed hereemphasizes that there are 3 aspects of the selfthat are relevant to, and affected by, manyforms of treatment and that are inextricablyconnected to the healthy outcomes that aresought in substance-abuse treatment. These 3core self attributes are: (1) effective emotionalself-regulation–which involves both overcom-ing debilitating emotional and behavioral inhi-bitions as well as controlling excessive emo-tional and behavioral responding; (2) an abilityto engage in persistent future-oriented,goal-di-rected behavior; and (3) the development of anonaddict identity structure.

As willbeclear,not every interventionorap-proach addresses all of these self aspects; how-ever, they each typicallyhave an effect on someof them. As these components are strength-ened, the likelihood of drug- and alcohol-freeliving increases. These three self-aspects havethe potential to provide us with a paradigm forcomparing treatment process and outcomesacross modalities.

EMOTIONAL SELF-REGULATION

Emotional self-regulation encapsulates tworegions of self-control; each of which may be aprimaryproblemfordifferentgroupswithin thesubstance-using population. The first of theseinvolves the ability to overcome the painfulemotions and inner states that inhibit self-ex-pression and would correspond to what Younget al. (1) have termed the emotional inhibitionschema, a schema that is frequently based on adirectedormodeledemphasison the repressionof feeling and the communication of desire.This may develop in the family setting and/orbe a reflection of the individual’s temperamen-tal style. This could encompass patients whosesubstance use has some relationship to depres-sion, anxiety, social anxiety, obsessive-com-pulsive behavior, and a general sense of notfeeling comfortable or safe in the world. Boththis self-dynamic, overinhibition, and the oneto follow it, lack of self-control, were perhapsmost clearly elucidated by some of the contem-porary psychodynamic theorists who were in-terestedinaddiction(2-8).Theseegopsycholo-gists, self psychologists, and object-relationstheorists saw that substance use was a way ofadapting to life because the patients did nothave sufficient psychological structures forsuccessful coping (7). The root of these deficitswas to be found in the traumatic and abusivechildhoods that they had experienced (2,5,8).

Wurmser (8) felt that substance abuse wasrelated to an overly harsh superego that left thepatient in a state of dysphoria and inhibition.The drugs or alcohol served to reduce the painand/or provided a vehicle for rebellion. He hy-pothesized that specific substances would ad-dress these problems. For instance, he believedthat psychostimulants would help those who

10 SUBSTANCE ABUSE

were depressed while alcohol would help withguilt, loneliness, and anxiety.

Kohut (5), in turn, felt that addicted patients,because of unempathic and often traumaticparenting, were frequently unable to developthenormalpsychicstructures thatwouldenablethem to cope or prosper in the world. The resultwas “a weakness in the core of his [or her] per-sonality” or “a defect in the self” (p. vii) that af-fected both coping and self-esteem. Drugs andalcohol are experienced as “curing the centraldefect” (p. vii)–at least temporarily. The sub-stance takes the place of the parent, and it en-ables the patient to feel whole and alive, strongand in control. When this fades, the deficitre-emerges, and the cycle commences again.

Thesecondaspectofemotionalcontrol is theability to successfully regulate and control theexpression of one’s emotions and behaviors.Young (1, 9) called problems with this kind offunctioning, Insufficient Self-Control. As Young(9) has described this dynamic, patients displaya “pervasive difficulty or refusal to exercisesufficient self-control and frustration toleranceto achieve one’s personal goals, or to restrainthe excessive expression of one’s emotions andimpulses” (p. 2). In this case, the self does notappear to be strong enough to modulate, con-trol, or contain the emotions that the person isexperiencing.

Khantzian (4) felt that many patients werehaving a great deal of difficulty controllingtheir emotions.He specifically linked theuse ofopiates with strong feelings of rage and aggres-sion. “Opiates are notoriously effective formodulating and relieving a range of intense,painful feelings; this is particularly true whenanger or aggression is involved” (p. 250). Whilethe relationship between a specific psychologi-cal issueandthesubstanceofchoiceisprobablymuch more idiosyncratic than this, the “self-medication hypothesis” in a general sense islikely to have some validity.

Yalisove (7) notes that “acting out” behavioris common in early recovery because once thesubstances are removed, the individual has nomechanism for coping with the power and thediscomfort of his or her emotions. He recom-mended interventions that involve helping “ad-dicts to develop the capacity to delay impulsesto act out,” (p. 71) through “teaching the addict

to recognize, label, and tolerate the affect andultimately understand its meaning” (p. 70).

A number of clinical reports and studiesmade links between emotional states and sub-stanceuse. In termsofprotectivefactors,a large(over 7,000 subjects), longitudinal study ofSwedish men (10), first at 18 then at 36, foundthat good emotional self-regulation and controlwas a protective factor against the onset of her-oin addiction. In a follow-up study of metha-done patients who had participated in a cogni-tive-behavioral treatment program for cocaineuse, Lovejoy et al. (11) found that after treat-ment the patients felt better able to address suchnegative emotional states as “anger, depres-sion, anxiety, and boredom”(p. 276). Theyalsobegan to learn to express their feelings to othersand they found this to be therapeutic as well.

The psychodynamic mode of treatmentspeaks to a process that is probably shared bymany of the psychosocial therapies describedhere. In the psychotherapy experience (2), thetherapist engages in the internalization processthat ideally would have been done by a goodparent. Through the consistency of the personandtherapeuticenvironment, thepatientbeginsto build inner structures, gaingreater emotionalself-control, and experience more frequentstates of well-being.

Marlatt and Gordon’s relapse preventionmodel (12) addresses the issue of emotionalself-regulation in twoprimaryways. The first isthat studies related to this approachhave shownthat both negativeand positive emotional statescanbeprecipitants for relapse. In termsofnega-tive emotions, frustration and anger are fre-quently the result of interpersonal difficulties,while such emotional states as depression andfear are seen as being more intrapersonal, ortaking place within the person.

Patients who have stress-related relapses arefrequently individuals whose lives are out ofbalance. Marlatt and Gordon (12) describedthis as a situation in which the “shoulds,” or theobligations and requirements that an individualmust meet, are dominating the individual’s lifeto the exclusion of the “wants,” or the thingsthatprovideenjoyment,pleasure,andmeaning.The therapeutic work here involves engagingthe patients in an analysis of, and a dialogueabout, the organization of their lives. Marlattand Gordon (12) also emphasized the impor-

Scott Kellogg and Mary Jeanne Kreek 11

tance of interventions that addressed the physi-ological aspects of stress. To this end, theymade a case for the central importance of bothaerobic activities (such as running) and relax-ation techniques (such as meditation, progres-sive muscle relaxation, and guided imagery).

The therapeutic community (TC) is an insti-tution that addresses all three aspects of the selfwhile maintaining a strong commitment to ab-stinence (13). The issues of emotional expres-sionandcontrolappear tobeintertwined.AsDeLeon (14) observed:

In the TC, expressing and experiencingfeelings in appropriate ways is central torecovery. These techniques are designedto evoke and teach individuals to “deal”with their feelings, that is, to label, ex-press, and manage them appropriately be-fore they lead to or trigger self-defeatingbehavior such as drug use. (p. 84)

Through the use of encounter groups and “hotseat” techniques, patients are pressured to bemore open about their feelings, experiences,and behaviors.Thestreet-orientedstanceof be-ing “cool” or unemotional will not be accepted;in fact, it will actively be opposed. The goal ofuncovering and revealing secrets may alsoserve as a form of emotional liberation as it po-tentially reduces a burden while helping the ad-dicted person feel connected to others. Psycho-drama (15) is also a technique that is used insome TCs as a way to elicit emotions. In turn,excessive emotional outbursts and uncontrolledbehaviorarealsoquite likelytobeconfronted.

The educational efforts of the TC include afocus on labeling emotions and then learning toexpress them appropriately. The labeling ofemotions serves to put a brake on the direct ex-pression of emotions as behavior, and thisserves to strengthen emotional and behavioralself-control. This is crucial because, in the TCview, addicted people typically have low frus-tration tolerance (14). TC members are alsotaught alternative behaviors to help them copeas well.

Alcoholics Anonymous (16,17) (AA) has aprogram for addressing the emotional needs ofthe recovering person. The emotional issues ofrecovering persons are generally discussed interms of depression or anger. There is a partial,

but not complete, overlap between the vision oftheaddictedperson in theAAliteratureandnar-cissistically-damaged individual described byKohut (5). While each see the addicted personas both grandiose and deeply needy, the keyrole of trauma that Kohut and other dynamicthinkers (2,5,6) emphasized is absent in the AAvision. In direct contrast to a psychodynamicunderstanding, the “neediness” of the addict isaddressed throughanunderstandingandaccep-tance of the belief that other people cannot sat-isfies these needs. Dependence on alcohol ordrugs was another attempt to address thesepains; but it inevitably failed to work. Depend-ence on a Higher Power is seen as the way tobring emotional stability to one’s life.

In terms of specific emotional regulationtechniques, Bill W., the co-founder of AA, rec-ommended a kind of walking meditation whichinvolved walking, breathing, and counting orrepeating prayers (18). He felt that meditationand prayer increased a sense of connectednessand that would lead to emotional balance.

Inamorebehavioralsense,herecommendedthat depressed individuals make a list of thebare minimum of activities that they have to ac-complish. They should do these first and thenslowly try to expand their list. The commoncore here is that action is therapeutic in thestruggle with depression.

SMART Recovery® (SR) falls squarelywithin the cognitive behavioral tradition withits roots in both Rational-Emotive-Behaviortherapy (19) and cognitive-behavioral therapy(12,20-22). SR believes that emotional distur-banceisamajorfactor indrugandalcoholprob-lems (23). By placing an emphasis on the pri-macy of thought over emotion, and by learningto manage and direct their internal dialogues,members are able to gain control over theiremotional responses and increase their frustra-tion tolerance (24). This program is not inhibit-ing as members discover that they are actuallyexperiencing a “wider range of emotions andfeel more alive emotionally, yet they find thatthis need not create problems or be disturbing”(24, p. 7).

WomenForSobriety (WFS)was foundedbyJeanne Kirkpatrick, PhD, in 1975, with the goalof trying to meet the specific needs of womenalcoholics. Like the 12 Step Fellowships,Women For Sobriety is a psychospiritual pro-

12 SUBSTANCE ABUSE

gram, but its roots appear to be more closelytied to the writings of Emerson and other writ-ers in New Thought metaphysics (25,26). Dr.Kirkpatrick’s insight was that “our thoughtscan change everything” (27, p. 2). This con-scious effort to change her thought patterns andher perspective on life led Kirkpatrick toachieve and maintain her sobriety. The vehiclefor recovery, from this perspective, is meditat-ing on the New Life Acceptance Program affir-mations, reading the literature, and attendingmeetings. She also believed that the inhibitionand frustration that women experience was ac-tually a major factor in their turning to sub-stances (28), and she strongly urged women totake steps to overcome that state.

In her essays addressing the issue of anxiety,Kirkpatrick stressed that one source of anxietyis the traditional role that women have been putin. Since they have been dependent on othersfor their survival, they have been conflictedabout expressing their feelings; this conflictleads to anxiety (29). The other source of anxi-ety for women is unrealistically high standardsas children, as moral beings, and as adults (i.e.,in marital, family, and work situations). Shebelieves that women should strive and be ambi-tious but make competence, instead of perfec-tion, the goal (30).

FUTURE-ORIENTED,GOAL-DIRECTED BEHAVIOR

The second aspect of the self involves the abil-ity to make plans, develop healthy and affirminggoals,andact inaconsistent, self-directedman-ner to achieve these ends. Manganiello (31)alsoproposed that these factorscouldbecentralto the recovery process. These kinds of con-cerns in psychotherapy are probably mostclosely associated with the existential psycho-therapy tradition (32,33). This involves both asense of self-efficacy and the ability to perse-vere. Purposeful behavior most likely overlapswith the factor of Conscientiousness on theNEO-PI-R (34) and the concept of internal lo-cus of control (35).

Philosophers of success (36) have empha-sized the importance of internally-maintained,future-oriented, goal-directed behavior in boththe process of life transformation and the

achievementof major accomplishments.Therehave been a number of studies looking at com-ponents of this process in addicted populations.Ofparticularrelevancehavebeenthestudiesonfuture time perspective, locus of control, andself-efficacy.

Future Time Perspective

A strong sense of the future and its connec-tion to one’s current activities has been seen asvery valuable in Western industrialized societ-ies. Psychologically, this perspective reflectssomeof theattributes thatarebeingproposedasimportant in the recovery process. For exam-ple, “Wallaceand Rabin (1960) havesuggestedthat the achievement of . . . [the human] abilityto project temporally parallels the growth anddevelopment of the self or ego” (cited in [37],p. 90). This sense of self is associated with de-sirable accomplishments as having a “futuretime perspective is tantamount to having a highachievement orientation” (38, p. 33). Taking abroader perspective, Lewin (39) wrote that“practically everyone of consequence in thehistory of humanity has been dominated by atime perspective which has reached out far intofuture generations” (p. 50).

This said, the actual role of future time per-spective (FTP) in the worlds of addiction andrecoveryhas beensomewhatcomplex.A short-ened FTP is a factor in delinquent behavior ingeneral, not just drug use (37,40,41). Heroinaddicts have been found to have shorter FTPthan normal controls (31,37,42), and in onestudy, alcoholics were found to have a shorterFTP than social drinkers (41).

Treatment appears to enhance an individ-ual’s FTP. Alvos et al. (40) found that intrave-nousdrugusers(IDUs)whowereorhadrecentlybeen in treatment (methadone maintenance,therapeutic community, or detoxification) hada longer FTP than currently-injecting IDUs.Henik and Domino (43) reported that, after 9weeks of treatment, patients in methadonetreatment had a longer FTP than waiting-listcontrols. Murphy and DeWolfe (44) believedthat alcoholics regained their FTP quickly oncethey entered treatment.

Notonlyis theabilitytoconceptualizethefu-ture important, the content of the conceptual-ization is important as well. Hulbert and Lens


(45) discussed Emrick’s (1970) work in whichpatients with negative views of the future didnot have as strong or successful a recovery.Husman and Lens (46) also noted that negativefuture images can sap an individual’s motiva-tion.

Alcoholics Anonymous and the other 12Step Fellowship programs address the issue ofFTP with the slogan, “One day at a time.” Thisconnects to the common practice of “countingdays,” and it has been symbolized with the im-ageof thecamel-ananimal thought tobeable togo for 24 hours without drinking. If recoveringindividuals are having difficulty conceptualiz-ing the future, breaking sobriety down into24-hour units may be ideal. In contrast, Hulbertand Lens (45) reported on a number of conver-sations with AA members who had achievedextended periods of abstinence. At this point inrecovery, they were feeling frustrated with theAA emphasis on “One day at a time,” and theywanted to base their lives on a longer timeframe.

Petry et al. (42) addressed these complexi-ties. First, it is possible that patients who al-ready have a longer FTP may be more likely tosucceed in treatment. Second, since an empha-sis on long-term negative consequences maynot be effective, using positive reinforcementsin a contingency management program that fo-cuses on targets that can be achieved in a shortperiod of time may serve to dramatically in-crease motivation for treatment. It may well bethat with continued abstinence and ongoing in-volvement in treatment, the FTP of the patientswill naturally begin to expand, especially asthey encounter groups that either directly or in-directly emphasize the development of an ex-tended FTP (i.e., a vocational program). In ad-dition, with success in treatment, the negativeimages of the future that some patients havemay begin to change as they cease their use ofsubstances and begin to experience progress intreatment. To successfully reintegrate them-selves into society, developing a longer FTP isprobably a necessity.

Perhapsofalloftheinterventionsthatarebeingdiscussed,WFSisthemostfocusedonfuture-ori-ented, goal-directed behavior. Kirkpatrick af-firms in her most popular talk, “When we setgoals, we are enthusiastic about living our life.We accept new challenges. We are forward-

looking” (47, p. 1). “I am saying that an alco-holic must move onward, upward, and forward”(48, p. 1).

Kirkpatrick actually warns against the dan-gerof theslogan,“Onedayata time.”Whileshebelieves that it has some usefulness in the pe-riod of early recovery, she feels that it shouldonly be applied to alcohol or drug use, and itshould be discarded once sobriety is stable.“There is something quite wrong with carryingthis attitude for the length of one’s life, becauseit does not take into account stretching andgrowing. It is far too limiting, and for some, iteven becomes crippling” (48, p. 1).

Locus of Control

Implied in a future-oriented, goal-directedperspective is the sense that the individual ex-periences himself or herself in ways that reso-nate with Henley (49), who wrote in the poemInvictus, “I am the master of my fate; I am thecaptain of my soul.” In psychological terms,this would be reflected in an internal locus ofcontrol (LOC), or the belief that one is anagentic force in the world (50).

Studies of LOC among substance abusershave met with mixed results. O’Mahoney andSmith (51), in a study conducted in Ireland,found no difference in LOC among heroin-ad-dicted prisoners, nonaddicted prisoners, andnormal volunteers. Manganiello (31) found thatheroin addicts had a more external LOC whencompared with normal volunteers. Calicchia(52), in a somewhat paradoxical interpretationof the same perspective, cited research data re-vealing that heroin addicts and alcoholics weremore likely to have an internal locus of control.The logic was that they originally had an exter-nal locus of control, but, through the repeateduse of heroin, they developed a substance-basedinternal locus of control. In his study, opi-ate-addicted patients were able to chose be-tween methadone treatment and medication-free treatment. He correctly predicted that themethadone patients would have a more internalLOCthantheabstinence-basedtreatmentgroup.He could not rule out the possibility that indi-viduals with an internal LOC would be morelikely to choose methadone over medication-free treatment.

14 SUBSTANCE ABUSE

In a longitudinal study, Schuckit and col-leagues (53) found that LOC did not predict theonset of alcoholism 10 years later, and Vielvaand Iraugi (54), in a Spanish study, found thatLOC didnotpredict treatmentoutcome. In con-trast, Nurco et al. (55) found that a cogni-tive-behavioral intervention led to an increasein internal LOC. In a Finnish study of alcoholtreatment, Koski-Jännes (56) found that inter-nal LOC was a significant predictor of post-treatment abstinence.

Relapse prevention (12,57) is a therapy ofempowerment. Patients are seen as being part-ners or co-investigators in the therapy, as cen-tral actors in their recovery. This approach isonly possible if they are seen as having aninternal LOC.

The therapeutic community, using powerfulsocial and communal techniques to inducechange and transformation in people, seeks tostrengthen the self-directive power of the indi-vidual. In a statement that captures both thesocial nature of the treatment and the agenticpowers of the individual, the therapeutic com-munity, Daytop, affirms, “Daytop contendsthat people are the captains of their own destinyand only they can do it, but they cannot do italone” (58, p. 1).

Contingency management (59,60-65) canalso help in the development or strengtheningof an internal LOC. While there is great suffer-ing connected to the addictive process, the ex-perience of early recovery may entail both asense of deprivation and loss of agency. Con-tingency systems that provide frequent rein-forcementsforpatients inearlyrecoveryhelp toshow them that their actions matter, and thatthey can have an impact on the environmentthat is positive (63). Silverman et al. (64) foundthat patients receiving reinforcements thatwere contingent on abstinence from cocainewere more likely to report that they relied onwill power than those who received reinforce-ments in a noncontingent manner.

Ingeneral,an internal locusofcontrol isnotafavored perspective in the 12-Step literature.While Bill W. (18) writes, “We have to grow orelse deteriorate” (p. 25), and “God more oftenhelps those who are willing to help themselves”(p. 42). On the other hand, he felt that “individ-ual strength,” “intelligence,” and “self-reli-ance”(p.139)wouldnotallowaperson toover-

come his or her addiction because these inter-fered with humility or the necessity of relyingon a Higher Power. This is perhaps summed upin the belief that addicted people should strivefor “neither dependence nor self-sufficiency”(p. 265), that they should live without depend-ing on other people and without trying to de-pend on themselves. SR, in turn, is internallyoriented, and the outcome achieved is related tothe members actions –“ultimately it is the indi-vidual’s determination and persistence to keepmoving forward that will determine how muchsuccess is achieved” (66, p. 2).

The different views on LOC between AAand SR were addressed by Li et al. (67). Notingthat an internal LOC has been associated withbetter treatment outcomes than an externalLOC, they compared the LOC orientations ofAA members and SR members. In a reflectionof their respective philosophies, the AA mem-bers had a significantly more external orienta-tion that the SR members. It is possible thatthere was some self-selection process at workas many of the SR members had attended AAbefore joining SR, while virtually none of theAA members had been to SR.

Self-Efficacy

Related to an internal locus of control is a be-lief in personal self-efficacy, a belief that onecansuccessfullyperformabehaviorormeet thedemands of a given situation. Originally cham-pioned by Bandura (68), the importance of selfefficacy in substance abuse treatment is di-rectly connected to Marlatt and Gordon’s (12)approach, as they make it one of the corner-stones of their work. Rather than see it as anoverall trait or as a drive for mastery, they be-lieve that self-efficacy is more situation-based.In their treatment model, a wide variety of sce-narios are reviewed to see which ones are moredifficult to cope with. The idea is to empowerthe person through the development of skillsand coping strategies that will support their ab-stinence. For example, a patient may find it rel-atively easy to avoid drinking at the workplaceholiday party, but find it much more difficult torefrain fromdrinkingwhenmeetingupwitholdfriends from high school. In short, the person’sself-efficacy differs in these two cases. Thewhole approach of identifying risk and devel-


oping strategies fits in with the overall impetusof future-oriented, goal-directed behavior.

A number of studies and programs have ad-dressed this issue. Retka and Fenker (69) ar-gued that use of narcotics gave some individu-als a feeling of “personal power” (p. 2). Marlattand Gordon (12) discussed studies in whichmen feel empowered after drinking alcohol;they then observed that women may seek toovercome helplessness through alcohol use. Inboth cases, the substance is seen as providingthe feeling that addicts are lacking in reality,and this may be part of the appeal.

Goldbeck et al. (70), Allsop et al. (71), andVielva and Iraugi (54) all found positive rela-tionships between self-efficacy (SE) and posi-tive treatment outcomes. Lagenbucher et al.(72) had a dissenting report with results goingin the opposite direction; there may, however,have been methodological problems with theirquestionnaire.

Moving the focus to other substances, Gul-liver et al. (73) found that baseline self-efficacywas partially predictive of relapse to smoking.InaDutchstudyof“harddrug”users, astrongersense of SE was associated with fewer days ofdrug-use related problems (74).

Treatment appears to lead to increases inself-efficacy. Two different focus groups stud-ieshavesupported this.Methadonepatients inacognitive-behavioral treatment program forcocaine abuse reported increases in confidenceand self-efficacy (11). McMillen et al. (75)found that the process of surviving years ofdrug use as well as being involved in treatmentboth led to a general increase in a sense ofself-efficacy.

IDENTITY AND RECOVERY

The thirdaspectof theself that canplayasig-nificant role in the recovery process is the de-velopment of strong and viable identities thatcan challenge and replace the addict identity.This view of recovery comes from a social psy-chological perspective with identity theoryspecifically developing out of the SymbolicInteractionist tradition (76). (The words “iden-tity,” “self,” and “role” will be used inter-changeably in this section.)

Identity theory proposes that individuals donothaveone identityor self, butmany.Eachso-cial setting, each social grouping, whether for-mal or informal, can serve as a reference group(77,78), and it has the potential to provide theindividual with an identity. The identity con-sists of such things as a definition of self, aworldview, a set of values or ideology, and anetwork of relationships.

Christiansen (79) has outlined three corecomponents of an identity. The first is that theyare self-definitions. In tune with the SymbolicInteractionist approach, individuals can thinkof themselves as a father, mother, pharmacist,or soccer player, and they can engage in a pro-cess of self-evaluation, that is, they can behappy or troubled by their performance in theseroles.Thesecondcomponent is therelationalorinterpersonal aspect of the identity. Selves arecreated, reinforced, and transformed in socialsettings. Identities thathavemanyrelationshipsconnected to them are likely to be moreimportant to the individual (76).

The third aspect is the agentic. Action is theexpression of an identityas well as a way of cre-ating one. To some degree, the therapeuticcommunity maxim of “Act as if” is a reflectionof this principle.The belief is that behaving likea recovering person will eventually lead to theinternal psychological changes that would sup-port a lifestyle of recovery. The other side ofthis is that most identities have no real strength,power, or meaning until they are manifested inaction (79).

Identity creation and maintenance can beconnected along a time continuum rangingfrom the present to the distant future (79). Theaimis tobeacertainkindofperson in the future.Patients at the beginning of a recovery processare not infrequently connected with educa-tional or vocational programs that offer a wayof obtaining a future identity or “possible self”(80).

Identity development is a creative processthat frequently involves a dialectical encounterbetween the group and the individual in whicheach influences the other (81). Individuals canchange their personal and social selves throughthe initiation of what has been called “identitywork” (82) or “identity projects” (83). Not in-frequently, the impetus to change begins when

16 SUBSTANCE ABUSE

the individual forms a relationshipwith an indi-vidual from a new reference group (84).

While each of these self-definitions has thepotential to impact on behavior, they are not allequallylikelytodoso.This isbecauseidentitiesare organized into a hierarchy of salience or im-portance in which the identities at the top of thestructure are of greater importance to the indi-vidual and will have a much greater impact onbehavior (76,85).

These self-definitions play a critical role inboth the addiction and recovery process. An-derson (86) has argued that people seek to cre-ateandmaintain their rolestructures.However,this is not an easy task, and some individuals,for personal or societal reasons, experiencegreat difficulty in doing this. The inability toconstruct viable social selves creates psycho-logical distress that may lead individuals toconsider identifying with “alternate socialgroups” (p. 253). “Drug subcultural groups”(p. 253) allow for easy entry into the group andprovide an identity that reduces the level of egoidentity discomfort, at least temporarily (86).

There are two important identity-basedchange mechanisms that play a central role inthe transition from addiction to recovery. Thefirst of these is what Goode (87) has called rolestress, or an experience of finding it to be in-creasingly difficult to fulfill the expectations ofa given role or identity. Stephens (88) felt thatthis was an important motivating factor forsome opiate addicts.

The second is role conflict. Here the individ-ual is torn between the incompatible require-ments of two valued identities (88). Many peo-ple will consider drug or alcohol treatmentwhen it is made clear to them that they will losetheir children or their jobs if they do not ceasetheir use of substances.

The essence of the recovery process, as men-tionedabove,will involve the reorganizationofthe identityhierarchywith thenonaddict identi-ties being given primary importance. At times,the creation of new identities will be a coreprocess.

There have been several studies on the rela-tionships among identity, drug and alcohol use,andrecovery.Kambacketal. (89)observedthatdrug-using networks did provide a kind of fam-ily structure and the material for identity cre-ation.Moore(90), inastudyofAustralianSkin-

head culture, found that their alcohol use pat-terns differed from Australian norms and thiswas specifically related to their Skinheadidentity.

Biernacki (91) looked at the processes in-volved in natural recovery (or recovery withouttreatment) from opiate addiction. He foundthree distinct paths which may well parallelthose used by people in treatment. The first wascalled Identity Reversion. Here the individualsreconnected themselves with activities, groups,andself-definitions thatwere important to thembefore the beginning of their addiction career.Thesecondpathwaswhathecalled IdentityEx-tension. Here the individual turned to an iden-tity thatwasco-existentwith theaddict identity,but was not completely tainted or spoiled (92)by the addiction process. The final form waswhat he called Identity Emergence. This wouldinvolve the creation of a new self, a self that didnot exist before the addictionprocess. This pro-cess would certainly be relevant not only tothose who had severely damaged their identitystructure through their drug use, but also tothose who had never been able to develop a via-ble identity structure.

Granfield and Cloud (93) looked at the suc-cessful identity strategies of middle-class ad-dicts, while Pursely-Crotteau and Stern (94)looked at the dynamics of role conflict amongpoor, addicted, pregnant women. Spunt’s (95)work revealed that methadone patients who de-veloped a treatment program identity were lesslikelytobeinvolvedincriminalactivities,otherthan drug dealing, than patients who main-tained a “street addict” identity. Kellogg (81),in a study of alcohol- and polysubstance-abus-ingmen, found that the identitystructuresof thesuccessfulparticipantsdifferedfromthosewhowere having difficulties with their recovery.Thesuccessfulpatientshadastronger identitiesas recovering persons and better connectionswith their treatment program.

Greil and Rudy (96) described what theycalled Identity Transformation Organizations(ITOs), organizations whose primary purposeincludes the creation of specific identities.They specifically identified Alcoholics Anon-ymousand the therapeuticcommunity(seealso[91]) as ITOs. Other self-help groups, such asSR and WFS, also have the potential to provideidentities to members. Psychotherapy, while


perhaps providing a transitional identity (97),can also served as a forum in which identity re-structuringanddevelopmentcanbenegotiated,planned, and implemented (79,97).

IMPLICATIONS FORBUPRENORPHINE TREATMENT

The introduction of office-based buprenor-phine treatment provides an interesting arenafor the assessment of the role of the three selffactors (98-100). At present, there is no re-search data on the impact of buprenorphinetreatment on these characteristics; however,some speculation is possible.

To the degree that individuals are able toachieve some form of life stabilization and re-duce their levels of stress, there should be agreater degree of emotional balance. If the pa-tient population that seeks out this kind of treat-ment contains large numbers of individualswith Axis II disorders, especially borderlinepersonality disorder, and/or high numbers ofpatients with histories of trauma, complexpatterns may emerge.

Patients who were using opiates to “selfmedicate”mayfind thatbuprenorphine is suffi-cient tocontrolopiatecravingbutnotanxietyoremotional lability. Conjunctive psychotherapycould be useful for these subgroups; whetherthey will actually receive it will probably varygreatly over patients and treatment settings(100).

In termsoffuture-oriented,goal-directedbe-havior, buprenorphine, like methadone,will al-low this to be a possibility. For those patientswho desire to set and achieve goals, they willhave a greater freedom to do so. Since, in manycases, there is no formal therapy program in-cluded,maynotfeelpressurefromthebupreno-rphine treatment setting to move forward. How-ever, these patients may have shorter addictionhistories and a less severe form of opiate de-pendence, so they may be a more motivatedgroup in general.

This issue will overlap with the identityquestion as well. Granfield and Cloud (93)found that one reason that individuals chosenatural recovery over treatment was that theyfeared gaining both an addict identity and a re-

coveryidentity.Theywantedtokeeptheir iden-titystructureintactorexpandit inotherways.

Office-based buprenorphine treatment, ifnot linked to psychosocial services, does notprovideanidentitystructure,so itshouldappealto patients with these same concerns. Office-based methadone treatment, which began as aproject from our laboratory in 1985, has beenfound repeatedly to be a success (101), whichgiveshope thatbuprenorphine treatmentwouldbe successful as well.

One difference, however, was that of-fice-based methadone treatment was only of-fered to patients who were doing well in treat-ment; buprenorphine will be offered to alltakers. As noted elsewhere, methadone pro-grams do provide potentially useful recoveryidentities for patients with severe addictions. Amiddle-ground approach would be to create in-duction centers in which patients would havesometherapeuticcontactas theyaremaking thetransition on to this new medication (102). Inthis way, strategies around nonaddict identityformation as well as the other “self” needscould be developed.

PERSONALITY, GENETICS,AND THE THREE SELVES

Not surprisingly, two of the three compo-nents of the self discussed here parallel aspectsof the five-factor model of personality as mea-sured by the NEO-PI-R (34). The Neuroticismfactor of the NEO-PI-R covers such experi-ences as anxiety, depression, self-conscious-ness, andvulnerability.Thefactor themesof in-hibition, angry hostility, and impulsivenesscould reflect problems with controlled emo-tional and behavioral expression. Future-ori-ented, goal-directed behavior, as noted above,has a parallel in the Conscientiousness factor,which, on the NEO-PI-R, involves such factorsas competence, order, dutifulness, achieve-ment striving, self-discipline, and deliberation.Studies have found that addicted individualsfrequently score higher on the Neurotic factorand lower on the Conscientious factor than nor-mals (103). These findings from personality re-search reflect the problem and may serve tosupport the need to address these aspects of theself with intensity and focus.

18 SUBSTANCE ABUSE

Plomin et al. (104) have emphasized the im-portance of integrating genetic findings in clin-ical settings.To touchon thisbriefly, therehavebeen some studies linking genes with personal-ity and behavioral factors that would be relatedto the three selves.

Specifically, the dopamine D4 receptor gene(DRD4)and theserotonin transportergenepro-moter region (5-HTTLPR) have been associ-ated with personality traits and behavioral dis-orders that may potentially put an individual atrisk for addiction while conflicting with thestrengtheningof the threeaspectsof theself thathave been addressed in this paper. Ebstein et al.(105) reported that the DRD4 gene was relatedto novelty-seeking behavior and to AttentionDeficitHyperactivityDisorder–ariskfactor forthedevelopmentofaddiction. Itwouldalsobeapotential challenge to future-oriented, goal-di-rected behavior. In turn, the 5-HTTLPR genehas been connected with both neuroticism anddepression; again this could be a challenge tothedevelopmentof successful emotional-regu-lation systems.

Another genetic variant, the A118G poly-morphism of the mu opioid receptor, intersectswith a number of the issues that have beenraised in this paper. Using in vitro cellular as-says, Bondetal. (106) found that the118G vari-ant receptors had a three-time higher bindingaffinity to beta-endorphin than the more com-mon receptor with no significant difference inbinding to other opiate ligands. They also re-ported a three-time greater potency in activa-tion of G-protein inwardly rectifying potas-sium channels by beta-endorphin for thevariant receptors.

Wand et al. (107) identified this A118Gpolymorphism as a functional variant in hu-mans as well. In a sample of normal volunteers,subjects with at least one copy of the 118G al-lele had higher levels of cortisol release whenadministered the opioid antagonist naltrexonethan subjects with the prototypic receptor. Thisagain affirms the interrelation between genet-ics, the endogenous opioid system, and stressresponsivity. O’Malley et al. (108) found thatnaltrexone decreases both craving and amountof alcohol self-administration among alco-hol-dependent subjects when compared to sub-jects receiving placebo. The subjects receivingnaltrexonealsoshowedhigher levelsofcortisol

and “cortisol levels were inversely related tourge to drink suggesting that naltrexone-in-duced augmentation of the baseline (unstimu-lated) or alcohol-induced (stimulated) HPAaxisactivitymaybeapotentialmediatororpos-sible marker of its ability to reduce alcoholcraving” (p. 27). The hypothesis is that alco-hol-dependent patients, in general, are suffer-ing from an underactivation of their hypotha-lamic-pituitary-adrenalaxis,andthatpartof thereinforcing effects of alcohol comes from thestimulation of this system (109). This biologi-cal perspective echoes the psychodynamic oneput forward earlier in this paper which pro-posed that patients use specific substances toachieve specific desired effects and that somesubstance-using patients will be trying self-stimulate. Naltrexone is helpful to patientsbecause it activates the system, making alcohollessrewardingandnecessarywhenconsumed.

Finally, Oslin et al. (110) found that alco-hol-dependent subjects with the 118G variantwho received naltrexone were less likely to re-lapse and took longer to reach high levels ofdrinking than patients on naltrexone withoutthis polymorphism. This exciting finding be-gins to give pharmacogenetics a practical rolein drug and alcohol treatment prognoses.

Nonetheless, genetics does not determinedestiny. Clinicians may have to realize that itwill be more difficult, but not impossible, forsome patients to develop these aspects of them-selves and to maintain their functioning. As thefield better understands the implication of find-ings like those in the Bond et al. (106), Wand etal. (107), and theOslinet al. (110) studies,workcould be done to accommodate psychosocialinterventions around genetic and personalityfactors.

ON BRAINS AND BEHAVIOR

Whilegeneticsmaybeonepartof thebiolog-ical equation, brain structure and function maybe another. There has been a growing interest inthe role of the Prefrontal Cortex (PFC) and theExecutive Cognitive Functions (ECF) (111) inawide rangeof psychiatricdisorders, includingthe addictions. ECF is a term that refers to thebrain activities that are involved in “planning,initiation, and regulation of goal-directed be-


havior” (111, p. 203). These functions arethought to be located in “the prefrontal cortexand some of its striatal and limbic connections”(111, p. 203). (This biological-functional nexuswill be referred to as PFC/ECF.) A growingbody of work has focused on the role of distur-bances in this area as a major contributing fac-tor in the initiation, maintenance, and failure torecover from the addictive use of substances(111-113).

The PFC/ECF is directly involved in thoseaspects of behavior that involve self-regula-tion, volition, purposefully-directed behavior,and the ability of the individual to resist imme-diate environmental influence (112). This partof the brain is, then, the biological companionto at least two aspects of self that have been fo-cused on here: emotional self-regulation andfuture-oriented, goal-directed behavior.

Problems with PFC/ECF functioning per-meate all aspects of drug use. Giancola andTarter (111), in a review paper, point to a seriesof studies that showed that children with defi-cits in PFC/ECF were at much greater risk ofdeveloping substance abuse problems. PFC/ECF problems also intersected with otherknown risk factors including conduct disorder/Antisocial Personality Disorder, difficult tem-perament, P300 brain wave abnormalities, ag-gressive behavior, and Attention-Deficit/Hy-peractivity Disorder. These, then, are childrenand teenagers who are likely to be having diffi-culty in school, and who may find that they arenot readily accepted by more positive peer net-works (114).

The use of many substances directly affectsthe functioningof the PFC/ECF (112). The out-come, especially with substances like cocaine,alcohol, and methamphetamine, may be a stateof “hypofrontality” (Majewska, 1996, cited in112). This means that the PFC/ECF is impairedand that there is an increased likelihood of im-pulsive behavior that is frequently geared to-ward immediategratification.Inaddition, thereare likely to be attentional and cognitive defi-cits (112). Given that some drug users may besuffering from pre-existing PFC/ECF difficul-ties, there may a further exacerbation of theseproblems with continued use of these sub-stances. Even those without pre-existing prob-lems can seriously impair themselves through

habitual exposure to these neurotoxic sub-stances. All of this may help to perpetuate thecycle of use.

Lastly, these PFC/ECF difficulties can helpmaketherecoveryprocessmoredifficult (115).It may well be that those who are more success-ful at reducing or curtailing their drug use mayhave lower levels of PFC/ECF impairment(113). Understanding this may lead to greaterpatience and empathy on the part of treatmentproviders; the three “self” goals delineated inthis paper may just be more difficult for somepatients–regardless of the therapeutic methodchosen.

Fortunately, recent work in neuroscience isbeginning to have some relevance to thepsychosocial therapies. With a deeper under-standing of the plasticity of the brain (116), it isnow understood that not only do genetics andsubstances affect the brain, but also psycho-therapy and the array of psychosocial treat-ments reviewed here can, potentially, lead tobeneficial brain changes as well. There aresigns that a “brain-based psychotherapy” maybe starting to emerge (116, p. 374). This has thepotential to reaffirm that much of our work, tothe degree that it is impacting on the PFC/ECF,may already be helping individuals increasetheir emotional self-regulation and develop afuture-oriented, goal-directed perspective. Italso means that, over time, it may be possible tofind out which aspects of these psychosocialapproaches are helpful to the PFC/ECF andwhicharenot,andwhat interventionsneedtobeincreased,modified,oreliminated(115,116).

FUTURE DIRECTIONS

Hopefully, thisbriefoverviewwill reveal theconstant re-emergence of some or all of theseself-categories in the various patient subgroupsand treatment interventions that are presentlytaking place in community-based and researchsettings. The case made in this paper is thatthese core aspects can provide a common focalpoint for dialogue and intervention. By makingsomeorallof theseconceptsat leastapartofev-ery interventionandanendpoint ineveryevalu-ation, itmaybepossible todevelopanempiricallanguage of change that both researchers and

20 SUBSTANCE ABUSE

clinicians can share. The common goal ofstrengthening these aspects of the self couldhelp inspire a new wave of therapeutic creativ-ity that could better serve all of our patients.

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24 SUBSTANCE ABUSE

Tooth Retention, Tooth Loss and Use of Dental CareAmong Long-Term Narcotics Abusers

Jing Fan, MD, MSYih-Ing Hser, PhD

Diane Herbeck, MA

ABSTRACT. This study examined tooth retention, tooth loss and use of dental care among agingmale narcotics abusers being followed-up for more than 33 years. The cohort of 581 male narcoticsaddicts admitted to California Civil Addict Program in 1962-1964 was tracked until 1996-1997.As of 1997, 284 (48.9%) were confirmed to be dead. A total of 108 surviving participants com-pleted the oral examination and survey of use of dental services. African American addicts showedthe least number of remaining teeth; and African Americans and Hispanics were less likely to uti-lize dental services compare to Whites. Factors significantly related to tooth retention were abusers’age (p = 0.0006), ethnicity (p = 0.01), income (p < 0.0001), smoking status (p = 0.03), and dentalvisits during the 12 months prior to the survey (p < 0.0001). These findings suggest that settingssuch as prisons and drug treatment programs that include dental care referral and follow-up wouldbe expected to enhance oral and general health among narcotics-addicted individuals. [Article copiesavailable for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address:<[email protected]> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press,Inc. All rights reserved.]

KEYWORDS. Narcotic, addiction, tooth loss, dental care

INTRODUCTION

Previous studies from Denmark (1), Italy (2),Holland(3),China(4),andtheUnitedStates(5)showed that heroin abusers exhibited moremissing teeth and poorer dental health thanthose in the general population. The underlyingpathogenicmechanismsforvariousdentalcon-ditions affecting heroin addicts are not well un-derstood. Govitrapong and his colleagues pro-posed that opioid use directly and negativelyaffected immune function (6), which could be

one possible reason that narcotic abusers hadincreasing susceptibility to various oral dis-eases which ultimately lead to tooth loss.Morabia et al. (7) reported a taste preference forsweet foods among heroin abusers and theyconcluded that this taste change was not a re-flection of low income or other economic con-cerns. It could be a consequence of heroin’seffect on the neuro-regulatory center that stim-ulates a craving for sugar. Zador et al. (8) sup-ported this finding and further reported thatwomen opioid abusers had a high sugar intake,

Jing Fan, Yih-Ing Hser, and Diane Herbeck are affiliated with the UCLA Integrated Substance Abuse Programs,Neuropsychiatric Institute, University of California, Los Angeles, CA.

Address correspondence to: Jing Fan, UCLA Integrated Substance Abuse Programs, 1640 South Sepulveda Bou-levard, Suite 200, Los Angeles, CA 90025 (E-mail: [email protected]).

This research was supported by the National Institute on Drug Abuse Grants DA09169-05, K02DA00139, andDA016383-01A1.



a low dietary fiber and energy intake, and thiseating pattern contributed to the high preva-lence of dental caries among narcotic addicts.

The addicts’ negative health behaviors alsocontribute to their vulnerability to tooth loss.For example, addicts were mostly heavy smok-ers (11) and smoking was reported as a risk fac-tor forperiodontitisand tooth loss in thegeneralpopulation (9,10). Nutritional status and oralhygiene have important effects on the mainte-nanceofahealthymouth,however, lowincomeor chronic diseases such as Hepatitis C and Blead addicts to nutritionaldeficienciesand poororal hygiene (1,2,4,11-16). Lack of dental careand treatment is another crucial factor. Regulardental visits provide preventive services, earlydiagnosis, and required treatment. The Ameri-can Cancer Society (ACS) recommends annualoral examinations for persons 40 years andolder (17), and the U.S. Preventive ServiceTask Force recommends regular dental visitsfor elders (age 65 years and older) (18). How-ever, utilization of dental services and care inthe US strongly depends on dental insurancecoverage (19,20). Dental insurance typically isprovided as an employee benefit, consequentlyretired and unemployed persons are less likelyto have a dental insurance. For heroin addicts,low income and a high unemployment rate mayresult in setting receiving dental services andtreatment far from a priority.

A national survey showed that partial andcompleted tooth loss is more prevalent in olderpersons and African Americans (21). Amongnarcotics addicts, information for edentulismwas limitedtoyoungerpeople:previousstudiesexamined subjects aged from 18-40 (1,2,5).Only one study of narcotics addicts conductedin China included 2.1% subjects who wereolder than 45 (4). Cross-sectional analysis wasutilized for those studies and no race/ethnicitycomparison was done. We conducted a 33-yearfollow-up study of narcotic addicts, and re-ported that severe medical consequences areassociated with long-term heroin use, includ-ing high rates of mortality (49%) and infectiousdiseases (41.7%) (11). Taking advantage of thislong-term follow-up study and objective medi-cal examinations, this paper investigates thetooth retention and tooth loss conditions for acohort of older narcotics abusers with along-term addiction history, and provides data

for ethnic comparison in tooth retention, toothloss, and use of dental services. The relation-ship between tooth retention and age, ethnicity,income, smoking, and dental care utilizationwas also explored.

METHODS

Subjects

The study sample was a subset of partici-pants in a 33-year follow-up study of Californianarcotics abusers. The original study consistedof 581 male narcotics abusers admitted to theCalifornia Civil Addict Program (CAP) from1962 to 1964. As we described previously (11),CAP was a compulsory drug treatment pro-gram for narcotic-dependent criminal offend-ers committed under court order. The programconsisted of an inpatientperiod followed by su-pervised community aftercare. At admission,the sample consisted of White (36.5%), His-panic (55.6%), and African-American (7.9%)addicts. Mean age at admission in 1962-1964was 25.4 years. The sample was limited to malesubjects because of the small number of femalecommitments to theCAP.Participantswere firstfollowed-up and interviewed in 1974-1975 aspartof an evaluationof theCAP. Thesecond in-terviewwasconducted10yearslater(1985-1986),and themost recent follow-upwasconducted in1996-1997. The 1996-1997 follow-up reached96% location rate (242 interviewed, 31 refusedor were too mentally dysfunctional to be inter-viewed, and 284 were confirmed to be dead).No statistically significantly difference in de-mographics was found between interviewedsubjects and those lost to follow-up.

In 1998, 108 males drawn from the total of242 surviving participants attending the last in-terview were selected to take medical examina-tions including oral exams and complete ahealth behavior survey. Due to budget limita-tions, those who lived within or near the LosAngeles area were given priority to be selectedfor this study. The characteristics of this sub-sample were similar to the overall 242 surviv-ing participants; specifically, the two groups didnot differ in heroin, alcohol, or tobacco use(12).

26 SUBSTANCE ABUSE

Procedures

Registered nurses were trained and per-formed the visual-tactile dental examinations.Participants were asked if they were wearingremovable dentures or partials, and if so, to re-move them before the examination. With apenlight, the nurse counted and recorded thenumber of natural teeth by the upper and lowerarch separately. If the tooth was missing or re-placed by full or partial dentures, or a fixedprosthesis (bridge), it was categorized as miss-ing. At the arch (jaw) and the whole mouthlevel, data on the presence/absence of eachtoothwere used as indicators for tooth retentionand loss. To be comparable with a nationalstudy (21), the summary assessment was basedon 28 teeth (third molars were not counted). Inthis paper, an individual without any naturalteeth was described as “edentulous”; and par-ticipants with all 28 natural teeth were de-scribed as “completed dentate”; individualswith one or more natural teeth in the mouthwere described as “dentate.” Subjects’ weightand height were also measured to count theBMI as an indicator of nutritional status. BMIwas calculated as weight divided by square ofheight.

A questionnaire derived from the NationalHealth and Nutrition Examination Survey(NHANES) and the National Health InterviewSurvey (NHIS) focusing on self-assessed den-tal health and dental care utilization was com-pleted by participants. Examples of surveyquestions included: “How long ago was yourlastvisit toadentistordentalhygienist?”(NHIS1993),“Howmanyvisitsdidyoumaketoaden-tist in the past 12 months?”(NHIS 1993), “Howwould you describe the condition of your natu-ral teeth?”(NHANE III), and “What type ofdental care do you need now?”(NHANE III).

Data on demographics, drug use history,smoking and drinking behavior, and other in-formation for all participants were availablefrom three previous in-person interviews at a10-year interval (11,22). All study procedureswere reviewed and approved by the UCLA In-stitutional Review Board. Participating sub-jects signed a separate informed consent formto complete medical tests including oral examin addition to the overall consent to participantin the study.

Analysis

Mean, standard deviation and percentagewere used to describe participants’ demo-graphiccharacteristics, substanceuse, andden-tal conditions. One-way ANOVA and Chi-square test were used for ethnic comparisonwith respect to the distribution of demographiccharacteristics, teeth status and dental care uti-lization. To investigate the relationships be-tween heroin use, dental care and teeth reten-tion, poisson regression was implemented inProc Genmod procedure in SAS. Bivariateanalysiswas performedfirst to explore the rela-tionship between number of remaining teethand heroin use, dental services, age, socio-eco-nomic status in terms of income and education,BMI, smoking and race/ethnicity separately.Factors statistically significantly related toteeth retention in bivariate analysis were in-cluded in the multivariate model. In this analy-sis, tobacco use was expressed as heavy/non-heavy smoker since few indicated theynever smoked (only 4 people self-reportednever smoking at the three follow-up inter-views). Consuming 20 cigarettes or more perday at the last follow-up was defined as heavysmoker and others were defined as non-heavysmoker. Income levels were dichotomized tocreate two categories by median split (high vs.low).

RESULTS

Sample Characteristics

All participants (N = 108) in the currentstudy were male. Among them, 37 (34.3%)were White,63 (58.3%) Hispanic, and 8 (7.4%)African American (Table 1). Their mean age atthe time of oral exam was 58.5 years (range =52.6-70.3 years) and African Americans were alittle older than Whites and Hispanics (p =0.02). The participants’ average monthly in-come was about $1,300, which included em-ployment wages, welfare, food stamps, andbenefits such as disability, unemployment, andsocial security. Whites and Hispanics had ahigher income than African Americans, andWhites’ average income was more than 3 timesthat of African Americans (p = 0.096). The

Fan, Hser, and Herbeck 27

mean BMI for the group was 26.0 ± 4.6 kg/m2,indicating they were less likely to be over-weight than California men at their age (54.6%were overweight versus 70.8% for Californiamen aged 55-64 years) (23). Hispanics had thehighest BMI, Whites followed closely and Af-rican Americans had the lowest BMI, indicat-ing a poorer nutritional status for AfricanAmericans (p = 0.03). Heroin use on averagewas 19.2 years, which was longer than their useof other substances such as alcohol (9.0 ± 8.2years), marijuana (8.6 ± 10.1 years), cocaine(2.3 ± 3.6 years), and amphetamine (2.5 ± 4.7years). Hispanic addicts showed the longestlengthof heroin use, which was almost10 yearsmore than that of Whites (p = 0.0001). Whiteaddicts showed the longest marijuana use (p =0.01) and African Americans reported the lon-gest history of alcohol use. Over half of partici-pants were unemployed and 6% were retired.None of African Americans in our sample wasemployed compared to more than half ofWhites who were employed at the most recentinterview (p = 0.003). Twenty-eight percent ofaddicts were heavy smokers, and it is morecommon in Whites and African Americansthan in Hispanics (p = 0.03). Nearly half of thesample did not complete high school. On aver-age,Whiteshad themostyearsofeducationfol-

lowed by African Americans than Hispanics(p = 0.008).

At the time of oral examination, about 37%reported past-year heroin use, and many re-portedcurrent tobaccouse(63%),alcoholdrink-ing (49.1%), and other illicit drug use (e.g., past-year use of marijuana was reported by 28.7% ofthe respondents, cocaine use by 16.7%, crackuse by 8.3%, amphetamine/methamphetamineuse by 11.1%). On the other hand, some subjectsmaintained abstinence from drug use for morethan 10 years, including heroin (43.5%), mari-juana (55.6%), cocaine (56.5%), crack (81.5%),and amphetamine (80.6%) (Table 1).

Tooth Retention, Tooth Lossand Utilization of Dental Service

Average number of teeth present. The aver-age number of natural teeth remaining for oldernarcoticsabuserswas15.6(SD=9.1) (Table2).African Americans had the least number ofteeth left (10.5). The mean number of teeth forthe whole group in the lower arch was 8.4,which was higher than the upper arch teeth(7.3). Again, African Americans retained thelowest number of both upper and lower teeth.From Table 2, we can see that the lower archconsistently retained more teeth than the upperarch across three ethnic subgroups, which indi-cated that elder addicts more commonly re-

28 SUBSTANCE ABUSE

TABLE 1. Characteristics of subjects by ethnicity

Hispanics(N = 63)

Whites(N = 37)

African Americans(N = 8)

Total(N = 108)

Mean (Std)

Age* 58.7 (4.0) 57.5 (2.8) 61.3 (4.1) 58.5 (3.8)Income ($1,000/month) 1.3 (1.4) 1.6 (1.4) 0.5 (0.3) 1.3 (1.4)BMI* 26.8 (4.7) 25.3 (4.2) 22.8 (3.1) 26.0 (4.6)Alcohol use (yr) 9.1 (7.3) 8.7 (9.7) 9.6 (8.4) 9.0 (8.2)Heroin use (yr)* 22.7 (10.3) 13.4 (9.6) 17.3 (11.2) 19.1 (10.9)Marijuana (yr)* 6.5 (9.0) 12.5 (11.2) 6.6 (9.6) 8.6 (10.1)Cocaine (yr) 1.7 (2.9) 3.1 (4.9) 3.1 (3.7) 2.3 (3.6)Amphetamine (yr) 2.0 (4.4) 3.4 (5.2) 2.0 (4.2) 2.5 (4.7)

N % N % N % N %

Employment* Employed 21 33.3 21 56.7 0 0.0 42 38.9Unemployed 38 60.3 16 43.2 6 75.0 60 55.6

Retired 4 6.4 0 0 2 25.0 6 5.6Education*

Less than High School 34 54.0 11 29.7 2 25.0 47 43.5High School or GED 23 36.5 12 32.4 3 37.5 38 35.2

College or Higher 6 9.5 14 37.8 3 37.5 23 21.3Heavy Smoker* (Yes) 13 20.6 14 37.8 3 37.5 30 27.8

*p < 0.05 for ethnic comparison.

tained their teeth in the lower jaw. Whites hadthehighestnumberof totalandlowerarchteeth.Hispanics exhibited the highest number of up-per teeth. Though White addicts showed themost teeth remaining, the dental exam revealedthatnoneof themhadcompleteddentate,whichwas the same as African Americans. Four His-panics (6.4%) had completed dentate. Com-pleted edentulous rate was high in AfricanAmericans (25%), followed by Hispanics andWhites.

Use of dental care and self-assessed dentalcondition. Utilization of dental services waslow in older narcoticsaddicts.On average,only38.9%ofoursamplehadvisitedadentistduringthe 12 months prior to the survey. Over half ofWhites visited a dentist in the last year, whichwas the highest rate among the three ethnicgroups. Hispanics showed the lowest rate ofdental visits (30%). The self-assessment datashowed that 69.2% of addicts perceived theirdental status as fair to poor. Though AfricanAmericans showed the least number of remain-ing teeth, 37.5% self-assessed their dental con-dition as good, which was similar to the rate ofWhites’ report. Not surprising, all three ethnicgroups reported high need for dental care.Overall, 83.2% reported dental care needed, in-cluding fillings (25%), tooth extraction (12%),dentures (18%), cleaning (17%), improvementof appearance (3%), gum treatment (1%), and/or other services (7%).

Predictors for Tooth Loss

As shown in Table 3, tooth retention in nar-cotics abusers was related to several factors. In

bivariate analysis, number of teeth remainingwas correlated with age (p < 0.0001), heavysmoking (p = 0.005), income (p < 0.0001), den-tist visit (p < 0.0001), ethnicity (p = 0.003),years of heroin use (p = 0.004), and BMI (p =0.01). No correlation was found with educa-tion. The multivariate poisson regression thenincluded all these significant variables. Givenall related variables in the multivariate model,age, heavy smoking, income, ethnicity, andhaving dentist visits in the past year maintainedtheir significant contribution to determine thenumberof teeth remaining inagednarcoticsad-dicts. The risk of tooth loss was increased if in-dividuals were African Americans, older, had alower income, were current heavy smokers,and did not see a dentist in the past year. No sig-nificant association was found between toothretention and BMI or heroin use in the finalmodel.

DISCUSSION

In the United States, oral health has substan-tially improved for most of the populationsince


TABLE 3. Multivariate poisson regression analysisfor remaining teeth

Estimate SE p

Age �0.03 0.007 0.0006Heavy smoker (Yes vs. No) �0.11 0.05 0.03Income (Low vs. High) �0.25 0.06 < .0001Dentist visit last year (No vs. Yes) �0.28 0.06 < .0001Ethnicity Hispanic vs. African American 0.29 0.12 0.01

White vs. African American 0.20 0.12 0.11BMI �0.003 0.006 0.60Heroin use 0.003 0.003 0.32

TABLE 2. Dental condition and dental care among narcotics addicts by ethnicity

Hispanic White African American Total

Total teeth 15.9 (9.1) 16.2 (8.7) 10.5 (10.2) 15.6 (9.1)Upper 7.7 (5.1) 7.4 (5.1) 4.4 (5.2) 7.3 (5.1)Lower 8.4 (4.5) 8.8 (4.5) 6.1 (5.3) 8.4 (4.5)

Missing teeth 12.1 (9.1) 11.8 (8.7) 17.5 (10.2) 12.4 (9.1)

Edentulousa 9 14.3 4 10.8 2 25 15 13.9Completed dentateb 4 6.4 0 0 0 0 4 3.7

Dentist visit last year* 19 30.2 20 54.1 3 37.5 42 38.9Self-assessed good condition 16 25.8 14 37.8 3 37.5 33 30.6Need dental care 52 83.9 31 83.8 6 75 89 83.2

*p = 0.06 for ethnic comparison.aEdentulous: without any natural teeth.bCompleted dentate: with all natural teeth.

the 1940s because of advances in knowledge,dental treatmentandpublicservicessuchasflu-oridation of drinking water (24). Tooth loss isno longer accepted as an inevitable part of hu-man aging. As a consequence, the edentulismrate in the United States has continuously de-clined from 11.2% in 1971 (25) to 9.7% in 1998(26). In 1997, a national survey of senior citi-zens (age 65 or older) indicated that individualsweremore likely toexperience tooth loss if theywere age 75 or older, non-Hispanic Black, cur-rent daily cigarette smoker, or if they had lessthan a high school education or no dental insur-ance (27). For ethnic comparison, national re-ports in 1988-1991 (NHANES III) indicatedthatHispanicshadagreaternumberof total,up-perand lower teethcompared toWhitesandAf-rican Americans. These data cover all adultsaged 18-75. Similarly, the National HealthInterview Survey (NHIS 1993) reported thatamong US adults aged above 65, fewer Hispan-ics had completed edentulism (18.2%) com-pared to 24.1% for Whites and 31.9% fornon-Hispanic Blacks.

In our study, African American addicts re-tained fewer total, upper and lower teeth thanWhites and Hispanics, and Hispanics showedthe lowest rate of completed edentulism. Thesefindings are similar to national studies of elderpopulations, though addicts showed fewerteeth remaining and a higher percentage ofcompleted edentulism than the general elderpopulation. Regarding dental service utiliza-tion, the NHIS 1998 survey showed that moreWhites had a dental visit in the past year(58.7%) compared with Hispanics (46.8%) andnon-Hispanic Blacks (37.3%). Our data alsoshowed that Whites had more dentist visits andAfrican Americans had the least, although thenational population data show higher rates ofdentist visits than the rates from our sample. Inthe present study, age, ethnicity, current heavytobacco use, low income and lack of dental carecontributedsignificantly to tooth lossaftercon-trollingforconfounders.This is consistentwithresults from the general population describedabove (10,21,27). United States populationdata also indicated that lacking dental insur-ance is associated with tooth loss (27). Manyparticipants in our study lacked stable employ-mentandhad fewer economic resources, whichmay translate into less access to dental insur-

ance and they may neglect dental treatmentfrom the list of life priorities. Low income mayalso contribute to nutritional deficiencies andpoor personal oral hygiene. Working together,unemployment and lower income induced asignificantly higher number of missing teethand a greater need for dental care for narcoticabusers.

The strength of our study is that the partici-pants were followed-up for over 33 years oftheir addiction careers, which allows us to ex-plore the long-term effect of narcotics addic-tion on oral health. The oral examination in thepresent study was objective, and conducted byregistered nurses, which significantly en-hances self-report data. Though the data areunique and useful, it should be pointed out thatour study has several limitations. Half of theoriginal baseline cohort had died prior to themost recent follow-upinterviewandoralexam-ination, which limited the generalizability ofthe study findings. The dental status of abuserscould be confounded by other risk factors suchasgender,poororalhygiene,or tastepreferencefor sugar, which were not available in this pro-spective study. In addition, dentists provide aseries of services including acute dental extrac-tion and regular preventive care. Different ser-vices could result in opposite conclusions. Thesurvey questionnaire used in this study did notdistinguish specific reasons for dentist visits,and though the analysis pointed to a monotonicrelationship between dentist visits and tooth re-tention, this result is exploratory and futurestudy should focus on the impact of both pre-ventive and acute dental care, as well as dentalinsurance coverage on tooth retention. Theother concern is the unbalancedethnic distribu-tion in this study (smaller group of AfricanAmericans than other races), which may de-crease the statistical power for the analysis andcause the unbalanced distribution for othervariables. Even using a small sample, our anal-ysis strongly suggested the ethnic difference inteeth retention and loss, which encourages fu-ture studies with larger samples and a balancedethnicity distribution to further investigatedental status among substance abusers bydifferent ethnic groups.

In summary, among long-term narcotic ad-dicts, African American addicts showed theleast number of remaining teeth, and African

30 SUBSTANCE ABUSE

Americans and Hispanics were less likely toutilize dental services compared to Whites.Age,ethnicity, tobaccouse, levelof incomeanddental care appear to be key factors related totooth loss. Dental health is associated with nu-tritional intake, quality of life, and social func-tioning (28, 29), thus impacting the general andmental health of narcotics abusers. In addition,narcotics abuse may be aggravated by opioidsbeing used as an analgesic for dental pain. Col-laborationbetweengeneraldentalpractitionersand drug treatment providers is recommendedwhen patients pursue drug treatment. Dentalpatient education aimed at improving heroinabusers’ oral hygiene should also be providedas a part of a comprehensive treatment plan.Settings such as prisons and drug treatment/methadone maintenance programs that includedental care referral and follow-up as a part of acomprehensive treatment/rehabilitation planwould be expected to enhance oral and generalhealth among narcotics-addicted individualsand promote their recovery.

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2. Angelillo, I.F., et al., Dental health in a group ofdrug addicts in Italy. Community Dent Oral Epidemiol,1991. 19(1): 36-7.

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7. Morabia, A., et al., Diet and opiate addiction: aquantitative assessment of the diet of non-institutional-ized opiate addicts. Br J Addict, 1989. 84(2): 173-80.

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9. Christen, A.G., A smoking cessation program forthe dental office: the time is right! Bull Eighth Dist DentSoc, 1991. 25(3): 13-5.

10. Albandar, J.M., et al., Cigar, pipe, and cigarettesmoking as risk factors for periodontal disease and toothloss. J Periodontol, 2000. 71(12): 1874-81.

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17. American Cancer Society, Cancer facts & fig-ures. 1998, American Cancer Society: Atlantic, GA.

18. U.S. Preventive Services Task Force, Guide toclinical preventive services. 2nd ed. 1996, Baltimore,MD: William & Wilkins.

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32 SUBSTANCE ABUSE

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Measuring College Student Drinking:Illustrating the Feasibility of a Composite Drinking Scale

Jiun-Hau Huang, ScDWilliam DeJong, PhD

Shari Kessel Schneider, MSPHLaura Gomberg Towvim, MSPH

ABSTRACT. This study explored the feasibility of a Composite Drinking Scale (CDS) designedto capture fully the phenomenon of problem drinking among college students while allowing easypublic understanding. A survey conducted at 32 four-year U.S. colleges included four consump-tion measures: 30-day frequency; average number of drinks per week; number of drinks usuallyconsumed when partying; and greatest number of drinks in one sitting in the past two weeks. Re-sponses were normalized and added to create a continuous distribution, which was then subdividedinto quartiles (CDS/Q1-Q4). The CDS is an easily understood scoring system, but compared to thesimplistic “binge drinking” measure, it captures a broader range of relative risks and more clearlyestablishes the quadratic relationship between consumption and alcohol-related problems. Devel-opment of the CDS will require further exploring the best set of questions to include, establishingU.S. norms for the general population, and then transforming those scores to a simple measure-ment yardstick whose meaning can be easily communicated to the public. [Article copies availablefor a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. Allrights reserved.]

KEYWORDS. Alcohol consumption, measurement, psychometric properties, college, student

Jiun-Hau Huang is Postdoctoral Fellow, Department of Society, Human Development, and Health, HarvardSchool of Public Health, 677 Huntington Avenue, Boston, MA 02115.

William DeJong is Professor, Department of Social and Behavioral Sciences and Youth Alcohol PreventionCenter, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118.

Shari Kessel Schneider is Research Director, Social Norms Marketing Research Project, Education Develop-ment Center, Inc., 55 Chapel Street, Newton, MA 02158.

Laura Gomberg Towvim is Deputy Director, Center for College Health and Safety, Education DevelopmentCenter, Inc., 55 Chapel Street, Newton, MA 02158.

Address correspondence to: William DeJong, PhD, Department of Social and Behavioral Sciences, Boston Uni-versity School of Public Health, 715 Albany Street, Boston, MA 02118 (E-mail: [email protected]).

The authors are grateful to their many colleagues on the Social Norms Marketing Research Project (SNMRP)who helped conduct the student surveys reported in this article, especially Jennifer Allard, Ingrid Bruns, KarenKaphingst, Amy Stern, and Cameron Ware. They are also grateful to the 32 site-based coordinators, whose hardwork provided the foundation for this study. The authors thank John D. Clapp of San Diego State University for hisinsightful comments on an earlier draft of this article.

This study was supported by grant R01-AA-12471 from the National Institute on Alcohol Abuse and Alcoholism(NIAAA) and the U.S. Department of Education to Education Development Center, Inc. (EDC).

The views expressed in this article are those of the authors and do not necessarily reflect the official position ofthe NIAAA or the U.S. Department of Education.



INTRODUCTION

Developing measures of alcohol consump-tion that both capture the phenomenon of prob-lem drinking and allow easy communicationwith the public is an enormous challenge. To bescientifically useful, a measure should be pre-cise, reliable, and valid, of course, but it shouldalso capture the full meaning of problem drink-ing, which is a multifaceted behavior. It shouldalso allow for accurate predictions of alco-hol-related problems. To be useful in publicdiscourse, however, the measure should also besimple and its meaning easily communicated tothe public.

Among the earliest and most commonly usedmeasures of alcohol consumption are quan-tity-frequency methods (QF). In essence, QFmeasures ask respondents to report on howmany days they typically drink within a giventime period and how much they typically drinkon a given drinking day. On the plus side, QFmeasures are relatively easy to administer, donot require much time, and provide a fairly reli-ableestimateofdrinkingfrequencyandtotalal-cohol consumption (1).

On the other hand, QF measures do not in-quire about heavy episodic drinking, whichmight not be “typical” for many individuals butnevertheless is strongly associated with alco-hol-relatedproblems.Heavydrinking,which issometimes called “binge drinking,” is com-monlydefinedashavingfiveormoredrinks inarow (2). A “heavy drinker” is typically definedas someonewho drinksat this levelat leastoncein a two-week period. For women, Wechslerand his colleagues defined heavy drinking asfour or more drinks in a row (3), but this stan-dard has not been universally adopted (2).

One study found that 31 percent of heavydrinkers identified through daily diary reportswere misclassified as moderate drinkers whenusing QF measures (4). Other researchers havereported even higher rates of misclassification(5). In a study of high school seniors and drop-outs, Ellickson and her colleagues found thatQF measures failed to identify 54 percent ofthose who engaged in heavy drinking (6).

Some researchers have improved on QFmeasures by folding in a question about heavyepisodic drinking (7). One survey study dem-onstrated that adding questions about atypical

drinkingtoordinaryQFquestions increasedthetotal consumption estimate for a sample ofadultsby 14 percent, illustrating that traditionalQF measures tend to underestimate the “true”level of total alcohol consumption (8).

On theside of simplicity, several researchershave utilized the heavy drinking measure by it-self (2). The principal downside of using thismeasure is its dichotomous nature, which cre-ates a very crude yardstick by which to measurechanges in alcohol consumption. Using thismeasure by itself creates additional problems,including creating inflated public perceptionsof the true extent of dangerous drinking (espe-ciallywhen it is referred to as “binge drinking”)and perpetuating the false notion that drinkingbelow that level is entirely safe (9).

The purpose of the present study was to ex-plore the feasibility of developing a more re-finedmeasureof alcoholconsumption,one thatcombinesseveralquestionsdesignedtocapturedifferent aspects of problem drinking but alsoprovides a simple yardstick that the public atlarge might find easier to understand. A na-tional survey of four-year college and univer-sity students asked four questions, which werebrought together into a Composite DrinkingScale (CDS): (1)numberofoccasionsonwhichalcoholwasusedinthepast30days, (2)averagenumberofdrinksconsumedinaweek, (3)num-ber of drinks usually consumed when partying,and (4) thegreatestnumberof drinks consumedat one sitting during the last two weeks. Re-sponses to these four questions were first usedto assess the abstaining versus drinking statusof each respondent, and then to compute a con-tinuous CDS score representing the overalllevel of alcohol use for each drinker. For pur-poses of simplification, and to facilitate com-parisons with a dichotomous measure of heavyepisodic (“binge”) drinking, the continuousdistribution of CDS scores was then dividedinto quartiles, and each drinker was assigned acorresponding quartile score.

We report here the basic properties, internalconsistency reliability, and construct validityof the CDS. Proponents of the heavy (“binge”)drinking measure have argued that it providesan easy shorthand for identifying problematicdrinkers (3). Accordingly, we compare the util-ity of the CDS in predicting alcohol-relatedproblems in comparison to the heavy drinking

34 SUBSTANCE ABUSE

measure. Finally, we outline the steps requiredto move beyond this illustration to create a newmeasure of alcohol consumption that will meetthe field’s scientific and public communicationsneeds.

METHODS

The Survey of College Alcohol Norms andBehavior (SCANB) is administered annuallyeach spring to students from 32 four-year insti-tutions of higher education that are participat-ing in the Social Norms Marketing ResearchProject (SNMRP). The SNMRP is a five-yearproject designed to assess the effectiveness ofsocial norms marketing campaigns in reducinghigh-risk drinking (10).

The 32 schools come from all four U.S. cen-sus regions (Northeast, North Central, West,and South). They range in size from approxi-mately 2,000 to 31,000 undergraduates andvary in terms of sector (private vs. public), per-centage of residential students, and studentbodydemographics.Theanalysis reportedhereuses SNMRP baseline data.

Survey Content

The SCANB is a self-administered, volun-tary, and anonymous mail survey that asksabout students’ alcohol-related attitudes, per-ceptions, and behaviors. The baseline SCANBadministered to a first cohort of 18 schools(Study 1) in 2000 consisted of 64 questions onstudent characteristics, alcohol use and its con-sequences, reasons for drinking and abstainingfrom alcohol use, perceptions of campus alco-holnorms,campusandcommunityalcoholpol-icies, and perceived social capital.The baselineSCANB administered to a second cohort of 14schools (Study2) in2001consistedof54 items;the number of questions was decreased toencourage higher response rates.

Alcohol Consumption

The SCANB defined a drink as “a bottle ofbeer (12oz),aglassofwine(4oz),awinecooler(12 oz), or a shot of liquor (1 oz) served straightor in a mixed drink.”

Concerning their own alcohol use, the respon-dents answered four key questions: (1) “Duringthe past 30 days, on how many occasions didyou use each of the following substances–alco-hol (beer, wine, liquor)?” The response optionsfor this scale (scored 1-7) were “Never,” “1-2times,” “3-5 times,” “6-9 times,” “10-19 times,”“20-39 times,” and “40 or more times.” For thenext three questions, a numerical fill-in re-sponse box allowed students to mark in 00 to 99drinks, thus creating an interval-level scale. (2)“What is theaveragenumberof drinks you con-sume in a week?” (3) “When you party, howmany drinks do you usually have?” (4) “Thinkback over the last two weeks. What was thegreatest number of drinks you consumed at onesitting? For how many hours did you drink?” Asecond numerical fill-in response box allowedstudents to report the duration of the drinkingepisode.

To be classified as an abstainer, a studenthad to report no alcohol use in response to allfour consumption questions. A student report-ing alcoholuse in response to one or more ques-tions was classified as a drinker. Students whodid not respond to one of the four questionswere still classified, but those who failed to re-spond to two or more questions were excludedfrom the analysis.

The drinkers’ responses to the four con-sumptionquestionswerecombinedintoaCom-posite Drinking Scale (CDS). Due to the vari-ous question formats, the overall distributionfor each of the four questions was normalized,yielding a z-score for each drinker on eachquestion. A CDS score was then calculated asthe sum of a drinker’s four z-scores. If a drinkerdid not respond to one of the four questions, az-score was imputed using the mean z-score forthe other three. Cronbach’s coefficient alphafor the CDS was calculated to assess its internalconsistency reliability (11). Next, the distribu-tion of CDS scores was divided into quartiles,and each drinker was assigned a score (Q1-Q4)on that basis.

The SCANB also asked respondents howmany times they had four or more drinks at onesitting in the last two weeks, and how manytimes they had five or more drinks. Heavy(“binge”) drinking was defined as the con-sumption of five or more drinks for men andfour or more drinks for women (3,12). Non-

Huang et al. 35

heavy drinkers were respondents who con-sumed alcohol but did not drink heavily.Among heavy (“binge”) drinkers, infrequentheavy drinkers were those who drank heavilyoneor two times,while frequentheavydrinkersdrank heavily three or more times.

Self-Reported Drinking Status

The survey asked respondents to describetheir alcohol use, both presently and duringtheir last year of high school. Response catego-ries for both questions included “abstainer,”“abstainer/former problem drinker in recov-ery,” “light drinker,” “moderate drinker,”“heavy drinker,” and “problem drinker.”

Alcohol-Related Problems

The survey asked respondents how manytimes they had experienced or engaged in 26 al-cohol-related problems during the past 30 daysduetotheirownalcoholuse, includingdrivingacar while under the influence of alcohol, ridingwith a drunk driver, and four problems relatedto academic performance (missing a class, get-ting behind in school work, performing poorlyon a test or important project, and turning in anassignment late). The response alternatives(scored 1-5) were “never,” “1-2 times,” “3-5times,” “6-9 times,” and “10 or more times.”Respondents who reported that they did notdrink alcohol skipped this question.

For CDS-defined drinkers, responses foreach of the 26 alcohol-related problems weredichotomized (dummy variable for having theproblem,withnothavingtheproblemastheref-erence group). The total number of indicatedproblems (up to 26) was calculated for each re-spondent who answered 18 or more items (i.e.,who failed to answer eight or fewer items);those who failed to answer nine or more ques-tions were assigned a missing value on this newvariable. Next, the total was dichotomized,with a dummy variable for having experiencedfive or more problems (and with having four orfewer problems as the reference group). Thiscut-off point, which separated the top one-thirdand bottom two-thirds of the distribution, wasused to facilitate comparisons to previousresearch on college students (12).

Finally, the total number of academic prob-lems (up to four) was calculated for each re-spondent who answered three or four of theitems; those who failed to answer two or morequestions were assigned a missing value on thisnew variable. This total was then dichoto-mized, with a dummy variable for having expe-rienced any academic problems (and with nothaving any problems as the reference group).This cut-off point separated the top one-fourthfrom the bottom three-fourths of the distribu-tion.

Control/Background Variables

The SCANB included 16 control/back-ground variables of interest. With recoding,some response categories were combined. Thevariables included gender (dummy variable formale, with female as the reference group); age(continuous variable in years); race/ethnicity(dummy variables for African American/Black, Asian, Hispanic/Latino, and Other, withCaucasian/White as the reference group);personal relationship status (dummy variablefor married/separated/divorced/widowed, withsingle as the reference group); student status(dummy variable for part-time status, withfull-time status as the reference group); studentclassification (dummy variables for sopho-more, junior, and senior, with freshman as thereference group); and grade point average(continuous variable on a four-point scale).

Additional variables included location ofresidence (dummy variable for on-campus,withoff-campusas thereferencegroup); typeofresidence (dummy variables for fraternity/so-rority house, residence hall/dorm, and other,with house/apartment as the reference group);living situation (dummy variables for livingalone and living with family/other, using livingwith one or more roommates as the referencegroup); parental education (dummy variablesfor one parent and both parents being a collegegraduate, with neither parent as the referencegroup);numberofclosestudent friends (dummyvariables for having none and 1-4 close studentfriends,withhaving5+as the referencegroup);yearof surveyadministration (dummyvariablefor2001,with2000as thereferencegroup);andtiming of survey completion (dummy variable

36 SUBSTANCE ABUSE

for during/after spring break, with beforespring break as the reference group).

Finally, the SCANB also asked about in-volvement in a fraternity/sorority (dummyvariable for Greek member/pledge, with non-Greek member/pledge as the reference group)and involvement in intercollegiate athletics(dummy variable for athlete, with non-athleteas thereferencegroup).Studentsweresaid tobea college athlete if they indicated “intercolle-giate athlete” when asked about extracurricularactivities, or if they indicated spending timeeach week on a varsity athletic team.

Sampling Method

The baselineSCANB was mailed to 300 ran-domly selected undergraduate students at eachof the 32 participating schools, for a total of9,600 students. The baseline survey was ad-ministered at 18 schools in the spring of 2000(Study 1) and at the 14 remaining schools in thespring of 2001 (Study 2). Each school’s regis-trar’s office provided a list of all matriculated,degree-seeking undergraduates, including bothfull- and part-time students. This samplingframe excluded students with out-of-state ad-dresses listed as their current or local address.For each school, the random sample of 300 stu-dents was stratified by class year (freshman,sophomore, junior, senior).

Survey Administration

Each school was put on a separate mailingschedule based on its academic calendar, withthe first survey mailing sent out three to fourweeks after the beginning of the spring semes-ter. Prior to the first survey mailing for Study 1,a “teaser” postcard was mailed out to alert stu-dents that the survey would be arriving soon;this was not done for Study 2 one year later.Thesecond survey mailing was scheduled to arriveapproximately two weeks prior to each school’sspring break. The third was sent out 2-3 weeksafter spring break. The fourth mailing, sent outapproximately two weeks after the third mail-ing, was an abbreviated (two-page) version ofthe SCANB.

Non-respondents received a reminder post-card a few days after the first survey mailingand 2-3 weeks after the second survey mailing.

In addition, project staff made reminder tele-phone calls after the second and third surveymailings to answer questions and encouragecompletion of the survey. Both rounds of re-minder calls involved up to three attempts toreach each student in person. On the third at-tempt, the caller left a message requesting thatthe survey be completed.

The cover letter that accompanied each sur-vey mailing served as the informed consentdocument. Students were told that they werenot required to participate and that they couldleaveaquestionblank if theydidnotwant toan-swer it. To preserve students’ anonymity, noidentifying information was put on either thesurvey instrument or its stamped return enve-lope. Rather, with every survey mailing, stu-dents received a separate postcard with aunique code number on it, with instructions tomail the postcard separately from the survey it-self to indicate that they had completed the sur-vey or did not wish to participate and that noadditional follow-up would be necessary.

A series of monetary incentives was used toincrease response rates. A $1 bill was includedwith the first survey mailing as an up-front in-centive (13). Students who filled out the surveybecame eligible for three types of prize draw-ings: one $100 cash prize per school for stu-dentswhoreturned thesurveywithinoneweek;five$50cashprizesper school for studentswhoreturned the survey by the end of the semester;and one $500 grand prize for one student na-tionwide who completed the survey by the endof the semester. With Study 2, the grand prizewas increased to $1,000 to encourage a higherresponse rate.

The human subjects committees at Educa-tion Development Center, Inc., and all 32 par-ticipating colleges and universities approvedthe study procedure.

Response Rate

A total of 330 of the 9,600 surveyed studentswere removed from the sample. Reasons for re-moval included the following: two or morepieces of undeliverable mail were returned;telephone contact revealed that the student wasno longer enrolled, had already graduated, orwas spending the semester abroad; the registrarverified that non-responding students who

Huang et al. 37

could not be reached by telephone were not en-rolled during the survey period; or participantsindicated on their survey that they were not en-rolled or were enrolled in graduate or profes-sional school.

These adjustments resulted in a final samplesize of 9,270 students. The number of com-pleted surveys was 5,210 for a response rate of56.2%. Response rates for individual schoolsrangedfrom45.3%to71.4%.Of thesurveys re-ceived, 4,858 (93.2%) were full-length sur-veys. The remaining 352 surveys (6.8%) wereabbreviated versions sent in the final mailing.

The reported analyses are based on the full-length survey responses from 4,798 students,after excluding 19 students who failed to indi-cate whether they were enrolledas undergradu-ates and 41 students who said they were formerproblem drinkers in recovery, either presentlyor during high school.

If a respondent failed to respond to two ormore CDS questions, then that case was ex-cluded from all CDS-related analyses; therewere 18 such cases (0.4%), leaving 4,780respondents. If a respondent met additional“missing value” criteria, then that case was ex-cluded from analyses that involved the vari-ables in question. As a result of these missingdata, the reported sample sizes for individualanalyses vary slightly.

Statistical Analysis

All statistical analyses were performed us-ingSAS (14). Descriptivestatisticswereexam-ined for all variables.

Frequency data for the alcohol consumptionvariables were examined for extreme or im-plausible values. When asked to specify the av-erage number of drinks per week for a typicalstudent at their school, four respondents gave aresponsegreater than80drinks formales,whilethree respondents did so for females. Giventheir implausibility, these responses were re-duced to 80 drinks. When asked to report howmany drinks students at their school have whenthey party, 15 respondents gave a responsegreater than 30 for males, while nine respon-dents did so for females. Given their implausi-bility, these responses were reduced to 30drinks. Finally, when asked about the greatestnumber of drinks they had consumed at one sit-

ting during the last two weeks, seven respon-dents indicated that the sitting had lasted morethan 24 hours. These data were declared miss-ing.Thealternativeofreducingtheresponses to24 hours was rejected, as that would also affectthe apparent rate of alcohol consumption.

Assessing the construct validity of the CDSinvolved looking at the relationship betweenthe CDS variable and a set of predictor variablespreviously found to be associated with heavy(“binge”) drinking in the College AlcoholStudy (CAS) (15). These six drinking-relatedcharacteristics were as follows: male; under 24years; Caucasian/White (if respondents identi-fied themselves as “Caucasian/White” only,not mixed with others); drinker in high school(if they identified themselves as a light, moder-ate, heavy, or problem drinker during their lastyear of high school); Greek member/resident(if they indicated “fraternity/sorority memberor pledge” when asked about extracurricularactivities, or if they indicated “fraternity/soror-ity house” as their residence); and college ath-lete (if they indicated “intercollegiate athlete”when asked about extracurricular activities, orif they indicated spending time each week on avarsityathletic team).Note that the race/ethnic-ity variable Caucasian/White was defined some-whatdifferently fromthecorrespondingSCANBcontrol/background variable.

With CDS treated as a cate gorical variable,Cochran-Armitage trend tests were used tocompare the proportions of respondents witheach drinking-related characteristic across CDS/Q1-Q4 drinkers. Second, with CDS treated as acontinuous variable, two-sample t-tests wereused to compare the mean CDS scores of col-lege student drinkers with and without each ofthe drinking-related characteristics.

Construct validity analyses also looked atfour measures of alcohol-related problems ex-periencedduringthepast30days.First, thepro-portions of respondents who drove under theinfluence of alcohol were compared acrossnon-heavydrinkers, infrequentheavydrinkers,and frequent heavy drinkers using chi-squaretests and Cochran-Armitage trend tests; thesame analyses were conducted to compareCDS/Q1-Q4 drinkers. Similar sets of analyseswere also conducted on the proportions of re-spondents who rode with a drunk driver, expe-rienced five or more alcohol-related problems

38 SUBSTANCE ABUSE

(out of 26 possible), and experienced one ormoreacademicproblems(outoffourpossible).

Next, a set of multivariate logistic regressionanalyses were used to examine the relationshipbetween drinking status and these four mea-sures of alcohol-related problems experiencedduring the past 30 days. One set of analysescompared frequent heavy drinkers and infre-quent heavy drinkers to non-heavy drinkers.Another set of analyses compared CDS/Q2,CDS/Q3, and CDS/Q4 drinkers to CDS/Q1drinkers. Both models adjusted for the 16SCANB control/background variables.

Multivariate linear regression analyses werealso used to examine the relationship betweendrinking status and the total number of alco-hol-related problems (out of 26 possible) expe-rienced during the past 30 days. One set of anal-yses compared frequent heavy drinkers andinfrequent heavy drinkers to non-heavy drink-ers. Another set of analyses compared CDS/Q2,CDS/Q3,andCDS/Q4drinkers toCDS/Q1drinkers. Again, both models were adjusted forthe 16 SCANB control/background variables.

Further, the mean, minimum, and maximumvalues of the four CDS items were tabulated byCDS quartile to illustrate theprofileof the“typ-ical” drinker at each CDS level. In addition,ANOVA using Scheffe’s Method was per-formed for each CDS item to make pairwisecomparisons of the means across the four CDSquartiles, applying a significance level of 0.05.In addition, CDS/Q1-Q4 drinking status wascross-tabulatedwith self-reporteddrinkingsta-tus and the measure of heavy (“binge”) drink-ing.

Lastly, Spearman correlation coefficientswere computed between the categorical five/four measure of heavy (“binge”) drinking (1 =non-heavy drinker, 2 = infrequent heavydrinker, and 3 = frequent heavy drinker) andboth the continuous CDS and categorical CDS/Q1-Q4 variables (range = 1, 4).

RESULTS

Background Characteristicsof the Student Sample

The background characteristics of the stu-dent sample (N = 4,798) are as follows: The

sample included more women (61.1%) thanmen (38.9%). The mean age of the students was21.8 years (SD = 5.6); the vast majority ofstudents (85.5%) were under 24 years of age.Respondents could indicate membership inmultiple race/ethnicity categories. Just overthree-fourths of the students (76.3%) wereCaucasian/White. Distribution across otherrace/ethnicity categories was as follows: Afri-canAmerican/Black,6.5%;Asian,10.3%;His-panic/Latino, 6.4%; Native American/Ameri-can Indian, 4.7%; and Native Hawaiian/PacificIslander or Other, 4.7%. Fully 91.1% of the stu-dents were single, with 8.9% being either mar-ried, separated, divorced, or widowed. Justover one-third (34.6%) did not have a parentwho was a college graduate, while 27.2% hadone parent and 38.2% had two parents whograduated from college.

Over nine out of ten students (92.4%) werefull-time. There were slightly more juniors(25.8%) and seniors (28.6%) in the sample thanfreshmen (22.9%) and sophomores (22.7%).The mean grade point average was 3.2 (SD =0.6, A = 4.0). Fraternity/sorority members andpledges constituted 13.2% of the student sam-ple. Approximatelyone in ten students (11.6%)was a college athlete. The majority of students(55.3%) lived off-campus. Nearly six out of tenlived in a house or apartment (58.5%), while37.9% lived in a residence hall, 2.2% lived in afraternity or sorority house, and 1.4% livedelsewhere. Nearly six in ten (59.3%) lived withoneormoreroommates;10.7%livedalone,and30.0% lived with family or indicated “Other.”More than half of the students (55.2%) had fiveor more close student friends, while 39.2% had1-4 and 5.6% reported having none.

Just over half of the sample (52.1%) com-pleted the survey in 2000 (Study 1), with theothers completing it in 2001 (Study 2). Finally,most students (84.8%) filled out the survey be-fore spring break, with 15.2% doing so duringor after spring break.

Composite Drinking Scale

The drinkers’ responses to the four con-sumptionquestionswerecombinedintoaCom-posite Drinking Scale (CDS) by normalizingtheresponsedistributionsforeachquestionandaddingthez-scores.Formostof theanalyses re-

Huang et al. 39

ported here, the CDS scores were divided intoquartiles(Q1-Q4).Bydefinition,abstainersdidnot report any alcohol consumption.

Internal Consistency Reliability

The Cronbach’s coefficient alpha was 0.89,indicating that the CDS has high internal con-sistency reliability. The item-total correlationsof the four CDS items ranged between 0.65 and0.81.

Construct Validity

As predicted, six characteristics associatedwith heavy (“binge”) drinking were alsostrongly associated with increased CDS scoresamong drinkers: being male, under 24 years ofage, Caucasian/White only (not combined withother race/ethnicity categories), a drinker inhigh school, a Greek member or resident, and acollege athlete. The mean CDS score for col-lege drinkers with each drinking-related char-acteristic was significantly higher than the cor-responding mean for drinkers without eachcharacteristic (all p < .0001, using two-samplet-tests). Moreover, the percentages of collegedrinkers with each drinking-related character-istic increasedfromCDS/Q1toCDS/Q4;allsixCochran-Armitage trend tests were significant(p < .0001). It is noteworthy that thepercentageofCDS-definedabstainerswhohadeachdrink-ing-related characteristic was always less thanthe corresponding percentage of CDS/Q4drinkers, but not consistently less than the cor-responding percentages of CDS/Q1-Q3 drink-ers. For example, 13.6% of abstainers diddrink in high school, compared to 42.0% ofQ1 drinkers, 59.1% of Q2 drinkers, 71.5% ofQ3 drinkers, and 84.8% of Q4 drinkers. In con-trast, the pattern by gender was as follows:42.2% of abstainers were male, as were 27.3%of Q1 drinkers, 29.6% of Q2 drinkers, 35.7% ofQ3 drinkers, and 59.8% of Q4 drinkers.

Table 1 shows the percentages of non-heavydrinkers, infrequent heavy drinkers, and fre-quent heavy drinkers who drove under the in-fluence of alcohol, rode with a drunk driver,experienced five or more alcohol-related prob-lems (out of 26 possible), and experienced oneor more academic problems (out of four possi-ble) during the past 30 days. As drinking levels

increased, so did the percentages of respon-dents experiencing alcohol-related problems.For example, the percentage of drinkers whoexperienced five or more alcohol-related prob-lems increased from7.7% for non-heavydrink-ers to 43.0% for infrequent heavy drinkers and75.9% for frequent heavy drinkers. All chi-square comparisons and Cochran-Armitagetrend tests were significant (p < .0001). Multi-variate logistic regression analyses were usedto estimate adjusted odds ratios, comparing in-frequent and frequent heavy drinkers to non-heavydrinkersandadjustingfor the16SCANBcontrol/background variables. All of the oddsratios were significant (p < .0001). The rela-tionship between frequency of heavy drinkingand experiencing alcohol-related problemswas clear. For example, adjusting for the 16SCANB variables, infrequent heavy drinkerswere 7.4 times as likely and frequent heavydrinkers were nearly 29.8 times as likely asnon-heavy drinkers to experience five or morealcohol-related problems.

Table1alsoshows theresultsofsimilaranal-ysesusingtheCDS/Q1-Q4measures.Again,asdrinking level increased, so did the percentagesof respondents experiencing alcohol-relatedproblems. For example, the percentage ofdrinkers who experienced five or more alco-hol-related problems increased from 4.4% forCDS/Q1 drinkers to 14.3% for Q2 drinkers,46.8%forQ3drinkers,and77.7%forQ4drink-ers. All chi-square comparisons and Cochran-Armitage trend tests were significant (p <.0001). Multivariate logistic regression analy-ses were used to estimate adjusted odds ratios,comparing CDS/Q2-Q4 drinkers to CDS/Q1drinkers and adjusting for the 16 SCANB con-trol/background variables. All of the odds ra-tios were significant (p < .0001). For example,adjusting for the 16 SCANB variables, CDS/Q2 drinkers were 3.6 times as likely to experi-ence five or more alcohol-related problemscompared to Q1 drinkers, while Q3 drinkerswere 18.3 times as likely and Q4 drinkers werenearly 82.8 times as likely.

Multivariate linear regression analyses wereused to estimate the total number of variousalcohol-related problems experienced by dif-ferent types of drinkers, first comparing infre-quent and frequent heavy drinkers with non-heavydrinkersandthencomparingCDS/Q2-Q4

40 SUBSTANCE ABUSE

with CDS/Q1 drinkers. Both sets of estimateswere adjusted for the 16 SCANB control/back-ground variables. All estimated regression co-efficients were significant (p < .0001). For ex-ample, adjusting for the 16 SCANB variables,infrequentandfrequentheavydrinkersonaver-age experienced 2.9 and 6.1 more alcohol-re-lated problems, respectively, than did non-heavydrinkers (N = 3,240; R2 = .41). Similarly, com-

pared with CDS/Q1 drinkers, Q2-Q4 drinkerson average experienced 1.3, 3.6, and 7.1 morealcohol-related problems, respectively (N =3,260; R2 = .47).

Drinking Levels Reported by CDS/Q1-Q4Drinkers

Table 2 presents the mean, minimum, andmaximum values of each of the component

Huang et al. 41

TABLE 1. Risk of Alcohol-Related Problems Among College Student Drinkers*

A. Comparing Infrequent and Frequent Heavy (“Binge”) Drinkers with Non-Heavy Drinkers†

Alcohol-Related Problem**Non-Heavy Drinkers

(n = 1,573)Infrequent Heavy Drinkers

(n = 1,328)Frequent Heavy Drinkers

(n = 869)

% % Adj. OR (95% CI) % Adj. OR (95% CI)

Drove under the influence ofalcohol

6.5 21.4 4.88 (3.68, 6.46) 31.1 8.00 (5.89, 10.86)

Rode with a drunk driver 4.1 20.1 5.96 (4.31, 8.25) 37.0 14.27 (10.18, 20.02)

Experienced 5 or more differentalcohol-related problems§

7.7 43.0 7.44 (5.84, 9.47) 75.9 29.77 (22.63, 39.16)

Experienced 1 or more differentacademic problems§

9.8 27.2 2.96 (2.34, 3.74) 49.5 7.66 (5.96, 9.84)

B. Comparing CDS/Q2-Q4 Drinkers with CDS/Q1 Drinkers‡

Alcohol-Related Problem**

CDS/Q1Drinkers

CDS/Q2 Drinkers CDS/Q3 Drinkers CDS/Q4 Drinkers

%(n = 956)

%(n = 944)

Adj. OR(95% CI)

%(n = 959)

Adj. OR(95% CI)

%(n = 942)

Adj. OR(95% CI)

Drove under the influence ofalcohol

2.9 9.7 4.43(2.67, 7.35)

23.5 14.33(8.80, 23.34)

33.8 26.22(15.92, 43.19)

Rode with a drunk driver 2.2 7.6 4.30(2.41, 7.70)

21.0 13.61(7.83, 23.66)

38.7 36.58(20.90, 64.00)

Experienced 5 or more differentalcohol-related problems§

4.4 14.3 3.64(2.40, 5.52)

46.8 18.31(12.32, 27.23)

77.7 82.76(54.29, 126.16)

Experienced 1 or more differentacademic problems§

6.0 14.2 2.62(1.81, 3.79)

29.8 6.32(4.44, 8.98)

50.1 16.30(11.36, 23.40)

* Sample sizes vary slightly across type of alcohol-related problem due to missing values. Adj. OR indicates adjusted odds ratio; CI, confidenceinterval. All ORs are adjusted for the 16 SCANB control/background variables; see Methods (Survey Content, Control/Background Variables)for listing of dummy variables and reference groups.

** In total, the SCANB survey asked about 26 alcohol-related problems, including driving under the influence of alcohol, riding with a drunkdriver, and four problems related to academic performance (see below). A problem was counted if it occurred one or more times vs. not at allduring the 30 days preceding the survey.

† Heavy (“binge”) drinking is defined for men as the consumption of 5 or more drinks at one sitting at least once during the two weeks precedingthe survey, and as 4 or more drinks for women. Non-heavy drinkers consume alcohol but do not drink heavily. Infrequent heavy drinkers drinkheavily one or two times in a two-week period, while frequent heavy drinkers drink heavily three or more times. Comparisons of non-heavydrinkers, infrequent heavy drinkers, and frequent heavy drinkers for each alcohol-related problem, using chi-square tests and Cochran-Armitage trend tests, are all significant at p < .0001. All ORs are adjusted for the 16 SCANB control variables, with non-heavy drinkers as thereference group; all are significant at p < .0001.

‡ See Methods (Survey Content, Alcohol Consumption) for details on the classification of Q1-Q4 drinkers based on the Composite DrinkingScale (CDS); CDS/Q4 signifies the heaviest level of alcohol consumption. Comparisons of CDS/Q1-Q4 drinkers for each alcohol-related prob-lem, using chi-square tests and Cochran-Armitage trend tests, are all significant at p < .0001. All ORs are adjusted for the 16 SCANB controlvariables, with CDS/Q1 drinkers as the reference group; all are significant at p < .0001.

§ The SCANB survey asked about four problems related to academic performance: missing a class, getting behind in school work, performingpoorly on a test or important project, and turning in an assignment late.

CDS items across the CDS/Q1-Q4 groups.ANOVA using Scheffe’s Method was per-formed for each CDS item to make pairwisecomparisons of the means across the four CDSquartiles. All of these comparisons were signif-icant (p < .05).

Self-Reported Drinking by CDS Status

Cross-tabulation of self-reported drinkingwith CDS status revealed that approximatelyoneoutof five respondents (19.1%)whoclassi-fied themselves as an “abstainer” reporteddrinking at least some alcohol when answeringthe four CDS questions: Q1 (16.5%), Q2(2.0%), Q3 (0.6%), and Q4 (0.0%). Most of theself-reported “light” drinkers were classifiedby theCDSasQ1(36.1%)orQ2(37.4%)drink-ers,whileaboutoneinfive(19.2%)wereclassi-fied as Q3 drinkers and just less than five per-cent (4.9%) were classified as Q4 drinkers; asmall number of the so-called “light” drinkers(2.3%) were classified by the CDS as abstainers.Among self-reported “moderate” drinkers,nearly half (47.7%) fell into the CDS/Q4 cate-

gory, putting them in the highest quartile; theothers were classified by the CDS as Q1 (1.6%),Q2(10.4%),orQ3(40.8%)drinkers.Almostallof the self-reported “heavy” drinkers (96.6%)were classified as Q4 drinkers.

Comparison of CDS and Heavy (“Binge”)Drinking Measures

The respondents’ heavy (“binge”) drinkingstatus was cross-tabulated with CDS status, asshown inTable3.More thanhalf (54.3%)of thenon-heavy drinkers were CDS/Q1 drinkers,and more than one-third (35.6%) were Q2drinkers. Interestingly, almost one-tenth (9.5%)were Q3 drinkers, putting them in the topone-half of drinkers according to the CDS.Most heavy (“binge”) drinkers were either Q3(36.5%) or Q4 drinkers (42.0%), while almostone in five (17.1%) was a Q2 drinker, puttingthem in the bottom one-half of drinkers accord-ing to the CDS.

Infrequent and frequent heavy drinkers werealso examined separately. Nearly half (47.5%)of the infrequentheavydrinkerswereclassified

42 SUBSTANCE ABUSE

TABLE 2. Distributions of Individual Composite Drinking Scale (CDS) Items: Profiles of CDS/Q1-Q4 Col-lege Student Drinkers*

CDS Item Description CDS Quartile Mean (SD)† Min Max

Frequency of alcohol use in the past 30 days‡ Q1 1.8 (0.5) 1 4Q2 2.7 (0.7) 1 5Q3 3.8 (0.9) 1 7Q4 4.8 (1.1) 1 7

Average number of drinks consumed in a week Q1 0.6 (0.8) 0 5Q2 2.4 (1.6) 0 12Q3 6.2 (3.0) 0 22Q4 17.9 (11.3) 0 80

Greatest number of drinks consumed at 1 sitting in last 2 weeks Q1 0.7 (1.1) 0 6Q2 3.0 (1.9) 0 10Q3 5.8 (2.3) 0 17Q4 11.3 (4.8) 0 30

Average number of drinks consumed when partying Q1 1.7 (1.3) 0 6Q2 3.5 (1.6) 0 10Q3 4.9 (1.7) 0 17Q4 8.8 (3.3) 3 24

* The Composite Drinking Scale (CDS) consists of the four items listed in the table. See Methods Section (Survey Content, Alcohol Consump-tion) for details on the construction of the CDS and the classification of CDS/Q1-Q4 drinkers; CDS/Q4 signifies the heaviest level of alcoholconsumption.

† For each item, ANOVA pairwise comparisons of the means across the four CDS quartiles were executed using Scheffe’s Method. All pairwisecomparisons are significant at the 0.05 level.

‡ Question: “During the past 30 days, on how many occasions did you use each of the following substances–alcohol (beer, wine, liquor)? Donot include drugs used as prescribed by a medical doctor.” The response options (scored 1-7) were: never, 1-2 times, 3-5 times, 6-9 times,10-19 times, 20-39 times, and 40 or more times.

as CDS/Q3 drinkers, while almost one-fourth(24.4%) were Q2 drinkers and more thanone-fifth (22.4%) were Q4 drinkers. Frequentheavy drinkers were predominantly Q4 drink-ers (72.0%), although one in five (19.6%) was aQ3 drinker. Interestingly, just less than 6 per-cent(5.9%)wereclassifiedasCDS/Q2drinkers.

Spearman correlation coefficients showedthat the heavy (“binge”) drinking measure cor-related0.77 with the continuous CDS score and0.74withthecategoricalCDSquartilemeasure.

DISCUSSION

The Composite Drinking Scale (CDS) com-bines fouralcoholconsumptionmeasures,eachof which can capture a different aspect of prob-lem drinking: (1) number of occasions onwhich alcohol was used in the past 30 days, (2)average number of drinks consumed in a week,(3) number of drinks consumed when partying,and (4) thegreatestnumberof drinks consumedat one sitting during the last two weeks. Formost of the analyses reported here, the continu-ous distribution of CDS scores was then di-vided into quartiles to create a simplified four-pointscoringsystem(CDS/Q1-Q4).Basedonalarge sample of students attending four-yearcolleges and universities in the U.S., the CDSwas found to have high internal consistency re-liability and good construct validity, as indi-cated by the strong association between theCDS/Q1-Q4 and characteristics known to beassociated with heavy (“binge”) drinking andreported alcohol-related problems.

The data reported here illustrate several ad-vantages to the CDS over other measures ofconsumption. Clearly, self-reported drinkingstatus is an inadequate measure. About one infour self-reported “light” drinkers had a CDSscore thatput theminthe tophalfof thedistribu-tion (Q3 or Q4), while nearly one-half of self-reported “moderate” drinkers fell in the highestquartile (Q4). Even declarations of being an“abstainer” cannot be fully trusted, as approxi-mately one out of five respondents who so clas-sified themselves reported drinking at leastsome alcohol when answering the four CDSquestions.

Measures of heavy (“binge”) drinking alsoappear to be inadequate for classifying studentsas problem drinkers. Heavy drinking was de-fined for men as having five or more drinks atone sitting in the last two weeks and for womenas four or more drinks (3). A key problem ispossiblemisclassification.About oneoutof tennon-heavydrinkerswasclassifiedasaCDS/Q3or Q4 drinker, which placed them in the top halfof the distribution of all college student drink-ers. At the same time, about one in five heavydrinkers was classified as a CDS/Q1 or Q2drinker,whichplacedtheminthebottomhalfofthedistributionofallcollegestudentdrinkers.

At the root of these misclassifications is thefact that the heavy drinking measure is a singledichotomous measure, whereas the CDS iscontinuous measure composed of four stronglycorrelated items. The correlation between theheavy drinking measure and the continuousCDS score was 0.77. This means that the heavydrinking measure could not explain approxi-mately41percentofthevarianceinCDSscores.

Huang et al. 43

TABLE 3. Comparisons of Heavy (“Binge”) Drinking Status and Behavior-Based CDS Drinking StatusAmong College Student Drinkers*

Heavy (“Binge”) Drinking StatusBehavior-Based CDS Drinking Status–Number (Row %)

Q1 Drinker Q2 Drinker Q3 Drinker Q4 Drinker

Non-Heavy Drinker 854 (54.3) 560 (35.6) 150 (9.5) 9 (0.6)

Heavy Drinker 98 (4.5) 375 (17.1) 801 (36.5) 923 (42.0)

Infrequent Heavy Drinker 76 (5.7) 324 (24.4) 631 (47.5) 297 (22.4)

Frequent Heavy Drinker 22 (2.5) 51 (5.9) 170 (19.6) 626 (72.0)

* See Table 1 for definitions of heavy (“binge”) drinking, non-heavy drinkers, infrequent heavy drinkers, and frequent heavy drinkers. Heavydrinkers include all drinkers who drink heavily, whether infrequently or frequently. See Methods Section (Survey Content, Alcohol Consump-tion) for details on the construction of the CDS and the classification of CDS/Q1-Q4 drinkers; CDS/Q4 signifies the heaviest level of alcoholconsumption.

This same problem would arise, of course, ifanyoneof thecomponentCDS itemswereusedas an individual measure. Note that the item-to-tal correlations of the four CDS items rangedbetween 0.65 and 0.81. The problem is also re-vealed when looking at the range of scores foreach of the component CDS items, brokendown by CDS quartile (see Table 2). In each ofthe CDS/Q1-Q4 groups, for example, therewere some respondents who reported consum-ing zero drinks in an average week. Relying onthis measure alone, some number of actualdrinkerswouldbemisclassifiedasnon-drinkers.

As noted, proponents of the heavy (“binge”)drinking measure have argued that it providesan easy shorthand for identifying problemdrinkers (3). It is therefore instructive to com-pare the predictive utilities of the heavy drink-ing measure and the simplified CDS/Q1-Q4scores. Consider the consequence of experi-encing five or more alcohol-related problems.Comparedwithnon-heavydrinkers, infrequentand frequent heavy drinkers were 7.4 and 29.8times as likely, respectively, to report this num-ber of problems, adjusting for the 16 SCANBcontrol/backgroundvariables.Thecomparableodds ratios for CDS/Q2, Q3, and Q4 drinkers,compared to CDS/Q1 drinkers, were 3.6, 18.3,and 82.8, respectively. Clearly, the CDS is ableto capture a broader range of relative risks thanthe heavy drinking measure, while also moreclearly establishing the quadratic relationshipbetween alcohol consumption and experiencingalcohol-related problems.

This advantageof theCDS is also evident forother measures of alcohol-related problems.For example, compared with non-heavy drink-ers, infrequent and frequent heavy drinkerswere 3.0 and 7.7 timesas likely, respectively, toreport experiencing one or more academicproblems, adjusting for the 16 SCANB control/background variables. The comparable oddsratios for CDS/Q2, Q3, and Q4 drinkers, com-pared to CDS/Q1 drinkers, were 2.6, 6.3, and16.3, respectively.

Likewise, compared with non-heavy drink-ers, infrequent and frequent heavy drinkers ex-perienced 2.9 and 6.1 more alcohol-relatedproblems, respectively, again adjusting for the16 SCANB control/background variables.Compared with CDS/Q1 drinkers, Q2-Q4drinkers experienced 1.3, 3.6, and 7.1 more al-

cohol-related problems, respectively. Resultsof multivariate linear regression analysesshowed that use of the CDS, as opposed to the“binge”drinkingmeasure, increased theamountof variance accounted for from 41% to 47% (a14.6% relative increase).

Regarding limitations, the SCANB survey,because itwasdesignedtoassess the impactofacampus-based prevention program, did not in-clude the full range of possible consumptionmeasures that might be included in a compositedrinking scale. While the four questions askedhere did create a useful scale, far more work isneeded to identify the optimal question set toapply.

In principle, this type of composite measureshould also be superior to quantity-frequency(QF) measures, which gauge general drinkinglevels but do not include inquiries about heavydrinking episodes specifically. As noted be-fore, some investigators have combined QFquestions with a question about heavy (“binge”)drinking, but that is sub-optimal due to severalproblems with that dichotomous measure (9).A weakness of the present study is that theSCANB survey did not happen to include QFmeasures against which to compare the CDSmeasure. This can also be addressed in futureresearch.

Gruenewald and his colleagues (16,17) havedeveloped a QF measure that asks respondentsa series of questions about their alcohol con-sumption during the past 28 days, first report-ing on how many days they had at least onedrink, then on how many days they had morethan one drink, three or more drinks, and six ormore drinks. From this information, three di-mensions of alcohol consumption can be re-ported: drinking frequency, mean drinks peroccasion, and a drinking variance estimate.Each individual’s drinking pattern is describedas a point in three-dimensional space definedby these variables. Improving on simpler QFmeasures, this scheme captures atypical or ex-treme drinking episodes. However, while thismeasure might have scientific advantages, itdoes not capture the concept of problem drink-ing through a simple, one-dimensional indexandthereforewouldbedifficult for thepublic tounderstand.

Another limitationof thepresentstudyis thatthe study sample included only college stu-

44 SUBSTANCE ABUSE

dents. Remember that the CDS involves nor-malizing the response distributions for eachquestion and adding the z-scores. This means,then, that the subjectivemeaningof theCDS, asa continuous scale, or the CDS/Q1-Q4 scores istied to the population being studied, in this casea sample of students from 32 four-year collegesand universities. Looking at a given study sam-ple, individualscanbecompared tooneanotherin terms of their CDS or CDS/Q1-Q4 scores,but they cannot be compared to members ofother samples.

Correcting this deficiency would require es-tablishing U.S. national norms for the compos-ite drinking scale. Once that were done, a givenCDS score would have real world meaning rel-ative to a standard distribution of CDS scores,just asan IQ scorehasmeaningagainst thestan-dard IQ distribution. For example, peoplewouldcometounderstandthataQ4scoresigni-fies a pattern of heavier drinking (and is morelikely to be associated with alcohol-relatedproblems) than a Q3 score, just as they under-stand that an IQ of 120 signifies greater intelli-gence than an IQ of 110.

Additional research would then be needed todeterminewhichofseveralscoringoptions–theCDS/Q1-Q4 based on quartiles, another point-based system (e.g., one based on deciles), or acontinuous CDS score–would work best. It isvery likely that a CDS/Q1-Q4 score tied to thenational norms would be simple enough for thepublic to understand, but in practice a four-point scale might not be fine-grained enough toserve research purposes.

In conclusion, a composite drinking scaleappears to be a viable measure of college stu-dent drinking with several scientific advan-tages over the heavy (“binge”) drinking mea-sure used in many studies (2). Additional workisneededto identify theoptimalsetofquestionsto include in such a measure, not only for col-lege students but perhaps also for the generalU.S. population. In order to make comparisonsacross study samples, as well as to improvepublic understanding of the data, it would benecessary to establish national norms for thecomposite drinking scale. This would be a ma-jor undertaking, but absent this effort, the fieldwill continue to be saddled with inadequatemeasures that give an incomplete or distortedpicture of problem drinking.

REFERENCES

1. Allen JP, Wilson VB (eds.) Assessing AlcoholProblems: A Guide for Clinicians and Researchers (2nded.). Bethesda, MD: National Institute on Alcohol Abuseand Alcoholism; 2003.

2. O’Malley PM, Johnston LD. Epidemiology of al-cohol and other drug use among American college stu-dents. J Stud Alcohol 2002; S14:23-39.

3. Wechsler H, Austin SB. Binge drinking: Thefive/four measure. J Stud Alcohol 1998; 59:122-123.

4. Flegal KM. Agreement between two dietarymethods in the measurement of consumption. J Stud Al-cohol 1990; 51:408-414.

5. Redman S, Sanson-Fisher RW, Wilkinson C,Fahey PP, Gibberd RW. Agreement between two mea-sures of alcohol consumption. J Stud Alcohol 1987;48:104-108.

6. Ellickson PL, McGuigan KA, Adams V, BellRM, Hays RD. Teenagers and alcohol misuse in theUnited States: By any definition, it’s a big problem. Ad-diction 1996; 91:1489-1503.

7. Dimeff LA, Baer JS, Kivlhan DR, Marlatt GA.Brief Alcohol Screening and Intervention for CollegeStudents (BASICS): A Harm Reduction Approach. NewYork: Guildford; 1999.

8. Fitzgerald JL, Mulford H. Self-report validity is-sues. J Stud Alcohol 1987; 48:207-211.

9. DeJong W. Finding common ground for effec-tive campus-based prevention. Psychol Addict Behav2001; 15:292-296.

10. Perkins HW (ed.). The Social Norms Approachto Preventing School and College Age Substance Abuse:A Handbook for Educators, Counselors, and Clinicians.San Francisco, CA: Jossey-Bass; 2003.

11. Cronbach LJ. Coefficient alpha and the internalstructure of tests. Psychometrika 1951; 16:297-334.

12. Wechsler H, Davenport A, Dowdall G, MoeykensB, Castillo S. Health and behavioral consequences ofbinge drinking in college: A national survey of studentsat 140 campuses. JAMA 1994; 272:1672-1677.

13. Edwards P, Roberts I, Clarke M, DiGuiseppi C,Pratap S, Wentz R, Kwan I. Increasing response rates topostal questionnaires: Systematic review. BMJ 2002;324:1183-1191.

14. SAS. SAS/STAT User’s Guide: Version 8.2.Cary, NC: SAS Institute, Inc.; 2001.

15. Wechsler H. Alcohol and the American collegecampus: A report from the Harvard School of PublicHealth. Change 1996; July/August:20-25,60.

16. Gruenewald PJ, Mitchell PR., Treno AJ. Drink-ing and driving: Drinking patterns and drinking prob-lems. Addiction 1996; 91:1637-1649.

17. Gruenewald PJ, Nephew T. Drinking in Califor-nia: Theoretical and empirical analyses of alcohol con-sumption patterns. Addiction 1994; 89:707-723.

Huang et al. 45

https://www.researchgate.net/publication/19505096_Self-report_validity_issues?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=

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https://www.researchgate.net/publication/13734080_Binge_drinking_the_fivefour_measure?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=

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Racial/Ethnic Differences in the Protective Effectsof Self-Management Skills on Adolescent Substance Use

Kenneth W. Griffin, PhD, MPHGilbert J. Botvin, PhD

Lawrence M. Scheier, PhD

ABSTRACT. A variety of cognitive and behavioral self-management skills have been posited asprotective in terms of adolescent substance use. This study examined whether these skills mea-sured in the 7th grade served a protective function in 9th grade substance use across ethnically di-verse samples of adolescents. Participants consisted of Black (n = 461) and Hispanic (n = 320)urban youth and White suburban youth (n = 757). Structural equation modeling indicated that asecond order Self-Management Skills latent factor consisting of first order latent factors of Deci-sion-Making, Self-Regulation, and Self-Reinforcement skills was protective for adolescent sub-stance use across racial/ethnic subgroups. However, Self-Management Skills were more stronglyprotective for suburban White youth and less protective for urban minority youth. These findingsare consistent with previous research showing that predictive power of risk and protective factorsderived from psychosocial theories varies widely across racial/ethnic subgroups of youth and isweaker among racial/ethnic minority youth compared to White youth. An important next step is tobroaden the focus of etiology research from individual-level determinants to studying adolescentsubstance use behavior in the context of the cultural background and primary social settings ofyoung people, such as family, school, and community environments. [Article copies available for afee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2006 by The Haworth Press, Inc. Allrights reserved.]

KEYWORDS. Adolescence, substance use, race, protective factors

The adolescent population in the UnitedStates is becoming increasingly ethnically andracially diverse and will continue to do so fordecades to come, as will the population at large(1). Despite this, there has been little compara-tive research on developmental processes overthe course of the teenage years for youth from

different racial/ethnicbackgrounds. Inparticular,research is needed to increase our understand-ing of the common and unique sets of risk andprotective factors for adolescent problem be-haviors across subgroups of young people dur-ing the transition to adolescence, when a num-ber of such behaviors first appear.

Kenneth W. Griffin and Gilbert J. Botvin (E-mail: [email protected]) are affiliated with Division ofPrevention and Health Behavior, Department of Public Health, Weill Medical College of Cornell University, NewYork, NY.

Lawrence M. Scheier is affiliated with LARS Research Institute, Las Vegas, NV (E-mail: [email protected]).Address correspondence to: Kenneth W. Griffin, PhD, MPH, Division of Prevention and Health Behavior, De-

partment of Public Health, Weill Medical College of Cornell University, 411 East 69th Street, KB-201, New York,NY 10021 (E-mail: [email protected]).

This research was supported by grants DA14964 and CA96467 from the National Institutes of Health.



A variety of self-management skills havebeen found to be protective for adolescent sub-stance use and related problem behaviors in-cluding decision-making and problem solvingskills, behavioral self-control, and cognitiveself-regulation strategies (2,3). The better youthareatconfronting,activelystrugglingwith, andmastering life problems through the use of theirown social, cognitive, and behavioral skills, themoreresilient theyappear tobe tobothnegativesocial influencesaswell asvarious internalmo-tivational forces (e.g., affect regulation) thatpromote substance use. Furthermore, skillsbuilding interventions that focus on compe-tence enhancement are increasingly recog-nized as an important way of helping youngpeople successfully meet developmental chal-lengesandavoidavarietyofnegativeoutcomesincluding substance use (4,5).

National and regional survey data demon-strate that thereare substantial racial/ethnicdif-ferences in prevalence rates for adolescent al-cohol, tobacco, and marijuana use. Black youthusually report lower levels of substance use rel-ative to White or Hispanic youth (6-8). Whilethe reasons for these differences are likely to bemultifactorial, research is needed to determineif competence-based etiologic models are ap-propriate for all youth or whether the protectiveeffects of competence skills differ across sub-groups of youth. In addition to the normativechallenges of adolescence, urban minorityyouth often must contend with exposure tocrime and violence, poverty, and a lack of edu-cational and occupational resources and oppor-tunities(9,10).Despite this,mostof theseyouthtransition successfully through adolescence,suggesting that protective factors play a centralrole in buffering these youth from risk. The lit-erature on psychosocial resilience illustrateshow youth raised in unfavorable environmentsmanage to develop competence in a variety oflife domains (11,12). Although competenceskills are likely to be important for all youth,they may play a particularly important role inpromoting resilience among urban minorityyouth because highly competent youth that aremore successful in conventional developmentaltasks may be more optimistic regarding futurelifeoptionsandperceived“futureselves”(13).

A goal of the present study is to test whethercompetence-based etiologic models of sub-

stance use are applicable across racial/ethnicsubgroups of youth. In particular, we examinewhethercognitiveandbehavioralself-manage-ment skills, taught in some contemporary pri-mary prevention programs for adolescent sub-stance abuse, are protective for later substanceuse among diverse subsets of youth. We focuson early adolescents because it is during theseyears that primary prevention programs forsubstance abuse are typically provided.

METHOD

Sample

The present study included two samples ofjunior high school students (total N = 1,538).The first sample consisted of suburban Whitestudents (n = 757) from 19 schools in upstateNew York, and a second sample consisted ofurban Black (n = 461) and Hispanic (n = 320)students from 19 schools in New York City.Participants were selected from the untreatedcontrol groups as part of two larger school-based drug prevention trials. Based on self-re-portedrace/ethnicity,over90%of thesuburbansample consisted of White students and over90%of theurbansampleconsistedofBlackandHispanic students. For comparison purposes,students reporting other racial/ethnic back-grounds were excluded from the respectivesamples. A small number of classrooms in theurbansamplewerebilingualandwereexcludedfrom the present study. In the suburban Whitesample, 52% of students were male and 77%lived in two-parent families. In the urbanminoritysample,40%weremaleand54%livedin two-parent families.

Procedure

In both of the larger prevention studies, all7th grade regular education classrooms in eachof theparticipatingschoolswereeligible topar-ticipate in the intervention trial. Students com-pleted a self-report questionnaire that assesseda variety of attitudes, intentions, and behaviorsrelated to substance use. Unique identificationcodes were used rather than names to empha-size the confidential nature of the survey, andstudents were assured that their responses

48 SUBSTANCE ABUSE

would not be made available to school person-nel, teachers, or parents. Questionnaires wereadministeredduringa regularclassroomperiodby a team of several data collectors who weremembersof thesameracial/ethnicgroupsas theparticipating students. Carbon monoxide breathsamples were collected from students beforethey completed the questionnaire, a procedurethat has been found to enhance the veracity ofself-reported substance use data (14). Reviewsof the scientific literature have concluded thatsurveys in school settings can provide highlyreliable data for research on substance useamong youth (15).

Following a baseline assessment in the 7thgrade, students were surveyed again in the 8thand9thgrades.Becausetheprevalenceratesforalcohol, tobacco, and marijuana use were rela-tively low during the initial years of the largerstudies, we modeled substance use in the 9thgrade as the primary outcome of interest.

Measures

Decision-Making Skills (α = .82) were as-sessed using four items from the Coping As-sessment Battery (16), which assesses appliedinformation-gathering strategies that individu-als may use when confronted with a specificproblem (e.g., “I get the information I need tomake the best choice”). Response categoriesranged from 1 (never) to 5 (almost always).

Self-Regulation Skills (α = .74) were as-sessed using four items from the RosenbaumSelf-Control Schedule (17). The Self-ControlSchedule measures cognitive strategies that in-dividuals may use in specific situations to man-ageanxietyordistress (e.g., “If I amfeelingsad,I try to think about pleasant things”). Responsecategories ranged from 1 (never true) to 5 (al-most always true).

Self-Reinforcement Skills (α = .75) were as-sessed using five items from the Frequency ofSelf-Reinforcement Attitudes Questionnaire(18). These items assess self-statements onemakes to reinforce one’s own behavior, such as“I silentlypraisemyselfevenfor smallachieve-ments” and “The way I achieve my goals is byrewarding myself every step along the way.”Response categories ranged from 1 (stronglydisagree) to 5 (strongly agree).

Substance Use. Indicators of cigarette, alco-hol, and marijuana use were used to reflect a la-tent construct of Substance Use. For each sub-stance, one item assessed the frequency ofengaging in the behaviors on a scale from 1(never) to 9 (more than once a day).

We have previously reported the psycho-metric properties of measures used in this study(19,20), and have found that the measures ofself-management skills are significantly corre-lated with other risk and protective factors foradolescent substance (21).

RESULTS

Attrition analyses were conducted to exam-ine the proportion of each sample that droppedout over the two-years of follow-up in eachsample. Approximately 23% and 33% of theinitial suburbanWhiteandurbanminoritysam-ples, respectively, did not complete the fol-low-up assessment in the 9th grade. Further-more, substance users at baseline were morelikely todropoutcompared tonon-users inbothsamples. These findings suggest that the studysamples were at lower than average risk andtherefore the present results are limited in thatthey may not be generalizable to all adoles-cents. Furthermore, the parameter estimatesmay be conservative due to the potentialrestriction in the range of the substance useoutcomes.

As shown in Table 1, rates of substance usediffered by race/ethnicity.Rates of lifetime andpast month use of cigarettes, alcohol, and mari-juana use in the 9th grade were consistentlyhighest for suburban White youth compared tothe two urban minority samples. As shown inTable 2, correlational analyses at the baselineassessment showed that the indicators ofSelf-Management Skills were more stronglyprotective in termsof substanceuse with subur-ban White youth, less so with urban Blackyouth, and least with urban Hispanic youth.

As shown in Figure 1 structural equationmodeling indicated that a second order Self-Management Skills latent factor consisting offirst order latent factors of Decision-Making,Self-Regulation, and Self-Reinforcement Skillswas protective for the combined sample interms of Adolescent Substance Use (β = �.25,

Griffin, Botvin, and Scheier 49

p < .001) and themodelhad a good fit to thedata(Robust CFI = .96, RMSEA = .035). However,multigroup SEMs by race/ethnicity indicatedthat the Self-Management Skills factor wasmore strongly protective for suburban Whiteyouth (β = �.27, p < .001; Robust CFI = .95;RMSEA = .037) compared to urban Blackyouth (β = �.16, p < .01; Robust CFI = .98;RMSEA = .027) and urban Hispanic youth (β =�.07, p = ns; Robust CFI = .97; RMSEA =.027).TheproportionofvarianceinAdolescentSubstance Use explained by the Self-Manage-ment Skills second order factor ranged fromR2 = .07 for suburban White youth, R2 = .03 forurban Black youth, and R2 = .01 for urban His-panic youth.

DISCUSSION

The present study examined whether self-management skills were protective for sub-stance use among racial/ethnic subgroups ofadolescents. Self-management skills were de-fined as the common variance among measuresof decision-making, self-regulation, and self-reinforcement skills, and substance use as thecommon variance among indicators of smok-ing, alcohol use, and marijuana use frequency.Findings indicated that the prevalence rates forsubstance use varied widely across racial/eth-

nic categories, consistent with previous epide-miological data (7), and that Self-ManagementSkills were most strongly protective for subur-ban White youth and significantly less protec-tive for urban minority youth. Similarly, theproportion of variance in substance use ex-plained by Self-Management Skills was high-est among suburban White youth and lessstrongly predictive for urban minority youth.

These findings are consistent with previousresearch showing that the risk/protective fac-tors derived from psychosocial theories varywidelyacross racial/ethnicsubgroups of youth,and that the predictive strength of these vari-ables is weaker among racial/ethnic minorityyouth compared to White youth (22,23). Thefinding that only a modest proportion of vari-ance in substance use was explained by themodelmayreflect the fact that theself-manage-ment skills model included only a small subsetof individual-level predictors. A variety of eth-nic or culture-specific factors that may contrib-ute to substance use behavior and/or psycho-social resilience among urban minority youthwere not included in the model. For example,research has shown moderate positive associa-tions between ethnic identityand various facetsof psychosocial functioning including self-es-teem,copingeffectiveness, andself-evaluation(24). To the extent that a strong sense of ethnicidentity contributes to the formation and crys-tallization of one’s identity, a crucial develop-mental task of adolescence (25), it may serve aprotective function. Furthermore, other largermacro-level etiologic factors, such as neigh-borhood characteristics and socio-economicfactors, were not included, and these ecologicalvariables may explain a larger proportion ofvariance in substance use among urban minor-ityyouth.Thus, inadditiontoexaminingtheex-tent to which competence-based etiologicalmodels can account for substance use across

50 SUBSTANCE ABUSE

TABLE 1. Rates of Smoking, Drinking, and Marijuana Use, by Race/Ethnicity in the 9th Grade

Cigarettes Alcohol Marijuana

Sample N Ever Use(%)

Past Month Use(%)

Ever Use(%)

Past Month Use(%)

Ever Use(%)

Past Month Use(%)

White 757 47.2 17.4 78.2 31.7 20.3 6.6Black 461 12.8 2.4 42.7 20.4 6.3 1.7Hispanic 320 20.3 3.1 52.2 13.4 2.8 0.3All 1538 31.3 9.9 62.2 24.5 12.5 3.8

TABLE 2. Correlations of Self-Management Skillswith Substance Use, by Race/Ethnicity

DecisionMaking

Self-Regulation

Self-Reinforcement

Sample N r p r p r p

White 757 �.233 .000 �.168 .000 �.097 .008Black 461 �.097 .037 �.043 .359 �.050 .282Hispanic 320 �.078 .162 �.046 .411 �.017 .766

All 1538 �.176 .000 �.128 .000 �.092 .000

ethnically heterogeneous subgroups of youth,it is important to consider various ethnic-spe-cific factors that may enhance resilience withinthese subgroups. Furthermore, these findingssuggest thatan importantnext step is tobroadenthe focus of etiology research from individ-ual-level determinants to studying adolescentsubstance use behavior in the context of one’scultural background and primary social set-tings, such as family, school, and communityenvironments. Because individual-level fac-tors appear to explain a relatively small propor-tion of variance in substance use across sub-groups of youth, this suggests that preventionprograms that focus on individual-level factorsshould be complemented by family and com-munity interventions as well as legal and policyinitiatives that facilitate change at the larger so-cietal level.

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Griffin, Botvin, and Scheier 51

Decision-Making

Get info needed to make best choice

Think of many possible solutions

Think about what will happen for each

Make best choice and then do it

I think about how to be less nervous

If sad, I think about pleasant things

If worried, I keep busy or think other things

If bothered, I think pleasant things

When I do well, I take time to enjoy it

I plan to enjoy myself afterwards

I reward myself with something special

I praise myself for small achievements

I reward myself each step along the way

Self-Reinforcement

SubstanceUse

Self-Management

Skills

Self-Regulation

drinking

smoking

marijuana

.61

.75

.70

.25�

.64

.73

.69

.62

.78

.78

.74

.55

.68

.69

.70

.51

.53

.72

.62

.69

FIGURE 1. Self-Management Skills and Adolescent Substance Use

https://www.researchgate.net/publication/12202676_Preventing_drug_abuse_in_schools_Social_and_competence_enhancement_approaches_targeting_individual-level_etiologic_factors?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=




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12. Masten, A. S., & Coatsworth, J. D. (1998). Thedevelopment of competence in favorable and unfavor-able environments: Lessons from research on successfulchildren. American Psychologist, 53, 205-219.

13. Oyserman, D., & Saltz, E. (1993). Competence,delinquency, and attempts to attain possible selves. Jour-nal of Personality & Social Psychology, 65, 360-374.

14. Bauman, K. E., Koch, G. G., & Bryan, E. S.(1988). Validity of self-reports of adolescent cigarettesmoking. International Journal of the Addictions, 17,1131-1136.

15. Barnea, Z., Rahav, G., & Teichman, M. (1987).The reliability and consistency of self-reports on sub-stance use in a longitudinal study. Addiction 82, 891-898.

16. Bugen, L. A., & Hawkins, R. C. (1981). The Cop-ing Assessment Battery: Theoretical and Empirical Foun-dations. Paper presented at the meeting of the AmericanPsychological Association, Los Angeles, CA.

17. Rosenbaum, M. (1980). Schedule for assessingself-control behaviors. Behavior Therapy, 11, 109-121.

18. Heiby, E. M. (1983). Assessment of frequency ofself-reinforcement. Journal of Personality & SocialPsychology, 44, 1304-1307.

19. Epstein, J. A., Botvin, G. J., Diaz, T., Baker, E.,& Botvin, E. M. (1997). Reliability of social and per-sonal competence measures for adolescents. Psycholog-ical Reports, 81, 449-450.

20. Macaulay, A. P., Griffin, K. W., & Botvin, G. J.(2002). Initial internal reliability and descriptive statis-tics for a brief assessment tool for the Life Skills Train-ing drug abuse prevention program. PsychologicalReports, 91, 459-462.

21. Griffin, K. W., Scheier, L. M., Botvin, G. J., &Diaz, T. (2001). The protective role of personal compe-tence skills in adolescent substance use: Psychologicalwell-being as a mediating factor. Psychology of Addic-tive Behaviors, 15, 194-203.

22. Gottfredson, D. C., & Koper, C. S. (1996). Raceand sex differences in the prediction of drug use. Jour-nal of Consulting & Clinical Psychology, 64, 305-313.

23. Vega, W. A., Zimmerman, R. S., Warheit, G. J.,Apospori, E., & Gil, A. G. (1993). Risk factors for earlyadolescent drug use in four ethnic and racial groups.American Journal of Public Health, 83, 185-189.

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52 SUBSTANCE ABUSE

https://www.researchgate.net/publication/225809279_Ethnic_identity_and_self-concept_in_Mexican-American_adolescents_Is_bicultural_identity_related_to_stress_or_better_adjustment?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=







Initiating Tobacco Curricula in Dental Hygiene Education:A Descriptive Report

Linda D. Boyd, RDH, RD, EdDKay Fun, RDH, MPA

Theresa E. Madden, DDS, MS, PhD

ABSTRACT. Two hours of tobacco instructions were incorporated into the baccalaureate dentalhygiene curricula in a university in the Northwestern United States. Prior to graduation, all seniorstudents were invited to complete anonymously a questionnaire surveying attitudes and clinicalskills in providing tobacco services to their clinic patients. Twenty students (67%) responded butno data was collected on the non-respondents. Eighteen (90%) reported practicing some of the “5A’s,” and a few reported sustained adherence to all “5 A’s.” Moderately successful clinical out-comes parallelled students’ moderate self-rating of their knowledge/skills. When asked to identifybarriers to sustained and ongoing full adherence, most students cited “patient resistance/disinter-est,” and their own “lack of knowledge or confidence in the skills.” Our preliminary findings sug-gest that additional content and training time may be required for dental hygiene graduates to feelhighly confident and knowledgeable, and for them to sustain comprehensive tobacco services oncein practice. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH.E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2006 byThe Haworth Press, Inc. All rights reserved.]

KEYWORDS. Dental hygiene, tobacco cessation, prevention, oral health, oral cancer, perio-dontitis, dental education

INTRODUCTION

Tobacco-Related Oral Diseases and DentalPractice-Based Cessation Services

Tobacco significantly increases, in a dose-dependent manner, risks for oral cancer, peri-odontal diseases, and diminished treatment

success following periodontal bone grafts,tooth extractions, and dental implant surgery(1-13).Tobaccocessationhowever,greatly im-proves periodontal health and treatment out-comes (9), as well as overall health (14,15).Patients seen in dental offices use tobacco attwo to three times the national average and“healthy” smokers are more likely to visit a

Linda D. Boyd is affiliated with the Idaho State University, Division of Graduate Studies, Department of DentalHygiene, 12301 West Explorer Drive, Suite 102, Boise, ID 83713 (E-mail: [email protected]).

Kay Fun is in private practice in Portland, Oregon.Theresa E. Madden is affiliated with Oregon Health & Science University, Department of Periodontology,

School of Dentistry, Portland, OR.Address correspondence to: Theresa E. Madden, DDS, PhD, Oregon Health & Science University, Department

of Periodontology, School of Dentistry, 611 SW Campus Drive, Room SD177, Portland, OR 97239 (E-mail:[email protected]).

This study was supported by the School of Dentistry at the Oregon Health & Science University in Portland, Oregon.Teaching materials were developed in part from resources available at www.projectmainstream.net



dentist thanaphysicianorotherhealthcarepro-fessional (2).Ofperiodontalpracticepatients inthe U.S., 75% are or have been tobacco-de-pendent (2). Periodontal patients generally areseen at three to four month intervals, and gen-eral practice patients are seen at six-month in-tervals, therefore providing dental profession-als many opportunities for tobacco prevention,cessationcounselling,andon-goingfollow-up.

In a formal position paper, the AmericanDental Association “. . . urges its members tobecomefully informedabout tobaccocessationintervention techniques to effectively educatetheir patients to overcome their addiction to to-bacco” (16). And further, the American DentalHygienists Association sponsors the SmokingCessation Initiative (SCI) campaign, which in-tegrates the 5 A’s intoan abbre-viated interven-tion referred to as “Ask, Advise, Refer: ThreeMinutes or Less Can Save Lives” (17).

Although 62% of dental professionals sur-veyed report beliefs that patients do not wantthemtoask, 59% of 3,088patients surveyedna-tionally (half smokers and half non-smokers)believed that tobacco cessation services shouldbe provided by dental practices (18). Sixty per-cent of Oregon residents believe dentists andhygienists should give their patients more in-formationabout thehealthrisksassociatedwithtobacco use and only 2% think members of thedental profession should provide less informa-tion (19).

Even thoughdentalprofessionalsusingbriefinterventions demonstrate successful patientquit rates (13.3% to 45.3%) comparable toother health professionals (20-23,29), this ser-vice is often overlooked in many dental prac-tices. About half of general dentists, dental hy-gienists and dental specialists report askingpatients about tobacco use (24), and only 8.7%of dentists report possessing “strong skills andknowledge in tobacco cessation” (25). Whilelack of reimbursement is an obstacle (26), den-tal professionals acknowledge that their pri-mary obstacles are insufficient knowledge,skillandconfidencegainedduringprofessionaltraining (25).

Tobacco Training in Dental Education

Until recently,dental professionals have hadscant formal tobacco intervention training. At

present, less than half of U.S. dental schoolshave incorporated formal tobacco training intotheir curriculum, while all programs requiretheir students to ask and advise patients abouttobacco use (26). Surveys of dental schoolswithout formal tobacco intervention training,reveal that 69% of students report routinelyasking patients about tobacco use, but 22% donot discuss tobacco cessation with them (27). Adental hygiene faulty survey indicates that amere 15-35% of dental hygiene programs in-clude content on brief motivational interview-ing, tobacco pharmacotherapies, or any basicinformation about practice-based cessationservices (28).

This report describes outcomes of a first at-tempt at infusing basic tobacco educationalcontent including “the 5 A’s,” into a baccalau-reatedentalhygienecurriculum.Systematic re-views support use of the “Clinical PracticeGuideline: Treating Tobacco Use and Depend-ence” utilizing the 5 A’s approach to tobaccointervention (29-32), developed by the Na-tional Cancer Institute (NCI) and the AgencyforHealthcareResearchandQuality(AHRQ).

METHODS

A quasi-experimental design was used on aconvenience sample. Data collection was viaself-report survey. Shortly prior to graduation,the entire senior class of 30 female dental hy-giene students was invited to complete anony-mously, self-report questionnaires aimed atelucidating the class’s attitudes toward, andtheir clinical skills in tobacco cessation coun-selling. Our questionnaire was designed to ex-plore the adequacy of the training we had pro-vided over the course of their baccalaureateeducation. Three main areas of inquiry wesought to study were as follows:

1. To what extent has the training in tobaccointervention translated into sustained andeffective tobacco counselling by dentalhygiene student trainees?

2. What barriers are perceived to exist in thestudent clinics?

3. What level of confidence do the studentshave in their personal clinical tobaccocounselling skills?

54 SUBSTANCE ABUSE

This study was deemed exempt by the Ore-gon Health & Science University InstitutionalReview Board. The training was incorporatedinto the required curriculum, but attendance ateach teaching session and completion of thesurvey were optional.

Description of the Teaching Contentand Methods

Approximately two hours of tobacco inter-vention training were incorporated into thedental hygiene curricula at School of Dentistry,Oregon Health & Science University in Port-land, Oregon. Subsequently the students wereexpected to practice providing these services totheir assigned patients in the student clinics.

Presented didactically, the first hour of con-tent summarized the evidence linking tobaccowith oral diseases, methods for assisting pa-tients inquitting, relapseprevention techniquesand universal prevention strategies for pediat-ricandadolescentpatients.All typesof tobaccoproducts were included (cigarettes, chewingtobacco, cigars, pipes, bidis, etc.). Later, an ad-ditionalhour-longsessionwasdevoted tosmallgroup discussion and role-playing focused onclinical skill building.

In this brief training, students were encour-aged to assess patients for co-morbid condi-tions that complicate tobacco cessation (un-treated depression, schizophrenia, hazardousdrinking or additional substance dependence).Studentswerealsoprovidedresources for inde-pendent learning. Included were handouts suchas the Fagerstrom Nicotine Tolerance test, theStages of Change, check-list for depression,DSM IV-R diagnostic criteria for various sub-stance use disorders, and lists of communityand web-based resources should they choose toconsult with or refer patients to commu-nity-based quit classes, or addiction medicinespecialists.

Although most of the clinical faculty at-tended the training sessions, there was no sys-tematic training or calibration of the faculty.Therefore,methodsforactualapplicationof thematerials in the student clinic setting, were leftup to the students and their immediate facultysupervisors.

Procedures

The dental hygiene students received theirquestionnaires in one of their seminar classesand were given class time to complete the sur-vey. The student survey was adapted from onedeveloped by the National Dental Tobacco-Free Steering Committee (NDTFSC) (33). Thesurvey consisted of 30 questions, includingquestions about demographics and personal to-bacco use history. The students were asked toestimatetowhatproportionof theirpatientshadthey provided tobacco intervention followingNCI/AHRQ 5 A’s. Six-point Likert-like scaleswere used to self-rate skill and to report fre-quency of various patients services: nearly all(91-100%), most (75-90%), majority (51-74%),some (25-50%), a few (1-24%), to none (0%).Responses to itemsonbarriersusedaforcedan-swer from three selections: a strong barrier,somewhat of a barrier, or not a barrier.

Analysis

Simple descriptive statistics were used tosummarize responses on the student question-naires. The frequency of responses to specificquestions was converted to percentages. Oursmall convenience sample was not sufficientlypowered to warrant advanced statistical analy-ses.

RESULTS

Of a class of 30 senior dental hygiene stu-dents, 20 (67%) completed the survey. Basiccharacteristics of the respondents appear inTable 1. No data was available on the non-re-spondents.Allwere femaleandmostwereCau-casian. Nine (45%) reported previous use of to-bacco, two (10%) reported current use, and theremaining nine never used it. Eleven (55)% re-called attending one hour of tobacco interven-tion training, four (20%) recalled attending twohours, and four (20%) reported non-attendance.Four (20%) reported prior training in tobaccocounselling.

Six students reported that “a few or less than25%” of their patients actually quit tobaccowhen asked the question, “With your assis-tance,what per centageof your patientsquit to-

Boyd, Fun, and Madden 55

bacco for any length of time.” One students re-ported assisting nearly all (91-100%) of hertobacco-using patients, whereas the others as-sisted up to half of theirs. For patients currentlyusing tobacco, responding students reportedspending an average of seven minutes offeringtobacco cessation services at the first appoint-ment and an average of 5 minutes at subsequentappointments. Three students provided quit as-sistance on “3 or more occasions” to each indi-vidual patient, and four did so on one or two oc-casions (Table 2, item #7).

The responding dental hygiene studentsrated their skill at providing tobacco counsel-ling in the mid-range between 3 and 4 (notshown) on a 6-point Likert scale from 1 “highlyskilled” to 6 “inadequately prepared.” Alltended to strongly agree that tobacco interven-tion is appropriate in dental practice. Whenasked about prevention for non-tobacco users,70% reported delivering a prevention messagefor up to half of patients with no history of to-bacco-dependence; 25% did so for “most” or“the majority”; and 5% for “nearly all” such pa-tients (Table 2, item #2).

Adherence to Each of the 5 A’sin the Tobacco Cessation Guidelines

A sole student reported applying all of the 5A’swith their tobacco-usingpatients,18 (90%)applied some of the 5 A’s guidelines, and two(10%) reported failure to engage in any of thecessation guidelines (Table 2).

Ask: All patients in the student clinics com-plete a written medical history form on whichthey circle “yes” or “no” to a “tobacco use”item, and this is reviewed by the student towhich the patient is assigned for treatment.Thirteen (65%) of the students reported ver-bally asking “a few or less than 25%” of theirpatients about tobacco, one asked “nearly all,”and six (30%) never asked verbally (Table 2,item #1).

Advise: All of the responding students re-ported advising patients to quit, but none did sofor more than 74% of tobacco-dependent pa-tients (Table 2, item #3).

Assess: Six (30%) of students reported rou-tinely assessing their patients’ Stage of Change(level of readiness) to quit tobacco use, whileonly one assessed the level of nicotine addic-tion with the Fagerstrom Test, and two ascer-tained theirpatients’ history of previous quit at-tempts. Of the co-morbidities complicatingtobacco cessation, students were more likely toassess routinely for depression and hazardousdrinking than for other psychiatric illness, eat-ing disorders or illicit drug abuse (Table 2, item#5).

Assist: Students were most likely to reportassisting cessation efforts by discussing withthe patient, their personal risks and unique bar-riers to quitting tobacco (> 50% of all patients),thanbyprovidingwritteneducationalmaterialssuch as pamphlets and resource lists ( < 50% ofall patients).

Arrange: One student arranged to providewritten prescriptions for bupropion for “some(25-50%)” of her patients. Likewise, one ar-ranged written prescriptions for nicotine inhal-ers. Unfortunately, 15 neglected to provide to-bacco-using patients with lists of local supportgroups and 16 did not mention web-based re-sources. Of the possible methods of arrangingfollow-up with a patient, students were mostlikely to do so at an appointment, as opposed tovia phone calls, Email, or regular mail. Fivepercent reported routinely providing follow-upat patient appointments.

Perceived Barriers to Implementationof Tobacco Intervention

Table 3 summarizes student ratings of sevenexamples of potential barriers to tobacco inter-vention. No students rated their own disinterest

56 SUBSTANCE ABUSE

TABLE 1. Characteristics of the Responding Den-tal Hygiene Students (n = 20)

Variable N

Female 20

EthnicityCaucasianNative AmericanOther

1811

Tobacco useNever used tobaccoCurrentlyEver used tobacco

929

# of hours of OHSU tobacco training you attended:NoneOneTwo

411

5

Have you had prior tobacco intervention training?YesNo

416


TABLE 2. Adherence to Tobacco Cessation Guidelines

Adherence to tobacco cessation practiceguidelines

(0)

0% none

(1)

1-24

%a

few

(2)

25-5

0%so

me

(3)

51-7

4%m

ajor

ity

(4)

75-9

0%m

ost

(5)

91-1

00%

near

lyal

l

1. What percentage of your patients did you askabout tobacco use?

30% 65% 5%

2. Of your patients that have never used tobacco,estimate the percentage that you have providedtobacco prevention information.

35% 35% 10% 15% 5%

3. Of your patients that use tobacco, what percentagedid you advise to quit?

40% 40% 15%

4. Of your patients that use tobacco, what percentagedo you assess for each of the following:

• Level of readiness to quit tobacco use 10% 35% 5% 20% 30%

• History of quit attempts 10% 45% 15% 20% 10%

• Level of nicotine addition 55% 25% 15% 5%

• Contraindications for pharmacologic smokingcessation aids

50% 35% 15%

5. Of your patients that use tobacco, what percentageof your patients did you assess for the following:

• Depression 5% 20% 15% 5% 5%

• Psychiatric disorder 75% 15% 10%

• Eating disorder 80% 15% 5%

• Hazardous alcohol use 35% 25% 25% 5% 10%

• Screen for illicit drug abuse 70% 10% 10% 5%

6. Estimate the percentage of tobacco using patientsthat you assisted by providing the following:

• Discussion of their personal risks & barriers 20% 30% 5% 25% 15%

• Educational pamphlets on quitting tobacco use 35% 45% 20%

• Pamphlet on tobacco use and periodontal disease 40% 45% 15%

• List of local support groups 75% 15% 10%

• List of web-based tobacco information sites 80% 15% 5%

• Information on Zyban (Bupropion) 50% 35% 15%

• Written prescription for Zyban 95% 5%

• Information on over-the-counter nicotinereplacement (nicotine gum & patches)

50% 35% 15%

• Information on prescription nicotine replacement(nasal spray or inhaler)

80% 15% 5%

• Written prescription for nicotine replacement (nasalspray or inhaler)

95% 5%

7. What percentage of your patients that use tobaccodid you assist with tobacco cessation on:

• less than one occasion 55% 25% 10%

• 1 to 3 occasions 65% 10% 10% 5%

• 3 or more occasions 75% 10% 5%

8. With your assistance, what percentage of yourpatients quit tobacco for any length of time?

70% 30%

9. What percentage of the time did you arrangefollow-up with a patient trying to quit tobacco with:

• a telephone call 75% 15% 5% 5%

• a postcard 95% 5%

• e-mail 100%

• at an appointment 55% 30% 5% 5% 5%

or discomfort as a strong barrier but most (n =17 or 85%) rated the patient’s disinterest or re-sistance as a strong barrier (n = 13 or 65%) orsomewhat of a barrier (n = 4 or 20%). Most (n =15 or 75%) reported lack of knowledge/confi-dence in tobacco cessation techniques as eithera strong barrier (n = 5 or 25%) or somewhat of abarrier (n = 10 or 50%). Fear of a negative re-sponse from the patient was rated as a strongbarrier by four (20%) and rated as somewhat ofa barrier by six (30%) of the students.

Althoughnostudents reported lackof facultysupport as a strong barrier, most identified lackof time (n = 13 or 65% strong or somewhat) oremphasis placed on completing graduation re-quirements (n = 11 or 55% strong or somewhat)as barriers (Table 3).

DISCUSSION

Evaluating the first infusion of two hours oftobacco curricula into our baccalaureate dentalhygiene program consisted of surveying asmall conveniencesample of students just priorto graduation. Additional limitations of thisstudy include an all-female cohort, a 67% re-sponse rate to the self-report questionnaire, anda lack of data concerning the ten (33%) non-re-sponding students. Despite the modest curricu-lar enhancement however, the responding stu-

dents rated as moderate, their knowledge andskills.Theyalsoreportedat leastpartial successpracticing tobacco cessation and preventionskills with some of their patients in the studentclinics.

Whileamajorityof students reportedneithermastery or ongoing utilization of all 5 A’s,those reporting attendance at both hours of thetobacco training were more likely (data notshown) to have carried out the first four of the 5A’s (ask, advise, assess and assist). Some re-ported administering the Fagerstrom NicotineTolerance Test, screening for hazardous drink-ing and depression, and/or determining pa-tients’ readiness to quit in terms of the Stages ofChange. There was a very low rate of providingwrittenorweb-basedquit resources.Therefore,we propose that future curricula include morecontent and skills-practice in accessing andmobilizing existing tobacco resources.

The majority (85%) perceived “patient dis-interest/resistance,” and half perceived “fear ofa negative response from the patient” as barri-ers. Previously, Campbell et al. (18) found that94% of dentists surveyed listed “patient resis-tance” as their most significant reason foravoiding private practice-based tobacco coun-selling. This fear appears to be grossly out ofproportion to the actual number of resistant pa-tient encounters, and to the nearly universal pa-tient expectation that dental practices addresstobacco (19). Aside from tobacco-dependentpatients in the Pre-Contemplative Stage ofChange (who usually do respond negatively),clinicians can expect other patients (includingtobacco-users in other Stages of Change) to re-spond politely and willingly engage in the dis-cussion (34). We hypothesize that the fear ofpatient resistance is over-rated by dental clini-cians and mostly due to overestimating theprevalence of Pre-contemplating tobacco-us-ers as well as misunderstanding clinician re-sponsibility toward the Pre-contemplator. There-fore, we propose that greater understandingamong dental professionals of the Stages ofChange, will greatly reduce this barrier.

Most students rated as barriers to routinelycarrying out tobacco counselling, “lack oftime” and “completing graduation require-ments.” Similar results have been reported byothers in dental education (33). Dental hygieneprofessionals must be competent in numerous

58 SUBSTANCE ABUSE

TABLE 3. Student Identified Barriers to TobaccoCessation Intervention

Barriers to providingtobacco cessationin the dental clinic

Strongbarrier

(1)

Somewhata barrier

(2)

Not abarrier

(3)

1. Lack of time 30% 35% 10%

2. Patient disinterest/resistance

65% 20% 0%

3. My own disinterestor discomfort

0% 35% 50%

4. Emphasis placed oncompleting graduationrequirements

25% 30% 20%

5. Faculty support 0% 45% 30%

6. Lack of knowledge/confidence in tobaccocessation techniques

25% 50% 0%

7. Fear of a negativeresponse from thepatient

20% 30% 35%

highly technical preventive skills. Dental stu-dents have more demands in a wide breadth ofdental restorative, diagnostic, prosthetic, andsurgical clinical procedures by the time theygraduate from professional school. To gaincompetence, extensive time is first spent in me-chanical simulation exercises, followed-upwith supervised operations on live patients.Graduates are immediately eligible for stateand federal licensure examinations to practice.This is perhaps in contrast to medical educationin which highly technical competence and eli-gibility for licensure follows residencies andfellowships. Therefore, dental trainees mustconstantly prioritise competing demands upontheir time, to avoid falling behind or failing tomeetgraduation requirements. Instead of beingperceived by trainees as an elective or optional“hit-or-miss” patient care service, tobaccocessation counselling would be more rapidlyadopted were it a required graduation compe-tency for all dental professionals.

Although none of our respondents identified“lack of faculty support” as a strong barrier, arecent survey done by others, found that dentalhygiene faculty felt only moderately confidentin delivering tobacco education (28). Further-more, 32% of US dental hygiene programs re-ported no available expertise or faculty time fortobacco education and several schools reportedno future plans to include tobacco because theylack knowledge of how to do so (26). This phe-nomena could explain why so few of ourstudents provided their patients with criticalwritten and/or web-based resource materials.Therefore,wepropose thatdental faculty shouldbe encouraged and rewarded for mastering evi-dence-based clinical guidelines for tobaccoprevention services, and for accessing existinginterdisciplinary and dental-specific educa-tional resources, in order to improve tobaccocurricula.

CONCLUSIONS

Given the limited formal teaching sessionswe carried out on clinical tobacco interventiontechniques, some successful outcomes wereanonymously reported by the students. We areuncertain of the generalizabilityof our findingsto male dental hygiene students or to dental stu-

dents of either gender. Our results suggest thatfemale dental hygiene students are amenable tosuch training and that they would likely benefitfrom more than two hours of structured prepa-ration time in their requiredcurricula in order tosystematicallyassimilate theskills in thestudentdental clinics.

Tobacco use is incompatible with oral health.Dentistry has historically been a leader in pro-viding health prevention services, and the mainfocus of the dental hygiene profession is oralhealthpromotion (35). A relatively recentaddi-tion to the scope of dental and dental hygienepractice (17), tobacco counselling is of utmostimportance in the prevention of periodontitis,oral cancer and dental treatment failures. Den-tal hygienists are an integral part of the dentalteam in providing such services. Therefore ad-ditional, larger scale research should be carriedout in order to determine the best educationalmethods for dental professionals to acquire andsustain effective tobacco counselling clinicalskills (36).

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https://www.researchgate.net/publication/15003241_Incidence_of_Attachment_Loss_in_Community-Dwelling_Older_Adults?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=



Initial Steps Taken by Nine Primary Care Practicesto Implement Alcohol Screening Guidelines

with Hypertensive Patients:The AA-TRIP Project

Peter M. Miller, PhDRuth Stockdell, RN, MSNLynne Nemeth, PhD, RN

Chris Feifer, DrPHRuth G. Jenkins, PhDPaul J. Nietert, PhD

Andrea Wessell, PharmDHeather Liszka, MD, MSCR

Steven Ornstein, MD

ABSTRACT. Many medical conditions are caused or exacerbated by heavy drinking, necessitat-ing alcohol screening and discussion in primary care practices. This is particularly true of hyper-tension, the most common primary diagnosis in the United States, which has been linked to theregular consumption of 3 or more standard alcoholic beverages a day.

The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) projectwas designed to improve detection and management of alcohol problems in primary care patientswith hypertension. Medical providers are being trained using the Practice Partner Research Net-work’s–Translating Research into Practice (PPRNet-TRIP) quality improvement model. Thisincludes a multi-method intervention (electronic medical records, on-site academic detailing,

Peter M. Miller (E-mail: [email protected]) is affiliated with the Center for Drug and Alcohol Programs,Medical University of South Carolina, Charleston, SC.

Ruth Stockdell (E-mail: [email protected]) is affiliated with the College of Nursing (PhD candidate), MedicalUniversity of South Carolina, Charleston, SC.

Lynne Nemeth (E-mail: [email protected]) is affiliated with the Clinical Services and College of Nursing,Medical University of South Carolina, Charleston, SC.

Chris Feifer (E-mail: [email protected]) is affiliated with the Department of Family Medicine, University of South-ern California, Los Angeles, CA.

Ruth G. Jenkins (E-mail: [email protected]), Heather Liszka (E-mail: [email protected]) and Steven Ornstein(E-mail: [email protected]), are affiliated with the Department of Family Medicine, Medical University of SouthCarolina, Charleston, SC.

Paul J. Nietert (E-mail: [email protected]) is affiliated with the Department of Biostatistics, Bioinformaticsand Epidemiology, Medical University of South Carolina, Charleston, SC.

Andrea Wessell (E-mail: [email protected]) is affiliated with the Department of Pharmacy and Clinical Sci-ences and Department of Family Medicine, Medical University of South Carolina, Charleston, SC.

Address correspondence to: Peter M. Miller, PhD, Center for Drug and Alcohol Programs, Medical University ofSouth Carolina, 67 President Street, P.O. Box 250861, Charleston, SC 29425 (E-mail: [email protected]).

This investigation was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (R25AA015066).



practice feedback reports and annual network meetings) to help practices increase adherence toclinical guidelines.

Qualitative analyses of initial steps taken by nine primary care practices toward the routine im-plementation of alcohol screening guidelines are presented. Organizational factors and providerand patient characteristics all influenced the method and consistency of alcohol screening and in-tervention. Perceived time constraints, patient sensitivity to questions about alcohol, and possiblestigma associated with a diagnosis of alcoholism were also relevant barriers requiring problemsolving. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH.E-mail address: <[email protected]> Website: <http://www.HaworthPress.com> © 2006 byThe Haworth Press, Inc. All rights reserved.]

KEYWORDS. Alcohol screening, brief intervention, primary care, hypertension

BACKGROUND

Numerous investigators have highlightedthe importance of early identification of alco-holusedisorders inprimaryhealthcare(Ander-son et al. 1993; Moyer et al. 2002). Physicianadvice about drinking is usually well receivedby patients and effective in reducing alcoholconsumption (Fleming 2002a). Evidence sug-gests that medical settings make it easier forheavy drinkers to respond positively to frankdiscussions about alcohol and health (Wallaceand Haines 1985; Sillanaukee et al. 2001).

Excessive alcohol use is associated with avariety of medical conditions including hyper-tension, themost commonprimarydiagnosis inthe United States (Corrao et al. 2004). Over-whelming evidence demonstrates an associa-tion between heavy drinking (3 or more stan-dard alcoholic beverages per day) and increasedblood pressure in both men and women, inde-pendent of obesity and smoking (Malhotra1985).

Alcohol screening and brief intervention byphysicians have been shown to reduce alcoholconsumption by 50%, with subsequent averagediastolic blood pressure decreases of 5.2 mmHg (Maheswaran et al. 1992). However, screen-ing hypertensive patients for excessive alcoholuse is not routine in primary care (Vinson2004).

While the scientific basis for alcohol screen-ing and brief intervention has been well estab-lished,Baborandcolleagues(2004;2005)haveduly noted that little research is available on theprocess by which alcohol screening is initiallyadopted and then routinely implemented in pri-mary care settings. The current study presents

factors related to the initial adoption of alcoholscreening with hypertensive patients in nineprimary care practices involved in the Acceler-atingAlcoholScreening–TranslatingResearchinto Practice Project (AA-TRIP), an ongoinginvestigation funded by the National InstituteonAlcoholAbuseandAlcoholism(NIAAA).

The AA-TRIP Project

Overview

Theprimaryobjectiveof theAA-TRIPstudyis to utilize the Practice Partner ResearchNetwork-Translating Research into Practice(PPRNet-TRIP) quality improvement model(Feifer and Ornstein 2004) to improve detec-tion and management of alcohol problems inhypertensive patients.

The PPRNet-TRIP quality improvementmodel uses a multi-method approach to facili-tating quality improvement in primary carepractices (Feifer and Ornstein 2004). The inter-vention’s theoretical framework is based on so-cial learning theory, adult organizational learn-ing, transtheoreticalmodelofchange,diffusiontheory, complex adaptive systems and organi-zational change models. PPRNet-TRIP useselectronic information tools and behaviorchange theory to facilitate adherence to evi-dence-based guidelines. Specific interventionmethods include (1) electronic medical record(EMR) skills training, (2) academic detailing,(3) performance feedback and review, and(4) annual network participatory meetings.Credible on-site “training-experts,” reminderprompts, performance feedback, and academic

62 SUBSTANCE ABUSE

https://www.researchgate.net/publication/11403893_Brief_interventions_for_alcohol_problems_A_meta-analytic_review_of_controlled_investigations_in_treatment-seeking_and_non-treatment-seeking_populations?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=

https://www.researchgate.net/publication/8357175_Strategies_For_Increasing_Adherence_To_Clinical_Guidelines_And_Improving_Patient_Outcomes_In_Small_Primary_Care_Practices?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=


https://www.researchgate.net/publication/8635940_A_meta-analysis_of_alcohol_consumption_and_the_risk_of_15_diseases?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=

https://www.researchgate.net/publication/21809831_Effectiveness_of_advice_to_reduce_alcohol_consumption_in_hypertensive_patients?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=

https://www.researchgate.net/publication/19238263_Use_of_a_questionnaire_in_general_practice_to_increase_recognition_of_patients_with_excessive_alcohol_consumption?el=1_x_8&enrichId=rgreq-126427dc2be1ad32a5fc18fd55f77ca5-XXX&enrichSource=Y292ZXJQYWdlOzY3MzI2NTE7QVM6MTI2NDg3NTg3OTg3NDU3QDE0MDcxNjgzOTk4NzA=


detailing have been shown to be effective inchangingproviderbehavior(Fleming,2002b).

To successfully adopt and implement clini-calguidelines, thePPRNet-TRIP improvementmodel suggests that primary care practices:

• Prioritize Performance (accept clinicalpractice guidelines, establish project lead-ers, use feedback practice reports to guideimprovement).

• Involve All Staff (extend staff roles incare delivery, train all staff on guidelines,arrange for staff to participate in regularimprovement meetings).

• Redesign Delivery Systems (use point-of-care tests, assign routine monitoring tonursing staff, establish protocols for fol-low-up of patients not-at-goal).

• Activate Patients (provide written infor-mation on guidelines, reinforce messageswith office posters).

• Use EMR Tools (use templates providingguidelines prompts, use internal messagingor chart flags for team coordination, usepersonalized results or web links for pa-tient education.

Alcohol-Focused Intervention

The Alcohol-Focused intervention consistsof providing National Institute on AlcoholAbuse and Alcoholism (NIAAA) written guide-lines on alcohol screening and brief interven-tion together with 4 training site visits byAA-TRIP staff over a 2 year period. The sitevisits reinforce information in the writtenguidelines, for example, providing training inthe4 basic“how-to” screening steps:Ask AboutAlcohol Use, Assess, Advise and Assist, Ar-range Follow-Up. Practices are encouraged toscreen all hypertensive patients on a yearly ba-sis. Because of the starting date of this project,an interim, preliminary version of the currentlyavailable 2005 NIAAA guidelines were dis-tributed to both intervention and control prac-tices (NIAAA 2005). Thus, some differencesexist in our screening algorithm compared tothe current version.

Practices are encouraged to use the AlcoholUseDisordersIdentificationTest -C(AUDIT-C)as an initial screening tool. The AUDIT-C is a3-question screening questionnaire adapted

from the originalAUDIT which was developedby the World Health Organization (WHO) foruse in primary health care (Bush et al. 1998). Inorder to standardize blood pressure measure-ments, BpTRU (VSM Med-Tech Ltd., Van-couver,BC,Canada)automatedbloodpressuremonitors were provided to all practices.

Practices also receive quarterly Practice Re-ports, providing feedback on current and pastscreening, intervention, diagnosis, and referralas well as comparisons with other practices. Inaddition, two staff members from each practiceattendanannualnetworkmeetingduringwhichattendees have an opportunity to exchange use-ful approaches to adopting alcohol screeningguidelines.

This paper presents preliminary, qualitativedata on initial steps at adopting alcohol screen-ing guidelines by nine primary care practices,followingdistributionofwrittenguidelinesandone on-site training visit.

METHODS

Sample

Twenty primary care practices around theUnited States volunteered for the project. Allpractices are members of PPRNet, a primarycare practice-based network in which all mem-bers use the same EMR (Practice Partner, Phy-sician Micro Systems, Inc., Seattle, WA). Prac-tices vary in size from 1 to 10 providers(including physicians, nurse practitioners, andphysician assistants) and vary in the types ofcommunities they serve (e.g., rural vs. urban).All practices submit quarterly data extracts toPPRNet offices in the Department of FamilyMedicine at the Medical University of SouthCarolina (MUSC).

After stratifying for number of providers ineach practice, practices were initially random-ized to an intervention or control group. Tenintervention practices receive the Alcohol-Focused PPRNet-TRIPintervention,whichin-cludes on-site academic detailing visits, quar-terly performance feedback and review withsite visitors, and an annual network meeting.Ten control practices receive written NIAAAscreening guidelines and performance feed-back only. The feedback for control practices is

Miller et al. 63

provided as part of a performance report whichincludes many indicators of quality care otherthan screening for alcohol use, e.g., diabetes,cardiovasculardisease,andcancerscreening. Itshould be noted that the focus of the presentstudy was only to describe the experiences of 9of the 10 interventiongroup practicesattendingthe annual network meeting, not to compare in-tervention with control groups.

Design and Procedures

To learn how practices have implementedalcohol screening, an initial annual networkmeeting was attended by two representativeseach fromnineof the ten interventionpractices,and the study investigators. In most cases, eachpractice sent one provider and one nurse ormedical assistant. The annual meeting pro-vided an opportunity for providers and staff tointeract with peers from other sites in order toshare best practice approaches and to discussbarriers to successful implementation of alco-hol screening. The meeting provided a sourcefor rich qualitative data, as the study investiga-tors facilitated a dialogue to probe how theimplementation process was occurring.

Written informed consent was obtained fromall practices prior to the beginning of the study.The informed consent document made prac-tices aware of all aspects of the study, includingdiscussions at annual network meetings. Thestudy design and informed consent procedureswere approved by the Institutional ReviewBoard of the Medical University of SouthCarolina.

During the four months prior to the networkmeeting, each practice received NIAAA writ-ten alcohol screening guidelines and an on-sitetraining visit by AA-TRIP staff. The visit in-cluded training on the effects of heavy drinkingon hypertension as well as step-by-step screen-ing and brief intervention guidelines.

Also during the four months prior to themeeting, practices were provided with an alco-hol screening template for use with their EMRsystems. The template includes an electronicform of the AUDIT-C questionnaire, withbuilt-in links for data recording. Therefore, asthe provider or staff member conducts thescreening, they can simply click on appropriateanswers so that the AUDIT-C responses,

scores, alcohol diagnoses, and interventionsare automaticallyelectronicallydocumented inthe EMR so that they are easily extracted at alater time. The template followed NIAAA alco-hol screening, intervention, diagnosis, and re-ferral algorithms and enabled EMR documen-tation of each of these activities.

During the one-day meeting, a group discus-sion was structured to determine how each ofthepracticeswas initiatingtheadoptionofalco-hol screening in their clinic routines. To initiateand stimulate discussion, the following fivequestions were proposed to the group:

1. How have you begun to incorporate alco-hol screening of hypertensive patients inyour practice?

2. How are data for alcohol screening, diag-noses, and intervention being docu-mented in the EMR?

3. What have been the major barriers en-countered to date in screening, diagnos-ing, intervening or documenting alcoholproblems in hypertensive patients?

4. How is the BpTRU being used in the of-fice to measure and record blood pres-sures for hypertensive patients?

5. Have there been any positive or negativeoutcomes from the study thus far?

Practices shared their responses with allmeeting participants in a group discussion. Is-sues raised during the discussions were re-corded on flip charts by an AA-TRIP researchteam member. Having multiple facilitators inthis process generated a robust dialogue witheach question. Responses to questions and is-sues raised in discussions were transcribedfrom the charts and summarized. The PPRNet-TRIP improvement model (refer to AA-TRIPProject section above) served as an organizingframework for the narrative, to highlight thestrategies used and the barriers experienced bythe practices. An important component of theAA-TRIP evaluation process was to assessadoption of the PPRNet TRIP model, as thepracticesmadeefforts to initiallyadoptandreg-ularly implement alcohol screening.

Responses to questions and issues raised indiscussions were transcribed from the chartsand summarized. A template style was used forcoding the information. Information was as-

64 SUBSTANCE ABUSE

signed to one of 5 practice improvement cate-gories that are basic to the PPRNet-TRIP im-provement model, i.e., Prioritize Performance,Involve All Staff, Redesign Delivery Systems,Activate Patients, and Use EMR Tools (refer toAA-TRIP Project section above). Data wereextracted from flip-charts by a research assis-tant and initially organized around these 5 cate-gories by one of the authors (Stockdell), a doc-toral nursing student. To provide a second levelof analysis, data organization around this frame-work was reviewed, critiqued and edited by theprimary qualitative analyst (Nemeth). Our anal-ysis investigated the degree to which thesepractices were using each of the PPRNet-TRIPimprovement categories to adopt and consis-tently implement alcohol screening.

RESULTS

In discussing results, practices are refer-enced by the state in which they are located.

Issues Related to Improvement Categories

Prioritize Performance

Overall, providers accepted the alcoholscreening guidelines and expressed new appre-ciation for the potential role of heavy drinkingin the management of their patients’ hyperten-sion. Providers reported that the issue of heavydrinking had become a more important priorityin their daily interactions with hypertensive pa-tients. Several practices reported that this pro-ject has allowed them to identify patients whothey had not suspected of heavy drinking. Forexample, the Kentucky practice, located in a“dry” rural county,hadmadeseveralnewrefer-rals to 12-step support groups since the screen-ing began.

Although thisproject specifically targetshy-pertensive patients, some providers (e.g., Con-necticut, Kentucky), recognizing the impor-tance of alcohol screening in general, were nowperforming alcohol screening on all patients.During the discussion, several other practicesexpressedaninterest inscreeningallpatients.

The Florida provider remarked that he haslearned to appreciate the detrimental affects ofat-risk drinking on his patients’ blood pres-

sures. Previously, he had been concerned pri-marily about his alcohol dependent patientswithout as much focus on the heavy drinking,non-abusive, non-dependent patient. The Con-necticut practice also noted their new ability toidentify varying levels of alcohol consumption(high-risk drinking v. alcohol abuse v. alcoholdependence)asopposed to less specificcatego-ries such as alcohol abuse vs. non-abuse. Rep-resentatives from several other practices ex-pressed agreement with this notion.

In viewing alcohol screening as a priority,the Texas practice found that their part-timeproviders were not as enthusiastic about imple-menting screening as the full-time clinicians.To deal with this issue, the practice director in-stituted regular discussions of the importanceof alcohol screening at weekly staff meetings.During these meetings the director re-empha-sized the importance of the alcohol screeningproject and reviewed screening and interven-tion procedures. As a result, compliance andenthusiasm have improved. Specific factors re-lated to these attitude and behavior changeswere not readily apparent, although this wouldbe a potentially fruitful area of investigation infuture studies. Other providers discussed thisweekly-review strategy and thought it mighthelp in their practices as well.

Itmightbenoted thataprimarywaytopriori-tize performance is through the use of quarterlyPracticeReports toguideimprovement.Nodis-cussions about this factor were generated sincethe project was underway for only 4 monthswhen the network meeting occurred and prac-tices had not as yet received their first practicereports.

Involve All Staff

The majority of practices were involvingvariousstaff in thescreeningprocess, includingproviders, medical assistants and nurses. Mostpractices adopted a routine in which supportstaff (i.e., nurses, medical assistants) initiatedalcohol screening. If the initial screening re-sults with the AUDIT-C were positive, the pro-vider then completed the screening using diag-nostic questions to determine the presence ofat-risk drinking, alcohol abuse and/or alcoholdependence. If necessary, the provider alsoprovided brief intervention or referral.

Miller et al. 65

This practice of nurses doing the initialscreening and providers following-up, whennecessary, with diagnosis, intervention and re-ferral appeared to be the most acceptable sys-tem for staff and providers alike. The initialscreeningbystaffsavedprovidersconsiderabletime. In addition, nurses and medical assistantspreferred that the provider perform the inter-vention and referral and felt that this would bethe system most acceptable to patients.

One of the practices recognized that theirnurses and medical assistants were having dif-ficulty distinguishing the need to initiate thescreening process because they were unable toroutinely identify patients with a diagnosis ofhypertension. The Vermont, Texas and Mary-land practices were able to share their supportstaff’s daily procedure of identifying hyperten-sive patients by reviewing the medication list,the problem list, or recognizing that the ap-pointment was a follow-up for hypertension.Once identified, these patients are targeted foralcohol screening, with the AUDIT-C ques-tions being performed after blood pressuremeasurement. If thepatientdoes notdrinkalco-hol or receives a score of 3 or less on theAUDIT-C, the evaluation concludes. If the re-sults are positive, the providers complete thescreening by asking diagnostic questions andproviding brief intervention or referral. Duringbusy times when nurses and medical assistantsmay not be able to provide the initial screening,providers perform this task. Providers in theVermont practice also try to screen all newlydiagnosed hypertensive patients at the time ofdiagnosis.

In the Michigan practice, medical assistantscomplete an initial AUDIT-C screen on any pa-tient who has an elevated blood pressure read-ing at their appointment. This practice is alsoconsideringexpandingscreening to includepa-tients without a diagnosis of hypertension.

Redesign Delivery Systems

Threemajor issues raisedregardingtherede-sign of delivery systems involved point of caredocumentation, use of the AA-TRIP EMRscreening template, and a reminder system fornurses, medical assistants and providers. TheNorth Carolina practice described using pointof care electronicdocumentationduring the pa-

tient’s visit. In the Maryland practice, medicalassistants identify hypertensive patients anduse chart flags as reminders for the staff to usethe BpTRU blood pressure monitor.

While the Vermont practice providers re-ported that they have assigned screening to thesupport staff, their support staff does not al-ways recognize the need for alcohol screening.While specific reasons for this attitudewere notentirely clear, it was apparently due to an insuf-ficient understanding of the influence of heavydrinking on hypertension. The providers havecontinued to instruct staff on the relationshipbetween heavy drinking and hypertension andremind them to initiate alcohol screening. TheFlorida practice plans to have the nurse ask allof the AUDIT-C questions in the future andhave the physician perform the diagnosticevaluation,brief interventionandreferralonly.

Since screening is performed on an annualbasis, the Maryland practice notes the date thatthe AUDIT-C survey was completed alongwith thedateof thepatient’s follow-upvisits. Inthis way, screening is not repeated if it has beenless than one year since the last evaluation.

An unexpected finding was that, in additionto alcohol screening, the AA-TRIP project hasenhanced thepractices’ focusonprocedures re-lated to blood pressure measurement. Practicesactivelydiscussed techniquesofbloodpressuremeasurement and their procedures in using theBPTRU monitor. Whether this focus on bloodpressure measurement led to increased alcoholscreening was not readily apparent.

Activate Patients

To promote patient participation in screen-ing, some practices were mailing reminders toall of their hypertensive patients regarding fol-low-up blood pressure screening. The Texaspractice mailed reminders to hypertensive pa-tients overdue for a blood pressure check, ask-ing them to schedule an appointment. Duringthis appointment an alcohol screen and a dis-cussion of the impact of alcohol on hyperten-sion were performed This practice has foundthat many patients were unaware of the rela-tionship between alcohol and hypertension andthat, in general, patients have responded favor-ably to the follow-up reminders and to alcoholscreening and education.

66 SUBSTANCE ABUSE

It should be noted that during initial site-vis-its, some practices requestedwrittenpatiented-ucation information to provide to hypertensivepatients who had positive alcohol screens. Dur-ing the network meeting, participants revieweda draft of an alcohol/hypertension patient edu-cation pamphlet prepared by the AA-TRIPteam and provided feedback and suggestions.Once finalized, this pamphlet will be providedto intervention practices for use in briefinterventions.

Use EMR Tools

Many practices were using the AA-TRIPEMR alcohol screening template provided bystudy personnel to streamline screening. Prac-tices agreed that this point-of-care screeningand documentation tool saved considerabletime and effort.

The North Carolina practice uses the AA-TRIP EMR screening template. Although ittook the providers a while to become accus-tomed to the template, the built-in automaticprompts have assisted them to implement anddocument screening more efficiently. In theVermont practice, upon completion of the tem-plate containing the AUDIT-C questions, tem-plate screening data go to the EMR, with alco-hol diagnoses going to the problem list sectionof the EMR.

The Maryland practice has streamlined thetemplate provided by creating multiple explod-ing quick text options (similar to macros inword-processingsoftware). In this format,onlythefirst threequestionsof theAUDIT-Cappearin any given template or note. If screening ispositive, more questions appear so that addi-tional screening and discussion of alcohol usewith the patient can be conducted. Therefore,when these providers open a template for hy-pertension to begin a progress note during a pa-tient encounter, alcohol questions automaticallyappear after the social history.

In the Connecticut practice, providers re-ported that they enter screening data into thetemplate but are reluctant to complete the sec-tionfordiagnosisofalcoholproblemsfor insur-ance reasons. This practice is also concernedwith entering a diagnosis of alcohol abuse ontheproblemlist (seesectionbelowonStigmaofAlcohol Diagnosis).

Other practices choose to use a paper formatof the AUDIT-C questionnaire rather than thepoint-of-care EMR template. Apparently, thesepractices felt that this procedure would allowthe patient to complete the screening questionson their own in the waiting room, thereby sav-ing time for nurses and medical assistants. Themedical assistants and nurses in the Michiganand Florida practices administer the AUDIT-Cquestions on paper to all hypertensive patients.In the Michigan practice, nurses and medicalassistants ask patients to complete a paperscreening form that includes the first 3 ques-tions of the AUDIT-C, with providers complet-ing the screening if further evaluation is neces-sary. Paper templates are later transcribed intothe EMR

Barriers to Alcohol Screening

AUDIT-C versus CAGE

Prior to the initiation of the AA-TRIP pro-ject, most providers had little knowledge of theAUDIT or the AUDIT-C as a screening tool.They were more familiarwith theCAGE whichmost of them had used for many years. Severalproviders spontaneously mentioned that theywere very satisfied with using the AUDIT-Cand preferred it to the CAGE questions. Theiropinion was that the AUDIT-C asked less per-sonally invasive questions and was better ableto detect non-dependent heavy drinking.

Perceived Time Constraints

Several practices noted staff resistance toscreening and using the BpTRU device, attrib-utingthis to timeconstraints.Severalnurses feltthat these two procedures slowed down theflow in the office. Nurses in the Vermont prac-tice have raised concerns about the extra timeneeded for alcohol screening and additionaldata entry, and the Kentucky practice staff alsofelt that alcohol screening was disruptive tothe office routine. Understandably, any initialchange in practice routine can be met with ini-tial resistance. However, other practices notedthat, with experience, alcohol screening can beincorporated into the nurse’s routine and doesnot representanunduetimeburden. Inaddition,since the BpTRU is an automated device,

Miller et al. 67

nurses in other practices found that while thepatient’s blood pressure is being monitored bythe BpTRU, they can be attending to othertasks.

Concern About Offending Patients

Several practices noted initial resistancefrom providers and support staff because ofconcern that alcohol questions might be offen-sive to some patients. Interestingly, with in-creasing experience with screening, nursingstaff found these concerns to be unfounded,with the majority of patients being receptive toalcohol screening. One provider (located in arural, “dry” county) was concerned that screen-ing might be offensive to non-drinking patientswho were abstinent for religious reasons. Otherpractices felt that this was a legitimate concernsince occasional patients in most practicesseemed to be sensitive about this issue. Thegroup discussed the importance of normalizingalcohol questions (i.e., “we are asking all ourhypertensive patients”) so patients do not feelthreatened or singled out.

Stigma of Alcohol Diagnosis

Severalprovidersnotedconcernaboutdocu-menting alcohol problems in the problem list ordiagnosis section of the EMR. This apprehen-sion was related to a concern that insurancecompanies would decline reimbursement forthese patients as well as the possible stigma re-lated to the diagnosis. Most providers were re-luctant to put the alcohol diagnosis into theEMR problem list. To address this issue, pro-viders in the Michigan practice have changedthe EMR recording so that it will place an alco-hol diagnosis in a lab table in the EMR ratherthan in the problem list section. This allows thestudy team to retrieve the diagnosis of alcoholusefordatacollectionpurposes,whilestillkeep-ingthediagnosisfromthepatient’sproblemlist.

DISCUSSION

Overall, we found that these 9 primary carepractices were beginning to successfully adoptalcohol screening guidelines and deal withpractical problems posed by initial efforts to in-

stitute routine alcohol screening of hyperten-sive patients. It was evident that the majority ofpractices were using many of the 5 improve-ment concepts inherent in the PPRNet-TRIPmodel. Prioritizing alcohol screening, involv-ingallstaff,andsuccessfullyredesigningdeliv-ery systems appeared to be essential to incorpo-rating alcohol screening into the practices. Inthis regard, these findings corroborate those ofBabor, Higgins-Biddle, Dauser, Higgins, andBurleson (2005) who found that success withscreening and intervention depends as much onorganizational factors and involvement of allstaff as it does on the actual implementation ofthe screening tool.

While itwasapparent thatpracticesacceptedalcohol screening guidelines, some individualproviders and staff were less than enthusiastic.This reluctanceappears to have more to do withpractical issues (e.g., perceived time con-straints, concerns about patient reactions, andinsurance issues regarding a documented diag-nosis of alcohol use disorder) as opposed tosubstantive disagreement with the need forscreening. We found that, with experience,practices became more time efficient in thescreening process, more accustomed to thescreening procedures, more comfortable inasking patients about alcohol use, and less con-cerned thatpatientswouldbeoffended.As timeprogressed, staffappeared tobecomemorepro-ficient in phrasing screening questions in waysthat were less threatening to patients. Indeed,staff found that many of these initial barrierswere more related to perceptions than realities.As other studies have noted (Babor et al. 2004),it is apparent that, with increasing experience,providersperceivefewerobstaclestoscreening.

Most practices in our study adopted an inter-disciplinary approach to screening in whichnurses, medical assistants, providers, and, insome cases, even information technology staffwere involved. It was evident that this team ap-proach (and, in some cases, team spirit) fos-tered successful implementation of screeningand helped engage those who were less than en-thusiastic. While each practice redesigned theirdelivery systems to accommodate screening indifferent ways, most assigned nurses and medi-cal assistants the tasks of identifying hyperten-sive patients and conducting the initial screen-ingwith theAUDIT-C.Thisprocedurescreened

68 SUBSTANCE ABUSE

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out the 70% to 80% of patients who typicallyscreen negative in primary care, allowing pro-viders to focus their time on the 20% to 30% ofthe remaining patients requiring more ad-vanced screening and possible brief interven-tion.

Practices found the EMR alcohol screeningtemplate provided by the AA-TRIP staff to beespeciallyhelpful indocumentingscreening. Insome practices, if the initial AUDIT-C screen-ing was positive, nursing staff would leave thetemplate in view, to prompt the provider to con-tinue with the screening algorithm, providingdiagnosis, interventionorreferral, ifnecessary.

Perceived time constraints were an issueduring early stages of the implementation ofscreening. Indeed, other investigators havefound that lack of time is one of the most impor-tantperceivedbarriers to implementingalcoholscreening in primary care (Barry et al. 2004).However, we found that time concerns did notcontinue to be an issue with most practices. Itwas apparent that, over time, screening becamemore routine and time efficient. In addition, be-cause most patients screened negative on theAUDIT-C, screening did not take up the amountof time that was first thought.

Finally, a major concern in many practiceswas documenting an alcohol diagnosis on thepatient’smedical recordbecauseofpossible in-surance repercussions and the stigma of an al-cohol diagnosis. Practices preferred either toavoid diagnosis altogether or to document thediagnosis in a non-diagnosis section of theEMR (e.g., a table). This issue deserves moreinvestigation as it appears to be a potential bar-rier to accurate documentation of alcoholdiagnoses among primary care providers.

Since theninepracticeswere involved in thisstudyfor less thanfourmonthsat the timeof thisnetwork meeting, these results must be consid-ered preliminary. The providers and practicestaff at this meeting were representatives frompractices and the discussion was based solelyupon their interpretation of the implementationof the guidelines by all members of their prac-tice teams. However, these findings will bevaluable in planning the design of future quali-tative studies of these practices, using more re-fined questions. In this way, it may be possibleto identify specific organizational, providerand patient characteristics that influence the

method and consistency of alcohol screeningand intervention. While the single-session flip-chart approach was a useful format to obtainrich qualitative data about initial barriers toscreening and solutions to those barriers, otherqualitative analytic methods (e.g., interviews,surveys)canbeused infuturestudies toprovidemore details on the issues identified in this pre-liminary investigation.

This study confirmed that alcohol screeningguidelines can be implemented in primary carepractices using a variety of strategies. The di-versity of experiences gleaned from these ini-tial attempts at adoption of screening guide-linesexemplifieshowpracticesdevelopuniquemethodsof implementationrelated to theirownsystem characteristics. It was also apparent thatthis network meeting provided practices an op-portunity to share methods of implementationand discuss ways to overcome initial barriers tosuccessful adoption.

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Journal ordering, copyright, and document delivery information continued

Journal Ordering, Copyright, and Document Delivery Information

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Measuring College Student Drinking

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