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Proceedings of the 34th International Congress on Alcoholism and Drug Dependence

Date: 10 Aug 1985 (est.)
Length: 560 pages
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100th Anniversary/100e Anniversaire PAPERS PRESENTATIONS Proceedings of the 34th International Congress on Alcoholism and Drug Dependence. Compte Rendu du 34e congr6s International sur I'Alcoolisme et les Toxicomanies August 4th to 10th, 1985 Calgary, Alberta Canada du 4 au 10 Aout, 1985 Calgary Alberta Canada Sponsored by the International Council on Alcohol and Addictions Hosted by the Alberta Alcohol and Drug Abuse Commission Parraine par le Conseil International sur les Probl~mes de I'Alcool et des Toxicomanies Organists par Ia Commission Albertaine contre I'Alcool et les Toxicomanies TIMN 321380
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FOREWORD This volume contains papers that were presented in the formal plenary and concurrent program sessions of the congress. All papers were printed as received. The papers are arranged alphabetically by title. The opinions expressed and any conclusions drawn do not necessarily have the endorsement of or represent the view of the International Council on Alcohol and Addictions or the Alberta Alcohol and Drug Abuse Commission. Papers presented in the information exchange sessions are available by title from the Alberta Alcohol and Drug Abuse Commission (AADAC), Suite -#803, 10109 - 106 Street, Edmonton, Alberta, Canada. T5J 3L7. AVANT PROPOS Ce volume contient des presentations qui ont ete soumis aux seances plenieres formelles et simultanees du programme du congres. Tous les presentations ont ete imprimes tels que requs. La disposition des presentations est par titre organise en ordre alphabetique. Les opinions y exprimees ainsi que toute conclusion qu'aient tire les participants ne sont pas nec6ssairement appuyees par le Conseil International sur les Probl'emes de 1'Alcoolisme et des toxicomanies ou par la Com- mission Albertaine contre 1'Alcool et les Toxicomanies ni representent-elles absolument leur point de vue. Les presentations donn6es au cours des seances d'6change d'informations sont disponibles par titre. Veuillez contacter la Commission Albertaine contre 1'Alcool et les Toxicomanies, #803, 10109 - 106 rue, Edmonton, Alberta, Canada. T5J 3L7. I ! TIMN 321382
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Alcohol, Drugs, and Tobacco: An International Perspective-Past, Present, and Future. Proceedings of the 34th International Congress on Alcoholism and Drug Dependence August 4-10. 1985 Calgary. Alberta, Canada Volume fl Papers ® 1985 Alberta Alcohol and Drug Abuse Commission Additional copies available from: I.C.A.A., P.O. Box 140, CH-1001, Lausanne, Switzerland L'Alcool, les Drogues et le Tabac: Perspectives Internationales-le Passe, le Present et 1'Avenir. Compte-rendu du 34e Congres International sur I'AIcoolisme et les Toxicomanies 4 - 10 aouf 1985 Caigary, Alberta, Canada Volume ii Presentations ® 1985 La Commission Albertaine contre 1'Alcool et les Toxicomanies Des exemplaires suppiementaires sont disponibles a 1'addresse suivante: C.I.P.A.T., Case postale 140, CH-1001, Lausanne, Suisse TIMN 321381
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TITLE INDEX PLENARY AND CONCURRENT PAPERS A C D AADAC's Clever Classmates: A Co-ordinated Ap- proach To Drug Education ............. 1 Acupuncture Treatment For Cigarette Smoking 5 Adult Children Of Alcoholics In Bermuda: A Com- parison Of Characteristics Within The General Population ......................... 5 Advances In Recent Knowledge-Epidemiological Studies ............................ 9 Alcohol And Country Music: The Values Of The Songs And Of The Fans ............... 12 Alcohol And Drug Impairment In Registered Nurses .......................16 Alcohol And Drug Prevalance In Occupational Fatalities In Alberta 1979-1983 ......... 19 Alcohol And Drug Use Among Montreal High School Students ................---.........22 Alcohol And Family Violence ............. 24 Alcohol And Memory Processes: Implications For The Elderly Alcoholic ...... ........... 27 Alcohol Dependence And Problem Drinking In A National Sample ..................... 29 Alcohol Education In Europe.............. 31 Alcohol Involvement In U.S. Highway Crashes- Making Policy Decisions On Incomplete Data -------------------------..39 Alcoholism: The Costs Of The Problem And Its Treatment ..........................43 The Alcoholism Rehabilitation Program Of The Cana• dian Forces .........................47 L'Alcoolique Tel Qu'ii Est Perqu Dans Une Popula- tion De Bilan De Sante ............... 49 An Analysis Of Policy And Program Implementa- tion For The Impaired Nurse: What Is Being Done In The United States ............ 53 Antecedents Of The Impaired Nurse ........ 56 Assessment And Variably Intense Intervention: A Systems Approach To D.U.I............ 57 An Assessment Of Alcohol Abuse Programs In Arctic Canada.... ........................ 60 An Assessment Of The Referral Procedures And A General Profile Of D.U.I. Offenders In The Circuit Court Of Cook County, Illinois ... 63 The Attitude Of Nurses Affecting The Rehabilitation Of Impaired Nurses Using And Abstaining From Drugs And Alcohol .................. 67 : Benefits And Drawbacks Of Using Pychotherapeutic Methods In Short-Term Rehabilitation Programs For Drinking Drivers ................. 68 The Best Of Both Worlds: A Retrospective Overview Of Substance Abuse Prevention ......... 74 British Opiate Policy And The Overprescribing Physi- cian: An International Perspective On An Im- portant Historical Era ................. 79 Canadian Addictions Foundation: Present Challenges And Fututre Thrusts .................. 81 Cannabis Information Program "Stay Real/Vive" Moi-Meme ......................... 83 Catabolism And Inactivation Of Acetaldehyde In The Animal Organism .................... 87 Characteristics Of Alcoholics In Alcoholics Anonymous ........................ 88 Characteristics Of The Senior High Student Who Drinks And Drives ................... 91 Children Of Alcoholics: A Systems Approach ..................................94 A Christian Perspective-The Christian Motivation, History and Contemporary Response.....98 Chronic Alcoholism-Predisposing Factor To Alzheimer Disease? Correlation Between Symp- tomatology, Electrophysiological Findings And Postmortem Neuropathology ........... 99 Clinical And Ultrasonic Study On Alcoholic Liver Disease...........................101 Cocaine Use In The United States Electronics Industry And Some Behavioral Treatment Approaches Designed To Treat Cocaine Addiction ......................... 103 Collecting And Reporting Alcohol-Related Morbidity Statistics .......................... 108 Combined Abuse Of Alcohol, Cocaine and Marijuana: Behavioral Consequences And Treatment Issues ............... . ... 105 A Comment Concerning Methodology Of Alcohol Choice Experiments ................. 113 Community Participation In Drug Abuse Control Prevention, Treatment And Rehabilitation In Selected Communities (Barangays) Of Metro Manila ........................... 115 A Comparison Of Psychotropic Drug Use Between The General Population And Clients Of Health And Social Service Agencies .......... 117 Conditions Of Legal Drug Use By Housewives, Employed Women and Men. Results And Problems Of A Population-Survey ..... 122 The Consequences Of Changing Smoking Habits On Lung Cancer Mortalities In 1900, 2000 And 2010............................. 126 Les Consultations Pour Les Jeunes Dans Un Cabinet De Praticien. Bilan Apres 4 Annees De Fonctionnement ....................i29 Creative Writing-Iherapy Used To Assist Chemically Dependent Adolescents Express Feelings .................................130 Criminal Law And Drug Control-A Look At Western Europe .................... 133 Criteres D'Utilisation Des Psychotropes Dans L'Abord Therapeutique Des Alcooliques ........ 142 A Critical Look At Children Of Alcoholics From A Child Development Perspective ........ 143 A Data-Model For The Treatment Of Alcohol And Drug Addicts ...................... 147 Deliberate Self-Harm Among Nigerians: The Use Of Chemicals And Psychotropic Drugs ..... 148 Demographic Profile Of Substance Use Disorder Patients Seeking Help In A Provincial Psychiatric Hospital Rehabilitation Program: A Study Conducted At Alberta Hospital Ponoka.. 150 Developing Smoking Prevention Materials: A Psycho• Social Approach .................... 155 The Development And Evaluation Of A Treatment Program Designed Specifically For Women .................................176 Development, Implementation, Evaluation Of It's Just Your Nerves: A Resource On Women's Use of Minor Tranquillizers And Alcohol ...... 157 Diazepam Impairs Long-Term Memory Storage And Retrieval, But Not Short-Term Memory .................................160 Dietary Factors And Alcoholic Cirrhosis .... 163 Dopamine And Opiate Systems Peculiarities As A Basis Of Development Of Alcohol Dependence: Role Of Genetic Factors .............. 165 Drinking Patterns Of First-Year Medical Students .................................166 Drug Addiction Among Ethnic Minorities In The Netherlands ....................•..169 The Drug Problem And Criminal Law In The Federal Republic Of Germany ............... 171 Drug Use Patterns Of Nursing Students In Scotland's Tayside Region: Implications For Education .................................173 Drugs, Consciousness And Society: Can We Learn From Others' Experience? ............ 174 E Economic Considerations In Alcoholism And Drug Dependence ....................... 179 Economic Costs To Society Of Alcohol Problems In Ontario And In Canada .............. 181 Educational Messages In Alcohol And Drug Education ...................•.....184 Effect Of Alcohol Intake During Pregnancy On Sleep Cycles In The Newborn ............. 185 The Effect Of Alcohol On The Activity Of Macrophage ....................... 188 The Effect Of Ethanol During The Brain Growth Spurt: Nursing Implications ........... 221 Ethanol Contents In Drink Drugs And Cool Beverages On The Market In Japan .... 191 Emerging Issues Of Human Rights And Confidentiality In Employee Assistance Programs-A Treatment Perspective .... 192 TIMN 321383 II
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V Van de Wijngaart, Govert F. Methadone: Treat or Treatment? University Of Utrecht, Bijlhouwerstr. 6, 3511 ZC, Utrecht, Netherlands ............. 314 Vendsborg, Per B., et al. A Prospective Controlled Investigation Of A Treatment Program For Alcoholism With The Goal: Increased Control With Alcohol Con• sumption Sct. Hans Hospital, 4000 Roskilde, Roskilde, Denmark ......................... 390 Vollers, Jan L Drug Addiction Among Ethnic Minorities In The Netherlands Min. Welfare, Health & Culture, Postbox 5406, 2280 HK, Rijswijk, The Netherlands.... 169 W Waahiberg, Ragnar B., et al. Planning And Organizing Mass Media Cam• paigns Statens Edruskapsdir., Box 8152-Dep, 0033 Oslo l, Oslo, Norway ............... 357 Walsh, Brendan M. Economic Considerations In Alcoholism And Drug Dependence University College, Dept. Of Political Economy, Dublin, Ireland, 4 .................. 179 Warkentin, Ed Where Are You When Your Client Needs You? B.C. Telephone Company, 5-3777 Kingsway, Burnaby, British Columbia, V5H 3Z7 ... 541 Wilsnack, Sharon C., et al. Gender-Role Orientations And Drinking Among Women In A U.S. National Survey University Of North Dakota, School Of Medicine, Neurosc., North Unit, Room 221, Grand Forks, NC, U.S.A., 58202 ....... 242 1 Yamada, Takashi Clinical And Ultrasonic Study On Alcoholic Liver Disease Osaka City University, Dept Liberal Arts, Health Sci, 3•3• 138 Sugimoto-Cho, Sumiyoshi-Ku, Osaka, Japan ...............•--••---•----101 Yamamoto, Hisafumi, et al. The Effect Of Alcohol On The Activity Of Macrophage Institue For Adult Diseases, Asahi Life Founda• tion, 1-9-14, Nishishinjuku, Shinjuku•ku, Tokyo, Japan 160.......................... 188 Yamauchi, Kazuaki, et al. Hepatitis B Virus In Hospitals For The Alcoholics Inter Project Corporation, Kurosawa Bldg., 1- 16.17 Toranomon, Minato-Ku, Tokyo, Japan, 105 ...................•----......259 Yatim, Datuk Rais International And National Control Policies- Impact Of International Control Systems On Regional And National Policies National Drug Research Centre, University Of Science, Malaysia, Minden, Penang, Malaysia ................................279 Yip, Rosanna A Critical Look At Children Of Alcoholics From A Child Development Perspective A.A.D.A.C., 1177 • 11 Avenue S.W., Calgary, Alberta, T2R 0G5 .................. 143 Yoshida. Akira, et al. Molecular Genetics Of Alcohol-Metabolizing Enzymes City Of Hope Medical Center, Duarte, Califor• nia, U.S.A. 91010 .................. 321 TIMN 321391 x
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Establishing The Salvation Army Family Recovery Program: A Residential Treatment Centre For Chemically Dependent Women And Their Children .......................... 194 An Estimate Of The Demand For Alcohol In Canada 1959-1982 ....................... 198 An Estimate Of The Demand For?obacco In Canada 1950- 1982 ....................... 201 Ethnic Differences In Reported Rates Of Alcoholism In Trinidad And Tobago ............. 204 Etude Du Mechanisme Par Liquel La Metapramine Reduit La Prise Volontaire D'Ethanol Par Le Rat .................................205 Evaluability Assessment And An Adolescent Alcohol/Drug Prevention Program ..... 225 Evaluating Media-Based Prevention Campaigns .................................208 Evaluation Of An Early Intervention Program For Problem Drinkers ................... 212 Evaluation Of An Inpatient Women's Addiction Treatment Program ................. 214 Evolutionary Origins Of The Preference For Alcohol .................................217 F Features Associated With Medication Compliance Among Alcoholics .................. 228 Follow-Up Of Former Residents O1The Emiliehoeve, A Therapeutic Community For Drug Addicts .................................231 The Formulation Of A National Policy On Alcohol In Australia ....................... 235 G Gender-Role Orientations And Drinking Among Women in A US. National Survey .-._. 242 The Generation Preschool Project ......... 236 Group Counselling With Alcohol Offenders: An Analysis And Typology Of DWI Probationers ............................ ---__-_237 H Health Services Use Patterns Of Male Alcoholics: Implications For Primary Care......... 256 Hepatitis B Virus In Hospitals For The Alcoholics .................................259 An Historic And Prophetic Perspective ..... 260 Hormonal Component In The Regulation Of Endogenous Ethanol Level In The Body .................................261 I Implications Of The "Learned Helplessness" Model For Alcohol Treatment .............. 263 Implications-What Do We Do Next?...... 264 Incest Among Women In Recovery From Alcoholism And Drug Dependency: Correlation And Implication For Treatment ............ 268 Individual Sensitivity To Alcohol As A Basis To Predict General Clinical Regularities Of Alcoholism ........................270 Individual Variability In Alcohol Taste Threshold Estimation ........................ 271 Influence On The Relationship Between Youth And The Youth Worker .. ............... 274 Interaction Between Methamphetamine And Alcohol................ .......... 276 Integration Of Alcohol And Drug Education In General Health Education ............ 278 International And National Control Policies-Impact Of International Control Systems On Regional And National Policies ................ 279 The International Treaties-Sufficient For Inter- national And National Drug Control? ... 282 International Workshop On Smoking ...... 289 Introduction Of Narcotic Antagonist Treatment In A Methadone Treatment Program...... 291 Involvement Of Youth In Alcohol Education By Means Of The Two-Step Model ....... 293 Is ]nitial Sensitivity To Ethanol Correlated With Alcohol Preference In Alcohol Drinking Rats and Non-Drinking Rats? ................. 297 K KHAT Abuse: An Increasingly Worrying Issue ....................................300 L A Longitudinal Study On The Concentrations Of Zinc And Copper In Pregnant Problem Drinkers: Relation To Fetal Outcome ........... 301 M "Marijuana Is Mother": A Study Of Semantic Changes In The Inner World Of Young, Polydrug Addicts Accompanying Successful Treatment In a Drug Rehabilitation Community...... 304 Media Based Prevention Program For Adolescents ....... ........................... 309 A Meta-Analysis Of The Epidemiological Results Of Existing Alcohoi-Related Longitudinal Studies By Age And Sex.... -................. 310 Methadone: Treat or Treatment? .......... 314 Model For Quantifying The Drug Involvement Of Medical Students ................... 316 Modifications Electro-Encephalographiques Liees Au Psychotropisme De L'Ethanol - . . . . . . . . 319 Molecular Genetics Of Alcohol-Metabolizing Enzymes.......................... 321 N The National Addictions Training System ... 322 The Nature And Extent Of Alcohol And Drug Use And Its Consequences In Canada ...... 324 Nicotine Chewing Gum, Rapid Smoking, And A "Placebo" Effect ....................325 Nursing Diagnosis In The Addicted Patient Population ............. . .......... 327 O One Major Problem Associated With Alcohol Treatment Programs Is The Inability To Keep Patients In Treatment Long Enough To Realize The Benefit .......................331 Outpatient Methadone Detoxification ...... 333 P Patterns Of Alcohol Use In The City Of Toronto .......-----------------------...397 The Peer Assisted Learning (Pal) Smoking Prevention Program .......................... 340 Peer-Led Approaches 7o Drug Abuse Prevention .................................342 Personal And Professional Self•Esteem Of Addicted Nurses ...........................343 Personality Types And High Risk Situations: What Is The Connection For Alcoholics And Substance Abusers? ..........................347 Perspectives On Treatment .............. 348 Perspectives On Treatment: Tobacco Addiction .................................350 Persuasion: Let's Get With ltl ............ 352 Phagocytotic Activity In Chronic Ethanol Treated Rats ............................. 353 Physiological Measures In Adolescents And Their Parentage .........................354 Planning And Organizing Mass Media Campaigns .................................357 Positive Approaches To Prevention ........ 359 Present And Future Support Systems For Alcohol Countermeasure Efforts .............. 360 Presentation Notes-Zoot Capri ........... 363 Pretreatment Assertion Levels As They Relate To Treatment Outcomes In An Alcohol Abusing Sample ........................... 365 Prevalence Of Alcoholism In A Clinic In Southern Thailand And Validation Of Mast And GGT vs Clinical Interview .................. 366 Prevention As The Socialization Of Experience- Inherent Contradiction In Prevention ... 369 The Prevention Of Alcohol-Related Problems Through Legal Control Measures.......370 Prevention Strategies-A Special Address ... 404 Prevention Strategies: Public Support For Alcohol Control Policies And The Constraints On Change .................................373 Prevention Training In The Drug Field..... 376 The Primary Prevention Of Drug Abuse: Major Promising Approaches ............... 377 Prise En Charge Psychiatrique Et Prise En Charge Alcoologique Des Alcooliques ......... 380 The Problems Of Addiction Nurses In Canada .................................381 A Propos De 200 Syndromes D'Alcoolisme Foetal Observes En 25 Ans: Quelques Precisions Cliniques Et Pathogeniques ........... 384 A Prospective Controlled Investigation Of A Treatment Program For Alcoholism With The Goal: Increased Control With Alcohol Consumption ...................... 390 Psychodynamical And Social Aspects Of The Relationship Between Life Cycle Events And Alcohol Abuse Of Women ........... 391 Psychoneurotic Profiles And Some Characteristics Of Drug Dependents In A Rehabilitation Centre, Malaysia ..........................393 Public Health Perspective In Alcoholism And Drug Dependence ....................... 395 a Quelles Structures Therapeutiques Faut-II Privilegler En France Pour Les Problemes D'Alcoolisation Et D'Alcoolisme? ................... 405 TIMN 321384 iii
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I 1 I i I t . R A Rational Approach To Alcohol Withdrawal ............ ..................._.407 The Reaction Of Clients And Staff To On-Site Urine Testing In A Methadone Programme ... 409 Recent Advances in Biomedical Knowledge Of Addiction ......................... 414 Recent Advances On Knowledge About Alcohol Pro- blems: Social And Behavioral Sciences . . 419 The Recovery Attitude And Treatment Evaluator IRatel An Instrument For Patient Progress And Treatment Assignment ............... 425 Reduction Of Community Alcohol Problems ................................. 427 Rehabilitation And Korsakoffs Syndrome Group Therapy Pilot Data .................. 434 Rehabiliting The Drinking Or Drug Impaired Driver: Its Evolution From Education To Intervention ....................... -------•.437 The Relationship Of Alcohol Consumption Rates, Hospital Morbidity Rates And Mortality Rates Of A Designated Geographical Population From 1940 .1979 ..................-----440 Results Of The Toblo Detox Center Activity .......... ....................... 443 RNact Nursing Careplan Generator ........ 446 The Role Of Alcohol Metabolizing Enzymes In Acute And Chronic Effects Of Alcohol ....... 451 S Secondary Prevention Strategies For Alcoholism In A Teaching Hospital: Routine Use Of The Cage Ouestionnaire In The Medical Work•Up ........... ...•.----------------- 454 Sex Differences In Cigarette Smoking In Canada, 1900 - 1978: A Reconstructed Cohort Study ........................-......,..457 Short-Term Psychodynamic Psychotherapy In The Therapeutic Community ............. 461 Simplification Des Tests Pour Le Diagnostic Des Toxicomanies, Ses Atouts Et Ses Inconvenients .... ............................. 462 Social And Health Issues: The US. Spirits lndustry's Approach ......................... 465 Social Origins Of Alcoholism In Women: Mirage Or Methodological Meagreness? ..... . .... 468 Strategies And Modalities For The Treatment Of Drug Dependents ...................469 Strategy For Prevention And Reduction Of Demand For Illicit Drugs In The International Programme Of Drug Abuse ....................-473 A Study Of Selected Psycho-Social Characteristics Of Western Manitoba Women With Drinking Problems . . . ...................... 475 Stress, The Family Environment And Multiple Substance Use Among Seventh Graders ................... .............. 479 Substance Use of Pregnant And Non-Pregnant Adolescents ....................... 495 Suicide Ideation And The Alcohol Dependent Per sonality: Implications For Treatment .... 485 Supervised Disulfiram: A Viable Alternative To License Suspension For DWI Conviction .............. ...................486 Symptoms Of Alcoholism: Clinic Alcoholics vs. Pro. biem Drinkers At Large .............. 491 T The Teaching Of Atcofiology In French Universities .......................... 499 Therapeutic Problems Of The Heroin Addicts In Thailand.......................... 500 Towards Freedom From The Pressure Of Cigarette Advertising: l.egislation Versus Self Regulation ............................ ...................504 Training Addiction Workers ............. 507 Treatment Outcome In Female Alcoholics: Findings From A Long-Term Follow-Up Study Of 44 Women .......... ••--------------513 Treatment Services: A Balancing Act....... 515 Trends In Alcohol Policy In Canada ....... 518 Trends In Tobacco Consumption In Seven Coun• tries 1950 - 1984 ...................521 U Undergraduate Alcohol Misuse: Peer Counselling As A Strategy For Prevention And Early Detection .... ........ ................•...528 Understanding Addictions Among Women: An In ternational Perspective .... . .... ... . ..529 Unveiling Powerful Psychosocial Predictors Of Alcohol-Induced Car Accidents ........ 531 The Use Of Alcohol By Members Of The Canadian Forces............................ 534 Using Electronic Pagers To Monitor The Process Of Recovery In Alcoholics And Drug Abusers ....... .-------------------------535 V Voluntary And Involuntary Drinking: An Animal Model For Alcohol Abuse? ........... 538 W Where Are You When Your Client Needs You? -•--•------- ---•••-•---.....541 World Trends In Smoking..... . . ....... . 543 iv TIMN 321385
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AUTHOR INDEX PLENARY AND CONCURRENT PAPERS A Abe Hirohiko, et al. Phagocytotic Activity in Chronic Ethanol Treated Rats Inter Project Corporation, Kurosawa Bldg., 1-16•17, Toranomon Minato-Ku, Toyoko, Japan, 105 ..............................353 Adrian, Manuella Economic Costs To Society Of Alcohol Problems In Ontario And In Canada Addiction Research Foundation, Statistical Infor• mation Sectn., 33 Russell Street, Toronto, Ontario, M5S 2S 1 .................. 181 Adrian, Manuella The Nature And Extent Of Alcohol And Drug Use and Its Consequences In Canada Addiction Research Foundation, Statistical Infor• mation Sectn., 33 Russell Street, Toronto, Ontario, M5S 2S 1 .................. 324 Agarwal, D.P., et al. The Role Of Alcohol Metabolizing Enzymes In Acute And Chronic Effects Of Alcohol University of Hamburg, Institute Of Human Genetics, 2000 Hamburg 54, Butenfeld 32, Hamburg, West Germany ............ 451 AI-Awaji, Dr. lbrahitn M. Prevention Strategies-A Special Address Ministry Of Interior, Riyadh, Saudi Arabia 404 Albrecht, Hans-Jorg Criminal Law And Drug Control-A Look At Western Europe Max-Planck Institute For Foreign & InternaL Penal Law, Gunterstalstrasse 73 D-7800, Freiburg, West Germany ............. 133 Alleyne, Brian C., et al. Alcohol And Drug Prevalence In Occupational Facilities In Alberta 1979•1983 Workers' Health, Safety And Compensation, 10709 Jasper Avenue, Edmonton, AB, T5J 3N3 ---------- - 19 Anderson, Gina S. Training Addiction Workers A.A.D.A.C., 7th Floor, 10909 Jasper Avenue, Edmonton, Alberta, T5J 3M9 ......... 507 Anokhina, I.P. Dopamine And Opiate Systems Peculiarities As A Basis Of Development Of Alcohol Dependence: Role Of Genetic Factors All-Union Research Institute Of Gen. & Forensic Psychiatry, Moscow, U.S.S.R., 121192... 165 i Baer, Paul E., et al. Stress, The Family Environment And Multiple Substance Use Among Seventh Graders Baylor College Of Medicine, One Baylor Plaza, Houston, Texas, U.S.A., 77030 ........ 479 Bardsley, Dr. John The Use Of Alcohol by Members Of The Canadian Forces Department Of National Defence, DPM 3-2, 101 Colonel By Drive, Ottawa, Ontario, KIA 0K2 ................................534 Barrucand, Dominique, et al. L'Aicoolique Tel Qu'il Est Per4u Dans Une Population De Bilan De Sante Centre Hosp. Univ. De Nancy, 29 Av. Du Marechal De Lattre, De Tassigny, Case Offic. No. 34, Nancy, France, 54037 ............. 49 Barrucand, Dominique, et al. Quelles Structures Therapeutiques Faut-il Privilegier En France Pour Les Problemes D'Alcoolisation Et D'Alcoolisme? Centre Hosp. Univ. De Nancy, 29 Av. Du Marechal De Lattre, De Tassigny, Case Offic. No 34, Nancy, France, 54037 ............ 405 Barrucand, Dominique The Teaching Of Alcohology In French Univer• sities Centre Hosp. Univ. De Nancy, 29 Av. Du Marechal De Lattre, De Tassigny, Case Offic. No 34, Nancy, France, 54037 ............. 49 Benichou, Dr. Lionel Criteres D'Utilisation Des Psychotropes Dans L'Abord Therapeutique Des Alcooliques 'Bauri' Sainte-Suzanne, Orthez, France, 64300 ........................... 142 Benichou, Dr. Lionel Prise En Charge Psychiatrique Et Prise En Charge Alcoologique Des Alcooliques 'Bauri' Sainte-Suzanne, Orthez, France, 64300........................... 380 Berliner, Arthur K. Group Counselling With Alcohol Offenders: An Analysis And Typology Of DWI Probationers Texas Christian University, Box 30790, Fort Worth, Texas, U.S.A., 76129 .......... 237 Bhatti, Tariq Prevention Training In The Drug Field 8732 - 163 Street, Edmonton, Alberta, T5R 2N6 ................................ 376 Blackwell, Judith C.S. British Opiate Policy And The Over-Prescribing Physician: An International Perspective On An Important Historical Era Addiction Research Foundation, 33 Russell Street, Ottawa, Ontario, M5S 2S1 .......79 Boismare, Francis, et al. Etude Du Mechanisme Par Lequel La Metapramine Reduit La Prise Volontaire D'Ethanol Par Le Rat Faculte De Medicine De Rouen, B.P. 97, St. Etienne Rouvray, France, 76800 ....... 205 Bowers, Marilyn, et al. Patterns Of Alcohol Use In The City Of Toronto City OFToronto, Dept. Of Public Health, 7 Fir., E Tower, City Hall, Toronto, Ontario, M5H 2N2 .................................397 Boyd, Nancy B. 'Marijuana Is Mother': A Study Of Semantic Changes In The Inner World Of Young, Polydrug Addicts Accompanying Successful Treatment In A Drug Rehabilitation Community 4949 Battery Lane, No. 303, Bethesda, Maryland, U.S.A., 20014 ............. 304 Brochu, Serge, et al. The Alcoholism Rehabilitation Program Of The Canadian Forces National Defence Headquarters, Surgeon General Branch, Ottawa, Ontario, KIA 0K2.....331 Buckwalter, Kathleen C. One Major Problem Associated With Alcohol Treatment Programs Is The Inability To Keep Patients In Treatment Long Enough To Realize The Benefit University Of Iowa, College Of Nursing, lowa City, Iowa, U.S.A., 52242 ............ 331 Buhringer, Gerhard, et al. Strategies And Modalities For The Treatment Of Drug Dependents Max-Planck•Institute Psychiatric, Parzivaistrasse 25, D-8000 Munchen 40, Munchen, West Germany ......................... 469 Buisman, Wim Educational Messages In Alcohol And Drug Education Fed. Alcohol & Drug Centres, Rembrandtlaan 2A, Bilthoven, Netherlands, 3723 ......... 184 Burian, Wilhelm Short-Term Psychodynamic Psychotherapy In The Therapeutic Community Anton Proksch Institut, Mackgasse 7.9, 1237 Wien, Wien, Austria ................ 461 Burns, Elizabeth M., et al. The Effect Of Ethanol During The Brain Growth Spurt: Nursing Implications University Of Iowa, College Of Nursing, Iowa City, Iowa, U.S.A., 52242 ............ 221 C Caliguri, Joseph P. Evaluability Assessment And An Adolescent Alcohol/Drug Prevention Program University Of Missouri, School Of Education UMKC, 5100 Rockhill Road, Kansas City, Missouri, U.S.A., 64110 .............. 225 Carle, Judith Suicide Ideation And The Alcohol Dependent Personality: Implications For Treatm2nt Safer Couns. Service, 103 • 3350 Fraser Street, Vancouver, British Columbia, V5V 4C6 ................................ 485 Casswell, Sally, et al. Prevention Strategies: Public Support For Alcohol Control Policies And The Constraints On Change University Of Auckland, Alcohol Research Unit, School Of Medicine, Auckland, New Zealand ................................373 Cherry, Andrew L Undergraduate Alcohol Misuse: Peer Counsel• ling As A Strategy For Prevention And Early Detection Salisbury State College, Social Work Department, Salisbury, Maryland, U.S.A., 21801 ..... 528 TIMN 321386 v
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1 I "This information could change your life", and "The more you know, the better judgement you have." fWembley) Changes the students would make if they were in charge included.: Change the blue book (AADAC Services) because it is not easy to read. Students would make it more interesting than just addresses. Each team should play more games. "The more games you play, the more you learn." Have more balanced teams. Teams should be composed of two grade sevens, two grade eights, two grade nines, and spare could be any grade. More questions up for grabs. More individual questions. Questions should be asked on a cross-section of all pamphlets. IV Media Coverage Background To gauge the impact of Clever Classmates on communities in the area, a com- parison of AADAC media coverage for the years 1983 and 1984 was undertaken. Methods Newspapers were collected from the Northwest Region for the months October- November 1983 and October-November 1984. Only those newspapers who were able to supply issues for both 1983 and 1984 were used. All papers except The Grande Prairie Daily Herald Tribune were weeklies. Table 4 shows the amount of newspaper coverage received in the 1983 and 1984 periods for Clever Classmates and for all other AADAC programs. Since Workplace '84 occurred only in 1984, it was separately described. Only five of the 13 newspapers covered Clever Classmates in 1983, most likely because the program operated only in the High Level and Peace River areas. All but one paper carried some news of the program in 1984. The five papers who covered Clever Classmates in 1983 all increased their coverage. Only one paper had a net decline in cover- ing AADAC programs. Total coverage of Clever Classmates increased by over 200% and coverage of other AADAC programs increased by 184%. Total AADAC coverage, excluding Workplace '84, increased 194%. With Workplace '84 included, there was a 203% increase in coverage. I Note that the Lakeside Leader/Slave Lake was unable to supply papers for a two-week period in 1983. The corresponding time period in 1984 was omit- ted so as to make a fair comparison between the years 1983 and 1984. 2 Originally the plan was to sample one day/week from the Grande Prairie paper according to a predetermined plan. However, the sampling plan, by chance, excluded all AADAC coverage In both 1983 and 1984. So, all papers from the prescribed 2 month period in 1983 and 1984 were done. The total coverage was divided by 5 (The Grande Prairie Herald Tribune publishes 5 days/week) to make it comparable to the weekly papers. Community Participation Thirty-seven community organizations were involved with the co-ordination and implementation of the project, contributing more than 425 hours of volunteer time. The Lions Club contributed a considerable amount of support by providing transpor- tation for students and sponsoring their hotel accommodations as well as a lun- cheon on November 24. Lions members also acted as judges and ushers during the Regional Championships. Parents contributed 257 hours of volunteer time, primarily as chauffeurs although one group in Grande Cache acted as team coaches where teachers were unable or unavailable to do so. Private businesses (predominantly from Peace River) donated food and sound equipment. Federal, provincial, local and Native Indian Band government officials provided 127 hours of volunteer time. Table 5 provides a detailed report of the services and time rendered by each group in each area. Tab_1_e_ 4: lEYSPAPER COYERAGE OF AADAC PRDGRAMS OCTOBER - MDYEiEER iH13 AMD 1984 (in Square Centimetres of Print) t 4 Mewspaper - Area. Clever Classmates 1983 1984 S Increase Other AADAC 1983 1984 Workplace '84 1984 onl Total Change f Banner Post - Manning 86 117 36.0% 22 8.35 The Post - Fairview 76 13 89 1169.2% Miles Zero Hexs - Griaahaw 20 54 170.0% 170.0% Northern Pioneer - Ft. YerAillion 10 106 960.05 2 783.3% The Echo - High Level 73 113 $4.8% 123 -42.3% Mountaineer - Grande Cache 43 54 25.6% 9 102 200.0% Record Gazette - Peace River 30 15 22 246.7% Daily Herald Tribune - Grande Pralri 26 9 10 20 522.2% Valley Views - Valleyview 82 20 G.P. This Week - Grande Priarie 14 139 Lakeside Leader - Slave Lake 13 86 South Peace News - High Prairie 58 The Signal - Rycroft 40 18 TOTAL 232 701 202.2% 193 548 40 203.3% TIMN 321394 3
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Area Office Coerounity Group Function Ti.e of Involve.ent Grande Cache Lions Club Procure light boxes 14 hours Provide Transportation and expenses to G.P. Set-up for co.etition Parents Coaches, Chauffeurs 60 hours Grande Prairie Cool-Aid Scorekeeper 4 hours R.C.M.P. Judge 4 hours Sturgeon Lake Reserve Scorekeeper 5 hours Town Administrator Scorekeeper 3 hours Lions Club Scorekeepers, Judges, money 12 hours for lights Parents Advertising, chauffeurs 40 hours High Level Dene Tha' Counselling Service Light Judge 3 hours F.C.S.S. Light Judges, Judge 15 hours Mental Health Judge 6 hours High Level Friendship Centre Judge 4 hours South Tall Cree Band Light Judge 1 hour Parents Chauffeurs ® hours High Priarie A.Y.C. Grouard Judge 6 hours Lions Club Monty for .eals and lodging Smokey River Interagency Group Sconkeepers 3 hours Caring Coemunity Office/Family Judge. Scorekeepers 9 hours Services Lureau F.C.S.S. Scorekeepers 14 hours Parents Chauffeurs 41 hours X.I.T.A.A. Judge 14 hours Table 5: COelRlMITY GROUPS/ORGAMIIATIOHS/tUSI11ESSES COMTRIffiUTIOXS Continued Area Office Coanunity Group Function Ti.e of.involvaeent Peace River Sagatara Friendship Centre Supply hall Lions Club Scorekeepers 3.5 hours M.I.T.A.A. eztension Office Judge 10 hours Association for People with Special Donated baked goods Xeeds Boston Pizza Donated Pizza Eacco Pizza Donated Pizza P.R. Co-op Bakery Donated do-nuts Kentucky Fried Chicken Donated chicken Village Sound Donated sound equipaunt/ca.era Maning & District Lions Club Scorekeepers/Judges 13 hours Slave Lake Slave Lake Legion Supply Hall M.H.A.D.A.P. Recruited scorekeepers 2 hours Lions Club Donated prizes Opportunity Corps Built light bozes 24 hours Parents Chauffeurs 106 hours TOTALS 37 groups 426.5 hours Conclusion The Clever Classmates program has expanded from involving 10 schools in 1981 to 37 schools in 1984. This has not been due to promotion of the program by AADAC but rather as a response to interest expressed by the schools. It appears that the program could further expand to other schools in the province. Drug and alcohol education will become a compulsory component of the Alberta Junior High Health Curriculum in 1986. The evaluation was positive in that the teachers saw value in the program and recommended future participation in it. Community involvement was extensive and through media coverage the profile of the program and of AADAC Increased substantially in Northwestern Alberta. Students found Clever Classmates to be a much more challenging and interesting method of learning. Suggestions for im• provement by teachers and students will be addressed by a task force and the program will continue to be implemented annually so long as there Is interest from the schools and support from the community. TIMN 321395 4
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and entertainment value of the program and whether they would recommend future participation in the program. - Methods Questionnaires were distributed to 31 schools and 36 teachers in the area. Thir- ty teachers from 23 of the schools responded (more than one teacher responded from Rosary Separate, Paul Rowe, La Crete and Wembley Schools). At some point, two additional questionnaires (one from La Crete and one from Wembley) were filled in by teachers not originally on the list of contact teachers involved in the program. All of the responses were used. Table 2: Teachers' Rating Of Usefulness of Clever Classmates Ratin9 Not Very Usdful Somewhat Useful Very Useful Team Members Self-Esteem (N=30) 3% 454 52% Other Students Self-Esteem (N=28) 32% 501 18% Team Members learning About Drugs (N=30) 0% 7% 93% Other Students Learning About Drugs (N=30) 17% 70% 13% Team Members Clarifying Attitudes 0% 47% 53% Other Students Clarifying Attitudes 20% 60% 20% (N=30) Team Members school Spirit (N=30) 17% 33% 50% Other Students School Spirit (N=30) 10% 57% 33% Teachers rated the value of Clever Classmates for students' self-esteem, for learn- ing about drugs and alcohol, for clarifying attitudes toward alcohol and drugs and for developing a sense of school spirit. Table 2 shows how teachers rated Clever Classmates for contest participants and for other students. There are two ways to view this data. On one hand, the low "Not very Useful" ratings, especially for team members indicate a basic level of support. This is sup- ported by the fact that, for team members, all of the areas were rated "Very Useful" by at least half of the teachers. On the other hand, the relatively high proportion of teachers choosing "Somewhat Useful" ratings for all of the areas, especially for students who were not team members, suggests there is room for considering changes aimed at improving the program. In terms of the program's objectives, all areas are likely to be substantially improved by encouraging wider and longer participation by students. The knowledge gains of those students who were not team members, in particular, could probably be increased. Table 3 shows how teachers rated the entertainment and education value of Clever Classmates. The program was rated high or very high in entertainment and educa- tional value for team members. Teachers perceived the program to be of more entertainment value than educational value for students who were not team members. The lack of substantial negative ratings for those who were not team members and the relatively low proportion of high or very high value ratings suggests, again, that the program's impact could be improved with wider par- ticipation among students. Nearly all (96%) of the teachers would recommend future participation. A third of the teachers placed conditions on participation. Most of the conditions men- tioned related to ensuring equity in the competition. Other concerns included time, funding, equipment needs, consistent judging, "fine-tuning" of questions and communications with teachers about scheduling. Table 3: Teachers' Ratings of the Entertainment and_ Educational Value of Clever Classmates_ f_or Tcam Members and Other Students Very Very r,ow Low Neutral High Hich Team Members' Entertainment (N-27) 0% 7% 22% 44% 26% Other Students Entertainment 496 15% 37% 44% 0% Team Members' Education (N=30) 0% 0% 3% 63% 33% Other Students' Education (N=30) 7% 7% 60% 20% 71 III Student Focus Groups Introduction During November 1984, interviews were held with some team members who participated in the Clever Classmates program. Three teams were interviewed and comments were recorded on tape. The three groups were: Wembley, Savan• nah and High Prairie. The Wembley team participated in the finals for their area, but did not advance to the Regional Competition. The Savannah and High Prairie teams both took part in the Regional playdowns. None of these teams were the final winners of the competition. Methods Some instructions were given at the outset of the interview as follows.: - a tape recorder is being used, so speak clearly and one at a time. - honest and frank opinions would be appreciated. Six major questions were asked. They were: - "What did you like or enjoy about the program?" - "What were the hassles or things you did not enjoy?" - "Was it worthwhile for you? How? Why?" - "What difference has it made to you? - "What would you change if you were in charge of the program? (What would you do diHerently?") Themes The overriding theme throughout the interviews was one of great enthusiasm. Even though students had been cautioned to speak one at a time, once a new thought was brought forward by one of the group members, everyone added their opinion to the discussion with great 'gusto'. On the following pages are some of the main points that surfaced from discus• sions with students. Focus Group Results Some specific things mentioned as being enjoyable to the students were: - The competition and "being under pressure". - "Learning this way is more fun than just studying." - Being involved. - Travelling and meeting new people. - Missing school. The hassles students mentioned had to do with: Running of the competition, i.e. buzzer boards or lights not acceptable, not being able to see scores posted during competition. Interference with other activities such as volleyball, hockey, etc. Although this was a problem, one of the boys stated, "I'd rather be doing this than playing volleyball." When asked if it was worthwhile for them, some replied that what made it wor- thwhile for them was: Recognition: "Making our school and coach proud of us." Social growth: meeting new people. One student said, "We will have more confidence in speaking out because we have 'real information'." Positive competitive atmosphere, "Most everyone was a good sport." The difference it made to the students was that it confirmed what the students suspected about drugs. Two comments were: "Now we know why drugs are not good." (Savannah) 2 TIMN 321393 i
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AADAC'S CLEVER CLASSMATES: A CO-ORDINATED APPROACH TO DRUG EDUCATION Robert Hale-Matthew4 B.Ed, MA. INTRODUCTION In 1981, AADAC began its community projects program based on the theme "Make the Most of a Good Thing, Make the Most of You". The High Level Area Office in Northwestern Alberta developed a quiz competition style team game for junior high students. The students themselves voted to call the game "Clever Classmates". Clever Classmates is a community-based program co-ordinated through rural AADAC offices and implemented through the local schools. With the approval of the principals and teachers, interested classes or groups of students form teams of seven members. Each team usually has a teacher or parent as a coach. The teams are given study packages which include AADAC pamphlets and informa- tion on topics such as drug abuse, alcoholism In the family, developing responsi- ble Independence, drinking and driving, and other related issues. Competitions are usually held in school classrooms or auditoriums. To run the contest there needs to be at least one moderator, two scorekeepers and a knowledgeable judge. Two contest "light panels" need to be borrowed or con- structed, with the circuitry designed so that only one light can go on at a time. If possible to arrange, the presence of an audience adds to the drama and excite- ment of the competitions. Community groups, businesses, service clubs and parents have become increas- ingly involved with the Clever Classmates program. In 1984, 37 different groups provided over 425 hours of volunteer time, and hundreds of dollars were con- tributed towards lunches, prizes and transportation costs. Lions Clubs from across the north provided funds and volunteers. These resources were especially need- ed for the championship playoffs, when students from all over the northwest needed assistance with accommodation, and transportation to Grande Prairie. Many proud parents provided support and encouragement as they accompanied the students to the finals. Clever Classmates has been well received by northern rural communities and school divisions, and the program is steadily expanding to other areas. It was first conducted in 1982 with 10 schools participating from Fort Vermilion and Northlands School Divisions. In 1983 the Peace River area joined in the contest bringing In schools from Manning, Deadwood and Dixonville. The total of par- ticipating schools grew to 18. In 1984, schools from the Slave Lake, High Prairie, Peace River, Grande Cache and Grande Prairie areas participated, bringing the total number of schools to 37. Many of the schools entered more than one team and there were actually 57 teams that competed over a period of two months. The 1984 Clever Classmates finals were held at the Grande Prairie College where the Northwestern Alberta Champions were determined. The Champions were Y.A.D.A. (Youth Against Drug Abuse) team from Roland Michener High School in Slave Lake. Each team member received a disc camera as their personal prize. They also will have their names inscribed on the Clever Classmates champion- ship plaque which will stay at Roland Michener until the next competition takes place, scheduled for October/November 1985. Clever Classmates makes learning exciting and fun. Besides the learning involv- ed, team spirit and school pride, there are other benefits for the participating students. For many of these kids it Is the only extracurricular activity available to them. For some it is the first time they have been selected as a special person, representing their school. For others, there is the excitement and adventure of travelling to a distant city, staying in a hotel and meeting lots of other kids. For some of the students on the Grande Cache team, travelling to Grande Prairie gave them their first ever opportunity to go to a movie theatre and to swim in an indoor pool. As Clever Classmates' popularity has increased, there has been a growing de- mand for a simple description of the program as well as some instructions for its Implementation. A brochure is now available and a handbook is currently being developed. Evaluation of Clever Classmates The evaluation was designed to cover five major areas: I Students' knowledge of alcohol and drugs (measured by comparison of pre and post questionnaires). 11 Teachers' reactions to the program (measured by a seven point questionnaire). III Students' reaction to the program Imeasured by focus group discussions and interviews with participating students). IV Media coverage of AADAC in northern newspapers (measured by tabulation of all articles on AADAC in Oct/Nov 1983 as compared to Oct/Nov 1984). V Community involvement measured by the time, money and effort contributed by groups in each community. I Student Knowledge of Alcohol and Drugs Pre and post-questionnaires were distributed to 370 students. Of that number, 147 were team members. The remaining number were simply other students in the schools. The pre-tests were done in September before the Clever Classmates program, which was conducted in Oct/Nov. The post-tests were administered in December. Table I shows that team members' scores averaged 12.7% higher after they had participated in Clever Classmates. The other students averaged 2% higher score in their post-tests. While team members showed considerable learning, some teaming took place for those students who were not directly in• volved with the program. In addition, 201 students were given the pre-test only and 257 were given the post-test only. Statistical tests were run to determine whether pre-test only, post- test only and pre•and-post test students scored differently. They did not. Table 1: Results of Pre and Post-Tests Pre-Test Post-Test Average Average Dlfference Grade 7 50.1t 62.91 + 12.8~ 8 53.7t 65.6{ + 11.9i 9 54.9% 68.4% + 13.4% Avg. 52.9% 65.6% + 12.7% other Students Pre-Test Post-Test Average Average Difference Grade 7 48.4% 48.6% * 0.2% 8 48.4t 51.3i + 2.9• 9 49.31 52.2t + 2.99 Avg. 48.7% 50.7% + 2.0% The table indicates that leaming occurred at every grade level and among other students as well as team members. Grade 9's scored the highest increase, 13.4%. The test is not adjusted to scholastic standards of A, B, C, D and F, and thus, the percentage scores have no inherent meaning. The test was intentionally made difficult in order to more accurately measure learning of material provided rather than learning of how to answer the test. II Teachers' Evaluations Introduction Teachers were asked to as{ess and provide feedback about several aspects of the program. Teachers rated administrative aspects of the program; how it fit to the school year and the amount of organizational and class time required. They also rated the program's impact in helping team participants and other students (who were not team participants) in the following areas: self-esteem, learning about drugs and alcohol, clarifying or developing attitudes toward alcohol and drugs and developing a sense of school spirit. Teachers reported on alcohol or drug education programs in their schools and parents' involvement in the local Clever Classmates program. Finally, teachers were asked to evaluate the educational value, I TIMN 321392
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envisioned that smaller demassified groups will receive and send a large amount of their own imagery to one another. Popular music reflects this demassi6cation in the increasing fragmentization of styles and in the steady proliferation of radio stations which specialize in one style or another. Country music, for example, is now available in Edson, where it was not 10 years ago. To provide effective prevention messages in an era of demassification, it will become necessary to design messages and formats which will appeal to more and more distinct subgroups. At the same time, country music has enjoyed a dramatic increase in popularity throughout North America in the past 20 years. Once the music of an isolated, impoverished rural minority, it now pervades all of North America. The cultural subgroup of its fans is no longer geographically defined, but now is delineated by the much less clear boundaries of attitudes and beliefs held in common with the music. We are still a culturally fragmented people, but our differences are less and less regional, and more and more matters of style and tastes. Country music reflects styles and tastes which are becoming more popular, which we must market to if we wish to influence the behavior of country music fans. While we have been able to demonstrate a correlation between country music values and those of country music fans, we have made no attempt to examine the difficult question of how these values are created and changed. Does the music influence the fans or vice versa? What power do producers have in the creation of taste through promotion? It is clear that country music fans and country music are both ambivalent and conflicted in the feelings about drinking, and both hold rather abusive attitudes towards alcohol. This does not mean, of course, that country music causes alcohol abuse. It may, however, reinforce the abusive and conflicted attitudes towards alcohol held by the fans. It probably does indicate that country music fans are more heavily involved with and affected by the abuse of alcohol than the population at large. Much more remains to be leamed about the role of music in North American culture through further study. FOOTNOTES i. Grlssin, John. Country Music: White Man's Blues, N.Y., Coronet Communica- tions, 1970. p. 297. 2. Chalfant, H. Paul and Robert E. Beckley. "Beguiling and Betraying, The Im- age of Alcohol Use in Country Music", Journal of Studies on Alcohol, vol. 38, no. 7, 1977. p. 1433. 3. Ibid. p. 1433. 4. Rankin, James G. Core Knowledge in the Drug Field, Etiology, National Health and Welfare, 1978. p.13. BIBLIOGRAPHY Bach, Paul J. and Schaefer, James M. "The Tempo of Country Music and the Rate of Drinking in Bars." Journal of Studies on Alcohol. Vol. 40, No. 11, 1979. pp. 1058-1059. Bain, Michael. Willie. Dell Publishing Co., Inc. N.Y., 1984. Byworth, Tony. Giants of Country Music. Bison Books Ltd., 1984. London England. Chalfant, Paul H. and Beckley, Robert E. "Beguiling and Betraying: The Image of Alcohol Use in Country Music". Journal of Studies on Alcohol. Vol. 38, No. 7, 1977. pp. I428-1433. Chalfant, Paul H. and Beckley, Robert E. "Contrasting Images of Alcohol and Drug Use in Country and Rock Music". Cretcher, Dorothy. Steering Clear. Winston Press, Oak Grove Minneapolis, 1982. Girdano, Daniel A. and Girdano, Dorothy Dusk. Drug Education: Content and Methods. 2nd Edition. Addison-Wesley Publishing Company. Reading Massachusetts. 1972. Grissin, John. Country Music: White Man's Blues. Coronel Communications, Inc., 1970. N.Y. Hoke, Marshall. "I Never Picked Cotton" - Country-Western Culture, 1972. Keller, Mark. "The Disease Concept of Alcoholism Revisited" Journal of Studies on Alcohol. Vol. 37, No. 11. 1976. Kenney, Jean, M.S.W. and Leaton, Gwen. Understanding Alcohol. C.V. Mosley Company, 1982. N.Y. McConnell, Harvey. "Country and Westery Music-a key to rural drinking". Ad• . diction Research Foundation of Ontario. Social Resources Series. Vol. 2-Article 71. Melhuen, Yehudi, Davis, Curtis W., Melhuen, T.O. The Music of Man. 1979. Naisbitt, John. Megatrends: Ten New Direction Transforming our Lives. Warner Books, 1982. N.Y. Rankin, James G. Core Knowledge in the Drug Field. Addiction Research Foun- dation, 33 Russell Street, Toronto, Ontario. 1978. Rogers, Jimmie N. The Country Music Message. Prentice-Hall, New Jersey. 1983. Rokeach, Milton. Beliefs, Attitudes and Values. Toffler, Aiwin, William Morrow and Comp. Inc. The Third Wave. New York. 1980. The Disease Concept of Alcoholism. Yellin Highland Park, N.J. Hellhouse Press. 1960. Vailiant, George E. Natural History of Alcoholism: Causes; Patterns and Paths to Recovery. Harvard University Press. 1983. Cambridge Mass. TIMN 321406 15
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Marcaurele, Katharine R., et al. Nursing Diagnosis In The Addicted Patient Population Roger Williams Gen. Hospital, 825 Chalkstone Ave., Providence, Rhode Island, U.S.A. 02908 ................................327 Marks, Linda Nance The Attitudes Of Nurses Affecting The Rehabilita. tion Of Impaired Nurses Using And Abstaining From Drugs And Alcohol Univ. Texas At Arlington, School Of Nursing, P.O. Box 19407, Arlington, Texas, U.S.A., 76019 ................................. 67 Marshman, Joan A. Treatment Services: A Balancing Act Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, M5S 2S1 ..... 515 Masironi, Robert World Trends In Smoking World Health Organization, 1211 Geneva 27, Geneva, Switzerland ................ 543 Mayfield, Demmie, et al. 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Perspectives On Treatment University Of Mexico, Department Of Psychology, Albuquerque, New Mexico, US.A., 87131 ............................348 Mintz, James H., et al. Cannabis Information Program'Stay Real/Vive' Moi•Meme Health & Welfare Canada, #478, Jeanne Mance Building, Tunney's Pasture, Ottawa, Ontario, KIA 1134 .......................... 83 Morose, Louise, et al. Presentation Notes-Zoot Capri A.A.D.A.C., 7th Fir., 10909 Jasper Avenue, Edmonton, Alberta, T5J 3M9 ......... 363 Morrow, Lorraine, et al. The Relationship Of Alcohol Consumption Rates, Hospital Morbidity Rates And Mortality Rates Of A Designated Geographical Population From 1940•1979 Lakehead Psychiatric Hospital, 580 N. Algama Street, Thunder Bay, Ontario, P7B 5G4 ................................ 440 Mosher, Vaughn, gt al. 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Supervised Disulfiram: A Viable Alternative To License Suspension For DWI Conviction Kingston Psychiatric Hospital, Alcohol & Drug Educ. Centre, Box 603, Kingston, Ontario, K7L 4V4 ......................... 486 N Nadeau, Louise Social Origins Of Alcoholism In Women: Mirage or Methodological Meagreness? 12, St. Curille, Outremont, Quebec, H2V 1H8 ................................468 Nanji, Amin A., et al. Dietary Factors And Alcoholic Cirrhosis Ottawa General Hospital, 501 Smyth Road, Ottawa, Ontario, K i H 31.6 ........... 163 Navaratnam, Dr. V. Advances In Recent Knowledge-Epidemio- logical Studies National Drug Research Centre, University Of Science, Malaysia, Minden, Penang, Malaysia ---. ... ... ....................... 9 Nencini, Paolo Khat Abuse: An Increasingly Worrying Issue Cattedra Farmacrologia Medica, La Cattedra Degli Studi, 'La Sapienza' Piazzale A Moro 5, Rome, Italy, 00186 ....................... 300 Niven, Robert Alcoholism: The Costs Of The Problem And Its Tieatment N.LA.A., 5600 Fishers Lane, Rockville, Maryland, U.S.A., 20857 .............. 43 No11, Alfons The International Treaties-Sufficient For Inter national And National Drug Control? 51, Ch. Du Crest D'El, 1239 Collex-Bossy, Switzerland ....................... 282 Nutter, Carolyn P. Evaluating Media•Based Prevention Campaigns A.A.D.A.C., 10909 Jasper Avenue, Edmonton, Alberta, T5J 3M9 ................... 208 O O'Connell, Kathleen R. 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Deliberate Self-Harm Among Nigerians: The Use Of Chemicals And Psychotropic Drugs Dept Of Psychiatry, University College Hospital, Ibadan, Nigeria ..................... 148 Olivennes, Dr. Armand Modifications Electro-Encephalographiques Llees Au Psychotropisme De L'Ethanol 14 Rue Berthollet, 75005 Paris, Paris, France ................................319 Oppenheimer, Tamar Strategy For Prevention And Reduction Of Demand For Illicit Drugs In The International Programme Of Drug Abuse UN Division Of Narcotic Drugs, P.O. Box 500, 1000 400 Vienna, Austria ............ 473 Ostrovsky, YU. M., et al. Catabolism And Inactivation Of Acetaldehyde In The Animal Organism Division Of Metabolic Regulation, Byelorussian SSR Academy Of Sciences, 50 Lenin Kosomol Blvd., Grodno 230009, USSR .......... 87 Ouimet, Lysane, et al. 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World Services Inc., Box 459 Grand Cen• tral Station, New York, New York, U.S.A. 10163 ..................................88 Pemjean, Alfredo, et al. Recent Advances On Knowledge About Alcohol Problems: Social And Behavioral Sciences TIMN 321389
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NAME AGE SEX OCCUPATION DATE TESTED I T, -T, (Timr)Ratio: Self-Actualizing Averaye: T,: Tc= 1: fl Your Ratio: TI: TC c 1: _ 11 0 - I (Support) Ratio: Self-Actualizing Avrraqe: 0:1= 1:3 Your Ratio: 0:1= 1 :_ 10 :i:0'.: 4 5 6 7 8 9 10 VALUING FEELING SELF-PERCEPTiON SYNERGISTIC AWARENESS INTERPERSONAL SENSITIVITY TIME INNER- SELF- EXISTENTI- FEELING SPONTA- SELF-REGARD SELF- NATURE OF SYNERGY ACCEPTANCE CAPACITY COMPETENT DIRECTED ACTUALIZING ALITY REACTIVITY NEITY Freely Has hiih ACCEPTANCE MAN, CON- Sees eppo- OF FOR Lives in the independent, VALUE Flexible in Sensitive to expresses seif-w.rUt Accepting of STRUCTIVE sHes ef tife AGGRESSION t INTIMATE CONTACT present self- HHds ralues application .wn needs feelin s ~ self in Sees man as as meaninZ- Accep s sepportive of seN- .f values and feelings irehav onlly spite ef essentially fully related feelings rf Has warm actualizing weaknesses good anger rr Interpersonal peeple e~resslon relationships TC I SAV Ex Fr S Sr Sa Nc Sy A C -125 ADULT NORMS -25 -120 -na - _ -25 - - -110 -25 -'30 - _ -9 -25 -705 - - -15 - - 20 -IS _ - _ -75 _ 20 -100 -20 - - -20 - - ^ 25 - - -95 - -e - - _ -20 -90 - - - _E5 - _ -20 - - - - -u - - - -7 - -20 - -1S - -oo - - -10 -15 - - -10 - - - - -15 -73 - -15 - _ - - -6 - - -70 _ - - -10 - -15 - - -65 - -10 - - - - -15 - -10 - - - -5 - ~60 - - -10 -10 - _ -s - - - - -55 - - - -10 -50 - - - - - - - 5 - r - -4 - -10 - - -45 -5 -5 - - - -5 -10 -5 - -- -3 TIME OTHER Re~- cts Rigid in Insensitive Fearful of Hes low Unable to Sees man as Sees Denies Has diffi- INCOMPE- DIRECTED values of appiicatite te own expressing self-worth accept self essent"ially rppesites ef feelings of eWty with TENT Dependent, self-actualiz- ef values needs and feelings with evil life as ti i anger er i warm Inter- enonal Lives in the seeks sup- ing peeple feelings behaviorally weaknesses antagon c s aggress on p laUons 'est or port ef n trture others' views t0 70 60 40 30 20 Raw Scons COPYRIGHT ® 1963, 1965 by EDUCATIONAL & INDUSTRIAL TESTING SERVICE, SAN DIEGO, CALIFORNIA 92107 REPRODUCTION OF THIS FORM BY ANY MEANS STRICTLY PROHIBITED ® P01 040 fa0 70 60 S ~. 50 a F 40 30 20 TIMN 321399 8
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Ciesielski, K.T., et. al. Chronic Alcoholism-Predisposing Factor To Alzeheimer Disease? Correlation Between Symptomatology, Elec• trophyslological Findings And Postmortem Neuropathology Alberta Hospital Edmonton, Psychiatric Treat• ment Centre, Box 307, Edmonton, Alberta, T5J 2J7 ........................... 99 Clark, David C., et al. Drinking Patterns Of First-Year Medical Students St. Lukes Medical Center, 1720 West Polk Street, Chicago, Illinois, U.S.A., 60612 ........ 166 Clark, David C., et al. Model For Quantifying The Drug Involvement Of Medical Students St Lukes Medical Center, 1720 West Polk Street, Chicago, Illinois, U.S.A., 60612 ........316 Clarke, Dr. James C., et al. Nicotine Chewing Gum, Rapid Smoking, And A 'Placebo' Effect School of Psychology, University Of New South Wales, Sydney, Australia ............. 325 Coambs, Robert B., et al. Diazepam Impairs Long-Term Memory Storage And Retrieval, But Not Short•Term Memory Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, M5S 2S1 ..... 160 Collishaw, Neil E., et al. An Estimate Of The Demand For Alcohol In Canada 1959-1982 Health & Welfare Canada, Bur. Of Tobacco Con• trol Rm 202, Tunney's Pasture, Ottawa, Ontario, KIA 0L2 ......................... 198 Collishaw, Neil E., et al. An Estimate Of The Demand For Tobacco In Canada 1950-1982 Health & Welfare Canada, Bur. Of Tobacco Con- trol Rm 202, Tunney's Pasture, Ottawa, Ontario, KIA 01.2 .....................,..... 201 Covington, Stephanie S. Alcohol And Family Violence 1129 Torrey Pines Road, La Jolla, California, U.S.A.,92037....................... 24 Creighton, Terrence D. Children Of Alcoholics: A Systems Approach A.A.D.A.C., 1177 - 11th Avenue S.W., Calgary, Alberta, T2R oG5 ................... 94 Croxford, Ronald Outpatient Methadone Detoxification Moreland Hall Alcoholism And Drug Treatment Centre, 26 Jessie Stret, Moreland, Melbourne, Australia, 3058 ..................... 333 D Dana, Robert 0., et al. Pretreatment Assertion Levels As They Relate To Treatment Outcomes In An Alcohol Abusing Sample Governors State University, University Pk, lllinois, U.S.A ...................... 365 Daoust, Martine, et al. Is Initial Sensitivity To Ethanol Correlated With Alochol Preference In Alcohol Drinking Rats And Non-Drinking Rats? Faculte De Medicine De Rouen, B.P. 97, St. Etienne Rouvray, France, 76800 ....... 297 Davison, Doreen, et al. Development, Implementation, Evaluation Of It's Just Your Nerves: A Resource On Women's Use Of Minor Tranquillizers And Alcohol Alberta Personnel Administration, 7th Fl., Kensington Place. 10011 - 109 Street, Edmonton, Alberta, T5J 3S8 ................... 157 De Haes, W.F.M. Integration Of Alcohol And Drug Education In General Health Education Municipal Health Department, Health Education Unit, Schiedamsedijk 95, Rotterdam, Netherlands, 3311 XH ................ 278 Dignam, Carol S. Evaluation Of An Early Intervention Program For Problem Drinkers AADAC Evaluations Branch, 7th Floor, Pacific Plaza Bldg., 10909 Jasper Avenue, Edmonton, Alberta, T5J 3M9 ................... 212 Disayavanish, Chamlong, et al. Therapeutic Problems Of The Heroin Addicts In Thailand Chiangmai University, Department Of Psychiatry, Faculty Of Medicine, Chiangmai, Thailand,50000 ....................500 Douglas, Jacqueline J., et al. Evaluation Of An Inpatient Women's Addiction Treatment Program A.A.D.A.C. Evaluations Branch, 7th Floor, 10909 Jasper Avenue, Edmonton, Alberta, T5J 3M9 ................................214 Doyle, Martha Kuhns Personal And Professional Self-Esteem Of Addicted Nurses Duquesne University, School Of Nursing, Pitts- burg, Pennsylvania, U.S.A., 15282...... 343 Draper, Ron Interhational Workshop On Smoking Health & Welfare Canada, Room 422, Jeanne Mance Bidg., Tunney's Pasture, Ottawa, Ontario, KIA IB4 ......................... 289 Draper, Ron Trends In Alcohol Policy In Canada Health & Welfare Canada, Room 422, Jeanne Mance Bldg., Tunney's Pasture, Ottawa, Ontario, KIA 184 ................:........ 518 Durell, Jack, et al. The Primary Prevention Of Drug Abuse: Major Promising Approaches 5600 Fishers Lane, Rockville, M.D., 20857 ................................ 377 Durrant, Rick Media Based Prevention Program For Adolescents A.A.D.A.C., 10909 Jasper Avenue, Edmonton, Alberta, T5J 3M9 ... . ............... .309 E Ellinger, Sybille, et al. Conditions Of Legal Drug Use. Results And Pro- blems Of A Population Survey Univers. Krankenhaus Eppendorf, Projekt: MEdikamente, Frauen, Martinistr. 52 D 2000 Hamburg 20, Hamburg, West Germany -.- ---------------------------- . 122 Endal, Dag Involvement Of Youth In Alcohol Education by Means Of The Two-Step Model I.G.T.Y.F., Keysersgt. 1, N•0165 Oslo I, Oslo, Norway .......................... 293 Engs, Ruth C., et al. Drug Use Patterns Of Nursing Students In Scotland's Tayside Region: lmplications For Education Indiana University, Hper Rm 116, Bloomington, I N, U:S.A., 47405 ....... . .......... 173 vi F Ferrence, Roberta G. Sex Differences In Cigarette Smoking In Canada, 1900-1978: A Reconstructed Cohort Study Addiction Research Fdn., 33 Russell Street, Toronto, Ontario, M5S 2S1 ........... 457 Ferrence, Roberta G. Understanding Addictions Among Women: An International Perspective Addiction Research Fdn., 33 Russell Street, Toronto, Ontario, M5S 2S1 ........... 529 Fillmore, Kaye Middleton A Meta-Analysis Of The Epidemiologicai Results Of Existing Alcohol•Related Longitudinal Studies by Age and Sex Alcohol Research Group, 1816 Scenic Avenue, Berkeley, California, U.S.A., 94704..... 310 Filstead, William J., et al. Using Electronic Pagers To Monitor The Process Of Recovery In Alcoholics And Drug Abusers Lutheran Center, 1700 Luther Lane, Park Ridge, Illinois, U.S.A. 60068 ................ 535 Finley, Britt Characteristics Of The Senior High Student Who Drinks And Drives Montana State University, 612 Eddy Street, Missoula, Montana, U.S.A., 59801 ...... 91 Forbes, William F., et al. The Consequences Of Changing Smoking Habits Of Lung Cancer Mortalities In 1990, 2000, And 2010 University Of Waterloo, Program In Geron• tology, Waterloo, Ontario, N2L 3G1 .... 126 Fraser-Mackay, Winnie An Assessment Of Alcohol Abuse Programs In Arctic Canada Dept. Of Social Services, Drug & Alcohol Divi- sion, Box 1769, Yellowknife, N.W.T. .... 60 G Gavaghan, Paul F. Social And Health Issues: The U.S. Spirits Industry's Approach Distilled Spirits Council, 1250 Eye Street NW #900, Washington, D.C., U.S.A. 2005 .. 465 Gedig, Udo J. Prevention As The Socialization Of Experience- Inherent Contradiction In Prevention Ministry Of Education, Mainz/Technical Univer• sity, Darmstadt, West Germany ........ 369 Gerace, Laina M. An Analysis Of Policy And Program Implemen• tation For The Impaired Nurse: What Is Being Done In The United States University Of Illinois, College Of Nursing, 845 South Damen Avenue, Chicago, Illinois, U.S.A. 60680 .............................53 Ghadirian, A.M., et al. Alcohol And Drug Use Among Montreal High School Students Douglas Hospital Centre, Medical Education, 6875 Lasalle Boulevard, Verdun, Quebec, H4H 1R3 .............................. 22 Giesbrecht, Norman, et al. Collecting And Reporting Alcohol-Related Mor• bidity Statistics Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, M5J 2SI ...... 108 TIMN 321387 ~
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the SPSS programs; Patricia Stuart for the preparation of the code sheet and coding manual; the Work Site Services Inspectors for their general assistance and Deb Kakoschke for the preparation of the manuscript. RBFERENCES I. Lewy, Robert, Pre-Employment Qualitative Urine Toxicology Screening, J.O.M. Vol 25, No. 8, p. 579-580. August 1983. 2. Atherley, G., Human Rights versus Occupational Medicine, lnternat J. Health Services, 13:(2)265-75. 1983. 3. Mott, Joy, Self-Reported Cannabis Use in Great Britain in 1981. Brit. J. of Addiction, 80, p. 37-43. 1985. 4. Schmidt, W. and deLint J., Estimating the Prevalence of Alcoholism from Alcohol Consumption and Mortality Data, Quar. J. Stud. Alc. 31, p. 957-64. 1970. 5. Gray, R.H., Poudrier, L.M. et al, Convergent Results of Two Methods of Estimating the Prevalence of Problem Drinking, J.O.M. Vol. 25 c7, p. 531-533. 1983. 6. SchuckiG M.A. and Grunderson, E.K.E., The Association Between Alcoholism and Job Type is the U.S. Navy, Quart J. Stud. Alc. Vol. 35, p. 577-585. 1974. 7. Shain M, Alcohol, Drugs and Safety an updated perspective on problems and their management in the workplace. Accid Anal and Prev Vol 14 No 3, p.239-46. 8. Canada Classification and Dictionary of Occupations Vol 1, Manpower at Im- migration Canada Ottawa K I A OS9..1971 9. American National Standard Method of Recording basic Facts Relating to the Nature and Occurrence of Work Injuries American National Standard Institute, Inc 1962 10. Lings, S., Jensen, J., Christensen, J.S. and Moller, J.T., Occupationai Accidents and Alcohol, Int Arch. Occup. Environ. Health, p. 321-329. 1984. 11. Manello, T.A., Problem Drinking Among Railroad Workers: Extent, Impact and Solutions, University Research Cooperation Monograph Series t4, 5530 Wisconsin Avenue N.W., Washington D.C. 20015. 1979. 12. Travers, D.J., Industrial Accidents and Problem Drinking, AJADD, Vol. 2, No. 2, p. 39-40. May 1975. 13. Warren. R., Simpson, H.M. et al, Drug Involvement Traffic Fatalities in the Province of Ontario, American Association for Automotive Medical Procedings October 7-9, 1980. CiaitAt PIYrUIEGa Cf SI$ RGIIGOLOGy St7eSENfaG n.25. J- S 7paber of cases in rhieh alcohoi vas detected 42 16.5 eumber of casea in which a drug (other than alcohol) vss detected 36 14.2 Bwber of cases in which an illicit drug ws 6 2,. idantifiad auaber of cases in rhieh drug vas a prescription dmy2 23 9.1 1o.ber of casas in which drug ras a non- prascription dros 9 3.5 y00ta0iCS 1Cannabis ves the only illicit drug detected. 27here wre casu in which more than one drug vas detected. TABLB 2 DIBSBIBt7TI08 OP Ai.COnoL CONCBBi8AiI08 ~.2 ALCONOL L_ZPLL ,L z s,8llDO =l SAELL 3 (7 CAS[S) DBDC COIm177ATIODs Meobarbital Secobarbital 02 /3 i6 07 Shaobromine Salicylic Acid phenobarbital Diphenylhydantoin /4 Codein Aeatas,inophen IS ietracycline Cannabis Lidocaine Diazepas ordiaz.pu Sheophylline Pheniranina Chiorphaniraaine Phenylpropanolaaine OCCDPlTIORaS HI1H 10 9E tngg ParAL [S ~339 OCCOPL'f10f • S DEBSICK MII1 39 11.5 TRUCK DRIVER 33 9.7 CWSSBUCSION LAE0U888 33 9.7 CD.ADIBG OPBE1208 22 6.5 LOOGEB, PALi.CY, etc. 12 3.5 PLU1SLLPIPB7ITf8Y 11 3.2 HBLDEB 10 2.9 TIMN 321411 20
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DISCUSSION Since our study was completed, a few publications have examined the ACOA factors. Gravitz' stated that the ACOA issues apply to "other people as well, par. ticularly to those who have been raised in dysfunctional families with high stress." Naturally, there Is likely to be tremendous variation regarding the degree of dysfunc- tion in individuals and their family of origin. In future studies, we believe that some measure of family function/dysfunction would be helpful. It is difficult to find a single instrument to measure as many factors as would be desired for this ACOA population, yet, the Personal Orientation Inventory seems to do just that. For our purposes, we needed a questionnaire that could be completed in a very short time and we have seen that a few issues are signifi- canL We recommend that the entire P.O.I. would be a very useful instrument for discovering more about the ACOA population. Furthermore, since ACOA workshops and self•help groups seem to be effective environments for change, we recommend that the PO1 would be quite useful as a baseline measure for marking change over time. The nature of the questions embodies the therapeutic content for personal growth and development. We have found that the questionnaire and the study itself have stimulated the communi- ty's awareness and has percipitated earlier referrals for ACOA treatment. REFERENCES 1. Gravitz, Herbert L, and Bowden, Julie D., Guide to Recovery: A Book for Adult Children of Alcoholics, Holmes Beach, Florida. Learning Publications, 1985. 2. Cermak, Timmen L., M.D.: A Primer on Adult Children of Alcoholics, Pom• pano Beach, Florida.: Health Communications, Inc., 1985. 3. Wegscheider-Cruse, Sharon: Choice Making for Co•Dependents, Adult Children and Spirituality Seekers, Pompano Beach, Florida: Health Communications, Inc. 1985. 4. Woititz, Janet, Adult Children of Alcoholics, Hollywood, Florida.: Health Com• munications, Inc. 1983. 5. Shostrom, Everett, "The Personal Orientation Inventory." San Diego, California: Educational & Industrial Testing Service, 1963. PERSONAL PP.OFILE INVENTORY DIRECTIONS: Circle the response that fits most accurately 1. (a) I have no objection to getting angry. (b) Anger is something I try to avoid. 2. (a) I can give without requiring the other person to appreciate what I give. (b) I have a right to expect the other person to appreciate what I give. 3. (a) I do what others expect of me. (b) I feel free to not do what others expect of me. 4. (a) I believe in saying what I feel in dealing with others. (b) I do not believe in saying what I feel in dealing with others. 5. (a) I am afraid to be angry at those I love. (b) I feel free to be angry at those I lave. 6. (a) My basic responsibility is to be aware of my own needs. (b) My basic responsibility is to be aware of others' needs. 7. (a) To feel right, I need always to please others. (b) I can feel right without always having to please others. @. (a) I only feel free to eopress warm feelings to my friends. (b) I feel free to express both warm and hostile feelings to my friends. 9. (a) I hesitate to show my weaknesses among strangers. (b) I do not hesitate to show my weaknesses among strangers. 10. (a) I only feel free to show friendly feelings to strangers. (b) I feel free to show both friendly and unfriendly feelings to strangers. 11. (a) People should always control their anger. (b) People should express honestly-felt anger. 12. (a) I am able to express my feelings even when they sometimes result in undesirable consequences. (b) I am unable to express my feelings if they are unlikely to result in undesirable consequences. 13. (a) I am afraid to be tender. (b) I am not afraid to be tender. 14. (a) I like to participate actively in intense discussions. (b) I do not like to participate actively in intense discussions. 15. (a) Sometimes I feel so angry I want to destroy or hurt others. (b) I never feel so angry that I want to destroy or hurt others. 16. I am (a) an oldest or only child (b) a middle child (c) the youngest child 17. For the most part, I was brought up living with: (a) both of my real parents (b) just my real mother (c) just my real father (d) one real parent and onestep parent 18. My gender is male _ female_ 19. Regarding drinking in my family, the following member(s) have had a problem: (a) both parents (b) mother (c) father (d) neither parent 20. Regarding my drinking behaviour: (a) I have never had a drinking problem (b) I have had a drinking problem and no longer drink alcohol (c) I might be developing a drinking problem. TIMN 321398 21. Regarding my age, I am: (a) under 20 (b) 20-34 (c) 35-49 (d) 50-64 (e) 65 + 7
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special interest seminars and self-help groups focused directly on co-dependency and adult children issues. Within a matter of weeks, people in Bermuda were identifying so rapidly with the ACOA characteristics, that self-help groups and workshops were established for further awareness, fellowship and support. The development was so attractive that non-ACOA individuals were looking for personal historic background which might qualify them for attendance. In a study conducted recently in California, it was found that 60% of the Helping Professionals were adult children of alcoholics. A high percentage of therapists treating ACOA's are ACOA's themselves.' It has been suggested that perhaps a sizeable portion of ACOA therapists have not fully explored their own issueS.2 Several of our population in the Helping Professions have found it extremely beneficial (both personally and professional- ly) to become as fully aware of these ACOA issues as possible. The obvious question by the end of 1984 was "Are there characteristics of ACOA's that emerge which distinguish them in some measurable way from the general adult population ?" There are nearly 20 characteristics commonly reported among this emerging ACOA population: Adult children of alcoholics are often misdiagnosed or unrecognized because their coping styles tend to be approval-seeking and socially acceptable; they themselves do not recognize the source of their distress.• MOST COMMON CORE ISSUES OF ACOA's 1. The most common central issue is the cluster of thoughts and behavioral pat- tems focusing upon Control and associated fear of being "out of Control". 2. The second core issue is "low trust" (including self as well as others); other dysfunctional patterns are set in motion or are interrelated to low trust such as low self-esteem and low intimacy function. 3. The third issue is "avoidance of feelings" and the belief that feelings are wrong and bad. Dreadful events of the past are discussed in adulthood with dissociated affect. 4. Fourthly, "over-responsibility" is a major ACOA factor with children grow- ing up believing they are responsible for other people's emotions and behavior especially negative emotion and behavior. 5. Another major characteristic attributed to ACOA's is "Ignoring one's own needs". It's guessed that, when children are raised in a family with Alcoholism,their needs are typically not addressed. Untreated ACOA's find that guilt Is associated with acknowledging or attending to their personal needs. To have needs is to be vulnerable---and that's bad! 6. One last Issue has recurred in treatment so frequently that it is necessary to mention. The "all or nothing" tendency is also referred to as the "black or white" phenomenon with no levels of gray in between the two extremes. EXAMPLE Totally trusting or not trusting at all! "All or nothing" has a pro- found effect upon the capacity to maintain a meaningful healthy relationship. It is believed that this phenomenon is useful in understanding the difficulties in establishing adequate and useful boundaries between one's self and others. METHOD SUBJECTS: Each February, there is a two-day indoor fair-type event with displays, events, foods, arts, crafts and commercial items. It i.s often said that one third of the com- munity provide the event and the other two-thirds act as spectators by suppor- ting the event. People were randomly approached to anonomously complete a set of questions. There were 362 questionnaires completed; 25% of the respondents were ACOA including 2% having had both parents with Alcoholism. Of the total population, 38% were oldest or only children, 30% were "middle" children and 32% were youngest. Regarding the parenting question, 75% were raised by both parents, 13% by a single mother, 6% by a combination parent/step parent, 1% by a single father and 5% by "other" which included adopted parents, grandparents or an institution. The age distribution was as follows: Under 20 20-34 35-49 50-64 Over 65 5% 43% 39% 11% 2% Regarding gender, respondents were 77% female and 23% male. Regarding "respondents own drinking behavior", 87% claimed to never have had a problem, 4% had had a problem and no longer drank alcohol, 6% felt they might be developing a problem and 3% of the subjects did not respond. Several subjects suggested there should have been an additional category: "I am present• ly drinking problematically and have not stopped." PROCEDURE The Personal Orientation Inventory5 consists of 150 forced choice questions and measures 12 factors including: Self versus other directed. Sensitivity to one's own needs Acceptance of agression Capacity for intimacy Fifteen questions were selected as most representative of the four factors; the questions did not isolate each factor from the other three due to overlapping. For example: (a) People should always control their anger vs (b) People should express honestly-felt anger In this example, by selecting (b), the respondent would score high on three of the four factors: (1) I.ocus of control where 'self mattered more than 'other'. (2) Sensitivity to needs. (3) Acceptance of one's own anger or agression ACOA's responses were measured for significant differences with the general adult population. For each of the fifteen questions, for the four scales and for general "self actualization" as measured by a high/low score on all 15 questions collectively. Additionally, the ACOA's and non-ACOA's were measured for differences regar- ding the development of their own drinking problem. Our population size was too small to establish any meaningful significance via a multi-factored analysis. Chi-square and cross tabulations were used to examine birth order, gender of self, gender of alcoholic parent, age and hi/low self-actualization as indicated by the 15 P01 questions. Unfortunately, the questionnaire neglected to ask respondents "if they had mar- ried an alcoholic." Many respondents commented on this including one woman who had married three men, each of whom became an alcoholic. She said her mother had experienced the same and did we think there was some connection? RESULTS Of the 15 questions, 3 differentiated the ACOA population from the general adult population: 1. (a) My basic responsibility is to be aware of my own needs. (b) My basic responsibility is to be aware of others' needs. This response was significantly different(.01 level) for ACOA's and non-ACOA's but not in the direction that we had predicted. ACOA's chose the focus of respon- sibility toward their own needs (a) significantly more than the general popula- tion. Gender, birthorder, age or any combination of factors provided no further explanation; there were no significant differences. One possible explanation might be that a higher degree of awarenes has been established among ACOA's in associa• tion with AA, AI Anon and the helping network. Cermackz has claimed that "up-to 40% of ACOA's leaving home, had not acknowledged that there was Alcoholism in the home." If we consider this to be valid then perhaps the fact that the ACOA's are more aware of "their needs" is a function of being more aware of land identifying) the Alcoholism in their family. 2. (a) People should always control their anger. (b) People should express honestly felt anger. This response was significant (.05 level) and was in the predicted direction. ACOA's felt people should always control their anger rather than express it. 3. ta) I am afraid to be tender. (b) I am not afraid to be tender. The general population expressed that they were not afraid to be tender, ACOA's were significantty different (.05 level) from non ACOA's. There were no other questions resulting in any significant differences nor were there any significant differences on the four scales or overall self-actualization. None of the other characteristics, including birth order, same gender, cross gender, or age made any difference. However,one relationship of factors did surface which was not "mainstream" for our study but, nevertheless, relevant for our purposes: Adult Children of Alcoholics were more likely to become alcoholics themselves compared to the non-ACOA population. This has been well established for many years; our data merely reconfirms the obvious. TIMN 321397
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Avenida Francisco Bilbao, No 1057, Santiago, Chile ............................ 419 Perry, Cheryl L. Peer-Led Approaches To Drug Abuse Prevention Division Of Epidemiology, Gate 20 Stadium, 1913 University Avenue S.E, Minneapolis, Min- nesota, U.S.A. 55455 ................ 342 Perzel, Joseph F., et al. Introduction Of Narcotic Antagonist Treatment ]n A Methadone Treatment Program Jersey Shore Addiction Serv., 51 Abbott Avenue, Ocean Grove, New Jersey, U.S.A., 07756 ................................291 Pinder, Lavada, et ai. The National Addictions Training System Health & Welfare Canada, #400 Jeanne Mance Building, Tunney's Pasture, Ottawa, Ontario KIA IB4 ......................... 322 Pisani, Vincent D. Assessment And Variably Intense Interventions: A Systems Approach To D.U.I. Rush-Presbyterian, St. Luke's Medical Center, 1720 W. Polk Street, Chicago, Illinois, U.S.A., 60612 ............................ 228 Pisani, Vincent D., et al. Features Associated With Medication Com- pliance Among Alcoholics Rush-Presbyterian, St. Luke's Medical Center, 1720 W. Polk Street, Chicago, Illinois, U.S.A. 60612 ............................ 228 Pietsch, Pamela K. Substance Use Of Pregnant And Non-Pregnant Adolescents University Of Illinois, College Of Nursing, 845 S. Damen, Chicago, Illinois, U.S.A., 60607 ............................•---495 R Ramsey, G. Ross Canadian Addictions Foundation: Present Challenges And Future Thrusts Alcoholism Foundation Manitoba, 1031 Portage Avenue, Winnipeg, Manitoba, R3G 0R8..81 Rigatto, Mario Perspectives On TreatmenC Tobacco Addiction Presidente Comite Sobre Contri, Del Habito De Fumar Latin Amer, Caixa Postale 1902, Porto Alegre, Brazil, 90000 ...... . ......... 350 Roese, Roswitha, et al. Voluntary And Involuntary Drinking: An Animal Model For Alcohol Abuse? York University, 4700 Keele Street, Downsview, Ontario, M3J I P3 .................. 538 Roetter, Kathy L. RNact Nursing Careplan Generator Martha Washington Hospital, Treatment Center, 2312 West Irving Park Road, Chicago, Illinois, U.S.A., 60618 ......................446 Rogers, Byron, et al. Trends In Tobacco Consumption In Seven Countries 1950-1984 Health & Welfare Canada, Rm 202 Bureau Of Tobacco, Tunney's Pasture, Ottawa, Ontario, K1A OL2 .......... .. ............_ 521 Room, Robin Drugs, Consciousness And Society: Can We Learn From Others' Experience? Alcohol Research Group, 1816 Scenic Avenue, Berkeley, California, U.S.A., 94709 ..... 174 Rossi, Jean J., et al. Personality Types And High Risk Situations: What Is The Connection For Alcoholics And Substance Abusers? Behavioral Consultants Inc., 2604 Demster #307, Des Plaines, Illinois, U.S.A., 60016 ................................ -347 S Saila, Sirkka-Liisa Results Of The Toolo Detox Center Activity Social Research Institute Of Alcohol Studies, Kalevank. 12, Helsinki, Finland, 00100..443 Schaefer, Susan, et al. Incest Among Women In Recovery From Alcoholism And Drug Dependency: Correlation And Implication For Treatment 3238 - 15 Avenue S., Minneapolis, Minnesota, U.S.A., 55407 ......................268 Schankula, Henry J. Persuasion: Let's Get With It! - Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, M5S 2SI ..... 352 Schioler, Peter Alcohol Education In Europe Ministry Of Education, Kobmagergade 11, DK-I 150 Copenhagen K, Copenhagen, Denmark .................................. 31 Shean, Ruth E. Towards Freedom From The Pressure Of Cigarette Advertising: Legislation Versus Self Regulation Australian Council On Smoking, 705 Murray Street, West Perth, W. Australia, 6005 .. 504 Siegal, Harvey A., et al. Rehabiliting The Drinking or Drug Impaired Driver: Its Evolution From Education To In- tervention Wright State University, niversity, P.O. Box 927, Dayton, Ohio, 45401 ...................... 437 Simmons, Margaret M., et al. A Comparison Of Psychotropic Drug Use Between The General Population And Clients Of Health And Social Service Agencies Addiction Research Foundation, 10th Floor, Durham Centre, 44 Bond Street West, Oshawa, Ontario, L 1 G 1 A4 .................. 117 Singh, Devendra Evoluntionary Origins Of The Preference For Alcohol University Of Texas, Austin, Psychology Depart- ment, Austin, Texas, U.S.A., 78712.....217 Single, Eric W. The Prevention Of Alcohol-Related Problems Through Legal Control Measures Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, M5S 2SI ..... 370 Sinha, Bhairava N., et al. Demogrpahic Profile Of Substance Use Disorder Patients Seeking Help In A Provincial Psychiatric Hospital Rehabilitation Program: A Study Con- ducted At Alberta Hospital Ponoka Alberta Hospital Ponoka, Psychology Depart- ment, P.O. Box 1000, Ponoka, Alberta TOC 2H0 ........ ......................... 150 Skirrow, Jan Implications-What Do We Do Next? A.A.D.A.C., 6th Floor-10909 Jasper Avenue, Edmonton, Alberta T5J 3M9 .......... 264 ix Skirrow, Jan Positive Approaches To Prevention A.A.D.A.C., 6th Floor-10909 Jasper Avenue, Edmonton, Alberta T5J 3M9 .. . . .. . .. . 359 Skretting, Astrid Influence On The Relationship Between Youth And The Youth Worker National Narcotics Advisory Bd, P.O. Box 8128, Oslo, Norway ...................... 274 Smith, Michael 0. Acupuncture Treatment For Cigarette Smoking Lincoln Hospital, Substance Abuse, 349 E 140 Street, Bronx, New York, U.S.A., 10454...5 Smith, Russell F. A Rational Approach To Alcohol Withdrawal Brighton Hospital, 12841 East Grand Hospital, Brighton, Michigan, U.S.A., 48116 ..... 407 Spoerer, Edgar, et al. Benefits And Drawbacks Of Using Psycho- therapeutic Methods in Short-Term Rehabilita• tion Programs For Drinking Drivers Afn-Assoc. For Education, Perfection & Driver Improvemt, 140 Duerener St. D-5000, Cologne, West Germany, 41 ................... 68 Steffens, Cheryll, et al. The Development And Evaluation Of A Treat, ment Program Designed Specifically For Women Sociology Department, Carleton University, Ottawa, Ontario .................... 176 Stone, Judith L., et al. Present And Future Support Systems For Alcohol Countermeasure Efforts N.A.G.H.S.R., 444 North Capital Street, Washington, DC, U.S.A. 20001 ........ 360 Sullivan, Eleanor J. Alcohol And Drug Impairment In Registered Nurses Univ.OFMissouri/St. Louis, 8001 Natural Bridge Road, St. Louis, Missouri, U.S.A. 63121 .. 16 Suwanwela, Charas Public Health Perspective In Alcoholism And Drug Dependence Chulalongkorn University, Vice•Rector Research, Rama IV Road, Bangkok, Thailiand, 10500 ................................395 T Tanchaiswad, Waran Prevalence Of Alcoholism In A Clinic In Southern Thailand And Validation Of MAST And GGT Vs Clincial Interview Prince Of Songkla University, Faculty Of Medicine, Department Of Psychiatry, Haadyai, Songkla, Thailand, 90110 ............ 366 Tarasov, Yu. A., et al. Hormonal Component In The Regulation Of Endogenous Ethanol Level In The Body Division Of Metabolic Regulation, Byelorussian SSR, Academy Of Sciences, 50 Lenin Kosomol Blvd, Grodno 230009, USSR .......... 261 Tittmar, Heinz-Gunther, et al. A Comment Concerning Methodology Of Alcohol Choice Experiments University Of Ulster, Department Of Psychology, Newtown Abbey BT370QB, Newtown Abbey, N. Ireland ..................... _ . . . 271 Tittmar, Heinz-Gunther, et al. Individual Variability In Alcohol Taste Threshold Estimation University Of Ulster, Department Of Psychology, Newtown Abbey BT3 70QB, Newtown Abbey, N.ireland ......................... 271 TIMN 321390
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Respondents were all asked what aspect of country music appealed to them. Most answered that they found It easy to listen to-one said, "It is not noisy and doesn't break your eardrums like other music". Most found a lot of personal meaning In the words, and they liked the fact that most songs are ballads, which means they tell a story. They felt the form and style made the messages readily understan- dable. Some felt the music really talked to them, and provided a form of solace or emotional release. The interview format used was informal and unstructured. Respondents were first questioned about their feelings about country music, with the interviewer leading the discussion so as to determine the depth of attachment felt, and the type of country music preferred. The interviewer would then lead the respon- dent into a discussion of their feelings about drinking values and behavior. No attempt was made to have the respondent link country music and drinking, and most did not Respondents were sensitive about discussing their feelings about drinking. Their responses were often initially guarded, until they became comfortable with the non-judgemental responses of the interviewer. After becoming less guarded, some of the respondents became quite voluble on the subject, though others remained reticent. The informal interview style helped the interviewer and respondents more free- ly explore and express respondents beliefs about alcohol use in our society. This style brought the interviewer in closer contact with the feelings of the respondents. RESULTS The responses of the participants to questions about their feelings and attitudes with regard to the use of alcohol were as varied as the respondents. However, a number of values were showed by most of the sample. All of the respondents considered alcohol use to be endemic in our society. Drinking is so common that it reaches from church services to athletic events. They felt that alcohol and its use is here to stay. All felt fatalistic about possible positive effects of alcohol and drug education, and were not hopeful that prevention pro. grams would be able to curb the steady increase in alcohol abuse. All of the respondents have been drinkers of alcoholic beverages, although some are currently abstainers. All felt that moderate use was the only proper, responsi, ble use of alcohol. When we began to talk about the respondents' use of alcohol, they all became defensive to some degree. They appeared to want to give the "right" answer to the AADAC worker, yet there appeared to be some conflict between what they were saying and/or what they did. The drug alcohol was considered socially acceptable by most of the respondents. However. most did not consider alcohol to be a legal drug, or even a drug at all. It was generally felt that alcohol must be kept under control because of its insidious ability to destroy people's lives. Most of the respondents felt that the drug could conquer anyone; that it was beyond an individual's control. In a com- plete tumaround in thinking, most felt that if an alcoholic wanted to they could stop drinking anytime. This thinking shows conflict over the manageability of alcohol. Alcohol is seen as an insidious, uncontrollable substance, thay may only be manageable by abstinence. People are believed to be relatively powerless over alcohol. At the same time all of the sample are or have been drinkers. The effects of ethanol on the system of the user makes it possible for many to have fun at a party. Respondents described it as lowering their inhibitions. One said that "A drink helps people get out of their shells so they can have more fun." Man's self-esteem Is further enhanced when he feels he belongs to a group and is accepted by his peers. Consuming alcohol with friends was seen by many of the respondents as a way of belonging, e.g. after work or after sports events. Be- ing part of a group and having that feeling of belonging is so important that some respondents would go to great lengths to get it. For example, abstainers would bring their own non-alcoholic beverages to a party so as to not make an issue of their abstention, and even those allergic to alcohol will consume it at risk to their own safety. Many respondents felt that drinking Is an essential part of maintaining friend. ships. It is a way of "sharing something with somebody". In many cultures, the sharing of food is an indicator to the guest that they are welcome in their host's home. Many respondents felt that, in our society, alcohol has replaced bread as the token of welcome and friendship. Some of the sample use alcohol as a way of coping with their "troubles". For them, going to the bar to drown their sorrows or to be with friends for support were viewed as acceptable reasons for consuming alcohol. They recognized that alcohol did not solve their problems, but they appeared reluctant to explore alter- native methods of resolving them. Some respondents indicated specifically that alcohol is useful in reducing stress. 14 Alcohol was seen as the easiest and most available drug to use for the relief of stress, anxiety, and any other pressures of life. One respondent said: "It lets me be out of control and get drunk at parties". He then added the rider "...but everybody does that". Here, alcohol is being used as a rationalization for being out of control. Some of the respondents viewed drinking as being an acceptable way to slip out of the confines of socially acceptable behavior. Liquor was the vehicle some of the respondents described as the most reliable drug to help them relax after a trying day. They felt they "deserved a drink" after a tough day. Table 111 illustrates respondents' explanations for why people choose to drink. REASONS Table 111 FOR DRINKING REASON NUHBER upper (stimutant) a R l 12 e axant To have fun 12 -- 33 choose alcohol to help them relax To reduce tnhibitions 5 To forget 7 To assuage problems 8 To relieve depression 4 -- 2h choose alcohol to help To reduce stress 3 them cope wtth tife To be macho 3 To be socially acceptable 45 Some respondents felt that the project should have focussed on drugs and rock music. They were surprised to discover that alcohol was a legal drug. They were aware of the many+ problems caused by alcohol abuse, but were still more con- cemed about the use and abuse of "drugs" lother than alcohol), although they had had little contact or experience with these substances. A few respondents felt that alcohol should be banned altogether. They felt that one must be forever vigilant or alcohol could creep up and ruin one's life. One respondent reflected: "I feel that if I don't control it lalcoholj, it will control me. No-one should drink; it could lead to alcoholism. CONCLUSIONS In conclusion there does appear to be a fairly clear correlation between the values and attitudes consuming alcohol expressed in country music and those values and attitudes stated by country music fari.s. In both value systems, alcohol is depicted as evil, cunning, and bequiling. Yet it is a common subject, and drinking it is socially normative. There is considerable value conflict over alcohol and man's ability to use it responsibly. Both the music and the fans refer to alcohol as a relexant, a social lubricant, and as a chemical escape from pain and tribulation. Both also describe it as the destroyer of families and of personal integrity. Chalfant and Beckley3 reported that norms for drinking presented in country songs were ambivalent. We have found the same ambivalence in the values expressed by country music fans. Chabalau• has printed out that this ambivalence about what constitutes acceptable drinking behavior does contribute to the misuse of alcohol. The use and abuse of alcohol is a common to pic in country songs. It is a con- flicted subject in the emotional world of the songs and of the audience, one which can be utilized over and over to highlight the periods of emotional turmoil that are the subject matter of all popular music. The fact that drinking themes are so prevalent in country music is a reflection of the prevalence of alcohol abuse as factor in emotional conflicts in the lives of country music fans. Understanding the system of values expressed in country music helps us under- stand the system of values held by its fans. This helps us understand the world as country music fans see it. This is essential knowledge for us, if we are to pro- duce messages which wiit tend to prevent the abuse of alcohol; messages which will promote responsibility and moderation. To paraphrase an old truism, "you can't talk the talk unless you can understand how to walk the walk". We live in an era of de-classification of the media. Toffler, in The Third Wave, TIMN 321405
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DOCSRASION'S WITH 10 0@ tl0li FASASS EL ACCIDENT iYFc ACCIDENT xzrsS R oF CORAC'I OCCOFASIOfS ACCIDRiTS SSRUGC sI FAid.f Ca1K.HT II.LCSRIC CORSACI 1l020R FIRL EXPIASIOr DtCSJSSIFI[D II RSC. $OaQ 20IIC TGQCLZ 7711-D=IIRICK tlA1 I 39 17 t 4 2 3 2 2 1 - i (43.6) (22.2) (11.1) (5.1) (7.7) (15.11) (5.1) (2.6) 9179-TSUCK DRIYLY / 33 3 4 4 7 3 11 - - 1 i (9.1) (12.1) (12.1) (21.2) (9.1) (33.3) (3.0) 6710/9E-LIlR0UR61 7 33 5 9 5 2 3 7 - 1 1 i (15.2) (27.3) (15.2) (6.1) (9.1) (21.2) (3.0) (3.0) 5711-IICAYASIOi/ / 22 - - 6 - 1 14 1 - - CRADIRG OFRASUR i (27.2) (4.5) (63.6) (4.5) 7513-LOCCER/FALLa e 12 S 2 - - - 2 - - - i (66.6) (16.9) (16.7) 0791-FLOlm6R/ 1 11 3 2 3 - 1 - 2 - FIFLFIST6R i (27.3) (15.2) (27.3) (9.1) (1t.2) 2335-ii[LDER / 10 2 2 - 1 3 1 1 - - i (20) (20) (10) (30) (10) (10) SOIAL 160 38 27 22 12 14 37 4 4 2 SA)LR 6 MCIDQI ?!!L SAliS 7 /CCID®S SSFL 1F ALCDHOL LRII.S n.42 IT F1tS 03 A7SLCL W ALCOFWL ALCOFpL DLiSCZ[D ALCOHOL LRYL[.S <sO.SnOC.1 2ts0.Rn00.1 ns ao ACCIDENT ?TFS 0 s 0 i ACCIDENT xrrS t 3 s s STRDCL Rx 7 23.3 1 8.3 STIOIC[ nr S 19 40 20 FALLS 4 13.3 6 50 FALLS 10 23.8 30 15 CAUGHT Il, DSDSII, ate. 4 13.3 0 - CAUGHT 11. IIRDRR, tc. 4 9.5 35 17.5 ILiCIRICAL COi2ACi 2 6.6 0 - ELECTRICAL C011TACS 2 4.8 1E 9 COiTACi WITH 'fOiICS, te. 3 10 0 - CO®SACT WITH S9iICS, tc. 3 7.1 21 10.5 t10TOR VSFQCULAi ACCIDENT t 26.6 5 41.7 tlOYOR FfliICULIR ACCIDENT 13 31 34 17 FIRL 0 - 0 - FIti 0 0 1 0.5 IZFLOSIONS 1 3.3 0 - iZlLOSI0IS 1 4 2 6 3 0 . . CA4[-IrS 0 - 0 - CAYR-IRS 0 0 5 2.5 URCLASSIFI6D ACCIDSlTS 1 3.3 0 - liiCLASSIFISD ACCIDIlIS 1 2.4 10 5.0 TDSAL 42 100 200 100 TIMN 321412 21
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(3.OBAL roxALS OF DRUG DEPE1tDFNrS ft H1 DRUG TYPB M1HWt RA1FS/1000 'Sl7rllL A) CAIOtABrB 29,698,000 7 29,698,000 B) PSTOnOIWDPIC SIaSTAMCFS 8,516,000 1) Sedati.e/ Depr.eaanta 4,178,000 1.8 11) 8ti.ulints 2,390,000 C) 111) Ballucinogena 2,008,000 CpCAIttt;-TYPg 1.4 5,985,000 1) Cooaine pasta/baee 4,375,000 10 Cooa tesr 1,610,000 D) OPIATi3 0.8 3,466,000 i) Opius 1,801.000 11) Heroin 1,115,000 E) iii) Other opiates 550,000 SO[.YFFIS 10,000 N),000 TOTA7. 47,675,000 However, with heroin, a different pattern emerges; heroin use in North America, whilst being high has infact stabilised but on the other hand it has spread rapid• ly, particularly among youth, in the East Asian/Pacific region. Also abuse of heroin has also spread in several European countries where previously abuse was in• significant. In South America, where there was endemic coca leaf chewing, a new and serious trend towards coca paste smoking, again particularly among the young, has emerg• ed. This trend also is now reported to have spread outside the South Americas. The phenomenon of cocaine free basing is another disturbing pattern which needs close monitoring. The increasing levels of abuse of Psychotropic substances presently being reported for the Near and Middle East, and East Asia/Pacific region is of very serious con• cem. This is particularly worrying since psychotropic drug use has become en• trenched into the drug abuse scene into these countries. With the trends being noted, extensive increases in level of alcohol consump• tion in Africa and Asia calls for a comprehensive approach towards the control of substance abuse. S iZ 2 W37Ali D~AMT Ti'PS-DFOGS 5TID18IdNT 1YPE tAt.LOCIN008d3 A) Afrioa (45) 10 12 3 D) Veria.s (40) 20 18 14 C) Ltrope (35) 27 22 18 D) IIsr aed Middle Sast 11 8 2 (2K) 8) Sut laia/Paaifio (34) 14 11 7 TOTAL (178) 82 71 44 ALCOHOL AND COUNTRY MUSIC: THE VALUES OF THE SONGS AND OF THE FANS Ena Gwen Ione4 RN. and Marshall Nok6; M.SW. INTRODUCTION Music has been the emotional language of mankind for centuries. A culture's values and attitudes are manifested in its music. Popular contemporary music in North America, in all its varieties, reflect the emotional tones of North American culture. In this project, we have attempted to define the values and attitudes towards drinking held by a group of people defined by their preference for a particular style of popular music, country music, and to examine the relationship between these values and those expressed in the lyrics of music. Country, or country and western, music is a distinct form of popular music. It originated in the hills of the Southern United States, and has expanded its area of popularity to cover the whole of North America. It is a style which is unique to North America. This study was begun with a literature review, to determine from previous studies what values and attitudes are expressed in country music regarding the consump• tion of alcohol. We then interviewed a number of informants who described themselves as country music fans, in an effort to determine what values and at- titudes they held about alcohol and its use. Finally, we examined the correlation between the values and attitudes expressed in the music and those held by the fans. The study took place in the town of Edson, Alberta, from January through March 1985. COUNTRY MUSIC Music flows through every facet of man's daily life. It speaks to him about himself and the rhythms of the society in which he lives. It is an integral part of our many rituals-for birth, love and sexual relations, marriage, death, the seasons, our joys and sorrows-with each calling for its own music. Music is thought to have preceeded language or art, and is considered man's oldest form of expression. Maybe the Africans are right when they claim music is magic. In no other art form are we able to express our emotions with such intensity. Through music there is an interplay between feelings and one's understanding of life. The early Greeks recognized the importance of music to man, and felt it was the primary element in building character and health. There is an honesty and intensity in music that words alone cannot attain. It evokes in us feelings that we might other• wise hide. Country music emerged from deep in the hills of Appalachia, where it was nur- tured at the homesteader's fireside. It is an unique form of communication, that resembles the face•to•face relationships of people with one another. In country music, the pulse and rhythm of the fan's life can be heard and felt. John Grissin, in his book Country Music: White Man's Blues, describes the music as becoming "the principal repository of the shared experience of generation of rural families _ their legends, history and ideas."' TIMN 321403 12 ~'
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ACUPUNCTURE TREATMENT FOR CIGARETTE SMOKING t Michael O. Smith, M.D. The Substance Abuse Division of Lincoln Hospital has been using acupuncture for the past I 1 years. Currently we treat 350 patients daily, primarily for alcohol and drug abuse. The ma(ority of our out-patient acupuncture detoxification pa. tients achieve a prolonged period of sobriety based on daily laboratory tests. These patients are chronic abusers, are frequently homeless, and many have psychotic problems as well. Our primary function is the treatment of alcohol and drug abuse so we have extensive statistics about this population. We have been equally suc- cessful in treating chronic heavy cigarette smokers but we have not had the time or opportunity to complete a detailed study in this area. One indication of the similarity in the two treatments is that patients receiving daily chemical depen• dent treatments also smoke many fewer cigarettes during the acute detoxifica- tion period. Acupuncture has been used as an important part of Chinese medicine for several thousand years. The same basic texts and charts have been used for 2,000 years. In the West, acupuncture has been practiced in France, including the University of Paris, for decades. Sir William Osler, considered the founder of the medicine in the U.S., used acupuncture himself for back pain and described these treatments in the first six editions of his seminal textbook of intemal medicine. Acupunc- ture is primarily related to pain relief by Western physicians today, but tradi- tionally acupuncture has been used as a preventive and homeostatic technique. In fact, pain relief is only occasionally mentioned in the basic acupuncture references. Our treatments for cigarette smoking and chemical dependency are based on the traditional applications of acupuncture. We will list the acupuncture points that are commonly used but certainly realize that most of you will not understand their location or full significance. Points that improve "lung function" may be used (e.g. Lung-9, Lung-I, Bladder-l3, Large Intestine-4). Points that improve "heat" and the yang aspect of vitality may be used (e.g. Governing Vessel• 14, Stomach 36). Points for anxiety, fear and the "empty fire" pattem may be used (e.g. Spleen-6, Kidney-3, ear-sympathetic, ear-shen men). Primarily we used prolonged stimula- tion of the ear-lung point. Prolonged stimulation involves either daily treatments or the use of a"press" needle that is left in place a week at a time and is pressed by the patient 3 times daily. Those readers who are familiar with acupuncture and Chinese medicine will know that there are different symptomatic and con. stitutional indications for these various points, but for most of you it would not be appropriate to cover these particulars. The mechanism of acupuncture has been discussed in many divergent contexts. The best approach is to say that acupuncture helps the body help itself, that is, it stimulates intrinsic balancing and healing processes. Acupuncture functions much like supportive psychotherapy. It is a physiological "message" to the body. The patient's own intentions play a role in treatment but it is easy to show that the fundamental effect is independent of suggestibility. In fact, the overwhelming suc- cess of acupuncture treatment of chemical dependent clients-especially those who are often hostile and resistant-offers excellent evidence In this regard. Patients who receive treatment for cigarette smoking usually notice that their desire or need to smoke decreases dramatically during the first days of treatment. Most say they feel like they have smoked enough already, that the cigarettes don't taste good any more, or that they want to stop smoking during the middle of a cigarette. A few people report an actual aversion to smoking. Alcoholics report very similar responses to alcohol craving with daily acupuncture treatment. Pa- tients are usually quite surprised by these results. They feel no anxiety or withdrawal symptoms. There is merely a quiet return to the level of awareness that all of us have early in life-the biological awareness that smoke in the respiratory passages is toxic. Smoking is addictive precisely because this toxic sensitivity is dulled by the process of continued smoking. It Is as though repeated attempts to rob a car would automatically turn off the burglar alarm. Acupunc• ture seems to restore our respiratory burglar alarm to normal function. Two critical treatment issues must be stressed. First of all, this acupuncture treat- ment leads to clearly better results in heavy smokers (more than 2 packs a day) than it does in lighter smokers. A survey of 60 patients by our colleagues at the Midwest Acupuncture Center showed 80% of the 2 pack a day smokers had a dramatic drop in intake; whereas 50% of the others noticed a change. This study used press needles in the ear-lung point in just one application. The acupuncture point selection is easy and reliable when the patient Is very toxic and smoking is the overwhelming imbalance in the body. However, when smoking Is merely one of many imbalances, then the acupuncture diagnosis and point selection is more complex and results are rarely dramatic. A similar effect occurs with chemical dependency treatment. Better statistics are obtained with more chronic alcoholics and more acutely psychotic cocaine abusers, for example. The second critical issue relates to the whole process of rehabilitation and change. Acupuncture never creates permanent change or "cure" in these conditions. Acupuncture does "set the table" for permanent change. Acupuncture treatment readily helps the heavy smoker reduce to 0-10 cigarettes daily with no motiva• tion on the smokers part (other than pushing the press needles). At that point the smoker must re-structure daily patterns and develop motivation to stop total- ly. Very few withdrawal symptoms will ever be felt but the aversion effect Is rarely strong enough for prolonged abstinence. Patients who stay at 5-10 cigaret- tes daily usually drift back to heavy smoking. Acupuncture gives a "free bonus" to stop smoking but not a "free ticket" for the whole ride. Therefore acupuncture treatment is a very valuable adjunct to behavioral and self help programs to stop smoking. We have seen the same response in chemical dependency treatment. Acupuncture reduces withdrawal symptoms markedly, reduces craving, improves sleep, vitality and emotional balance. All of these ef- fects assist the total rehabilitation process enormously, but they are not a substitute for the changes in self-awareness and social relationships that are necessary for real improvement. Acupuncture helps us help ourselves. ADULT CHILDREN OF ALCOHOLICS IN BERMUDA: A COMPARISON OF CHARACTERISTICS WITHIN THE GENERAL POPULATION Vaughn Mosher, M.S, M.H.S and Nadine Anderson, Ph.D. Bermuda has a population of approximately 56,000 individuals from many dif- ferent countries of origin including England, Scotland, Ireland, Canada, U.S. as well as from the Island to the South, Australia and New Zealand. The racial ratio is approximately 60% black and 40% white including quite a large Portuguese sub-culture from the Azores. As a tourist community and as an intemational business center, Bermuda is well known for its beauty and its calm. It is difficult to believe that Bermuda has one of the highest density rates in the world, in that there are only 20 square miles. In 1974, Bermuda ranked first in the world in per capita consumption of alcohol (19.251itres of absolute alcohol per person) with France just behind (18.96 litres). By 1982 Bermuda had lowered its per capita consumption to 10.1 litres (or 8.8 litres when adjusted for tourism). The most recent international figures have ju~t been released 11983) ranking France highest 114.81, Portugal second (14.3) and East Germany third (14.1). Bermuda figures for 1984 and 1985 will show an even more dramatic downtum 5 as a result of new drinking and driving legislation and the introduction of the alco-analyser. A treatment service exists providing counselling and inpatient detoxification for approximately 250-300 people per year. Alcoholism is covered as an insured hospital benefit; the entire population has access to treatment. Families are counselled in treatment whenever possible and, by 1985, there are five AI-Anon/Alateen groups per week as well as 22 AA meetings per week. In the last four years, and especially in the past 18 months, a new focus has swept through the Alcoholism Recovery Network. We have known for many years that children of alcoholics were more likely to develop alcoholism than children from non-alcoholic backgrounds but, until recently we have been unaware of the specific kinds of dysfunction children of alcoholics "carry into adulthood." 1 3 From mid 1984, the ACOA phenomenon germinated in Bermuda as a result of exposure to the 1984 Rutgers Summer School of Alcohol Studies where courses, TIMN 321396
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III d. Describe a typical teachers training course in AE or where AE is en integrtt part. Topics Length and structure Teaching material, manuals for teachers. ................................................................ ................................................................ ................................................................ .......... . .................................................... . 5. Parents involvement a. Are parents informed about the content (message) of any AE given to their off-spring? ................................................................ ................................................................ b. Are parents participating in decisior•: and/or p'lanning of AE? ................................................................ ................................................................ 6. Some specifics about content of a typical AE in your country. a. Is the teaching aimed at abstinence? ................................................................ ................................................................ b. Is the teaching aimed at diminishing alcohol-related problems (damages)? ................................................................ ................................................................ c. Is the teaching primarily i. risk oriented ++ ii. Situation oriented ++ ................................................................ ................................................................ ++ See definitions in the note at the end of the questionnaire 36 TIMN 321427
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I t;illese, John T., et al. Rehabilitation And Korsakoffs Syndrome Group Therapy Pilot Data University Of Alberta, Department Of Psychology, Edmonton, Alberta ........ 434 Grant, Marcus The Best Of Both Worlds: A Retrospective Over• view Of Substance Abuse Prevention World Health Organization, Division Of Mental Health, Ave. Appia, 1211 Geneva 27, Geneva, Switzerland ........................ 74 Gray, Elspeth M., et al. Developing Smoking Prevention Materials: A Psycho•Social Approach University Of Bristol, Set Project, School Of Educ., 22 Berkley Square, BS8 IHP, Bristol, England .......................... 155 Griffith, Paul R., et al. Implications Of The 'Learned Helplessness' Model For Alcohol Treatment Trl•County Employee Assist. Pg, 492 Grant Street, Akron, Ohio, U.S.A., 44311 ..... 263 H Haack, Mary R. Antecedents Of The Impaired Nurse Univ. Of Illinois At Chicago, Dept. Of Physiology/Biophysics, 845 South Damen Avenue A., Chicago, Illinois, U.S.A., 60612 .................................56 Hale-Matthews, Robert AADAC's Clever Classmates: A Co•ordinated Approach To Drug Education A.A.D.A.C., 2204, 10320 - 99 Street, Grande Prairie, Alberta, T8V 6J4 ............... I Halkias, Daphne Establishing The Salvation Army Family Recovery Program: A Residential Treatment Centre For Chemically Dependent Women And Their Children The Salvation Army, 1335 Broadway, San Diego, California, U.S.A. 92101 ............. 194 Halmesmaki, Erl-a, et al. A Longitudinal Study On The Concentrations Of Zinc And Copper In Pregnant Problem Drinkers: Relation To Fetal Outcome University Central Hospital, Hartmaninkatu 2, 00290 Helsinki, Helsinki, Finland ...... 301 Harford, Thomas C. Alcohol Dependence And Problem Drinking In a National Sample N.I.A.A.A., Division Epidemiology 14-C-26, 5600 Fishers Lane, Rockville, Maryland, U.S.A., 20879 .....:........-•---•------------.29 Haver, Brit Treatment Outcome In Female Alcoholics: Find- ings From A Long-Term Follow-Up Study of 44 Women Sandviken Hospital, Dept. Of Psychiatry, Bergen, Norway, 5035 ..................... 513 Hawks, David V. The Forumlation Of A National Policy On Alcohol In Australia W.A. Alcohol & Drug Authority, Salvatori House, 35 Outram Street, West Perth, West Australia, 6005.............................. 235 Henneberg, Maria, et al. Simplifications Des Tests Pour Le Diagnostic Des Toxicomanies, Ses Atouts Et Ses Inconvenients Centre Medical D'Enseignement, Post- Universitaire, 01 •813, Rue Marymoncka 99, Bydgoszcz, Pologne ................. 462 Hicks, Beverley A Study Of Selected Psycho-Social Characteristics Of Western Manitoba Women With Drinking Problems Manitoba Health, 340 Ninth Street, Brandon, Manitoba, R7A 6C2 . . . .............. 475 Hoekstra, Marten A Data-Model For The Treatment Of Alcohol And Drug Addicts Federation Of Agencies For Alcohol And Drug Care (FZA), Postbox 171, 3720 AD, Bilthoven, The Netherlands ................... 147 Hoke, Marshall, et al. Alcohol And Country Musir. The Values Of The Songs And Of The Fans A.A.D.A.C., Box 3042, Edson, Alberta, TOE OPO ........................... _12 Holder, Harold D., et al. Reduction Of Community Alcohol Problems Th Human Ecology Institute, # B 211 North Col• umbia Street, Chapel Hill, N. Carolina, U.S.A. 27514 .............................427 I loffe, Semyon, et al. Effect Of Alcohol Intake During Pregnancy On Sleep Cycles In The Newborn University Of Manitoba, 770 Bonnatyne, Win• nipeg, Manitoba .................... 185 Irizawa, Yoshito, et al. Ethanol Contents In Drink Drugs And Cool Beverages On The Market In Japan Kyoto Prefectural University, Dep. Legal Med., Kawaramachidori, Kamigyo-Ku, Kyoto-Shi, Kyoto, Japan 602 ......................... 191 Ivanets, Nikolai N. Individual Sensitivity To Alcohol As A Basis To Predict General Clinical Regularities Of Alcoholism All-Union Research Institute Of Gen. & Forensic Psychiatry, Kropotkinsky, Moscow, U.S.S.R. ................................270 J Jenkyns, Michael, et al. The Reaction Of Clients And Staff To Onsite Urine Testing In A Methadone Programme A.A.D.A.C., 8944 - 182 Street, Edmonton, Alberta, T5T 2E3 ...................409 Jonckheere, S. Dyane The Problems Of Addiction Nurses In Canada 16 Tulane Crescent, Ottawa, Ontario, K2J 2H6 ................................ 381 K Kalant, Harold Recent Advances In Biomedical Knowledge Of Addiction Director, Neurobiology, Social & Biological Stud. Div., 33 Russell Street, Toronto, Ontario, M5S 2S1.............................. 414 Koistinen, Paavo, et al. Psychodynamical And Social Aspects Of The Relationship Between Life Cycle Events And Alcohol Abuse Of Women Jarvenpaa Social Hospital, Haarajoki, Finland, 04480.......... ------•----•--....391 Komura, Setsuo, et al. Interaction Between Methamphetamine And Alcohol vii Kyoto Prefectural University, Dep. LeKal Med., Kawaramachidori, Kamigyo Ku, Kyoto Shi, Kyoto, Japan 602 .........................276 Kooyman, Martien Follow-up Of Former Residents Of The Emillehoeve, A Therapeutic Community For Drug Addicts Erasmus University, Preventive & Social Psychiatry, P.O. 1738, 3000 Dr Rotterdam, Rotterdam, The Netherlands .......... 231 Krishnaswamy, Dr. Soroja, et al. Psychoneurotic Profiles And Some Character istics Of Drug Dependents University Kebangsaan, Faculty Of Medicine, Dept. Of Psychiatry, Kuala Lumpur, Malaysia ................................ 393 L Laforest, Lucien Unveiling Powerful Psychosocial Predictors Of Alcohol•lnduced Car Accidents Faculte De Medicine, Dept. Sciences Sante Commun., Universite De Sherbrooke, Sherbrooke, Quebec, J I H 5N4 ........ 531 Lawton, J. Kenneth A Christian Perspective-The Christian Motiva tion, History And Contemporary Response International Christian Fed., Prevention Of Alcoholism, 27 Tavistock Sq., WCIH 9HH, London, England .................... 98 Lawton, J. Kenneth An Historic And Prophetic Perspective International Christian Fed., Prevention Of Alcoholism, 27 Tavlstock Sq., WCIH 9HH, London, England ................... 260 Lemoine, P. • A Propos De 200 Syndromes D'Alcoolisme Foetal Observes En 25 Ans: Quelques Precisions Cliniques Et Pathogeniques Centre Hospitatier. Universitaire de Nantes, -# 15 Rue Alfred de Musset, 44035 Nantes, Cadex, France ........................... 384 Lenton, John D., et al. Combined Abuse Of Alcohol, Cocaine And Marijuana: Behavioral Consequences And Treat• ment Issues. Veterans Admin. Medical Ctr., 1670 Clairmont Road, Decatur, Georgia, U.S.A. 30033. .. 105 Lester, David, et al. Physiological Measures In Adolescents And Their Parentage Rutgers University, Center Of Alcohol Studies, New Brunswick, NJ, U.S.A. 08903..... 354 Levison, Toby Emerging Issues Of Human Rights And Confiden• tiality ln Employee Assistance Programs-A Treatment Perspective Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, M5S 2S1 ..... 192 Lowe, G. Alcohol And Memory Processes: Implications For The Elderly Alcoholic Department Of Psychology, The University, Hull, United Kingdom, HU6 7RX ............ 27 M Magruder-Habib, Kathryn, et al. Health Services Use Patterns Of Male Alcoholics: Implications For Primary Care Veterans Administration, Medical Center, 508 Fulton Street, Durham, North Carolina, U.S.A. 27705 ............................256 TIMN 321388
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IU d. Is there an age limit for consumption of alcohol in your country? i. No ii. < lo iii. lo < 18 iv. 19< 21 7. Combination with other topics. a. Is AE given together with drugeducation and/or medicineducation and/or tobaccoeducation? ............................................................... ............................................................... b. Are all these taught at the same age-groups? ..........., .................................................. ............................................................... 8. Evaluation reports and other litterature. a. Please list one or more recent evaluation studies from your country. If possible, please send one copy (even if only as a loan) ............................................................... ............................................................... b. Please list some important studies on methodology and/or m-&ssage (content) of AE in your country. ............................................................... ............................................................... c. Has there been any report to Unesco, Council of Europe, or any similar body describing the AE (among others)-in school or out- side the school in your country? If so, please report on the work, its contract number and its author(s). ............................................................... ............................................................... TIMN 321428 37
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Table 2 Table 3 ALCOIiOL DErE1DENLE AND MtOBLEX DR11R1116 8T HOUSENOCD INCOME AND OLCUPATIONAL STATUS, tn fercenta ALCODOL DEfE1DEN0E A7D tROLLEN DXINKING 8T SEX /YD IWtITAt STATUS, Nondependent In fercenta N Non Drinkers Xonproble. Drinkers Proble. Drinkers Dependent Drinkers 0ccelatlan X X0n- Drinkers XoMependent Ne~rnble. DrineeK XenOependent freble. Drinkers DspeMant Drinkers Me rrofessioaal 241 17 70 5(5)b 6 (10) YRtta-collLr 202 25 58 10 (13) 7(9) X.rital ;t+tya tl6rco11ar 162 31 52 5 (7) 25 (18) Xan IYrr(e0 601 29 60 3 (4)b 7 (10) WOW DlrorcaA 61 23 45 16 (21) 16 (20) frofesstenal 311 26 67 3 (4) 5(6) Serarat.d 19 26 42 7 (9) 25 (34) uMta-ullar 266 36 57 3 (5) 4 (7) WeowA 35 46 46 0(0) 9(16) tlee-cellar 202 50 44 2(5) 4 (7) Xev.r Narriea 146 14 66 12 (14) s(10) i1"seAa16 1M4- rrfe6 Nv"" 77 0 5 (3) (6) Xax DMer 56,000 69 41 46 2 (2) 12 (20) $6,000-9,999 111 34 48 5 (7) 13 (20) Dirorcad 101 24 63 7(19) 7(9) f1D,000-19,999 247 26 59 5 (6) 11 (14) SeparatM 34 36 60 2 (4) 0(0) f20,080-29,999 132 21 6S 8(10) 6(8) Y/Me[ 144 65 35 D(0) D(0) 630,000-39,999 78 14 74 • 8(9) 6(6) Naear XarrisA 149 26 62 7 (9) 6 (18) $40,000 a.6 esr 60 3 65 6 (6) 7 (7) a 9erunts an ret9kt" flrre; tatals are actual v.ber of less cases 1(en. 000 Dr 66r f6 160 56 34 5(12) 3(7) b PercMts in p.reethists are based .x res0onoe.ts .h0 {rant dwin9 tte y.ar , , f6,000-9.999 158 42 52 2 (3) 4 (7) f10,o00-19,999 278 36 55 4 (6) 3(5) S2D,000-29,999 176 34 60 2 (3) 4 (7) f70,o00-39.999 50 18 75 5 (6) 2 (2) 1160.000 a.d 6eer 52 12 82 1(2) 5 (6) a ferceets are w19" ff9eres; totals are actwl eumber of Iess casn 6 hrcaa4 iX parbetAesls an bese6 .a respMents rir 6raM Mr(n9 tXe year ALCOHOL EDUCATION IN EUROPE Peter Schioler Alcohol Education Core Group and Section at the 34th International Congress on Alcoholism and Drug Dependence, Wednesday 7th August 1985. Calgary, Alberta, Canada. Class-room education has been one of the classical instruments in European Health Education for several decades. The wide spread knowledge about alcohol, tobacco. Psycho-active medicine and illicit drugs has been considered to be part of the in- dividual's needed equipment to take partial-responsibility for one's own health and lifelong promotion of good health. In Europe, apart from most of the Nordic countries (Finland, Iceland, Norway and Sweden) the consumption of alcoholic beverages has been widespread, or ubiquitous. Only small and very idealistic groups have wanted general abstention in their nation. The use of alcohol has been the preferred type of intoxication or mild use of stimulant or relaxant in the entire cultural history for at least two millenia. The impact on the national culture of alcohol and other intoxicants is strongly varied in the European regions. Different regions use different beverages. Different socio. cultural groups prefer different beverages, or distribute the weekly consumption in different patterns. It is a hopeless task to attempt a complete description of the distribution of the consumption through Europe The only evidently possible way to deal with these issues is to approach the intoxicant consuming phenomena locally and with a multidisciplinary community based-model for theory and methodology. The phenomena vary of course widely with which intoxicant is studied. But in some European countries there is found a tendency that consumption patterns are simila; especially in an anthropological way of considering the phenomena, for alcohol and cannabis. Different nations react differently and more or less violently against the use of these two intoxicants. This has something to do of course with 31 TIMN 321422
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,duestionnaire (AE: Abbreviation for Alcohol Education.) 1. Legislation a. Is AE a compulsory issue in school curriculae? ................................................................. ................................................................. b. Is AE mainly placed in certain classlevels (age groups)? ................................................................. ................................................................. c. Is AE supported by a compulsory number (minimum) of teaching periods? ................................................................ ................................................................ d. Is there any terminal test or examination of which AE is a part or a main issue? .............:.................................................. ................................................................ 2. Part of Health Education a. Is AE considered to be an autonomous subject? ................................................................. ................................................................. b. Is AE treated as a part of Health Education? ................................................................. ................................................................. 3. Integration a. Is AE given as a subject integrated in the general school curriculum? or .................................................:............... I ................................................................•
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V 9. Name and country of the correspondent to this questionnaire ..................................................................... .................................................................... ................................................................... Note. In this con tex t the te rms are de fined as follows : 1) Risk-oriented teaching is primarily oriented towards the risks, dangers, negative implications in consuming alcohol or misusing .alcohol. It is generally using methodologies and concepts aiming at feelings of guilt, aversion, fear, anxiety, despise, even hate of the behaviour when consuming alcohol or of being intoxicated. It is frequently aimed at abstinence. 2) Situation-oriented teaching is based on the same physical mental and social facts as any other main trend in alcohol education. In stead of concentrating on aversion or other negative attitudes, about alcoholl alcohol use, or the alcohol user, this type of teaching is aiming on developping a conscious attitude and well trained decision making skills to be used in situations where the individual meets alcohol in social or ritual contexts. Situation-oriented alco- hol education is an integrq( part of Health Education and shares the responsibility for a health improving lifestyle between the individuals and their society (community). 3) It is rarely possible to point out a teaching system used in syste- matic teaching, which is either one or the other of the above ma-an classes of teaching. This questionnaire attempts to find some trends in European teaching as a part of a constructive discussion at Calgary and maybe later between the North-American and the European continents. Thank you for your collaboration. Peter Schi0ler 38 TIMN 321429
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ALCOHOL AND DRUG PREVALENCE IN OCCUPATIONAL FACILITIES IN ALBERTA 1979-1983 RC. Alleyne, MSc; G. Jamieson, Mo; J. KalnA M.D. & RR Orford, M.D. INTRODUCTION The relationship between alcohol, drug abuse and industrial accidents is an area of interest to all concerned with occupational health and safety. There is a persis- tent belief that industrial accident rates are higher in alcohol and drug users, but evidence to support or negate this opinion is scarce. Faced with this deficiency, researchers have tried several different approaches to estimate the prevalence of the problem in both the general population and in industry. Lewy' used a pre-employment qualitative urine toxicological drug screening pro- cedure on 500 prospective hospital employees and found that 33(6.6%) of them were positive for either valium, barbiturates, amphetamines, phencylidine or opiates. However, 13 (2.6%) of those screened were confirmed to be true positives when referred to a reference laboratory for confirmatory testing and only one person was not hired. Because of its low yield, Lewy concluded that a pre• employment screening approach, is not a cost effective procedure. The use of such pre-employment screening has also been questioned on the basis of con- cerns about the infringement of workers' rightsz. Despite its limitations self-reporting is another approach that has been tried. Us- ing this approach Mott; found that five percent of a sample of persons 16 years or older reported that they had ever used cannabis. The highest proportion of both males and females who said they had ever used cannabis was found in the 25-34 age group. Schmidt and deLint4 estimated the prevalence rate of alcoholism in Ontario by using alcohol consumption data, death rates from liver cirrhoses and death rates from suicide (assuming that alcoholism and suicide are closely related). All three methods produced a similar estimate of approximately 1.7%. In another study, Greg et als used two methods, one based on average per capita consumption and the other using a questionnaire. Both methods produced almost identical results and showed that approximately 18% of the military personnel on a Cana- dian Armed Forces air base consumed alcohol at or above a level that is thought to be hazardous to health. Although employment on a military base maybe con- sidered to be unique, Schuckit and Grunderson6 have shown that there are many similarities between certain military and civilian occupations and that in those occupations there are more drinkers. Despite these efforts, a reliable estimate of alcohol and drug abuse in the work place still remains an unknown factor. We, like Shafn' are unaware of many studies that have properly investigated the relationship between industrial accidents and substance abuse. In Alberta all non-highway related, fatal accidents within the jurisdiction of Alberta's Occupational Health and Safety Division are carefully investigated by a SigniFi= c.ant Incident Review Board (SIRBI• This evaluation process includes the review of toxicological information made available by the Medical Examiner's Office. Using this data base we have initiated an ongoing study to determine the fre• quency with which alcohol and drugs are associated with occupational fatalities. This report summarizes our findings to date, based on 339 cases reviewed from 1979• 1983. METHODS Toxicological reports on occupational fatalities that occurred in Alberta between January 1, 1979 and December 31, 1983 were reviewed and age, sex, occupa- tion, accident type and the presence and level of alcohol or drugs were record- ed. Drugs other than alcohol were classified as either prescription, non-prescription or illiciL Included in the group of illicit drugs were cannabinoids, cocaine or am- phetamines. Occupation codes used were based on the Canadian Classification and Dictionary of Occupations,$ while accident types were coded following the American National Standard Method for Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries.9 RESULTS The fatalities were predominantly males with a mean age of 32 years, with 22 Years being the most frequently occurring age. The other general findings of the review are summarized in Table 1. Out of the 339 fatalities, toxicologic tests were done in 254 cases. Most of the 85 cases on which tests were not done, were fatalities between 1979 and 1980 when routine screening of industrial fatalities was not yet formalized. Presence of alcohol was reported in 42 (16.5%) cases. The distribution of the alcohol levels are shown in Table 2. Of the 42 cases, 30 (71%) had alcohol levels less than 80 mg/100 ml, the legal definition of impairment for driving automobiles. The drugs, other than alcohol, that were detected in 36 (14.2%) cases were grouped under the major headings of cannabis, antihistamines, pain killers or barbiturates and diazepams. Drug Combinations were found in 7 cases, and these are listed in Table 3. A large variety of occupations were represented in the fatalities reviewed. There were, however, seven specific occupations, shown in Table 4, in which 10 or more fatalities occurred during the five year period. When the occupations with 10 or more accidents were correlated to the type of accident, as shown in Table 5, "struck by" "motor vehicle accldents" and "falls" three were the three prime types of accidents. When the accident types were correlated with the presence or absence of alcohol, "falls" and "motor vehicular accidents" were the two accident types that occured more frequent where alcohol was detected. This association was further strengthen- ed when the accident types were correlated with alcohol levels less than or greater than 80 mg/100 ml. The numbers are, however, too small for reliable statistical analysis. These results are shown in Tables 6 and 7. Although there were only 36 cases where drugs other than alcohol were iden- tified, a correlation between accident type and the presence of a drug other than alcohol was attempted. The analysis showed that "cave-ins" and "caught in or under" were the accident types which were proportionately more frequent where drugs were detected. However, when drugs which are pain killers and prescrip- tion drugs are discounted there remained only six instances in which an illicit drug (cannabis) was found. In these, six different occupations and five types of accidents were identified. Only motor vehicle accidents were duplicated. DISCUSSION Although alcohol was detected in 42116.5%) fatalities, only 12 (4.7%) had alcohol levels in excess of the legal limit of 8Omg/100mL The figure of 4.7% is very similar to the figure of 3.0% reported by Lings et aI10 and 4.0% reported by Manello" , but much less than the 20% quoted by Travis''-. Data for drugs other than alcohol, especially for cannabis, is very tenuous. The six cases are too few to allow any valid inferences to be made. The Medical Ex• aminer's Office has also informed us that in the past although toxicological samples may have been collected, routine tests for illicft drugs such as cannabinoids were not always performed on industrial fatalities. Currently all industrial deaths will have samples analysed. For this reasons no inferences can be made about the prevalence of cannabinoids in occupational fatalities at this time. The drugs other than cannabis that were detected were predominantly pain killers. They were found proportionally more frequently in cases that were victims of cave-ins or were caught in or under equipment. This association is consistent with attempts to lessen the pain of such victims while conveying them from worksites to hospitals, therefore it would appear that the drugs found in these cases have not contributed to the cause of the accident. The six cases in which cannabis was identified did not cluster around any particular type of accident or occupation. The type of accidents that were found most frequently associated with elevated alcohol levels, falls and motor vehicular accidents, are ones where Interference with coordination could contribute to the accident. It is well known that alcohol does interfere with coordination. Although the numbers are to small for statistical analysis this finding adds to the internal validity of the data. Our results indicate that the data base being used is capable of generating infor- mation which has the potential to provide useful estimates of the prevalence of drugs or alcohol in occupational fatalities in.Alberta. Estimates for illicit drugs such as cannabis should also be possible as better drug screening methods and protocols are developed. Cimbura et al", using traffic fatality data from Ontario, has been able to determine that 12% of all victims of fatal traffic accidents in a year were drug related, and that in approximately one-third of these, cannabis was the only drug found. As we collect more data, we hope that our on-going study will yield a better understanding of the contribution of alcohol and drug abuse to industrial accidents. ACKNOWLEDGEMENTS We thank the occupational health nurses, Marlene Gray and Peggy Szumlas for their assistance with collecting the data; Blair MacKinnon for his assistance with 19 TIMN 321410
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Subjects' reports on their families of origin showed that, as expected, the chemical ly dependent nurses had more familial alcoholism and familial depression. They were more likely to have lived in a home where heavy drinking was common; to have an alcoholic family member, to have a parent die due to alcoholism or drug abuse; and to have depressive illness in the family. As expected by the parental alcoholism and depression reported, chemically depen- dent nurses more often were required to assume parental roles in their families than the non-chemically dependent nurses did. Black (1981) found that individuals who chose a caretaking profession learned to take care of others in their family or origin. This may be true for the nurses reported here. The literature is replete with documentation on the familial aspects of alcoholism. Studies of genetic and environment influences indicate that children of alcoholics have an increased probability of developing the disease Bissell and Haberman (1984) found one-third of their sample of recovering alcoholic professionals to be children of alcoholics; one-fourth of the chemically dependent nurses in this study have one or both parents who are alcoholic. In addition to familial alcoholism, depressive illness has been shown to be associated with alcoholism in families. In fact, female alcoholics more often have a dose female relative with depression than male alcoholics (Schuckit, 1972). The results reported here concur. That education histories and educational achievement did not differ was an unex- pected finding. Bissell found alcoholic nurses to have the same high academic achieve- ment and advanced education reported here (Bissell & Jones, 1981; Bissell & Haberman, 1984). However, Bissell did not compare her sample with non-chemically dependent nurses and these results showed the non-chemically dependent nurses performed just as well academically as the chemically dependent nurses Since 64% of the non-chemically dependent nurses reported graduating in the top one-fourth of their nursing class, explanation of the high achievement reported by non-chemkally dependent nurses is suggested. Possibly, the better performing student may be more likely to have been successful when employed in nursing and, therefore, to have remained in the profession and be accessible for this study. Also, the more suc- cessful nurses may have a greater commitment to the profession and be more like ly to respond to a request to participate in the study. The association between chemical dependency and multiple sexual problems was found. One suggestion for this finding may be that a child in an alcoholic family may be more likely to have been molested and then may be more likely to have problems with sexuality as an adult. Wilsnack (1973) reported that feminine sex role functioning is impaired in women alcoholics. Results reported here, in com- paring two samples of mostly female nurses, concur. Homosexuality also was associated with chemical dependency in this study. Subjects' current families showed the chemically dependent nurses to have less stable marital relationships, as expected, when at least one spouse is chemically dependent. Fewer are married; for those who are married, they have been so a shorter length of time; and, more than have been divorced. Higher divorce rates have been reported for female alcoholics in the general population (Gomberg, 1974). Chemically dependent nurses had fewer children; and, for those with children, they had smaller families. It may be that progression of chemical dependency, sex ual dysfunction, homosexuality, and marital instability combine to make parenthood less likely. Chemically dependent nurses reported more illness and medical treatment than the non-chemically dependent nurses in agreement with previous research. Levine et al. (1974) found drug dependent nurses to have extensive medical histories and frequent, regular use of medical services. In summary, there were significant differences between chemically dependent nurses and non-chemically dependent nurses on the following variables: gender; familial alcoholism; familial depression; sexual trauma and functioning; sexual preference; parenthood status; marital history; physical health; depressive iliness; and, alcoholism in spouse. There were a number of variables in which no statistically significant differences were found between chemically dependent nurses and non-chemically dependent nurses. These include: age, sibling rank, basic nursing education, nurs- ing school class rank, highest educational degree held, academic achievement, length of time since nursing education completion, and years employed in nursing. Several limitations in methodology indicate that the results of this study should be considered cautiously. The two populations selected for sampling diffeied in possi- ble representativeness. Due to the inaccessibility of the recovering chemically depen- dent nurse population, a convenient, purposive sample was selected and this selection of chemically dependent nurses was not controlled by the investigatos Represen- tatives of local peer assistance organizations distributed surveys to nurses enrolled in their programs and selection may have been influenced by the time and place of distribution as well as other unknown conditions. The number of subjects who had access to the survey is unknown and, therefore, the response rate not known. The sample was selfselected by response. Variables associated with responsiveness to complete the questionnaire also are unknown. More importantly is the fact that this study showed differences between recovering chemically dependent nurses and non-chemically dependent nurses; nurses who are active chemical dependents are not included due to lack of accessibility. There may be characteristics associated with the ability to recover that are unknown. Although the selection of non-chemically dependent nurse sample was random, the participating state boards of nursing were those who had the capability to ran- domly select nurses' names, put the names and addresses on mailing labels, and whose charge for this service was nominal. Since only six state boards of nursing met these criteria, the sample may have reflected a regional bias unknown to the researcher. The low response rate may contribute to a positive bias in the non- chemically dependent nurse sample and, possibly, the chemically dependent nurse sample No attempt was made to control for this possible bias inherent In mailed survey research. Personal experiences with alcoholics or alcoholism may have In• fluenced the propensity to participate. Again, the influence of these factors is unknown. In addition, all data collected utilized anonymous self-reports. The accuracy of reports of events with emotionally laden memories is uncertain and conclusions should be made with caution. Although methodological weaknesses require reluctance in generalizing the fin- dings, this work represents an early, much needed contribution to the limited knowledge on chemical dependency In nursing. Improved methodology in subse quent studies would render results more reliable Little is known regarding variables associated with recovery for chemically dependent nurses. Bissell and Haberman (1984) have reported on a five to seven year followup of recovering alcoholic pro- fessionals. Such longitudinal work with recovering chemically dependent nurses should continue. The problem of alcoholism and drug addiction impacts on the individual nurse, his/her family, employer, and, most importantly, the patient. In addition to helping nurses recover from alcoholism and drug dependency, it is the patient's health, safety and recovery that mandates development of strategies to identify, intervene and prevent alcohol and drug impairment in nurses. References Bissell L & Haberman P W (1984) Alcoholism in the professions. New York: Bissell, L & Jones, R.W. (1981) The alcoholic nurse Nursing Outlook, 29 (21:96-100. Bush, C. (1983, May) A review of research: The impaired nurse Paper presented at the First National Symposium on the Impaired Nurse, Emory University, Atlan• ta, GA. Ewing, J.A. (1984) Detecting alcoholism: the CAGE questionnaire Journal of the American Medical Association, 252(14(:1905-1907. Ewing, J.A., Rouse, B.A. (1970, February) Identifying the hidden alcoholic. Presented at the 29th International Congress on Alcohol and Drug Dependence, Sydney, Australia. Gomberg, E. (1974) Women and alcoholism. In Franks, V, and Vansanti, B. IEdsJ Women in therapy-new psychotherapies for a changing society, New York: Brun- ner/Mazel, Inc Jaffe, S. (1982) Help for the helper: First-hand reviews of recovery. American Jour- nal of Nursing, 8214j:578-579. Levine, D.G., Preston, P.A. & Lipscomb, SG. (1974) A historical approach to understan- ding drug abuse among nurses. American Journal of Psychiatry, 31(9):1036-1037. National Council of State Boards of Nursing (1980-1981) Preliminary sample of board actions. Unpublished data. National Institute on Alcohol Abuse and Alcoholism (NIAAA) (1978b( Third Special Report to the U.S Congress on alcohol and Health from the Secretary of Health, Education, and Welfare, June 1978, Noble, E.P., ed. DHEW Pub. No. (ADM) 78-569. Washington, DC: Superintendent of Documents, U.S. Government Printing Office Poplar, J. (1969) Characteristics of nurse addicts. American Journal of Nursing, 69(11:117-118. Schuckit, M. (1972) The alcoholic woman: A literature review. Psychiatry In Medicine, 3:37. Talbott, D. (1983, May) The impaired health professional. Paper presented at the First National Symposium on the Impaired Nurse, Emory University, Atlanta, GA. Talmadge, M. (1982) Descriptive study of chemically dependent nurses. Unpublished master's thesis. Nell Hodgson School of Nursing, Emory University, Atlanta, GA. TIMN 321409 18
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Im ~'j~j1}{7~I, C u .a h T i ~ 1.} 1 i m al ~ ~ h 0 ; 4R''.,,iJ3{{{ r e i ~^ ~ i ~ ~b py ~ I 5 e ¢ d PAPERS VOLUME II PRESENTATIONS
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II b. Is AE given as a specific subject, independent of the systematic school-didactic courses? ................... :............................................ ................................................................ c. If a is the case, please name some topics where AE may be given (Biology, Sociological issues, Language and Litterature, Mathematics, Chemistry, Physical Training, others) ................................................................ ................................................................ d. Is AE offered by one of the student's usual teachers/or by another teacher/or by a school nurse/or by a school physician/or by an outside person (physician, temperance representative, senior student, recovered alcoholic, alcoholic in treatmnet, others)? ................................................................. ........................................................ :........ e. How many years may AE be given in school3lor r4,k ................................................................. ................................................................. 4. Teachers training a. Do teachers receive any specific AE during their training before leaving training school, etc.? ................................................................ ................................................................ b. Do teachers receive any specific AE-related didactic training before leaving training school, etc.? ...........................:..................................... ..............................................................,... c. Are teachers offered any training in AE, its methodology, its content, i's conceptuology while in service? ...................~............................................. ................................................................. TIMN 321426 35
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reports of psycho stimulant abuse in Africa is not significant, reports on illicit traffic indicates quite large movements of these drugs into that region. In most parts of the globe these drugs are abused by the younger population as well as to the cccupational groups whose work requires long hours of alertness. A significant proportion of psycho-stimulant abuse arise out of prolonged therapeutic use of these substances. These substances are also, often, associated with polydrug use. The last group of psychotropic substances reviewed here are the hallucinogenic compounds. The abuse of these substances are limited and the global rate for abuse was 0.47 per 1000. Further the abuse problem has been primarily reported by the United States of America, who has a abuse rate of 9.1 per 1000. Some, but much lesser levels of abuse have been reported as occurring in the Carri- bean, Australia, Canada and Switzeriand. This group of substances have not shown the type of global spread as demonstrated by other dependence-producing substances. Some of these hallucinogenic substances are naturally occurring. However, a wider variety can be synthesised relatively inexpensively and easily. Further very small quantities are required to produce the hallucinogenic effects. Since these substances have been known to occur naturally, it is not surprising that some indigenous use has existed. However, currently the primary users are primarily urban youths. Cocaine-Type The cocaine-type substances are abused in several forms, including coca leaf, the paste extract and the pure salt. Nearly six million abusers of cocaine-type substances have been reported. Of this groups the majority were cocaine paste or salt abusers. More recent reports in the literature strongly suggests that the abuse of cocaine salt is increasing extremely rapidly particularly in North America and Europe. Existing data indicate that high levels of abuse are being reported in U.S.A., Peru, Argentina and Bolivia. Relatively, high incidence of abuse has been reported in Canada and Brazil. However, in respect of abuse, adverse consequences and even prevalence of use there are significant difference between the various cocaine-types. Recently, in 1984, the World Health Organisation reviewed the cocaine abuse situation. From the reports received, it was clear that in the United States, bet~ ween 1974 and 1982, the number of persons who reported having used cocaine, at least once, rose from 5.4 million, in 1974, to 21.6 million in 1982. During the same period the number of current users of cocaine rose from 1.6 million to 4.2 million. In recent NIDA report it was stated that among high school seniors, only 9.0% had ever tried cocaine, in 1975, and 1.9% were current users, however in 1983 the percentage of those who had ever used increased to 16.2% and cur- rent users to 4.9`Y. Canadian data also indicate an increase in rates of cocaine use Smart (1983) reported that in 1978 the percentage of Canadians, aged 18 years and older, who had ever used cocaine was 2.7%, but by 1980 for the same age group, use had in- creased to 3.3%. - Since the coca plant is indigenious to the South American region, it is not supris- ing that traditional use exists. The traditional way of use was by chewing of the leaves. However, this pattern has changed and now using crudes refinement pro. cedures a coca paste has been produced, and this is smoked. Coca paste smoking began in Bolivia and Peru, but has now spread to several other countries. Un- published studies indicate that the prevalence of coca paste smoking in the ur- ban and rural areas of Bolivia, Colombia, Ecuador and Peru is rapidly increasing. In Europe, several countries including France, ltaly, Portugal, Spain and the United Kingdom, I I report increases in cocaine use. A survey conducted in Bayem, Federal Republic of Germany, showed that the prevalence rate of 4% for 1973, has in- creased to 7% in 1980. The East Asia/Pacific region remains relatively untouched by the cocaine epidemic except for reports of cocaine use in Australia and, to a lesser level, the Philippines. Concern regarding cocaine abuse has increased over the last few years, especial- ly,since cocaine free-base became available. The use of the free-base has been demonstrated to produce more severe adverse effects. Cocaine produces euphoria or central nervous system stimulation. However, these effects are relatively rapidly and is replaced by anxiety, depression or apathy. Smoking of cocaine produces more marked effects. Prolonged use of cocaine can lead to psychological deterioration. OPIATES Over 3 million persons have been reported to be abusing; opiate-type drugs. Of this population it was reported that 1.8 million were opium users, about 1.1 million were heroin abusers and 0.55 million were abusers of other opiates. II However, from scientific publications it would appear that whilst numbers of opium users have not increased, in many instance reduced; the number of heroin abusers have increased significantly. Again, like the cocaine-type substances there are distinct difference in the pat• terns of use and prevalence levels for the two major opiate-type li.e. opium and heroin). High rates of abuse of opium have been reported for the Middle East and Asia/Pacific region. The key countries in this area reporting high levels of abuse include Pakistan, Sri Lanka, Iran, Afghanistan, Laos and Vietnam. Abuse, but at a slightly lower level, was reported for Burma and Hongkong. Nearly all the neighbouring countries reported some level of abuse. From the epidemiological profile it Is clear that opium abuse is a regional problem and is localised. The highest rates are reported in opium-producing and neighbouring countries. Even survey results that has been reviewed show a similar pattern of use. Opium is either eaten or smoked using a special pipe. McGlothin 119781 reported that opium-eating was an individual habit, whereas opium smoking was a social behaviour, similar to alcohol consumption. Further opium consumption has been mainly limited to adults and elderly males. Further, a significant proportion of opium abusers initially take the drug as a self-medicament for pain. Cessation of use will, after prolonged consumption, manifest abstinence syndrome. Further, because opium tends to suppress appetite, users often are emaciated and demonstrate ill-health. Heroin abusers reported would approximate to 1.1 million persons. Heroin has been abused widely in North America for several decades and even in Europe for well over 25 years, however, it has only recently, over the last ten to twelve years it has spread in the East Asia/Pacific region. In Europe, a second sudden and serious wave of heroin use has been reported over the last ten years. Particularly affected are the United Kingdom, Federal Republic of Germany, Switzerland and Italy. In Asia, Pakistan which was a traditional opium consuming country, since 1979, has reported extensive abuse of heroin, especially amongst its former opium users. Heroin abuse spreads like an epidemic, hence epidemiological data are quickly outdated. To meet with this sudden demand for heroin, there has been a marked Increase in the numbers of illicit laboratories to convert opium into heroin. Further, unlike the early 60's these laboratories are no longer located outside the poppy cultivating areas but also found within the producing sites. This change, has in effect enabl- ed the production of low-cost heroin, and also changed the pattern of illicit drug traffic- Currently, United States, Italy, Iran, Thailand. Malaysia, Singapore, Hongkong and Australia have reported to have severe heroin abuse problems. Closely followed with a similar problem but at a less level of severity, are Canada, United Kingdom, Federal Republic of Germany, Sweden, Switzerland, Pakistan, Burma and Laos. Over the recent years more and more countries are reporting heroin abuse pro- blem, but are unable to provide epidemiological data. The patterns of use of heroin varies quite widely. In the Asia where the drug is relatively cheap and of high purity, the mode of consumption is primarily by smoking. It is smoked either by mixing it in tobacco cigarettes or inhaling the vapours produced by holding a naked flame under the. heroin which Is placed on a tin foil. If it is inhaled through a drinking straw, it is known as "chasing the dragon" and if inhaled using the cover of a match box then it is known as "playing the mouth organ". Originally these modes were strictly limited to Asia, however, in recent year, it has spread to several European countries. In general, the mode of consumption in U.S.A. and Europe is mainly by injection, and in, travenous injection is the predominant means of injection. Heroin abuse because of its capacity to spread rapidly involves all social and economic strate of society. Alienated young males in urban areas are generally at risk, however, when one reviews recent reports, it would appear that even others are significantly involved. Hence, in defining risk populations, it Is essen tial one takes a broader view. A common consequence due to the wide fluctuations of purity and quality of heroin, is accidental overdose and sometime death from respiratory depression. Infections are also common among heroin dependent due to either the use of unclean needles and also to poor health. Since heroin use has a strong tendency to spread rapidly, particularly among young people who remain Impaired for several yeats, it must be given a high priority in international efforts to combat substance abuse. In conclusion it is worthy to recall that some forms of substance abuse appear to spread in an epidemic patCem, whereas others follow endemic lines. In reviewing the trends of substance abuse in several countries, it would appear that over the last fifteen years there has been enormous changes. With the exception of alcohol, traditional forms of substance abuse such as opium eating and smoking, as well as coca chewing have been stable over this period or even declined. TIMN 321402
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14. Bilodeau, L Drug Use Among Students in the Secondary Schools and CEGEP's in Montreal 1969• 1971. Office pour la Prevention et Traitement d'Alcool et des Autres Toxicomanies, Quebec, Canada, 1971. 15. Lamontagne, L, Tetrault, L and Boyer, R. Consomation d'Alcool et Drogues chez les etudiants: I Consomation effects et raison d'Utilisation d'alcool chez les 6tudiants au niveau collegial CEGEP. L'Union Medicale du Canada 108: 219-228, 1979. 16. Smart, R.G., Fejer, D. and Alexander, E. "Drug Use Among High School Students and Their Parents in Lincoln and Weliand Counties", Toronto: Addiction Research Foundation, 1970. 17. Smart, R.G., Fejer, D., Smith, D. and White, WJ. "Trends in Drug Use Among Metropolitan Toronto High School Students, 1968-1974" Toronto: Addiction Research Foundation, 1974. 18. Smart, R.G., Goodstadt, M.S., Sheppard, M.A. and Liban, C.B. Alcohol and Urug Use Among Ontario Students in 1979 and Changes from 1977: Preliminary Findings Alcoholism and Drug Addiction Research Foundation. Toronto, Ontario, 1979. 19. Kovess, V., Murphy, H.B.M., Tousignant, M. et Fournier, L Evaluation de l'etat de sante de la population des territoires de DSC de Verdun et Rimouski (unpublished). 20. The United Nations and Drug Control. Published by Division of Narcotic Drugs, Vienna, United Nations, p. 4•5, 1982. 21. Smart, R.G., Fejer, D. and White, WJ• "The Extent of Drug Use in Metropolitan Toronto Schools. A Study of Changes from 1968 to 1970", T'oronto: Addic• tion Research Foundation, 1970. 22. World Healm Organization Bulletin, No. 50 "A Methodology for Student Drug Use Surveys". 23. Valla, J.P. 1983 La Experience Hallucinogene, pp. 100• 107 ed Masson. 24. Rosenberg, M. "Society and the Adolescents Self-image", Princeton, New Jersey, Princeton University Press, 1983. 25. Cohen, S. Drug Abuse: Predisposition and Vulnerability. Drug Abuse and Alcoholism Newsletter, Vol. XII, No. 7, September 1983. 26. El-Guebaly, N., Offord, D.R. The Offsprings of Alcoholics A Critical Review. Am. Journal of Psychiatry, 134:4, 357-365, 1977. 27. Schuckit, M.A. Alcoholism and Genetics: Possible Biological Mediators. Biological Psychiatry, Vol. 15, No. 3, 437-447, 1980. 28. Popham, R.E. and Schmidt, W. Words and Deeds: The Validity of Self-Report Data on Alcohol Consumption. J. Stud. Alcohol, 42(3), 355-358, 1981. 29. Tolone, W.L and Dermott, D. Some Correlates of Drug Use Among High School Youth in a Midwestem Rural Community. lnt. J. Addiction, 10(5) 761-777, 1975. ALCOHOL AND FAMILY VIOLENCE Stephanie S Covington, Ph.D. Violence..... family...... surely it is totally irrational to find a link between these two words, for they stand for such opposite concepts! Everyone knows tliat implicit in the concept of family is assurance of a safe, nurturing, supportive environment. How can that have any association with the aggression and hostility explicit in violence? What could possibly be happening in a society where such a linkage has, in fact, come about? As American society has evolved, the prevailing atmosphere in many of our com• munities requires that doors and windows be kept locked, and that we participate In self-defense classes in order to protect our homes and ourselves from violent intrusion from the outside. Crime statistics show that homodde, rape, assault, and robbery increased by 50% between 1975 and 1980. Such "epidemic" growth, were it to occur In the form of a disease, would be cause for immediate establishment of control centers across the country-if this were a germ destroying people That violence is not treated as a priority issue is an indictment in itself. We already know that alcohol plays a key role in the perpetration of crime in the United States. In the following statistics from the National Council on Alcoholism (1) the relationship between alcohol use and crime is obvious a. in robbery cases, 72% of the offenders had been using alcohol; b. in murder cases, 86% of the offenders and 40% to 60% of the victims had been using alcohol; c in rape cases, 50% of the rapists had been using alcohol; and d. in assault cases, 72% of the offenders had been using alcohol. While many acknowledge the pervasiveness of crime, there is a continuing denial of the fact that abuse has occurred, and is continuing to occuti at an alarming rate within families. The reality of today's living is that we are not safe even with those we know. In fact, the probability of suffering abuse from someone we know is greater than from a strangec The sad fact is that what is happening within the microcosm of the family is a direct reflection of the violence pervading our culture and the world. Conflict is an inevitable part of all human interaction. Paradoxically, the more in• timate the bond between people, the higher the level of potential conflict. Since the family is one of the most intimate connections, a particularly high level of potential conflict exists in its relationships. However; as long as conflict within the family is ignored or simply dismissed as "wrong:' there can be no impetus to discover and learn effective techniques for nonviolent resolution of such conflict. Violence In the family reflects current cultural mores and social violence, exemplified by physical punishment in schools, the acceptance of the death penalty, and the espousal of war as a solution to conflict. The portrayal of violence that prevades the media "normalizes" such behaviors. Thus, our society has apparently accepted violence as a legitimate way of solving problems. There is growing acknowledgement of the association between family violence and alcohol use While the research is still scarce and not all the data is consistent, studies to date indicate the following: alcohol is a factor in 56% of the fights or assaults in U.S homes; alcohol is a factor in 40% of all family court problems; alcohol has an association in 34% of the cases of child abuse (2),; 50% of alcoholic parents are child abusers (3); 66% of children in alcoholic homes are abused (7); 67% of sexually aggressive acts against children involve alcohol use; 80% to 90% of husbands who batter use alcohol (4, 5); 70% of battered women are frequent drinkers (8); 39% of sexually aggressive acts against women involve alcohol use; 35% of incest perpetrators are heavy drinkers (6); 50% of incest victims are from alcoholic homes (7). One explanation of the relationship between alcohol and violence is based on the premise that the disinhibiting effects of alcohol dissolve the super ego, and one's control system becomes dysfunctional. In addition to lowering inhibitions, alcohol also has a long-term agitating effect on the drinker, causing sleeplessness, irritabili• ty, increase in aggressive fantasies, and impairment of cognitive functions. However, whatever the neurophysiological changes that occur in an individual using alcohol, a clear cause-effect relationship between alcohol and violence has not yet been established. It has been postulated that some abusers use alcohol deliberately, in order to act out their aggression. In cases of sexual abuse, which are often premeditated, this is particularly evident. In alcoholism research to date, while no set descriptive patterns of an alcoholic personality or the alcoholic family have evolved, there are visible trends, i.e. com• mon threads. For example, there appears to be a cross•generational transmission of both alcoholism and violence in families. In this generational cycle of family violence, males who were abused as children become abusive adults. Women who were physically abused as children become child abusers and/or victims of an abusive partner. Also, women who are incest survivors often marry men who perpetrate incest. . As one scrutinizes the data on social and family violence more closely, It is glaring• ly apparent that gender differences exist between the survivors and the perpetrators of family violence. In general, men are the perpetrators and women are the sur• vivots. However, in order to understand specifically the role that abuse plays in the lives of women, and to see another view of the relationship between alcohol and violence, I would like to discuss the results of my own research on the subJect. Following is data collected on 70 American women-35 recovering alcoholics and 35 nonalcoholic Caucasian women from San Diego and Orange Counties in Califor• nia. The research focused on a number of aspects of the subjects' lives, including sexual experience and dysfunction, sexual orientation, and abuse-physical, sex• ual, and emotional. For purposes of the study, the two groups were paired on age, 24 TIMN 321415
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has a highly fragile 'memory trace: easily disrupted by external interfering stimuli in a few minutes. STM deficits are 'precutsors (and strongly indicativel of possible later forgetting. Recovery of memory functioning Other studies (4) have investigated alcoholic patients firstly maintained on large doses of alcohol for 3-4 days; then denied alcohol for 2-3 weeks. In tests of serial learning there was no improvement in learning during the weeks of withdrawal. Free recall, however, indicated improvement in memory, normalizing after thir teenth day off alcohol, and primarily due to STM recovery. In view of these fin- dings, memory recovery time I1-2 weeksl should be considered in such cases before releasing patients and before commencing therapy and retraining. More recent studies involving electro-encephalography (EEG) and brain scans (CATI confirm the possible reversibility of alcoholic brain damage (2)• Physiologically, the maximum change expected in the majoriry of alcoholics occurs after 5-12 weeks' abstinence. Such findings at least offer cognitively impaired alcoholics rather more hope than in the past and encourage a positive approach to their rehabilitation. Moreover, if abstinent alcoholics can recover their cognitive abilities 122) to what would be normal expectancy for their age, then there are obvious implications for the concept of premature ageing 123). Therapeutic implications The issue of what processes are involved in alcoholic memory failures has impor- tant relevance for the choice of therapeutic approach to alcoholism. St.D. learning may at least partly explain memory loss for events occurring whilst drinking. This could, indeed, constitute the basis for'loss of control: After a few drinks, the alcoholic 'forgets' the (negative) consequences of heavy drinking-consequences usually ex- perienced In a sober state Thus, if SLD. learning is a prominent characteristic of alcoholic drinking, then therapy should be undertaken in both the sober and in- toxicated states. By contrast, alcohol-induced consolidation failure implies that various techniques for strengthening registration and consolidation of learned information must be emphasized during therapy. One theory of alcohol dependence proposes that an altered repertoire of drug-state responses develops with repeated drug use (24). If the alcohol-specific behaviours are more reinforcing than normal sober behaviou; then the subject may use alcohol to gain access to the alcohol-response repertoire, rather than because of any intrin- sically reinforcing drug effects. Another theory proposes that St.D. learning is a directly causal factor in alcoholism and drug dependence (24). The notion is that the dissociative barrier prevents recall in the sober state for many of the negative consequences of alcohol abuse Concluding remarics Alcohol itself (although an obvious aetiological factor) is clearly not the only factor involved in alcoholic memory impairment. The severity of impairment is positive. ly related to excessive drinking over a period of at least 10 years, and could involve a total life-time consumption of more than 400 gallons of absolute alcohol. Almost by definition, this means that most of these cases are older people. At the same time, other factors, such as multi-vitamin deficiency, neurological dysfunction, and brain ageing may be significantly related to memory impait7ttent. The processes of ageing and alcohol intoxication appear to have much in common in the way they affect memory and learning (6). Both ageing and heavy intoxica- tion can produce significant impairment of short-term memory, whereas long-term memory may be almost unaffected. Unfortunately, the combination of ageing and excessive alcohol abuse is additive, resulting often in very severe impairment of short-term memory. Hopefully, howevet; there are recent indications tliat uich deficits may be reversible after a period of abstinence, therapy and rehabilitation. References 1. BIRNBAUM, I.M. & PARKER, E.S (1977i Acute effects of alcohol on storage and retrieval. In Alcohol and Human Memory (I.M. Birnbaum & E.S. Parker, Eds.), Hillsdale: Erlbaum, 99-108. 2. GUTHRIE, A., PRESLY, A., GEEKIE, C. & MacKENZIE, C. 11980) The effect of alcohol on memory. In Psychopharmacology of Alcohol (M. Sandler, Ed.), N.Y.: Raven Press, 79-88. 3. TARTER, R.E.11975) Psychological deficit in chronic alcoholics: a review. Int,I.Ad- dict., 10, 32Z 4. ALLEN, R.P., FAILLACE,I..A. & REYNOLDS, D.M. (1971) Recovery of memory functioning in alcoholics following prolonged alcohol intoxication. J.nervmenLDis., 153, 417-423. 5. BOTWINICK, J. 119811 Neuropsychology of aging. In Handbook of Clinical Neuropsychology ISB. Fllskov & T.J. Bolls, Eds.), NY: Wiley, 135. 6. FREUND, C. & BUTTERS, N. (1982) Alcohol and aging: challenges for the future Alcoholism: clin. & exp. Research, 6, 1-2. 7. WOOD, W.G. & ELIAS, M.E (19821 Eds., Alcoholism and Aging: Advances in Research, Boca Raton: CRC Press, Inc 8. FREUND, G.119821 The interaction of chronic alcohol consumption and aging on brain structure and function. Alcoholism: clin. & exp. Research, 6, 13-21. 9. FREUND, G. (1973) Chronic nervous system toxicity of alcohol. Ann.Rev. Phar• macol., 13, 217227. 10. FREUND, G. (1980) Cholinergic receptor loss in brains of aging mice Life Sciences, 26, 371-375 11. ECKARDT; MJ., PARKER, E.S, NOBLE, E.P., FELDMAN, D.1. & GOTTSCHALK, LA. (19781 Relationship between neuropsychological performance and alcohol consumption in alcoholics. Biol.Psychiatr., 131, 551. 12. MILLER, M.E., ADESSO, V.J., FLEMING, J.P., GINO, A. & LAUERMAN, R.11978) Effects of alcohol on the storage and retrieval processes of heavy social drinkers. Jxxp.Psychol.: (Human Learning and Memory), 4, 246•255. 13. WICKLEGREN, W.A. (1975) Alcohol intoxication and memory storage dynamics. Memory & Cognition, 3, 385-389. 14. HARTLEY, JT, BIRNBAUM, I.M. & PARKER, E.S. 119781 Alcohol and storage deficits: Kind of processing7 J.verb.Learning & verb.Behav., 17, 635-647. 15 LISMAN, S.A. (19741 Alcoholic 'blackout': State-dependent learning? Arch.gen.Psychiatr., 30, 46-53. 16. WEINGARTER, H. & FAILLACE, L.A. (1971) Alcohol state-dependent learning in man. J.nervment.Dis, 153, 395-406. 17. LOWE, G. (1981) State-dependent learning induced by moderate amounts of alcohol. Current Psychol. Research, 1, 3-8. 18. LOWE, G. (19821 Alcohol and sLete-dependent learning: differentiating between storage and stimulus hypotheses. Current Psychol. Research, 2, 215-222. 19. OVERTON, D.A. (1976) Drug state-dependent learning. In Psychopharmacology in the Practice of Medicine (M. Jarvik, Ed.), N.Y.: Appleton, 73•79. 20. PETERSON, R.C. (1977) Retrieval failures in alcohol state-dependent learning. Psychopharmacology, 55, 141-146. 21. WARRINGTON, E.K. & WEISKRANT7., L(1970) Aminesic syndrome: consolida- tion or retrieval? Nature (London), 228, 628-630. 22. LEBER, W.R., JENKINS, R.L. & PARSONS, O.A. (1981) Recovery of visual-spatial learning and memory in chronic alcoholics. J.ciin.Psychol., 37, 19. 23. PARSONS, GA. & LEBER, W.R. (1982) Premature ageing, alcoholism, and recovery. In W.G. Wood & M.F. Elias (Eds), Alcoholism and Aging: Advances in Research, Boca Raton: CRC Press, Inc., 79-92. 24. OVERTON D.A. (1978) Major theories of state-dependent learning. In Drug Discrimination and State Dependent Learning IB.T. Ho, D.W, Richards & D.L. Chute, Eds), N.Y.: Academic Press, 283-318. 25. JONES, B.M. (1973) Memory impairment on the ascending and descending limbs of the blood alcohol curve Jabn.Psychol., 82, 24-32. 26. DRACHMAN, D.A. & LEAVITT J. (1974) Human memory and the cholinergic system: a relationship to aging, Arch. Neurol., 30, 113-121. 27. FINE, E.W. & STEER, R.A. (1979) Short-term spatial memory deficits in men arrested for driving while intoxicated. AmerJ.Psychiatr., 136, 59459Z 28. KILPATRICK, DG., McALHANY, D.A., McCURDY, R.L., SHAW, D.L. & ROITZSCH, J.C. (1982) Aging, alcoholism, anxiety and sensation seeking: an exploratory investigation. Addictive Behaviors, 7, 139-142. TIMN 321419 28
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The language of country music is simple and straight forward. The use of simple lyrics, in uncluttered patterns, allows the song writer to describe complex, inter- woven emotions with gut-stabbing reality. For the listener, the theme should be immediately recognizable. The song writer wants the audience to say: "yes, that's exactly how I felt", and to want to listen again and again. The goal of the popular song writer is to appeal to his audience, to sell records. To do so, he presents songs which do not challenge or come in conflict with the audience's values and attitudes. He produces songs which speak to the au- dience of themselves and the world as they see it. In tum, the music serves to maintain the cultural continuity of the fans. It helps to confirm their sense of identity and their place in society. A review of the lyrical content of popular country music reveals that drinking alcoholic beverages is a familiar theme. Drinking is often mentioned in "lovin' " or " cheatin' " songs as a reaction to the pains or joys being expressed. Chal- fant and Beckley,2 in their analysis of thirty country songs, were able to identify a number of values that related to the use of alcohol. In twenty-five of these songs, liquor is portrayed as "evil". Drinking is presented as inevitably leading to the ruin of family life; as promoting sexual adventures outside the traditional monogamous relationship, and leading to personal ruin. Three songs describe alcohol as an effective means of escaping from reality, at least for a little while. The song writer tells us that alcohol doesn't really solve the problems, but it temporarily makes it easier to cope with the harshness of life. Fourteen of the songs describe alcohol as a part of life, and drinking it as a signifi- cant and pervasive aspect of culture. Drinking is frequently valued as a tool for mood enhancement, enhancing sociability and alleviating stress. Drinking is clearly viewed as wrong, yet often in the same song it was the way the actors choose to deal with life and its problems. Reference to drinking behavior in country music reflect strong value conflicts regarding drinking. Alcohol is viewed as evil, as a "tool of Satan", and yet it is also accepted as an integral part of life. Alcohol is often presented as being neither escapable nor controllable. The moderate, nonharmful use of alcohol is not describ~ ed. When drinking is mentioned, it is excessive and abusive in nature. THE COUNTRY MUSIC FAN For the purpose of this project, a country music fan is defined as a person who prefers to listen to country music above all other forms of popular music. The amount of time each respondent spends listening to music was noted during the interviews. It should be noted that the amount of time spent listening did not always reflect the level of devotion the fan expressed for the music. Fans of country musid are often devoted to it, and identify strongly with its images. A key characteristic of the country music fan is that he not only listens to the music but also pays a great deal of attention to the content of the lyrics. The emotionalism of the lyrics is very appealing to the listener, but the most impor- tant element appears to be the subject matter and how it is dealt with. Popular music tends to emphasize the peaks and valleys of one's emotional life, and country music sometimes seems to deal only with life's saddest moments. Emotions run high at these times, and they can therefore be movingly expressed. Country songs describe life's lows and highs with great colour and emotion, thereby acting as a surrogate spokesperson for the listener. The combination of easily understan- dable lyrics with compelling descriptions of emotional moments in the listener's life -attracts and maintains the devotion of the fans. The country music production industry does what it can to enhance fan devo. tion. Country fans are remarkably loyal, and will maintain their love of country music for a whole life time. Country performers are kept in closer contact with their audience than other popular performers. Public appearances that include personal contact are a frequent part of the performers routine. Their personal lives are promoted as being just like other "ordinary" people. Country perfor- mances, recordings, and videos are relatively unobscured by the electronic technology which permeates other popular music forms. Everything possible is done to maintain a sense of identity between the fans and the performers. The fan population tends to be mainly adult, white, conservative in social values, married or previously married, and not wealthy. Country music is described as "the music of the people". DESCRIPTION OF SAMPLE The 56 country music fans interviewed were residents of the town of Edson, Alberta and the surrounding district. Edson is a community of 7,200 located on the Yellowhead Highway, 200 kilometers west of Edmonton, in the foothills of the Rocky Mountains. The town was established in 1910, as a railway turnaround town on the Grand Trunk Railway (now the Canadian National)• Coal mines rapidly developed in the foothills to the Southwest, transporting their coal via branch lines through Edson. The economy of the area has always been largely based on resource exploitation-oil and gas, coal mining, forestry, and related 13 manufacturing, construction and service businesses. Historically, Edson has been subject to a series of economic swings-the "boom and bust" cycles characteristic of the resource exploitation town. Our sample was randomly chosen from the local population, with twenty-two males and thirty-four females participating. Forty-two lived in the Town of Ed- son, and fourteen in the surrounding rural area. Only respondents over 17 years old were included, as 18 is the legal drinking age and the age of adulthood in other ways. There were twelve respondents within the 18-25 year age range, 21 between 26 and 40, another 20 between the ages of 41 and 60, and three over 60 years old. The age distribution of respondents is fairly representative of the community as a whole. Table 1 Age of Respondents NUMBER NU MBER AGE OF MALES OF F EMALES 18-25 4 8 26-40 7 13 41-60 9 12 61-80 2 1 TOTAL 22 34 Occupations of respondents are also reasonably representative of Edson as a whole. Nine people were administrators, four were store owners/managers, seven fell in the professional category (e.g.nurses, teachers, counsellors), fifteen held secretarial/receptionist/clerical position, three were in sales; ten were labourers, and eight were full-time housewives. A number of the respondents were unemployed at the time of their interview. Potential respondents were identified by word-of mouth networking. Each potential participant was asked if they listened to country music, and if they preferred it above other popular styles. This identified the true country music "fans". This fairly casual approach to participant selection was necessitated by time and staff• ing limitation. An effort was made to obtain an equitable cross-section of ages represented. The interview format was designed to create guidelines and continuity for the informal, somewhat conversational interviews. Specific questions about country music were asked, to determine what sub-style they preferred: traditional, western swing, or country-rode. Traditional country music refers to that which maintains the voice and strings format, with little musical elaboration. Western swing now means that drums and steel guitar have been added; this style is usually "up- beat". Country rock includes large incursions of mainstream rock and roll sounds- this style is most likely to be popular outside of country music circles, as "cross• over" music. Table 11 OCCUPATIONS HALE FEMALE Administrative Personnel 5 4 Store owners/Managers 3 1 Professionals (Nurses, teachers) 2 $ Secretarial/Llericai 2 12 Sales people 2 2 Labourers 2 Mome Managers 8 TOTAL 22 34 TIMN 321404
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education, marital status, and religious background. Averaging 38 years in age, the majority of these women were from middle-class backgrounds. Their education levels ranged from grade school to advanced graduate degrees, with the largest group reporting some college Over two-thirds of the sub- jects were employed outside the home, at occupations ranging from service-worker to professional positions. Sixty-eight percent were Protestants, 29% were Roman Catholics, and 3% were Jewish. Forty-two percent were married or living with a sexual partner; 26% were single, the same number were divorced, 3% were widowed, and the same number were separated. For the alcoholic women, the average length of sobriety was 7.5 months, having drunk alcoholically an average of 9 1/2 years. This group volunteered to participate in the research from AA, recovery, and hospital treatment programs in lesbians. It appears that simply being born a woman in this world puts one at high risk of becoming a victim of some form of abuse-physical, sexual, and/or emotional. Certainly this was reflected in the experiences of my research subjects. Surely by now it is common knowledge that sexual abuse, i.e- incest, rape, and molestation, Is an act of violence, not passion! These are not sexual acts, but rather acts of aggression and social control. Violence and sexuality are dominant themes in the experiences of the alcoholic woman in this study-74% had experienced sexual abuse, 52% had experienced physical abuse, and 72% had experienced emo- tional abuse. By comparison, of the nonalcoholic subjects 50% reported sexual abuse, 34% physical abuse, and 44% emotional abuse. These different types of abusG althougft experienced by both groups of women to a startlingly significant extent, appear different for the alcoholic women in quantity, quality, and extent. The alcoholic women were abused by more perpetrators, had more instances of abuse, and for a longer time span in their lives. The most prevalent perpetrators of sexual abuse on the alcoholic women were male relatives and unknown males, while boyfriends and other unrelated, but known, males abused them in 20% of the instances recorded. For the nonalcoholic group, 60% of the instances were perpetrated by the latter group. In combining both groups of responses, 93% to 100% of the sexual abuse perpetrated on these women was by males, and 77% to 87% of the perpetrators were known to the women. Incest, I. e sexual activity with a family member, accounted for 34% of the reported sexual abuse among the subjects. For the nonalcoholic population, 16% of their sexual abuse involved incest. Fifty-eight percent of the alcoholic group's sexual abuse experience involved rapes. The comparison group experienced more instances of molestation (41%) and more attempted rapes (14%) than the alcoholic group. Twice as many alcoholic women than nonalcoholic women were incest and rape sur- vivors! While all sexual abuse is traumatic, the data indicated that alcoholic women are more likely to experience these most serious of sexual assaults. In _regard to frequency, combining the data on the sexual abuse perpetrated on these women, 16% to 19% of the abuse occurred one or more times a month for one year or more (chronic), 35% to 48% of the incidents occurred more than once, and 36% to 46% were single incidents. As for the length of time (duration) over which sexual abuse occurred, 14% of the sexual abuse experienced by the alcoholic women went on for more than 10 years, and came from the same perpetrator. None of the nonalcoholic subjects reported this kind of abuse longevity. A summary of the data on sexual abuse showed that the alcoholic group was sub- jected to a wider variety of sexual abuse perpetrators, experienced more instances of abuse, and had more multiple incidents and longer duration of sexual abuse than the nonalcoholic women. The alcoholics also reported more incidents of incest and rape. Data on the physical abuse experienced by these women was also gathered in this research, with 51% of the alcoholic women and 34% of the nonalcoholic women reporting physical abuse In general, the majority of abuse was perpetrated by fathers/stepfathers, husbands, and boyfriends/unrelated males on both groups of women. In all cases, the perpetrators were known to the women, with- 82% of the physical abuse coming from men and 18% coming from women-i.e, mothers and stepmothers. Forty-five percent of the physical abuse experienced by the akoholfc women occurred once a month or more over one year or more (chronic). Approx• imately 30% of the physical abuse for both alcoholic and nonalcoholic subjects ex- tended over 10 years or more, and came from the same perpetrator(sl• In summarizing the physical abuse data, while there was not a statistically signifi- cant difference between the number of alcoholic and nonalcoholic women repor- ting physical abuse, there is a different quality in the abuse described by the alcoholic women. The alcoholic women reported more instances of physical abuse, of greater frequency and variety, and of a more violent nature than the nonalcoholic women. Seventy-one percent of the alcoholic women reported emotional abuse, compared to 44% of the nonalcoholic women, which was statistically significant_ In sharp contrast to the data on sexual and physical abuse, where the perpetrators are predominantly male, perpetrators of emotional abuse were 43% female and 57% male for the alcoholic group, and 36% female and 64% male for the nonalcoholic 25 group. Paralleling the physical abuse data, the alcoholic group reported a greater frequency of abuse (averaging 3:2), nearly three times as much chronic abuse, and nearly twice as many cases of emotional abuse enduring for 10 years or more, parallel- ing the sexual abuse data. Overall, the data on emotional abuse is similar to the sexual and physical abuse data presented earlie>: The alcoholic women reported a greater number. of perpetrators of abuse and experienced more instances of each type of abuse. They also reported a wider range of types of abuse and, similar to the physical abuse data, more in- tense abuse It is important to note the age when abuse began in the lives of these women. For example, among subjects who had been sexually abused, 100% of the alcoholic women and 65% of the nonalcoholic women had been abused by age 10. For those physically abused, 74% of the alcoholic subjects and 82% of the nonalcoholic sub- jects had been abused by age 10. And for those who had been emotionally abused, 100% of both groups had experienced their first abuses by age 10; 100% of the abused women in both groups had experienced abuse by age 20. While statistics, in and of themselves, tend to be boring, the abuse statistics on women and children in the U.SS are too alarming to be taken for granted: - By age 18 -38% of all female children have been sexually assaulted; -16% of these incidents have been incest 191; -7% of the male population have been sexually molested (10); - 70% of the female prostitute population and 80% of the female drug addicts are incest victims as children (11); - Over 90% of child sexual abuse is committed by heterosexual men against female children (12); - 75% of the sexual abuse against children is perpetrated by a family member, or by someone known to the child (12); - That 1.8 million women are abused annually is considered a conservative estimate..more realistically it is twice that figure (13). In the State of California alone: - 50% of the married women are assaulted by their husbands sometime during their married life (14). In the Ins Angeles County alone.: - One out of every 2.8 women over the age of 14 have been raped at least once in their life (15). Figures corroborating the results found in my research are available in the follow. ing 1982 studies of female substance abusers in hospital-based treatment programs: At the Eagleville, Pennsylvania, program: - 60% of the women had been physically abused; - 93% had been emotionally abused; - 73% had been sexually abused, with - 47% having been incest survivors At Phoenix General Hospital in Arizona: - 63% of the women had been victims of rape or incest before the age of 14. All of this evidence attests to the fact that misogyny, hatred of women, is not just a theory of the past or simply a feminist concept. It is "alive and well" in our modern society, both a pervasive and constant issue for females of all ages to deal with. Public acknowledgment of this information can allow consideration of the possibility that, for some women, the use of alcohol and other drugs has become a way to deal with the emotional pain resulting from earlier abuse by someone close to them, someone they trusted. Early abuse often leads to continual victimization. Let us now move to the topic of incest, the most hidden and traumatic form of abuse. These cases are where the children pay for the affection and attention that should be freely given. From a therapeutic viewpoint, incest Is best viewed along a continuum-from covert to overt incest. Covert incest is characterized by household voyeurism, ridicule of developing bodies, "inadvertent" touching, sexual hugs, and the use of sexualizing/objectifying language. Overt incest involves blatant sexual contact, i. e fondling, french kissing, fellatio, penetration, and intercourse. Judith Herman's study on incest (6) included a description of the dynamics of in- cest and an analysis of the effects of this experience on the female survivors: ...these women alone suffered the consequences of their psychological impair- ment. Almost always, their anger and disappointment were expressed in self destructive action: in unwanted pregnancies, in submission to rape and beatings, in addiction to alcohol and drugs, in attempted suicide Thus did the victims of incest grow up to become archetypally feminine women: sexy without enjoying sex, repeatedly victimized yet repeatedly seeking to lose themselves in the love of an overpowering man, contemptuous of themselves and of other women, hatrl-working, giving, and self-sacrificing. Consumed with rage, they nevertheless rarely caused trouble to anyone but themselves. In their own flesh, they bore repeated punishment for the crimes committed against them in their childhood. (6, p. 108) Daughters of covertly seductive fathers exhibited a milder form of the incest victim syndrome in adult life Like the overt incest victim, they tend to feel contempt TIMN 321416
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using behaviour, and more importantly on substance abuse-related problems. In reviewing the literature one finds that there is a longer history of epidemiological research in relation to tobacco and alcohol conducted in use in Western coun- tries whilst studies on other substances, particularly the illicit drugs and the non- medical use of licit substances are studied to a lesser extent. Conversely in develop- ing countries, particularly in the Asia/Pacific region, there are very few studies on alcohol and tobacco, however, much more has been published on drug substances, especially those of illicit manufacture. This bias in epidemiological research especially in the developing world has been influenced by the sudden spread and upsurge in the problems associated with illicit substance abuse. Instead of giving a detailed description on the epidemiology of substance abuse; and attempt will be made to give a global picture of the problem of selected substances which are widely abused or whose abuse is rapidly spreading. ALCOHOL Over the last few decades there are reports that indicate considerable increases in alcohol consumption and consequently alcohol-related problems throughout the world. In several European countries, the annual per capita consumption in terms of pure alcohol equivalence has increased from three litres in 1950 to nearly twenty litres in 1980. Several countries in the Asia/Pacific region have recently reported marked increases in alcohol consumption and more worringly alcohol- related disorders. A similar explosion in alcohol use is being witnessed in Africa. On the positive side, recent W.H.O. report indicated that in North America and a few Western European Countries, the level of use was levelling and in some instances, even showed a slight decline. In conclusion one cannot but accept the fact that alcohol Is probably the most overused intoxicant. Drug Abuse An analysis of trends in the frequency and severity of drug abuse showed an overall general increase of this problem in most countries of the globe. Whilst specific drug types predominate in particularly geographic regions, over the past decade reports indicate a trend towards a broader diffusion of the types of drug use across these regions. Further there has been a tremendous increase in the tendency towards polydrug use and also to the use of drugs in combination with alcohol. Recent reports of the United Nations estimated that there were approximately 48 million drugs abusers in the world. Of this some 30 million were Cannabis users, 4.4 million cocaine users, 1.6 million coca users, 1.7 million opium-dependent persons, and I million heroin-dependents. About 8.5 million were dependent on multiple drugs which included those persons who used amphetamines bar- biturates, sedatives, tranquilisers and other psychotropic substances either singularly or in combination. Whilst data with these drugs were scanty, the general trend reported was one where abuse of these substances was distinctly on the increase, and this increase was parallelled with increasing availability on both licit and illicit markets. Of more recent origin, in many parts of the world, was the problem of the sniff- ing or inhaling of volatile solvents. Whilst estimates of the number of persons associated with this problem appear to be small, the numbers again appears to be increasing rapidly. Having provided a general profile, let us examine in detail the major substances that are being reported as being abused widely. Table I shows that global totals for major drug types being reported as being abused. Cannabis is undoubtably the most frequently abused substance. A total of 29,698,000 persons representing 62% of all reported abusers. In terms of rates there are 1 I per 1000 persons who were cannabis abusers. Surprisingly Psychotropic drug abuse is ranked as the second most widely abus- ed group of substances. However, it should be pointed out, that, under this category several substances such as the barbiturates, tranquilisers, amphetamines, and hallucinogens were all grouped together. 8,516,000 persons were reported to have been associated with its abuse, representing 18% of the total problem with a rate of 1.8 per 1000 persons. - The next most frequently reported substance of abuse was of the coca type. 5,985,000 persons or 13% of the total abuse problem were associated with its above. The rate per 1000 was 1.4. 3,466,000 persons were reported to be in- volved in opiate drug abuse. This represented 7% of the total abuse problem and the rate was 0.81/000 persons: Cannabis Cannabis is obviously the most widely used substances; which has been reported worldwide. Based on available information, a gross profile of the extent of cannabis use as well as the rate of use has been developed. Realising that the profiles have been developed based on data submitted by Governments to the United Nations and/or its specialised agencies, which are normally based on identified abusers, there is a strong possibility that these are gross underestimates. Except for a small minority of countries, most reported some degree of cannabis use. Twenty-five countries were classified in the "High use" category senegal was the leading country in Africa, United States of America for the Americas, Italy for Europe, Pakistan for the Near and Middle East, Australia for the Asia/Pacific region. One of the major reasons for the widespread use of cannabis Is the fact that it grows relatively easily, and particularly in these areas where use is high. Cannabis is usually smoked, however, in the Near and Middle East region it Is frequently used in the form known as'Bhang". Bhang is a drink made from an infusion of cannabis and water. Another form in which it is used, which also arose initially from the same region, is known as hashish or Charas, has now become widespread. This product is really cannabis resin and hence is extreme• ly potent_ One cannot demarcate any particular section of the community which use can- nabis. Epidemiological findings support the view that all segments of society analys• ed from an age, education, income perspectives are involved. However, there is some evidence to suggest that in Africa, Middle East and in certain parts of Asia, use is more prevalent in the rural setting, whereas in the rest of the world it is more prevalent in the semi-urban/urban settings. There are several reviews on the social and health consequences of cannabis use (3, 4, 5,j. In summary it can he stated that moderate use of cannabis induces a state of intoxication which leads to mental and physical impairment of funa tion and in some instances acute psychosis. Chronic use has more wide ranging consequences including some degree of physical and psychological dependence. PSYCHOTROPIC DRUGS The term Psychotropic Drugs has been used to encompass a wide range of phar- maceutical products that affect neuronal activity. This category includes three broad groups of drugs: a) The depressants-the barbiturates, sedatives and tranquilisers b1 the stimulants-the amphetamines, and c) the hallucinogens Table 2 shows the distribution of countries reporting abuse of psychotropic drugs. It will be noted that 47% of 178 countries reported problems with the abuse of depressants; 40% with stimulants and 25% with hallucinogens. By region 27% of African countries reported a problem of stimulant abuse, 22% with abuse of depressant drugs and only 7% a hallucinogenic drug problem. The countries of The Americas reported that half of them had a problem of abuse of depressant drugs, 45% with stimulants and 35% with hallucinogens. 77% of all European countries reported abuse of depressant drugs; 63% with stimulant drugs and 51% hallucinogenic drugs. Depressant drugs presented the biggest psychotropic drug abuse problem for the Near and Middle East countries with 46% of them reporting existance. 33% reported a stimulant drug abuse problems with hallucinogenic drugs. 41.2% of the countries of Asia/Pacific region reported problems with the abuse of depressant drugs. 32.4% reported abuse of stimulant drugs and 20.6% abuse of hallucinogens. DEPRESSANT TYPE It is obvious except for Africa, the depressant drugs are the most frequently reported drugs of abuse for the Psychotropic group. The barbiturates, methaqualone, ben- zAdiazepine etc. are all examples of depressant drugs. The Americas reported the highest prevalence rates and only Denmark reported similar rates. Illicit traffic for these drugs exist, however, since they are mainly produced legal- ly, diversion of legally manufactured drugs is the principal source of the illegal supply. A significant portion of the abuse problem for this group arises as a consequence of therapeutic use or overuse. They are also abused frequently as one of several drugs in the polydrug abuse scene. Acknowledged that these drugs have a wide spectrum of therapeutic use, and also the potential to produce dependence, it is not therefore suprising that several persons have become dependent on them. The Psycho-stimulant drugs are the next most frequently reported as being abus• ed in this category. Amphetamines, methylphenidate are examples. The majori- ty of abuse reports have been from the Americas. Japan has the largest abuse prevalence in the Asia/Pacific region. In Europe-Finland and Sweden also report relatively widespread abuse. Legitimate supply of the psycho-stimulants are the major contributors to the availability problem through certain amphetamines are synthesised illegally. Whilst 10
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ALCOHOL AND MEMORY PROCESSES: IMPLICATIONS FOR THE ELDERLY ALCOHOLIC G- Lowe SUMMARY The processes of ageing and alcohol intoxication appear to have much in common in the way they affect memory and learning. Both ageing and heavy intoxication can produce significant impairment of short-term memory, whereas long-term memory may be almost unaffected. Unfortunately the combination of ageing and excessive alcohol abuse is additive, resulting often in very severe impairment of short-term memory. Recent findings are described of the complex interactions between alcohol learn ing and memory deficits, and ageing. There are indications that nutritional defi- ciency and brain damage may also be involved, although the nature of the causal interaction is still unclear. Various lines of animal investigations may, however, help to establish causal links. Types of alcohol-induced memory deficit in humans are described, including'blackouts; partial amnesiasand'state dependent' learning lor dissociation). Memory storage and retrieval mechanisms are also discussed in rela- tion to alcohol abuse and ageing. Finally, some therapeutic implications are con- sidered, together with studies investigating recovery of memory functions after alcohol withdrawal. In the elderly, excessive alcohol abuse lespecially late onset excessive drinkingi is an increasing problem. Yet relatively little research has been directly concerned with the effects of alcohol on the cognitive abilities of specifically elderly alcoholics. There is, however, a relative abundance of studies on alcohol impairment of human memory 11,2), on memory processes in alcoholics (3,4), and on memory deficits in the ageing person (5,26)• It is possible that the older brain is more vulnerable to the deleterious effects of alcohol 161; and cognitive deficits (especially in learn ing and memory) associated with alcohol abuse (111 are similar to certain kinds of impairment with ageing 13,7). Furthermore, increasing numbers of elderly per sons abuse alcohol, and it seems likely that the effects of alcohol abuse and ageing are additive 171. Indeed, some researchers have raised the question of whether alcohol is a chemical agent which advances the clock of biological ageing 16). lt is, therefore, of interest to determine what relationships exist between the biological mechanisms and consequences of ageing and alcohol use and abuse (281. ComplQx interactions I should point out initially that the problems under investigation are not easy to sort out, largely due to the complex ways in which various contributing factors may relate to, or interact with, each other (8)• As for alcohol, we know that at least moderate amounts affect the central nervous system (CNSI and can produce temporary memory deficits 12,27(. Chronic alcohol abuse usually leads to some degree of brain damage Ineuronal loss) 19,10) and to more severe and more perma nent memory dysfunction. Furthermore, nutritional deficiency might also be related to brain damage and cognitive impairment (2). Finally, ageing itself usually involves various CNS changes, neuronal loss and possible cognitive deficiencies 151. Alcohol abuse IAAI, nutritional deficiency INDI and brain damage IBDI often co- exist together in an individual, but the nature of the causal interaction tif anyl Is unclear. Alcohol abuse may lead to nutritional deficiency, which in turn may cause brain damage. Alternatively, an underlying form of brain damage may lead to alcohol abuse and nutritional deficiency; and further alternatives are possible In the elder ly alcoholic we have the additional factor of ageing, which further compounds the complex inter-relationships. Alcohol and memory There is considerable evidence that alcohol intoxication interferes with memory processes 11.2,12,13,141. The most severe memory disturbance is the alcoholic 'blackout; an inability to recall events that happened during a drinking episode, even though consciousness was neither significantly clouded nor lost I151. Such a profound memorial deficit might be accounted for by an inability to transfer short term memories to long-term storage sites I11. It is quite possible that alcoholic blackouts are much more common than we might assume A brief memory gap lasting minutes may not come to awareness, and even long ones may be ignored. A lesser condition, often associated with cocktail party effects, is a transient and partial amnesia which becomes observable when the drinker later tries to remember the contents of what seemed to be a significant conversation at the time I161. Memory losses can occur in non-alcoholic drinkers after considerably lower doses than those associated with the blackout. A decreased ability to recall may take place at blood alcohol levels IBALI of 40 mg/dI (approximately one and a third points of beer), and it seems to decrease in a linear fashion as the BAL rises. State-dependent learning and memory One of the major difficulties in determining and explaining the effects of alcohol on longer-term retention is that the effects of acute intoxication wear off after a few hours, leaving the person in a different physiological state. The problem Is one of determining the extent to which the observed memory deficit is due to 'normal forgetting and the extent to which it can be attributed to the change in physiological state. State-dependent (St.D.) learning is the term used to describe the finding that behaviour learned in one drug state is better remembered when retention Is tested in the same drug state 115.161. In our laboratory we have recently demonstrated the St.D. learning effects of alcohol on human volunteers. These subjects learned a 19-item route map when either sober or under a moderate dose of alcohol lapprox. BAC = 81 mg/dil and attemp ted to recall the information 24 hours later in either the same or different state. We found that subjects who learnt while sober re-called better when sober than when intoxicated; and other subjects who learnt while 'drunk' recalled better when 'drunk' again than when sober. Subjects who experienced changed states li.e. Ill learn while drunk-recall while sober or liil learn while sober-recall while drunki had 'dissociation' decrements-their recall was relatively poor (17(. Clinical observations suggest that drinking may facilitate recall of experiences which occurred while previously drinking, and several recent studies have reported that St.D. learning can be produced with clinical doses of other commonly used drugs 119). There are, of course, significant variations in St.D learning depending upon the particular drugs and learning tasks used: recognition, for instance, as opposed to recall, seems not to be susceptible (20). Yet it is important to appreciate that it occurs not only in carefully designed experiments but also under more everyday conditions of moderate social drinking and general medical treatment.'fhe implica tions could be especially relevant when drug therapy is combined with other treat• ment which is designed to retrain the individual. Effects of alcohol on storage and retrieval Many of our memory problems seem to involve retrieval (or recalll difficulties. Items that have been stored in memory and are potentially available for recall are not necessarily retrievable But yet suitable cues can bring seemingly'unrecallable material to our consciousness and hence verbal output stage Itl. Another example of this storage retrieval distinction is the 'tip of the tongue phenomenon; wherein infor mation escapes ones memory for a period of time, yet seems to be very close to consciousness. When we experience a 'tip of the tongue state we are often conff dent that we know the specific information 'in question; and indeed are usually able to recognize it correctly at a later time. Also, relearning material originally learned weeks (or months/yeatsl earlier is often accomplished significantly more rapidly than new material. This suggests that 'usable traces' exist I131. Does alcohol affect storage, retrieval, or both? Does alcohol alter the way new information is encoded? Do intoxicated subjects use the same learning strategies as sober sub fecrs? Does alcohol impair the consolidation of memory traces? 1'here is evidence that retrieval deficits play a role in alcohol-induced amnesias. For example. retrieval processes are impaired in Korsakoff patients 1211 and there are certain similarities between the nature of memory losses during acute intoxication and Korsakoff's amnesia 121. The fact that heavy drinkers are often slower to respond, especially when BAI. is rising 1251, on simple naming tasks also suggests that retrieval deficits may play a role in alcohol-induced memory impairment. Identifying the locus of alcohol's effects on memory has important implications for dealing with problems that arise during and after alcohol intoxication. If retrieval processes rather than storage processes were disrupted. then alcohol-induced deficits in memory would be transitory. Upon return to sobriety, information could again be used to its full extent. There is some indication, however, that weaker memory _ traces may also be formed when new information is encountered in an intoxicated rather than a sober state. Alcohol is a CNS depressant and it may impair the storage phase of memory by preventing effective consolidation lor'strengthening'I of the trace 1181. Prolonged alcohol intoxication and memory impairment In studies of alcoholics who drank large amounts of alcohol for 14 days or so. daily assessments were made of short-term memory ISI'MI and 24 hours recall. SI'M was significantly and progressively impaired with increasing levels of Intoxication. Impaired STM was more significantly affected than longer-term memorv-which is also observed in ageing. The major defect in STM, due to heavy prolonged intox ication. is not in registration but in retention. It seems that the intoxicated sub(ect 27 TIMN 321418
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ADVANCES IN RECENT KNOWLEDGE - EPIDE.NiIOLOGICAL STUDIES Dr. v. Navaratnam INTRODUCTION The use of dependence-producing substances Is not a modem problem of the world, as the use of such substances dates back to Neolithic times. Archeological evidence exists for the growth of plants like cannabis which date back several decades B.C. Evidence also exists regarding the religious and mystical use of these natural substances, however whilst one can find documentation of ritual and medical use of these substances, early accounts of its social use are absent 11, 21. In the late 60's and early 70's, in nearly all countries, substance abuse became a major and increasingly important threat which has transcended geographic, political and cultural boundaries. It was noted that substance abuse particularly among the young, has rapidly increased. In some parts of the world new syn- thetic psychoactive substances are being abused with the traditional opium-based drugs; in other parts the opium-based drugs are being ccncurrently used with the "newer" synthetic substances. Supply and availability patterns have responded and kept pace with growing demand for these substances. Hence, one may con• clude that the 60's and 70's set the stage for the spread of the contemprory pro- blems of substance abuse. It is generally recognised that policy makers and planners at the local, national and international levels need accurate information on the magnitude of substance abuse with respect to substances used, patterns of use and the essential characteristics of users and their environment. The rate at which the use of a given substance is increasing or decreasing in size over a period of time is another important dimension. In this review the scientific field examined is epidemiology. What is Epidemiology? EPIDEMIOLOGY may be defined as the study of the distribution of a disease or condition in a population and of the factors that influence that distribution. The phenomena or condition being examined are substance-related problems. In this instance, the phenomena being quantified and studied are not, of course diseases or symptoms In the biological sense, but rather syndromes of behaviours (as well as the sociological and psychological conditions associated with or con- tributory to, those behaviours). The etiology of those behaviour patterns and the study of their consequences are sometimes encompassed under the epidemiological rubric, as well. There is a wide array of methodologies available in this general field of inquiry: surveys of general populations, surveys of special subpopulations isuch as students or conscripts), longitudinal surveys of panels of subjects, surveys of populations of known users, information systems based on data from treatment agencies, systems which report related medical consequences (such as medical emergencies and deathsi, law enforcement reporting systems (such as seizures, arrests, price and purity), and so on. Since each of these approaches has the capacity to address somewhat different questions, the selection of appropriate techniques rests with the questions policy makers or scientists wish to be able to address. One might, for example, primari- ly be interested in determining the number of chronic heroin users at a particular point in time. The methods currently available for answering that question are quite specific. They tend to be quite expensive, are generally relatively inaccurate, and will yield little or no information about the misuse in the population of other illicit or of psychotherapeutic substances. On the other hand, the method which is probably most useful for assessing the numbers and types of abusers of psychotherapeutic substances and illicit substances other than heroin-surveys will not likely answer the question of how many chronic heroin users there are. In the conduct of epidemological studies it is essential that these are not pure academic but respond to generating information which has relevance and direct- ly facilitates the functions of policy and programme planners. The areas of infor- mation commonly sought are on: a. the extent, distribution and patterns of substance abuse and substance abuse- reiated problems b. the factors and processes involved in the spread of substance abuse, its related problems and to changes over time c- the characteristics of persons with various types of substance abuse related problems d. the course and outcome of substance abuse related problems of various types and severity e. the social, behavioural and other correlates of substance abuse-related problems L the impact of policies and programmes on the incidence and prevalence of substance abuse related problems. Having determined the broad areas of information that can be or more appropriate should be generated by epidemiological studies, one can briefly review the techni- ques that can be utilised in these studies. METHODOLOGICAL REVIEW As mentioned earlier there are several epidemiological approaches to obtain estimates however the three most common one are: ii Surveys. ii) Enumeration of suspected or positively Identified abusers. iii) Indirect indicator estimates. Surveys, both of the general population and of special populations are among the most widely used methods for estimating the size and characteristics of substance abusing groups. However, there are some methodological limitations. Firstly, the appropriateness of the study sample. The question of sampling is quite complex in the design of surveys and this issue can affect the validity of the results. Since there is variability in substance abuse behaviour within and between com- munities, it is very likely that when large scale surveys are carried out, unless extreme care is exercised, these variations may be masked or smoothed out. Fur- ther great caution has to be exercised in interpreting survey data, particularly since demographic and other characteristics have to be taken into consideration. Also experienre shows that surveys have been effective in describing certain types of substance abuse phenomena, on the other hand they appear to be unsatisfac- tory in estimating substances of abuse which are considered as Illicit. Inspite of these limitations several large surveys have been carried out. These include the Annual American Youth Survey conducted by the Social Research Centre, Michigan U.S.A., Household Surveys in the U.S. by the National Institute of Drug Abuse, special population surveys in Burma, Thailand, Malaysia, Philippines, India and so on. In view of the limitations of survey methodologies, other non-survey approaches have been utilised. The most common approach has been to enumerate actual cases. These are counts of positively identified (or suspected) substance abusers, by various medical, law enforcement, and other involved agencies. Enumerations of this type-commonly known as Registers-usually identify the chronic or criminally associated substance abuser. As such they tend to reflect a "biased" or selective profile of the situation. These lacunae in Registers may deter one from utilising this procedure. However, carefully constructed Case Registry Systems, utilising a multi-agency reporting procedure can be invaluable in providing epidemiological information on the ex• tent and nature of the substance abuse problem in a particular locale. If it is pro• perly developed and managed, it can also provide relatively good Inferential estimates of the identifiable component of the substance abuse problem. Case Registries have been used in several countries including Malaysia, Singapore, Hongkong, United Kingdom, Canada, U.S.A. to mention a few. Another approach for the epidemiological assessment of substance abuse, Is by studying certain conditions or phenomenon connected with substance abuse. However it must be emphasised that this approach is only useful to get crude prevalence estimates, and applicable where a relationship exists between abuse and the observed phenomenon such as property crimes associated with the abuse of illicit substances, or social and public health problems which are linked with the abuse of specific psychoactive substance. Again this procedure is limited in that it assess only consequences of substance abuse, which normally are manifesta- tion of chronic effects. It must be obvious that no single approach will be able to give the complete epidemiological information. Therefore it is essential that a comprehensive ap- proach be used in the conduct of epidemiological studies. The appropriateness of the different epidemiological procedures to generate rele- vant for particular types of informational needs will not be discussed as there are several reviews of this subject (W.H.O. Technical series 50, 55, 56, 60; Arif and Griffiths Public Health Papers 73.) REVIEW OF THE EPIDEMIOLOGY OF SELECTED SUBSTANCES OF ABUSE There are very few reviews in the literature on the global epidemiology of substance 9 TIMN 321400
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ALCOHOL AND DRUG USE AMONG MONTREAL HIGH SCHOOL STUDENTS A.M. Ghadirian, M.D.; ME Subak, M.D.; V. Kovess; M.D.; G. Gregoire, M.D. and R. Prince, M.D. Alcohol and tobacco use among adolescents has reached endemic proportions to the point of becoming fully institutionalized in our society. Cannabis use seems to follow the same pattern of social acceptance in recent years. Previous Canadian studies (1-5) indicate a general increase in the use of alcohol and drugs by this age group, who are at risk for the development of alcoholism and drug addiction. American high school students in comparison, have continued to increase the use of cannabis, while the use of other illicit drugs has remained steady (6). In a 27-year longitudinal study of alcoholism in college students, Filmore and associates (7) reported that most of the students do not develop a chronic disorder in later life. In today's environment, however, this finding is not sup- ported by others 18). There have been a vast range of studies and reviews on the problem of alcohol and drug abuse, particularly that of cannabis (1,2,4,9). A salient fact emerging from these reviews suggests the important role of the environmental factors, social models and social reinforcements (9) on the develop- ment of drug abuse. The role of peer and parental influences has been well establish- ed during the recent years (10-13). In Montreal, early studies conducted by Bilodeau (14) showed an increase in the proportion of drug users from 1969 to 1971. There was an increase in the proportion of students who used drugs from 11.7% to 30.4%. Moreover, drug use was reported to have increased among females. More recently, Lamontagne et al (15) reported that the percentage of male alcoholics in their sample of col- lege students was rising alarmingly to 14.6%. (Alcoholism criteria in his sample was defined according to the DSM III of the American Psychiatric AssociationJ. In a recent national survey of alcohol use in Quebec (5), it was reported that drinking was high among predominantly younger females. Smart, Fejer and Alexander, 1970 (16) and Smart, Fejer, Smith and White, 1974 (17) showed that the prevalence of cannabis use increased from grade 7 to 9 and decreased from grade 1 I to 13. In a more recent survey, Smart et al., 1979 118) indicated that since 1977 the use of cannabis and tobacco have increased among younger students (13 years and under) and the use of cannabis alone also increased among adolescents of 14 and 15 years of age. More recently (1983), Kovess and associates [ 191, in a survey of general popula- tion in Quebec, found that nearly 50% of the young people of 15-24 years of age smoked tobacco. There was an equal sex distribution. They reported that 32% of the same sample in urban areas used cannabis. The investigatois explored the use of the following drugs consumed more than five times in the past in the same population and reported that cocaine, amphetamine and psychedelic drugs were used by 9.33%, 5.62% and 6.74% of the above sample respectively. There are a number of factors which might influence drug use. Important among these factors are curiosity, peer pressure, family breakdowns, lack of positive at• titude toward frustration, and a sense of alienation. Environmental factors such as migration, rapid urbanization, poverty and unemployment are also contributing factors (201• Some authors suggested that individuals with emotional disturbances may be more attracted to the use of hallucinogenic substances (McAcee et al, 1969; Smart and Fejer, 1969; Frorch and Gershon, 1968). The role of the family structure has been emphasized by several investigators. Some of the authors suggested relationship between the prevalence of marijuana use and a tendency to avoid living with parents (Smart, Fejer and White, 1970 121) and Kelloris, 1977 (22). Valla (23) suggested three different parameters in relation to drug abuse: 1) the quality of parent-child relationship; 2) the family's degrees of adaptation to the social values; 3) the parental utilization of drugs. In view of these findings we decided to explore certain parameters which might bear some significance in the choice of drug use and its continuation such as family relationships and individual motives as well as other factors are outlined in the objectives. OBJECTIVES The objectives of this epidemiological survey were threefold: -- I 1 to study the occurence of alcohol and drug abuse among the adolescents of the Montreal region, and to determine the trend of substance abuse in the 1980s; 2) to explore the role of family and environment in the adolescents' attitude toward alcohol and drugs; 31 to evaluate the motives for the use of alcohol and drugs and to explore how adolescents relate these to their purpose in life. - MATERIAL AND METHOD In our study of two high school students in Montreal area, a structured question- naire was used for the assessment of alcohol and drug use by the students. Our sample consisted of the student population of two high schools which were chosen for their linguistic background; one in English and the other French. The choice of two high school populations with socio-linguistic differences was to explore the influence of their cultural values on their attitude toward drugs which is the subject of another paper. An authorization was obtained from school authorities to make this survey in the -high schools. The surveyed classes were almost fully attended on both days and there were no refusals to fill in the questionnaires. The students in the sam• ple came from comparable middle class socio-economic backgrounds. While the French high school sample consisted of a homogenous French Canadian popula- tion, the English high school population consisted of a large number of students from diverse cultural backgrounds. Our sample consisted of 100 students from an English school and 106 from a French school. 57.1% of the students were males and 42.4% were females. The mean age for all was 16.3. Approximately 85% of the adolescents lived with the natural parents, while 18.5% indicated that their parents were separated or divorced. About 10% of the sample had one deceased parent. On the day of the survey, the research team distributed the questionnaires, outiined the purpose of the study, and assured the students of its confidentiality and anonymity. The following areas were explored by the questionnaire: 1) demographic data: age, sex, religion, school grade and ethnic background; 2) use of alcohol: percen- tage of students who use it; types of beverage used; reasons for its use; use of alcohol and drugs combined; 3) use of drugs: different types of drugs used (tobac• co, cannabis, hallucinogens, inhalants, non-prescription tranquilizers, sedatives), introduction to drugs: reasons for its use; 4) adolescents' selfesteem assessment (with the use of Rosenberg's Self-Esteem Scale (24), their emotional problems; violent behavior while under the influence of drugs and/or alcohol; their goals in life, and 5) family structure and ethnic background; parental drug and alcohol use. RESULTS Descriptive results of alcohol and drug use among the student sample: Use of Alcohol: In our survey, 92% of the students reported that they had used alcohol during the past year, 67% had used it during the past 30 days and 38% had drunk in the preceding I to 5 days; only 10% never used alcohol. Beer was the most frequently used beverage (34.1%). It was important to determine also the frequency of alcohol consumption as it has been established by a National Survey on Alcohol Consumption that heavy drinkers among youth tended to go on binges (5). About 6.3% of the students admitted to having 10 drinks per week, representing 31.5% of the monthly drinkers. A significant finding was that those who did not drink alcohol, did not use any drugs and rarely smoked tobac co, whereas, those who used alcohol took at least one drug. Use of Tobacco: Our results showed that 25% of the students never smoked, while 47% smoked during the past thirty days. This percentage probably represents the real smokers who show a very high prevalence. The percentage of those who started smoking but stopped was 17%. There is also a correlation between smok• ing and use of alcohol as shown by the results. Females were over-represented in the smoking tobacco in the preceding year, 68.2% versus 50.4% for males. Age was not found to be significant. Use of Cannabis: In our sample, approximately 53.7% of the students indicated that they had used cannabis at some point in their life, 46.3% had used it during the past 12 months and 25.4% used it during the past month. Use of Amphetamines and other Stimulants: A rather high percentage, 12% of the sample, admitted the use of amphetamines or other stimulants without a physi- cian's advice; 8.3% indicated that they had used these drugs during the past 12 months; about 6% had used them during the past 3 months. The amphetamine users reported that they were often violent under the influence of drugs and that they had overdosed (50% of the users) with amphetamines. The amphetamine users indicated that they did not wish to stop using these drugs. Use of Inhalants: 9.3% admitted to have inhaled glue, spray or gasses at some point in their life. About 8% indicated that this experience took place during the - past 12 months and 3.9% experienced during the past 3 months. More females i I i 22 TIMN 321413
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ALCOHOL AND DRUG IMPAIRMENT IN REGISTERED NURSES Eleanor J. Sullivan, RN., Ph.D. The purpose of this study was to identify in a population of registered nurses those factors associated with development of impairment due to chemical dependency (alcohol or drug dependency). Alcoholism and drug dependency are serious, life-threatening diseases for many in today's society, but the problems and the dangers when nurses suffer from these diseases is much greater than with others in the population. Alcohol or drug dependent nurses are seriously impaired in their ability to perform their professional nursing functions. Their clinical judgment and skill may be compromised thereby endangering their patients. The identification and intervention of alcohol or drug impaired nurses is further complicated by the fact that nurses can, and many do, lose their license to prar tice nursing. Others in society may experience the social stigma of alcoholism but few )physicians, dentists, pharmacists also may lose their licenses) compromise their professional future when they admit to alcoholism or drug dependency. A quantitative description of the national population of nurses recovering from chemical dependency was collected and compared with a description of a ran- dom sample of licensed registered nurses who were not identified as impaired. Information was collected on selected variables including: demographics; family history (past and current); education; medical history; lifestyle characteristics, and, alcohol and drug related behaviors. Background and Rationale Although there is a great deal of information regarding the incidence of alcoholism and drug addiction in society, there are few studies addressing chemical dependency among the 1.6 million registered nurses in this country. When the problem is addressed in populations of health care personnel, it is primanly the impaired physician who is discussed. However, drug addiction is the primary cause of disciplinary action against nurses, according to a survey of state boards of nursing (National Council of State Boards of Nursing, 1980). The nurses who are disciplined by state boards of nursing are those who: use drugs; steal them; and are caught doing so. Consequentiy, those numbers, though high, represent only a portion of the drug users and seldom include nurses who abuse alcohol. In addition to the number of nurses addicted to drugs, Bissell and Jones ( 1981) estimate that at least 40,000 nurses are alcoholic. The very real fear of license revocation and/or job loss encourages nurses to conceal the problem. Additionally, denial is characteristic of addictive diseases. These factors contribute to the reluctance of nurses to seek treatment even when their professional functioning is impaired by chemical dependence. Another vulnerable population, patients, are put at risk by nurses whose com- petence is threatened by addiction. Nurses care for patients 24 hours a day, often working at night with few other health professionals in attendance. They are responsible for the use of lifesaving equipment, and the administration of medica- tions and procedures. These activities, when carried out by a drugged or intox- icated nurse, may be dangerous or even fatal. Also, nurses monitor clinical situations and frequently need to act immediately. The sins of oinission of an inebriated nurse may be as deadly to patients as the more apparent incorrectly performed procedures. Research done to date has addressed characteristics of the impaired nurse who is recovering from chemical dependency. Bissell has completed the most com- prehensive work in the study of alcoholic professionals (Bissell & Jones, 1981; Bissell & Haberman, 1984). She interviewed 100 recovering alcoholic nurses in the early 1970's and the work suggests that: the recovering alcoholic nurse is highly motivated: Is both academically and professionally successful: nurses abuse alcohol as well as drugs; and, little or no help exists to assist the nurse with recovery. Other studies describe similar characteristics of the recovering alcohol and/or drug impaired nurse IBush, 1983; Jaffe, 1982; Levine, 1974; Poplar, 19691. Except for Bissell's work, past research has been conducted in limited geographic areas and has utilized fewer than 100 subjects. To date, research has been descrip- tive and/or anecdotal, addressing characteristics of small samples of recovering impaired nurses. However, in spite of this lack of sound research-based intervention strategies, the profession has responded to the need. Since 1981, several state nurses' associa tions (divisions of the American Nurses Association) have established support programs to aid impaired nurses. These peer assistance programs utilize volunteer nurses Ipeers) to help chemically dependent nurses. The peers refer chemically dependent nurses for alcohol or drug treatment, medical or legal assistance and serve as a support person dur,ng a one to two year rehabilitation period. Although 16 there have been descriptive reports from each state's records, organized data has not been collected from the various programs. No substantial conclusions may be drawn from such scant information and, therefore, intervention strategies cannot be planned and preventive action cannot be developed. The gaps in existing knowledge are to a great extent the result of problems in methodology. They are: 1) overall, a major part of the reported data has been collected in general or physician populations; 2) in those studies concerned with nurses, only one selected subjects from a national population of impaired nurses; 3( most studies are descriptive anecdotes rather than quantitative statements; 41 most studies focus on either the alcoholic nurse or the drug addicted nurse, only limited work includes both alcoholic and drug addicted nurses; and 5) on most reported studies, data were collected more than ten years ago and, given societal changes in regard to alcohol and drug use/abuse, current research is needed. Methods Two national target populations were identified: i I registered nurses recovering from chemical dependency; and 2) registered nurses not identified as chemically dependent. Access to the population of chemically dependent nurses is difficult. They are extremely reluctant to be known; social stigma of alcoholism and drug dependency in society puts their professional future at stake. Therefore, contact with state organizations with peer assistance programs for chemically dependent nurses was made taking into consideration the very sensitive nature of this problem. Addi- tional access to the chemically dependent nurse population was gained by notices in national publications and at national meetings requesting the assistance of in- dividuals with access to recovering chemically dependent nurses. Access to the registered nurse population in the United States also is difficult. There is no national registry of nurses, each state licenses Its own residents and most states have thousands of registered nurse licensees. In an attempt to access a representative sample of this huge population, twenty state boards of nursing, representing all regions of the country, were contacted. Six state boards had the facilities to provide a random sample of 300 registered nurses licensed in the state and to do so for a minimal cost. The participating states were: Maine, Ten- nessee, Missouri, Nevada, Idaho, and Maryland. An extensive questionnaire was distributed to a sample survey of two popula• tions. The instrument was developed based on characteristics, identified in the literature, as associated with alcohol of drug addition in nurses (Bissell & Jones, 1981; Levine, Preston & Lipscomb, 1974; Poplar, 1969). The questionnaire re- quests information conceming: demographics; family history (past and present); education; employment history; medical history; and alcohol and drug related behaviors. Experts in addiction treatment contributed to refinement of the ques. tionnaire. In order to screen the sample of licensed registered nurses not identifed as im- paired for chemical dependence, five questions were included. If non-chemically dependent nurse subjects answered affirmatively to any of the five questions, they were excluded from the non-chemically dependent nurse group, and, from the study. Four of the questions asked were adapted from the CAGE Question- naire (Ewing & Rouse, 1970). According to Ewing (1984), the questions may be paraphrased to fit the clinical population. In this sample of registered nurses in which mood-altering chemicals (drugs) and prescribed medications may be as familiar as beverage alcohol, the words "drugs" and "medications" were added when questions regarding alcohol use were asked. Distribution of the instrument to the recovering chemically dependent popula• tion of nurses was conducted by the peer assistance program committee in the participating states and by requests for surveys by mail or at national meetings. Representatives from 24 states participated in the distribution. All responses were anonymous; the only identification tabulated was the state of origin as designated by,postmark. In this way, the researcher did not have access to the names of the respondents, and members of the peer assistance com- mittees or others who distributed the instrument to recovering nurses did not have access to subjects' responses. There were 139 responses received from chemically dependent nurses residing in 19 states; the response rate is not known since the number of questionnaires distributed to the population is unknown. Responses received from the non• chemically dependent nurse sample totaled 522. Surveys were sent to nurses licensed in six states. but the non-chemically dependent nurse respondents resided = TIMN 321407
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ALCOHOL DEPENDENCE AND PROBLEM DRINKING IN A NATIONAL SAMPLE Thomas C. Harford and Douglas A. Parker Knowledge of extent or prevalence of alcohol problems is basic to planning strategies to prevent or reduce problems that arise from alcohol use Technically, prevalence fs a statistic that represents an estimate of the number or proportion of individuals in a community, region, or nation who are affected by or exposed to a particular health-related condition, or who manifest a behavior or characteristic believed to be an indicator or precusor of the condition. Since the early 1960s, survey research has directed attention to estimating the prevalence of alcohol problems in the general population (1-6). One result of that effort has been the recognition that not all alcohol problems are limited to alcohol dependence and its adverse effects on physical and mental health. A wide range of alcohol-related consequences have been noted but their interrelationships are relatively weak (5,7). A DWI arrest Is not necessarily a strong predictor of family problems, a job disruption or alcohol dependence. More recent efforts distinguish between two broad classes of alcohol problems-alcohol dependence and adverse effects of alcohol (4,5,8). Diagnostic criteria for alcohol dependence include physical symptoms of withdrawal and/or tolerance and loss of control 19,10). Survey instruments for use with general populations incorporated many of the behaviors and symptoms postulated by Jellinek as common among alcoholics (11). Population estimates are based on self reported symptoms of potential alcohol dependence, such as tremors, morning drinking, blackouts, and inability to stop drinking. The classification of respondents as alcohol dependent is arbitrary (Le, two or more symptoms within the past year) and measures have not been standardized across surveys. Recently, Parker et al. (8) distinguished between more severe and less severe forms of alcohol dependent symptoms and developed a Guttman scale for estimating the prevalence of alcohol dependence among employed men and women in metropolitan Detroit. Approximately 12 per- cent of the sample was identified as alcohol dependent. Traditionally, population surveys have studied a wide variety of problems associated with the use of alcohol (e.g., job performance, accidents, financial difficulties, in- terpersonal problems, etc) Recent studies acknowledge that alcohol problems vary in their severity (4,8). Losing a job because of drinking is more severe than being late for work because of a hangover. The present study develops estimates of alcohol dependence and problem drinking and examines their distribution in demographic categories in a national sample of adult men and women. Method Data for the present study were drawn from the 1979 national drinking practices survey conducted by the Social Research Group of the University of California, Berkleyk A stratified area-probability sampling frame was used to draw a sample of adults 18 yeats of olde; living within the coterminous states. Within each household selected, one randomly chosen adult was selected for interview. A response rate of approximately 70 percent yielded 1,722 respondents from the 2,696 occupied households assigned to field work. A weighting scheme including age, sex, educa- tion, number in household and location of interview was applied to the data to approximated the U.S. househol population. Specific information on the sample and research design is provided elsewhere (5). Of the 1,772 respondents in the study, approximately 66 percent were current drinkers (drank within the last 12 months). Fstimates of the current prevalence of alcohol dependence and problem drinking are based on this sample of current drinkers. Alcohol Dependence The measure of alcohol dependence was based on 12 items related to symptoms of potential dependence According to DSM-lll (9), withdrawal is the most severe form of alcohol use disorder. Withdrawal symptoms, which are demonstrable after heavy drinking by those addicted to alcohol, include hand shakes in the morning after drinking and morningdrinking to get over the effects of last night's drinking. Morning drinking is often an indication that drinking is being undertaken to suppress withdrawal symptoms. Although they may be indications of dependence on alcohol, they may also reflect fairly short-term physiological con- sequences of a heavy drinking episode (5, i3). Respondents were classified as manifesting withdrawal if they reported one of the following symptoms at least once in the past year. My hands shook a lot the morning after drinking. I have often taken a drink the first thing when I get up in the morning. I have taken a strong drink in the morning to get over the effects of last night's drinking. Loss of control over drinking is treated as an experience indicating a moderately severe form of dependence (9). Respondents were classified as manifesting loss of contml if they reported one of the following symptoms at least once in the past year: ' I was afraid I might be an alcoholic I deliberately tried to cut down or quit drinking, but was unable to do so. Once I started drinking it was difficult for me to stop before I became com• pletely intoxicated. I sometimes kept drinking after I promised myself not to. Other deviant drinking behaviors, such as skipping meals or tossing down drinks, are viewed as less severe forms of alcohol dependence in the present study. Respondents were classified as exhibiting symptomatic behaviors if they reported one of the following at least once in the past year: I had a quick drink or so when no one was looking. I have taken a few quick drinks, before going to a party to make sure I had enough. I have skipped a number of regular meals while drinking. I have tossed down several drinks pretty fast, to get a quicker effect from them. I have awakened the next day not being able to remember some of the things I had done while drinking. Problem Drinking The measure of problem drinking was based on 22 items related to a wide variety of negative consequences associated with alcohol use. Both the content and frequency of occurrence were considered in the determination of severity. High severity involved formal disruptions of social and occupational functioning. Respondents were classified as having experienced a severe problem If they reported one the following at least once in the past year: I have lost a job, or nearly lost one, because of drinking. My drinking contributed to getting hurt in an accident (in.a car or elsewhere). Drinking led to my quitting my joh Drinking may have hurt my chances for promotion, or raises, or better jobs. I had an illness connected with drinking which kept me from my regular job for a week or so. My drinking contributed to getting involved in an accident in which someone else was hurt or property was damaged. I have been arrested for being drunk. I have been arrested for driving after drinking. Moderate severity included being warned by others of excessive drinking, disrup- tion of relationships with others, and other infringements on activity (i.e., late for work, spending money for alcohol which was needed for essentials). Respondents were classified as experiencing a moderately severe problem if they reported one of the following at least once in the past year. My drinking interfered in some way with the way I raised my children. People at work indicated that I should cut down on drinking. My drinking was involved in losing a friend or drifting apart from a friend. A physician suggested I cut down on drinking. I felt that my drinking was becoming a serious threat to my physical health. Friends have indicated that I should cut down on drinking. A policeman questioned me or warned me because of my drinking. I spent money on drinks that was needed for essentials like food, clothing, or payments. I have stayed away from work or gone to work late because of a hangover. I have gotten high or tight while on the job. Respondents were classified as having a less severe problem associated with alcohol if they reported one of the following as having occurred in the past year: My drinking sometimes made me bad tempered or hard to get along with. Drinking caused me to get into a heated argument. I spent too much money on drinks, or after drinking. I have driven a car sometimes after drinking when I would have been in trou- ble with the law if they happened to stop me. Based on the present conceptualization of withdrawal, loss of control, and symp• tomatic drinking, the Guttman scale of alcohol dependence has a reproducibility of.96 and a scalability of.75 for men. Similar coefficients were obtained for women 1.96 for reproducibility and .75 for scalibility). Respondents who report more severe conditions of dependence clearly tend to report less severe conditions of dependency as well. Based on the Guttman analysis, withdrawal was assigned a scale value of 3, loss of control a scale value of 2, symptomatic behavior a scale value of 1. Clearly, any particular cutoff is an arbitrary definition of alcohol dependence. A cutoff of 3 or more (which includes at a minimum either loss of control and symptomatic 29 TIMN 321420
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combined with a aversion oriented teaching. In order to obtain some basic information about different European approaches to school educauon and family orientation about alcohol a questionnaire was sent to a number of European centres with whom we are in contact. The questionnaire is reproduced as appendix I in this paper. The countries represented were Den. mark, Norway, Sweden, Finland, United Kingdom, Iceland, Netherlands, Belgium, Federal Republic of Germany, France, Spain, Switzerland, Italy, and Greece represen- ting Western Europe exclusively. The questions asked were I. I egislation a. Is AE compulsory issue in school curriculae? Five nations answered yes to this question. Two of these countries, where we had asked two centers, one of them said no. Nine said no and one is at present engaged in activating a project by which it may be possible to introduce legislation. The fact that AE is not compulsory does not mean that AE is not offered on another basis. Such volontary or regional educative activity is reported on a large to a small scale. b. Is AE mainly placed in certain class-levels lage groups)? The same two nations showed the same uncertainty. Apart from that three answered yes, one said it was given on all levels, and six said na c. Is AE supported by a compulsory number (minimuml of teaching periods? Only one country had such an arrangement, and it will probably soon be discatd. ed. Eleven countries left it to the particular school to decide when they judge that the pupils have had enough education. On the other hand as little as one hour is legitimate under such circumstances. d. Is there any terminal test or examination of which AE is a part or a main issue? 2. Part of Health Education a. Is AE considered to be an autonomous subject? Five nations thought so, while three others thought not. The rest of the nations were rearranging their educatlon to give a more negative answer to this question. b. Is AE treated as a part of Health Education? 10 nations think that this is so while one prefers a specific alcohol (and drug) education independent of Health Education. It is perhaps not easy to see the practical meaning of this finding. I do not believe that the country in question does teach without referring to general health education. 3. Integration. a. Is AE given as a subject integrated in the general school curriculum? Seven countries said yes and three no. This must be seen in the light of the presently vivid debate on integration of everyday-concepts into the formal school teaching. bh or, Is AE given as a specific subject, independent of the systematic school didactic courses? Four countries use this approach while six have decided againstit. c. If a is the case, please name some topics where AE may be given (Biology. Sociological issues, language and Litterature Mathematics, Chemistry, Physical 1raining, others). It is by far most common to let the teachers do the teaching of AE. Only one country, in which teachers are not yet trained in AE applies people from out- side the school, and they mostly use persons from the medical professions. e. How many years may AE be given in school for each student? This varies from 9•l2 to 0.5 and 1-2. - 4. leachers trainingg a. Do teachers receive any specific AE during their training before leaving training school, etc? In five countries yes and in all the rest no. -i'he positive answer were given in NorthWestern Europe b. Do teachers receive any specific AE-related didactic training before leaving training school, etc? Much de,bate on health education has been on the didactic methodologies. Has this debate had any impact on the training of teachers? To this five said yes and five na c. Are teachers offered any training in AE, its methodology, its content, its con- ceptuology while in service? 1'his was generally affirmative only one answer being negative. d. 1'ypical teachers training courses were not described. A large amount of lit- terature was received and through that it seems generally to be the factual knowledge rather than the methodology these courses are aiming at. But this conclusion is perhaps not fair to those who deal very thoroughly with dedactic 5. Parents involvement a. Are parents informed about the content lmessagel of any AEgTven to their offspring? 5 countries said yes and 5 no. h. Are parent's participating in decisions andior planning of AE? Both these questions were mainly answered negatively. 'I'his is a surprising detail that should be studied much closer before accepted as a picture of the truth about AE in Europe. G. Some specifics about content of a typical At: in your country: a. Is the teaching aimed at abstinence? Everyone denied this. b. Is the teaching aimed at diminishing alcohol•related problems Idamagesl? All were af6rmative c. Is the teaching primarily i. risk oriented it. situation oriented All claimed that their education was situationoriented but five nations also use risk-oriented teaching. The two terms used in I. and ii. were defined as seen in appendix i. The rest of the questions have little value for this paper. In preparation of this paper the impression was that there is a very energetic atmosphere of research and evaluation in entire Europe at the moment. Conclusion The very diverse activities in the many different European centers for education make for a very interesting situation in Europe at present Apart from the question. naire the informatiodobtained gave a continuation of many discussions Initiated a long time ago with many people active in the field. Especially the ICAA-EEC group has been very valid, but so has the Nordan in the Nordic countries. It Is very important to see the development of the attitudes representative of other sciences towards education. We have over the last decade been through a period where the Finnish-Canadian axis of sociologists' approach: that to reduce alcohol problems, there should be government policy to reduce the availability of alcohol, the socall• ed control policy, were almost the only one discussed. Its impact on some, nations policy against alcohol-related problems and their prevention was so strong that educa- tion in many places was regarded as being hardly meaningful. This period is now in a marked way behind us. It has been replaced by a period were a multidisciplinary attempt is being made to cope with the alcohol-related problems. The school and other youth services share a great part of society's responsibility for checking this part of human frailty. I wish to thank everyone who have helped in preparing this paper that was made over three weeks. The material will probably be studied more Intensely in the near future. References l. Alcohol Policy in Sweden 119821: A Survey by the Swedish Council for Infor• mation on Alcohol and Other Drugs ICANI 2nd edition. p 23 ff. 2. Pirrko Nikander 119831 Personal communication. 3 Editor 11985i: Conversation with Seldon D. Bacon. British Journal of Addiction 80. t19851 115-120, nr 9 in a series of Interviews. TIMN 321424 _ 33
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TABLE 2 Average Length of Stay (LOS), Ratio of LOS With and Without Alcohol Abuse Comorbidity and Proportion of Discharges for Individuals with Alcohol Abuse Comorbidities by ICD-9-CM Categories CD-9-CM Categories verage LOS Ratio: LOS with Alcohol Abuse Comorbidity to LOS Without Comorbidity Proportion of Total Discharges with Alcohol Abuse Comorbidity 162 Malignant neoplasm of trachea, bronchus and lung 10.50 1.42 1.00 250 Diabetes mellitus 9.47 1.06 0.75 276 Disorders of fluid electrolyte and acid-base balance 7.79 1.01 1.79 345 Epilepsy 5.33 1.22 3.45 401 Essential hypertension 6.35 1.30 2.04 410 Acute myocardial infarction 10.91 0.81 0.82 413 Angina pectoris 5.35 1.78 1.01 414 Other forms of chronic ischemic heart disease 8.06 0.91 0.61 427 Cardiac dysrhythmias 7.16 1.16 1.19 428 Heart failure 19.71 1.01 0.87 436 Acute but ill-defined cerebro- vascular disease 14.93 1.35 1.02 486 Pneumonia, organism unspecified 7.98 1.16 0.94 491 Chronic-bronchitis 8.44 1.04 1.87 496 Chronic airway obstruction, NEC 9.52 0.63 1.90 530 Diseases of esophagus 6.28 1.26 2.52 532 Duodenal ulcer 7.12 0.58 1.16 535 Gastritis and duodenitis 5.30 0.97 4.86 571 Chronic liver disease and cirrhosis 10.18 0.89 13.71 572 Liver abscess and sequelae of chronic liver disease 15.26 0.69 18.08 577 Diseases of pancreas 9.38 1.30 11.65 578 Gastrointestinal hemorrhage 7.11 0.90 4.87 599 Other disorders of urethra and urinary tract 7.00 1.21 0.67 ~682 Other cellulitis and abscess 8.68 1.25 1.78 820 Fracture of neck femur 18.02 1.18 0.75 823 Fracture of tibia and fibula 8.83 1.54 2.36 850 Concussion 3.51 0.71 2.51 854 Intracranial injury of other and unspecified nature 6.48 0.30 5.06 873 Other open wound of head 3.66 1.05 5.25 965 Poisoning by analgesics, anti- pyretics, and antirheumatics 3.44 1.11 9.20 969 Poisoning by psychotropic agents 3.83 0.52 12.05 977 Poisoning by other and unspecified drugs and medicinal substances 4.25 2. 09 8.49 Source: RTI Analysis of National Hospital Discharge Survey. 46 TIMN 321437
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i i 5.54i reported that they used it once a week. Those who inhaled drugs. used at least two other drugs and also drank and smoked more than those using other drugs. Use of Tranquilizers: The prevalence of use of these drugs with and without a physician's prescription was 6.3% and 6.5% respectively. These figures seem to be relatively low in comparison with the use of other drugs. Approximately 4% of the participants indicated that they had used tranquilizers during the past 12 months and 3% had used them during the past 90 days. Age of First Use of Alcohol and Certain Drugs: The mean age for the first use of alcohol and tobacco was 13-14 years for 37.6% of alcohol users and 29.3% of tobacco users. First use of cannabis was quite early; 28.8% of students admit- ted to have used it in the age range of I 1 to 14, while 22.4% used it from 15 to 16 years of age. Non prescribed tranquilizers and psychedelic drugs and in- halants were first used at 15-16 years and amphetamines at 13-16 years. Approx- imately 54% of the students used alcohol first as compared to 8.8% who used drugs first. Consumption of alcohol significantly correlated with age as follows: its use was increased to a peak at age 16 and then declined up to age 19. Drugs, Behaviour and Goal in Life: There was a minority of respondants who declared to have experienced violent behaviour under the influence of drugs. This was reported in 8% of the drug users, without specification of the type of drug, and in 1.6% of those under the influence of alcohol. It is interesting to note that the users of hallucinogenic drugs reported no violent behaviour. Thirty-three percent of those using tranquilizers admitted to have experienced violent behavior. In general, the users of cannabis indicated that the majority (60%) did not have a goal in life; the users of hallucinogenics gave the same negative answer in a greater percentage 178%), whereas the non-users of hallucinogenics gave a 50% answer in this regard. Motives for the use of drugs: The reason most frequently given for trying non-medical drugs for the first time was "curiosity" (25.9%). The reason for continuation of the use of drugs was "en. joyment" (31.9%), while any other reason such as "to be sociable", "to feel less blue or down", "to feel less nervous", "to feel more creative", represented only small percentages of positive answers. These answers give a vague and global idea and more specification will be necessary. Family Structure and Parental Drug and Alcohol Use The family characteristics of alcohol and drug use in our sample were as follows: 18.5% of students had a member of the family who drank heavily. The father was perceived as a "heavy drinker" by 14% of the students, while 13% of the mothers were reported as users of "nerve pills". The percentage of families in which the fathers took "nerve pills" was also high, 9.3%. There was a positive correlation between the "heavy drinker" parents and their amphetamine user children I10%) In the total sample of amphetamine users. There was also a positive correlation between the mothers who used nerve pills and their children who used sedatives as compared to those mothers and their children who did not use nerve pills 112% and 13% respectivelyl. Moreover, 14.9% of the adolescents who took tranquilizers came from families where father and/or brother used "nerve pills". There seemed to be a correlation between the absence of a parent and the degree of drug use. We found that in families where mothers were deceased, 33% of the adolescents reported that they have used prescribed tranquilizers during the past 12 months. On the ther hand, 33% of the adolescents whose fathers were deceased made use of amphetamines. Also, 14% of the adolescents living with their natural father alone or living in institutions reported to use tranquilizers without prescription. Since these findings are based on the adolescents' percep. tion of parental alcohol and drug use, its accuracy is difficult to be determined. However, alcoholism in the family is the only disorder for which genetic predisposi• tion has been substantiated scientifically by a large number of observations 125,26,27i. DISCUSSION In the 1970s much importance was given in Quebec to field surveys of alcohol and drug consumption and its related factors. In recent years, however, a virtual absence of research progress has been noticed. Nevertheless, the fact remains that both the problem of drug abuse and its con- tributing factors continue to be of great importance and still need to be address ed. The present study was undertaken with a proper prospective to survey a small sub-population sample of high school students in an age group reported to be most apt to abuse both alcohol and drugs ( I ). The sampling per se already constitutes an important limitation, considering that the school dropouts, probably the most affected population, was missed. Other limitations of this study are presented by the impossibility of validating self-reporting as well as the likelihood of under-reporting, particularly by those who are heavy users of alcohol (28). As a result, very often in these kinds of surveys, the actual drug use is underestimated. Parental influence in the use of alcohol and drugs has also been studied by several authors: Smart and Fejer, 1972 112); Smart, Fejer and Alexander, 1970 (16); Tolone and Derrmott, 1975 (29). However, the findings with respect to alcoholism in the family is the only substance for which genetic predisposition has been substan- tiated scientifically by a large number of observers (25,26,27). In our study the influence of parental loss is reflected on the choice of drug of abuse: in families where there was a high prevalence of deceased mothers, adolescents reported to make use of prescribed tranquilizers, whereas in the families where they suf- fered loss of a father, the adolescents tended to use more amphetamines. This finding possibly suggests two interesting phenomena: a) the children of these par ticular families incorporated prescribed or non-prescribed drugs as a way of over• coming their own grieving from a loss in the family, although we don't know how long ago the parents were deceased; b) tranquilizers were prescribed in the case of loss of the mothers, while amphetamines were chosen by those who lost their father. This finding has important psychodynamic implications in the adoles cent reaction to parental loss through the kind of drug use. It also shows that those who received tranquilizers had consulted a physician to obtain a prescrib- ed medication. On the other hand, the use of amphetamine may also indicate serious underlying despair or depression requiring a stimulant. There was no signifi• cant difference in so far as sex distribution is concerned between males and females in the use of alcohol and marijuana during the preceding 12 months. Moreover, we found important differences in the use of alcohol with reference to age. Among the motives for drug use, pleasure and curiosity played important roles in our sample. This corroborates previous findings (20). However, according to Sidney Cohen (251, reasons given by a person concerning his vulnerability to drug use are sometimes meaningful and sometimes are rationalizations. Thus, the underlying causes are "muitifactorial", the nature of which can hardly be well explained by curiosity or similar reasons. Another point of interest was that 33% of adolescents who made use of tranquil izers also reported that they experienced violent behavior. The use of tranquilizers probably lowered their inhibition over their emotions such as rage and anger. Also, a finding of special interest was the fact that the ratio of female to male in the use of inhalants was three to one. Whether this tendency Is sex related, or occurred by coincidence, remains to be explored. The authors would like to acknowledge with thanks the secretarial assistance of Mrs. Valerie Lenihan. REFERENCES 1. Canadian Commission of Inquiry into the Non-Medical Use of Drugs. Can• nabis. Ottawa, Canada, Information Canada, 1972. 2. Canadian Commission of Inquiry into the Non-Medical Use of Drugs. Final Report of the Commission of Inquiry into the Non-Medical Use of Drugs. Ot• tawa, Canada, Information Canada, 1973. 3. Le Dain. G., Secondary School Students and Non-Medical Drug Use: A Study of Students Enrolled in Grades 7 through 13. Public Archives of Canada, Ot- tawa, 1970. 4. Marihuana in Canada 1980/8l. A National Survey of the Department of Na. tional Health and Welfare, Health Protection Branch, Ottawa, 1980/81. 5. Special Report on Alcohol Statistics. Expert Committee on Alcohol Statistics. Ministry of National Health and Welfare and the Ministry of Supply and Ser• vices, Ottawa, Canada, 1981. 6. Johnston, L.D., Bachman, J.G. and O'Malley, P.M. Drug Use Among American High School Students 1975-1977. National Institute of Drug Abuse. Washington, D.C., U.S. Government Printing Office, 1977a. 7. Fillmore, K.M., Bacon, S.D. and Hyman, M.D. The 27-Year Longitudinal Panel Study of Drinking by Students in College, 1949-1976. Berkeley, University of California, School of Public Health, Social Research Group, 1979. 8. Favazza, A. Alcohol and Special Populations. Journal of Studies on Alcohol, Suppi. no. 9: 87-89, 1981. 9. Jessor, R. Marihuana: A Review of Recent Psychosocial Research. Handbook on Drug Abuse, edited by B. Dupont, A. Goldstein and J. O'Donnel, pp. 337-356, 1979. 10. Penning, M. Adolescent Marihuana Use: A Review. The International Jour- nal of the Addictions, 17(51. 749-791, 1982. 11. Kandel, D.B. Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. Washington, D.C.: Hemisphere (Halsted-Wiley) 1978b. 12. Smart, R.G., Fejer, D. "Drug Use Among Adolescents and their Parents: Clos ing the Gap in Mood Modification". J. Abnorm. Psychol., 79(2), 153 160, 1972. 13. Smart, R.G. The New Drinkers: Teenage Use and Abuse of Alcohol. Journai of Addictions, 23: -223, 1976. 23 TIMN 321414
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thc fact that cannabis use is always illicit whilst not all uses of alcohol are. It, is perhaps also an indication of the fact that cannabis in spite of a sometimes very convincing law enforcement has been absorbed in some western cultures and has found a niche in the modern lifestyle of a number of otherwise different groups. The similarities appear in the pattern of use among moderate users, that is about 90% of all users. Only little alcohol is consumed at work although this seems to vary from branch to branch. This means that the consumption takes place mainly in those parts of the day that people spend outside their place of employment. This simple fact is of very great importance when one observes alcohol problems and a possible means to cope with them. We often hear that the day is divided into two parts: Work f+ transport to and from work), and leisure time This is in fact a surprising statement when one thinks of all the many duties and activities the large majority of people undertake when at home lor in relation to home activities). The socalled leisure time is thus not a free or relaxed way of spending time It requires the same or more sense of respon- sibility to bring up children and adolescents, maintain, renew and develop a mar- riage or other nudear grouping, coping with material and economic reality, promoting the family's social and cultural life~ maintaining the house, living up to the stan- dard of the chosen lifestyle It requires a similar energetic undertaking to perfect hobbies, be it a sport, a collection, an amateur art of some sort, an interest in politics, in nature and or pollution. It requires substantial activity to serve ones religion or ideology. In other words it requires a healthy and active mind and a well controlled health to maintain the lifestyle that we reach for. I realize that in Europe this is perhaps too much modelled after a well-to-do middle class structure. But it is a fact that large groups of the working classes are adopting., as well as they can, the same model and its ideals. It is in this important part of our everyday life that the consumption of alcohol primarily takes place In Northern Europe alcohol is used for relaxation, as a social stimulant, and in a number of common ritual contexts. This use has become even more dominant over the last few decades. During these years the use of alcohol containing beverages has spread to larger groups-in some countries up to 95% of all the population 15 years of age and older. Women are said to drink more frequently and more openly. Some believe that women drink more which is more doubtful in Northem Europe. Youth is said to use alcohol outside the home showing a lower initial age. Youth certainly drink more openly. They consider themselves to be consumers in general. And they have more money to spend than earlier generations had. It is a general trend that alcohol use is positively correllated with income and degree of education. In Southern Europe, which differs from the Northern Regions in that they are wine producing and that wine Is considered to be an essential part of the diet and of the general and especially the agricultural economy, some slightly different pat terns are seen. We know very little about women as a separate group. Youth in Greece are reported not to show any important alcohol-related problems. In these areas it is most common to assess alcohol problems through the medical consequenses of alcohol consumption. In the Northern European countries a number of other types of alcohol-related problems are weighted as very important. These are related to the family., the work, the education situation. This is not evident in other parts of Europe although the tendency in Spain. Portugal and Italy as well as France is similarly directed. In all parts of Europe the alcohol-related problems are the targets of alcohol public policy. This also is mirrored in the practical educational programmes. One important draw-back is that it is generally found to be difficult to reach the parental groups. While it is easy enough to reach youth and establish school educa- tion on alcohol seen from several cultural, social, economic, public health, biomedical and basic biological and scientific points of view it has always been very difficult to hit the targets in the adult population. This, therefore, is one of the primary goals for modern research and opinion-making in recent years. _ ln the following part of this presentation we will tum to certain regions and ex- amine the approach of some selected European states in the planning and execu- tion of the alcohol-educational programmes against the damage done for potentially present with one or another probability( in alcohol consumption. First we will attempt some conceptual clarification. T'he aim of school education in all European countries is to create an atmosphere in the broad masses of the population in which some, be it few or many restric- tions against private, individual patterns of use may be controlled from the govern. ment or local authorities. In Finland such teaching idealizes total abstention and this negative attitude to alcohol use is dominant in Iceland, Norway and Sweden. Another norm that is promoted especially in these countries is the special restric- tions in force for youth up to what in other countries is considered a very high 32 age without guaranteeing a sufficiently high maturity of the personality. It Is thus farely well accepted in the Nordic European countries that teenagers may marry at 15-16 years of age. They may give birth to children and bring them up. One may vote to all political, democratic and parliamentarian institutions and participate in general referendum when 18. At that age one may obtain a drivers Iicence At 16 one may join the military services as a professional soldier. But In the same population it is considered possible to promote and maintain a norm considering consumption of alcoholic beverages especially unhealthy for persons under 20 years. Parents are impressed that they should not let their young ones take part In any consumption of alcohol at their own home before that age and the public propaganda and sobriety campaigns use terms such as "pushers" for parents greaking this norm! This kind of approach is not widespread in Europe. And it is very doubtful that is will be in the foreseeable future. Never-the-less, quite a number of groups all over Europe use methods and adhere to attitudes that are just as aggressive against the drinking pattern disregarding a number of traditionally accepted and utilized non-pathogenic and/or useful effects of moderate consumption. It must be expected that such a norm system must be supported by very aggressive educational programmes as well as a number of other preventive and availability- controlling endeavours may be felt by the individual. In all Nordic countries health promotion is very positively received. It is designed to place part of the respon• sibility for health and health maintenance on the individual. The community also bears a responsibility in accordance with the Nordic countries long tradition for a wellfare system on a high level of respect for human wellbeing, 'physically, men- tally and socially' as required in the constitution of WHO. This division of responsibility between the individual and her or his community leads to a development of a sense of responsibility in the ind!vidual. This Important part of personality development is in most countries in Europe considered to be the central or one central goal for health education and even more so in specific alcohol education. An example of the expression of this view can be found in the publication: Alcohol Policy in Sweden, 1982, where it is stated: "The aim of education on alcohol, other drugs and tobacco is to give the pupils requisite qualifications for their independent and responsible decision, both in principle and in concrete choice, regarding their own use : "With well-founded and detailed argumentation, school must simultaneously point out clearly the positive value of total abstinence from alcohol and tobacco first and foremost during the period of growth. Furthermore it must be pointed out that all use of drugs not prescribed by a doctor involves danger and is against the law. The pupils must be given a clear idea of the necessity, in society today, in several connections especially at work and in traffic, of totally avoiding the use of alcohol, whatever their alcohol habits otherwise may be : And later: "A personal attitude to questions connected with the use of alcohol, drugs and tobacco must be based on sound knowledge Therefore education must be founded on facts based on scientific data and given as comprehensive information as possible regarding the effects from physiological, psychological, social and economic points of view and regarding the risks of addiction and danger-signals':(I) This quotation is a fairly good representative for other Nordic countries although Finland when describing their school alcohol education as a temperance education according to Pirrko Nikander (2( equates the terms temperance and abstention. Denmark is perhaps an example of more continental European approach. Here again much stress is upon giving the pupils the necessary knowledge to enable them individually to make decisions. The aim is, however, not to educate pupils to abstinence even in their puberty or adolescense. This is considered unrealistic and not an attractive approach to adult problems relating to lifestyle. Since alcohol is so widely used and its use incorporated in so many cultural con nections and everyday situations it becomes necessary to approach alcohol-related problems in a very broad range of ways. In a Conversation with the British Journai of Addiction 131 the American sociologist Selden D. Bacon who has been actively involved with most of the development of alcohol-related concepts and scientific theory, remarks that no single science Is able to give a full picture of the concept that has had so many names of which one is Alcoholism. He also claims that while the disease concept was a very welcome development in the years after the second world war, where it replaced a moralistic approach it is far too narrow to cover to-days knowledge It requires a multidisciplinary endeavour (3). The synthesis of the data collected into a comprehensive concept useful for prediction of alcohol-related problems as part of a much broader field of problematics seems to be possible only if the data are brought within the corr text of the everyday life of the person having the problems and her or his com munity. This is taking the step of moving the holistic approach away from an intellectual polyhistoria somewhat scientific level and in the direction of the realistic situation in which the different elements of the alcohol-related problems are felt. The Danish approach is thus not based on the reduction of availability model TIMN 321423
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for womankind, and to hold men in high regard. They had many difficulties in establishing rewarding personal or sexual relationships-which related to their own lack of self-respect. Howeve>; they were spared some of the worst punishments of the overt incest victim. For example, it was not characteristic of them to feel obligated to submit to physical abuse or to attempt to destroy themselves. In their descriptions of family dynamics, striking similarities between covert and overt incest victims became apparent Generally, both groups came from traditional patriarchal families, where the physical and economic control of the family rested with the father. These fathers were usually respectable citizens in their communities. Sex roles were rigidly and traditionally defined in these families; conservative religious attitudes and sexual motality, including a rigorous double standard of sexual behavior; prevailed. The overtly incestuous family represents the pathological extreme of male dominance, while the covertly incestuous family exhibits a iesser; more commonplace variety of that characteristic In both types of families, daughters learn that fathers rule, that mothers submit, and that the ordinary female condition is contemptible One important difference between the covertly and overtly incestuous family is the power of the mother as an agent of child protection. Families in which mothers were rendered unusually powerless through battering, physical disability, mental illness, alcoholism, or the burden of repeated childbearing, appeared to be at par- ticularly high risk for the development of overt incesL However, families where a more equal balance of power was preserved, overt incest did not develop, despite the apparent sexual interest of the fathers in their daughters. Mothers who were able to function competently in their traditional roles, and who did not submit to abuse themselves, effectively protected their daughters from incest, even though they and their daughters were often bitterly estranged. Therefore, the most effec- tive barrier to overt incest appears to be the degree of social control exerted by the mother, not a father's impulse control. Although incest may in the early stages of discussion in the U.S., it is a phenomenon that occurs in all cultures. I would hypothesize that in any culture, the greater the degree of male supremacy and the more rigid the sexual division of laboi; the more f requent one might expect the taboo on father-daughter incest to be violated. Con- versely, the more egalitarian the culture, the more the child-rearing Is shared by men and women, the less one might expect to find overt incest between father and daughter. The same logic would apply to particular families within any one culture. My hypothesis cannot be confirmed or disproved by cross-cultural studies on the prevalence on incest, si nce no reliable data is available for comparison. However, this point of view has been validated through the study of incestuous families, where father-daughter incest appears to be only a single manifestation of paternal rule. As treatment providers, how do we use this information? We must be willing to acknowledge the possible existence of abuse within the families we see. We must be aware that our clients may be either survivors or perpetrators of abuse We can no longer be part of the denial system that permeates alcoholism and family violence Nor must we assume that the condition will be alleviated in sobriery. Perpetrators of violence often continue physical and sexual abuse after they have stopped drinking One of the issues in alcoholism treatment is the need for the client to deal with the past 1163. The alcoholic must come to accept his/her past precisely as is hap, pened. The recovering person must also accept the likelihood that past events may continue to affect his/her present life situation. Perpetrators of abuse need to ac cept responsibility for their behavior. Treatment programs in the U.S. that specialize in work with families in which sex ual abuse has occurred 117) agree on the following strategies: i. Report the situation to the criminal justice syuem; 2. Remove the father from the family; 3. Utilize parent self-help groups, i.e., Parents United, Families Re-United: Parents Anonymous. 4. Strengthen the mother-daughter relationship. What about the alcoholic woman who has been abused? These women need to be in treatment groups with other women where they can feel safe, and where they can share their experiences, their pain, and their secrets. This is a place where what a woman says is HER TRUTH because it is HER experience and HER reality. A woman's group is a place where the silence surrounding abuse can be broken, and where this issue can be dealt with in a sensitive manner. A session on violence can begin by asking if anyone knows a woman who has been raped, and discussing what the experience was like for her. Encourage the women to share what they do in adjusting their lives to protect themselves. Ex plore how women are portrayed in and used by the media, then progress into a discussion of how we have been used by others. i. e., our fathers, brothers, husbands, and lovers. A facilitator can move the group discussion f rom the least sensitive areas gradually into more intimate issues As women start sharing these experiences, they find the commonalities in their lives. Their sense of isolation and alienation can be broken. Through the process of sharing their experiences, the trust level builds between them. The area of trust and intimacy in relationships is a problem area for all alcoholics. The major love relationship in an alcoholic' s life is with the liquor bottle. Often the alcoholic has been using alcohol for years to modify her/his emotions. Therefore, feelings can be "strangers" to the newly recovering person. The issue of intimacy is more complex for the woman alcoholic My research shows that the abuse she has experienced is predominantly perpetrated by those close to her. Thus, she has learned not to trust. Her experience has been that those who are supposed to be caring, loving, and nurturing are often her abusets. Since her most violent sexual and ph ysical abuse was almost solely per petrated by men known to her, her heterosexual relationships are bound to be affected. It is crucial that the issue of abuse experienced by women be dealt with In alcoholism treatment If staff are not trained for this specialized area of counseling, then resources for referral must be developed. Alcoholic women are filled with guilt, shame, fear, denial, low self esteem, and isolation. These feelings are magnified in the physically, sexually, and emotionally abused woman. Women have special issues and unique experiences to deal with in their lives. Therefore, it is imperative that women be in alcoholism treatment groups with other women, where together they can learn to love, value, and trust themselves-and each other. This is a way to break through the barriers to recovery. The information in this article has dealt with the treatment of abuse in individual families. However, with all our efforts focused on individual pathology, we will not solve the causal problem rooted in our social structure. As long as societies continue to oppress women and fathers to dominate their families, such men will have the power to use and abuse their children. Therefore, prevention of abuse in the family will ultimately require a radical transformation of the family. Rule by the father will have to yield to the cooperative rule of both parents. Division of labor by sex will have to be altered so that fathers and mothers share equally in the care of their children. Men are also oppressed by this patriarchal system, which denies them a part of their emotionality. All of the qualities associated with mothering-tenderness, emo- tional responsiveness, and nurturing-are suppressed by most men. The result is the formulation of a male psychology where dominance is revered, and the capaci- ty for caretaking is atrophied. Our children need to grow up with a new and different image of mother and father. Copyright 1983 by Stephanie S. Covington-All rights Reserved REFERENCES i. National Council on Alcoholism. Facts on Alcoholism. New York: 1979. 2. Kempe, H., and Heifer, R. E. Helping the Battered Child and His Family. New York: Lippincott, 1972. 3 Speeker, Gisela. "Family Violence and Alcohol Abuse:' Paper presented at the 24th International Institute on Prevention and Treatment of Alcoholism, Zurich: 1978 4. Roy, Maria. Current Survey of 150 Cases. In: Roy, M. lEd.), Battered Women. New York: Van Nostrand Renhold, 1977 5. Carder, J. H. "Families in Trouble' Paper presented at the 24th International Institute on Prevention and Treatment of Alcoholism, Zurich: 1978 tz Herman, Judith. Father-Daughter Incest. Cambridge: Harvard University Press, 1981 7. Black, Claudia. It Will Never Happen to Me. Denver: M.A.C., 1981 8. Scott, P. 0. "Battered Wives:' British Journal of Psychiatry, 125: 433-441, 1974 9. Russell, Diana E. H. Rape in Marriage New York: Macmillan, 1983. 10. Finkelhor, David. Sexually Victimized Children. New York: Free Press, 1979. 1 1. National Abortion Rights Action League. 12. Child Sexual Abuse Task Force, San Jose, California -13. United States Civil Rights Commission, 1978 14. California Commission on the Status of Women, 1978 15. Los Angeles County Protocol for the Treatment of Rape and other Sexual Assault, 1981 iQ Wallace, I. "Critical Issues in Alcoholism Therapy:" In: Practical Approaches to Alcoholism Psychotherapy. New York: Plenum Press, 1978 17. Child Sexual Abuse Treatment Program, San Jose, California Child Protective Services, Tacoma, Washington. Child Sexual Abuse Project, Los Angeles County, California TIMN 321417
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crashes. Vermont has a law requiring tests of surviving drivers, while Delaware has an official policy to test surviving drivers. Only three States-Colorado, Nebraska, TABLE n.-Number of states where 80% (or more) of driver fatalities are tested and the BAC (s available from FARS Year No. States States 1975 6 CA, CO, DC, NH, NJ, Rl, 1976 5 CA, CO, NJ, OR, RI 1977 9 CA, CO, HA, NV, NH, NJ, OR, RI, W7 1978 8 CA, CO, DC, HA, HH, NJ, OR, RI, 1979 9 CA, CO, DE, DC, NH, NJ, OR, RI, WI 1980 13 CA, CO, DE, DC, HA, NH, NJ, NM, OR, RI, SD, VT, WI, 1981 13 CA, CO, DE, DC, HA, MD, NV, NH, NJ, OR, RI, VT, WA, WI, 1982 15 CA, CO, DE, DC, HA, MD, NV, NJ, NM, OR, Rl, UT, VT, WA, WI 1983 14 ' CA, CO, DE, DC, HA, IL, MD, NV, NJ, OR, RI, VT, WV, WI, and Utah-test and report BAC levels on more than half of the surviving drivers involved in fatal crashes. 11/ (See table IV.) Nationwide, BAC levels were determin- ed and reported on only 165 percent of the surviving drivers involved in fatal crashes. (See table V.) Table lII.-Testin8 of fatally in)ured drlvers 1975-19a3 (FARS) Year % Tested w/known Results % Tested w/tmknown Results 4a Not Tested Unknown If Tested 1975 39.9 9.8 37.7 13.7 1976 40.8 10.2 39.6 9.3 1977 43.2 11.5 33.5 11.8 1978 41.0 12.8 33.6 11.4 1979 44.9 12.6 33.6 9.0 1980 46.6 11.0 34.7 7.7 1981 48.6 10.6 35.1 5.5 1982 54.3 10.8 29.4 5.6 1983 56.7 10.5 28.0 4.7 Testing in Injury-Producing Crashes Epidemiological studies of injury-only accidents estimate that between 18 and 26 percent involve alcohol.12 In 1982 alone NHTSA estimated that approximately 708,000 persons were injured in alcohol-involved highway crashes. Clearly, reduc- tions in alcohol-involved injury-producing crashes also must be measured and demonstrated.13 Unfortunately, no State routinely measures alcohol involvement in injury-only crashes because existing State laws do not permit BAC testing of drivers involved in non-fatal injury-producing crashes unless they have been arrested for driving while under the influence (DWI). The only national statistics available on injury-producing crashes are those gathered in NHTSA's National Accident Sampling System (NASS). Since 1979 NHTSA has investigated and placed into the NASS computer files approximately 10000 accidents randomly selected from police reported accidents across the United States. The repor- ting of alcohol data in the NASS accident files is, however, even less complete than in the FARS system, because States test so few drivers involved in injury-only crashes. Table IV.--Numbers of states where 50% (or more) of surviving drivers (in fatal crashes) are tested and The BAC is available from FARS Year NO. States 1975 2 1976 4 1975 3 1978 2 1979 3 1980 4 1981 4 1982 5 1963 5 States CO, DE CO, DE, NE, UT CO, DE, NE, CO, DE DE, NE, VT DE, NE, UT, VT CO, DE, NE, VT DE, NE, SD, UT, VT CO, DE, NE, UT, VT Table V: -Testine of surviving drivers involved in fatal crashes (FARS) Year % Tested w/known Results % Tested w/utdmown Results % Not Tested Unknown If Tested 1975 9.9 3.6 73.0 13.5 1976 10.4 4.6 73.2 11.8 1977 10.8 4.8 68.6 15.8 1978 10.9 5.3 69.7 14.2 1979 12.0 5.6 70.6 11.8 1980 13.9 5.4 71.1 9.8 1981 14.6 4.5 73.9 7.0 1982 16.3 5.4 71.5 6.9 1983 ' 16.5 5.7 71.8 6.0 NOTE: Surviving drivers account for about 55 percent of all drivers In fatal accidents. 40 Estimating Alcohol Involvement in Crashes Because accurate and complete data on the presence of alcohol in all drivers in• volved in fatal and serious injury crashes have been largely unavailable, researchers as well as Federal, State, and local policy making officials have been forced to estimate the extent of alcohol involvement in all fatal crashes (and, in some cases, in all types of highway crashes) from the limited information available on fatally injured drivers. But, as noted above, most States do not even routinely collect BAC data on all drivers killed and must estimate the overall level of alcohol involvement in all drivers who die in highway crashes. Consequently, the national statistics published by NHTSA and others are, in fact, derived from a sample of 15 "good" states that have high BAC testing and reporting leveis.'* Extrapolating alcohol involvement from driver fatalities to other crash populations (i.e., all drivers in fatal crashes or injury crashes) can, however, introduce biases which can distort the true level of alcohol involvemenL13 In a recent analysis of the FARS system, Voas found that "there is no subset of FARS data which can truly be considered to be..randomly and completely collected... Drivers (in the 15 good States sample) are not a random sample of the fatally injured drivers from their States'16 Because more drivers who are involved in the types of fatal accidents known to have high alcohol-involvement (i.e., nighttime, single-vehicle, rural, and those involving drivers 15-35 years of age) tend to be tested for alcohol than those in other types of accidents (eg., daytime, multivehicle, or urban,), extrapolations not corrected for these differences tend to overestimate the number (and propor- tion) of alcohol-involved drivers." Voas also states that "perhaps the greatest potential for overestimating the number of alcohol-related fatalities is the extrapolation from results for fatalities to the results for survivors (of fatal clashes):" The principal reason for this bias, again, appears to be an oversampling of nighttime, rural, and single vehicle crashes. In his study of FARS data from the 15 "good" States, Voas found that 45 percent of the fatalities are from nighttime crashes, compared to 40 percent for survivors; 50 percent of TIMN 321431
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drinking or withdrawall was used to estimate the prevalence of alcohol dependence in the sample of current drinkers. This estimate was crosstabulated with the pro• portion of respondents who reported alcohol problems of at least moderate severity. The percentages of respondents with and without alcohol dependence and pro- blem drinking were based on the subsample of current drinkers. These percen- tages were adjusted by multiplying them by the percentages of drinkers in the total sample or subsample. This yielded percentages of persons with and without alcohol dependence and problem drinking within the total sample population. The percen• tages are weighted to the national household population. Results As shown in Table 1, 34 percent of the total sample are nondrinkers and 56 per- cent are nondependent, nonproblem drinkers. Of the remainde>; 6 percent are classified as alcohol dependent and an additional 4 percent are classified as nondepen- dent problem drinkets Overall, at least 10 percent of the total sample provide evidence of alcohol-related problems of at least moderate severity These rates are higher when the sample base includes only those respondents who reported drinking alcohol in the past year. Consistent with other research, higher proportions of men than women reported alcohol dependence and problem drinking. The ages of alcoholics in the clinical population normally range from 35 to 60, whereas those with serious drinking problems in the general population tend to be in their early 20s (4, 7). Table 1shows that the proportions of nondependent problem drinkers is highest among men and women aged 18-25 years. The propor- tions of alcohol dependent drinkers are highest among men aged 18-45 years and among women aged 18-25 and 36-55 years. The proportions of alcohol dependent drinkers, when compared to nondependent problem drinkers, are higher among men aged 26-45 years and among women aged 36-55 years. It is clear from Table 2 that both alcohol dependence and problem drinking are related to marital disruption for men. Alcohol dependence is higher among men who are divorced or separated. Nondependent problem drinking is higher among divorced and single men. Among women, both alcohol dependence and nondepen. dent problem drinking are higher among those who are divorced and not married. Traditionally alcohol problems tend to be more prevalent among persons in posi. tions of lower social status. Table 3 shows that, among men, lower household in- come is associated with higher rates of alcohol dependence while moderate to higher family income is related to higher rates of alcohol problems. There is no consistent relationship present for women. Consistent with the association with lower family income, alcohol dependence rates are higher among men in blue-collar occupa• tions while alcohol problem rates are higher in white-collar occupations. There is no consistent relationship present for women. Conclusions The prevalence rates reported in this study are more conservative than those nor- mally reported in the literature on alcohol problems. The chronicity of akohol pro- blems is a function of age (7). Among older males interrelationships criteria of drinking problems yield less "spontaneous remissions" over time 1141. The present analysis indicates that the inclusion of symptomatic behaviors weighted equally with more severe symptoms of dependency will yield higher prevalence estimations in the general population and over-estimation among younger adults. Polich and Orvis 14) have expressed concern that too broad a conception of drinking problems can misguide both treatment and other public policies. Continued effort in both the conceptualization of alcohol problems and in instrument development is clearly needed for informed guidance in alcohol policy. FOOTNOTE 'Presently, the Alcohol Research Group, Medical Research Institute of San Fran- cisca California. The sample design and field work were conducted by the Response Analysis Corporation of Princeton, New Jersey. REFERENCES 1. Cahalan, D., Cisin, I.H., and Crossley, H.M. American Drinking Practices. Monograph No. 6 New Brunswick, NJ.: Rutgers Center of Alcohol Studies, 1969. 2. Cahalan, U Problem Drinkers. San Francisco: Jossey-Bass, Inc., 1970 3. Cahalan, D. and Room, R. Problem Drinking among American Men. Monograph No. 7, New Brunswick, N.J.: Rutgers Center for Alcohol Studies, 1974. 4. Polich, J.M. and Orvis, B.R. Alcohol Problems: Patterns and Prevalence in the U.S. Air Force. Santa Monica, California: Rand, 1979. 5. Clark, W.B. and Midanik, L Alcohol use and alcohol problems among LISS adults: Results of the 1979 national survey. In: National Institute on Alcohol Abuse and Alcoholism. Alcohol Consumption and Related Problems Alcohol and Health, Monograph No. 1. Washington, D.C.: U.S. Government Printing Office, 1982, pp. 3-52. 6. Wilsnack, R.W., Wilsnack, S.C., and Klassen, A.D. Women's drinking and drink. ing problems: Patterns from a 1981 national survey. American Journal of Public Health, 74, 1231-1238, 1984. 7. Fillmore, K.M. and Midanik, L. Chronicity of drinking problems among men: A longitudinal study. Journal of Studies on Alcohol, 45, 22&236, 1984. 8. Parker, D.A., Kaelber, C., Harford, T.C., and Brody, J.A. Alcohol problems among employed men and women in metropolitan Detroit. Journal of Studies on Alcohol, 44, ]026-1039, 1983. 9. American Psychiatric Association Task Force on Nomencalture and Statistics. Diagnostic and statistical manual of mental disorder IDSM-Illl. Washington, D.C., 1980. 10. Edwards, G. and Gross, M.M. Alcohol dependence: provisional description of a clinical syndrome. British Medical Journal, l, 1058-1061, 1976. 11. Jellinik, EM. Phases of alcohol addiction. Quarterly Journal of Studies on Alcohol, 13, 673-684, 1952. 12. Clark, W.B. A very brief history of surveys on alcohol use and drinking pro- blems in general populations. In Social Research Group. Draft Report on the 1979 National Survey. Berkley, California, 1981. pp 143-166. 13. Room, R. Measurement and distribution of drinking patterns and problems in general populations. In: Edwards, G. et al. (Eds.). Alcohol-related Disabilities. Geneva: World Health Organization, 1977, pp. 61-87. 14. Roizen, R., Cahalan, D., and Shanks, P. "Spontaneous remission" among un• treated problem drinkers. In: Kandel, D.B., IEd.) Longitudinal Research on Drug Use: Empirical Findings and Methodological Issues. New York: John Wiley & Sons, lnc, 1978, pp. 197-221. .LLCB10. 9E.flOE1CE AID IROKE/l OIIKIK. ST SES A/D AGE, In MruntS N 1- @rlnLen ..a.qenemt MAra9ian ert~+sy_ .enc.vma.nt rrotls DrIMert flrYrntent 9rlMrrf Tuul 1772 34 56 .(Q6 6(S) M.n 362 26 60 6(U e (1l) ll- IUIB 40 SI 3(4) 4 (6) ) aK an 1F25 111 0 p 12 (13) 12 (13) 26-35 167 20 41 6 (i) n(16) 36-as 12S 29 se 3(S) lo (14) .S-SS 111 21 a 6(S) s(6) S6-/S 121 0 6/ 2(7) s(e) 6N ICl 4 S3 1(1) 2(t) r... 1i-2s 162 1s 67 a (10) 6(a) M-35 233 ]0 SS . (6) 3 (6) Y-1s 1)a 37 9 1(2) s(q f(-SS 110 45 so e(a) S(e) SS.SS Iu 65 44 1(2) o(o) 6N lfi ~ 36 a(ro) o(1) + nrcpb ue rillttN tfprn; ntals are abtt .rMr .r lns c.Hs 6 Nrcnis I. Mrealrsts are 4sN an res».MSts Ws 4M MrIM tRa S.ar TIMN 321421 30 p :
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r., 1 he 53.2 billion costs uf fetal alcohol syndrome tFASi iricluded treatment costs of 50.7 billion, special education and other services of 5t.7 billion, and lost and reduced productivity of $0.8 billion. 7. Violent and property crime are strongly related to alcohol abuse. Total social costs were $6.9 billion, including $2.3 billion for direct crime expenditures, 52.4 billion for homicide, 50.4 billion for lost productivity of crime victims, and $1.8 billion for lost productivity of incarcerated criminals. II. THE COSTS OF ALCOHOLISM TREATMENT The other side of the coin is the impact of alcoholism treatment on medical care utilization. The NIAAA has supported a number of studies in this area. I should like to highlight some of our recent findings. First let me note that a review of about a dozen studies on the impact of alcohol treatment on medical care utilization found evidence of a decline in medical care utilization following treatment for alcohol abuse in HMOs and employee-based alcoholism programs. These reductions ranged from 26 percent to 69 percent, with a median reduction of 40 percent. One study of alcoholism treatment in HMOs recently completed by Health Associa tion of America, and supported under contract by NIAAA, indicates that, in four study sites, providing alcoholism services reduced sick days, absenteeism from the workplace, and utilization of certain types of medical services by alcoholic clients and their families. In another recent study, this one of State employees in California, we examined 90 families with an alcoholic member, who were all enrolled in Blue Cross/Blue Shield. The families were followed for a period of five years, and the results show• ed that the total medical care costs per family member decreased substantially over time once the alcoholic family member entered treatment. At the end of the study, inpatient costs per person per month of both comparisons families and alcoholic families were similar. Outpatient costs of the alcoholic families were actually lower. In a cost-simulation study which we funded, we examined economic impact with relation to Insurance finance mechanisms, utilizing findings from a number of studies of alcoholism treatment This particular study estimated that the average annual reductions in total health care costs ranged from about $790 per person for fee-for- service plans to some $1,650 per person for pre-paid pians. Finally, a study of health insurance claims of the Aetna Federal Employees Health Benefit program enrollees, covering a four year period, found that alcoholism treat- ment can be cost effective. For this particular population studied, the data showed a gradual increase In health care utilization and cost for alcoholics during the three (3) years preceding alcoholism treatment with the most dramatic rise occurring in the 6 months prior to admission to alcoholism treatment. Following initiation of alcoholism treatment, general health care costs and utilization dropped significantly and reached pretreatment levels. The study estimated that the average alcoholism treatment (in this case, inpatient treatment) could be offset by reduced health care costs within 2 to 3 years following the initiation of treatment. I wish to spend a moment on this study and more closely examine the impact of alcoholism treatment on health care utilization and cosL One of our prime ques- tions was "Do alcoholics use less overall health care (thereby reducing costs) after they begin alcoholism treatment?" The trend is clear. Figure 1 plots average monthly total health care costs for con- tinuously enrolled alcoholic individuals (See footnote I on sample selection aiteria). In general, from 36 months to 12 months before alcoholics began treatment, there was a gradual but modest rise in their monthly total health care cost. During the final months before alcoholism treatment began, however, health care costs rose faster. The average alcoholic had health care costs of $167 per month over the period from 36 months to 6 months prior to treatment In the six month period immediately before alcoholics began treatment, however, their overall health care costs averag ed $452 per month. In the final month, costs rose to an average of S1,370 per person. Let me comment at this point that the high costs we are seeing here are due, in part, to the fact that the Aetna plan Is almost solely an inpatient plan. This does not effect the trends I wish to show you, only the amounts involved and the length of time after treatment before the initial, high pretreatment costs can be recovered. To continue, based on this data, we infer that, within the six months prior to the start of alcoholism treatment, emotional and physical problems of alcoholics escalate Alcoholics manifest their worsening problems by using more health care services. _ It is clear from the data that after alcoholics start alcoholism treatment, their health care costs drop fairly rapidly for at least 12 months, as we can see in this Figure 1. The pattern of overall health care costs was similar for males and females. While females had slightly higher health care costs before treatment and in the first year following the start of treatment, costs for both groups were roughly comparable after this point. However, we also learned that alcoholics of different ages showed distinct health Average Monthly Total Health Care Costs for Treoted Alcoholics by Month Pre ond Post tnitial Alcoholism Treatmer,t iw i +0 -30 -20 -18 B ,9 2C DC . WMER OF VnM IEVOKE'a*SR ntE1TKr- rs.: r~ns aw.u,. v..u~.c rl.fa W M...ae1W.~. care cost patterns. Thus we found a clear association between age and the extent of the drop in health care costs following the start of alcoholism treatment. We examined three age groupings, under 45 years old, 45 to 64, and 65 and older. Alcoholics in each age group followed the general pattern of the total group. By 36 months after the start of alcoholism treatment, the health care costs of the youngest age group had dropped to levels comparable to those experienced 36 months prior to treatment. The health care costs of the two older age groups also dropped significantly following the start of alcoholism treatment. However, the costs did not reach levels as low as those existing several years prior to treatment. This finding is understandable for two reasons. First the health care costs of persons who are past middle-age-and particularly those over 60-increase substantially as they become older. Second, older alcoholics have been drinking for many more years and thus have developed more serious physical health problems than younger alcoholics. It is more difficult for alcoholism treatment to reverse the effects of this long-term chronic drinking. Conclusion What we can conclude is that, in the aggregate, these studies offer increasingly persuasive evidence that (II alcoholics and their families use more health care serv vices than nonalcoholics, (2) this elevated demand is reduced substantially follow- ing treatment for alcoholism, and (3) the benefits of alcoholism treatment outweigh its cosds. DIAGNOSIS AND HOSPITAL CARE FOR SUBSTANCE ABUSE There are a number of ways of assessing costs related to treatment. I should like to briefly summarize a number of interesting findings based on our examinations of hospital discharges, lengths of stay, and specific diagnoses of substance abuse and alcohol abuse in the United States. I shall highlight these from five perspectives: A. Days of Hospital Care for Substance Abuse B. Hospital Discharges for Substance Abuse C. Comorbidity and Length of Stay for Alcohol Abuse When Alcohol is Primary Diagnosis D. Comorbidity and Length of Stay for Primary Diagnoses other than Alcohol Abuse; and E. Inpatient Length of Stay for Substance Abuse To begin, lets look at: TIMN 321435 >i ~ i T 44
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r TABLE 2 TABLE 3 DP1qGRAPHIC DATA COHCERNING PATISIIIS TREATED THROUGH ALCOHOLIC REHABILITATION CLINICS T1iE SIX ALCOHOLIC REHABILITATION CLINICS (ARC) 12 HONTH FOLL04-UP 1980-1983 1980-1983 1980 1981 1982 1983 CATECORYe 1980 1981 19®2 1983 JU 1 46.2% 56.3% 51.72 51.4% Range 17-52 17-54 17-55 18-52 Average 29.5 29.9 28.1 28.2 18.12 17.2% 14.5% 13.1% 17-25 41.0% 1.4.6% 49.2% 49.9% 3 15.3% 7.5% 11.7Z 12.4% Over 25 59.0% 55.4% 50.8% 51.1% e f Total 1-3 79.62 81.0% 77.9Z 76.9Z SeX Hale 97.0% 96.9Z 95.3% 04.92 4 10.1% 6.92 9.5% 9.92 Fesule 3.0% 3.12 4.7% 5.12 5 10.32 12.1% 12.52 13.LR Marital Status Total 4-5 20_4Z 19_0Z 22_02 23_-0Z Married 54.7Z 48.8Z 40.5% 42.9% single 40.62 41.4% 49.22 49.5% a CATEGORY Sep or Div 4.7Z 9.8% 10.3Z 7.6% Rank Officers 2.2% 2.9Z 3.32 3.3Z 1 - Total Abstinence 2 - One or Two Slips but Currently Abstinent 3 - Returned to Drinking but Without Problems W-Ctp 5.02 6.51 6.8% 4.5% as Defined in CFAO 19.31 Sgt 17.2% 13.LZ 11.3% 13.1Z 4- Returned to Drinking with Continued Problems MCp1 15.7Z 16.3% 14.8Z 13.3% 5- Released for Alcohol Related Problems Cp1 26.22 27.2% 24.31 23.0% Pte 33.2% 33.2Z 40.0% 40.6% •e Categories I to 3 are considered successful outcome. Civ 0.52 0.5Z t.3Z 2.7% L'ALCOOLIQUE TEL QU'IL EST PERIqU DANS UNE POPULATION DE BILAN DE SANTE A. D'Hou[aud and D. Barrucand Dans le cadre d'une recherche plus vaste"` sur "I'alcoolique tel qu'il est perv. qu'ii se per4oit, qu'il se croit per~u. il a ete procede b une demarche aupr'es de deux populations de bilan de sante, l'une a Lille, I'autre a Nancy. Lexploitation de l'ensemble des 2 800 documents recueillis netant pas achevee, nous nous sommes interesses aux 407 premiers questionnaires codifies de Nancy pour nous faire une idee sur les grandes orientations a attendre de lensemble Nous proposons d'envisager successivement: • qui est I'alcoolique? • son environnement social, • les attitudes des rESpondants a son dgard, • I'etiologie personnelle et sociale de son alcoolismeI • comment il peut s'en sortir. • une recapitulation des resultats et des orientations. A. Qui est L'Alcoolique? 1. Calcoolique en g6neral Une t de rEponses OUI NON N.A. CNOIX pesaonne alcoo par` l nhaque E14men de 1'Elenent le plua bosc crop 62,2 1/,7 23,1 13.3 troit plus que ee qu'elle peut supporter 52,6 22.1 25.3 7,9 est trts sovvent7vre -" af.9 ~2;,3 2l,e 4,f est d6pandante de 1'aleool ' pe ~ ut s'eapFcher de ge,0 2,7 11,3 e4,4 / ~ie M. A. 9,5 7nta1 100,0 40 TIMN 321440
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in nursing: The professiori s response to the problem. ANA Division on Psychiatric and Mental Health Nursing Practice, Task Force on Addictions and Psychological Dysfunction. 2. Bissell, L & Haberman, P. (1984). Alcoholism in the professions. New York: Ox. ford University Press. 3. Bissell, L & Jones, R(1981). The alcoholic nurse. Nursing outlook 29, 96-101. 4. Cole, E.R. (1985). Mini on the scene: State nurses' associations and the impaired nurse. Nursing Administration Quarterly, Spring, 27-43. 5. Dilday, R.C. (1983). 1983 update: Georgia Nurses' Association impaired nurse program. Georgia Nursing, 42 (2), 6. 6. Ensor, B.E., Dilday, R.C., Marakal, B.M., Heins, M., & Bowman, R.A.11982)• What the SNA's are doing in Maryland, Georgia, Ohio and Tennessee. American Journal of Nursing, 82, 581-84. 7. Fitzgerald, K.W. (1983). laving with Jellinek's disease. Newsweek October 17, 1983, 22. 8. Gerace, LM. (19851. The stress process in nurse educators: A study of variables associated with role strain and psychological dysfunction. Unpublished doctoral disser• tation proposal, University of Illinois at Chicago, College of Education. 9. Green, P. 119831. Chemical dependency in the nursing profession. l he Kansas Nurse, 27, 17-18. ] 0. Haack, M.11985)• Antecedents of the impaired nurse: Burnout, depression and substance use among student nurses. Unpublished doctoral dissertation, University of Illinois at Chicago, College of Nursing. 11. Isler, C. (1978). The alcoholic nurse: What we try to deny. RN, 41, 48•55. 12. Jefferson, LV. & Ensor, B.E. (1982). Help for the helper. Confronting a chemically impaired colleague. American Journal of Nursing, 82, 574-577. 13. O,Connor, P. & Robinson, R.S. (1985). Managing impaired nurses. Nursing Ad. ministrative Quarterly. (Winter Issue), 1-9. 14. Rawls, J. (1971). A theory of justice. Cambridge, Massachusetts: Harvard University Press. COOPERATIVE POLICY FOR THE IMPAIRED NURSE Colleague or employer identifies-impaired nurse Nurse is reported to professional organization ~ Trained volunteers (peer professionals) Counsel impairedI nurse into treatment Nurse refuses to cooperate or seek treatment; Nurse is reported to state board Formal investigation takes place ~ ~ Formal hearing Agreed upon probation, takes place for "consent agreement• discipline of takes place and the license nurse seeks treatment License is Reports from employer and revoked treatment agency are made t~ the state board Follow-up monitoring takes place '1, Case report on file Figure 1 ~ Nurse seeks treatment, suspends practice as agreed upon in informal written contract I Nurse meets treatment and practice contract; com- munication maintained be- tween employer, profes- sional organization, treatment~agency and nurse Follow-up monitoring is agreed uppn Case remam li•ns private TIMN 321446 55
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in 18 states. There were 1800 mailed; the response rate is 30%. Data consisted of questionnaire responses received from recovering chemically depen- dent nurses and a sample of nurses not identified as impaired in the participating states. The two groups were compared for differences associated with the variables under study: education; employment; family history; medical history; and, alcohol and drug related behaviors. The two groups were compared via chi-square analysis and descriptive measures utilized appropriately. Level of significance for all findings reported is less than .001 unless otherwise specified. Results The sample consisted of 661 RNs; 139 are recovering chemically dependent nurses; 522 are not identifed as chemically dependent in the sample selection. However, out of 522 who responded to the survey, 384 answered "no" to all of the five alcoholism screening questions; 92 answered "yes" to one or more questions; and 46 did not respond to the screening questions. Only non-chemically dependent nurse subjects with negative responses to the screening questions were included in the study. The adjusted sample sizes are: 139 recovering chemically dependent nurses and 384 non-chemically dependent nurses. Comparison of the chemically dependent nurse and non-chemically dependent nurse revealed no significant differences in ages with both groups ranging in age from 21 to over 50. Significant differences between the groups were found in regard to gender with males accounting for 12% of the chemically dependent nurse sam- ple but only 2% of the non-chemically dependent nurse sample beirtg male. Family History Family histories of the two groups were compared. There were no differences found when comparing sibling tank. Approximately 70% of both groups are first or se- cond born children. The subjects were asked if family circumstances were such that they may have assumed parental roles during their childhood. In the chemically dependent nurse sample, 48% indicated that they had acted in parental roles while only 22% of the non-chemically dependent nurses responded affirmatively. Significant differences were found when comparing alcoholism and drinking behaviors in the families of subjects. The chemically dependent nurse more often reported a family member is akoholiG that one or both parents died from alcoholism or drug addiction; and, that heavy drinking was commonplace in the home. In the chemically dependent nurse sample, 62% reported an alcoholic family member while only 28% of the non-chemically dependent nurse sample reported family akoholism The two groups were compared for the incidence in each family member (father, mother, sibling, grandparent, spouse, child, other relative)• In each case, the chemically dependent nurses more often had an alcoholic relative. More of the chemically dependent nurses 116%) reported that one or both parents died from aicoholism; 2% of the non-chemically dependent nurses reported paren- tal death due to alcoholism. Drug addiction accounted for the death of 5% of the chemically dependent nurse samples parents but none of the non-chemically depen- dent nurse samples parents died from drug abuse. Heavy drinking in the home was reported by 32% of the chemically dependent nurses but by only 10% of the non-chemically dependent nurses. More of the non-chemically dependent nurses 129%) reported no drinking in the parental home than the chemically dependent nurses (14%). The subjects were compared on family history of depression. More chemically depen. dent nurses (55%) than non-chemically dependent nurses (36%) reported depres- sion in one or more family members. Again, individual family members were compared and differences were significant for every relative. Education The educational histories of subjects were compared and no significant differences were found. Approximately equal numbers of both groups received their basic nursing education in similar programs (diploma, associate degree and baccalaureate). The length of time since completing basic education in nursing ranged from one to more than twenty and no significant difference between the groups was found. Also, no differences were found when comparing the highest degrees earned; 43% of both groups had earned a baccalaureate or higher degree and 1% of both groups had doctorates. Academic achievement was compared and, again, no significant differences found. Approximately 80% of each group reports an average grade of "B" or better 13.0 to 4.0 grade point average on a 4.0 scale) in basic nursing programs and 74% report a similar academic record in all higher education, including advanced degrees. Class rankings in subjects' basic nursing programs were compared with no significant differences found. Approximately 64% of each group reported graduating in the upper fourth of his/her nursing school class and over half of each group has receiv- ed academic honors or awards. Sexuality Subjects were asked to report problems related to sexuality or sexual function and 17 differences found between the groups were significant. -i he majority 154%i of the chemically dependent nurses reported sexual difficulties while 21% of the non• chemically dependent nurses stated that sexual problems had occurred in their lives. Subjects were asked to identify the nature of the sexual problem. There was a signifi- cant difference in the number of chemically dependent nurses reporting Incest, sexual molestation, out-of-wedlock pregnancy, miscarriage, abortion, illness or surgery affecting body image and problems with sexual dysfunction. A significantly higher number of chemically dependent nurses (13%) reported homosexual preference than the non-chemically dependent nurses 12%). Current Life Situation Most nurses (approximately 50% in both groups) have been employed in nursing for more than 10 years but fewer of the chemically dependent nurses (71%) are employed in nursing at the present time than the non-chemically dependent nurses (87%)• Although this difference is statistically significant, it Is not surprising since the chemically dependent nurses were accessed through peer assistance programs where they had been referred for help with recovery. Since chemically dependent nurses may lose their nursing licenses, it would be expected that some would no longer be employed as registered nurses. Subjects' current family histories were compared. Significant differences were found in their marital status, more non-chemically dependent nurses currently are mar- ried (78%) than the chemically dependent nurses 148%I• The non-chemically depen- dent nurses have been married longer than the chemically dependent nurses; 49% of the non-chemically dependent nurses have been married ten years or longer, while 14% of the chemically dependent nurses report a decade or more of mar- riage. Additionally, 50% of the chemically dependent nurses have been divorced while only 21% of the non-chemically dependent nurses report a previous divorce. Of those subjects who are married, more chemically dependent nurses (20%) have alcoholic spouses than the non-chemically dependent nurses (7%). However, more alcoholic spouses of the chemically dependent nurses 116%I are recovering from the disease than spouses of the non-chemically dependent nurses (3%). As expected with more marital stability in the non-chemically dependent nurses, they report parenthood more often than the chemically dependent nurses; 76% of the non-chemically dependent nurses have children while 49% of the chemical• ly dependent nurses da The non-chemically dependent nurses also have more children; 30% have three or more while only 17% of the chemically dependent nurses have a family of that size. Fewer (28%) of the chemically dependent nurses' children live with them than the non-chemically dependent nurses (56%), however. A description of recent health problems was requested. More chemically depen- dent nurses (65%) were hospitalized in the past five years for medical problems related to physical health than the non-chemically dependent nurses (52%). The level of probability of this difference was less than .02. Excluding visits related to hospitalization and routine examinations, more chemically dependent nurses (59%) have seen a physician in the past five years than the non-chemically dependent nurses (47%) and again, the level of probability of this difference is less than .02. The chemically dependent nurses also report a significantly higher incidence of depression; 64% say they have suffered from or been treated for depression while only 16% of the non-chemically dependent nurses report depressive illness. Discussion The results of this survey represent a beginning attempt to identify characteristics of recovering chemically dependent nurses that differentiate them from their non- chemically dependent colleagues. The first quite interesting finding was that 18% of the group presumed to be non-chemically dependent responded positively to questions that could indicate a present or potential problem with alcohol or drug dependency and an additional 8% did not respond to the questions which may or may not indicate a problem with dependency. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) estimates that 10% of the general population are alcoholic and the National Institute on Drug Abuse INIDAI suggests that I to 2% are drug addicted. The NIAAA (1978b1 further suggests that women have a lower incidence (l to 5%) of alcoholism than men 15 to 10%) and since women con• stitute 97% of the nursing population, the possible incidence in this sample of nurses seems inordinately high. However, the screening questionnaire is designed only to identify possible problems with alcohol and, in this modified questionnaire, drugs as well (Ewing, 1984). Talbott (1983) suggests that the incidence of chemical dependency in the general population of nurses is one in seven but such an estimation is still less than the surveY results reported here. Another obviously significant finding is the incidence of males in the population of recovering chemically dependent nurses. In other descriptive studies of chemically dependent nurses, males in the sample also were over represented IBush, 1983; Talmadge, 1982). The results of this work confirm that there are more males in the population of recovering chemically dependent nurses than the incidence of males in the nursing population would suggest. The effect of the higher incidence of male alcoholics in the general population may be applicable here. TIMN 321408
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ALCOHOLISM: THE COSTS OF THE PROBLEM AND ITS TREATMENT Robert Niven, M.D I. THE COSTS OF ALCOHOUSM Alcoholism is a treatable disease. Left untreated, the costs of alcoholism can become staggering The combined cost to the U.SS economy of alcohol, drug abuse and mental illness disorders was 190.7 billion in 1980 according to findings from a new study we supported. The 1980 costs of alcohol abuse and alcoholism alone account for almost half that total amount, namely, 895 billion; the costs of drug abuse approach 46.9 billion. It is projected that the 1983 costs of alcohol abuse and alcoholism have risen to 116.7 billion. Table 1. Estimated and Projected Costs of Alcohol Abuse and Alcoholism 1980-1983 (S in billions) Cost Estimated Costs Proj.ct.d costs category 1980 1981 1982 1983 Oir.ct costs Treatment and Support 105 Support (1.0) Treatment (9.5) Crime 2.3 Pubtic (21) Private (03) Property Ioss/Damage ('1 Motor vehicle crashes 2.2 $18.0 $20.3 s22.3 523.9 Social welfare programs 12.1 13.6 149 2.5 2.6 26 2 4 2.6 2 7 Other 2 9 3.2 3 5 3,7 tndlr.ct costs $71.6 579.7 $37.1 s92.a MorbWd+ty 54 7 60.9 666 709 Reduced produciroity (506) (564) (616) (656) (in worktorce and household) Lost employment (4 1) (46) (50) (53) (in longterm treatment) Mortality 14 5 15.8 17 1 182 Incarceration 1.8 2.2 2 7 3 0 Motor vehicie crashes 0.5 0.5 0.6 - 0 6 Victims o( crime 0.2 0.2 0.2 02 Total 589.5 5100.0 S1o9.1 5116.7 Glossary to Table Crime-Government and private costs for police protection, legal services, adjudica. tion, correction and property destruction. Direct costs Real expenditures on goods and services to fight the consequences of alcohol abuse lncarceration•Inst employment and household productivity of offenders jailed because of alcohol use. Indirect costs-Losses from employment and/or household productivity due to alcohol abuse. Morbidiry•Reduced productivity on the job, lost employment, impaired productivi ty in the household, and disability. Mortality-)nsses due to premature death, including the value of employment and household productivity. Motor vehicle crashes (direct cos(s)•Property damage, and police and court costs due to alcohol-related accidents. Motor vehicle crashes lindirect costsfl'ime lost from employment and household productivity due to alcohol-related crashes. Other-Special education, fire losses, and highway safety expenditures. Social welfare-Fxpenses of disbursing social welfare benefits to persons disabled because of alcohol abuse. Support•Health support services including prevention, education, research and pro fessional training. Treatment-Health services for detoxification, rehabilitation and treatment for alcohol related illnesses and injuries. Victims of crime-Inst employment and household productivity of victims of alcohol related crime. Totals due not add due to rounding. •less than fifty million dollars li.e., less than $00.051: '" means the data were not reported. Source: Tables 1-1, G3, G•4, and G-5 in F.conomic Costs to Society of Alcohol and Drug Abuse and Mental Illness: 1980 by Henrick J. Harwood, Diane M. Napolitano, Patricia L Kristiarlsen, and James J. Collins, Research Triangle Park: Research ')Fiangle Institute, 1984. PHS Contract Na ADM 283-83-002 Components of Treatment and Support, Crime, and Morbidity are indicated in paren• theses Alcohol and Work Force Productivity Alcohol abuse affects productivity among the general population far more than we had previously recognized. According to our latest study, problem drinkers are 21 per cent less productive when compared to otherwise similar persons. This amounts to 49.8 billion in reduced productivity. Although the costs, such as these, are rising, the overall prevalence rate of alcohol abuse and alcoholism has remained stable over the last five years, amounting to about 10 per cent of the workforce. Alcohol and Fetal Alcohol Syndrome Fetal alcohol syndrome (FAS) is a set of serious birth defects including mental im• pairment that researchers have linked to maternal drinking during pregnancy. Some believe that the incidence rate of FAS ranges as high as I in 600; however even we we make the very conservative estimate of I in 1000 for FAS, this amounts to 3600 such neonates born in 1980, which account for 14.8 million in health treatment costs. More dramatically, of the 68,000 FAS children under age 18, the total treatment costs amounted to 670 million in 1980. If we add to this the 160,000 FAS adults requiring treatment, with their costs approaching 760 million, one can readily see that FAS costs have surpassed the 1.5 billion dollar mark. Realize this is a conservative estimate on two counts: (1) it assumes a very conservative rate of 1 in 1000, and (2) it does not include costs related to the mental impairment, reduced productivity, or potential institutionalization for some cases throughout their lives. Rough estimates of the potential indirect productivity losses from fetal alcohol syndrome are 510.5 million in the adult population. Conclusion: I wish to stress that the increases in costs should not be interpreted as resulting from growth in incidence, or prevalence, or severity of the disorders. Part of the rise is due to inflation, part is due to enhanced methodologies in estimating the extent of the costs, and I suspect part is due to the increased awareness that af flicted persons should seek out help. let me briefly highlight some of the finding,s: ). l:osses of potential productivity lindirect cousl due to alcohol abuse and alcoholism were equal to approximately 2.7 percent of the S2,632 billion Gross National Products IGNPI in 1980 2. Real goods and services Idirect costsl used to fight alcohol abuse were about 0.07 percent of the GNP in 1980. 3- 'I'he largest single economic consequence (S50.6 billion in 19801 was redured productivity in the workforce and household. 4. About 10 percent of our Nation's workforce Is impaired by alcohol abuse ac• counting for a cost equal to 1.9 percent of the annual GNP in 1980. 5. There were 69,000 premature deaths in 1980 due to alcohol abuse accounting for costs totaling 14.5 billion. 43 TIMN 321434
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Days of Hospital Care for Substance Abuse 11.5 Million Days of. Hospital Care for Substance Abuse* (National estimate, 1983) Primary diagnosis 54% • Total estimated days of care: 282.9 million Source; RTI (NHDS 1983) Hospital Discharges for Substance Abuse Secondary diagnosis 46% Fig. 2 1:1 Million Hospital Discharges With Diagnosis of Substance Abuse* (National estubate, 1983) PPrimary diagnosis 50% • Total estimated hospital discharges=42.6t$1111ion Source: RTI (NH :S 1983) Comorbidity and Length of Stay for Alcohol Abuse Fig. 3 Comorbidity and Lengtii of Stay in Discharges With Primary Diagnosis of Alcohol Abuse* ( M = 479,000) Comc,rb,dity 72 . • Alcohol :CD LOS. An::tmctic mean length of stay No comorbidity 28% I his graph depicts comorbidity and length-ofstay in discharges with primary diagnosis of alcohol abuse. Among substance abusers in treatment for alcohol abuse, 72 per• cent had at least one diagnosis in addition to a first listed diagnosis of alcohol abuse or alcoholism. Alcohol abusers with multiple diagnoses received treatment an average of 10.9 days, 2.2 days longer than alcohol abusers with no additional diagnoses reported. I wish to point out that it is essential to bear in mind that multiple diagnoses repre sent health conditions detected and recorded on medical records during the cur• rent treatment episode. They do not necessarily represent all comorbidities present at the time. Some conditions may have gone undetected; other may have been detected but unrecorded. The NHDS data therefore may represent conservative estimates of the extent of alcohol•related comorbidities among clients in hospitals in the 1983 NHDS. The converse of Figure 4 is to examine comorbidity and length of stay when the primary diagnosis is other than alcohol abuse. We asked the question: "For a par• ticular primary diagnosis, do patients with alcohol abuse as a secondary diagnosis have the same, longer; or shorter lengths of stay in treatment7" In Table 2, preliminary findings indicated that patients with substance abuse secondary to other disorders had hospital stays of 9.4 days. Patients with no substance abuse recorded on their discharges stayed 65 days. Where substance abuse was secondary to a primary diagnosis of mental illness, the length of stay was 14.9 days; and where it was secon dary to other disorders, it was &2 days. The important finding of Table 2 is in the second column of data. That column indicates whether patients with an alcohol abuse comorbidity had longer or shorter lengths of stay than other patients. For those illnesses where the ratio Is greater than 1.0, patients with a secondary alcohol abuse disorder stayed in the hospital on average longer than other patients. Where the ratio Is less than 1.0, patients with a secondary alcohol abuse problem on average stayed in the hospital for a shorter length of stay than other patients. For example, the ratio for malignant neoplasm of trachea, bronchus and lung (ICD•9-CM-1621 is 1.42. Patients with this primary disorder having a secondary diagnosis of alcohol abuse on average had a greater length of stay than patients without alcohol abuse indicated. The ratio indicates that these patients with a secondary alcohol abuse problem stayed 42 percent longer than patients without alcohol abuse comorbidity. Similarly, for persons with a primary diagnosis of diabetes mellitus IICD 250), patients with an alcohol abuse diagnosis had a length of stay which was 6 percent longer than that of patients without an alcohol abuse comorbidity. For 20 of the 31 disorders listed, patients with a secondary alcohol abuse problem had a greater length of stay than other patients. For the other 11 disorders, patients with a secondary alcohol abuse disorder had a shorter length of stay than other patients. The greatest increases in length of stay were seen for poisoning by unspecified dnlgs (109 percent increase); angina pectoris, fracture of tibia and fibula, and malignant neoplasm of trachea, bronchus and lung. However, for some illnesses, presence of an alcohol abuse comorbidity was related to significantly shorter length of stay. The shortest were for intracranial injury la 70 percent decrease/; poisoning by psychotropic agents, la 48 percent reduction), and duodenal ulcer la 42 percent reduction). It is noteworthy that for various liver diseases (ICD 571 and ICD 5721, presence of an alcohol abuse comorbidity was correlated with a reduced length of stay: I I percent and 31 percent reductions, respectively. Conclusion: While it has been previously demonstrated that persons with primary or secon. dary substance abuse problems on average have greater lengths of stay in short• term hospitals than other patients, it appears that it does not always lead to greater length of stay. For a significant number of disorders, it has been found that length of stay for substance abuse is somewhat shorter than the average. We will need to conduct more detailed studies to determine how or why alcohol abuse comor bidities affect length of stay for other disorders. Inpatient Length of Stay for Substance Abuse Se..rcc. R- ,r:riDS1983) F•tg• 4 ~ TIMN 321436 45
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tests until 1981 Before that, the absence of such a law was to be considered a major barrier to complete reporting. State officials in Arkansas now expect that their reporting level will improve dramatically. The lack of a State law, however, does not appear to be a barrier to complete reporting in all jurisdictions. The District of Columbia and Maryland, for example, do not have specific statutes requiring chemical tests in fatal crashes (as in Uniform Vehicle Code Section 10-116I, but nevertheless attain high reporting levels through the broad authority and the com- mitted efforts of their medical examiners to investigate violent deaths. In some States with coroners rather than medical examiners, the medical/forensic expertise is not present at the local level to organize and manage a permanent system to obtain and analyze blood samples. Moreover, since coroners are frequently lay people leg., undertakersl, they have other obligations and are not always con. cerned with gathering such accident data. In Ohio, for example, there are 88 in- dependent, elected coroners, one in each county. Obtaining the ongoing cooperation of so many local officials has proved difficult to the detriment of the alcohol testing program. During the course of this inquiry, I have noted that some police and medical per- sonnel acknowledged a reluctance to test and report blood alcohol information. Some police, for example, said they are reluctant to request a test for fear of causing embarrassment to families. More commonly, however, police are so occupied with other duties, such as securing the crash scene and helping the injured, that they do not make the effort to go to a hospital or obtain a blood sample in some other way. As cited in a Safety Board study on repeat offender drunk drivers," physi- cians and hospital personnel are often reluctant to perform blood alcohol analyses or to release results for fear of involvement in lengthy litigation: Finally, some States and localities simply lack the resources (or have assigned higher priorities to other needsl to establish a complete alcohol involvement reporting system. I believe that Federal efforts to improve alcohol reporting by the States warrant increased emphasis. The principal resources available in this regard are the highway safety funds allocated to the States to collect fatal accident data (funds commonly used to hire State FARS analyst personnel) and NHTSA headquarters and regional staff. The primary responsibility for providing technical assistance to and supervi sion of State data collection is assigned to 10 NHTSA regional staff members who are designated as regional FARS contract technical managers (regional CTMsI. Because of the limited staffing of NHTSA regional offices, the regional CTMs (as well as the other regional staffl are responsible for other highway safety programs in addition to the individual State FARS systems in their regions. Consequently, the regional staff is severely limited in the time available to work for :mproved alcohol reporting in each of their States. Conclusion With the current high level of public and official interest in the problem of drunk driving and the considerable amount of local, State, and Federal funds being ex pended to counter it, there is a critical need to determine whether programs are, in fact, reducing alcohol-related deaths and injuries. Legislators, elected officials, and program administrators at all levels of government do not wish and cannot afford to make policy and program decisions based on incomplete or misleading informa tion. Based on the evidence I have examined, however, it appears that in many States the very information required to make these decisions is incomplete and may be potentially misleading FOOTNOTES ' Editorial, The Quarterly Joumal of Inebriety 26: 308-309, 1904. 2 Miles. W. R., Alcohol and Motor Vehicle Drivers, Proceedings, 13th Annual Meeting of Highway Research Board Washington, D.C., Dec 7-8, 1933. ' Secretary of Transportation, 1968 Alcohol and Highway Safety Report. lHereinafter referred to as "I968 Report"1 " Federal highway safety grant funding lat a FY 1985 level of S126.5 millionl is allocated each year ro the States to supplement state highway safety of resources- Accordingly. States develop annual "Highway Safety Plans' (HSPI to allocate this funding which are supposed to reflect the relative need for programs in ffte various highway safety program areas (i.e., alcohol, seat belts, emergency medical service, police traffic services, pedestrian safety, etc.l. Determinations of program "need" are supposed to be based upon an empirical "Problem Identification" process that, for example, indicates the level of alcohol involvement in the States highway crashes and the impact of the alcohol countermeasure programs in reducing these crash leveis Because, historically, countermeasure programs have only achieved small reduc- tions in alcohol-related crash levels, there is a concomitant need for highly accurate and precise data which can allow measurement of small changes in crash levels. 5 Program Standard 4.4.8, "Alcohol in Relation to Highway Safety" authorized under 23 US.C. 4021a)• ° Highway Safety Program Manual Na 8, National Highway Safety Bureau, Federal Highway Administration, January 17, 1969.1emphasis added) ' The National Highway Safety Bureau flater; the National Highway Traffic Safety Administrationl began collecting available fatal crash data from the States in the 1960's A National Accident Summary was first published in 197Q and from 1972-1974 the Fatality Analysis File was the respository for state accident data- These were both partial files, however, which did not include data from every state. $ Program Standard 4.4.8 op.cit- 9 The 80 percent reporting level is considered by NH7SAs National Center for Statistics and Analysis, Iwhich operates FARSI and other experts familiar with the problems inherent in testing and reporting blood alcohol involvement in highway crashes to be a "good" reporting level and reasonably close to complete reporting. Drivers who die more than 4 hours after a crash are not routinely tested because test results would not be representative of the BAC at time of crash. California, for example, found that 3 out of 4 drivers who had not been tested died more than 4 hours after their crash. In addition, medical treatment, such as transfusions, can preclude testing. 10 In the FARs a "known" BAC result is one that is available to the FARS analysts. As discussed later, BAC testing may be performed in a given State but the results are not made available by a hospital, or some other State agency to the State office that maintains accident records. " For 1983, FARS indicates Delaware tested (with known results) 90 percent of surviving drivers; Vermont-71 percent; Nebraska-60 percent; Utah 53 percent; Colorado-51 percent. '= Fell J.C., Alcohol Involvement in Traffic Accidents. Recent Estimates from the Na• tional Center for Statistics and Analysis, Farris, R. et al. A Comparison of Alcohol Involvement in Exposed and Injured Drivers. NHTSA Report No. DOTHS•4-00854, 1977: and Terhune, K.W. and Fell, J.C. "The Role of Alcohol, Marijuana and Other Drugs in the Accidents of Injured Drivers", Proceedings of the 25th Annual Con• ference of the American Association for Automotive Medicine, California, 1981. " Injury crashes are, in fact, a statistically better measure for evaluating countermeasure program impact because their larger numbers allow smaller changes to be detected in States or localities that have few fatal crashes. 'd Fell, op. ciL 15 Voas, R.B, op cit. Zyiman R., "A Critical Evaluation of the Literature on 'Alcohol• Involvement' in Highway Deaths:' Accident Analysis and Prevention 1984; 6(2): 163-204. '" Voas R.B. op cit. '7 Voas does indicate, however, that the sample of fatally injured drivers from the FARS 15 "good" states can provide a reasonable basis for a national estimate of the alcohol involvement in all fatally injured drivers if corrected for oversampling from night and single vehicle crashes. '$ Safety Study: "Deficiencies in Enforcement, Judicial and Treatment Programs Related to Repeat Offender Drunk Drivers;' September 18, 1984 NTSB/SS-84/04. APPENDIX HIGHWAY SAFETY PROGRAM STANDARD 8 ALCOHOL IN RELATION TO HIGHWAY SAFETY PURPOSE to broaden the scope and number of activities directed toward reducing traffic ac- cident loss experience arising in whole or part from persons driving under the In- fluence of alcohol. STANDARD Each state, in cooperation with its political subdivisions, shall develop and implemented a program to achieve a reduction in those traffic accidents arising In whole or in part from persons driving under the influence of alcohol. The program shall pro• vide at least that: 1. There is a specification by the State of the following with respect to alcohol related offenses: A. Chemical test procedures for determining blood-alcohol concentrations. B. I11 The blood-alcohol concentrations, not higher than 0.10 percent by weight, which define the terms "intoxicated" or "under the influence of alcohol"; and 12) A provision making it either unlawful, or presumptive evidence of illegali• ty, if the blood-alcohol concentration of a driver equals or exceeds the limit so established. il. Any person placed under arrest for operating a motor vehicle while intoxicated or under the influence of alcohol is doomed to have given his consent to a chemical test of his blood, breath, or urine for the purpose of determining the alcohol content of his blood. Ill. To the extent practicable, there are quantitative tests for alcohol: A. On the bodies of all drivers and adult pedestrians who die with four hours of a traffic accidenL B. On all surviving drivers in accidents fatal to others. IV. There are appropriat~ procedures established by the State for specifying: A. The qualifications of personnel who administer chemical tests used to deter mine blood, breath, and other body alcohol concentrations; B. The methods and related details of specimen selection, collection, handling and analysis; C. The reporting and tabulations of the results. V. The program shall be periodically evaluated by the State, and the National Highway Safety Traffic Administration shall be provided with an evaluation summary. 42 TIMN 321433 =
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Phis graph represents the number of substance abuse discharges distributed by length of inpatient stay in days. The graph is based on the National Hospital Discharge Survey sample.'I'he same distribution characterizes the sample vieighted to estimate National discharges. The graph makes a number of important points: i. The substance abuse inpatient client population is not homogeneous with respect to treatment experience as represented by length-ofstay. We already knew this, of course, but might have predicted a bimodal distribution representing detox- ificatlon and rehabilitation services. Instead we find a multimodal distribution. 2. Over half of substance abuse clients in hospitals in the NHDS received 7 days or less of care; I1 percent remained one day or less in treatment; and another Il percent received 5 days of treatment, the length-of-stay for many detoxifica- tion programs. 3. Only 18 percent of clients received care of two to four week's duration. This where we might expect rehabilitation cases to fall. 4. There are 7 day peaks in the multimodal distribution, namely 7, 14, 21, and 28 days. These peaks, along with a modal li.e, most frequent) length-of-stay of 5 days, suggest an interaction between treatment patterns and insurance benefits. Many policies provide coverage for multiples of the 7 day week. Finally, the distribution demonstrates the inadequacy of the mean to characterize treatment patterns for distributions where treatment experience is highly mixed, as in this case. The geometric mean is equivalent to the median and falls within the seven-days-or-less range, at six days. The arithmetic mean falls between major peaks representing shorter and longer treatment experiences. Each of the current alcohol abuse DRGs also appears to represent mixed treatment experience, though to varying degrees. For example: 1. in DRG 436 iaicohol dependence6 18 percent of clients received treatment for 7 days or less, but... 2. in DRG 437 (alcohol abuse without dependence), 90 percent of clients receiv- ed treatment for 7 days or less. Alcohol abusers classified in DRG 438 lalcohol substance Induced organic mental syndromel appear to represent a number of treatment modalities: 57% of clients received 7 days or less of care; 16% received 8-14 days of care; 19% received 15-21 days of care; and 17% received more than three weeks of care. Since the majority of substance abusers-62 percent-treated in hospitals in the 1983 NHDS were classified as DRG 438, DRG strongly influences the shape of the distribution in the graph, which includes all substance abuse DRGs. Footnote I Unbiased longitudinal analyses can be carried out only for those for whom a com• plete record of utilization data exists. Individuals and families who lacked continuous enrollment with Aetna over the four years have not been included in these analyses for this reason. THE ALCOHOLISM REHABILITATION PROGRAM OF THE CANADIAN FOR('JES S Brochu, J. Bardsley and I. Roy INTRODUCTION Alcohol misuse has received increasing attention over the past decade in the Cana- dian Forces ICF)• One response to the problem has been the development of specializ- ed programs designed to treat alcoholics. Thus, the CF Alcoholism Rehabilitation Program (ARPI was inaugurated in 198Q As part of this program, six Alcoholism Rehabilitation Clinics fARCsI in five major locations in Canada and one in West Germany (l.ahr) offer a 28-day treatment. The six clinics were named after their region as follows: Pacific in Esquimalt, Prairie in Winnipeg, Central in Kingston, Eastern in Valcartler, Atlantic in Halifax and Canadian Forces Europe (CFEI in tah[ These clinics are staffed by military personnel and civilian counsellors. THE PROGRAM The ARP is a three-phase program which progresses as follows: a. Phase I-During this initial step, a problem with alcohol misuse is recognized by the individual or detected by the supervisor. A medical assessment is com- pleted and if alcoholism is diagnosed, the member is detoxified. He is then informed as to what to expect in Phase II. Initial paperwork and other ad- ministrative arrangements are also completed. b. Phase Il-Phase II Is a four week period in an ARC. Each ARC is staffed by a Director, a professionally trained therapist (usually a social worker) a senior counsellor and several counsellors plus an administrative clerk. All counsellors, therapists and directors receive training on the ten-week U.S. Navy Addiction Treatment Specialist Course given at San Diego, California. The mainmay of treatment is group therapy. Ancillary treatment components are physical fitness, nutrition education, individual counselling, spiritual guidance, AA, lifeskills train- ing, relaxation sessions and alcohol-related education. The ARCs make liberal use of films, videos, books, and other educational material in the treatment process. The supervisor will normally be invited to attend the ARC for a super- visor day. The purpose of this day is to acquaint supervisors with the Clinics program and to ensure the supervisor and member understand what is expected of each other in Phase lll. Counsellors consider alcoholism as a family illness, thus family involvement is also a component of therapy. Antabuse or Temposil is used in most clinics. After 28 days, the member is discharged from the ARC with a follow-up treatment agreement. C Phase III-Phase III is an important part of treatment. Back at the unit, the physi- cian originally treating the member continues medical care during this one• year of follow-up. At a station or smaller unit, the referring nursing officer or medical assistant will be responsible The physician or other primary health care worker is usually assisted by either a Base Alcoholism Counsellor (BAC) or a Phase III Coordinator as available. During this phase, patients are encouraged to continue attendance at AA and to use other appropriate facilities both on the base and in the civilian community. Family members are encouraged to use Al Anon and Al Ateen. Although obligatory treatment officially ends after one year, it is possible to extend this Phase III period if considered advisable by medical authorities. PATIENT POPULATION The statistics reported are about patients who have been treated In 1983 and who completed the one-year follow-up in 1984. So, in 1983, 662 patients have been treated in the 6 ARCs: 262 in Atlantic region; 65 in Eastern region; 96 in Central region; 100 in Prairie region; 87 in Pacific region and 52 in Europe. These figures represent an increase of 103% over the previous year (Table I)• The patients were between 18-52 years old for an average age of 28.2. It is interesting to note that 4&9% of the subjects are in the 18-25 age group (Table 2)• Of the population treated 5.1% were female; this group represents 8.2% of the total Canadian Forces In 1983. Of the subjects, 49.5% were sngle, 42.9% were married and only 7.6% were separated or divorced. Privates and Corporals represent a large portion of the population treated with 40.6% and 23.0% respectively of the 662 patients. Officers represented only 33% of all patients treated at ARCs in 1983. These statistics are fairly stable through the years since 1980, although we notice a slight trend to treat more young single males. EVALUATION A twelve-month follow-up evaluation is completed on each patient at the end of Phase lll by asking the Phase III coordinator to define he progress of his client according to a Table divided into five categories: 1. Total abstinence. 2. One or two slips but currently abstinent. 3- Returned to drinking but without problems (as defined belowl. 4. Returned to drinking with continued problems. 5. Released for alcohol-r,elated problems. According to CF policy there is alcohol misuse when the use of alcohol: 1. Interferes with performance of duty or regular attendance at the place of duty. 2. Creates an administrative burden by causing domestic or other problems. 3. Interferes with satisfactory social or economic functioning. 4. Interferes with health. 5. Otherwise reflects discredit upon the Service. Table 3 presents the results of the 12 month follow-up for patients originally 47 TIMN 321438
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Examples for projective materials: Drawing an intersection 1."No entry into the comfortAble side of life" 2."Longing for infantile happiness in an over-controlled ego" Meine Kreuzung! 1 ~ tr LE~ ~~ ~ ...^. N I f I I 72 TIMN 321465
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3."Hesitating to decide which way to go" 4."Cycles overtaking a truck: protest against authority (father)" Meine Kreuzung! I 1 Z:31 tZ11 ~ ----cit ~ g 73 TIMN 321466
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fatalities are from single vehicle accidents, compared to only 30 percent for sur• vivors; and 60 percent of fatalities are from rural accidents, compared to 50 per cent for survivors. Estimates of the extent of alcohol involvement in injury-only crashes are even less precise than those for fatal crashes. This is because states test so few drivers involv- ed in injury-only crashes and almost never test passengers, pedestrians, or other road users. Moreover, because police only test drivers they suspect were drinking, the blood alcohol concentrations of those measured are less likely to be represen. tative of the entire population of injured drivers. The net effect of these biases would tend, therefore, to underestimate the proportion of alcohol-involvement and overestimate the average BAC in injury-only crashes. Deficiencies in State Alcohol Reporting Systems. Obviously, the two problem areas in State data systems to measure and report alcohol involvement in fatal and serious injury crashes are the failure to test all drivers and the failures to report results on tests that are obtained. Considering the latter category first, FARS statistics for "drivers tested with unknown results" indicate that, in a number of states, BPC tests have been performed but not reported on a substantial number of fatally injured drivers. (See table V1.) In 13 States, tests are performed on an additional 10 percent or more of fatally-injured drivers, but the results are not known by the State agency responsible for collecting accident records. For three States, 30 to 50 percent of the test results are unknown to the agency responsible for collecting accident reports. TABLE VL--BAC testing of fatally Injured driven -1963 FARS DRIVER FATALlTlES tate o. of Drivers Percent Drivers Tested With Known Results Percent Drivers Tested With Unknown Results ercent Drivers Not Tested ercent Unknown If Driver Tested Total 24,135 56.74 10.52 28.07 4.67 Alabama 555 52.07 20.90 26.49 .54 Alaska 92 45.65 9.78 4.35 40.22 Arizona 371 61.46 5.93 21.29 11.32 Arkansas 347 10.09 17.67 54.47 17.58 California 2,487 66.45 .24 13.31 - Colorado 365 84.66 - 15.34 - Connecticut 266 65.41 10.15 24.44 - Delaware 60 100.00 District of Columbia 21 a5.71 4.7B 9.52 - Florida 1,374 3.84 34.21 58.97 3.20 Oeorgla 756 69.58 1.46 26.97 - Hawaii 82, 89.02 - 10.98 - Idaho 160 36.25 11.86 46.25 5.63 Illinois 864 81.22 2.71 15.50 .57 Indiana 639 51.33 13.46 31.77 3.44 Iowa 320 56.25 6.25 35.00 2.50 Kansas 284 31.82 4.92 38.26 25.00 Kentucky 455 71.21 4.19 24.40 .22 Loulsiana 547 15.17 51.92 32.91 Maine 134 56.96 2.99 35.07 2.99 MarylaaM 380 86.64 - 12.63 .53 8tassachusettx 347 59.09 23.34 5.49 12.10 UichiBan 727 58.05 1.93 39.06 .96 Minnesota 344 76.16 3.76 9.68 10.17 Mississippi 432 17.59 .46 49.77 32.16 Yfaouri 533 28.71 2.44 24.20 44.65 Montana 176 71.91 7.30 19.10 1.69 Nebraka 151 76.16 1.99 15.69 5.96 Nevada 133 93.23 .75 6.02 - New Hampehtre 110 83.64 14.55 21.62 - New Jersey 464 62.33 .86 16.81 -- New Mexico 272 76.47 6.46 11.03 4.04 Naw York 1,002 63.37 .70 11.46 24.45 North Carolina 666 78.74 6.59 14.22 .45 North Dakota 72 6.94 26.39 66.67 - Ohio 910 34.40 29.34 27.91 6.35 Oklahoma ~ 511 73.19 - 26.61 .20 Oregon 329 - - - - Pennsylvania 1,001 74.43 4.80 20.78 Rhode Island 54 94.44 - 1.85 3.70 South CarolJna 459 57.73 11.33 30.94 - South Dakota 94 70.21 - 29.79 - Tennessee 648 77.01 .15 22.84 - Texas 2,175 1.93 31.77 66.30 - Utah 141 72.34 1.42 26.24 - Vermont 55 90.91 - 7.27 1.62 Vityinia 534 79.40 3.00 17.60 - Washin6ton 412 78.64 1.21 18.20 1.94 Weet Vi+qinia 272 62.35 . 1.10 16.54 - Wbconsin 437 87.19 .92 11.44 .46 Wyoming 11 75.66 2.70 20.72 .90 41 The primary reason for the large numbers of unknown test results appears to be the lack of a formal system and/or personnel to link BAC test reports (typically sent to State health departments) with fatal accident reports collected by state police, public safety, or transportation agencies. For example, when a staff person was designated in the North Carolina Department of Public Health to coordinate tox• icology results with Department of Public Safety accident analysis personnel, the percent of fatally injured drivers tested and reported to the FARS increased from 45.04 percent (1982) to 78.74 percent (1983). Similarly, in 1982, when Alabama added a full-time FARS analyst to coordinate records, the percent of fatally injured drivers and reported tested increased from 175 percent to 52.0 percent. If ad• ministrative solutions such as these could be implemented and unknown test results become known, reporting levels in five more States would immediately rise to 80 percent. (See Table VI.) HoweveS failure to test fatally injured drivers remains by far the biggest problem in those States with poor reporting levels. Failure to test is frequently the result of a combination of factors. The most common reasons we identified for failures to test are: no legal authority lack of expertise personal reluctance by those in the "testing system" ia, police, physicians, cor• oners, etc.) lack of resources (financial, personnel) Table VIL--State law nquirin8 BAC tests on fatally injured drivers. States States States With Ww With Without for Testing Surviving State Law Law Drivers Alabama x Alaska x Arizona x Arkansas x California z Colorado x Connecticut x Delaware x . District of Columbia x Florida x Georgia x Hawaii . x Idaho x nlfnots x Indiana x Iowa x Kansas x 8:entuekq x Louisiana Maine x x Maryland x Massachusetts x Michigan x ldinnesota x Mississippi x xifsouri x 1Nontana x Nebraska x Nevada x New Hampshire x New Jersey x New Mexico x New York x North Carolina x North Dakota x Ohio x Oklahoma x Oregon x Pennsylvania x Puerto Rico x Rhode Island z South Carolina x South Dakota x Tennessee x Texas x Utah x Vermont x x Virginia x Washington x West Virginia x Wisconsin x Wyoming x Total 41 11 1 - State has sLblished policy for testing surviving drivers involved in a fatal crash. Forty-one States or jurisdictions linciuding District of Columbia and Puerto Rico) have laws specifically authorizing blood alcohol tests on fatally injured drivers. (See tabfe VII.) In some of the remaining States in which there is no specific legal authority td have a BAC test performed, this lack of specific authority results in incomplete testing and reporting. Arkansas, for example, did not have a law authorizing such TIMN 321432
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ALCOHOL INVOLVEMENT IN U.S. HIGHWAY CRASHES- MAKING POLICY DECISIONS ON INCOMPLETE DATA John V. Moulden The tragic contribution of alcohol to violence on our highways has long been recogniz- ed. In fact, within 5 years of the fitst fatal motor vehide crash in the United States, the relationship of alcohol to highway death and injury was described in a 1904 scientific journal as a developing public safety and health problem.' In the years that followed, State and local officials recognized by that State laws did not deal adequately with the problem of drunk driving and that the critical information needed to measure the nature and extent of the problem did not exist. One report indicates that in 1924 it appeared ':..to be the belief of traffic commis- sioners and other informed individuals that probably one fourth to a third of our automobile accidents jwere)_at least partly chargeable to alcohol use by drivers"2 But, as the landmark 1968 Alcohol and Highway Safety Report to Congress states, "Due to the lack of sufficiently precise data, exact estimates of the nature of the problem in the U.S. in the first third of the century..are not possible'' The need for accurate and reliable information on the involvement of alcohol in highway crashes is, in fact, even more pressing today than ever before. Since 1980 there has been a virtual explosion of interest and activity nationwide concerning the drunk driving problem. Enormous commitments of financial and human resources are being made annually in every State to implement or expand drunk driving countermeasure programs.4 New laws to toughen drunk driving statutes have been enacted in most States, and Congress has passed several laws to encourage State action. National, State and local officials are under considerable public pressure to reduce the approximately 23,500 akohol-related highway deaths and 650000 akohol. related injuries suffered each year. To allocate resources fo> and to evaluate the effectiveness of, our drunk driving laws and programs at the State and national level, each State must know both the level of, and the changes in, the level of alcohol involvement in highway crashes. Such knowledge is also a critical prerequisite to the planning and implementation of effective countermeasure programs. However; a recent review I have conducted of State and national accident reporting systems indicates that this critical informa. tion may no4 in fact, be available in every State During the 1960's and 1970's, several landmark steps were taken to improve the availability of accident data. As a result of the Highway Safety Act of 1966, the Depart- ment of Transportation became the principal Federal department in the fight against drunk driving. On June 26, 1967, the Secretary of Transportation issued the first 13 National Uniform Standards for State Highway Safety Programs. These standards established prerequisites that States must meet to receive Federal highway safety funds provided by the 1966 Act. The eighth standard, "Alcohol in Relation to Highway Safety," required each State to obtain quantitative tests for alcohol "on the bodies of all drivers and adult pedestrians who die within four hours of a traffic accident landJ on all surviving drivers in accidents fatal to others"5 (See appendix.l The accompanying "Highway Safety Program Manual" to Standard No. 8 emphasized that the purpose of the Standard was, in part, "to ensure that States and their com- munities have accurate information on the extent to which the immoderate use of alcohol is a factor in the highway crashes in their jurisdictions, to serve as a basis for resource allocations and for determining the effects of countermeasures:'" The National Committee on Uniform Traffic l.aws and Ordinances (NCUTI.OI, which develops the Uniform Vehicle Code (the model traffic law for the United Statesl, also expressed the need for accurate crash records by adopting in 1975 a new sec tion 110-1161 of the code which requires the determination of alcohol involvement in all drivers or pedestrians involved in fatal highway accidents. However, the most significant7 national effort to improve the collection, analysis, and use of traffic accident data began in 1975 when the National Highway Traffic Safety Administration (NHTSA) established the Fatal Accident Reporting System (FARS). FARS is a computerized file containing data on all fatal motor vehicle ac• cidents in the 50 States, Puerto Rico, and the District of Columbia. It is the first census of fatal crashes in the United States and is regarded as the most complete data base available on fatal accidents. Operating on an annual budget of approx imately $3 million, FARS employs more than 100 full and part-time Federal and State staff for its operation. The reporting system enables a State-by-State determination of the extent to which each State has "accurate information on the extent to which immoderate use of alcohol is a factor in the Ifatall highway crashes in their jurisdic tions."B Using FARS data, I have completed such an assessment and examined the current status of State alcohol-highway crash data. The results indicate that con siderably more than half of the States do not collect sufficient data on drivers who are fatally injured in highway accidents to allow an accurate, ongoing assessment of the extent to which alcohol is present in such accidents. Testing of Fatally Injured Drivers For the latest complete reporting year, 1983, only 14 States determined and reported blood alcohol concentration (BACI test results on 80 percent 9/ or more of the fatally injured drivers who died in their States. (See tables I and 11.1 Twenty-seven States determined and reported BACs for 50 to 79 percent of their fatally Injured drivers, while 10 States reported on fewer than 50 percent. Nationally, alcohol test results are known for only 56.7 percent of all fatally injured drivers,10 17.8 percen- tage points more than the 1975 reporting level of 38.9 percent when FARS was established. (See table 111.1 The poor testing and reporting levels by States to the FARS point to one of several deficiencies in our current national and State accident data bases which limit the usefulness of these systems for measuring the level and changes in the level of alcohol related highway crashes. u,5,< nna.wS.S asa..< WEM<C ca«EnKu u..w..cE <o,o< cEO+~< .~,.,. ~,.. .DL~M,< M<.~ _::5:::•VfnTS ~.~., ~..-.~. ~.,.:,. NEV. wuK~m[ MEw JF.SE~ M[w .HaKO MEw To.. NWT« p<Rfn< EMtq FMEGL/. rf)IMSTIV<yY ~UF.TC ~~LG M,ppE KJ.MO sou+~ wxw sarrN wam< T[MNFS[[E TEYaS ur.~ VT6M.< W.SMMCTtlN Figure t Percent Frrtslly Injured Drivers T.st.d With Known R.sults - 1f®3 FARS 1C. 7M ]C~ .p4 10~ N 10•, f:.'•. W 10.`. ,, . Ell u41111110TAWMirr~./, wjrss~ii n t 1 1 i 1 1 1 1 1 1 1 = aSSTwxfCt _Se-]TR = ME.Tr.Tw,MM ~.j UIRHCNM 1UflhTS Testing of Surviving Drivers in Fatal Crashes To assess accurately the role of alcohol in highway crashes and to evaluate the impact of State and Federal countermeasures, studies of alcohol-involved fatally in jured drivers alone are insufficient and potentially misleading. When a multivehi cle fatal crash occurs, the driver (or driversl responsible for causing the crash may not be fatally injured. In single vehicle fatal crashes, the drivers' injuries may not be fatal. I believe that BAC data on the drivers who survive fatal crashes and on all drivers involved in serious injury crashes are needed to complement informa tion on fatally injured drivers. Despite the fact that approximately 55 percent of all drivers involved in fatal crashes survive the ctactt. in 1983, only two States-Delaware and Vermont-routinely tested for and reported the BAC levels of a significant portion of surviving drivers in fatal 39 TIMN 321430
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conceived program will aid a subgroup of clients while failing with other subgroups. It may be speculated that such approaches account for the majority of unsatisfac• tory results by other programs. The Cook County ADES program rejects a stilted unidimensional response to a multidimensional human problem to D.U.I. with emphasis on Assessment and Levels of Intervention. WORKS CITED IN TEXT Brown, Robert A., "Measurement of Baseline Drinking Behavior in Problem-Drinking Probationers, Drinking Drivers,, and Normal Drinkers," Adflictive Behaviors 6(1): 15•22 11981) Cloud, Luther A., "Alcoholism: A Case for the Disease Definition," Psychiatric Opi nion 15 (101: 15-17 11978) Comptroller General of the United States, The Drinking-Driver Problem-What Can Be Done About It? (Report to the Congress), Washington, D.C: U.S. General Ac- couting Office, 1979 Donovan, Dennis M., Marlatt, G. Alan, and Salzberg. Philip M„ "Drinking Behavior, Personality Factors and High-Risk Driving: A Review and Theoretical Formulation,: Journal of Studies on Alcohol 44 (3): 395-428 (1983) Ewing, John A., "Matching Therapy and Patients: The Cafeteria Plan," British Jour- nal of Addiction 72 (1): 13-18 11977) Guydish, J. "Substance Abuse and Alphabet Soup," Personnel and Guidance Jour- nal 60(7): 397-401 (1982) Hagen, R.E., Williams, R.L, McConnell, EJ., and Fleming, C.W., An Evaluation of Alcohol Abuse Treatment as an Alternative to Drivers License Suspension or Revoca don, Final Report to the Legislature of the State of California in Accord with Chapter 890-1977 Regular Legislative Session, Sacramento: California Department of Motor Vehicles and Department of Alcohol and Drug Abuse, 1978 Hall, R.W., "Alternatives to the Criminality of Driving While Intoxicatd; Joumal of Police Science and Administration, 5: 138- 144 (1977) Hart, Larry, "A Review of Tretment and Rehabilitation Legislation Regarding Alcohol Abusers and Alcoholics in the United States: 1920-1971, "International Journal of Addictions 12(51: 677-678 11977) Hodgson, Ray, Stockwell, Tim, Rankin, Howard, and Edwards, Griffith, "Alcohol Dependence: The Concept, its Utility and Measurement, "British journal of Addic- tion 73 (4G 339,342 (1978) Holden, Robert, "Rehabilitative Sanctions for Drunk Driving An Expetimental Evalua- tion, "Journal of Research on Crime and Delinquency c20 (11: 55-72 (19831 Holser, M.A., "A Socialization Program for Chronic Alcoholics," International Jour- nal of the Addictions 14: 657-674 (1979) Kastrup, Marianne, Dupont, Annalise, 'Bille, Mogens, and Lund, Hans, "Drunken Drivers in Denmark: A Nationwide Epidemiological Study of Psychiatric Patients, Alcohol and Traffic Accidents, "Journal of Studies on Alcohol 44 ( I I: 47-56 (19831 Kern, Joseph C., Schmelter, William R. and Paul, Stewart R, "Drinking Drivers Who Complete and Drop Out of an Alcohol Education Program", Journal of Studies on Alcohol 38 (1 l: 89-95 (1977) McCreery, Patrick, "The Three Spheres of Alcoholism," MH 60 (3): 9.15 (19761 McDermott, ignatlus, and Moran, Eve Boronczyk, "Alternatives to D.U.1. Prosecu- tion and Alcohol Safety Programs, "Misdeameanors, Traffic Violations, D.U.1. Illinois Institute for Comtinuing Legal Education 119811 McGuire, Frederick L., "Treatment of the Drinking Driver, "Health Psychology 1121: 137• 152 (19821 Meck, Donald S., and Baither, Rick, "The Relation of Age to Personality Adjust- ment among D.U.I. Offenders," Journal of Clinical Psychology 36(l) 342-345 (19801 Michelson, L., "Effectiveness of an Alcohol Safety School in Reducing Recidivism of Drinking Drivers," journal of Studies on Alcohol 40: 1060•1064 (1979) Oet, Tian P., and Jackson, Paul R., "Social Skills and Cognitive Behavioral Approachesto the Treatment of Problem Drinking, Journal of Studies on Alcohol 43 (5): 532547 (1982) Orosz, Sharon B. "Assertiveness in Recovery," Social Work with Groups 5(11: 25•31 119821 Panepinto, William C., Garrett, James A„ Williford, William R., and Prince, John A., "A short-term Group Treatment Model for Problem•Drinking Drivers," Social Work with Groups 5(1 k 33-40 (1982) Peer, Gary G„ Lindsey, Ann K., and Newman, Patrick A., "Alcoholism as Stage Phenomena: A Frame of Reference Counselors," Personnel and Guidance journal 60 (8): 465-469 11982) Pisani, Vincent D, "Family Deficit: A rationale for Group Approaches to the Pro. blem of AlcoholLsm and Addiction," Proceedings of the 13th International Institute for the Prevention of Alcoholism. 1967, 99 107 Pisani, Vincent D., "Reaching the Unreachables: A Holistic Approach to Treating Alcohol and Drug Abusers," Presented at the annual meeting of the Illinois Association of Mental Health Center Administrators, October 1969 Pisani, Vincent D, 'The Detoxification of Alcoholics -Aspects of Myth, Magic or Malpractice,: Jounral of Studies on Alcohol 38 (5) 972-985 (19771 Pisani, Vincent D., McDermott, 1. and Kilbane, P. "D.U.I. Levels of Intervention: A ten Year Experience" Presented at the 33rd International Congress on Alcohol and Drug Dependence, Tangiers, Africa, (1982) Poulos, C., Jean, "What Effects Do Corrective Nutritonal Practices Have on Alcoholics?" journal of Orthomolecular Psychiatry 10 (11: 61-64 (1981) Ringoet, K., "Depth Psychological and Cultural-Ethological Aspects in Connection with Alcoholism," Acta Psychiatrica Beigica 80 (2): 175-182 119801 Salzberg, Philip M., and Klingberg, Clark, L "The Effectiveness of Deferred Pro• secution for Driving While Intoxicated; journal of Studies on Alcohol 44(2): 299-306 (1983) Saunders, Bill, and Richard, Glen, "In Vinto Veritas: An Observational Study of Alcoholics and Social Drinkers Patters of Consumption," British journal of Addic• tion 73 (41: 375•380 (1978) Saunders, David L, "Prevention and Control of'Drunk Driving': Lessons for Social Work," Health and Social Work 4(4): 84•106 11979) Scolos, Pascal, and Fine, Erick W., "Short-term Effects of an Educational Program for Drunken Drivers," journal of Studies on Alcohol 38: 633-637 (1977) Selzer, Melvin L, Vinokur, Amitam, and Wilson, Timothy D., "A Psychosocial Com• parison of Drunken Drivers and Alcoholics," journal of Studies on Alcohol 38: 1294-1312 (1977) Skinner, Harvey A., and Allen, Barbara A., "Alcohol Dependence Syndrome: Measure• ment and Validation," journal of Abnormal Psychology 91 (3): 199-209 (1982) Smart, Reginald G., Gillies, Marion, Brown, Geoff and Blair, Nancy L, "A Survey of Alcohol-Related Problems and Their Treatment,: Canadian journal of Psychiatry 25 (3): 220-227 11980) Steer, Robert A., Fine, Eric W., and Scoles, Pascal E., "Classification of Men Ar• rested for Driving While Intoxicated, and Treatment Implications;' journal of Studies on Alcohol 40: 222-229 (19791 Swenson, Paul R., Strickman-Johnson, David L, Ellingstad, Vernon S., Clay, Thomas R., and Nichols, James L., "Results of a Longitudinal Evaluation of Court-Mandated DWI Treatment Programs in Phoenix, Arizona," Journal of Studies on Alcohol 42: 642-553 11981) Wells-Parker, Elizabeth, Miles, Shelly, and Spencer, Barbaram "Stress Experiences and Drinking Histories of Elderly Drunken Driving Offenders,: journal of Studies on Alcohol 44 (31: 429-437 119831 Whelan, Michael, and Prince, Michael, "Toward Indirect Cognitive Confrontation with Alcohol Abusers," International Journal of the Addictions 17 (5): 879-886 (1982) TIMN 321450 59
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reponses. Du reste, sur ce point, comme sur les precedents, il n'y a pas 6% de CHOIX. En revanche, les deux autres propositions (quand la personne alcoolique peut dire non a 1'alcool, quand elle sait faire face a ses problemes) receuillent des scores assez voisins: 11% is 20% de non-r6ponses, de 3h 4% de NON, mais de 77% a 85% de OUI. Ce que les CHOIX confirment par 87,5% en leur faveur, le fait de dire non is i'alcool i'emportant toutefols (48,7%) sur le fait de savoir faire face a ses probl'emes (38,8%). 2. Avec quelle aide s'en sortir? •sYgtue' des sE wz a . peut , d•incl,easabuveu~nts 2. 1•eide des eideeins 3. pzsoiche de soa entonra9e 4. sa vulontE pereonnslle dg ='}leae L le pla vportant 13.0 c.1 1612 59.2 100,0 qu•oa Tableau 12: Sur quelle aide peut compter 1'alcoolique pour sen sortir d'apres 407 repondants du bilan de santt; (pourcentages). Coptimisme des repondants dans Ia precedente question se renforce encore pour poser au tableau 12 la volonte personnelle comme le facteur le plus eminent (83,1% de OUI, triss peu de NON et de non-reponses), voire le plus determinant Ipres de 6 CHOIX sur 10). Dans les OUI, les trois autres facteurs se suivent de tres pres. Seuls les CHOIX etablis. sent une diffdrence entre I'aide de 1'entoutage proche 116,2%) ou celle (presque 6gale) des mouvements d'anciens buveurs 113%) d'une part, et 1'aide des medecins (seulement 6,1%) d'autre part: la volont6 personnelle apparait ainsi pres de 10 fois plus preconisee que la contribution m@dicale. Faut-il supposer que les C.H.A.A. demeurent encore inconnus ou sont meconnus ou que les repondants songent davarr tage aux medecins generaiistes? Notre questionnaire nest pas assez explicite pour autorCser 1'une ou I'autre de ces interpretations. 3. Les attentes de I'alcoolique 2. 1'oide O0I NON N.R. I chaque E1E-t 3 ,3 13,9 25.! WI RoR R.R. A 4haque E1E.ent 65,4 11.3 23.1 67,6 8,9 23.5 71,7 7.1 21,2 83.1 4.7 12,2 qu•on 1s soigne 145.7 24,3 30,0 4. qu'on 1e diri9e t36,1 qu'oa 1'ei.e N.R. 29,0 34.9 52,1 15.0 32.9 CtlOIX de 1'EiEeent 1e plus 1~Portant 24.0 22,4 7.9 9.3 19,4 100.0 Tableau 13: Les attentes de 1'alcoolique d'apres 407 repondants du bilan de sante (pourcentages). 1)ans la question abord@e au tableau 13, il n y a pas coherence entre les reponses par OUI et celles par CHOIX. En effet, dans celles par OUI, les items successits sont peu distants les uns des autres trois depassant ia moiti@ (ecoutet: aider, aimer). deux sont en dessous de la moitie, sans toutefois comporter plus de NON (soigner, diriger)- En revanche, les CHOIX mettent en relief trois attentes (dans 1'ordre decroissant: aider: soigner, 6couter) et minimisent fortement les deux autres laimer, dirigeri. Autre ment dit, les attitudes interventionnistes ou dirigistes sont releguees loin derriere celles d'attention aux autres et d'eftcacit6 (aider, soigner, 6couter). F. RECAPITULATION ET ORIENTATIONS 1. Les principaux resultats Chez 407 repondants d'un bilan de sante, 86% reconnaissent 1'alcoolique a sa depen dance vis-A-vis de I'aicool et plus de 9 sur 10 y voient un processus auto-destructeur, se manifestant chez I'homme davantage par la violence (50%I et rendant la femme plutot malheureuse (66,8%). Du reste, le plus souvent mariee (70%I. celle-ci nexerce pas d'activite professionnelle 157,5%) et se presente apparemment com, meles autres [65,6%i. Dans son lieu de travail, 1'alcoolique est d'abord dangereux (80%), Ia cas echeant ii est "a proteger" (54,8%). Dans son environnement de vie, ses voisins plaignent surtout la famille (70,3%) et restent genes (53,8%I. Aux yeux des repondants, un collegue de travail qui boit passe plus souvent comme etant un boulet ~ tirer (51,6%) et tout alcoolique inspire avant tout de la pitie (65,1%). Mais, au total, ce demier est quelqu'un a aider (86,5%I, qu'll soit responsable (68,1%I, coupable (45,2%), victime de circonstances (55,3%) ou de Ia soci@t@ (34,9%). A vral dire, s'il boit, c'est, chez presque tous, pour combler un manque, chez les femmes davantage pour remedier a la solitude, chez les hommes plutot pour dprouver un plaisir. Quel que soit son sexe,l'alcoolique sen sort quand ii peut dire non a I'alcool (84,3%), quand il sait faire face a ses problemes (77,6%). A cet effet, plus que de 1'aide de son entourage proche (71,7%) ou de son m6decin (67,6%) ou de mouvements d'an• ciens buveurs (65,4%), ii a besoin de sa volonte personnelle (83,1%). Neanmoins, il demande qu'on 1'aide (55,3%I, quon I'ecoute (55,5%I, qu'on I'aime 152,1%), s'il le faut quon le soigne 145,7%), moins frequemment quon le dirige 136,1%). 2. Ixs grandes orientations 11 est envisage de s'interesser uiterieurement aux croisements des questions entre elles au niveau des deux populations totales de Nancy et de Lille, afin de recher• cher des families de repondants dans la sequence des questions. ISar exemple, de s intetroger respectivement sur les autres r@ponses de ceux qul tiennent 1'alcoolique pour victime et de ceux qui lui imputent une responsabilite, voir une culpabilite Ou encore sur les autres reponses de ceux a qui il fait plti6, de ceux qu'il laisse indiff2rents, de ceux a qui il inspire de la gene Ou encore sur les autres reponses de ceux qui sont enclins a I'ecouter par rapport a ceux qui preferent le soignet; ou raider, etc.. Surtout notre questionnaire sera a rapprocher de ceux des autres enquetes mendes successivement aupres de 150 patients du Centre d'Hyglene Alimentaire et d'Alcoologie (C.H.A.A.) de Nancy (comment chacun d'eux per4oit les autres alcooli- ques et se perqoit lui-meme), aupres des 150 femmes de consultants vues au sein du meme C.H.A.A. (comment elles per4oivent leur conjoint soigne pour alcoolisme), aupres des 250 repondants faisant partie des personnels soignants de C.H.A.A. en France (comment ils perqoivent les alcooliques qu'ils cbtofent quotidlennement), enfin aupres des 100 anciens buveurs appartenant a des associations de soutlen (ieurs questions sont tr6s proches de celles posees aux patients du C.H.A.A. de Nancyl. Ces questionnaires, bien que tres differents les uns des autres, ont com- porte certaines questions communes ou voisines Les tableaux que nous avons prdsentes n'avaient pour but que de proc6der 5 une premiere approche d'un probleme aux multiples aspects et encore tres peu explore. "• Contrat Haut Comite D'Etude et d'Information sur 1"Aicoolisme n. 1982/02. TIMN 321443
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ASSESSMENT AND VARIABLY INTENSE INTERVENTIONS: SYSTEMS APPROACH TO D.U.I. Introduction Exactly what is D.U.I.? "Driving Under the InHuence' (of alcohol or other mind/mood altering substances) is not in itself an illness. More properly, it is deviant behavior, a specific type of "Improper Vehicular Management". Persons involved in this behavior come from a variety of genetic and psychosocial backgrounds. Even under ideal conditions, driving is a best a risky business. When combined with a variety of physical or emotional stress factors, including alcohol or drug use and abuse, the operator of a vehicle may experience an "additive stress effect" which often significantly impairs the ability to maintain control of the vehicle. Recent interest in D.U.I. behavior results from a vareity of social, economic and political pressures. D.U.I. is a human condition, an unacceptable misbehavior. In order to deal with it effectively, we must define and measure it. We should initiai- ly "type" the behavior, measure its "intensity" and then determine its "duration". Next we must match the appropriate existing methods and levels of intervention with the configuration of the above parameters as they exist in a particular, unique person's genetic and psychosocial background. Such an approach is admittedly very difficult but it is a challenge to the behavioral scientist. Intoxicated drivers are a diverse population, and reach intervention programs by a variety of paths. The D.U.i. offender falls into a subgroup which receives intervention as a result of legal referral. Despite the diversity, it is possible to make a few generaliza- tions that apply to most D.U.I. offenders. The most important is that the majority are not alcoholics or drug addicts. There is a need for programs specifically design- ed to handle diversity. One such program is the Alcohol and Drug Education Services Program of Cook County, Illinois. The program was founded by Reverend Ignatius McDermott M.S.W. in recognition of the individuality and diverse needs of D.U.I. offenders. It is based on over thirteen years of experience in meeting these needs through varied measune.s. In particular, it seeks to determine each person's unique status and to adjust measures of intervention accordingly. In this presentation, it is my intent to briefly review the literature, including the seriousness of the D.U.1. problem; legal developments; success of D.U.I. programs; diversity of alcohol abusers; and the range of approaches to intervention with D.U.I. offenders and alcohol abusers generally. I will then outline the Cook County pro- gram's approach with special emphasis on assessment and levels of intervention, the critical components of D.U.I. The Seriousness of the D.U.I. Problem Automobile accidents are a major source of injuries and property damage in the United States and other countries. Donovan et al. (1983) report that one-third of injuries and one-half of fatalities are related to alcohol use. Using these authors' statistical data, D.U.I. was responsible for roughly 20,000 deaths and 400,000 disabling injuries in the U.S. in 1976. These authors note impairment of cognitive, sensory- perceptual, and motor skills resulting from alcohol use. Comparative data from Kastrup et al. 11983) on the basis of data from two Danish central statistical registers, indicate that one-third to one-half of all fatalities result from traffic accidents. Higher blood alcohol levels are associated with more serious injurSes. They estimate that 67% of all accidents result from the effects of alcoholo consumption. These two recent studies and a review of previous studies of the impact of alcohol consumption on traffic safety support similar conclusions. D.U.I. is clearly a major social problem, one causing a high number of deaths, injuries, and incidents of pro. perty damage. - Legal Aspects Guydish (1982) distinguishes among four responses of society to alcohol abuse and other forms of substance abuse: the legal, based on moral principles and legislation; the medical, based on a disease model and using drugs and detoxification procedures as therapy; the traditional, based on support and the achievement of abstinence; and on emerging model based on modification of individual's contingency sets. In this century, it has increasingly been recognized that alcohol abuse in not under the full volitional control of the abuser, and should be classified as 'sick' rather than 'bad'. Given this recognition, criminal penalties of the traditional sort become less justifiable. Hall (1977) notes the following weaknesses of the punitive approach: failure to change the attitudes and behavior of the D.U.I. offenders; lack of police support; unequal justice and corruption of police officers; self-defeating effects; and Vincent Q Pisani, Ph.D. A placing the defense counsel in the role of trying to prevent a 'guilty' verdict, thus interfering both with aid to the individual and with protection of society from fur- ther D.U.I. behavior. Hart (1977) points out two related developments in the U.S. One, is the Uniform Alcoholism and Intoxication Treatment Act, drafted in 1971, which decriminalizes alcohol intoxification and alcoholism, and provides for protective custody and volun. tary treatment of persons intoxicated to the point of incapacitation. This act has not been wholly successful in its achievement of its aims, however. The second, is the National Alcohol Countermeasures Program of the U.S. Department of Transpor- tation. Under the guidelines of this program, 35 Alcohol Safety Action Projects (ASAPsI were started. These programs involved charging of intoxicated drivers with an ap- propriate offense, and the sentencing of these drivers to accept treatment and educa tion as an altemative to license revocation. Pressure for increased penalties, need not interfere with programs of therapeutic intervention. However, combining legal penalties with therapeutic programs has certain problems. Kem et al. (19771 notes that involvement of the legal system makes participation in therapeutic intervention a result of coercion. This coercion clashes to a degree with the goal of having clients willingly commit themselves to participation in therapy. At the same time, it increases the likelihood that of• fenders will accept intervention. Thus, despite certain tensions, the relation betwee the legal and therapeutic systems is basically one of symbiosis. The Success fo D.U.I. Programs One general study completed by the Comptroller General of the United States (1979), and a second overview by Saunders (1979), revealed mixed results. However, bas- ed on the examination of the 25 ASAP pilot projects, advantages as well as disad- vantages are apparent.l3oth early identification of the problem and varied factors encourage acceptance of treatment, including: trauma of punishment, legal limits, and awareness. Swenson et al. (1981), Hagen et al. (1978), and Michelson (1979) reporting on studies done in Arizona, California and Florida respectively, found little evidence for the effectiveness of short-term treatment. They find no signifi- cant favorable effect from program participation. In many cases, participants had worse traffic violation records and accident records than controls. Holden (1983) describes a study in which 4126 D.U.i. offenders were exposed to probation supervision, education and therapy, both or neither. No combination of treatment conditions had any effect on rearrest rates after two years. McGuire (1982) and Salzberg and Klingberg (1983) compare D.U.I. offenders referred to programs and drinking drivers not referred to such programs. McGuire finds favorable effects on light drinkers, but not on heavy drinkers. There were higher rates of alcohol-related traffic violations in the treatment group than in the control group. Thus, the evidence is no more than doubtful for the value of many existing pro- grams. The question remains open, however, whether this is due to inherent in- tractability of D.U.I. cases or to specific flaws in the programs reviewed. The Cook County program has a number of special features intended to avoid the problems of other programs, centered on division of D.U.I offenders into subgroups to which different treatment interventions are appropriate. Suiting the intervention to the offender may offer a path to higher success rates. The Diversity of Alcohol Abusers Alcohol and drug abuse occur in varied patterns, ranging from persons who have simply drunk qr drugged to excess on one occasion to those who are chronically intoxicated, and from mild loss of control to very severe intoxication. For the therapist, the milder forms of abuse are a desirable point of intervention, since they offer an opportunity to deal with less firmly established patterns of abusive behavior. This makes D.U.I. programs beneficial to early intervention in the development of alcohol and drug abuse. It is crucial to be aware of how D.U.I. clients differ from alcoholics or drug addict. Intervention suited to one group may not be ap- propriate or effective for the other. Pisani 11967, 1970, 1977, 1982) suggest that alcohol and drug abusers can be op- timally helped only after evaluation of the bio. psycho-social deficit present and the amount of regression incurred by the substance of abuse. He proposes using a holistic approach, consisting of five levels of intervention (assessment, education, guidance, counseling, therapy), after such evaluation, each level is suited to specific degrees of pathology. Additional studies by Peer et al. (19821, Smart et al. 119801, McCreery 119761 and TIMN 321448 57
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pears to increase in diversity as the "enforcement net" increases, but there is no scientific basis for that observation to date An independent research and evalua tion project is currently addressing that issue ADES risk assessment indicates that approximately sixty (601 percent of the population require remedial or guidance intervention while forty 1401 percent are in need of more intensive intervention in counseling or therapy. How does this compare with other geographic areas? Is this population mix an urban area with a high probability of incarceration of offenders the same as an area with a low probability of punitive measures? We would conclude that there is, indeed, a need for more~study regarding standar• dization of DtJi population information and the impact of various strategies on these populations FOOTNOTES 'Rule of the CourL• The Illinois Supreme Court allows the individual Circuit to promulgate rules, not in conflict with Supreme Court rules, generally for the ad. ministrative purposes of the CircuiL A rule of the Court becomes a rule of law. 2ADES programmatic terms: repeat offendeS prior arrest but no previous referral. Recidivist: prior DUI intervention participation LAIRDICs RACE BLACK % WHITE S HISP % OTHER S TOTAL S 8-4,999 64 21.26 230 9.51 16 10.88 5 23.91 315 18.91 5,KOi.999 41 13.62 250 10.33 28 19.05 2 9.52 321 11.11 10,000-14.999 41 13.92 316 13.96 29 19.73 5 23.81 391 13.54 15,000-19.999 46 13.29 296 12.24 13 12.24 2• 9.52 356 12.33 20,900-24.999 46 15.2/ 330 13.64 26 17.68 2 9.52 404 1399 25,000-29,999 28 9.30 259 19.7] 9 6.12 6 1.04 296 19.25 30,000 k oeer 41 13.62 783 39.51 21 14.29 S 23.81 805 27d7 TOTAL 301 10.@ 2419 63.Y4 147 5.89 21 8.73 211112 169.09 SEX MALE S FEMALE S TOTAL S 0-4,999 257 10.17 S9 16.02 315 16A1 5.000-0,f99 241 16.33 68 16.57 321 11.11 ,000-L4.999 330 13.66 61 16.85 3!1 13.54 ~5,000-19,9/9 291 11A4 57 15.75 356 12.33 29,000-24.999 359 14.21 45 12.43 464 13.99 25,9Lt0-29.999 27 IO.K 21 530 296 19.25 36,009 4 sver 5 745 2f.49 60 76.57 aa5 2TJ7 TOTAL 2526 97.47 362 12.53 2868 186A8 OCCUPATIOR RACE BLACK S WHITE S NISP S OTHER S TOTAL S BLUE COLLAR 168 57.14 1D95 45.55 66 52.90 9 45.09 1331 417.06 WHITE COLLAR 27 9.18 699 29.08 PI ]6.89 3 15.K 759 S6.It PROFESSIONAL 29 9.66 271 11.25 14 11.29 3 15.00 317 11.15 STUDENT 4 1.36 1 K 4011 6 4.80 1 5.00 117 4.11 UNENPLOYED 66 22.45 233 9.69 ID 14.40 4 20.00 321 11.29 TAL 294 18.34 2404 84.56 125 4.40 29 8.76 2343 108.00 SEX MALE % FEMALE % TOTAL S BLUE COLLAR 1216 49.6i 102 2f.t1 1338 {7 K WHITE COLLAR 624 25.07 126 35.59 750 . 26.38 PROFESSIONAL 279 11.21 38 16.73 317 11.15 SfUDENT 1K 4..2 17 4J0 117 4.12 UNEMPLOYED 250 16.04 71 20.96 321 11.29 TOTAL 2439 t7.55 354 12.45 2843 11141.011 EMPLOYMEN7 STTATLC RACE BLACK S WHITE % HISP % OTHER % TOTAL % STUDENT 2 6.64 57 2.30 6 3.92 2 9.52 67 2.26 UNEMPLOYED 60 25.64 217 1143 18 11.76 4 19.05 399 13.46 ALL OTHERS 230 73.72 2125 65.72 129 14.31 15 71.43 24" 64.26 TOTAL 312 10.52 2479 83.61 153 5.16 21 6.71 2965 100.00 SEX MALE % FEMALE S TOTAL % STUDENT 56 2.17 11 2.68 67 2.26 U1IEIIPLOYED 338 13.09 61 15.97 399 13,46 ALL OTHERS 2189 64.75 310 81.15 2499 04.20 TOTAL 2583 87.12 362 12.86 2965 100.00 MARI2AL STATUS RACE BLACK S WHITE % H1SP % OTHER S TOTAL S NEVER MARRIED 71 22.19 1213 48.56 58 38.16 5 25.00 1347 45.05 MARRIED 164 51.25 209 32.03 71 46.71 11 55.00 1046 34.98 WIDOWED 8 2.50 40 1.60 0 0.00 1 5.00 49 1.64 DIVORCED/SEPT 45 14.06 366 14.73 16 11.64 3 15.00 434 14.52 I.IVE-IN/COMMQN LAW 32 10.00 77 3.00 5 3.29 0 0.00 114 3.91 TOTAL 320 10.70 2498 83.55 152 5.08 20 0.67 2990 100100 SEX MALE S FEMALE S TOTAL % NEVER MARRIED 1166 44.76 1Bi 4^.01 1347 45.05 MARRIED 975 37.43 71 19.44 1046 34.98 WIDOWED 31 1.99 19 4.68 49 1.64 nIVORCED/SEPT 344 13.21 90 23.38 434 14.52 VE-IN/COMMON LAW t9 3.42 25 6.49 114 3.01 TOTAL 2605 87.12 315 12.88 2990 100.00 1914 Caaposlte by Raee Ctrrac[eristies BIact White Hupanlc AR Late 30's Mid 201s Late 20's Eduestlan High School Grad Htgh School Grad' C Some H/8h School Annual EarNn6 About $12,000 with some ollege ADout 520,000 About $15,000 Oceopatlon Blue Collar 51. Collar Blue Collar Marrtal Status Marrled StnBk Married 1984 Coapoute by Ses ^trraeterunes Mak Female ' A8r Educatlen Late 20's Hqh School Grad/ ~'th so°e College late 20's High SOhool Gradt nlth some College Annual E.rnln 6 Ahout 530,008 About $9,000 O..Wticn Blue Collar White Collar Marital Statu6 Smek Sln61e
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AN ANALYSIS OF POLICY AND PROGRAM IMPLEMENTATION FOR THE IM- PAIRED NURSE: WHAT IS BEING DONE IN THE UNITED STATES Laina Gerace, R1V., M.S.N. The purpose of this paper is to provide an overview and analysis of policy and program implementation which deals with the issue of impaired practice within the nursing profession in the United States. The problem of professional impair- ment is not new to nursing or to society in general. However, only recently have professional organizations, induding nursing, addressed the problem. The term "professional impairment" is used to refer to the interference of psychological dysfunctions and/or chemical (drugs, alcohol) dependency with ac- ceptable professional practice. The problem is not unique to any one career or pro. fessional group. Indeed, impairment is a problem affecting society as a whole. Recent attention by the media in the United States on road accidents and subsequent in- juries and deaths caused by drunk drivers affirm this. One reason the professions, as well as society at large, have been slow to deal with the problems of chemical abuse and psychological dysfunction is the existence of denial about the problem. Denial of the problem leads to avoidance of both the identification of the scope of the problem as well as lack of policies and programs to address the problem. Fitzgerald (1983) called alcoholism "the most neglected health problem" today, stating that, "neglect springs from denial, the hallmark of alcoholism." Denial is a central component of both psychological dysfunction and addictive disorders and such denial exists within the health care professions as well. In this regard Isler (1978) noted that health care professionals "tend to look the other way" when confronted with substance abuse in their own members. Thus, when professional groups say they do not have a problem related to professional impairment within their own group this most likely reflects denial of the real situa. tion. Such denial is actually "enabling," a term which refers to supporting responses or failure to take action on the part of colleagues or institutions, thereby allowing impairment to continue unchecked. Exposing the problem of professional impairment, on the other hand, risks arous- ing undue concern by the general public and other professional groups about the extent of the problem. In other words, when nursing makes public information about impairment within its own ranks, the severity of the problem might be ex. rated by outside groups. The media, as consumer advocates, might sensationalize the problem. Such reactions are based in part on a lack of knowledge about addic- tive diseases and psychiatric illnesses. Currently, in the United States, alcobol and drug abuse education are a focus of educational programs in the public schools as well as in the media. Thus education of the public is beginning to take place. However, education, also needs to take place within each professional group in order to build professional awareness about the impairment problem and the nature and course of addictive diseases and psychological dysfunction. The nursing profes sion has begun this process by publishing a variety of articles on professional im- pairment in professional joumals IBisseil & Jones, 1981; Jefferson & Ensor, 1982; Fnsor, Diiday, 1985) and in the official publications of state level professional organiza. tions. Workshops are also being offered in various regions of the country to educate nurses about professional impairment. Because attitudes about impairment on the part of the general public, other profes sional groups and those of nurses themselves may still be moralistic and uninform ed, it is important for the profession to acknowledge the problem and to formulate Policies and implement programs without exaggerating or emotionalizing the scope of the problem. A realistic attitude may be as follows: Most practicing nurses are healthy individuals whose practice is effective and responsible. When a nurse becomes Professionally impaired protocols exist to facilitate early intervention. While pro. tection of the public needs to be served by the policies and programs which are formulated to deal with the problem, such protection must be balanced by the rights of the impaired nurse as well. It is an indication of maturity within our pro iession to recognize and address the problem of professional impairment. Professionals are as human as anyone else, therefore are subject to the same vulnerabilities as any other human being. Health care professionals, however, tend to view themselves as helpers, not as recipients of help and often deny vulnerabili- tY to diseases, including chemical dependency and psychological dysfunction. In wder to begin to deal effectively with the impairment issue, individuals and pro le"'onal groups need to acknowledge that nurses have the same vulnerabilities as Other persons to the development of addictive diseases and psychological dysfunc- Uoill IANA, 19841. More important, the rights of the nurse whose practice is im- Pau'ed are the same as the rights of any other individual. These rights are articulated ~ the American Nurses' Association in their excellent policy document as follows: 1' ~ogttition as an individual with a disease 2 referral to comprehensive treatment programs 3 confidentiality and protection from slander and stigmatic behavior 4. appraisal of legal rights regarding self incriminating testimony 5. benefits and health provisions accorded those with other diseases 6. modifications in the work setting that allow the nurse to utilize professional skills and education during recovery from illness 7. modifications of factors in the workplace that would increase the Fisk of illness The absence of policies and programs that take into account these rights actually means that the nurse as a professional person is accorded less value and protection than workers in other areas, such as manufacturing, where employee assistance programs support the well-being and rehabilitation of the impaired employee and where the outcome goal is to return the employee to the work situation. Scope of the Problem LitUe reliable data exist on the prevalence of psychological dysfunction and alcohol/drug dependency in nurses. The prevalence on psychological dysfunction is more difficult to estimate than alcohol/drug dependencies partially because ac- tion on licensure due to psychological problems rarely occurs, and when it does occur it is classified under illnesses in general. Prevalence of alcohol/drug impair• ment can only be estimated from (1) information about actions taken by state boards of nursing for violations of the nurse practice act involving substance abuse and (21 from what we know about alcohol and drug dependence in general. ( l l Information about actions taken by state boards of nursing has been compiled by the National Council of State Boards of Nursing. This council is an organization which has as its membership the state boards of nursing. A data bank containing cases which sustained disciplinary action against nursing licensure Is maintained through report given to the council by each state (excluding California and Georgia- LPN Board only). The case categories most closely reflecting discipline related to alcohol/drug related impairment are: a) action involving drugs b1 actions involving administering medications The first category involves drug abuse, alcohol abuse and diversion of drugs for self. The second category involves not giving drugs when signed out, use of illegal prescriptions and misuse of wastage or wastage not accounted for. In category lal action involving drugs, the unpublished reports of the National Council of State Boards indicated discipline for 2,364 registered nurses and 1,128 for licens- ed practical nurses from 1980-1984. In category Ib) actions involving administer- ing medications, 493 registered nurses and 352 licensed practical nurses were reported from 1980-1984. With the total practicing registered nurses in the United States estimated at 1.4 million and licensed practical nurses at 900,000, It can be seen that this is a very small number of cases. However, since licensure discipline generally occurs when behavior is overtly in violation of the nurse practice act, these figures do not reflect the realistic picture of the scope of the problem. 121 Estimates about alcohol and drug dependence in the nursing profession can be made from what is known about alcohol and drug dependence in general. Bissell and Jones f 1981) estimated that about five percent of American women are ad• dicted to alcohol. Since the majority of nurses are women (96%), the assumption can then be made that at least five percent of the 1.4 million nurses in practice are alcoholic and an unknown number are simultaneously or independenUy also addicted to drugs. According to the ANA (1984) publication, addiction to drugs in the general population is estimated at 2-3 percent, and psychiatric illness at 2-3 percent for psychoses and 5-8 percent for depression. These estimates are considered to be low because they are based on diagnosed populations and do not account for those individuals who are not referred for treatment. The Policy Formation Process Professional state level as well as national organizations and specialty groups have had key roles in intitiating a formal position statement by the American Nurses' Association IANAI to address the problem of nurses whose practice is impaired by drugs, alcohol or psychological dysfunction. Under the direction of Dr. Madeline Naegle IPace University), whose doctoral work was in women and alcohol, the ANA Task Force on Addictions and Psychological Dysfunctions was established. This task force combined the interests and expertise of three groups: The ANA Division on Psychiatric and Mental Health Nursing Practice, the National Nurses Society on Addictions and the Drug and Alcohol Nursing Association IANA, 19841. The task force provided the leadership necessary for the passage of the 1982 Resolu• tion for Action on Alcohol and Drug Misuse and Psychological Dysfunctions by the ANA which declared that the profession of nursing needs to address "misuse of alcohol and other drugs and emotional and psychological dysfunction" in its own 53 TIMN 321444
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AN ASSESSMENT OF ALCOHOL ABUSE PROGRAMS IN ARCTIC CANL`iLA Winnle Fraser-Mackay 1ivo of the more frequently asked questions regarding Alcohol and Drug Program. ming in Arctic Canada are, "What are the differences between programs operating in Northern and Southern Canada?" and "Are these programs really effective and what is most effective in the delivery of cross-cultural programs?" I hope to be able to provide you with a wealth of information on our Alcohol and Drug Abuse programs and how they operate in Arctic Canada. The Alcohol related problems of the Arctic are unique: therefore, solutions and pro- gramming have to be unique Arctic Canada is equivalent in size to 3,376,698 square kilometers, 1,304,903 square miles, or about one third of the total area of Canada, approximately equal in size to India, with a sparse population of 48,000. Traditionally, peoples of the High Arctic were divided into two groups-those peo. ple who spoke variations of the lnuit (Eskimo) language and followed a certain style of life, typified by the kayak and the snowhouse. In general, these were peo- ple of the Barrens and the coast. The second group were Athapaskan speaking people (Dene) whose culture was typified by the snowshoe and the canoe These Northern Indians were people of the land, forests and lakes. Alcohol was first introduced to the indigenous population in the Northwest Ter- ritories in 1771 by the fur trading and whaling companies. Whalers operating in the Eastern Arctic tended to restrict alcohol to their own use; in the Western Arr tic they distributed it, and even taught the natives how to make home brew. According to Jeness i1964), the whalers' sexual, as well as economic, exploitations of indigenous people was combined with the indiscriminate distribution of alcohol. However, Jeness goes on to state that this exploitation and discrimination which was resented by several indigenous groups and the newly arrived missionaries was ended on July 1, 1958. A proclamation by the Governor in Council permitted the Indians to consume liquor in all licensed premises. A second proclamation in January, 1957 extended full liquor privileges to both Indians and Inuit in the Northwest Territories. The face of the Arctic changed significantly with the advent of the mining opeta. tions, the establishment of regional government offices, the industrial development following the Second World War and the construction of the Distant Early Warn- ing Line These events brought job opportunities to the Native People, encouraging the development of larger communities and exposure to the vices as well as the virtues of the whites. The old ways changed. The population of the Native people increased with the advantages of medical science, but the job opportunities did not keep pace. A primitive culture had been catapulted into a modern world which included unrestricted ac- cess to alcohol. Alcohol abuse is an all-pervasive problem in Arctic Canada. Eighty percent of all deaths are alcohol-related. One death in four is a violent death. This includes an alcohol-related suicide rate double the rest of Canada. We have boating, snowmobile and small aircraft accidents rather than the alcohol-involved automobile fatalities of the south. With the traditional ways changing, family violence has also increased dramatically. But while the results of alcohol abuse are amply manifested in social problems, an anomaly exists in the physical realm. The incidence of cir- rhosis of the liver is much lower in the Northwest Territories than in southern Canada and there have been no deaths reported as a result of cirrhosis of the liver. Ninety-five percent of incarcerations are alcohol-related in the Northwest Territories, where there is no social stigma attached to a jail sentence. Many crimes are com- mitted with the express purpose of "joining friends and escaping Isolation : This attitude is typical of the thinking of the northern people to whom social relation- ships and family unity are an integral part of their life. For the people of the north, there is no such thing as solitary drinking nor drink- ing in moderation. Alcohol is to be shared in a group and generally in a public place. In some areas there is no public place to drink so "partying" and weekend binge drinking takes place throughout the community with parties progressing from one home to another. One example would be the community of Cambridge Bay, where the beer outlet is situated in the Hudson's Bay store Beer sales are held weekly. Fvllowing this regular event, the inddences of absenteeism from work, family violencG child neglect, criminal offenses and suicides rise dramatically. This behaviour is a typical exam- ple of the imbalance found in many communities-one of the major problems of the north. Alcohol abuse and it's problems has resulted in the erosion of much of the Native culture, most notably in the loss of traditional respect for the elders and the leader- 60 ship formerly provided by them. The erosion of traditional culture has caused grave concern and several steps to reduce this prevalence of alcohol abuse have been taken at the local level to encourage a return to earlier cultural pursuits. The ap• proach of the people and ours in solving these problems is wholly through com- munity effort-an approach as unique as the problem. Even the availability of alcohol is decided by each community through local liquor plebiscites. To hold a plebiscite, the community must send a petition to the Minister of Justice and Public Services in the capital city of Yellowknife, asking him to allow the com• munity to vote on the matter. A sixty percent vote for change would provide the community with new regulations from the Minister in Yellowknife. In deciding the availablility of alcohol the community has three choices: I) No Restrictions: People in the community are free to import or have as much alcohol as they wish (subject to income). They can make beer and wine according to existing regulations governing the making of alcohol; 21 A Prohibition System: People in the community are forbidden to import, have or make alcohol within a community. There is usually a stated area or radius within which these ac- tions are illegal; 3) A Control System: People may decide that they want to limit the amount or kind of alcohol allowed into the community. They may wish to limit the ordering privileges of those who have abused the use of alcohol. Delivery of alcohol and drug services in Arctic Canada is community-based and the thirty-five alcohol and drug programs are sponsored by the Band (Dene) Coun• cils and Hamlet Councils. Community programs receive their funding through the Government of the Northwest'1'erritories, via Alcohol and Drug Services, a divi- sion of the Department of Social Services; funding is also provided from the Na. tional Native Alcohol and Drug Abuse Program (N.N.A.D.A.}?), an agency of the Federal Government Department of Health and Welfare. These funds are approved by the Alcohol and Drug Co-urdinating Council jA.D.C.C.j, a body that represents Native Organizations and has three members at large, appointed by the Territorial Minister of Social Services. The thirty-five existing Community Programs applied to the Alcohol and Drug Co- ordinating Council and received funding. Programs must fall into one of six categories: 1) Residential 'Iheatment-Non-Medical: Residential treatment involves detoxification, rehabilitation, recovery services, individual group counselling, therapy, recreational services and extended care. This type of project is the most costly due to larger numbers of staff, cost of facilities and overall operating costs. The Northern Addiction Program belongs in the residential category. 21 Non-Residential Gounselling: Individual or family counselling is provided for individuaLs or families with alcohol and drug related problems, on an out-patient basis. 31 Youth-Oriented Intervention: These projects are designed to inform, support and counsel young people ex• periencing problems due to personal or parental abuse of alcohol and drugs. 4) Diversionary: These projects are designed to provide non-alcohol related activities usually in the form of recreational and social alternatives to divert people from alcohol in their idle time. These programs are usually youth-oriented. 51 Preventive Education: These projects are designed to present alcohol and drug information to com, munity residents, schools and agencies. The goal of these types of projects Is to encourage individuals to make responsible decisions for themselves on the use of alcohol and drugs. 61 Regulatory: Projects involved in regulatory practices usually are responsible for administer ing and regulating liquor orders under the liquor ordinance One of the more unique of the thirty-five community based programs is that of the Child Development Centre of Fort Norman. Here, high-risk children, many from alcoholic families, are provided an alternate environment. The counsellors encourage the growth and development of the children through educational and social ae tivities, offering them a more productive lifestyle The effectiveness of this program, which has been in existence for over five years, has been evaluated through com• parisons with siblings who have not taken part in this program. The participants in the program are more self-confident, less withdrawn and better prepared for the normal school program. TIMN 321451 -
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AN ASSESMENT OF THE REFERRAL PRO CEDURES AND A GENERAL PROFILE OF D.U.I. OFFENDERS IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Thomas F. O'Shea Introduction Cook County, Illinois encompasses the major portion of metropolitan Chicaga It is an area in excess of 5,000 square miles with a population of over five million five hundred thousand (5,500,000) people. Approximately three million two hun- dred thousand (3,200,0W) individuals in Cook County are licensed drivers. The Circuit Court of Cook County serves the City of Chicago and some 125 in- dividual communities adjacent to the City, all of which have their own individual law enforcement agencies and independent governments. To illustrate the magnitude of the operation, there are 355 Judges and more than 600 prosecuters in the system, all concentrated in an area of approximately 5,000 square miles. The Alcohol and Drug Education Services (AD1S) program was established to pro• vide a service to the Circuit Court of Cook County in the form of substance abuse assessments with recommendations for social/health intervention in addition to traditional sanctions. It has been our experience in Cook County, Illinois that when the DUI "problem" or the drinking/drugged driver is discussed, the discussion generally has evolved around is.sues concerning safety on our streets and highways. That concern cer- tainly is laudable and we do not in any way, wish to minimize the impact of traffic related fatalities on the fabric of society. The "flip side" of that "coin" of concern is to assess the blame for the condition. All too often it appears to be very easy to scapegoat the criminal justice system in general and the judiciary specifically. Courts have been accused of being too harsh, with punitive sanctions that do not allow for consideration of what is iden- tified as the root cause of the problem, the alcohol or other drug. Courts have also been accused of being too lenient when diversionary tactics are applied. In either case, the courts are accused of being insensitive to the problem, depending on whose "ox is being gored": An initial point of this dialogue is that there are multiple interests that react to the offense of drinking and driving or otherwise drugged driving, all of whom have agendas that must be satisfied in order to bring the individual offense to a positive conclusion. In the area that the Alcohol and Drug Education Services (ADFS) program functions, the concerns of the Legal/Criminal Justice System, which has primary responsibility for the offense, must be addressed. The Safety System, which includes the State of Illinois licensing authority, the Secretary of State, the Federal Department of Transportation, the State Department of Transportation, and various private safety initiatives, such as the National Safety Council, the American Automobile Association (AAA) etc., all have stated concerns for public safety. Citizen groups in Cook County, Illinois that have an active concern regarding the impaired driver are the Alliance Against Intoxicated Motorists (AAIMb Mothers Against Drunk Drivers (MADD), Students Against Drunk Drivers (SADD), Remove Intoxicated Drivers (RID), to name a few. The Health Care./Substance Abuse System has an obvious interest in the impaired driver because of the drugs involved. Of additional concern is the necessity to have these other elements of society pro- vide the legal system with additional identification and assessment components to enable the Court to provide dispositions in these matters that incorporate the needs of these other systems. The ADES Program perceived a need to integrate the con- cerns of the various systems and the increasing awareness within our society, by what we believe is an accurate method of identification and sorting of the DUI population. Dc Pisani, in his presentation, has indicated the diversity of the DUI population in our area. We will attempt to profile that population, provide some practical ap- plication to sorting the offenders by perceived social and/or health risk, and apply- ing the appropriate level of intervention for each offender. The Court Process In the adjudication of DUI cases, the Circuit Court of Cook County is governed by its Rule 11A, which states': Prior to entering into plea negotiations or considering for supervision, a defendant Who has been charged with violating Section 11-501 of the Illinois Vehicle Code (driving while under the influence of alcohol, other drugs or combination thereof), IIL Rev. Stat, 1083, ch. 951/2 par. 11-501, the court shall first review and have tnaIe a record of each of the following: a. The facts and circumstances of the violation with the specific attention to the level of alcohol concentration in the defendant's blood and to whether per• sonal injury or property damage resulted from the violation. b. A recidivist check by an agency capable of providing a record of any prior super vision orders. c The written alcohol or drug evaluation of the defendant with special attention to any alcohol or drug related driving offenses. d. The past driving record of the defendant with specific attention to any alcohol or drug related driving offenses. e. Whether in connection with the circumstances of the violation, the driving privileges of the defendant have been suspended as a result of a refusal to sub, mit to a chemical test. f. If the defendant requests a sentence of supervision, he shall make a statement to establish: 1. That an Order of Supervision Is in the best interests of the defendant and his family; 2. That an Order of Supervision is in the best interest of the public, and 3. That there are other matters in mitigation for consideration g. Any other factors deemed relevant by the Court or brought to the attention of the Court by either the defendant, the States Attorney or victim. Thus, the Court has expanded it's traditional measurements used in criminal cases. Prior criminal background, premeditation, deviant behavior, and circumstances of the offenses are still applicable but have been enhanced by elements of the in• dividuals social behavior and specifics regarding substance use/abuse In other words, what risk is this defendant to society and himself from the stand- point of the legal, safety, and health issues involved? There is a common measure- ment for all systems. Within the measure is a different meaning or common denominator for each system. With the adoption of new DUI legislation in 1982 in Illinois, including a "per se" conclusion at .10 B.A.C., defending the DUI offense has become more difficult. It is not uncommon for both the prosecution and the defense to enter into plea negotia- tions on this offense. Before there can be any agreement, all elements must be in compliance with Circuit Court Rule 11.4. Defendants are referred from the Court to the ADES Program either on a"Pre, Sentence" basis, if a plea of guilty has been entered by the defendant, or a"Pre- Trial" basis if by agreement of both the prosecution and the defense Defendants not wishing to avail themselves of the procedures may go to trial, which is their right. Defendants found guilty after trial, are also generally referred to ADES for a "Pre-Sentence' assessment. Defendants are referred by the Court to the ADES program on a 23 to 30 day basis which is the next court date available to the defendant on the normal Circuit Court of Cook County cycle. Since the disposition of the case is dependent on the assessment, the responsibility to follow the ADES procedures weighs heavily on the defendant. As stated by Dr. Pisani, a number of written instruments are utilized to assist the rogram in concluding a risk factoc These include a Personal Data Form, an Attitudinal Study, M.A.ST:, an ADES Substance Abuse Assessment, a Behavioral Assessment Scale, and the Education and Referral Officer's (EROIs) impressions. Also influenc- ing the risk factor are certain criteria that impact the Court's traditional method of evaluation. These include prior alcohol/drug related offenses and the circumstances of the offense Tradition measurements in safety and health issues are high BAC, prior remedial guidance, counseling or treatment, prior inpatient rehabilitation and prior Alcoholics Anonymous (AA) or other self-help attendance. Thus, the ADES process includes elements of risk that impact all three systems; legal, safety, and health. From the accumulated information, both positive and negative, gathered during the assessment, a report is prepared for the Court that contains all elements of significance A risk factor of 0, 1, 2, or 3, increasing in severity, is included in the report. A level of intervention is recommended with the level of risk. The Court requested, after extended exposure to the numerical risk sequence, that an opinion be rendered, in the report, as to the perceived effect of the recom- mended intervention on the individual's risk factor. A statement is included as to whether the perceived risk can be modified by implementation of the ADES recom- mendations. TIMN 321454 63
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Tableau 6: Ce qu'est un coll'egue de travail qui boit aux yeux de 407 repondants du bilan de sante (pourcentages)• 2. Les sentiments a Mgard de 1'alcoolique masculin et feminin i des zEppnses L'alcoolique 00I NON N.A. ~ eTaque ElEs~ent _ _ c80IX de 1'EiEaent le plus iarportant  r 1. rcus fait •pitiE 65,1 16,7 16,2 41,5 47.4 2. voua fait penr 34,9 36,6 23,5 16,0 6,4 3. vous Lisse indMErent 11,1 54,3 36,6 5.9 2.7 4. us inspire de la ygne 45,7 25,3 29.0 10.1 17.2 5. wus iaspire do s,bpris 27.5 42,0 30,5 11,3 8,4 N.R 15.2 17.9 7ata1 100.0 100.0 Tableau 7: Les sentiments a 1'egard de I'alcoolique chez 407 repondants du bilan de sante (pourcentages). Devant I'alcoolique en general Itableau 7), la reaction la plus repandue (les 2/3) a ete la piUe, ensuite le gene (pr6s de la moiti8), devent la peur (plus d'un tiers), le mepris (plus d'un quart) et 1'indifference (1/I0eme). Le meme distinction des CHOIX par sexe que dans le tableau pr6cddent revele que les repondants sont plus enclins 5 la piti6 pour une femme (47,4%) que pour un homme (41,5%) ainsi que plus a la gene (respectivement 17,2% et 10%), alors que 1'alcoolique masculin suscite beaucoup plus de peur (16% et 6,4%), de m8ptis (11,3% et 8,4%) et d'indifference (5,5% et 2,7%). 3. Les reactions devant I'alcoolique 6 des rEpona.s OOI NON N.R. ®OIX de rouz y ehaque E1 6-nt 1'ElEaent 1e plus ,?us. 1'alooo- inportant 1. quslqs'un A zedoutez 24,e •4,2 31.0 6.9 2. quelqe'un A aider 86,5 5,2 8,3 84,3 3. quelqu'un A laisser toeber 6.6 63.1 38.3 3.9 N.R. 4.9 --tnu1 ,-, -•--- - - - - - ---~00:0 Tableau 8: Ixs r¢actions devant 1'alcoolique de la part de 407 repondants du bilan de sante (pourcentages). Des trois elrsments de reponse proposes au tableau 8, le seul qui est positif, quei- qu'un ~ alder, recueille presque autant d'adhdsions dans les CHOIX (84,3%) que dans les OUI (86,5%), ce qui est rare, suscitant encore moins de NON (5,2%) que de non•r6ponses (8,3%). Autre signe dans le meme sens pres des 2/3 des repondanis sopposent a i'idee de le laisser tomber (seulement 6,6% y seraient enclins). D. L'ETIOLOGIE PERSONNELLE ET SOCIALE DE L'ALCOOLISME 1. 1.'aicoolique est-il victime ou responsable? Tableau 9: les alcooliques comme victimes ou responsables aux yeux de 407 repon- dants du bilan de sante (pourcentages). Les deux questions suivantes contribuent a soulever le probleme de 1'etiologie de 1'alcoolisne: en partlculiet faut-il incrimer la responsabilite du su)et ou son environne- ment (tableau 9)? Notre dchantillon de repondants laisse une impression de perplexite: "responsables" (68,1% de OUI) precede "victimes de circonstances" (55,3%); "coupables" (45,2%) vient dgalement avant "victimes de la societe (34,9%). La m@me hierarchisation se &6gage des CHOIX de 1'element le plus impottant: "respon• sables" (35%i et "coupables" (15%) atteignent ensemblent 50%, tandis que "vic- times de circonstances" (26,3%) ou "victimes de ]a soci6te"' ideux fofs moins: 13,8%), 51 totalisent un peu plus de 40%. Ce qui ne saurait suffir ia trancher le d6bat. Ls des rEponses .lscooly~,es l i p0I NON Q•R. 6 eh.que ElEs ne y Eldment le plus iwport.nt 1. vi et ieu de 1a socidtE 34,9 36,9 28,2 13,8 2. vieti.es des airconstances 55,3 19,9 24,8 26.3 3. coupables 45,2 26,3 28,5 15,0 4. responsables 68.1 12,0 19,9 35,1 N.R. 9,6 _.,_-9bt7 -2OO;0a.•a 2. Pburquoi 1'alcoolique en vient-il a boire? A 1'aspect plus sociologique du probleme dans ia question precedente (tableau 9) stlcc6de son aspect plus psychologique au tableau 10. Les 3/4 des OUI donnent prioritd a combler un manque, plus de Ia moltie insistent sur le fait de rem@dier a la solitude, un peu moins de la moiti@ tiennent it 6prouver un plaisir, presque 3 sur 10 @tant frappes par les dures conditions de travail. 1-es CHOIX, sollicit@s pour l'un et 1'autre sexe, montrent par detfi la meme hidrar• chisation des 61@ments, que remddier a la solitude est deux fois plus imputd aux femmes (31,5% et 16,5%), alors que 6prouver un piaisir 1'est deux fols plus (20,9% et 8,9%) et que supporter de dures conditions de travail I'est quatre fols davantage (10,3% et 2,5%) aux hommes, combler un manque survenant 5 I'dgalitd en premiere position (42% et 43,2%) pour les deux sexes. 0'apras .ou %des rEponses psa 1'aloooliqoe ¢oit pour 'r 53.3 24,6 22,1 pfui-1ipaoiCintel ~- 16.5 31.5 I 42.0 43,2 ~ 20,9 8,9 ONI NON N.R. 1, ehaque ElEm.nt 1. r..fdier & sa solltude 2. cueblez un .anque 3. Epronver un plaisir 4. supporter de duzes conditions do travail Yota1 74,2 10,6 15,2 45,2 27,8 27,0r 29.2 41.3 29,5 10,3 2,5 10.3 13,9 100.0 100,0 Tableau 10: Pourquoi l'alcoolique en vient a boire d'apr6s 407 rdpondants du bilan de sant6 (pourcentages). E. COMMENT L`ALCOOLIQUE PEUTIL S'EN SORTIR? 1. Sur quels criteres apprecier qu'une personne alcoolique s'en sort? Peut-on se defaire des exces de consommation d'alcool (tableau 11(? Seulement un repondant sur 10 estime cela irrealisable pour 5 qui le crolent possible, mais 4 ne se prononcent pas ces proportions expriment bien 1'embarras du public sur un point controvers€• a otre s des zEponses par: vis, unealeooli9ve personne e OUI NON N.R. 1 ehaque E1Eaent CNOIX de 1'616uen 3 lus ie- pgrtant 1. qusnd lle sait faize faee 1 ses prebltaes 77,6 3,9 18,5 38,8 2. quand elle peut dire non ~ 1'aleccl 84.3 3,0 12,7 48.7 3. quand e13e ecr•sore aodEtE~t 33,9 33,4 32,7 3,2 6. elle ne s'en sort Ssaais 11,1 19,1 39,5 2,7 N.R. 6,6 9'otai 100,0 Tableau 11: A quels criteres apprecier qu'une personne alcoolique s'en sort d'apres 407 repondants du bilan de sante (pourcentages). La moddration est-elle une voie? la-dessus, 1/3 de OUI, 1/3 de NON, 1/3 de norr TIMN 321442
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membership, and called for programs of assistance and intervention as well as mechanisms for ongoing collection and dissemination of information, including educa- tional and research activities related to the impaired nurse. Preceding the passage of the 1982 Resolution, there had been "grass roots" state level concern about the problem of the impaired professional, developing in the late 1970's and continuing even now. A review of state nurses association literature (from a file kept at the College of Nursing at the University of Illinois at Chicago) revealed that psychiatric mental health nursing sections, recovering nurses and nurses with interest and experience in treatment of chemical dependencies were most active in providing state level leadership. Activities ranged from educational to development of peer assistance networks. In 1983-84, approximately two-thirds of all states published information on the impaired nurse. Development of liaisons between the state nursing associations and state boards of nursing have been ongoing throughout the policy process. The major overall purpose of state boards is to ensure that nursing care is safe and that the public is protected, whereas the overall purpose of state professional nurses associations Is to act as advocate and support to Its membership. By working cooperatively to deal with professional impairment the interests of both the public and the impaired nurse can be safeguarded. Before the development of the liaisons between state nursing associations and state boards, the usual way to deal with the impairment problem was to allow impair- ment to continue until it was too obvious to ignore and then report the nurse to the State Board of Examiners for violation of the Nurse Practice AcL Each state Nurse Practice Act contains a section on grounds for refusal, suspension or revoca- tion of the license. Illinois, for example, includes °ls habitually intemperate or in- toxicated or is addicted to the use of habit-forming drugs" as grounds for discipline. Some states have also added a mandatory reporting clause into the nurse practice acL Such a clause requires that an administrator/employer observing that a nurse's practice is impaired due to habitual intoxication or drug addiction or that such a nurse is diverting habit-forming drugs belonging to the hospital or nursing home must file a written report of this to the State Board of Nursing unless the nurse participates in a course of counseling and/or treatment under the monitoring of the agency. The latter underlined part of the mandatory reporting clause from 11- linois' Nurse Practice Act reflects the cooperative nature, which should ideally ex- ist, in policies for the impaired nurse. Unfortunately, not all states have this flexibility in their clauses. The basic issue in the relationship between a professional society and a board of nursing, therefore, is the method of reporting violations of practice act to the board of nursing. "Questions on what is reported, when and how, must be answered in a manner that reflects an understanding of the mandates of the state's laws and nurse practice act and of the individual nurse's tighis. There must be safeguards to both rights and responsibIlities." (ANA, 1984, p. 12.) As program implementation becomes more secure in terms of peer assistance net- works through the professional organizations and smooth referral systems Into cooperating treatment agencies, nurses can be channeled into the professional organization's referral program rather than into the state board system. For exam- ple, the Tennessee Board of Nursing during its November 1983 meeting endorsed the Impaired Nurse-Peer Assistance Program sponsored by the Tennessee Nurses' Association as an appropriate channel to report nurses who are impaired. The goal of such a program is to get the nurse out of practice (temporarily, while ill) and into treatmenL Only if the nurse does not cooperate is the matter reported to the state board. Thus, reporting is used as a leverage to get the nurse into treatment. The use of reporting to motivate the nurse into treatment Is appropriate because as Green (1983) pointed out, recovery from alcoholism or drug addiction does not occur from spontaneous insighL It occurs when the pain from experiencing the consequences of chemical abuse "penetrates the defense system shielding the per- son from reality." A model for the cooperative policy is portrayed in F'igure 1. Depicted are the chan- nels by which the state board and the state professional organization cooperate to remove the impaired nurse from practice and to facilitate entry into treatment, and to monitor progress and rehabilitation. The impaired nurse is reported by a colleague or employer (or by herself) to the professional organization's peer assistance network where trained volunteers who are peer professionals counsel the nurse into treatment Such treatment preferably takes place in an agency familiar with professional impairment and cooperative with the monitoring necessary for follow through. Only if the nurse refuses treatment Is a report filed with the state board. Should it become necessary to file a report with the state board, the board can still maneuver the nurse into treatment through an agreed upon probation, a "con- sent agreement" that the nurse will cooperate with treatment while the license is suspended. In either case, once the nurse is In treatment, progress is monitored for a prescribed amount of time (perhaps two years). In the case of a totally un• cooperative nurse, the license is revoked in the interest of public safety. The overall goal of the cooperative policy, therefore, is to identify and assist the impaired nurse to seek treatment so that, given the same rights as any other person with an addic- tive disease, the nurse will be restored as a useful member of the profession. State level program implementation based on the cooperative model has three im- portant components as was outlined by Dilday (1983). The first of these is educa- tion to provide information needed by nurses to learn about professional impairment and how to implement an impaired nurse peer assistance program. The second program component is treatment entry. A systematic method for identifying and facilitating the impaired nurse into treatment while suspending practice is essen- tial. The third component, treatment and rehabilitation, needs to provide for a system of communication between employer, professional organization, treatment agency and nurse so that all work together for treatment and follow-up. Most important, this component must also provide for subsequent re-entry into nursing practice when feasible and appropriate. In addition to the above program components, research is another essential con- tribution. We need to find out more about factors that lead to or place professionals at risk for impairment such are being studied by Haack (1985) and Gerace (1985). Longitudinal studies on the course of impairment, such as the studies by Bissell (1984) are extremely valuable for our understanding of the impaired professional. For the future, I believe we need to keep improving data banks on the impaired nurse cases in the United States, maintaining, of course, complete anonymity and confidentiality. More research needs to be done on psychological dysfunction as well, since this is a less clearly defined area of professional impairment. Policy Evaluation Policy for the impaired nurse can be evaluated by examining it in terms of the "least advantaged" recipient. A just society is one which would be created by in- dividuals if they had no idea how they would fare in such a society (Rawls, 1971). Any policy must work to the advantage of the least advantaged members of the society. Bringing this concept to the problem at hand, the question becomes: Does the cooperative policy as it is developing in the United States, work to the advan- tage of the least advantaged members in the health care system? Most likely, the least advantaged member in the health care system is the patient because of the patient's status in the system, vulnerability due to iilness and dependency on the nurse for well being. An uninformed observer may view the cooperative approach as one which "mol- ly coddles" the nurse. Such an observer may believe that when a nurse Is impaired the license to practice should immediately be revoked and the nurse suspended from practice. This belief, however, is not grounded in any factual basis. Bissell (1984) demonstrated that in the course of addictive disease in health care profes- sionals, most entered treatment with their licensure intact and were still practia ing. Few had ever been admonished about their drinking or drug use by colleagues. This, again, seems to reflect the denial system which accompanies addictive diseases as well as psychological dysfunctions. Professionals tend to function in "enabling" roles much as do families of chemically dependent members. Reporting the im- paired practitioner tends to occur very late in the disease process. Programs based on the cooperative policy, however, encourage early case finding and have mechanisms in place to support the nurse through treatment entry and throughout rehabilitation, hopefully restoring the nurse back to practice. This can actually benefit the patient in two ways. The first is that, because the profession is becoming educated and programs are facilitative, the nurse whose practice Is impaired will be suspended from practice much earlier than would otherwise oc- cur. This provides increased patient safety. Secondly, impaired nurses are characteristically among the best achievers (Bissell, 1981). Therefore, as these nurses are rehabilitated, the best of the practitioners are returned to the bedside, thus benefiting the patienL In terms of social benefits, professional colleagues of the impaired nurse also need to be considered. Those who have experienced having an impaired colleague In the work environment can remember the costs to professional well being in terms of agonizing over what to do about the problem, filling in for the colleague in the work situation and experiencing concern for the impaired nurse's welfare. Now policies and protocols are developing to guide colleagues when one of their own is impaired, creating a greater sense of security when situations like this occur. Thus colleagues, health care institutions, and public welfare, as well as the impaired nurse are all served through the cooperative policy. This is not to imply that program development for the impaired nurse in the United States is problem free. At this point in time only 18 states have peer assistance networks fully established, although 17 additional states have programs in the developmental stages. (Cole, 1985). Details about program linkages and communica- tion systems are often difficult to work out and funding for such activities is not easily obtained. However, with the state boards and state professional organiza- tions working together both the impaired nurse and the public safety will be pro' tected. Such cooperation should filter down to local levels for program development and implementation. Reference List 1. American Nurses' Association. (1982). Addictions and psychological dysfunctions 54
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trrated at one ARC in 1983. According to this lable, at the one year follow-up. 51.4 .• of the subjiwts were totally abstinent, 13,1% experienced one or two slips and 12.4 ;. returned to drinking without identified problems. l hus, 76.9% of the patients treated in 1983 showed some improvement at the end of 12 months of follow-up However, 9.9% of the subjects returned to drinking with continued pro. blems and 13.1% were released for alcohol-related problems. The results of previous years are similar with apparent success rates of 79b%, 81.2% and 77.9% for 1980. 1981 and 1982 respectively. These results are similar to the ones reported for the I LS Navy IBucky, 1980 a and b; Bunne, 1980; Kolb et al., 1975; and Skuja et al, 19801. DISCUSSION I hese results could be attributed, in part, to the early diagnosis of alcoholism and to the fact that the majority of our patients did not experience any important social disruption. In fact, most patients treated are young, have a regular job and only a few of them have suffered a marital rupture. However; since no control group was used, it is impossible to attribute the changes observed to treatment given. I•hus these statistics must be interpreted with caution. Moreover, it should be noted that this measure is based on a relatively short period of time 112 month follow•up1 and on a staff report IPhase III Coordinatorl. Findings from different studies indicate that during this 12 month interval, variations in group data are frequent and data for individual subjects continue to show some variability even after this period of time According to Oxford et al., 1976; Caddy et al., 1978; Maisto et al., 1980; Sobell and Sobell, 1982, twelve months is the lowest accep- table limit for a follow-up. In general self-reports remain the source from which one bases the conclusion about efl6ctiveness of treatment. This method is often consfdered with skeptici.urt. In many situations this attitude was not based on a systematic examination of the facts ISobell and Sobell. 1975: Harford et al., 1976; McCrady et al., 1978; Maisto et al„ 1979; Cooper et al., 198i; Polich, 1982; Leonard et al., 1983; Skinner in pressi. However in a work setting, where the self-report could potentially be used by the supervisor in a detrimental way, it is wise to stay away from this measure as a s•ole source of data. In fact, it is now recognized that no single source of alcohol treatment outcome data can be expected to be error-free. Thus, it is highly recommended that reports designed to be mutually corroborating be obtained from multiple sources [Sobell and Sobell. 19801. Using an ancillary supervisors report to measure a pa ticnts improvement is better than using a self•report alone in the work setting. CONCWSION Despite the reported successful outcome of the Alcoholism Rehabilitation Program since 1980, a new evaluation program will be put in place in 1986. Multiple sources of data and longer follow-up periods are the two main characteristics differentiating this new evaluation from the former one The evaluation of treatment effectiveness will be based on three different sets of data: 1. Ouestionnaires addressed to: a. patient; b. medical officer: c. supervisor; and d. Phase Ill coordinator. 2. laboratorv tests 3. Official records. I his new evaluation design will address ten main variables: alcohol consumption: work performance: work problems: iliness: hospitaliration; liver funcnon: life ex• pectancy: social lifc• and locus of control. Data covering the one year period before the beginning of the Phase 11 will be collected retrospectively and compared with the data gathered at intervals of 0. 12, 24 and 00 months follow-up periods, com mencing with the completion of the Phase II. REFERENCES fi1ICK5" S.F. 11Q80a1. The 1976 Evaluation of the Navy's alcohol rehabilitation pro grams. In G.A. Bunn: tiS Navy Alcohol Studies Vol i, Naval Alcohol Rehabilita. tion t:enter: San Diego. BI ICKY. S.F. 11980bi. I'he 1977 Evaluation of the Navy's Alcohol Rehabilitation, Alcohol Safety Action INASAI'I, and Alcoholism Counsellor TrainingPrograms In G.A. Bunn: Y.S Navy Alcohol Studies, Vol i, Naval Alcohol Rehabilitation Center: San Diega BI INN, (;.A.119801. fhe 1978 F.valuation of the Navy's Alcohol Rehabilitation, Alcohol Safety Action (NASAPI, and Alcoholism Counsellor'Iiaining Programs. In G.A. Bunn: US. Navy Alcohol Studies. Vol I. Naval Alcohol Rehabilitation Center. San Diego. (:ADI)Y, G.R.. ADDINGION. H.J.. PF.RKINS. D. 119781. Individualized behaviour therapy for alcoholics: A third year independent double~biind follow-up. Behaviour Research and Therapy. 10. 345 362. C(x)Pf:R. A.M., SOBEI.. M.B., St)KELI. I_C., MAISIO. S.A.I19811. Validity of alcoholics selfreports, duration data. International Journal of Addiction, 16. 401,400. HARFORD, 'i:C., DORMAN, N., FEINHANDLER, SJ.Ii9701. Alcohol consumption in bars: validation of self-reports against observed behaviour. Drinking and Drug Practice Surveyor, 11, 13-15. KO1.B, D.. GUNDERSON, E.K.E., BUCKY, S. (1980). Effectiveness of treatment for Navy enlisted men in alcohol rehabilitation centers and units. In G.A. Bunn: I LS. Navy Alcohol Studies. Vol I, Naval Alcohol Rehabilitation Center: San Diego. LFANARD, K., DUNN, NJ., JACOB, T.119831. Drinking problems of alcoholics: cor respondence between self and spouse reports. Addictive Behaviour, 8. 309 373. MAISfO, S.A., SOBELI., LC., SOBF.LI., M.B. 119791. Comparison of alcoholics self reports of drinking behaviour with reports of collateral informants. lournal of Con• sulting and Clinical Psychology, 47. 100-112. MAISI-0, S.A., SOBEI.I., M.B., SOBELL, L.C. 119801. Predictors of treatment out come for alcoholics treated by individualized behaviour therapy. Addictive Behaviour. 5, 259-264. McCRADY, BS., PAOLINO, TL. I.OMGABAUGH. R. 119781. Correspondence bet ween reports of problem drinkers and spouses on drinking behaviour and impair ment. Journal of Studies on Alcohol, 39, 1252-1257. ORFt)RD,1., OPPENHF.IMER, E, EDVVARDS, G.1197h1. Abstinence or control: the outcome for excessive drinkers two years after consultation. Behaviour Research and Therapy, 14, 409•418. POLICH J M 119821. The validity of self-reports in alcoholism research. Addictive Behaviours, 7. 123•132. SKUJA A I WOOI) D BIICKY S.F. (19801. Reported drinking among post treat ment alcohol abusers: a preliminary report. In G.A. Bunn: I IS. Navy Alcohol Studies. Vol 1. Naval Alcohol Rehabilitation Center: San Diego. SOBELL, L.C.. SOBELI„ M.B. 119751. Outpatient alcoholics give valid selfreports. Journal of Nervous and Mental Disease. 161, 32•42. SOBF.LL, L.C., SOBEI.I., M.B. 119821. Alcoholism lieatment Outcome E:valuation Methodology in National Institute on Alcohol Abuse and Alcoholism. Alcohol and Health Monograph No. 3. Prevention, Intervention and 'Geatment: Concerns and Modeis. NIAAA, Washington, D.C. S()BELI., I-C x SOBEI.L. M.B.11980). Convergent validity: An approach to Increasing confidence in treatment outcome conclusions with alcohol and drug abusers. In: i_C. Sobell, M.B. Sobell & f_Warel IEdsl. Evaluating Alcohol and Drug Abuse Ireat ment Effectiveness: Recent advances. New York: 1'ergamon Press, 177-183. TABLE I NUMBER OF PATIENTS TREATED AT THE SIX ALCOHOLIC REHABILITATION CLINICS (NtC) 1980-1983 NECIOU7 1980 1981 1982----TM Aclsntic 201 244 239 262 Eastern 10 51 38 65 cenarnl 19 43 98 96 Prairie 68 103 71 100 Facific 54 78 90 87 Europe 49 65 64 52 401 584 600 662 Z Change/Year +45.6% +02.82 +10.3% TIMN 321439 48 4
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In the latter case the expert's report will contain a recommendation for a course participation. If the applicant enters and leaves the program without violating the contract which he has signed before (e.g. by arriving at a session while under the influence of alcohol) he will regain his drivers license Fvrty percent of all applicants for driver's license renewal are eligible for course participation. About another 30 percent qualify without going through a rehabilitation program, while the remaining 30 percent show those kinds of deficiencies that even by completing a course they would not qualify for future driving- In the Federal Republic of Germany three programs are objectives for a long-term evaluation study (Bundesanstalt fuer Strassenwesen, 1978,1984 l. The individual psychological program IRAK (lndividualpsychologisches Rehabilita. tionsprogramm f(ir alkoholauffaellige Kraftfahrer) This program confronts the offenders with their personal patterns of behavior which are consolidated by their life•style The application of the program's philosophy is an attempt to analyse the driver's life-style as far as it concerns his drinking and driving in order to achieve a relevant correction pENSCH and LEMM. HACKENBERG). 2. The behavior modification program IFT (named by the institute that developed the program) uses techniques of the psychology of leaming. In order to avoid future DWls, particular methods such as self-control and self-observation are introduced and trained. 3. A third program called LEER (that is the name of the town where it was set up in 1971 and it is by chance the German term for 'empty') is based on various techniques of different theoretical background (group dynamics, behavior modification, etc). The three programs are applied almost nation-wide About 50 000 drivers have gone through these programs since 197Z While two programs (IFI• and IRAK) have a time length of 26 hours 18 to 13 ses sionsl the third program (LEER) has a duration of 16 hours 14 to 6 sessions). Since the latter program is designed as a long-term program, there are additional sessions one resp. two years after the main program has finished. In Salzburg, Austria, a rehabilitation program for DWI is being carried out for three years now. There are seven sessions of two hours taking place once a week. The maority of partkipants-all males with the average age of 30 years-is tested before entering the treatment phase.They are assigned to treatment by the drivers license authority according to the recommendation of the testing psychologist who is in charge of the Austrian Road Safety Board (Kuratorium fuer Verkehrssicherheitl. The average number of drinking and driving offences prior to treatment Is L& All the courses are conducted by psychologists. These moderators are either ex perts on driver qualification diagnosis and prognosis of the probability of recTdivisrn and/or therapists resp. engaged in clinical psychology. 'fhe size of the groups is limited to 10 drivers at the most. - Course participation for second offenders is restricted to persons who do not show the following features: excessive drinking resp. alcohol addiction addictions other than alcohol toxicant-related defects mental diseases acute life crisis psychic and physio-psychic deficiencies significantly reduced intellectual ability; low learning capability serious offences against the law other than DWI numerous traffic offences within the last ten years insufficient knowledge of the German language All three programs being applied in West-Germany have two major components. One part is informational: Ten topics are to be gone through by means of filling out work-sheets and discussing the students answers: l. Alcohol content of popular beverages and estimation of the blood alcohol con centration (BAC) at a given number of glasses of a given kind of alcoholic drink. 2. Residuary alcohol 3. The influence of alcohol on perception 4. The influence of alcohol on reaction and physical movement 5. The influence of alcohol on the state of mind 6. Characteristics of alcohol addiction 7. Strategies of avoiding drinking and driving 8. 'I'he increase of the accident risk with rising blood alcohol concentrations 9. The probability of recidivism lfl BAC-limits and legal consequences This kind of informational working takes considerably less time than the therapeutical approach of the programs. 09 The process The use of psychotherapeutical methods in short-term DW1 rehabilitation programs is both important and problematic It is important because a lasting change of behavior requests a clarifying insight into personal or inter-personal problems which lead to increased alcohol consumption and to drinking and driving conflicts. The persons who are involved in a DWI program have an extrinsic motivation as far as they are expecting to get back their driver's license at the end of the pro- gram. They do not primarily wish to get more knowledge of themselves. So they are prepared to enter an educational program. Every psychological approach has to take this into consideration. If a certain program task does not evidently meet the expectations of a driver who wants back his privilege to operate a motor vehi• cle there is a risk that the program is devaluated as a whole The better the so• cralled 'face validity' of a therapeutical technique is, the more attention and cooperation can be achieved. The following descriptions of two programs are given to demonstrate the chances and the limitations of techniques taken from the arsenal of therapeutical methods as they exist in Alfred ADLER's individual psychology resp. in MORENO's psychodrama. As mentioned before, one of the German programs (1RAK) is based on Alfred Adler's individual psychology. Using techniques of Adler's psychotherapy the trainer Imoderator) and the group try to analyse the life-style of each driver. The personal strategies with which the individual is to overcome his problem are meant to come to light using the interpretation of memories from the early childhood, dreams and other projective materials e.g. the drawing of an intersection I see appendix II or the naming and interpreting of a proverb. A brief description of the individual's life and a detailed description of what hap• pened before each DWI event are also taken into consideration. Through these means every effort is done to demonstrate that excessive and uncontrolled drink. ing is a problem solving strategy and is regarded as a compensatory technique. The personal problem-solving-process is pointed out to each participant through group dynamic techniques and the individual significance of alcohol consumption is discussed. We interpret the personality as the sum of the individual patterns of behavior which help him to reach his objective eg. acceptance, selfesteem and personal estimation Therefore, alcohol has manifold functions: Alcohol can offer consolation when you face a problem It can lessen tension and stress It can give more courage to inhibited or shy people It can serve as a contactmaker. It also works off pent-up feeling of aggression when a'black•out' is used as a kind of protection. The over-adapted 'daytimepersonality doesn't want to be associated with last night events. Having a'black•out' the personality is going to be excused and alcohol is to blame. This is the reason for the loss of memory the day aftec The aim of the group work is to give each person an understanding of the individual relationship between drinking as a strategy and the individual's objective in view. When a participant explains that he grew up as the youngest of eight children and was physically the smallest in his class, it is easy to understand that he has developed a range of elevated objectives e.g. to be the most intelligent or to be the best joke•tellec The desire to be always the center of attention is directly derivated from inferiority-feelings caused by suffering from being the smallest. Such a person will probably go to stop for nothing in order to gain importance. Alcohol will then 'lend him wings' and make him wittier and a better entertainer. For each participant we work out strategies he uses when approaching a problematical situation, the advantages and disadvantages of these strategies and the near and distant objectives that he is persuing by these strategies. The fact that excessive alcohol consumption takes over a certain function in the individual's strategy system is indisputable from our point of view. Is is not to make this clear to a driver, because his feelings of guilt make him more resis• tant. Here the group serves as the moderator's 'mechanical arm' as BA')TEGAY mentioned in 1972. There is no use of isolating the driver's drinking habits as the center of attention. Again, this would only put a stigma on him as it so often happens in his family- and devaluate him. From a psychological point of view the main task Is not finding out that the person drinks 15 glasses of beer a day, but becoming aware which feelings of inferiority, fears, blockages, hopes and wishes lie behind the daily alcohol consumption. Drinking alcohol is only a small part of a habit as the behaviorists understand it For the main part it can be traced back to a lack of self-importance which is compensated for the time being-through alcohol. With the group members we talk about their real problems e.g. about serious pro• blems in a relationship or about the feelings of incapability. These fears are often TIMN 321462
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ALCOHOL AND DRUG PROGRAMS OF THE NORTHWEST TERRITORIES ' X_. .~ $AFFIN REGION r ~ fJ,i C T' ~ ~ ~ ~s ~ yst rRiv INUVIK ~ R71 ON ( f~ _~- ~ ~ 7e.~,~,'~° P i/fJ : i. . ~ `- ~Y - ~' ~ KtTIKMEOT ~~t-~I~ ` ' Q VER ~ p ~ < A ` ~~ •~•~ ra+cxc.roRE ;RJ~_vA~l4S.EE~'- ` t T '.: f 2 • ({({({~~~++'' ~. ~ '\ - . [au6 ~ : 3*, i - E w~~Vli ~ 3rC' 4 , - ~ r . _ - C WEItS M Y.^ \\! k , G , lj f, I ~t^ ~ r FQ2T • =,.E t. ~.< .E • FT. SMITH r • y ~ .. _ ~~ .JESEJx~ ,R. ~{~E,~ ` / aR.•ES/I.JM.E~` ,•+c~iSYl~riI ~, , , ~ ~ ...., ` k.w.af GC,[ *EWM TOIW p A , .. .. • .C~ 1 ~~ S Z aS4iE ew c h an'- - Mant[ oba -a! Sa"ut~... ~ ,- eC iano , O n The traditional way of •'sharing" of the Dene was reflected in the beginning of the Peel River Alcohol Society in Fort Macpherson. A couple who returned from an Alcohol Treatment Centre~ "Henwood" (Alberti, were so inspired by being able to change their own lifestyle that they decided to help others achieve a similar lifestyle of sobriety. In the beginning they visited each other's homes and started an Alcoholics Anonymous group. Then, in 1974, they received funding to have ••back to the land" Piograms in the summer which involved hunting and fishing and living under canvas in their own traditional lifestyle. In addition to providing a counselling service, the Society also operates a recrea. tanal centre for the community as an alternative to alcohol misuse A unique feature Of this program is the six-month rotational employment period of the counsellors. This prevents burnouts, provides an opportunity for utilizing a greater number of counsellors and expands the community resource base. A far•northern camp, the Knute lang)uvenile Rehabilitation Centre, is for boys ten to sixteen years of age with alcohol, drug or solvent problems, self or family related. The twentyeight day rehabilitation program uses both the native cultural pursuits of hunting, fishing and trapping, with counselling provided in the evening. This program includes Dene and Inuit living below the Treeline. The Baffin Regional Alcohol Council is the only Regional Council to operate in the Northwest Territories. The members are elected by the community alcohol committees in the Baffin area of the Northwest Territories. They provide direction to a staff who operate the Baffin Regional Development Information Centre which distributes information on alcohol and drugs. The staff also travel to communities to provide consultation services as well as training other staff to serve in the com munities. There are two treatment centres for alcohol and drug problems in the Northwest Territories. One is located in Inuvik and the other in Yellowknife, each providing cross-cultural programs in three different languages, making them available to all the people. Both programs operate in a non-medical setting in close liaison with 61 TIMN 321452
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lableau 1: Oui est 1'akoolique aux yeux de 407 r6pondants du bilan de sante: pourcen- tages de reponses par OUI et par CHOIX de I'element le plus important. D'apr8 le tableau l, pour identifier 1'alcoolique, la plupart des rdpondants recourent au critere de la dependance vis-a-vis de l'alcool: 86% des OUf et prps des 2/3 des CHOIX. Les trois autres propositions (ou items) de la question sont faiblement reprdsentes, I'exces de boisson dtant presque double de la tolerance individuelle et triple de l'ivresse. L'homme alcoolique et la femme alcoolique 6 d s OOZ f070 N.R. L~ nses ow11We : ze 1 cbaqw flEsat des zLpon- on lieu s P.r' R e tzavail 0p1 NON N.R. I ehaque E1Esent do 1•61(eent 1s plus S.portant 1.pzoductit 3,9 63,9 32,2 3,0 2. dangereuz 60,3 ..1 11,6 50,4 ~3. 1 E1i.iner 25,1 46.4 28,5 11,3 4. t prot6ger 56,e 27,4 27.e 25,1 N.R. 10,2 Sota1 100,0 2. I.es reactions des voisins de 1'alcoolique 1. se d6tzuit 93.9 1.5 4.6 69.1 1 , 2. ut violent 50,1 20,2 29,7 7. 3. est aalMureuz 52.s 17.0 30.2 13.1 4. est de aanvaise toi 34,6 32.9 12,5 2.7 6 de rEpnses 001 NON N.R 0~ _- A chaque E1Ee.ent d 1'{lEvePt ~e ~ N.R. a,0 p us is+portan ~ total 100,0 t la faaille 2 i l 70 3 7 6 22 1 33 4 . p a qnen , , , ~ . 3. vszlent. ignorer 33.9 32,7 33.4 10,1 4. ont eavie de venir ' ' il± !3 dt 44,5 23,6 31.9( 29.7 e.s 407 repondants du bilan de sante Tableau 2: Ehomme alcoolique d apr (pourcentages). N.R. 16,0 Total 100,0 I do ripoasee 00I 7qM N.R. I ~p~ Z ElErnt ~,~El6.eat.lr ~ 1 c9uqne eooeligue .. z 1• YaPottrs . *l ae d6truit 91,4 1.2 7.6 65,1 a. eet vielente p. est sulMureuse K. est do asuvaise !oi 32,. 29.5 3.,1 66,6 .,1 25t1 30,7 32,9 36,4 ClOIX de 1'Elf~eat M pl~nt_ 1.7 21,1 3,2 {,9 Sbtal 1a0.0 Tableau 3: Ia femme alcoolique d'apres 407 rdpondants du bilan de santti Ipourcentages). La comparaison des tableaux 2 et 3 fait bien ressortir par dela le caractere auto- destructeur (pour ne pas dire suicidaire) presque universellement reconnu (a remar- quer le taux tr~s bas de non-rdponses a cet item) ii i'alcoolisme masculin et feminin (plus de 9 OUI sur 101, la predominance de la violence du cote des hommes et celle du malheur du c6te des femmes, l'impact de la mauvaise foi etant reduit chez les uns et les autres, surtout dans les CHOIX. Trois autres questions visent il cardcteriser la femme alcoolique separdment: a) 57,5% des rdpondants pensent a une femme mariee (pour 24,8%it une celfilataire); bl 70%, a une femme qui ne travaille pas (pour 15.2% a une femme qui travaille); c) 65,5%, io une femme apparemment comme les autres (pour 24,9% ii une clocharde); les autres informateurs ne se sont pas prononces sur ces trois points. B. UENVIRONNEMENT SOCIAL DE L'ALCOOLIQUE 1. 1.'alcoolique dans son lieu de travail Tableau 4: Ce qu est I'alcoolique dans son lieu de travail d'apr6s 407 repondants du bilan de sante Ipourcentages) Peu de r~pondants (tableaux 4) se sont risques a reconnaitre comme productif un alcoolique (3,9% de OUI, 3% de CHOIXI; un peu plus vont jusqu'a envisager de 1'@liminer li OUI sur 4, 1 CHOIX sur 10). Pour une majorit@, il est dangereux (8 OUI sur 10, 1 CHOIX sur 2), la moititi moins cherchant plus positivement a le pro- teger Il CHOIX sur 4(. Tableau 5: Les reactions des voisins de 1'alcoolique d'apres 407 r@pondants du bilan de sante (pourcentages). Comment reagissent, non plus les collegues de travail, mais les voisins de 1'alcooli- que d'apres nos rdpondants (tableau 5) ? La distribution des CHOIX rdvele des posi. tions moins tranchees: d'aprbs 1 sur 10, ils sont genes (plus de la moities des OUI); d'apr~s I sur 10, ils veulent ignorer (le tiers des OUI ); d'aprl:s 3 sur 10, ils ont envie de venir en aide (moins de la moitie des OUI); d'apres I sur 3, 11s plaignent Ia famille (7 OUI sur 10). Autrement dit, il y a un peu plus de voisins ii se placer d'embi@e du cdte de la famille que du cote de 1'alcoolique. C. LES AI"I'ITUDES DES REPONDANTS A LEGARD DE L'ALCOOLIQUE 1. L'alcoolique comme dventuel coll6gue de travail Si les rdpondants avaient un coilegue de travail qul boit (tableau 61, plus de Ia moitid le tiendraient pour un "boulet ii tirer": cest Mldment de r~ponse qui, dans cette question, suscite le moins de NON et le moins de non-reponses. Plus d'un tiers le consid'eraient comme indigne de confiance, presqu'autant se refusant, du reste, a une telle rdaction. Les trois autres dlements intentionellement favorables suscitent trols a quatre fois plus de NON que de OUI et prps d'un tiers de non-rdponses: qu'il passerait pour @tre un bon vivant est nettement moins retenu (12%) que pour etre sympathique (16,7%) et que pour fair tout ce que les autres ne veulent pas fair (17,7%). Dans cette question, les ' HOIX ont ete sollicitds stsparement pour un collegue de travail masculin et feminin. La principale difference tient au taux de non-rdponses plus eleve pour une femme que pour un homme: compte-tenu de cela, Ia femme apparait plus souvent tenue pour indigne de conflance et I'homme pour un boulet a tirer. - - a de-rEpcnses i"8ae de Lr~a~a~il pars OU C NON N.R. ; Mque EiEeent r~ Y~mf~t~ 1: 1. est na bon vivant 12,0 54,6 33.4 2. est syapathique 16,7 47,2 36,1 3. at indigne do coaiianee- 16.4 35.6 26.0 n.5 26,0 e. Sait tout ce qu'on no veut 17.7 45,9 33,4 7,6 5.9 . _pas faire ____ 5. ast un bnulet A tirer 51.6 27:5 20.9 30,5 26.0 N.R. 23,6 29.0 Total 1 00.0 19810 50 TIMN 321441
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THE BEST OF BOTH WORLDS: A RETROSPECTIVE OVERVIEW OF SUBSTANCE ABUSE PREVENTION Marcus Grant 1. Introduction It Is possible to see the world of substance abuse as a bittlefield. As far as one can see, from horizon to horizon, there are casualties. Some are alYeady dead, some are dying, and others are still making desperate and pitiful efforts to save themselves. They are casualties of the damage caused or exacerbated by drug-taking, smoking and excessive drinking, such as liver cirrhosis, cancer of the lung and hosts of other physical diseases. They are victims of road traffic accidents, of fires and of crimes. They are the victims of domestic violence, including child abuse They are suicides. They suffer from anxiety, depression and a whole range of mental health problems. Despite the severity of the condition of these casualties, despite the apparent ubi- quity of the battlefield, there seems little sign of any abatement in the hostilities. The great heaps of dead and dying mount daily higher. _ There is, of course, concern. Faced with such carnage, it would be diffictilt to maintain indifference, either at a national or at an international level. But concern does not in itself presume effective action. It seems, indeed, that there has been some disagree• ment about how best to proceed in dealing with the costly and distressing pro. blem of this global battlefield. Various strategies have been suggested. There are, first, the laissez-faire free market economists whose view is that man is by nature a warlike animal; that the carnage is indeed distressing but that, given the right approach, it need not necessarily be quite so costly as seems inevitable at first sight. They point to the long history of the hostilities and to the indications that they are, if anything, increasing. In such circumstances, the elasticities of demand being favourable, they see worthwhile op- portunities for the state to maximize revenue If the battle is a fact of life, then it can be taxed to the hilt. A proportion of the revenue thus generated may have to go to financing services to alleviate the suffering of the casualties, but in ag- gregate terms, the world population problem being what it is, it is probably no bad thing to allow the scale of the battle to continue to escalate. Such a view, of course, is incompatible with the public health perspective, incom. patible with a sense of common humanity and incompatible, certainly, with the aims of WHO. What, then, are the health options that are advanced as alternative strategic approaches? There are those who see the most urgent need as the im- provement of the efficiency of the treatment systems. Confronted by the horrifying spectable of all those casualties, they argue that the first priority must be the welfare of those already damaged. They plead for better hospitals, better accident and emergency units, better psychiatric care, more staff and new technology. Then there are those who, without wishing to ignore the plight of the present sufferers, believe that the priority must be the prevention of future suffering. There are two separate camps within this group. Supporters of one of these, arguing for health promotion, seek to persuade the combatants to lay down their arms or, at the very least, to use them for sporting purposes only. They are also anxious to counsel those who, though wounded, may yet recover if only they see the error of their ways and crawl away from the battlefield. The other camp, still in sym- pathy with the broad aim of prevention, have little faith in the likely effectiveness of these persuasive efforts, however eloquent or rational they may be. This camp hols the view that the only way to reduce the battle is to reduce the means with which to fight it. They argue for control policies that would restrict the number of cartridges issued daily to combatants, or limit the number of official munitions stores or, like the economists but with a different aim in mind, charge such a high fee for the privilege of fighting that few would be prepared to pay it. None of these strategies is ridiculous. All have their advantages and would, in one way or another, lead to improvements in the present intolerable state of affairs represented by the substance abuse battlefield. What is, however, immediately ap- parent is that, while any strategy might have some effect, all are partial. If, indeed, the level of casualties is to he reduced, then the economists, the treatment agen- cies, the health promoters and the control policy advocates all need to be brought together. Researchers also need to be persuaded to come out of their bullet-proof hides to help in forming a concerted and integrated approach to the development of a range of linked strategies that can be continuously evaluated. That, in essence, is what prevention is all about If a retrospective overview of substance abuse preven- tion is to be useful in any way at all, then its utility must be measured by the extent to which it helps understand the successes and failures of the past, and point the way towards seeing fewer failures and more successes in the future 2. Prohibition or Moderation Despite the enormous variety of activities that can be included under the heading of prevention, nearly all of them can be accommodated within two major approaches to substance abuse-namely, limiting the availability of drugs, or reducing the de mand for them. The former includes efforts that encompass the setting of limits on the production and marketing of alcoholic beverages, the introduction of mechanisms to regulate the supply of pharmaceuticals, the imposition of restric• tions on where cigarettes may be smoked, as well as a host of strategies, such as crop substitution, which have been applied to narcotics. Reducing the demand for drugs entails the provision of information about their health-compromising effects, of education about norms and values that restrain socially irresponsible behaviour, and of leisure activities as alternatives to those that involve drinking or drug-taking, as well as a concern with ameliorating the more general social conditions that may instigate substance abuse. There is some evidence that prevention activities belong• ing to both major approaches have been effective in reducing consumption and inappropriate patterns of use under certain circumstances, in certain groups, and during particular historical periods. Since both kinds of effort reinforce each other, since there is no incompatibility between them, their simultaneous Implementa tion could well have a synergistic outcome Historical experience with control efforts to limit the availability of alcohol and drugs has been remarkably diverse across different cultures and within countries over time The range has been from total prohibition to few-if any-regulations. While no single type of control effort can be urged as likely to be effective in all circumstances or for all countries irrespective of their cultural and economic background, three important generalizations can be made (1) The effectiveness of any specific type of control effort will depend in part on its integration into a clear governmental policy position that has been carefully defined and coherently expressed. 121 The effectiveness of any single control measure probably depends on Its being embedded in a series of mutually supportive efforts that together constitute a comprehensive and coordinated programme of prevention. 131 Control measures are likely to be more effective if preparation has been made for their acceptance by the public through appropriate public education and information. 2.1 Preventing Alcohol Abuse Turning, therefore, to specific historical examples of preventive efforts in the field of alcohol abuse, there are at least two aspects of the nineteenth century temperance movement which require investigation in order to clarify the social factors which operate to challenge the practicability of outright prohibitionist policies. It is clear, from an anthropological point of view, that alcohol is a special commodity, carry jfig ritual significance and associated with altered states of consciousness. Equally, it is clear even from medieval sources, that the association between excessive drinking and social disruption has long been recognized. Thus, both at an individual and community level, there canf hardly be such a thing as a holistic response to alcohol. It is a complex substance and its consumption involves complex behaviours. Cer, tainly, different social groups are likely to adopt different sets of values with regard to drinking and are therefore likely to respond differently to any suggestion that it should be proscribed. It can be argued, therefore, that in its singie-minded fervour, the nineteenth cen, tury temperance movement simply failed to take account of the complexity of the values associated with alcohol and underestimated the extent to which it was in• tegrated with all levels of personal and social functioning. Whether this integration is viewed in terms of ambiguous symbolic meaning or economic deter• minism or even the ruthless pursuit of the pleasure principle, is probably less im' portant than recognizing the extent to which, in a pluralistic society, it is seldom likely to be possible to achieve consensus on any alcohol policy other than one based upon a compromise between the principles of market justice and the prirr ciples of social justice The second aspect of the history of the temperance movement which is relevant here concerns the substantial decline in its scope of influence occurring since its heyday in the nineteenth century. It is difficult for the temperance movement not to seem old fashioned now, simply because its influence was so great in the nine, teenth century. Had it been less successful, more marginal then, it would have been easier for it to seem more successful and less marginal now. What is being sug gested here is that particular strategies may be viewed as having a greater or lesser potential for effective influence, not so much because of intrinsic qualities suscepti' ble to analytic examination and assessment, but rather because of the accident of having been tarred with a particular historical brush. The very term temperance, which is, after all, an unexceptionable concept, now has the power to conjure up 74 TIMN 321467 ~
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1984; Bissell, 1981; Daniel, 19841 The fifth question sought to determine attitudes which would affect the long- term rehabilitation and return to work of the impaired nurse. The question ask- ed if impaired nurses "deserve much consideration from the nursing profession." The education program presented a few of the stressors faced by nurses in the workplace of today. The participants recognized that the impaired nurse was fac- ed with problems associated with high values of patient care, incongruence in the health care system, and other factors which contribute to employee burnout. These and many other variables lead the impaired nurse to seek ways to escape and cope with excessive stress which the participants were also continuing to battle. The post test indicated that the participants experiehced greater empathy toward their impaired colleagues and indeed these peers do deserve considera- tion from the nursing profession. The seventeenth question asked if impaired nurses "have a psychiatric disorder." Studies by Bissell 11981 j reflected that the medical and nursing profession hold a negative attitude toward the chemically dependent person. Seeing this person as being weak willed and immoral, rather than ill and deserving of treatment. The change in the attitude of the participants on the post test indicates that educa. tional programs can assist In helping professionals to recognize that dependence upon alcohol and drugs is a psychiatric disorder. The change in attitude toward the impaired nurse as being ill rather than weak willed or immoral will con- tribute to a more positive rehabilitation the chemically dependent nurse seeking to return to the workplace. - The change of attitude shown on the post questionnaire in response to question nineteen, "I am not in sympathy with these nurses," points to the worth of educa• tional programs regarding the issue of the impaired nurse. This strong change in attitude on the post questionnaire indicates that negative attitudes-of profes- sional nurses toward the impaired nurse can be changed through the presenta- tion of educational programs. On questions twenty and twenty-four, a yes and no response was requested. Ques- tion twenty asked if "recovery Is possible" and question twenty-four asked, "after treatment the employer should return the recovering nurse to the workplace," Better than fifty percent of the post questionnaires indicated a changed opinion from "no" to "yes." The recognition that recovery Is possible and that the recover• ing nurse should return to the workplace is essential if rehabilitation is to be successful. The implications are that positive and negative attitudes of professional peers can be modified through educational programs and can contrihute to the rehabilita• tion of the impaired nurse. Through the collaboration of nursing education and nursing service, the problems faced by the impaired nurse can be presented. In- creased awareness of the profession of these problems will facilitate Interven• tions which result in the impaired nurse seeking treatment and rehabilitation. The return of the impaired nurse following rehabilitation to the workplace will contribute to the profession. Through increased recognition of this complex issue, the profession will seek more healthful means of extending care to the impaired employee. References Cited Barr, Marjorie A. and William D. l.erner, "The Impaired Nurse" A Management Issue," Nursing Economics, Vol. 2, May-June, 1984, pp. 196 201. Bissell, LeClair and Robert W. Jones, "The Alcoholic Nurse," Nursing Outlook, Vol. 29, No. 2, February, 1981, pp. 96-101. Daniel, lrvene Query, "Impaired Professionals: Responsibilities and Roles," Nurs- ing Economics, Vol. 2, May-June, 1984, pp. 190-193. Green, Patricia L., "The Impaired Nurse: Chemical Dependency," Journal of Emergency Nursing, Vol. 10, No., January/February, 1984, pp. 2126. Gruca, Jo Ann Kudia, "Oncology Rehabilitation," Rehabilitation Nursing, May- June, 1984, p. 27. Pryor, Jean, Unpublished interview with Dr. Jean Pryor, President, Texas Board of Nurse Examiners, 1985. BENEFITS AND DRAWBACKS OF USING PSYCHOTHERAPEUTIC METHODS IN SHORTTERM REHABILITATION PROGRAMS FOR DRINKING DRIVERS M Jensch * MM Ruby *, E Spoerer* and W D. Zuzan*** The Problem Drunk driving is a lasting major traffic safety problem. Since law enforcement is generally weak the individual driver's chance of being detected is very low. The average number of a driver's undetected drinking and driving offences before he gets caught by the police, is estimated between 80 and 300 IMUF.LLERI. Looking at those people who have been already convicted because of driving a motor vehi. cle while under the influence of alcohol IDWII, punishment is obviously little deter- ring and rather ineffective: Many drivers being involved in an alcohol-related accident or committing a driving while intoxicated offense apparently do not change their drinking and driving behaviot The recidivism rate for first offenders in the Federal Republic of Germany Is about 36 percent within a ten-year-period. Study results indicate that there is no significant difference between particular modes of penaf ty: Fines, driver license revocations and imprisonments have almost the same deterring effect IBUIKHUISENI. Compared to first offenders second offenders have an even higher recidivism rate: sixty out of every one hundred drivers have a third detected offense against the drinking and driving law. Furthermore, both first and second offenders relapse in a remarkably short period of time: Nearly two third of all first offenders who have a second offense within a ten-year-period show up in the first three years. So do more than one half of the DWI recidivists IKUNKELI- These figures demonstrate the relatively poor effectiveness of ordinary treatment measures for this particular groups of drivers. While the majority of the overall driving population is deterred from drinking and driving, traditional means of cor- rection have little or no effect on DWI repeaters. In order to reduce the extremely high recidivism rate special forms of treatment have been developed. They do not replace the means of traditional corrective ef forts Rather they are additional measures within the system of judicial and ad. ministrative procedures. The Programs Rehabilitation programs for DWI came up when the evaluation of common driver improvement programs ISPOERERI indicated the need for separate treatment forms for those drivers who got into trouble with their drinking and driving habits. In Austria and in the Federal Republic of Germany the establishment of rehabilita• tion provisions for DWI offenders has been a long process that is not yet finished. The first DWI offender rehabilitation course was started in 1971 (WINKLERI. Today the assignment to a DWI program takes place in conjunction with a screen ing procedure that is called a medico-psychological examination. This kind of com pulsory check-up is unique for some European countries. A German DWI offender is considered by law no longer qualified for the operation of a motor vehicle II) if he has two DW I offences within a five year-period or (21 if the level of his blood alcohol concentration is .20 % or more together with no signs of impaired capabili• ty or (3( if the BAC exceeds .25 % no matter what his mental and physical condf tion was like. After the period of revocation which is determined by the judge the driver applies for the renewal of his driver's license. Next, he is faced with the so-called 'standard presumption' of having lost the qualification for driving unless he proves the contrary by presenting a medico-psychological certificate. This cer, tificate is the result of the screening test carried out by an authorized institute. The outcome of the medical and psychological screening test can be one of the following: (1) the result is'positive i.e- the presumption of the driver's license agem cy, saying that the applicant is unqualified, is rejected, (2) the result is negative I. e the presumption cannot be rejected because of relevant physical and/or psychological findings, 131 the result is negative, too, but the ascertained deficien des of qualification such as an inadequate attitude towards drinking and driving or problematical drinking habits are regarded as to be remedied by participating in a rehabilitation program. ,8 TIMN 321461 ~ --~
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Hodgson et al. 119781 recognize diverse subgroups of alcohol abusers, dividing sub- jects into abstainers, social drinkers, semi-dependent drinkers and problem drinkers. They call for differential behavior in problem drinkers, while Saunders and Richard 11978) find no such behavioral differences. Several authors, including Panepinto et al. (1982), Selzer et al. 11977), Cloud 11978) and Ringoet (1980), point out explicitly that drunk drivers do not fit the alcoholic model, and recommend treatment based on this recognition. Thus, differences can be found at the psychological, behavioral, and even metabolic levels. Attention has also been given to identifying subtypes of D.U.I. offenders. Scoles and Fine (1977) note the diversity of such offenders as a]najor obstacle to suc- cessful intervention. Several studies, such as those by Kem et al (1977), Meck and Baither 11980), and Wells-Parker et al. (1983) link these with differences to member- ship of varied populations as definded by such factors as age and ethnkity. Con- trasting drinking drivers who complete an alcohol educatin program with those who drop out, they noted that noncompletion of the program is associated with non-white ethnicity, lower age, and higher blood alcohol content at time of arresL All these findngs give evidence to suggest a need for recognition of age and social differneces, and more specifically perhaps also of class and sexdifferences, in the circumstances under which D.U.I. occurs and the proper forms of intervention. These studies offer a diversity of pictures of alcohol and drug abusers, but they do seem to favor several conclusions. Ftrst, alcohol and drug abuse takes varied forms. Second, the specific form known as alcoholism or drug addiction is not necessarily a valid model for the needs and problems of D.U.I. program clients. Third, these clients themselves are diverse, and any attempt to reduce them to uniformity Is likely to lead to invalid therapeutic intervention. Skinner and Allen (19$2) offer one tool for such an approach to intervention: a scale designed to measure the degree of alcohol dependence in a given client This scale, tested on 225 sub- jects, reveals high internal consistency. A high score is associated with more drink- ing, social consequences from drinking, psychopathology, physical symptoms, and failure to keep appointments for therapy. This type of approach is needed to imple- ment the recognition of client diversity. Approaches to D.U.I Intervention The single most important feature of an effective program for D.U.I. offenders is the inclusion of a variety of options, and matching the offenders appropriately to the options. This may be voluntaristic, Ewing (1977) or complusory, Steer et al. (19791 Both approaches seek to suit the treatment to the client; they differ primari• ly in their assessment of the client's ability to judge his or her own needs. Intervention can take a variety of forms. The simplest is the provision of informa- tion. However, with some clients it becomes necessary to provide various forms of counseling, motivation, and therapy. Several approaches to change are suggested. Wheian and Prince (1982), and Oei and Jackson (1982) propose a cognitive ap- proach designed to reinforce realistic beliefs about drinking behavior. A second ap- proach is based on changing the client's social skills and attitudes. Orosz 11982) and Holser (1979) theorize that excessive drinking reflects inadequate social skills. A more traditonal psychotherapeutic approach is outlined by Panepinto et al. (1982) proposing that treatment begin with evaluation. Other programs have sought to train clients in behavior skills, on the assumption that the D.U.I. offender does not wish to become incapacitated, but cannot judge his drinking accurately. A final approach is direct medical therapy. Poulos 11981) and Steer et ai. (1979), suggest these methods are suited toclients who are physically addicted to alcohol, or who have suffered long-term physical deterioration as a result of chronic alcohol abuse. The spectrum of possible interventions runs from an educational model to a medical one. Obviously not all of these can be appropriately used with any one client, but the wide spectrum of possibilities is needed. It is necessary to provide individualiz- ed evaluation and intervention for offenders, as if found in "clinical" intervention. This principle is gaining recognition, and the U.S. National Highway Traffice Safety Administration (1980) offers a manual for pre-sentencing investigating officers which stresses the variety of types of D.U.I. offenders, and provides criteria for distinguishing between social drinkers, problem drinkers, and alcoholics. - The ADES Program The Alcohol and Drug Education Services (ADES) program of Cook County, lllinois, is an attempt to deal with the problem of D.U.I. and related problems through varied forms of intervention designed to meet the individual offender's needs. The ap- proach followed includes education and guidance, monitoring, punishment and refer- ral for counseling or therapy with a holistic modified punitive framework. Measures suited to the invidual offender are selected through a systematic assessment pro- cedure at the strt of intervention. - The program was developed in collaboration with the Chief Judge, Honorable Harry Commerford and in cooperation with the court system, and is presented as an alter- native to the attempt to avoid conviction. The client is asked to take part voluntari- ly, in exchange for avoiding the additional legal punshiments and the status of a convicted D.U.1. offender. Sentencing judges retain the option of imposing fines, jail sentences, and suspension of driving privileges. ADES gives judges the oppor tunity to offer a widerspectrum of response to the offense. McDermott and Moran (1981) have stated that, while the primary purpose of ADES is evaluative and educational (parameters established by Dr. Vincent D. Pisani, ADES clinical director), an equally important function is to refer clients with life problems involving alcohol or drug abuse to approporiate agencies. Motivation comes from the realization that the program is working in the client's interests. Participation is begun immediately after a court appearance where social disapproval is express. ed, and successful completion of the ADES program is generaly required before removal of probationary status and regaining driving privileges. The basic purpose is to change the client's behavior by changing his or her atttitudes and motives. External penalties are not sufficient, what is needed is a change in the client's own attitude to D.U.I. behavior. The first and most crucial step in the program is assessment. ADES uses several tests and measurements to achieve this. They include: A Personal Data Form, An Attitudinal Study, The tvlichigan Alcohol Screening Test, The ADES Substance Abuse Assessment, and an interview with an Educational and Referral Officer (ERO) dur• ing which the client completes a Behavior Assessment Scale (BAS). The results of these measurements are ueed to determine a "risk factor" ranging from 0 to 3. Two subscores are computed, one for the Behavior Assessment Scale and one for all other measures. These computations are made separately and "in the blind" Le. from two separate individuals; a Psychologist for BAS and an ERO for other measures. They are then averaged, with greater weight being given to that obtain• ed by the ERO. The risk factors are interpreted, and recommendations are made to the referring court on the basis of the risk factor determined for the client. Ex• perience with this system shows about 20% of clients to have risk factor (0), 42% risk factor (1), 35% risk factor (2), and 3% risk factor (3). After determination of a client's risk factor, appropriate interventions are selected. A basic scheme is used which comprises four broad levels of intervention after the initial assessment phase: education, guidance, counseling and therapy. The first two are provided by ADES itself, the latter two by outside agencies In collabora- tion with ADES. Education and guidance is offered to all clients to provide infor- mation which will be personally relevant, and provide the motivation for change. Those with patterns of chronic substance abuse or other life problems are referred to outside agencies for courueling. A minority are found to have problems so severe as to necessitate medical treatment in hospital based fascilities. This level often fits the classic pattern of alcoholism or addiction to other substances. With these latter two groups, ADES retains the role of overall coordinator, and is responsible to the courts for monitoring the client's progress. Extensive records are kept. However, under Illinois State Law, these records are confidential and in faa written consent of clients ts required both to transfer records from any subagency to ADES or from ADES to the courts. Failure to complete a program, results in immediate notification to the courts and other concerned agencies. The result can be a full hearing and appropriate penalties. Within this overall system, two distinct levels have been defined for intervention. Level I is intended primarily for clients who lack inforrnation about the effects of alcohol on behavior, and do not present with significant life problems. Level II is for clients who exhibit more profound behavioral problems. In both levels clients undergo initial needs assessnent Level 11 clients attend four two-hour sessions devoted to lecture, films, and discussion groups, which provide information on the effects of alcohol, the factors which trigger its use, the methods of gaining improved con- trol over alcohol use, and the laws regulating alcohol consumption. Level ll clients attend twelve sessions of special education and also take part in group monitoring sessions. In addition, they are referred to outside agencies. In both levels, client's progress is assessed and reported to the court. Within level I & 11, several distinct tracks are available: the genral population pro- gram, a youthful offender program; a women's program; and a poly drug program designed for clients aged 17-30 who have abused substances other than or in addi• tion to alcohol. These programs thus cover a wide range of client situations, with options for mild or severe problems. This diversity is central to the design of ADES. A comprehensive judgement as to the effectivemess of ADES remains difficult to obtain. Recidivism is low. In 1980, 96.3% of participants had never previously taken part in ADES. We continue to question our results and have therefore initiated a comprehensive research study to investigate the long term effectiveness of the program. ADES makes a number of referrals of problem drinkers, concentrating the resources of other agencies on the recipients with the greatest need for them. Clinical experience reveals improvements in clients of ADES. Further, the legal system of Cook County has come to regard ADES as a useful alternative to con• ventional means of dealing with D.U.I. offenders. The ADES program is unique in its use of a holistic modified punitive approach with multiple levels of intervention. It has long been recognized that the better a program matches the actual characteristics of the target population, the more success it will attain. A wrongly conceived pro• gram will have no effects, or can even be counterproductive. A too Narrowly 58 b
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detailed in the first part of this paper. Data is based on a sample size of 2888 in dividuals or nearly seventeen 1171 percent of the total population served through Cook County's ADES program in 1984. In analyzing offenders by highest level of educational attainment and sex, ADFS statlstks relate that the female offender is somewhat more highly educated than the male DUI referral. The main educational difference occurs, howevet; at the high school level with substantially (8.19%) more women reporting high school graduation than men. While more men reported college graduation, the differences that ADES clients indicated between men and women for some college attendance and graduate school experience were minimal. Overall, more than two-thirds (78.2%) of all ADFS participants a'ie high school graduates with a small percentage having advanced education. Interestingly, the best educated lcollege graduates and above) have nearly the same percentage (16b8%1 of DUI occurrence as do those persons 116.62%) who report only some high school attendance. If one approaches the 1984 ADFS data to observe racial composition and educa- tional achievement, one notes that nearly sixty (60) percent of the black popula. tion reports high school graduation or above, while slightly more than eighty (801 percent of the white population reports the same information as compared to slightly less than fifty 150) percent of the Hispanic population. Overall, while the vast ma- (ority of referrals report high school graduation or above, there are noticeable dif- ferences in education in the racial breakdown of the ADES population. Records of personal income of ADES referrals show that 64.4% earn over 515,000 per year. In addition, if one accounts for all ADES referrals earning S3Q000 per year: one sees that approximately 278% are in the higher bracket. Broken down by racial composition, white referrals are the most affluent with Blacks and Hispanics nearly even in the higher income levels of the ADFS population. Conversely, the least affluent groups are the Black referrals followed by Hispanics, and whites. Most referrals to ADES also identify themselves as either "blue or white collar ; with a much higher (47%) percentage claiming blue collar status Occupational status, analyzed with race, reveals somewhat more minority clients in blue collar jobs than white ADES participants. Interestingly, the persons identifying themselves as "pro fessional" in occupational status are roughly the same (10.77%) across racial.lines and nearly parallel with the numbers 111.29%) not employed. Almost eighty-five 1851 percent of male DUI referrals are employed compared to about eighty-one 1811 percent of female offendets Nearly half 146.6G%) of the males are blue collar workers while more than half (5359%) of the females are in white collar occupations. Hispanic and white ADES clients report more total employment 185%I than Black clients 174%I. Approximately one fourth of Black DUI referrals in Cook County are unemployed. The DUI offender is by and large a single person. Sixty-one 1611 percent of the ADFS population is divorced/separated, widowed, or never married. Of the single group, forty-five 145) percent have never married. Females claim single status more often (75%1 than the male (58%) DUI clients In the ADES program. The percen tage 127%1 of married male offenders is double that 118%I of female offenders. In summation, the findings of the ADFS program in 1984 show a DUI client pro. file of an under•thirty single white male employed in a blue collar occupation with earnings of between S20A00 and 530,000 per year. Significant differences do occur, however, in comparison by race and/or sex. Minority offenders, concentrated in the city, are usually slightly older, less affiuent, and lesser educated than the maprity of white offenders. Female DUI clients are the poorest of all offendePs despite somewhat higher educational attainments and white collar Statuses. As stated in the beginning of this paper, the purpose of this report is to describe select variables of the Cook County DUI population referred to Alcohol and Drug Fducation Services. What is not noted in this profile analysis are the functions of these variables in the drinking and driving behavior of the ADES client and the interrelationship of the variables to each other. A cursory observation of the data as presented here reflects changing demographic patterns in many large metropolitan areas. The "typical" offender remains young, white, and male. There are. however, some signs that at least in cities, the DUI offender might becoming slightly older and tnight be a member of a minority racial/cultural group. Indeed, this descriptive analysis lends itself to further questions for Dlll research and to further dialogue regarding effective DUI intervention at all levels. We have presented a general profile of the drinking driver in Cook County. 11 linois. Given the relative population mix, the impact of the Illinois DUI laws and the enforcement of those statistics, the level of societal concern and the levels of Perceived impairment of this population, is this population representative of the DUI population locally, nationally, or for that matter, internationally? As stated previously, the drinking/driving population in Cook County. Illinois ap sEZZ-f REPERAL POPULATN7M 1978 19:9 1980 1981 1912 1983 1984 M 93 F 7 91 9 90 10 91 9 9o 10 88 12 r 13 AGB-S AGE GROUP 1978 19'9 1980 1981 1992 1983 1984 20 & w0er 19 21-39 41 31-49 16 41-5. 13 S1i0 9 61Awer 2 24 35 19 12 8 5 16 41 21 13 7 2 14 43 21 12 8 2 13 43 22 13 8 1 t0 45 21 l3 2 8 !4 25 1/ 7 2 RACIAL 91ACKfiROURD-s 1978 1979 1986 1981 1982 1983 1984 MHR'E tl BLACK 8 R2SPAXIC 3 95 19 5 95 10 5 84 10 6 9o 11 9 78 11 11 84 11 5 PN20R AiRl8T8-Dt8-t 1979 1979 1980 1961 1982 1983 1984 NONE 66 BINGLE 25 YULTIPLE 9 77 15 9 77 I6 5 84 IS 5 u 15 3 83 14 3 84 13 3 2RLATRALYBER-f 1978 1979 1990 1981 1992 1983 1984 Y}T.. 8A No NA 36 64 33 67 33 67 53 47 56 44 59 3' ACCIDEIR lNOLVffi7-S 1978 1979 1980 1981 1982 1993 1984 1 YPS NA NO NA 24 76 28 75 23 7: 24 76 23 . 28 72 IDUCATN7N 3000 sampleE RACE BLACK 7 NXII'E 4 XISP s OTHER f TOTAL f SOME ELEMENTARY 51 15.99 60 2.40 41 26.9' 1 4.76 153 5.12 SOME NNiH HCHOOL 78 24.45 379 15.17 38 25.00 2 9.52 497 16.62 RIGH SCHOOL GRAD 166 33.23 925 37.01 40 26.32 2 9.52 1073 35.87 BOYE COLLEGE 68 21.32 674 26.97 2® 13-16 7 33.33 769 25.71 COLLEGE GRAD 7 2.19 278 11.12 7 4.61 5 23.81 297 9.93 SOME ADV/DEGREE 9 2i2 183 7.32 6 3.95 4 19.05 202 6.75 TlAL 319 19.67 2499 93.55 152 5.08 21 0.70 2991 100.00 SEX MALE f FEMALE • TOTAL 1 SOME ELEMENTARY 147 5.64 6 1.55 153 ' 5.12 SOME N1GH SCHOOL 429 16.47 68 17.62 497 16.62 KIGR SCHOOL GRAD 9r 34.82 166 43.01 1073 35.85 SOME COLLEGE 666 25.5: 103 26.68 '69 25.71 COLLEGE GRAD 27S 10.56 22 3'0 297 9.93 SOME ADV/DEGREE 181 6.99 21 5.44 202 6.75 TOfAL 2605 8:.09 386 12.91 2991 100.00 TIMN 321458 65
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the community hospital. T here has been a marked increased in admissions to the treatment centres of youth aged seventeen to twenty-four and of women in the past two years. - One of the most common concerns voiced by those in the program is,'"How do I say no to my friends when offered alcohol during my recovery?" In the Dene traditional way of "sharing" one does not say "no" to a friend or elder. Native peoples find it difficult to participate in group therapy sessions as this is not part of their culture. One approach used is the "circle" of story swapping which enables them to express feelings and relate to one another-an important part of treatmenL An example of the effectiveness of this approach was demonstrated when an Inuit per- son and a Dene related so well they learned to converse ift each other's language. In general, as would be expected, some of these programs are more effective than others. In evaluating the projects, the accepted evaluation models of the south are not appropriate in the Northwest Territories. The prime criteria here is to meet the needs of the community as seen by the community. The most effective pro- grams are the ones in which the community is allowed to conduct the program in its own way with a selfevaluation component that looks not only at the pro- gram but at the community changes. In a few communities, guidance is needed for a period of time to develop effective programs In these cases, a trained native social worker Iwhen possiblel or an alcohol and drug specialist will work with the community for at least two years, providing leadership and training for people in the community who will then carry on the programming. Southern Canada places emphasis on professionalism with programs staffed by univer- sity graduates. On-the•iob training is a major component in developing our alcoholism workers and is carried out in the Northwest Territories or in available Native pro- grams This develops a worker who is familiar with the culture, tradiflons and language in the community. It might not even be necessary for that person to be literate. For example, Annie, a local native woman, told me that she had given up drinking and was ready to help other Indian people. I suggested she call on Northern Addic- tion Serivces and speak to the trainer and the supervisor of the Detox Centre. She did, and when it was learned that Annie could not read or write English, we had her record all of her reports on a cassette which were typed by the secretary the next day and signed by the Supervisor. Annie spoke fluent Chipewyan and was born in the Northwest Territories. Since many people in the program speak only Chip, Annie is invaluable as a counsellor with skills not usually provided irl an academic background. The vast distances between communities, the extremes in climate with snow covering the ground for over eight months of the year in the Arctic, blizzards, white-outs, ice fogs, winter temperatures as low as minus fifty-seven degrees celsius, long hours of darkness in winter and extended hours of sunlight in the summer, and the sparse mixed population are characteristics we have in common in varying degrees with other circumpolar countries such as Finland, Norway, Sweden, Denmark, Greenland, U.S.A. IAlaskal, Iceland and Russia lSiberiai. Our shared problems are delivery of services to isolated areas, limited availability of trained staff, lack of appropriate resources, alcohol-fractured communities and general health and social problems. Finland has a community approach to alcohol problems similar to the Northwest Territories in their local option policy. This policy allows their communities and local municipalities to decide on how liquor is retailed. Norway, on the other hand, has chosen to follow a regulatory model with the sale of alcohol in the hands of the State Alcohol Monopoly. Legislation governing taxa. tion. alcohol content and age of consumption is frequently examined. Norway still has the strictest regulations in the worid covering drinking and driving. Sweden, like Norway, has had a long tradition of government intervention in the manufacture and sale of alcohol, provision of treatment of alcoholics and state• supported information and research. In Greenland the native Eskimos were formerly prohibited from purchasing alcohol. Prohibition was lifted after World War 11 and consumption rose rapidly. Ten per- cent of disposable income was spent on alcohol. Following the introduction of seif• government in 1979, rationing of alcohol was instituted after a referendum. Accor- ding to available information, the average consumption of alcoholic beverages has markedly decreased. A shared similarity among Fairbanks. Alaska; Inuvik, Norman Wells, and Tuktoyuktuk in the Northwest Territories; and Aberdeen, Scotland la non-circumpolar areal was the impact from the pipeline and oil and gas exploration and developmenL Li€estyles and drinking patterns of those people imported into these areas, and the local in- habitants, changed radically. Alcohol consumption increased significantly and all the problems of a boom were in evidence. In reviewing the approaches to the control of alcohol abuse taken in differing coun- tries. it is obvious that the solutions vary and in many cases could still be con• sidered to be in an experimental phase It is rather like the approaches made to cope with the epidemic of tuberculosis during the 1930s and 1940's Many diverse 62 treatments were tried until eventually a stardardized treatment process was recognized and has led to an almost tuberculosis-free society. Unfortunately, alcoholism, unlike tuberculosis is further complicated by serious behaviour changes which impact on all areas of community life. Probably no one standardized treatment will ever be available for alcoholism that will apply to all people in all countries. A conference such as this international gathering may well bring us closer to our appropriate solutions. So often we look at the many different approaches and see only what does not work. I ask you to change that perspective and look at the aspects In your pro- gramming that do work and realize the progress that has been made toward a solution. In the last ten years in the Northwest Territories a great deal of positive change has taken place: for example most of Arctic Canada's alcohol and drug programs are now staffed by northern people who are recovering alcoholics, a large percen- tage of whom have received treatment and training in the Northwest Territories. Community leaders are now having a serious look at their responsibility in con- trolling alcohol abuse in their communities. This was demonstrated recently at a Dene conference on Alcohol and Drug abuse. Eleven resolutions were passed and a committee stuck to lobby the Territorial Government for changes they feel are vital to the survival of their traditions and their people. Another conference consisted of ninety alcohol and drug workers throughout the North who met in Churchill to discuss training needs and perceivbd necessary program changes. They passed several resolutions to be placed before the Territorial and Federal Governments. Several of those recommendations are presently being implemented. The lack of appropriate resource materials has been a long-standing problem. To date, several communities have developed posters, and pamphlets. A booklet, Listen to Us , that reflects the feelings and concerns of Inuit children and a book, Hole in the Ice, that features characters and situations familiar to the children of the North have also been developed. An advisory committee representing Native organizations and communities was set up to work with the Territorial Depart- ments of Education and Social Services in the development of curriculum materials that are appropriate. Along with the communities, the media are promoting the annual Alcohol Awareness Week. Community action groups are starting up and drawing attention to impaired driving responsible bartending, drug awareness programs for parents, and other alcohol and drug problems peculiar to their community. More action is being taken in the area of the Fetal Alcohol Syndrome, such as posters in liquor stores resulting from resolutions passed by the Canadian Consumers Associa- tion and the Territorial Nursing Association. There has been an expansion of employee assistance programs and many more Alcoholics Anonymous, AI-Anon and Alateen groups started. These are some of the positive changes that have taken place in Arctic Canada in the last ten years. I am sure that similar positive changes have taken place in your programming. I urge you to keep in mind the progress that has already been made as we, each in our own way, address alcohol and drug problems. REFERENCES Alcohol in the World of the Eighties, Soher Forlags, ICAA International Council on Alcohol and Addictions,; Circumpolar Health '81, Proceedings of 5th International Symposium on Circum- polar Health; N.W:1: Data Book 84/85, A Complete Information Guide to the Northwest Ter- ritories and its Communities. Outcrop lid., Yellowknife, NWT. t1964) Jeness Personal Communication: Rachel Gladue Yellowknife Thelma Tees Yellowknife Evelyn Blondin Yellowknife Bertha Blondin Fort Franklin Elizabeth Collins Fort Macpherson Robert Cunningham Yeilowknife Dr. Michael Igoe Yellowknife Jo Ann CrateThomas Yellowknife Sister A. Celeste Fort Norman Annie Mercredi Yellowknife The Lennie Family: Ernestine Fort Norman Johnny Fort Norman Gordon Saskatoon, Saskatchewan Angus Rae-Edzo Ernie Yellowknife Perry Moore-Lennie Saskatchewan TIMN 321453
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..-~a uw ac:uracV faithough not the ealidityl of the method of converting sample to pr+pulation results. which make jt wise not to press the quantification of these results too far. Whenever the focus is on a small subset of the entire sample, as for example those individuals that are very young or very old, the confidence limits are much wider. However the consistency from survey to survey and within each survey creates con• fidence in the averaged observations of characteristics and trends in the very large body of recovering alcoholics that is sampled here. These observations are of interest to us of Alcoholics Anonymous and, we hope, to the professional community and the public as well. ACKNOWLEDGEMENT ` We want to acknowledge helpful discussions with Professor Joseph Sedransk of the State University of New York in Albany regarding the design of the sampling plan. Percentage of Respondents Fg` 4 under 31 years of Age 2U 20"lb 15% 11% 10 8 ~a 7ib 6% 3% c c z d o U a d a0 1968 1971 1974 1977 1980 1983 Survey Year Fig 6 Addiction of Alcoholics to Drugs 100 • 80- a, . 0 60 • U_ 40 ° 'O • ~ Q d C' 20 '.• d a 10 20 30 40 50 60 70 80 90 Age:'years TIMN 32148 . 90
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images of the most dull and ktll-joy forms of bikotry. - The question of the practicality of a preventive strategy aimed at the elimination of alcohol is brought into sharp focus by the history of the introduction of Prohibi- tion in the USA in 1917 and its subsequent repeal in 1933. The failure of efforts to enforce the regulations, both as a result of the corruptibility of enforcement agencies and the energy and imagination of those seeking to evade the regulations, has been well documented and is indeed part of popular culture through its frequent represen. tation in feature films. What is interesting is the extent to which absolute proscrip- tion actually permitted the principles of market justice to operate at their most crudely opportunistic level, unimpeded by a socially sanctioned code of restraining influences. The growth in criminal activity associated with bootleggirig and the operation of speakeasies las distinct from, and in addition to, the illegal act of supplying the liquorl clearly posed individual and social problems that arguably caused far greater damage than the alcohol problems which Prohibition was supposed to alleviate. An unanticipated effect of Prohibition was to make criminals of large numbers of otherwise law abiding citizens. Developing social policy always involves establishing priorities. Whether the basis of prioritisation has to do with the strict economic cost to society of particular pro• blems or sets of problems, or whether it is underpinned by some less utilitarian moral system, there can be little doubt that, despite the fall in the liver cirrhos:s death rate, Prohibition failed in the USA. The other costs were simply, whatever the system of arithmetic used, too high. Again, we have an example of an attempt to impose an absolute solution which is evidently out of step witli the wishes of a substantial proportion of the population and which is actively opposed by a small but influential group who have a vested interest in promoting its failure. In such circumstances, and particularly at a time of economic uncertainty, as in the USA during the 1920s, the opportunities for exploitation soon came to seem like a way of life When Repeal was finally introduced, all it did was to regularise drinking practices which, though formally illegal, were already and always had been well integrated into the social fabric Finally, then, and most relevantly from a contemporary point of view, in terms of the practicality of imposing a ban on alcohol, there is the case of orthodox lslam, and its increasing influence, expressed both economically and militanly, upon the world. Unlike the example of Prohibition in the USA, here we have a case where the absence of alcohol represents the normative position of a particular society. The elimination of alcohol from non-Islamic countries is, in a sense, part of an evangelical activity, since in the Islamic countries themselves total abstinence is not culturally dissonant. On the other hand, one important point to be made here Is that the position of Islamic countries Is, in actual practice, much less absolutist than is often supposed. Apart from Iran, where vigorous enforcement of prohibi tbn has apparently reduced the availability of alcohol to negligible amounis• changing socio economic conditions in other Middle Eastern countries are er6ding the ex tent to which the Koran, which constitutes a code of civil and criminal law as well as advocating a religious doctrine, is being interpreted literally with respect to its injunctions against alcohol. At present, the production, importation, sale and con. sumption of beverage alcohol are still completely prohibited in Saudi Arabia. Libya. the Yemen Arab Republic, Kuwait and Qatar. In Bahrain and Pakistan, however, importation and use by foreigners Is permitted, although the production and con sumption by Moslems is not. Other countries, such as Iraq, Egypt, Lebanon and Sudan do not enforce prohibition. This rather confused picture has two layers to it since it is necessary to ask first whether laws prohibiting the supply of alcohol exist and secondly, if they do, whether they are enforced. In general, as oil-producing countries establish increased com munications with other cultures, stimulating the availability of consumer goods, tourists and foreign workers, so a widening gap appears between fraditionai or thodox abstinence and the growth in opportunities for smuggling and illegal pro. duction of alcohol. Currently, Iran's response has been to harden its attitude to the punishments imposed for infractions of the regulations, whilst some other coun tries have tended to relax the laws and customs, either through legislative change or through the simpler process of turning a proverbial blind eye. Obviously, where there Is widespread popular adherence to a religious doctrine which is seen as being integrated with civil and criminal law prohibiting the use of alcohol, prohibition is likely to prove an effective control policy. Where, however• that belief system is being challenged, or where enforcement is seen to be ineffec- tive or tokenistic, other, less traditional influences are likely to predominate• par- ticularly when these are perceived, as is the case of Western drinking practices, as being in some important way more "civilised" than the traditional orthodoxy. 7urning, therefore, from the practicality of prohibition to its desirability, the issue becomes one of testing whether Western drinking practices, moderate or immoderatt; can be deemed worthy of the epithet "civilised": Is it, the neoprohibitionLsts may legitimately ask• civilised to die of liver cirrhosis? Is it civilised to drive your motor y - ~ inem steak supper.+, or tnc purportetltt therapeuttc aovantagc•, of the cam4-radc n. of the good old.e English pub. The question is a serious one• posing, as it does• a doubt about the quality of particular modes of life and suggesting that some land not necessarily those which simply have the lowest rates of damagel are, in a fun damentally moral• social and aesthetic sense, qualitatively superior. To an extent, recalling the compromise between the principles of market and social justice which was mentioned earlier in this paper, John Stuart Mill's contention that "each is the proper guardian of his own health, whether bodily, or mental and spiritual" requires to be re examined in the light of the principles of public health, but not without losing sight of the spirit of vital libertarianism which echoes through the concept of civilised drinking. What is civilised, surely, is the presump• tion that rational choice remains within the grasp of the individual and that social policy provides an arena within which that rational choice can be legitimately ex ercised. 2.2 Preventing Drug Abuse Because many drugs of abuse are illegal in most countries, preventive efforts in this field have concentrated more upon measures to limit availability than has generab ly been the case with respect to alcohol. There is considerable• though not wholly unequivocal support, for this from the accumulated experience of the past. Suc cessful attempts to reduce the supply of heroin, by means of seizures and crop reductions, have produced reductions in illicit heroin availability, heroin dependents and heroin-related deaths. Legal reductions in cannabis availability might well reduce cannabis availability, at least temporarily, but would probably cause other drugs to be substituted. Legal restraints seem to have their greatest impact when combined with educa tional and rehabilitative efforts. The most successful legal restraints appear to be tightening controls of licit supplies: it is more difficult to have a direct impact on iliicit supplies. The most remarkable changes in drug abuse on a national level are those described for India, Japan. China. Sweden and Singapore. But such policies have their losses as well as their profits• and concern has often been expressed about the social and psychological problems created by the excessive use of repres slon to control drug abuse because of the danger that the legal suppression of one type of drug will lead to the use of another. The impact of international controls needs to be further studied. As regards primary prevention through education and persuasion, virtually all coun tries with illicit drug problems have made some educational effort, if only of an information-giving nature. Most drug education attempts to influence attitudes and drug-related behaviour. There is a lack of information on the impact and role of mass media as a tool for the primary prevention of drug abuse. Existing informa tion suggests that such media will not of themselves have much influence on at titudes and behaviour, and that their role should be one of providing information about drugs. their harmful effects, and places where more information can be found and help given. More information exists on school programmes, and the outcome of drug education programmes conducted in school settings has not yet been very impressive. The positive results are frequently outweighted by inconsistent or •'no effect" results. Several studies suggest that drug education efforts may actually be harmful. The reviewed paper concluded that such education projects should at pre sent be seen as topics for further research rather than as a means of educational attack which can be confidently recommended. A number of other possible elements within primary prevention also deserves con sideration. Some start has been made on the study of "parent education program, mes• which have the intention of training parents as a source of information for their own children. Programmes for training teachers and other professionals have been reported. Some work has been carried out on community activities as alter natives to drug taking. In one study of the expressed needs of drug users• assistance in finding a job and in finding more constructive leisure pursuits were given far greater salience than need for treatment. I urningto secondary prevention-the early identification and treatment of Individual cases of drug abuse-one might expect that early intervention would prevent the -_ development of full-blown addictive lifestyles. Several programmes for early treat ment of drug abusers have been described but few have been evaluated. This ap proach does seem promising. By tertiary prevention was meant treatment of drug abusers at a fully developed stage of dependency. Such treatment can be preventive in that drug abusers receiv ing treatment are less likely to cause others to start using drugs. Fven if not entirely successful. treatment might mean longer periods of abstinence, during which social stability and health could be at least partially restored. In the review paper, it Is considered that tertiary prevention through treatment is feasible but not an effec tive method for prevention. Treatment is costly in terms of time and effort as well as finance. Some interesting possibilities for treatment studies do exist, especially _~ i^ as(tt~° ~r nn _ ns livin in the
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TABLE I Aided Awareness of Risks of Cannabis Use in the Primary and Secondary Target Groups for Cannabis Inforcation Program 1983-85 Prisarv Target Group 1983 1 1985 ~ F BGrau[ unborn babies 83 76 1 82 2 Harder to study 75 77 71 2 More dangerous to drive car or ride bike 75 69 1 74 2 Habit forming 78 72 1 71 3 Causes lung cancer 52 48 51 Avarage 73 68 70 Weighted Number (821) (846) (856) Secondary Taraet Group Can harw unborn babies Can reduce driving sklils Can limit learning disabilities Can be hsbit forming Can cause lung cancer Average Weighted Number 58 60 (618) (6801 . Ds ference statistically significant at .05 level between 1983 and 1984 2. Difference statsstacally signaficant at .05 level betrecn 1984 and 1985 3. Difference statistically significant at .05 level between 1983 and 1985 TABLE 3 Discussions vith others as a Result of Seeing Cannabis Ads for Primary Target Group, 1904-85 Had discussions rith. Priands 10 Parents 7 Oth.rs 5 All 12-18 year olds Those erare olds ampaign 1984 19®5 194 1985 6 6 6 l 162 112 92 18 12 9 272 182 152 R.ighted Nu.ber (846) (856) (469) (,496/ 2. Differance statistically significant at .05 level batrsen 1984 and 1985 TABLL 4 Salf-Reported Use of Cannabis by Prisury Target Group for Cannabis Inforsmtion Prograa. 1985-85 197 1906 195 1 1 8 Ever used 25 26 16 Used in past 12 .onths 16 17 17 Used in past .onth 10 n/c 11 Dsed onee per reek or swrs in past .onth 5 n/e 6 Used once daily or wre in past reek 1 n/c 1 TABLE 2 Attitudes Toward Marijua a Use by Primary Target Group for Cannabis Information Program. 1983-85 1983 1984 1985 i t t 1 Parson should not feel fzes to ssw),e marijuana 79 75 77 rhsnsver he/she likas Non-user should insist that friends do not , surijuane in his/her home Person should not offer joint to non-user You should rork hard to eneourage friend to quit smcking emri3uar.a 72 74 763 78 79 80 79 78 77 Average 77 77 78 Weighted Number (821) (846) (856) Neighted nusber (821) (846) (056) n/c Msults not ee.pazable bacauee of rording changes. TABLE 5 Intention to Saoke Marijuana in 5 years by Priewry Target Group, 1984-85 1~ 984 1905 e 9 Definitely would not be uaer in five years 70 72 Probably will not be usar 10 17 Probably or definitaly will be user 11 10 1. Difference statistically significant at .05 level between 1983 and 1984 3. Difference statastteally significant at .05 level between 1983 and 1985 86 Maighted nuaber (046) (056) I TIMN 321479 ~
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AN ASSESMENT OF THE REFERRAL PROCEDURES AND A GENERAL PROFILE OF D.U.I. OFFENDERS IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Thomas F. OShea Introduction a. The facts and circumstances of the violation with the specific attention to the level of alcohol concentration in the defendant's blood and to whether per• sonal injury or property damage resulted from the violation. b. A recidivist check by an agency capable of providing a record of any prior super- vision orders. c. The written alcohol or drug evaluation of the defendant with special attention to any alcohol or drug related driving offenses. d. The past driving record of the defendant with specific attention to any alcohol or drug related driving offenses. e Whether in connection with the circumstances of the violation, the driving privileges of the defendant have been suspended as a result of a refusal to sub• mit to a chemical test f. If the defendant requests a sentence of supervision, he shall make a statement to establish: 1. That an Order of Supervision is in the best interests of the defendant and his family; 2. That an Order of Supervision is in the best interest of the public, and 3. That there are other matters in mitigation for consideration g. Any other factors deemed relevant by the Court or brought to the attention of the Court by either the defendant, the State's Attorney or victim. Thus, the Court has expanded it's traditional measurements used in criminal cases. Prior criminal background, premeditation, deviant behavior, and circumstances of the offenses are still applicable but have been enhanced by elements of the in- dividuals social behavior and specifics regarding substance use/abuse In other words, what risk is this defendant to society and himself from the stand- point of the legal, safety, and health issues involved? There is a common measure ment for all systems. Within the measure is a different meaning or common denominator for each system. With the adoption of new DUI legislation in 1982 in Illinois, including a "per se" conclusion at .10 B.A.C., defending the DUI offense has become more difficult. It is not uncommon for both the prosecution and the defense to enter into plea negotia. tions on this offense. Before there can be any agreement, all elements must be in compliance with Circuit Court Rule 11.4. Defendants are referred from the Court to the ADES Program either on a "Pre Sentence' basis, if a plea of guilty has been entered by the defendant, or a"Pre TriaP' basis if by agreement of both the prosecution and the defense Defendants not wishing to avail themselves of the procedures may go to trial, which is their right. Defendants found guilty after trial, are also generally referred to ADES for a "Pre-Sentence" assessment. Defendants are referred by the Court to the ADES program on a 23 to 30 day basis which is the next court date available to the defendant on the normal Circuit Court of Cook County cycle Since the disposition of the case is dependent on the assessment, the responsibility to follow the ADES procedures weighs heavily on the defendant. As stated by Dr. Pisani, a number of written instruments are utilized to assist the mgram in concluding a risk factor. These include a Personal Data Form, an Attitudinal Study, M.A.S.T., an ADES Substance Abuse Assessment, a Behavioral Assessment Scale, and the Education and Referral Officer's (EROIs) impressions. Also influenc- ing the risk factor are certain criteria that impact the Court's traditional method of evafuation. These include prior alcohol/drug related offenses and the circumstances of the offense Tradition measurements in safety and health issues are high BAC, prior remedial guidance, counseling or treatment, prior inpatient rehabilitation and prior Alcoholics Anonymous (AA) or other self-help attendance Thus, the ADES process includes elements of risk that impact all three systems; legal, safety, and health. From the accumulated information, both positive and negative, gathered during the assessment, a report is prepared for the Court that contains all elements of significance. A risk factor of 0, 1, 2, or 3, increasing in severity, is included in the report. A level of intervention is recommended with the level of risk. The Court requested, after extended exposure to the numerical risk sequence, that an opinion be rendered, in the report, as to the perceived effect of the recom• mended intervention on the individual's risk factor. A statement is included as to whether the perceived risk can be modified by implementation of the ADES recom- mendations. I Cook County, Illinois encompasses the major portion of metropolitan Chicago. It is an area in excess of 5,000 square miles with a population of over five million five hundred thousand (5,500,000) peopie. Approximately three million two hun- dred thousand (3,200,000) individuals in Cook County are licensed drivers. The Circuit Court of Cook County serves the City of Chicago and some 125 in- dividual communities adjacent to the City, all of which have their own individual law enforcement agencies and independent governments. To illustrate the magnitude of the operation, there are 355 Judges and more than 600 prosecuters in the system, all concentrated in an area of approximately 5,000 square miles. The Alcohol and Drug Education Services (ADES) program was established to pro- vide a service to the Circuit Court of Cook County in the form of substance abuse assessments with recommendations for social/health intervention in addition to traditional sanctions. It has been our experience in Cook County, Illinois that when the DUI "problem" or the drinking/drugged driver is discussed, the discussion generally has evolved around issues concerning safety on our streets and highways. That concern cer- tainly is laudable and we do not in any way, wish to minimize the impact of traffic related fatalities on the fabric of society. The "flip side" of that "coin" of concern is to assess the blame for the condition. All too often it appears to be very easy to scapegoat the criminal justice system in general and the judiciary specifically. Courts have been accused of being too harsh, with punitive sanctions that do not allow for consideration of what is iden- tified as the root cause of the problem, the alcohol or other drug. Courts have also been accused of being too lenient when diversionary tactics are applied. In either case, the courts are accused of being insensitive to the problem, depending on whose "ox is being gored". An initial point of this dialogue is that there are multiple interests that react to the offense of drinking and driving or otherwise drugged driving, all of whom have agendas that must be satisfied in order to bring the individual offense to a positive conclusion. In the area that the Alcohol and Drug Education Services (ADESI program functions, the concerns of the Legai/Criminal Justice System, which has primary responsibility for the offense, must be addressed. The Safety System, which includes the State of Illinois licensing authority; the Secretary of State, the Fedetal Department of Transportation, the State Department of Transportation, and various private safety initiatives, such as the National Safety Council, the American Automobile Association (AAA) etc., all have stated concerns for public safety. Citizen groups in Cook County, Illinois that have an active concern regarding the impaired driver are the Alliance Against Intoxicated Motorists (AAIM), Mothers Against Drunk Drivers IMADD), Students Against Drunk Drivers (S4DD), Remove Intoxicated Drivers IRID), to name a few. The Health Care/Substance Abuse System has an obvious interest in the impaired driver because of the drugs involved. Of additional concern is the necessity to have these other elements of society pro- vide the legal system with additional identification and assessment components to enable the Court to provide dispositions in these matters that incorporate the needs of these other systems. The ADES Program perceived a need to integrate the con- cerns of the various systems and the increasing awareness within our society; by what we believe is an accurate method of identification and sorting of the DUI population. Dr. Pisani, in his presentation, has indicated the diversity of the DUI population in our area. We will attempt to profile that population, provide some practical ap- plication to sorting the offenders by perceived social and/or health risk, and apply- ing the appropriate level of intervention for each offender. The Court Process In the adjudication of DUI cases, the Circuit Court of Cook County is governed by its Rule 11.4, which states,: Prior to entering into plea negotiations or considering for supervision, a defendant Who has been charged with violating Section 11-501 of the Illinois Vehicle Code (driving while under the fnfluence of alcohol, other drugs or combination thereof), IIi. Rev. Stat., 1083, ch. 951/2 par. 11-501, the court shall first review and have made a record of each of the following: 1 63 TIMN 321456
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ANTECEDENTS OF THE IMPAIRED NURSE Mary R Haack, RN., Ph.D. Work related stress in health professionals can lead to impairments such as bur- nout, depression and substance abuse. Impairment refers to the presence of certain dysfunctions which lessen the ability of the professional to use good judgement and to deliver safe patient care (American Nurses' AssociaUon, 1984). The topic of impairment has been discussed in the United States since the mid-seventies when physicians initiated the first programs for intervention and treeatment of their col. leagues (Bissell & Haberman, 1984). The nursing profession did not establish a policy to address the problem of impairment until 1982 when a resolution was passed at the ANA convention In Washington, D.C. The focus of research and Intervention for the impaired nurse has been limited to problems of substance addictions. The purpose of this study was to expand the perspective of impairment to include burnout and depression and to explore these dysfunctions as they occur among students of nursing. By so doing, it was possible to look at the antecendents of impairment before the students are practicing profes- sionals and to examine the relationships between the variables. METHOD Subjects in this study were sophomores, juniors, and seniars in an undergraduate program of a college of nursing. The majority of the students were between 22 and 25 years of age The students tended to come from college educated families (father 60%; mother 51%). Eighty-five percent of the students were single Seventy percent of the students held part-time jobs. Of the total number of students (n=367), 300 participated in the study. Data were collected through self-administered questionnaires which included the Staff Burnout Scale for Health Professionals (SBS-HP), Maslach Burnout Inventory (MBI), Center for Epidemiologic Studies Depression Scale (CES-D), Drinking and Drug Consumption and Social Support Reliability and validity for the burnout, drink- ing and depression measures are reported in the literature (Jones, 1980; Maslach & Jackson, 1981; Haack & Harford, 1984 and Radloff, 1977). Information concern- ing social support was generated from nine items that were adapted from existing social support scale (Gardner et al., 1984). Adequate reliability and validity for these items have been established by Haack (1985). RESULTS BURNOUT. The overall mean burnout score as measured by the SBS-HP was 63.5 (s.d. 16.2) (n=260). This score is considered in the high range of burnout and is consistent with the mean for practicing nurses who work in high stress areas such as intensive care (Jones, 1980). An analysis of variance of the MBI sub-scales by year in school yielded significant differences for emotional exhaustion and deper- sonalization (calloused feelings toward patients) F(3, 298) = 511; p-3C:01) F(3, 299 = 4.7; p -3C-.01). DEPRESSION. The mean for the CES-D was 21.8 (s.d. = 10.4) (n=199). This score is greater than the cutoff of 16 which is suggested by Radloff (1977). Subjects who score above the cutoff of 16 are considered at risk for dinKal depression. The CES- D is a measure of depressive symptoms and is not a diagnostic measure of dinicai depression. Further inquiry Is indicated to determine the clinical significance of this finding. SUBSTANCE USE AND ABUSE. Approximately 80 percent of the sample of students were current drinkers. The mean number of drinking days in the past month for the total sample was 4.6 days with a mean total consumption of 12.6 drinks and a mean average consumption of 2.45 drinks per occasion. Thirteen percent of the sample reported that the use of alcohol or drugs had interferred with work or school. The most recent information on the prevalence of alcohol and drug use among young adults is available from the 1982 National Survey on Drug Abuse (Miller et al., 1983). Comparison of the reported lifetime prevalence statistics by student nurses with national estimates is reported in Table I. TAitE I COIYAlISO. OF LIFETIIIE f'tt1ALE0CE AW FlEpUENCT BF SIMSTAMCC 6SE AT WYC il Ai 1YITIOML SYtYET BN MIK AMAE. IU IElLEIR s.KUnce C.f/ef.e . 97 11.t T..a<c. x 77 A1sNw1 N }5 Aspfrtn p N.c S1.ry/M Pflit L N.t Ii.rtj.ana ]f N AAML.fars u 1. Tr.np.llfi.rt i 15 N.ressants 3 15 [.caf.. 12 2! w1t.N.ytnz 2 21 /Mnfe 0.7 1 +stWe.t .rrsr . . )W. (a)Student nurse n = 300. {b)Nationai Survey n = 2000. 1982 National Survey on Drug Abuse, Young Adults ages 18-25 (Miller et ai., 1983). (c)No = not obtained. This comparison indicates that, with the exception of alcohol and amphetamines, the prevalence of the use of marijuana and other substances was lower than the national estimates for this sample of student nurses. SOCIAL SUPPORT. The literature suggests that there is a strong relationship bet. ween social support and other variables such as use of alcohol and drugs (Jessor & Jessor, 1972), depression (Kandel, 1982) and burnout (Pines et al., 1981). Pearson product moment correlations between social support variables and drinking variables in this study yielded a significant relationship between peer interaction and total quantity of alcohol consumed (r =.22) (p -3C- .001) (n = 298). The correlation indicate that the frequency of interac- tion with close friends significantly relates to quantity of akrohol use, and that most of the social support occurs within a drinking context. Pearson product moment correlations between social support variables and the subscales of the MBl yielded a significant relationship. The number of friends and the extent of concern expressed in the environment were both significantly related to greater feelings of personal accomplishment Ir =.24) (p -3C- .01) (n = 298) and (r = .29) (p -3C- .01) (n = 299). Significant negative correlations were obtained between all social support variables (with the exception of family sup- port) and depression symptoms (r = -29) (p -3C- .01) (n = 301). DISCUSSION This study had demonstrated that students who are involved in nursing education are at risk for stress related disorders such as burnout, depression and substance abuse which may be implicated in or could lead to impairment of professional practice The study further indicates that students would benefit from educational techni- ques that facilitate supportive interaction between students and faculty and students and their peers. It also indicates that students need training in interpersonal skills, stress management, and analysis of environmental stress. Further research Is in- dicated to evaluate the form and the timing of these interventions. The American Nurses' Association (1984) has recommended the following programs to address the issue of impairment within the educational setting: 1) group discus- sions about substance use and consequences; 2) nursing student involvement in campus programs which support responsible drinking; 3) the establishment of peer support groups; 41 the creation of policies which support treatment of substance abuse problems for impaired students; 5) information sharing regarding treatment programs that are appropriate for students; 6) and experiential and didactic learn- ing about substance use in the curriculum. These interventions are indicated by this study as well. REFERENCES American Nurses' Association: Addictions and Psychological Dysfunction in Nurs• ing: The Profession's Response to the Problem. Kansas City, ANA, 1984. Bissel, L and Haberman, PW.: Alcoholism in the Professions. New York, Oxford University Press, 1984. Gardner R., Wilsnack, S., and Slotnick, H.: Communication, social support, and alcohol use in first year medical students. Journal of Studies on Alcohol 44:188-193, 1984. Haack, M.R. and Harford, T.C.: Drinking patterns among student nurses. The Inter- national Journal of the Addictions 19(5):577-583, 1984. Haack, M.: Antecendents of the Impaired Nurse: Bumout, Depression, and Substance Use Among Student Nurses. Doctoral dissertation, University of Illinois at Chicago, Health Sciences Center, 1985. Jesso; R. and Jessoti S.L: Problem Behavior and Psychosocial Development: A Longitudinal Study of Youth. New York, Academic Press, 197Z Jones, J.W.: Preliminary Manual: The staff burnout scale for health professionals. Park Ridge, IL, London House Press, 1980. Kandel, D.B. and Dukes, M.: Epidemiology of depressive mood in adolescents. Ar, chives of General Psychiatry 39:1205-1212, 1982. Maslach, C. and Jackson, S.E. The measurement of experienced burnout. Journal of Occupational Behavior 2:99-113, 1982. Miller, P.M., Cisin, I.H., Gardner-Keaton, Hardell, A.V., Wirtz, PW., Abelson, H.I., and Fishburne, P.M.: National Survey on Drug Abuse: Main findings 1982. DHHS Publication No. ADM 83-1263, Rockville, MD, 1983. Pines, A.M. and Aronson, E.: Burnout: From Tedium to Personal Growth. New York, Free Press, 1981. bM.tf.nai S.r..7 a. 20W.- 7fQ wtfwul s.r..y « Ms5 AMt.. T..y Ap1ts a9rf 19-25 (M/11rr t at.. 1lp)l. aM - Mt MtJ/M/ TIMN 321447 56
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the community hospital. There has been a marked increased in admissions to the treatment centres of youth aged seventeen to twenty-four and of women in the past two years. One of the most common concerns voiced by those in the program is, "How do I say no to my friends when offered alcohol during my recovery?" In the Dene traditional way of "sharing" one does not say "nd' to a friend or eldec Native peoples find it difficult to participate in group therapy sessions as this is not part of their culture. One approach used is the "circle" of story swapping which enables them to express feelings and relate to one another-an important part of treatment. An example of the effectiveness of this approach was demonstrated when an Inuit per- son and a Dene related so well they learned to converse in each other's language. In general, as would be expected, some of these programs are more effective than others. In evaluating the projects, the accepted evaluation models of the south are not appropriate in the Northwest Territories. The prime criteria here is to meet the needs of the community as seen by the community. The most effective pro- grams are the ones in which the community is allowed to conduct the program in its own way with a self-evaluation component that looks not only at the pro- gram but at the community changes. In a few communities, guidance is needed for a period of time to develop effective programs. In these cases, a trained native social worker (when possible) or an alcohol and drug specialist will work with the community for at least two years, providing leadership and training for people in the community who will then carry on the programming. Southern Canada places emphasis on professionaiism with programs staffed by univer- sity graduates. On-the-pb training is a major component in developing our alcoholism workers and is carried out in the Northwest Territories or in available Native pro- grams. This develops a worker who is familiar with the culture, traditions and language in the community. It might not even be necessary for that person to be literate For example, Annie, a local native woman, told me that she had given up drinking and was ready to help other Indian people. I suggested she call on Northern Addic- tion Serivices and speak to the trainer and the supervisor of the Detox Centre. She did, and when it was learned that Annie could not read or write English, we had her record all of her reports on a cassette which were typed by the secretary the next day and signed by the Supervisor. Annie spoke fluent Chipewyan and was born in the Northwest Territories. Since many people in the program speak only Chip, Annie is invaluable as a counsellor with skills not usually provided in an academic background. The vast distances between communities, the extremes in ditnate with snow covering the ground for over eight months of the year in the Arctic, blizzards, white-outs, ice fogs, winter temperatures as low as minus fifty-seven degrees celsius, long hours of darkness in winter and extended hours of sunlight in the summer, and the sparse mixed population are characteristics we have in common in varying degrees with other circumpolar countries such as Finland, Norway, Sweden, Denmark, Greenland, U.SA. (Alaska), Iceland and Russia fSiberial. Our shared problems are delivery of services to isolated areas, limited availability of trained staff, lack of appropriate resources, alcohol-fractured communities and general health and social problems. Finland has a community approach to alcohol problems similar to the Northwest Territories in their local option policy. This policy allows their communities and local municipalities to decide on how liquor is retailed. Norway, on the other hand, has chosen to follow a regulatory model with the sale of alcohol in the hands of the State Alcohol Monopoly. Legislation governing taxa- tion, alcohol content and age of consumption is frequently examined. Norway still has the strictest regulations in the world covering drinking and driving. Sweden, like Norway, has had a long tradition of government intervention in the manufacture and sale of alcohol, provision of treatment of alcohohcs and state supported information and research. In Greenland the native Eskimos were formerly prohibited from purchasing alcohol. Prohibition was lifted after World War Il and consumption rose rapidly. Ten per• cent of disposable income was spent on alcohol. Following the introduction of self government in 1979, rationing of alcohol was instituted after a referendum. Accor ding to available information, the average consumption of alcoholic beverages has markedly decreased. A shared similarity among Fairbanks, Alaska, lnuvik, Norman Wells, and Tuktoyuktuk in the Northwest Territories; and Aberdeen, Scotland la non-circumpolar area) was the impact from the pipeline and oil and gas exploration and development. Lifestyles and drinking patterns of those people imported into these areas, and the local in- habitanis, changed radically. Alcohol consumption increased significantly and all the problems of a boom were in evidence. In reviewing the approaches to the control of alcohol abuse taken in differing coun- tries. it is obvious that the solutions vary and in many cases could still be con- sidered to be in an experimental phase. It is rather like the approaches made to cope with the epidemic of tuberculosis during the 1930's and 1940"s Many diverse treatments were tried until eventually a stardardized treatment process was recognized and has led to an almost tuberculosis-free society. ljnfoirtunately, alcoholism, unlike tuberculosis is further complicated by serious behaviour changes which impact on all areas of community life. Probably no one standardized treatment will ever be available for alcoholism that will apply to all people in all countries. A conference such as this international gathering may well bring us closer to our appropriate solutions. So often we look at the many different approaches and see only what does not work. I ask you to change that perspective and look at the aspects in your pro- gramming that do work and realize the progress that has been made toward a solution. In the last ten years in the Northwest Territories a great deal of positive change has taken place: for example most of Arctic Canada's alcohol and drug programs are now staffed by northern people who are recovering alcoholics, a large percen- tage of whom have received treatment and training in the Northwest Territories. Community leaders are now having a serious look at their responsibility In con- trolling alcohol abuse in their communities. This was demonstrated recently at a Dene conference on Alcohol and Drug abuse. Eleven resolutions were passed and a committee stuck to lobby the Territorial Government for changes they feel are vital to the survival of their traditions and their people. Another conference consisted of ninety alcohol and drug workers throughout the North who met in Churchill to discuss training needs and perceived necessary program changes. They passed several resolutions to be placed before the Territorial and Federal Governments. Several of those recommendations are presently being implemented. The lack of appropriate resource materials has been a long-standing problem. To date, several communities have developed posters, and pamphlets. A booklet, Listen to Us , that reflects the feelings and concerns of Inuit children and a book, Hole in the Ice, that features characters and situations familiar to the children of the North have also been developed. An advisory committee representing Native organizations and communities was set up to work with the Territorial Depart• ments of Education and Social Services in the development of curriculum materials that are appropriate Along with the communities, the media are promoting the annual Alcohol Awareness Week. Community action groups are starting up and drawing attention to impaired driving, responsible bartending, drug awareness programs for parents, and other alcohol and drug problems peculiar to their community. More action is being taken in the area of the Fetal Alcohol Syndrome, such as posters in liquor stores resulting from resolutions passed by the Canadian Consumers Associa• tion and the Territorial Nursing Association. There has been an expansion of employee assistance programs and many more Alcoholics Anonymous, Al-Anon and Alateen groups started. These are some of the positive changes that have taken place in Arctic Canada in the last ten years. I am sure that similar positive changes have taken place in your programming. I urge you to keep in mind the progress that has already been made as we, each in our own way, address alcohol and drug problems. REFERENCES Alcohol in the World of the Eighties, Soher Forlags, ICAA International Council on Alcohol and Addictions,; Circumpolar Health '81, Proceedings of 5th International Symposium on Circum• polar Health; N.WT. Data Book 84/85, A Complete Information Guide to the Northwest Ter- ritories and its Communities. Outcrop Ltd., Yellowknife, N.WT. (1964) Jeness Personal Communication: Rachel Gladue Yellowknife Thelma Tees Yellowknife Evelyn Blondin Yellowknife Bertha Blondin Fort Franklin Elizabeth Collins Fort Macpherson Robert Cunningham Yellowknife Dr. Michael Igoe Yellowknife Jo Ann CrateThomas Yellowknife Sister A. Celeste Fort Norman Annie Mercredi Yellowknife The Lennie Family: Ernestine Johnny Gordon Angus Rae-Edzo Ernie Perry Moore-Lennie Fort Norman Fort Norman Saskatoon, Saskatchewan Yellowknife Saskatchewan , TIMN 321455 62 9
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influence others to do so as well. I he new British heroin users, unlike their pre 11ar counterparts, were acting as role models for others and initiating their friends into heroin use Those who were joining their ranks would not be officially iden tified for some time, and in the meantime they too would be creating new cases of dependence. Thus, the official Home Office statistics on "non-therapeutic addicts" increasingly represented only part of the recreational opiate-using population, and probably only a small one at that. The Doctor-Dependent Relationship The new British junkies were handicapped in respect tolfull performance of the American junkie role, in so far as there was no black market in illicit opiates to add excitement and danger to their lives. However, they were quick to pursue the other option open to them, one which would bring tears of envy to the eyes of junkies across the Atlantic. They began to appear in the offices of doctors who might be persuaded to write prescriptions for legal, pharmaceutical supplies of co- caine and heroin. I'he new English users were not like their elders who were expected, with help of a general practitioner, to make attempts to reduce the size of their habits, work- ing towards abstinence, and then, if all else failed, they might be prescribed maintenance therapy. Rather, the new users were seeking out professionals with the deliberate intention of obtaining the prescription drugs to permit them to con tinue in the deviant life style of their choice. They were not looking for medical help from a trusted physician, but were seeking a "script doctor': The essence of this distinction was captured by Hepworth 119821 in an interview she conducted in the 1960s. Her respondent reported that she had visited "about 40" doctors before she found one who would prescribe a drug; she said, "I didn't want to go to our family doctor about this... I thought it would really upset him:' (p.214(. This surely is not the kind of doctor-patient relationship envisaged by the Rolleston Committee. Young 119711 suggests that the overprescribing physicians of the late 1950s and ear- ly 1960s were used unfairly as scapegoats, presented as the "germs' which had "caused" the epidemic, the corrupters of innocence. In my reading of the literature. he seems to be the only chronicler of the times to present an alternate and more satisfactory account by noting that the doctors were ':..cajoled into providing for an existing demand rather than the primary cause of this demand:' IR-2081. Thus, in a sense, the drug users corrupted the doctors, homing in on the more vulnerable members of the medical profession, exploiting that vulnerability, creating a grey market in pharmaceuticals and thereby increasing their own numbers to a point where they became a visible social problem. 'i hose who have tried to understand how and explain why Rolleston policies fail ed speak of the sheer numbers of opiate users in the post-War period: they atso note how the socio-dcmographics changed and a subculture arose. I would suggest that not enough attention has been paid to the way the new heroin users had im- ported an essentially American role model and that "conning a quack" was a junkie skill that was part of the performance of that role "Script doctots" are an integral part of the lore of American funkies who turned to doctors throughout the twentieth century, particularly during the 1940s when imported heroin became scarce because of wartime conditions. William Burroughs 119531 offers advice on how to manipulate what he terms "a writing croaker": Some will write only if they are convinced you are an addict, others only if they are convinced you are not... With him [one oldtime doctor] it was simply necessary to present a gentlemanly front.... Another doctor was always drunk and it was a matter of catching him at the right time..Still another doc tor was senile, and you had to help him write the script....Generally speaking, old doctors are more apt to write than the young ones. Refugee doctors were a good field for a-while, but the addicts burned them down...You need a good bedside manner with doctors or you will get nowhere (pp-33-34t Even in the United States, where doctors had been criminalized for their prescrib inK practices for thirty years, 3]unkie could hope to find a vulnerable physician. William Burroughs and Jack Kerouac were the most influential American writers whose works are mentioned when British drug users speak of the formation of their attitudes toward drugs (Hepworth, 19821. It is interesting. too, that the only novelist from Great Britain who is reported to have aroused interest in drugs and to have promulgated drug mythology is Alexander Trocchi; his novel, Cain's Book_ 119601. has a Scottish heroin-using hero, but the book is set fn New York City and his characters are archetypical American junkies- When drug legislation came into force in the U.S. and Canada, there was aiready an established opiate-using subculture drawn from the underworld of gamblers, vagrants, prostitutes and persons of varying shades of criminality fTerry & Pellen, 19281. Although there was a somewhat similar cocaine-using subculture in Lon. don at the time that the Rolleston Committee was convened, it was sufficiently small and apparently so fragile that it had disappeared by 1930 iParssinen. 19831. It seems reasonable to assume that, had an American-style heroin-using subculture appeared earlier, the troublesome overprescribing physician also would have ap- peared much sooner. As soon as North American drug laws were in place. opiate users found doctors to prescribe for them. 1 here is no doubt that some of these doctors were well meaning, ethical physicians who were deeply concerned about the fate of the newly criminalized dependent. Nevertheless, the same could not be said for some of their colleagues. One of the first test cases under the Harrison Act involved a physician who indiscriminately sold thousands of prescriptions for profit 15chur, 1965). In preliminary research at the National Archives in Ottawa, I have found many cases of Canadian doctors prosecuted during the 1920s whose prescribing behaviour would be deemed unethical by any standards. However, such cases are highly unlikely to have arisen in the absence of large numbers of drug users sharing information about "script doctors" and swarming to their offices. The threat to the stability of British opiate policies arose with the appearance of American-style English heroin users The sudden appearance of overprescribing physi cians was most probably a result of this historical change, not its cause. Increased availability of opiates from over-generous prescriptions increased the contagiousness of this group of heroin users, but was not the cause of it. The seeds of the sub• culture had been sown, and if pharmaceutical supplies had not been available, im- ported illicit heroin would simply have appeared on the streets of London some years earlier. No particular policy recommendations derive from this analysis of the demise of the Rolleston era. The argument is based on the assumption that, at least to the present, there have always been members of the medical profession who, for honourable or less honourable motives, will reach for a prescription pad when con• fronted by a certain type of exploitative patient. It also assumes that such patients, in search of opiates or other drugs, will continue in future to appear In doctors' surgeries. Pblicymakers can try to deal with the problem by applying more stringent criminal : sanctions against doctors or inventing new laws to punish "prescription shoppers" Prescription of certain drugs can be limited to appointed specialists and regulations can be enacted to specify the conditions under which these drugs can be ad- miniuered. However, as long as we have non-medical drug users who discover the recreational or lucrative possibilities of pharmaceuticals before pharmacologists or medical professionals have even considered them, such policies are reactive rather than active Although this analysis betrays pessimism with regard to the persistence of the ex. ploitative drug user in the doctor's office, it should not be assumed that there are no positive steps that can be taken. There is no logical reason why private practi- tioners cannot deal on an individual basis with such difficult patients, should they choose to do so and should they be prepared for the problems they will encounter. There is also no reason why, on the Rolleston model, medical societies should not be capable of disciplining their own members when necessary. REFERENCES Berridge, V. Drugs and social policy: The establishment of drug control In Britain 1900-30. British Journal of Addiction, 79: 17-29. 1984 Blackwell, J. Drifting, controlling and overcoming: Opiate users who avoid becom- ing chronically dependent. Journal of Drug Issues. 13: 219 35. I983 Burroughs, W. Junkie. New York: Ace Books.lOriginally published under the pen name William Lee.) 1953 Glatt, M.M.. Pittman, DJ., Gillespie, D.G. and Hills, D.R. The Drug Scene in Great Britain: "Journey into Lonetiness:' London: Edward Arnold. 1967 Great Britain, Ministry of Health Report of the Departmental Committee on Mor• phine and Heroin Addiction. London: HMSO. 1926 Great Britain, Ministry of Health Drug Addiction: Report of the Interdepattmental Committee, 29 November 1960. London: HMSO. 1961 Great Britain, Ministry of Health Drug Addiction: The Second Report of the Irr terdepartmental Committee, 31 July 1964. London: HMSO. 1965 Green. M. A history of Canadian narcotics control. The formative years. University of Toronto Faculty of faw Review, 37: 42-79. 1979 Hepworth, D.M. Addiction in Britain: Patterns of Narcotic Abuse in the Mid Sixties. Ph.D. thesis. University of London (L.S.E.). 1982 Judson, H.F. Heroin Addiction in Britain. New York: Harcourt Brace Jovanovich. 1974 Musto. D.F. The American Disease: Origins of Narcotic Controls. New Haven: Yale I lniversity Press. 1973 Parssinen, T.M. Secret Passions, Secret Remedies: Narcotic Drugs in British Society, ` 1820-1930. Philadelphia, Pa.: Institute for the Study of Human Issues. 1983 Schur, F M. Crimes without Victims. Englewood Cliffs. N.1..: Prentice Hall. 1965 Spear, H.B. The growth of heroin addiction in the United Kingdom. British Journal of Addiction, 64: 245-255. 1969 Stimson, G.V. Heroin and Behaviour. Shannon, Ireland: Irish llniversity Press. 1973 'ferry, C.E. and Pellens, M. The Opium Problem. New York: Committee on Drug Addictions and the Bureau of Social Hygiene. 1928 'li-ebach, A.S The Heroin Solution. New Haven, Conn.: Yale l Iniversity Press. 1982 Trocchi, A. Cains Book. London: John Calder. 1960 Waldorf. D..Orlkk, M., and Reinarman, C. Morphine Maintenance:'I'he Shreveport CliniG 1919-1923. Washington, D.C.: Drug Abuse Council. 1974 Young, I. The Drugtakers: The Social Meaning of Drug t Ise. London: Paladin. 1971 80 TIMN 321473
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THE ATTITUDES OF NURSES AFFECTING THE REHABILITATION OF IMPAIRED NURSES USING AND ABSTAINING FROM DRUGS AND ALCOHOL Ltnda Nance Mar4 R1+1., EdD.; John C. Reed, EdD. and Deanna Alexander, RN., CADAC PROBLEM S'TATEMENT: s professional nurses from a four-state region toward the practicing nurse who is abusing alcohol and drugs to attitudes toward the impaired nurse who sought treatment and is abstaining from alcohol and drugs. The problem addressed in this study was to determine the effect of an educational program on the attitudes of practicing nurses toward chemically dependent (im- paired) nurses. The problem of study sought to identify the attitudes that are affea ting the identification, treatment, rehabilitation, and return to practice of the impaired nurse from the perspective of the practicing nurse. INTRODUCTION: A major concern of the profession of nursing today is the issue of the impaired nurse Impairment may take the form of psychosocial probiems; howevey it is generally the term used to describe the nurse who is chemically dependent. The ever in- creasing numbers of professional nurses struggling with the problems associated with chemical dependence and the long term effects on the profession is a major concern of nursing. Alcoholism and drug addiction is not new to the general population or to nursing. Due to the stigma of substance abuse, it is difficult to determine the numbers of chemically dependent nurses. When discussing addiction in the general population one usually estimates a group of five to ten percent. It is becoming evident that the problem is much greater in the practicing population of professional nurses today. The magnitude of this problem affecting nursing is a source of concern of the Na- tional Council of State Boards of Nursing which reports in 37 of 58 member boards in a one-year period, 67 percent of cases heard dealt with impaired nurses. (Green, 1984) The Texas Board of Nursing indicates that the problems of the impaired nurse are great. A large majority of the nurses called before this licensing board are due to charges related to unsafe practice and unprofessional conduct associated with substance abuse. (Pryo; 1985) The practicing professional is often the first to recognize the problems associated with chemical dependence when acute intoxication is obvious. The professional peer becomes aware of the extent of the problem as he recognizes that the chemically impaired nurse is guilty of: "(a) deceiving the patient; (b) subjecting their patient to the possibility of increased pain, and (c) misleading the physician about the requirement for medication and making him or her the unwitting accomplice to an illegal acti' (Daniel, 1984, p-190( While self regulation is a time-honored privilege of the profession of nursing, voluntary discipline and surveillance often results in an ethical dilemma. Regulation of the profession becomes more difficult for the practicing nurse faced with a peer who is abusing alcohol or drugs. The questions becomes "What Is best for the individual, the profession, and the public?" Nurses recognizing the existence of a problem with a colleague are repeatedly requesting assistance. Another large segment of the profession seemingly choose to use denial as a means of coping with this pro- blem. (Daniel, 1984; Barr, 1984) The professional nurse recognizes the need to safeguard the client and public from the unsafe and unprofessional conduct of the impaired colleague, yet is faced with the decision of what action should be taken. Frequentiy the professional chooses to ignore the problem, and the doak of secrecy begins. "The reasons for secrecy are many: a need to perceive health care providers as infallible; fear of liability if such impairment is acknowledged by the individual or institution; lack of resources to deal with the problem;, and conflict bet- ween viewing impairment in the workplace as a disciplinary issue rather than an indicator of an employee needing assistance:' (Barr, 1984, p- 1961 Although policies which support the rehabilitation of impaired nurses are considered to be cost-effective, programs are needed to provide education and referral of nurses to sources of care. Rehabilitation efforts are directed toward assisting the individual to maintain his abilities, prevent disabilities, and render the individual fit to engage in life's activities. (Gruca, 1984) Bissell recommends that: "No nurse shall lose her job or her license to practice her profession because of alcoholism or other chemical dependency without first being offered appropriate treatment as alternative' (1981, p. 101) One must question if the attitudes of the practicing professional peer does not hamper the rehabilitation of the impaired nurse due to attitudes associated with the stigma of alcoholism and substance abuse Continued denial of this problem or lack of knowledge becomes a great obstacie for the nurse needing rehabilitation. The purpose of this research project was to determine the attitudes of practicing POPULATION Eighty-one registered nurses from four states participated in the study. The majori- ty of the participants were from Texas. Sixty-four percent reported being employed as staff nurses, twenty-seven percent in management, and the remainder being employed as consultants or educatots. The majority of the participants were female with a mean age of twenty-six. The mean for years of experience in nursing was eight years and sixty-nine percent reported to have a Bachelor of Science or higher degree in nursing. DATA COLLECTION: At a regional conference of nurses, prior to a presentation entitled "The Chemical- ly Dependent Nurse; the audience was asked to complete an attitudinal survey on their attitudes toward (1) practicing nurses who were chemically dependent and (2) practicing nurses who were abstaining chemically dependent nurses. Following the presentation concerning chemically dependent nurses the audience was again requested to respond to the same attitudinal survey. The study was replicated by administering the questionnaires to ten different groups in Texas No significant difference was found in similar populations. ANALYSIS OF DATA: The data from the pre and post attitudinal survey were tested with a t test at the significance level of 0.05. The analysis was accomplished and results obtained are shown below. HI There was a significant difference between attitudes of registered nurses prior to an educational program regarding chemically dependent nurses and rehabilitated chemically dependent nutses. (N=81) t = 11.89 significant at the 0.05 level or better H2 There was a significant difference between attitudes of registered nurses following an educational program regarding chemically dependent nurses and rehabilitated chemically dependent nurses. (N = 811 t = 4.89 significant at the 0.05 level or better H3 There was no significant difference in attitudes of registered nurses regarding chemically dependent nurses using alcohol and drugs following an educational program. (N=81) t = .16 H4 There was a significant difference in attitudes of registered nurses toward rehabilitated chemically dependent nurses following an educational program. (N=81) t = 558 significant at the 0.05 level or better RF.SULTS AND IMPiICATIONS: There was a more negative attitude held by practicing nurses toward chemically dependent nurses than toward abstaining chemically dependent nurses. On both pre and post presentation surveys there was a significant difference in attitudes reported toward chemically dependent nurses and abstaining chemically depen- dent nurses There was also a significant difference in reported attitudes toward the chemically dependent nurse when the pre presentation was compared to the post presentation survey results. Following the presentation the audience reported a more positive or accepting attitude toward the chemically dependent nurse Analysis of responses to select questions within the questionnaire demonstrated distinct changes in attitudes of the participants on the pre and post questionnaires. The greatest amount of change occurred in test questions 2,4,5,17,19,20, and 24. In questions 2,4,15,17, and 19 the participants were asked to indicate their attitudes toward the impaired nurses currently using alcohol and drugs and their attitudes toward impaired nurses abstaining from alcohol and drugs. Question two asked if the participant viewed the impaired nurse as being depended upon to be honest. Responses on the post test indicated that the participants became more open and trusting of the impaired nurse after establishing a relationship with an impaired nurse through the educational presentation. Question four asked "some of our best nurses are from this group:' Through the educational program the participants discovered that the impaired nurse is not usually the "bad apple" of the profession, but likely to be a highly motivated, outstanding, achievement oriented nurse in the top one-third of the graduating class. (Green, 67 TIMN 321460
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I he Court then includes the risk factor in it's deliberations. The Court may, in it s wisdom, either reject the recommendations or include them as a pan of the sentencing package, as a condition of compliance with the sentence. As stated before, since the assessment Is not limited to a clinical/medical evalua. tion but rather with the combined societal issues that make drinking and driving so abhorrent, we believe that the risk can be better managed. The results of several years of Circuit Court DUI intervention and the accumulated experience of the ADES program has provided a sizeable amount of statistical data which reveals substantial commonality within the diversity of the DUI offender population. a in this presentation, we will observe the numerical variables of Cook County's ADES clients as reported in calendar year 1984. We believe it necessary to further identify the population that has been referred to us by the Court Proper manage- ment of DUI intervention and prevention requires elementary demographic analysis to construct effective responses to drugged drivers. Minor changes are occurring from time-to-time. Therefore, we turn now to a brief look at the DUI offender in Cook County, Il- linois as seen by the Alcohol and Drug Education Services in 1984. General Profile of the DUI Offenders' Referral to the Alcohol and Drug Education Services of Cook County, Illinois Since 1978, the Alcohol and Drug Education Services (ADES) program of Cook County, Illinois has maintained a battery of statistics which describes the DUI of fender who is referred to ADES for assessment and, generally, for intervention services. The purpose of this paper is to present a general descriptive profile of the DUI offender in Cook County, Illinois and to offer a more in-depth profile of the ADES program referral population. Limitations to this information include delineating the study to only those DUI offenders referred directly by the Circuit Court of Cook County to Alcohol and Drug Education Services and to restricting the more in- depth analysis of the referral population to a random sample of 2888 individuals served by ADES in calendar year 1984. Further recognition is given to the study having been conducted in a large 15,500A001 urban complex of the Midwestern United States. Metropolitan Chicago does offer. however, the opportunity to study DUI offenders from the vantage points of large racial mixes, economic diversity, and urban/suburban population trends which are common in the large, older urban centers of the United States. Thus, the statistical information presented in this paper describes the DUI offender in terms that may be com mon in other urban areas of North America. The pre sent description also allows the raising of a number of questions for further com parative research both in individualized urban areas and in rural/suburban communities in North America and in other parts of the world. First let us look at the general population referred to ADES. Significantly, in 1984, The ADES program responded to nearly 18,000 referrals compared to nearly 3500 persons in calendar year 1978, the first year with comprehensive statistics available. The 18,000 persons represent the vast majority of Cook County DUI referrals available for referral/intervention services. Since 1978, the overwhelming 191%1 majority of referrals has been male. Howeves in 1984, the ADES program recorded a drop in male clients to eighty-seven 1871 percent and an increase in females to thirteen 1131 percent. Of course, this statistical change. does not allow one to speculate at this point that there will be additional increases in the numbers of female DUI offenders in future years. ADES research does indicate that the proportion of women holding drivers licenses and having traffic accidents is much larger than the number referred to Cook County's l)UI intervention system. Nationally, women hold one-third of the drivers' licenses and are involved in approximately one-third of the traffic accidents. It is possible that fewer women drive and drink to excess or is it possible that cultural biases interfere with the process of DUI intervention for females? These questions need to be researched outside of the scope of a DUI intervention program. As noted in the examination of the sexual comparison of DUI offenders, there has also been a consistency of percentages in the age breakdown of ADES referral popula tion. Program statistics for the past seven years reveal that the Cook County DUI offender is both male and young with a majority of referrals being under age thirty 1301. However, there has been a gradual decline in this majority from sixty (601 percent in 1978 to fifty-two 1521 percent in 1984. The increase in referrals in the 31-40 age bracket is consistent with the bulge of the post-World War II "baby boorri : This decrease in the percentage of younger offenders is totally related to the decline of the youngest group, those twenty (20) years of age and younger. The group of offenders between the ages of twenty-one 1211 and thirty 1301 has remained relatively constant in the past seven f7i years In the past, ADES information showed an inverse correlation with higher ages and f)itl referral. This correlatwn has remained constant with some change in 1984. fhe middle age group Ibetween thirty-one [31 ] and fifty [50] again showed gradual increase to approximately thirty-two 1321 percent of the total referral population. However, in program year 1984, the "middle aged" group comprised thirty-nine 1391 percent of the total population referred to Alcohol and Drug Education Ser• vices in Cook County, Illinois. The oldest group Ififty-one [51] and upwards) has held rather constant over the last ew years following a peak of thirteen (13) percent in 1979. Overall, drinking and driving remains a young petson's offense as reflected in Cook County ADES statistics. This writer notes, however, the steady decrease in the number of referrals from the youngest group over the years. As the next youngest groups t21-40) age, will there be larger increases in the referral population in the middle age range segments of ADES? One could attribute the gradual reduction in the number of the youngest (under twenty [20]) offenders to the net effect of Illinois raising its legal drinking age to twenty-one (21) in 1980. However, DUI intervention professionals must also con• sider the effects of education and the general state of the economy in the past few years among many other variables, including law enforcement policies, even to begin to assess these small changes in the age groups referred for DUI intervention services. If one analyzes DUI statistics from the point of racial characteristics, one observes that overwhelmingly, the typical offender is the younger, white male Cook Coun- ty ADES information indicates that whites have comprised from eighty 1801 per• cent to eighty-nine 189) percent of the referral groups over the past seven 171 years. The minority IBlack, Hispanic) population has averaged about fifteen 1151 percent over the same period of time One must also note, however, that consistent with residential patterns, the minbri- ty population constituted only five (5) percent of the suburban referral group but fifty-one 1511 percent of the similar city group in calendar year 1984. Unless residential patterns change in the city, one could expect the minority group population to remain the majority of ADES city referrals in the next few years. Furthermore, the Hispanic population in the City of Chicago is the fastest growing segment of any racial group. Currently the Hispanic group's referral to ADES falls significantly below that group's proportion in the city's total population. However, information about the city's Hispanic community indicates a very large proportion of younger members. The large proportion of young Hispanics who become of driving age could have implications for future DUI intervention programs in the urban setting. To analyze further the general profile of a DUI offender is to observe the numbers of prior DUI arrests or the incidents of DUI recidivism. In 1978, DUI repeat of• fendets composed thirty-four (34) percent of the total referral population.2 By 1984, repeat offenders were only sixteen 1161 percent of the ADES population. Sources of ADES repeat offender information are the limited public records available, ADES own recidivism file, other intervention programs, and from offenders' self-reports. The offenders self-reports' have proven the most reliable. The reduction in ADES repeat offenders can generally be interpretated as a positive sign that Dtll intervention does reduce the likelihood of a person's repeating a drunken driving offense. This writer must also note that the reduction in the percen• tage of repeat offenders entering the ADES program needs to be placed in the perspec- tive of five years of very rapid growth of the total A DES population. It has also been the program's experience that as Program referrals Increase so does diversity of the population. In the early years of the A DES program, defendants were selec- tively referred by the Court by means of identification of a"problerri : In subse- quent years as the enforcement "net" broadened and judicial acceptance of the intervention concept increased, the percentage of referrals at significant high risk has declined. This transition has culminated with the adoption of Circuit Court rule 11.4 which mandates assessment prior to disposition of all Dtll offenders. An independent study, forthcoming in two to three years, will examine the effects of ADES intervention upon DUI recidivism. One variable of importance in the in• dependent study may be the inverse correlation of rapid general referral growth and the percentage of decline in ADES recidivism statistics. Effective January lst of 1982. numerous changes were made to the DUI statute in Illinois. Among the changes were the introduction of the "per se' conclusion and the strengthening of the implied consent (breathalizerl provision. The result has been a reversal of percentages in the number of defendants submitting to the breath test (breathalizerl. In 1981, only 33% of the defendants submitted to the test. In 1984 that percentage had increased to 59%. This change is emphasized more dramatically when the City of Chicago referral population, with It's less sophisticated minority groups are isolated from the basically white, middle class referrals from suburban Cook County. In suburban Cook County, over 70% of the population are submitting to the breath test, while in Chicago that figure is still below 50%. Profiles The introduction to this work proposed further analysis of the general profile as 04 TIMN 321457
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BRITISH OPIATE POLICY AND THE OVERPRESCRIBING PHYSI- CIAN: AN INTERNATIONAL PERSPECTIVE ON AN IMPORTANT HISTORICAL -ERA icsBtackwel s Despite popular misconceptions and the epithet, "British System ; the laws and regula- tions governing opiate use and distribution in the United Kingdom in most respects have been very similar to those developed in North America and other western countries. The crucial difference occurs in the area of medical use of the opiate drugs, specifically the conditions under which physicians in Britain have been per- mitted to prescribe opiates for their patients, especially those patients who are depen- dent on these drugs. In every society there are chronic or terminal cases where the regular administra- tion of prescription opiates has resulted in dependence. These "medical" or "therapeutic addicts" are not considered to be a social problem, as long as they do not become cured of their other health problems. It is standard medical practice for physicians to continue to prescribe opiates for such patienta Where countries differ, however, is in regard to opiate-dependent patients who have no other organic condition to justify the administration of opiates. In various times and piaces such patients have been called "narcotic add icts ;"dope fiends" or "junkies ; signifying that the dependence has arisen from recreational use of heroin or other opiates and suggesting that they are a moral or social rather than a medical pro. blem. The British refer to them as "non-therapeutic addicts": Initially, British policymakers were similar to their North American counterparts in the essentially law-enforcement approach they took toward the problem of the non-therapeutic dependent IBerridge, 1984). The Home Office specified that the prescription of opiates "solely for the gratification of addiction" was not a legitimate medical justification. However, they were receptive to medical opinion on the sub- ject and, because of the ambiguity of the regulations concerning opiate prescribing, no physicians were prosecuted for prescribing maintenance doses to their depen- dent patients. This stands in marked contrast to the North American situation where police investigations and arrests of doctors occurred shortly after the passage of the first drug legislation lGreen, 1979; Musto, 1973j- To clear up uncertainty over policy, in 1924 the British Government appointed an advisory committee to look into the matter. It was chaired by Sir Humphrey Rolleston, President of the Royal College of Physicians. The committee was com- posed of medical professionals and favoured medical testimony in its proceedings. Its conclusions were to be the basis of British opiate policy for over forty years. the years of the "Rolleston Era": The Departmental Committee report (Great Britain, 19261 concluded that, although the law provided for criminal sanctions against doctors who abused their prescrib- ing privileges, the medical profession could, and rightly should, police itself. It recom- mended that medical tribunals be established to investigate questionable medical practice5. --- Another crucially important conclusion of the Committee concerned "apparently incurable cases" of dependence. Continuous administration of drugs to non-therapeutic dependents who otherwise would be unable to function well in their social roles was deemed to be legitimate medical treatment. It was assumed that there would always be some individuals with drug problems in society, so the question became how to manage them in the most sensible manner and how to minimize the harm they caused to themselves and others Thus, in Bdtainppiate use was unequivocally defined as a medical matter and the profession asserted its right to discipline its own errant members and leave well- conducted physicians free to make their own medical judgements without fear of being harrassed by the police. By this time in the United States, doctors continued to be arrested and some members of the profession were becoming frightened even of prescribing regular doses of opiates to patients with terminal illnesses IWaldorf et al., 19741. It should not be forgotten that, compared to North America, there were relatively few opiate dependents in the U.K. during the formative years of British policy. The first year that the Home Office produced reasonably complete statistics, 1936, there were 616 dependents on their files. Of these, 147 were members of the medical profession. Most of the rest were "therapeutk addicts : By 1953, there were only a few dozen individuals known to the Home Office as "non-therapeutic addicts" (Judson, 19741. During the 1940s and 1950s, only two British doctors had their opiate prescribing practices brought to the attention of the authorities (Trebach, 19821. The British may not have had a "system" per se, but their situation was an enviable one Unfortunately, the post-War years brought an increase in non-medical drug use and new problems which were to prompt new policies, signalling the end of the Rolleston era. In 1958, the number of non-therapeutic dependents known to the Home Of- fice was still very modest, only 68. Then the figures began to mushroom: 122 known in 1960; 580 known in 1965; and by 1968 over 2400 IStimson, I973i. In 1960 and 1964, two committees reported on policy with regard to psychoac- Uve drugs, both known by the name of their chairman, Sir Russell Brain. The first Brain Report IGreat Britain, 1961) overlooked the symptoms of the brewing epidemic and did not recommend any significant departures from Rolleston policy. However, the committee had to be reconvened when the official statistics revealed frighten- ing increases every year after the release of the first Brain report. The second report lGreat Britain, 1965) pointed an accusatory finger at a small number of physicians. These doctors were prescribing large maintenance doses of heroin and cocaine to patients, who in turn were selling or giving away their surplus supplies to new users or to others who preferred not to go directly to a physician. There is no doubt that these prescriptions fed the new epidemic of heroin dependence. There was no black market of any significance in imported illicit heroin or cocaine in Britain at the time. The problem quite clearly stemmed from a "grey market" in pharmaceutical drugs stolen from the legitimate supply system or diverted from legal, if excessive, prescriptions. About ten or twelve English physicians at one time or another seem to have been guilty of "overprescribing", but it is too simplistic to attribute the downfall of a suc cessful opiate policy solely to them. "A few bad apples" is a tempting explanation, but one must also ask why the medical barrel had been so remarkably free of them for over forty years. This paper takes the position that, rather than considering these doctors purely as contributors to the demise of the Rolleston era, it is more theoretical• ly appropriate to view their emergence as one indicator of the social and cultural changes that were already threatening to undermine this previously workable policy. The Advent of the British Junkie The handful of non-therapeutic opiate dependents Iiving in Britain before 1950, several of whom were from socially prominent families, could not have been said to constitute a drug-using subculture. Nor did they appear to be "contagious'; that is, they were not introducing new users to heroin. They were also not clustered in any particular geographic area, but scattered throughout the country. Undoubtedly, there were some social contacts and small friendship networks among dependents and, as Spear 11969) has noted, it is likely that there was some borrow- ing and lending of drugs within these groups. However, aside from a small opium trade contained within the Oriental community, there was no evidence of widespread selling of opiates. Shortly after the end of the Second World War, a modest cannabis trade arose In London, but it was apparently unrelated to the opiate dependents on the files of the Home Office. Then, in 1950 and 1951. there were two major thefts of phar• maceutical supplies of morphine, heroin and cocaine. The latter coincided with a scarcity of cannabis and it seems that a number of cannabis users were willing to try the pharmaceutical drugs as substitutes. Those who made up this market represented a new type of British drug user. Many of them were the denizens of Soho jazz clubs, either musicians themselves or ad- mirers of this style of music IGlatt et al., 19671. At this time, jazz mythology was intertwined with drug mythology, and a large proportion of the most revered and influential musicians were dependent on heroin. The post-War British drug users fancied themselves as Bohemians and were subject to American influences through modern art and poetry, as well as music This transatlantic influence could be heard in their language, which was peppered with American argot. Furthermore, these new drug users had clearly articulated notions about how to act out the role of the American-style junkie. Apparently, this did not necessarily come about by interpersonal iniluence, because the subculture was fairly well developed by 1955, before American and Canadian heroin users began to Immigrate in noticeable numbers. Rather; it was an indirect cultural transmission through music and literature, but as such it was no less effective in convincing those vulnerable to its influence that being a "junkie" was a desirable deviant role. I have noted elsewhere iBlackwetl, 19831 that a distaste for junkie role models is a powerful deterrent to opiate users who are vulnerable to adopting careers of chronic dependence Conversely, those who positively identify with the romantic outlaw mythology of heroin are more likely to embrace the role They are also likely to 79 TIMN 321472
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~yG~ H,IS LyGIs His 4~ 1-N~'CH-~ N I CH-IW' CH CH- I R PIG. I Irr.nr.ible binding of ac.uld.b7d. su proaia REFERENCES l. Ostrovsky Yu.M., Sadovnik M.N. In: Itogi Nauki i'Iechniki VINffI, vol. 13 Toxicilogy Irussl, Moscow, 1984, pp. 93150. 2. Truitt E.B., Walsh M.J. In: Biology of Alcoholism, vol. I Biochemistry, eds.Kissin B., Begleiter H.B., Plenum Press, N.Y.•L., 1971, pp.161•195. 3. Lindros K.O. In: Research Advances in Alcohol and Drug Problems, eds. Israel Yxt al., Plenum Publ.Corp., 1978, vo1.4, pp.ll1•175. 4. Pietruzko R. In: Biochem.Pharmacology of Ethanol, ed.Majchrowicz E., Plenum Press, N.Y., 1975, pp.131. 5. Altschuler M.D., Werthessen NT., Miller SA: J.Toxicol. and Environ.Health, 1977, vol.3, N 4, pp. 755-758. 6. Bonnichsen R.K.,Brink N. In: Methods in Enzymology, eds.Colowick S.P., Kaplan N.O., Acad.Press, N.Y., 1955, vol. I, pp.495-500. 7. Tottmar SO.C., Pettersson H., Kiessling K.H: Biochem.J., 1973, vol.135, N 4, pp.577-586. 8. Lieber C.S., DeCarli L.M:J.Biol.Chem., 1970, vol.245, pp 2505•2512. 9. Westerfeld WW:J.Biol.Chem., 1945, vol. 161, pp.495-50I. 10. Hoberman H.D: Biochem.Biophys.Res. Commun., 1979, vol.90, N 3, pp.764•768. li. Horton A.A. Biochem.Biophys.Acta, 1971, vol.253, p.514. 12. Dajani R.M., Danielski J., Orten J.M: J.Nutr., 1963, vol.80, N 2, pp. 196 204. 13. Raskin N:Ann.N.Y.Acad.Sci., 1973, vol.215, pp. 49•53. 14. Satanovskaya V.I., Ostrovsky Yu.M., Sadovnik M.N., Bankovsky A.A, In: The special FEBS meeting on enzymes. Abstr.,Dubrovnik•Cavtat, 1979, S5 36. IS. Renson J., Weissbach H., Undenfriedn S-MoI.Pharmacol., 1965, vol.1, N I, pp.145-148. 16. Badawy A. Britj.Alcohol and Alcohol., 1977, vol. 12, N 4, pp.146•149. 17. Andronova LM., Ushakova M.M., Kudrjavicev R.W., Barkov N.K: Pharmacol, and Toxicol., Irussl, 1982, N 5, pp. 101•105. 18. Ostrovsky Yu.M. In: Ethanol and Metabolism, ed.Ostrovsky Yu.M., Iruss.l, Minsk:Nauka i Teknicha, 1982, pp. 6•41. 19. Stevens VJ., Fant1 W.J., Newman C.B., Sims R.V.,Cerami A., Peterson CM. J.Clin.ln vest., 1981, vol.67, pp. 361•369. 20. "Isuboi K.K., Thompson P.J., Rush E.M., Schwartz H.C: Hemoglobin, 1981, vol.5, pR 241•250. 21. Stepuro 1.1., Zavodnik 1.B., Ostrovsky Yu.M: Ukr. Biochem. J., 1982, vol.54, N 2, pp. 123•128 Iruss.) 22. Collins M.A. In: The Alkaloids, Acad.Press, N.Y., 1983, vol.21, pp.329•343. 23. Summers M., Lightman S•Biochem.Pharm., 1981, vol.3Q pp. 1621•1623. CHARACTERISTICS OF ALCOHOLICS IN ALCOHOLICS ANONYMOUS Gordon M. Patrick and Joan K Jackson SUMMARY. The General Service Office of Alcoholics Anonymous has surveyed A.A.member- ship in the United States and Canada on a triennial basis since 1968, to determine characteristics and trends of interest to members, the professional community and the public. The sixth survey in this series was conducted in the summer of 1983, and some results and comparison with previous surveys are reported here The fifteen year period that the series spans has seen the registered membership of A.A. grow at an average rate slightly over 8% per year, and has also witnessed changes in some of the characteristics of the membership. The women were 22% of the sample at the beginning of the period, but have risen to, and apparently stabilized at, about 30%. The percentage of young people Idefined as under 31 years of agel was constant at about 7% during the early years of the period but began to rise sharply in 1977 and is now about 18%. The survey has inquired about drug addiction among alcoholics only since 1980, but the percentage of the population claiming such addktion in addition to alcoholism went from 24% to 30% from 1980 to 1083. As we have learned, such trends have limited predictive value in and of themselves. Some show two distinct regimes during the fifteen years: others seem to have been in a continual process of change. However one characteristic that seems to have persisted during the entire period is what might be called the macro•dynamics of the recovery process. Apparently the length of time. on the average, spent by members in various stages of recovery has remained roughly the same in the face of other trends. 88 TIMN 321481
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hidden behind a wall of false self-confidence. But In most cases this wall is fragile and quickly torn down by the group. Often the moderator has to interrupt the discussion because the members of the group treat their fellow-colleagues quite harshly and confront them harder than the moderator would do. All things considered, we seldom suggest alternative drinking habits to the par- ticipants. More often we aim at behavioral changes vis-a•vis their partners and en• courage the participants to get out of their steadfast roles e.g. to avoid future conflicts instead of drinking alcohol as a means of conflict avoidance. In every case we prevent moral and other devaluations because they merely depreciate the person and in the sense of self-fulfilling-prophecy effect him psychologically in a negative way. Alfred Adler s individual psychology recognizes that problems can overcome through encouragement and a positive attitude towards the future. That doesn't mean that the negative aspect of the problem-solving-behavior should be 'swept under the carpeC To sum up the most important steps of the short-term life•style analysis while using the approach of ADLER's individual psychlogy one can state:. Firstly, we have to understand the psychological dynamics of drinking. In no way must we condemn them. Then we find out the individual's typical life-style problem-solving-strategles and discuss their advantages and disadvantages. False strategies, e.g. always to say 'yes, I'll do' or always to be nice and plea sant, are shown up, their former importance is evaluated by analyzing early childhood memories and they are questioned as far as their present significance is concerned. The reason for inferiority complexes and for the lack of self-confidence are discovered and invalidated. New useful alternative patterns are worked out e.g. 'I can also be disliked every now and again' or '1 can say no sometimes'. Finally, encouragement and self-confidence must be put across. Nearly all par- ticipants have parts within their personality that have been discouraged. The Salzburg, Austria, DWI program combines lifestyle analysis according to Alfred ADLER's Individual pschology and psychodrama techniques (RUBY). Psychodrama was developed by ].L MORENO as a group therapy and' it is con- sidered as an acting method. With psychodrama a situation is not only reported narratively but is also performed. Psychodrama is established as psychotherapy: it Is both therapeutical and educational. It is known as a useful and effective method for the treatment and rehabilitation of alcoholics IWEINERI. Particular psychodrama techniques can be applied in conjunction with other forms of therapy e.g. individual psychology, behavior therapy or transactional analysis. They were taken over by MORENO from the steps of role development in early childhood: The 'auxiliary ego'•technique represents the young child's phase of'all identity'. The 'auxiliary therapist' (the 'double') represents intimate roles and figures in the client's past and present world (WEINER). The root of the 'mirror'•technique is in the child's phase of 'all reality'. The child is recognizing himself as he does when seeing his own image in a mirror. This is the phase of role perception or role recognition. Through role reversal, the last stage of role development, the recognition of the 'you' takes place. This is the phase of role taking or role playing. Three stages are distinguished by MORENO: role taking resp. role acting, role play- ing and role creating. The first means taking over existing roles. Role playing is playfully using and trying roles including changing role patterns, finally leading to role creating in the sense of self-fulfillment. Since in short-term rehabilitation programs psychodrama must be group-oriented, the performance of a protagonist means conflict treatment for a problem that con- cems all members of the group. The most common techniques a"re role playing and role reversal. Because of the time limitation no techniques can be used that promote regression. So there is no performance of traumatic childhood events. Most group members have the opportunity of identification which is discussed and reflected in the phase of evaluation. Pathological acting e.g. driving while under the influence of alcohol is replaced by therapeutical and controlled acting out various situations, and by trafning the group members for future situations through better understanding. By role-playing the drivers obtain a great deal of benefit from the situation, giving them a deep insight and motivation and helping to understand themselves better, encouraging community spirit and group identification. Role playing also brings about an effec• tive re-education in the sense of 'behavior-drama' )PETZOLD). With the help of role playing, course participants get trained to refuse invitations to drink and say 'no' to friends tenacious demands. They learn to cope with feel• ings such as being an outsider. They are also trained to choose a proper alternative to driving if they have been drinking i.e. calling a taxi. By the technique of role reversal and the mirror-technique interactions can be seen more clearly. Fur[hermore, the probing to the sources of conflicts and frustrations can be more successful. Both techniques reduce operating on a mere intellectuai base and they promote new experiences through slipping into the role of another person. By swapping roles at the right moment the protagonist can be drawn into a dialogue with himself at considerable depth. A young man, for instance, performed a situation in which-being under the influence of alcohol-he found himself in an aggressive dispute with a police officer. By role reversal he took over the role of the police officer and acted by means of his super-ego and represented the parental part of his personality. So he was able to get angry on his lack of discipline and social adaptability. Afterwards he could reflect this with role feed•back which followed his perfor• mance. This emotional insight will rather contribute to a change of behavior than an intellectual or rational understanding. The 'double' e.g. the technique of the auxiliary ego is helpful for the protagonist in achieving a more differentiated thinking and in coming to terms with himself. An important part of treatment is helping him to understand the motivation behind his drinking and the way the consumption of alcohol fits into his patterns of in• terpersonal behavior. Another young man performed the events which led to his DWI offense. Through his performance a partner conflict became obvious. While doubling, he, for the first time, became aware of his inferiority feeling and his relation to his girifriend:'1 feel that with my friend I have to act as a strong man.' He recognizes that his kind of display pattern went without any effect and, furthermore, it resulted in disadvantages. Psychodrama achieves a quick and useful level of emotional involvement, thereby providing insight in a way that purely verbal methods cannot duplicate (BLUME e.a.l. For clarification of feelings, these become personalized or demonstrated through the 'auxiliary chair-method. Once a group member learned by role playing that usually he did not admit anger to himself. When he slipped into the role of anger he realized how strong his anger was and that it resulted from his early anxiety of being rejected. Alcohol helped him to 'rinse' the anger but it did not help to reduce it. Through challenge, mutual analysis and replaying a support of greater personal in. tegrity can be achieved. The method of psychodrama 'demands immersion of the total person-mind, personality and body-into contact with reality In a spontaneous action wherein the individual is in contact with the unconscious, developing skills through ridding himself of himself in practicalness and concreteness without "think- ing" but in terms of forgetfulness and action' )WEINER). Conditions for role playing on the level of symptoms are consolidating group cohe• sion, ego strength and familiarity with psychodrama techniques ITRUOEL). The performance of abstract contents is rejected and is therefore of no use if the degree of familiarity is low. After analysis of his life style one group member provoked the moderator with a statement that he came off badly and that he was eager to learn something new about himself. He got another chance by performing a red traffic light which-as a kind of 'internal brake'-was the significant element of his draw• ing showing an intersection. With his refusal he demonstrated his inner blockade. Actually he intended to tempt the group leader to a power struggle. In this situation the client's performance was an acting out and a game of self-defending. It left the client in his conventional patterns of behavior. Comparatively, a non- intervention or an optimal frustration in accordance with psychoanalysis would have been better. This, as a matter of fact, is inevitable in short-term rehabilitation approaches. Never• theless, it has sometimes proved useful to have a group member personify alcohol (BLUME e.a.). The role of schnaps once has been played very vivacious and tempting by a rather shy and introvert group member. This he recognized through role feed-back. Basically the rules of short-term therapy are to be taken into consideration. As an essential factor of indication generally the need of high motivation, in particular the motivation to personal change, is demanded (PRITZ). The initially low motivation of the course participants, that obviously is determin• ed by the wish to regain the driver s license, can be changed by using psychodrama techniques. Frankness and sincerity are intensified by increasing confidence. The method seems suitable enough to lead to a positive change of behavior as far as the drinking habits of the course participants are concerned. The presence of a focal conflict (e.g& alcohol and driving) is a favorable condition for the success of a short-term treatment IPRITZ). When using psychodrama techni• ques, one often gets as far as the core of the conflict. According to the time available both substantial experience and an appropriate assess- ment of the usefulness of a regression to the core conflict or its elucidation are necessary. The flexibility of the psychodrama method and its various techniques have been 70 TIMN 321463
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5.2 Knowledge A second objective for the Cannabis Information Program was "to raise awareness of the adverse health and social effects associated with cannabis use among the primary and secondary target groups". As can be seen in Table I, in the primary target group, the average agreement with five risk statements regarding marijuana use was lower at the end of the first year of the campaign than it was before the campaign began. In addition, the percentages agreeing dropped for four out of five of the individual items (three out of four statistically significant at .05 level). However, there seemed to be a reversal between the first and second years, with increases intgreement on three of the items and overall slight increase in average agreement (two out of three items statistically significant). On the other hand, there was a statistically signifi- cant decline on one of the items. These results are difficult to interpret, but they do seem to suggest a possible trend toward increased perception of risk in the primary target group during the second year of the campaign. It is also possible that the negative changes during year one were due to the fact that there were some changes in phrasing of the question between 1983 and 1984 which might favour fewer responses because of its directness (e.g. changed from "can cause lung cancer" to "causes" lung cancer). With regard to the secondary target group, as also can be seen in Table 1, there seems to be a positive trend toward identifying risks between the first and se- cond years, although the percentage differences are not statistically significant. Thus, based on the surveys of the primary and secondary target groups, it is undear at this point whether or not the campaign will achieve its objective of raising awareness of the adverse health and social effects of cannabis use, although there seems to be a trend in that direction. It might also be noted here that in the study of those who requested the Stay Real booklet, over three quarters (76%) indicated that the pamphlet provided them with new information about cannabis, principally in the areas of health risks associated with its use. In other words, those who received and read Stay Real appeared to have increased their awareness of the health and social effects of cannabis use (at least in their own views), a finding which is consistent with the second objective of the program. 5.3 Attitudes A third objective of the program was "to develop a social climate supportive of the non-use of cannabis and other drugs among the primary target group". To measure this objective, respondents in the survey of young people were ask- ed whether or not one should support a variety of actions related to marijuana use. Table 2 shows the proportion of primary target group members who sup- port non-use of marijuana among their peers. As can be seen, there has been little movement in the proportion who support the non-use of marijuana over the course of the first two years of the campaign-the average support being iden- tical in 1983 and 1984, and only one percent higher in 1985, (although there was a significant increase in the proportion who felt that a "non-user should in- sist that friends not smoke marijuana in his/her house between 1983 and 1985). Similarly, there was only a slight and statistically insignificant change in the pro- portion who reported that they had not started smoking marijuana to be part of a group of friends (increase 85% to 87% between 1984 and 1985) and no change in the proportions reporting that they helped and supported a friend trying to quit marijuana (21% in 1984 and 1985). In addition, the proportion who felt that people should never start smoking fluctuated only slightly over the two years of the campaign, remaining at quite a high level (78% in relation to men and in relation to women in 1985). Thus, overall, as far as can be determined from the surveys of the target population, there does not appear to have been much change in support of non-use of marijuana among the primary target group over the first two years of the program, although perhaps a slight tendency in that direction. On the other hand, the program appears to have stimulated considerable discus- sion of marijuana use by the primary target group. Specifically, as shown in Table 3, at the end of the first year, ten percent of all 12-18 year olds reported that they had discussions about marijuana with friends as a result of seeing the cam- paign ads. Seven percent reported discussions with parents and five percent with others. The proportions increased to 18, 12 and 19 percent respectively if only those aware of the campaign are considered. Interestingly, the proportions in both groups increased significantly over the course of the second year of the cam- paign suggesting that the campaign is continuing to increase discussion of can- nabis Issues within the peer group and with parents. Moreover, it is interesting to note that most of the discussions have to do with the specific or general harm- ful effects resulting from cannabis use. For instance, among those that had such discussions in 1984, 28% discussed "specific effects", 20% "unspecified effects", 19% "not starting" and 21 % "general effects". Thus, although it may appear from looking at the attitudinal items that there has not been much of a shift in the social climate surrounding drug use among young people since the introduction of the campaign, the information on discussions about marijuana leaves one hopeful that the campaign may indeed have made some contribution to changing the social climate in a positive direction. The study of those requesting the Stay Real pamphlet also gives reason to be hopeful in that as a result of reading the pamphlet, 50% reported having discus- sions with their children or parents, 48% discussed the cannabis issue with their friends, 26% sought further information about cannabis and 5% sought counseil- ing or professional services. If these findings are projected to the more than a million and a half people who received Stay Real, it suggests a very substantial impact indeed. 5.4 Marijuana Use The final objective of the program was "to discourage the use of cannabis within the primary target group and to delay onset of use among younger members of the group". Although it is recognized that behavioural indicators are slow to change and cannot be attributed solely to the effects of the advertising campaign, marijuana usage patterns have been monitored during the campaign. As shown in Table 4, there has in fact been little if any change in self-reported marijuana use by the primary target group over the first two years of the campaign. However, as indicated In Table 5, there appears to have been a slight but not statistically significant in- crease in the proportion of the primary target group reporting that they would definitely not be smoking marijuana in five years. In addition, there was a slight increase (from 84% to 87%) in the proportion who claimed that they have not driven a motor vehicle or ridden a bicycle after using marijuana. Thus, there may have been at least a slight movement in the direction of reduced marijuana use over the course of the first two years of the Cannabis Information Program. However, there is no evidence of delay of onset in the younger members of the group as yet, suggesting that at best we have had only partial success in achiev- ing our fourth objective. 6. CONCLUSION To summarize, "it appears as if the Cannabis Information Program has been ex- tremely successful in reaching its primary and secondary target groups over the first two years of the campaign. It appears however, to have been less successful in improving awareness of the risks of cannabis use, in changing the normative climate surrounding use or in reducing use itself although there are some en- couraging signs. In particular, the contribution that it has made to increasing discus- sion of cannabis Issues among young people and between them and their parents appears to have been substantial. We hope that these encouraging trends con- tinue and that the program will make the contribution of which it is capable. In the meantime, it is our intention to apply the lessons that we have learned to date and to continue to study the impact of the program. With regard to the latter, we are currently discussing the possibility of doing a controlled study on the impact of the Stay Real pamphlet on the primary target group using schools. We hope that the study will tell us whether or not a resource such as Stay Real can reach its primary target group and affect knowledge, attitudes and behaviours and what is the most effective way of delivering it so as to maximize its impact. As for the former, we have learned a great deal in implementing this and other campaigns targetted at adolescents over the past few years. We are presently us• ing this knowledge in developing a new national anti-smoking program target- ted at adolescents (i.e. new improved Generation of Non-Smokers Program). We will continue to conduct research on addiction programs targetted at youth in order to discover what social marketing techniques and messages are effective with this complex group. REFERENCES l. Canadian Gallup Poll, Gallup Omnimus Survey, Ottawa: Dept. of Justice, 1981. I. Rootman and L Jones, Cannabis Information Program: Baseline Evaluation Report, Ottawa: Health and Welfare Canada, 1983. Heffring Research Group Ltd. Cannabis Information Program Evaluation Report 1984, Ottawa: Health and Welfare Canada, January, 1985. Currie, Coopers and Lybrand, Final Report on a Quantitative Assessment of "Stay Real/Vive Moi-Meme" Pamphlet, Ottawa: Health and Welfare Canada, October, 1984. TIMN 321478 85
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~ jru> abu..c prubicnG+. 3. Combined or Separate Approach In i96o the World Health Organization held in Geneva an Expert Committee on the subject of "Services for the Prevention and lieatment of Dependence on Akohol and other Drugs :-I he report of this Committee recommended what was called a "combined" o>; as it is now sometimes termed, "rnmprehensive" approach to alcohol and drug-related problems. In some countries, a comprehensive approach to alcohol and drug problems had already been initiated before the 1966 Expert Committee s4s far back as the mid-twenties, the British Society for the Study of Inebriety (now the Society for the Study of Addiction) had included a sub-title to cover study of addiction with which, in fact, it had also been concerned for many years. The Alcoholism and Drug Addiction Research Foundation of Ontario, Canada, was founded in the late nineteen-forties and became active in the fields of prevention, treatment and research. The German Central Office against Addiction Dangers, a national voluntary government-supported association, had included other drugs in its programme for many years, although its main thrust was in the area of alcohol-related problems. In most countries, however, alcohol and drug programmes both governmental and private were separate. In 1964 the International Council on Alcohol and Alcoholism (as the International Council on Alcohol and Addictions was then called) began its activity in the drug field by including a session on amphetamines, at the request of the British Medical Association, during its International Institute in London. The tendency in the direction of a comprehensive approach was reinforced by the rapid expansion of drug use in the nineteen-fifties. However, new programmes set up to help drug users did not on the whole wish to be involved with the organizations concerned with alcohol. The movement in the United States to integrate State Alcoholism Commissions in Mental Health or Public Health Divisions resulted in the closer association of alcohol and drug-related problems in the Health Administration sphere. The fact that the control measures in implementation of the Single Convention of 1961 concerning Opium, Cannabis, and Coca leaves were applied in many countries through the Ministries of the Interior or Justice, reinforced, however, separation of policies and procedures to deal with alcohol and drugs. Although it is dear that among the professional groups both in treatment and prevention it was felt that it would be logical to develop a comprehensive approach, the statutory requirements of the in ternational and national control systems impeded any such developments. So far as can be judged, professional organizations found the comprehensive approach workable but it needed the impetus which the 1966 WHO Expert Committee was able to achieve wide measure of application. By 1965 the United Nations Commission on Narcotic Drugs had begun to look seriously at the question as to whether international control of some substances other than those covered by the Single Convention on Narcotic Drugs of 1961 was desirable. The WHO representative to the 20th Session of the United Nations Commission on Narcotic Drugs in December 1965 stated that the WHO Expert Committee Ion Drug Addiction) considered that any substance with sedative or stimulant effects should be examined in regard to the possible need for control, except for alcohol and substances under international narcotics control. The exclu. sion of alcohol was maintained in all the preliminaries leading up to the Conven. tion on Psychotropic Substances of 1971. The circulation of the 1966 WHO Expert Committee Report to Ministries, Depart- ments and the professional public generally, from 1967 onwards, gave impetus to the tendency to a comprehensive approach to alcohol and drug dependence. In some countries such as Belgium and Australia, integration of the two wbjects was adopted as a principle very quickly. In Belgium and in Quebec, Canada, for in- stance, the phrase alcohol and other addictions (or dependendesl soon found favour. The problem of some wine-growing countries had already been alluded to by a French participant in the Expert Committee, who had drawn attention to the dif ficulty in such countries, where dietary use of wine was normal, of presenting wine to the public as a drug substance. In fact, to this day, the French Governmental High Committee of Study and Information on Alcoholism has no mandate to in- clude drugs in its programme and the private National Committee although discussing this question over many years, has not officially adopted a comprehensive approach. The Soviet Union also keeps these two questions separate although treatment and prevention of both come within the sphere of the Ministry of Health. What are termed "alcoholic beverages" and "nan-otic drugs" are classified in different categories from the medico-juridical and social points of view In the United States at Federal level, the National Institute on Drug Abuse INIDAI is separate from the National Institute on Alcohol and Alcohol Abuse INIAAAI although both come under one umbrella body, the Alcohol, Drugs and Mental Health Administration IADAMHAI. There are numerous other examples of countries which developed more or less separate approaches, with respect to the establishment of national coordinating bodies. The concept of a combined approach was also taken up in the treatment area. At first numerous programmes combining treatment for both alcoholism and drug drpernience came up against certain maior problema I his was largely brought about by the fact that the type of patient or client differed considerably in age, attitude to society and to treatment outcome. The notion often held in the nineteen-sixties that alcohol would be replaced by the substances newly discovered by the young generation proved to be incorrect and from the seventies onwards a much younger age group with alcohol-related problems manifested itself. These facts worked in favour of a comprehensive treatment approach. The need for a "polydrug" approach in treatment has shown itself indispensable. It must be admitted that opinion as to effectiveness of combined treatment vary greatly. Attitudes of both patients and staff are of great significance Obviously, the alcoholic patient who wishes to be treated in a familiar type of envir4nment to which he or she has been accustomed with the supportive role of such program mes as Alcoholics Anonymous insisting on abstinence will be more comfortable in that programme The experience of such a combined programme as that of Eagleville in Pennsylvania would indicate that their results can be compared favourably with separate pro• grammes and in their view the advantages outweigh the disadvantages. W hat emerges in general is that alcohol dependence and other drug dependence are part of the same problem and that although a totally integrated treatment may never respond to all the needs of patients a comprehensive treatment unit where a certain separa• tion and a certain association can exist may well be the most desirable situation. In the area of prevention, the position is somewhat different. Alcohol prevention and educational programmes have had a much longer history than those on other drugs. They tended to rely very largely on factual information about alcohol and its effects. When a comprehensive approach was adopted they were often brought into contact with a lifestyle change-orientated programme which was a distinct ad vantage. Alcohol information has now focused more and more on drinking behaviour and learning how to make reasonable decisions on how much, when, and where to drink. The conclusion that one would reach is that alcohol and drug (and also tobacco( education must be comprehensive The balance between the cognitive and effec tive approach to prevention is a delicate one and there is much more investigation and experience needed before final judgements can be reached and their practical implications taken into account. Now that countries are more than ever multiracial, the combined approach must take account of religious and ethnic sanctions such as prohibition of alcohol for Muslims, prohibition of tobacco for Sikhs and so on. It is perhaps too early to com- ment on the effectiveness of the comprehensive approach as concerns tobacco since experience in this approach is limited. It would also be important to know from groups engaged in combatting tobacco use, their views on the comprehensive ap~ proach to alcohol, drugs and tobacco. The WHO Expert Committee report thought that research might be one of the more productive areas in which there could be a combined approach. There is strong ground, for example, for research on the similarities and differences in alcohol and opiate dependence. The present patterns of polydrug use have certain impor• tant practical implications in everyday life The ability to carry out operations which involve judgement and creative faculty is vital today. The question of vehicle driv- ing is a case in point. The combined effects of say alcohol and marihuana on drivw ing skills and the combination of other drugs in similar situations is a priority for research. Most organizations concerned at first with alcohol and traffic have now extended their terms of reference to include the influence of drugs on driving and promote research particularly on the effect of drugs in combination. The comprehensive approach in research presupposes an ongoing interchange of information and experience between the different disciplines. It is not easy to assess the degree to which this has taken place, but it is probably more intensive on a national than on an international level. In the alcohol field alone one could wish for more interchange between the disciplines. The 1966 WHO Expert Committee did not deal with tobacco. Similarly, for many years, programmes on alcohol and drugs, with few exceptions, did not in• clude tobacco use in their terms of reference. In addition to the perceived basic -difference, there were several reasons for this. In the first place and particularly in the private sector, the problems of tobacco were seen as the concern of cancer, heart and tuberculosis organizations. In the treatment area, it was felt that if there was insistence that the alcoholic had to be abstinent to recover, one should be more lenient about a habit which was regarded as of less harm. These views have chang• ed considerably in the last fifteen to twenty years. There is now a trend discernible to develop a comprehensiveapproach to these substances in the area of preventive education. Substance misuse education demands that all dependence producing substances are considered including tobacco. There are also important elements common to all three substance areas namely the impact of commercial interests, advertising, etc., particularly in developing countries. In summary, therefore, the picture which emerges is of some combination some of the time The 1966 WHO Expert Committee report recommended the establish• ment of national coordinating bodies in the fields of alcohol and drug dependence. 76 i TIMN 32146 ~
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CANNABIS INFORMATION PROGRAM "STAY REAL/VIVE" MOI-MEME James H. Mintz and Irving Rootman 1. Introduction This paper has been prepared for the International Congress on Alcobolism and Drug Dependence, which will be held in Calgary, Alberta, in August 1985. It is intended to describe the Cannabis Information Program, and present the results after two years in operation. A final report will be prepared at the end of the program (i.e. April 1986). 2. Background In anticipation of proposed legislative changes, a three-year information program to discourage cannabis use was planned to complement a legal information pro- gram being undertaken by the Departments of Justice and the Solicitor General. While the process to introduce the legislation was delayed, the demand for public information increased. Groups like the Canadian Home and School Parent-Teacher Federation, the Headmasters' Association of Ontario, Provincial & Territorial Drug Agencies and the National Organization to Reform Marijuana Laws (NORML) requested that the federal govemment provide information on the safety and health risks of cannabis, whether or not any legislation was being put forward. To pro- perly prepare for the campaign, the Health Promotion Directorate commissioned a qualitative study amongst youth on cannabis in February 1982. This study found that peer pressure was considered to be a stong influence on the decision to use marijuana and that use appears to decline when teens reach their twenties. These findings were consistent with other Canadian and interna- tional studies. The study also found considerable confusion and ignorance among teens and adults about cannabis use as well as a desire for accurate information. (For further details see Appendix 1). In addition a national survey of young Canadians between the ages of 12 to 19, carried out by the department in May 1982, found that slightly more than one in four of this age group had tried marijuana at least once. This led to an estimate of approximately 1.4 million Canadian teenagers who have tried marijuana. Nine- teen percent of the teenagers questioned reported that they had used marijuana during the past year. Fourteen percent, or an estimated one-half million adolescents between the ages of 12 to 19, admitted using marijuana during the past month. Six percent reported the use of marijuana during the past week. Finally, a number of health hazards had been identified by research scientists. There was general agreement that: cannabis use impairs motor ability, including driving ability; cannabis use impairs short-term memory, intellectual performance and lear- ning ability; regular, long-term poses health risks to the respiratory system, may impair the immune and the reproductive systems, and can lead to dependence. Based on the above information and requests from the public and national and provincial groups the Health Promotion Directorate developed a national can. nabis information program. Although it was originally intended to accompany the introduction of cannabis legislation in August 1982, the Minister of National Health and Welfare gave approval to proceed with the development of an in- dependent information program which would reach both teenagers and parents. In January 1983, the Minister gave approval to finalize program materials and begin the campaign two months later. 3. DESCRIPTION OF THE CANNABIS INFORMA TION PROGRAM 3.1 Objectives To create awareness of the campaign among the primary and secondary target group To raise awareness of the adverse health and social effects associated with cannabis use; To develop a social climate supportive of the non-use of cannabis and other drugs; To discourage the use of cannabis within the primary target group and to delay onset of use among younger members of the target group. 3.2 Target Groups Primary: 10 to 18-year-olds Secondary: Parents of 10 to 18-year-olds. 3.3 Structure of Program The program is a three-year awareness and information campaign comprised of paid advertising and print materials. Using an attitudinal approach, two televi- sion spots have been created to reach the primary group. A cheque insert that accompanied 3.9 million family allowance cheques was designed to reach the secondary target audience, parents. Advertisements were also placed in the March/April 1984 issues of T.V. Guide (T.V. Hebdo) and Readers Digest (Selea tion du Reader's Digest). In addition, provincial drug agencies, law inforcement agencies, volunteer drug organizations, school associations etc. are encouraged to promote and distribute the informational program booklets. 3.4 Creative Strategy The informational print campaign is designed to bring the problem out in the open. This part of the campaign is not alarmist nor sensational, but gives factual information to parents and adolescents about drug use among teens, its effects, symptoms, legal aspects, health hazards etc. The television campaign is directed towards young people from 10 to 18 and uses television to present a positive message for a cannabis-free voyage towards maturity. Whereas the print campaign is largely informational, the television cam- paign seeks to build an attractive level or "space" in which a teen can go about his or her life without cannabis, yet without the stigma of being a "goodie" or "wimp" The research studies indicate that much confusion exists as to the dangers of con• tinuing use, and that parents particularly are unfamiliar with the symptoms of use and idiosyncracies of the users. There is a lot of mist surrounding the mari• juana issue, and Stay Real tries to clear the air to bring the problem into daylight so that parents and teens can approach it in a natural manner. The tonality of the campaign is objective, simple and non-preaching. Specifically, the.television campaign seeks to create a positive atmosphere for non-use. The premise for the campaign strategy is that real life experience is more challenging and rewarding than experience which has been artificially altered. For a full description of the creative strategy see Appendix IL 3.5 Campaign Components a) Television Campaign It is standard advertising practice to develop at least two equally viable ap• proaches and to test both with the target group. The first approach, entitled "Passages", is intended to communicate to teenagers the importance of using good judgement and remaining true to themselves in the face of social pressures to use cannabis. The second approach used "wild horses" as a symbol of teenagers' natural exuberance and "wildness" juxtaposed against the suppress- ing nature of cannabis. The approaches were tested with focus groups in Van- couver, Toronto and Montreal. Teenagers understood the message in the first approach i.e. "Passages", but did not respond favourably to the symbolism of the wild hotses. Consequentiy, with some revisions, two commercials were produced "High Winds" and "Heavy Seas". The commercials are run on all major networks (paid advertising) in Canada. They reach approximately 55% of the primary target group (adolescents 12-17), an average of three times per week. Over a period of one month it is expected that 80% of the target group would be reached. b) Publications Stay Real is the titie of the 24-page pamphlet on the health risks and social climate associated with cannabis use and is directed to parents and teenagers. It takes a straightforward look at the issues, risks and the climate surroun- ding the cannabis issue. As with the television campaign, the kids' section of Stay Real encourages young people to remain true to themselves and not to submit to peer pressure. The parents' section describes at length the social pressures young people face and provides factual information on the health risks of cannabis use. The middle section is entitied "Common Ground- Common Sense" and encourages discussion between parents and children on the issues. Straight Facts on Drugs and Drug Abuse is intended to supple. ment Star Real and is distributed on request. Since it covers all known drugs which are abused, the intent of the publication is to answer broader ques- tions from parents and teens alike. c) Print Campaign Print advertisements directed to parents appeared in major consumer magazines, i.e. Readers Digest and T.V. Guide. The advertisements, like the family allowance insert, invite parents to send for the Stay Real booklet. (See 83 TIMN 321476
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CATABOLISM AND INACTIVATION OF ACETALDEHYDE IN THE ANIMAL ORGANISM YU. M. Ostrovsky, V I. Satanovskaya, I. L Stepurcf N. A. Yaroshevich and M. N. Sadovnik As a natural composite of metabolism. acetaldehyde is constantly formed in the body during conversion of pyruvate IEC, phosphoethanolamine IEC 4.2.9971, pentose phosphate IEC, threonine IEC 4.1.251 and soA other compounds II1. The level of acetaldehyde is increased in alcoholism and under some other states of the organism 12,31. Being a highly reactive substance, acetaldehyde readily in teracts with many components of the cell 141, thus manifesting its toxic effect 15i. Excess acetaldehyde is mainly eliminated by its oxidation to yield acetate 141, by reduction to ethanol (6) or by means of fixation with other compounds which form less toxic substances 171. We studied the adaptive changes of the systems of acetaldehyde catabolism during alcohol intoxication and withdrawal periods, the interaction of acetaldehyde with blood proteins, and the formation of new compounds from acetaldehyde. METHODS The experiments were performed on rats obtained from the Rappolovo breeding colony of the USSR Academy of Medical Sciences Chronic alcohol intoxication was induced by prolonged ifor 6-12 monthsl ingestion of 10 20% Iw/vi ethanol solutions as drink. Acute intoxication was achieved by intraperitoneal in[ections of ethanol at a dose of 2.5 g/kg body weight. Samples of liver were assayed for activities of alcohol dehydrogenase 161, aldehyde dehydrogenases 171 and MEOS 181. ["C] Acetaldehyde at concentrations up to 0.1 mM was added to the 10 ml of fresh whole human blood, and 7 mg of NaBH, was added to the mixture. In 10 or 60 min, erythrocytes and plasma were separated by centrifugation, and the cells washed with isotonic solution of NaCi. Erythrocytes were hemolyzed and the membranous fraction was collected by centrifugation at 20000xgxh. Low-molecular-weight components and proteins were separated on Sephadex G•25 and then on TSK-60 gel. Radioactivity of different fractions was countered in dioxane scintiliator with a Nuclear-Chicago Mark 11 counter. Aldol condensation was studied in the presence of amino acids and proteins at 10 mM concentration of all the components. Identification of the reaction products and kinetics of their formation were determined with an NMR-spectrometer, model BS 487C ITestal and with an MAT311 mass spectrometer IVartanl- Acetoin was measured from the reaction with -naphthol (9). 5-Deoxy-D xylulose-l-phosphate was ob tained by incubating F1,6•P with crystalline aldolase and ['`C] acetaldehyde in a dialysis cell against a solution of hemoglobin to bind labeled pentose phosphate RESULTS AND DISCUSSI ON The literature data on the changes in aldehyde dehydrogenase IALDHI after alcohol intoxication of different types are contradictory: either stimulation 111, 121 or the absence of shifts 1131 in the enzyme activity, and no information on the withdrawal period is availabiz In the earlier experiments on female rats, we did not find 1141 changes in the ac tivity of liver AI.DH with low affinity to the substrate On the contrary, the activity of the enzyme with high affinity to acetaldehyde was sharply decreased by the 5th month of intoxication and normalized after 2 weeks following ethanoTwithdrawai- A week after ethanol withdrawal, the activity of mitochondrial low KF;AI.DH was 2 fold increased in rats with 6 months intoxication /0.050 ± 0.003 and 0.100 t 0.013 mol/min/g tissue; P < 0.0011. In acute alcohol intoxication, the same en zyme was markedly activated 17.10 ± IA6 and 12.7 ± 0.99 nmol/min/mg pro tein; P < 0.0011 as early as in 1S h. As in the previous studies 1141, we have not found any appreciable shifts in the activity of the enzyme with high K„ to the substrate. From the data obtained we can draw an unequivocal conclusion that the adaptive shifts in the activity of ALDH take place only via one, the mitochondrial low K, form of the ALDH. The enzyme with low affinity to acetaldehyde seems to be used exclusively in catabolism of other aidehydes, e,g. those formed from some xenoblotics 1151. the high adaptability of mitochondrial low K,-AI.DH is of special interest since the enzyme operates at nearly endogenous concentrations of acetaldehyde and those usually arising in alcohol intoxication. In chronic alcohol intoxication I i yearl, the MEC7S activity in the rat liver was increased 1137 ± 23.8 and 883 ± 64.1 nmol/min/g tissue; P < OD01t, while ADH was somewhat in. hibited 12.9 t 0.01 and 2.2 ± 0.04 nmoi/min/mg protein; P < OAiI. These shift appear to be adaptive because Mf:US functions at rather high ethanol concentra tions li, 161, and what really matters, controls the irreversible process of alcohol elimination via the formation of acetaldehyde. During ethanol withdrawal, microsomal oxidation was rapidly normalized, whereas ADH was simultaneously activated. Since ethanol concentration in the body is not elevated within this period and may even be lower than its endogenous level 1171, the increased content of ADH can satisfac• torily be explained by only one suggestion: the enzyme functions as a regulator in the system of endogenous ethanol/endogenous acetaidehyde 118). It would be appropriate to go back to the above-discussed shifts in the ALDH content in similar situation: only the enzyme with low Kn, to acetaldehyde, i.e Af.DH which is pro bably involved in providing homeostasis of endogenous acetaldehyde. Partial inac• tivation of acetaldehyde can be brought about by its interaction with proteins 119, 201, amino acids 1211, bio-genic amines 1221 and peptides 1231. To estimate quan• titatively the contribution of the first mechanism into the process considered, we calculated radioactivity of the blood proteins after exposure to the labeled acetaldehyde It was essentially the same in 10 and 60 min, which indicates a rapid establishing of an equilibrium in the reactions described. The total distribution of the label between blood cells and plasma averages 85:15. If we evaporate the proteitr free filtrate~ i.e remove ["C] ethanol which has been formed after the NaBH, treat• ment, we shall be able to estimate the amount of acetaldehyde bound to the low molecular-weight components lamino acids, peptides, etc.l. In erythrocytes, the bin ding of acetaldehyde to both hemoglobin and low-molecular-welght components is nearly the same. In blood plasma, the low molecularweight components bind to the label to a greater extent than does albumin ITabie 11. Acetaldehyde, which is bound to -5C-E- amino groups of lysine, also interacts with the neighbouring nucleophilic groups in the polypeptide chain to form covalent bonds IFig. 11, which we have shown in an earlier paper 1211. His, l.is, Tyr, Cys-SH residues may play a role of such nucleophiles. Kinetics of reversible and irreversible binding of acetaldehyde to serum albumin is presented in Fig. 2. The third way to inactivate acetaldehyde in the human blood is the formation of new products of aldol con• densation. Aliphatic amino acids and proteins Ialbumin, hemogiobini are nonspecific catalysts of the process. In the presence of the proteins. 2,3-butylene aldehyde is the main product of such condensation. This compound was isolated from the in cubation mixture and identified by the methods of NMR and mass spectrometry. The aldol condensation can also proceed enzymatically in the presence of crystalline aldolase and result in the accumulation of 5-deoxyDxyfulose. I-phosphate which is rapidly fixed with hemoglobin 110l. TABLZ t DISTYIbCTIOI 07 L7lC] ICSTALDiDIDB BtTO'2A 8200D COltP0I3IT3 Ii P:BCeTTB 0) TOTiL BIDIOACTIVITY E1ood ooayon.ns. Ao.tald.ipd. biadln9 Sr7tbroo7T... 4.5 - 5.0 % Lioslob3a 2.0 - 2.1 % Las-aol,m,Lr_..,ltnc 2.5% ooapa.md. lYabr.n.. 3.0 % pli,,,, 2.5 - 2.8 % Libusla 0.6 % OLbr Drot.ia. 0.2 % Do.-aoLCOlar-wSihs eoayound• 2.0 - 2.2 % TIMN 321480 37
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proved useful for the rehabilitation of drinking drivers. Psychodrama guarantees an almost immediate emotional involvement through action and experience which is often difficult to achieve for DWIs. The Profit In Austria an evaluation study has been carried out that included 375 subjects. While 101 subjects had been course participants during their imprisonment, another 216 went through the rehabilitation program without having been arrested. The size of the control group was 58. The follow-up study for the drivers which have not been artested showed 15.7 percent recidivists after an average observation period of 29 months. Members of the control group relapsed by 27.6 percent, the average observation period being 31 months. Another finding indicated a correlation between severity of mal-adjustment prior to rehabilitation and success of rehabilitation itself: The more an individual ac• cumulated revocations of his driving license, the less was the chance of recidivism. While 13.2 percent of the experimentals with two or more revocations had another DWI offence, 46.2 percent of the controls with the same degree of incrimination showed up with another drinking and driving event (MICHALKE). As for the Federal Republic of Germany a comprehensive evaluation study is in progress in order to assess the value of the overall program. The objective of the rehabilitation efforts is twofold: First, the experimental group is expected to show a more adapted future behavior related to drinking and driving than a control group. Second, the recidivism rate within a ten-year-period for course participants is ex- pected to drop at least to 36 percent. This corresponds with the individual recidivism probability which is considered by jurisdiction the highest that can be tolerated. If the first objective is achieved the program will be efficient. Furthermore, the program will be successful, if the second goal is reached, too. - The comparison between the experimental group I course participants) and the control group is rather rigorous, because the control group consists of drivers who qualified for re-iicensing without having to go through a rehabilitation program first They are suspected to have a low probability to commit a further DWI offense The evaluation study Is not only focused on group comparison and follow-up in- vestigation. It also cares for the progress of the different programs themselves. For that reason the institute that Is responsible for the evaluation study is up-dating the immediate effect of the programs (using beforeand•after questionnaires aa cording to the particular course objectives defined by the program authors) the increase of knowledge of alcohol and traffic safety (using also questionnaires) the contents of course reports written by the moderators The follow-up period is now 36 months. As can be seen in figure t(appendix 11) the recidivism rate for course participants (experimental group) after one year has been 5.6 percent while members of the control group relapsed by 7.6 percent. When these figures are compared with the one prior to rehabilitation programs 113. 2 percent) the reduction of recidivism after one year is 57.6 percent for the experimental group and 41.9 percent for the control group After two years there is a reduction of 59.8 percent for course participants and 43.6 percent for those drivers who got back their license without treatment. After three years the cor- respondent figures are 63.9 %(experimentals) and 47.8 % (controls). If this trend will continue there is good reason to assume that the programs are not only effec- tive but also successful. This may be also true in the long term. References: BATTEGAY, R. 119721, Der Mensch in der Gruppe (The individual in the group). Bern/Stuttgart/Wien BWME, S B., ROBINS,1., BRANSTON, A. ( 1968(, Psychodrama techniques in the treatment of alcoholism. Group psychotherapy, Vol XXI,4,pp.241-246 BUIKHUISEN, W. (1971), Kriminologische und psychologische Aspekte der Trunkenheit im Strassenverkehr (Criminological and psychological aspects of drunk driving). Hannover: Medizinisch-Psychologisches Institut des Technischen UeberwachungsVereins Hannover e.V., Report 2 Bundesansralt fuer Strassenwesen (Ed.) (19781, Beeinflussung und Behandlung alkoholauffaelliger Kraftfahrer (]nfluencing and treating DWI offenders . Koeln: Bundesanstalt fuer Strassenwesen. 85 pp. Bundesanstalt fuer Strassenwesen (Ed.) (19821, Kurse fuer aufiaellige Ktaftfahrer lCourses for traffic offenders). Koeln: Bundesanstalt fuer Strassenwesen. 339 pp. JENSCH, M., LEMM-Hackenberg, R. ( 1981), Alkohol und Lebensstil (Alcohol and lifestyle). Faktor Mensch im Verkehr, Heft 31. Btaunschweig: Rot Gelb Grfin. 182 pp. KUNKEL, E. (1977), Die prozentuale Verteilung der zeitlichen Abstaende zwischen den Trunkenheitsdelikten im Strassenverkehr (The percentage distribution of tem- poral distances between DWI of fences). Blutalkohol, XIV, pp. 129-143 MICHALKE, H.11985), Effizienzuntersuchung der bisher in Osterreich durchgefiihrten 71 Driver Improvementburse l~)tudy or the efficiency ol onk-Er improvrmcnt cour~~~ carried out in Austria up to now) Zeitschrift fuer Verkehrsrecht MORENO, J. L 1 19591 Gruppenpsychotherapie und Psychodrama (Group psychotherapy and psychodrama). Stuttgart: Thieme Muelleti A. (1976), Der Trunkenheitstaeter im Strassenverkehr der Bundesrepublik Deurschland The DWI offender in the Federal Republic of Germany). Frankfurt/Bern: Lang 262 pp. PETZOLD, H.G. (1977), Behaviourdrama als verhaltensmodifizierende Phase des tetradischen Psychodrama (Behaviordrama as the behavior-modifying phase of tetradic psychodrama). Integrative Therapie,l,pp.2039 PRITZ,A. (1983) Grundprinzipien und Indikationsstellung in der analytischen Kurz• therapie (Basic principles and indication of analytic short-term therapy). Aerztliche Praxis und Psychotherapie,Vol. 5,l,pp. 17-22 RUBY, M.M. ( 1985) Die Anwendung der psychodramatischen Techniken bel alkoho)auffaelligen Kraftfahrern in Driver Improvement•Kursen IThe application of psychodrama techniques in driver improvement courses for drunk drivetsl. Dritter Internationaler Workshop Driver Improvement, 26:28. September 1985 In Damp (Deutschland). Koeln: Bundesanstalt fuer Strassenwesen, pp.124•126 SPOERER, E. (1972j, Driver Improvement: Moeglichkeiten der Rehabilitierung von verkehtsauf(aelligen Kraftfahrern Driver improvement: Chances of rehabilitating traffic offenders). Frankfurt: Tetzlaff, 128 pp. TRUOEL, L(1981), Psychodrama mit Suchtkranken (Using psychodrama for treating addicts). Psychodrama in der Praxis, Pfeiffer Publishing,pp. 202-223 WEINER, H.B. (1965), Treating the alcoholic with psychodrama. Group psychotherapy. Vol. XVIII, i/2,pp. 24-29 WINKLER, W. 11974), Gtuppengespraeche nach wiederholter Trunkenheit am Steuer (Group discussion after repeated drunk driving). Blutalkohol, Xl,pp. 178-188 *AFN-Association for Education, Perfection and Driver Improvement (Gesellschaft fuer Ausbidung, Forthildung und Nachschulung), Cologne, Federal Republic of Germany **Insutute of Forensic Medicine, University of Salzburg (Institut fuer Gerichtliche Medizin, Paris Lodron-Universitaet), Salzburg, Austria ***Road Safety Board, Salzburg Division IKuratorium fuer Verkehrsslcherheit, Zweigstelle Salzburg), Salzburg, Austria . .. ~a cenholgrwp (qwfifxafronM*~>+~tmhabiGhrbn) E.eperimentelyvac}o(Qua/ilJcXians/krrelub.7iblion) ; , ~ . . . . . . r.irr DeNalqoment of DWl reYldrvism forsacond offenders in a tenyrar periodpriortorehabilitsGix+progromsandnow. TIMN 321464
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Appendix III for sample ads and cheque insertl- 3.6 Review Process Departmental officials of the Health Protection Branch, the Solicitor General and Justice Departments were presented with campaign concepts and a general over- view of the campaign early in its development. The concepts were also shown to interest groups such as the Canadian Addictions Foundation, the Headmasters' Association of Ontario, the Council on Drug Abuse, the National Organization for the Reform of Marijuana Laws (NORML), the Canadian Guidance counsellors Association, as well as the Canadian Home and School Parent-Teacher Federa- tion. The campaign was also shown to the Federal-Provincial Sub-Committee on Alcohol and Other Drug Problems, which is made up of executive directors of provincial and territorial drug agencies. There was general support from all quarters. 3.7 Timing The campaign was launched in March 1983, with the release of the family allowance cheque insert, the broadcast of the television commercials, and the mass distribution of the Stay Real and Straight Facts booklets. The television spots, which are shown during "prime teen time", have been on the air since 1983, and will continue to March 31, 1986. The length of the period of exposure varies in each region according to the incidence of cannabis use (i.e. longer in British Columbia, shorter in Quebec). Due to a limited budget, commercial time was bought during varying periods of the year. For example, in 1984-85 the schedule was as follows: August 20 through September 10 October 8 through November 17 January 14 through February 11 3.8 Media Strategy and Rationale Media Selection Thirty second television spots in all English and French television markets in Canada were selected as the sole medium to reach the primary target group of teens 12-18 years of age. a) Television was selected as the sole advertising medium for the primary group because: it provides broad "potential" reach of the primary teen 12-18 target market; its broad geographic coverage provides support in smaller urban and rural markets; - a significant percentage of the adult population is reached b) Consumer magazines were selected as the sole advertising medium for the secondary target group i.e., parents of teens 10-18 years old for the following reasons: magazines provide the opportunity for detailed copy; the long life of the medium allows the target group to reflect upon the message and refer to it over time. c) Radio was considered and subsequently rejected as part of the media mix for our primary target market because: - the cost to cover smaller markets with teen-directed radio would severely reduce the number of weeks of the campaign; - there are only a limited number of radio stations targetted to teens outside of major urban centers; - any "spillover" advertising to the secondary target groups would be minimal based upon the time periods purchased in order to reach the primary teen target group. 3.9 Regional Variations Stay Real is a national information program. Except for the variance in provincial prevalence rates, the qualitative and quantitative studies showed that there were no discernible differences in attitude, behaviour and knowledge amongst various populations i.e. socio-economic status, sex, relegion etc. The only regional adaptation that was made to the program was in media plann- ing. Media weight purchased through the national networks was based on the prevalence rates of cannabis use in each province or region. For example, in 1983 the campaign was extended for 28 weeks in B.C., 25 in the Prairies, 19 in On• tario, 12 In Quebec and 15 weeks in Atlantic Provinces. (See Appendix for media blocking Chart). 4. EVALUATION DESIGN The main vehicle for evaluating the impact of the Cannabis ]nformation Program in the primary target group is a survey of young people carried out annually ear. ly in the year. The first one was conducted in January and February 1983 by the Canadian Gallup Poll Limited one month before the introduction of the pro. gram. One thousand four hundred and thirty (1430) 12-18 year olds participated in an interview and completed a selfadministered questionnaire dealing with awareness of the program, knowledge about cannabis, attitudes toward its use and patterns of use. Similar questions were asked about the other two Direc- torate advertising campaigns-Dialogue on Drinking, and Generation of Nom Smokers. The second wave of the survey with similar content, and methodology was carried out in February 1984 approximately one year after the introduction of the program. One thousand four hundred and forty seven (1447) 12• 18 year olds participated at that time. In February 1985, another 1443 were interviewed and completed the questionnaire. The response rate in the target group was over 70% in the first two waves and 63% in the third. The main vehicle for evaluating the impact of the program on the secondary target group is also an annual survey carried out at the same time as the youth survey. The first wave of this survey however, was conducted in 1984, one year after the introduction of the campaign as it was decided in this case to rely on the results of an earlier survey (1981) carried out by the Canadian Gallup Poll for baseline information ( I). In February 1984, 672 adults with children between the ages of 10-18 were interviewed on the Gallup Omnibus Survey about their awareness of the Cannabis Information Program as well as their knowledge about and use of cannabis. The same questions were repeated in February 1985 when 626 parents with children in the primary target group were interviewed. The response rates were approximately 60% in both years. In addition to the annual surveys of the primary and secondary target groups, a special study was carried out in 1984 to determine the impact of the Stay Real pamphlet on those who had requested it in response to advertisements placed in March/April 1984 issues of two national publications (T.V. Guide/T.V. Heb- do and Reader's Digest/Selectton du Readers Digest). Two hundred and sixty (260) individuals who had requested a copy of the pamphlet completed a question- naire mailed to them two or three months after they had been sent the pam- phlet Discounting those individuals who did not receive a copy of the pamphlet, this represents a response of 27%. However, a random telephone survey of 30 individuals who did not return a completed questionnaire found that those who returned and those who did not return questionnaires were comparable demographically and held similar opinions about key aspects of Stay Real. The questionnaire covered a large number of topics including: recall of the content of the pamphlet; reasons for requesting it; assessment of the pamphlet and knowledge gained as a result of reading it; and behavioural results of receiving it. lt is impossible to present the results of these studies in detail In this paper and, indeed, the analysis of the results of the second year of the campaign has not as yet been completed. However, it is possible to present some of the key results to date. Those who are interested in more detail can request copies of the evaluation reports that have been completed (2,3,4). 5. RESULT TO DATE 5.1 Awareness of Campaign As noted above, one of the objectives of the advertising campaign for the Can• nabis Information Program is "to create awareness of the campaign among the primary and secondary target groups". At the end of the first year of the cam- paign, 56% of the primary target group (teens) recalled seeing the two television ads used and 66% did so at the end of the second year, a statistically significant increase. Of these, 17% had seen or written for the Stay Real booklet by the end of the first year and 24% had by the end of the second. In addition, 15% spontaneously mentioned the "Stay Real" slogan at the end of the first year and 13% mentioned it at the end of the second. Other themes which were part of the advertising campaign were also mentioned by substantial numbers in both years. For example, 13% and 11% mentioned "resisting peer pressure" at the end of the first and second years respectively. In contrast, less than four percent recalled having heard the message (Stay Real) prior to the introduction of the campaign. Thus, it appears as if the advertising campaign has achieved substan- tial levels of awareness within the primary target group. It also appears as if there were increases in awareness between the first and second years. In addition, a special analysis carried out at the end of the first year of the campaign found that those who used marijuana tended to be more aware of the campaign than those who did not, suggesting that the campaign was reaching those at risk within the primary target group. As for the secondary target group iparentsl, they too appeared to be aware Of the campaign, although as expected, the levels are lower than for the primary group. Specifically, 33% reported that they had seen or heard the message "Stay Real" at the end of the,fitst year and this increased to 38% by the end of the second (not statistically significant). Sixteen 116) percent had seen or heard of the Stay Real booklet when it was shown to them at the end of year one and 19% said they had at the end of year two. Thus, there may have been a slight increase in awareness in the secondary target group over the course of the se cond year of the campaign, although not as substantial as was the case for teens, which is not surprising, given the greater investment of resources in trying to reach the latter group. TIMN 321477 -1 84
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membership population lapproximately 5001, the major source of CAf funds emanated from the Federal Government and the official jurisdictional agencies located in the Territories and Provinces of Canada. 7 o reward and encourage this financial support, CAF was structured in such a way as to favour these official agencies utilizing block voting during the election of Board members, the adoption of resolutions and in the selection and communicatlon of policy statements Again, such recognition reinforced the elitist view of CAF especially since most of the officials of CAF have traditionally been employed in these agen• cies which are capable of bearing travel and accommodation expenses. An additional set of structural problems resulted from circumstances beyond the direct control of CAF. In the mid-1970's the forerunnerbf the Sub-Committee on Alcohol and Other Drug Problems was created. Consisting of the C.E.O. of each of the official jurisdictional addiction agencies IFederal/Provindal/Territoriall, this group meets on a regular basis to share information and work cooperatively on projects of mutual interest. In essence, CAF was replaced as the forum wherein these influential bodies could work colloquially with one another. Finally, it has been suggested that the mere existence of strong jurisdictional agen. cies which may have no interest in fostering or encouraging the development of a national organization has hampered the growth of CAE This latter allegation re mains a hotly debated issue in the addictions field. Accountabilities A final challenge faced by CAF which, at first, may seem inconsequential, became a contributor to the short term and often precipitous decision making of this organiza- tion. Recalling that the preoccupation of the organization has been with fund rais- ing, the subtle contribution of CAF's accountability to its members and funders is often missed. To attract members, CAF needed money and products. To make pro- ducis, CAF needed members and their money. The national Board having only financial resources to meet twice a year tended to use this time to discuss the implementation of current projects (awareness weeks, conferences, symposia, etc.) which would prove to the membership and funders alike that tangible benefits resulted from participation in or support of this organization. The need to demonsirate both viability and accountability to the membership and funders, while universal- ly regarded as an important task for any organization, contributed to the organiza- tion's inability to address the generic problem of resource acquisiiion. ADVISORY ORGANIZING AND PLANNING COMMITTEE: A FUTURE THRUST Recognizing the above dilemmas, the Board resolved to commit time and energy towards the development and implementation of a long-term plan for the future growth of CAE Initial work followed a planning procedure utilized by other NGO's as detailed in Figure I below. FIGURE 1 Prepare Organization for Planning by Developing Mission Statement ! 2. 3. 4. Gather Data Needs: Internal/External Assessment: Future Capabilities 5et Goals 1 Develop Operational Dbjectives N. - 5. Evaluate Results and Reassess Goals Plan Action Irple:uent Projects 7. •-- -. 6. Budget In addressing Steps I to 3 in this process, the Executive Committee, working with a Management Consultant, adopted a mission statement and a series of related goals as a shared vision designed to focus the future energies of the organization. These were: Mission Statement: The Canadian Addictions Foundation is the national authority providing leadership in dealing with the abuse of alcohol and other drugs by formulating policy statements, advocating an informed position, and addressing the needs and concerns of its members. Goals: 11) To establish financial independence and a well-equipped, confident, permanent staff. 121 To develop a recognized national authority acknowledged by other professional groups and by all levels of government. i3) To establish effective processes that allow for interaction with the shaping of points of view of significant decision-makers. (4) To initiate and assist programs that will decrease the abuse of alcohol and other drugs. (5) To encourage an active membership through affiliated local chapters and other interested groups. (6) To complement existing systems, or to establish new systems, for the effective exchange of information between all significant constituents. (7) To remain an adaptive organization that allows for response to changing needs. To develop operational objectives, the Board tumed once again to one of the original founders of CAF: Dr. J. George Strachan. Dr. Strachan worked tirelessly and taught the executive that new, imaginative and innovative measures were required if CAF was to access the necessary funds for program support. Further, he impressed upon them that CAF required the guidance and assistance of key Canadians who could, through their personal contacts and affiliations, make real and effective contribu• tions of both their abilities and positions to enable CAF to become the active and properly funded service foundation it should be. The concept of an Advisory Organizing and Planning Committee IAOPC) was ap- proved by the Board of Directors in December 1982. It was decided that the member• ship of the AOPC should be drawn from the most representative medical, legal, social, spiritual, business, labour and professional interests in Canada. This Indud ed recovered alcoholics. The title bf this body was chosen to reflect its primary task. It is advisory to the Board, concerned with the organization and visionary planning required to rebuild a national organization. In order to protect the authority of the Board, the AOPC is time limited, and its membership includes the President and Vice-President of CAE Further, the Executive Director was designated to serve as Secretary to the AOPC. The goals of the AOPC are as follows: (1) To assist the Board in raising the seed monies and operational funds necessary for the future development of CAF; (2) To assist in acquiring representative and respected Canadians to serve as in• fluential governing members of the Board and committees of CAF; (3) To assist the Board in achieving a sound operating base and level of funding consistent with future needs and aspirations of CAF; (4) To assist the Board and Executive in launching a program designed to ensure the immediate and long-range viability of CAF; 15) To promote and assist CAF in becoming an effective and respected national voice and authority on addictions in Canada. The responsibility to establish the AOPC rests with the President of CAF. Ongoing funding and services in kind contributions have been accessed from supporters for the three-year period between 1982 and 1985. These resources were negotiated so as to allow the Executive and Board an opportunity to focus their energies on the establishment of the AOPC and to work with this body to develop long-range objectives and strategies. To facilitate this task, Dr. Strachan drafted a comprehen- sive planning prospective. This document envisioned the AOPC as a body design- ed to enhance, as opposed to abrogate or weaken, the existing CAF structures. It is hoped by many that the Advisory Organizing and Planning Committee will com- mence meeting during the calendar year of 1985. CONCLUSION CAF was born out of the communication needs of addiction colleagues working in Canada. Throughout early developmental stages, this national organization ex• perienced numerous challenges, a major challenge being the lack of appropriate finances. Despite these challenges, CAF has made a national contribution to the addictions field in Canada. The present long-term planning strategy focuses on the establishment of an Advisory Organizing and Planning Committee. With assistance from this group of key Canadians, CAF intends to become the national authority providing leadership in dealing with the abuse of alcohol and other drugs by for• mulating policy statements, advocating an informed position, and addressing the needs and concerns of its members. RELATED DOCUMENTS 1. The Canadian Addictions Foundation: A Planning Perspective for the Period 1982-1985, G. Ross Ramsey, President, June 1982. 2. Canadian Addictions Foundation: A Statement of Intent Towards Building a Na- tional Authority on Addictions, G. Ross Ramsey, President, July 1982. 3. Rationale for the Establishment of an Advisory Organizing and Planning Com mittee 1AOPC) by the Canadian Addictions Foundation, G. Ross Ramsey, Past President, January 1983. TIMN 321475 82 -A
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I he concept ot a national alcohol policy for example, as pioneered particularly in the Nordic countries, was felt to have great value and indeed to be almost an itn perative if alcohol-related problems were to be tackled realistically. In the last thirty years governmental organs of inter-minisierial or inter-agency type have been set up in many countries. In the field of alcohol dependence there was gradual recognition of the inadequacies of a compartmentalised approach to pro blems posed by alcohol consumption in the community. The concept of a national alcohol policy involving the production and supply, taxation of alcoholic beverages, legislation, education, treatment of alcohol-dependent persons, seemed to be necessary if any radical progress in the limitation of alcohol problems in a given country was to be achieved. 6 This concept has, of course, not been put into practice in a number of countries in which the compartmentalized system may still be said to operate but the general tendency is to develop at least some Inter-agency lines of communication. The question to be discussed is whether overall inter-ministerial, inter-agency bodies represen, tative of a wide spectrum of activities pertaining to alcohol and drug consumption and dependence provide an effective means of controlling this dependence, and if so, in what measure they should be executive, advisory or cooperation-facilitating to be effective? There exist state organs concerned only with alcohol problems or only with drug problems or both, some dealing primarily with prevention and excluding treatment which is left in the jurisdiction of the Ministry of Health, or dealing with both prevention and treatment. The fact is that until comparatively recently there existed in many countries a lack of communication between the professionals in the treatment/prevention area and those in the control system. Although at international level this was not the case it most certainly was at national and local levels. This may be illustrated by reference to a conference organized by the International Council on Alcohol and Addictions in the early 1970s. Until this event the professionals treating drug dependence in that country had had no contact and did not even know the representatives of that country in the United Nations Commission on Narcotic Drugs. And this was not an isolated case. It can readily be understood that the implications of a combin. ed approach were not fully realized or understood. The result was a certain polariza. tion manifested by hasty moves to integration on the one hand and resistance to this on the other. The relevance of the comprehensive approach to overall national health planning and development needs careful consideration. There have always been those in favour of the integration of alcohol and drug problems in mental or general health programmes and those on the other hand who have felt that the special character of alcohol and drug problems needed specialized agencies and personnel to deal with them adequately. 4. National and International Efforts Within the context of the previous discussion of trends in substance abuse preven- tion, It is important to see what WHO has done and is continuing to do in this area. Both the alcohol and drug programmes of WHO are located within the mental health programme, which gives central attention to the preservation and enhance- ment of mental health at all ages in the specific sociocultural settings of Member States. Many approaches within these programmes are entirely complementary and the number of joint activities is increasing. It is within this positive climate that WHO's comprehensive approach to the alleviation of alcohol and drug-related pro. blems is being actively developed. 4.1 Alcohol Abuse During the period of the Sixth General Programme of Work (1978-1983J, a major change occurred in WHO's activities in the area of alcohol abuse. The concept of "alcoholisrri' was replaced with the much broader range of "alcohol-related pro- blems': In consequence of this important shift in emphasis, a number of broad fines of action were started, which relied upon the active involvement of all WHO regions and reflected the growing concern of Member States throughout the world. The work in the European Region and in North America in the alcohol policy area was of particular importance, whilst in the Western Pacific Region alarm at increas- ing alcohol consumption led to the adoption of a wide-ranging resolution by the Regional Committee in 1982. Information from 80 countries on the prevention of alcohol-related problems was collated by WHO and published and an Expert Committee on Problems related to Alcohol Consumption held. In addition, WHO carried out a large collaborative study in measuring and improving community responses to alcohol-related pro blems in Mexico, Scotland and Zambia. In an effort to respond to the challenges contained in resolutions of the World Health Assembly, current programme activities have been concentrated on major Priority areas. These areas were selected as a result of a careful assessment of ex. pressions of needs by countries and after consultation with WHO regional offices. Significant developments in each of these areas are highlighted below. 77 f-itstly, it was recognized that the prevt•ntwn of akohoi-related problems is one essen tial part of the promotion of health. A major new programme initiative has now begun with an international workshop to develop guidelines for the assessment of health promotion approaches to the reduction of alcohol problems. Four developing countries from different regions are participating in this activity, which Is leading to the development and testing of specific approaches to the prevention of alcohol• related public health problems, with special emphasis on the needs of developing countries. Meanwhile, in the European Region, work in prevention has focused particularly on vulnerable and high-risk groups, beginning with a review of dif ferent approaches to the prevention of alcohol problems in young people. The second line of work seeks to promote cooperation with the media. An inter• national meeting on alcohol and health held in Geneva in November 1983 iden- tified promising advocacy approaches. This meeting involved media practitioners and communication scientists. Their recommendations. which are now being im plemented, include the preparation of press kits of basic information on physical diseases caused by alcohol, on alcohol dependence and on alcohol and the family. A review document has also been prepared on the impact of TV on the mental health of adults and children which uses alcohol as a case study. A third important target audience for advocacy is the scientific community. Through the encouragement of research in alcohol, and in particular through the proposals of a 1984 task force on the prevention of alcohol-related problems in adolescence, vigorous attempts are being made to stimulate increasing interest in this area of work. Another good example of the use of advocacy within the scientific com• munity is the stimulation of work on biological risk factors for alcohol dependence, which relies upon long-term international collaborative effort, involving several centres. A review was undertaken of the various documents on alcohol production, con• sumption and related health problems issued or drafted by the Organization dur- ing the past few years. This review revealed that the information available has been insufficiently exploited for advocacy purposes. A series of publications and documents are now being prepared. These include a comprehensive report on trends in alcohol production and trade, with discussion of their public health implications and sug gestions for future work. Articles in World Health Statistics Quarterly, the WHO Chronicle and World Health Forum also deal with this topic. Meanwhile, in collaboration with the International Labour Organisation IILOj and the International Council on Alcohol and Addictions, WHO prepared six regional reviews of alcohol-related problems in the employment setting and the responses which are currently offered to them. The Regional Office for the Americas has been especially active in stimulating policies and programmes on alcohol and drug problems in employment settings Meanwhile, specific proposals have been developed for joint action by ILO and WHO, focusing on preventive measures appropriate for employment settings. A review of the world literature on the prevention and management of alcohol problems in the family setting will be available later in 1985. It will be used to determine ways in which WHO can best approach this complex field and become usefully involved. This remains a topic with great potential for development, and is already an important emphasis within both the advocacy and treatment areas. 4.2 Drug Abuse Prevention of health problems linked with drug dependence has high priority in the programme It concerns prevention of dependence on narcotic drugs as well as prevention of problems arising in connection with the use of psychotropic substances. Thus, the development of a strategy and guidelines for the prevention of dtug dependence involved the collaboration of investigators in 35 countries, who prepared descriptions of work on the prevention of drug abuse In their country. The second phase of the project will involve the analysis of this material and the preparation of a basic document which will analyse cross-national aspects of prevention policies. The reports of the meetings of an advisory group to the project are available. The final report on this project will be available in 1985. In view of the considerable increase in the use of cannabis during the past ten years and the increasing concern in many countries about its health consequences, a scientific group was convened jointly by WHO and a WHO collaborating centre, the Addiction Research Foundation IToronto, Canadai. The Group reviewed ex isiing scientific, clinical and epidemiological information on the potential and ac- tual hazards to health, resulting from nonmedical use of cannabis and its various psychoactive constituents and preparations. WHO also organized, in collaboration with the International Union of Pharmacology, an international meeting on can- nabis in Oxford IUnited Kingdomi in August 1984. WHO was requested to promote the intiation and strengthening of national and international programmes for the assessment, scheduling, control and appropriate use of narcotic and psychotropic substances, and to develop appropriate guidelines for these activities. WHO has developed these guidelines which describe the ef forts undertaken by the international community, national authorities and profes. sional groups concerned, to limit the use of dependence-producing drugs with TIMN 321470
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Fg 7. Comparison of Most Important Reasons for Coming into A.A. .i 2.0- : c . i '0 • • j• No. Citing AA Member i• Ratio: 0.5 No. Citing Counseling & Rehab, m0 ¢ 10 20 30 40 50 60 70 80 90 Age years •-.-.-.-•-.-• Fig 8 10 20 30 40 50 60 70 80 90 Age'Years CHARACTERISTICS OF THE SENIOR HIGH STUDENT WHO DRINKS AND DRIVES Briit Finlev INTRODUCTION Akohol-related accidents are the most frequent cause of death and disability of American Youth-The advocates of health promotion and primary prevention have only recently focused bn youth, akohol, and traffic accidents This paper discusses a descriptive study Of self-report data on drinking and driving behaviors of students in Grades 10 through 12 in Western Montana. While the information generated at the national levei may assist in the discussion of trends, the specific nature of local demographics is useful in targeting population for prevention. This is particularly true in rural communities since there is conflicting information about rural-urban differences in student drinking Patterns. Almost all studies on youth and akohol use self-reports. Such data is thought to represent underreporting from the respondent IDel.uca, 19811. The results of this survey will be given in terms of grade; Lowman (Fall, 19811 suggests that grade levels represent social groups better than does age. THE SURVEY An Alcohol Student Survey tool was created by the investigator. The 126 items took about 45 minutes to self adminiuer and were divided into four sections: demographi-s; _ curricular placement of alcohol and drinking and driving content; drinking and atcohoi related behavior: and driving and drinking items. With permission portions of [he tool were from instruments used by the University of Michigan Highway Safety Research Itutitute The section on drinking and alcohol related disorders was replicated with Permission from Lassey and Carlson at the University of Idaho. The tool was pre tested at one school for grades 10-12 in the county before use with this sample The data Were Analyzed by the Statistical package for the Social Sciences. One limit of this soft. ware is that it divides only to the thousandths. Hence~ chi square analysis significant levels will be recorded as .0000 when it may be .00001. The tooi was designed to measure where content on alcohol and drunk driving i.s plac ed within curricula and which media was effective in communicating driving and drink tnR tnessages The section on drinking and alcohol-related behaviors reviewed frequencyt amount and kind of alcohol beverage used. It also asked where and when drinking occurred and with whom the student drank. The number of times drunk in the last Year/last month was also measured. Reasons for drinking and not drinking were rated as well, and data on peer attitudes and behavior were gathered. Adolescent indices of alcohol misuse as defined by Donnovan and Jessor 11978) were measured. This corr cePt has been tested as useful in determining a soctopsychological theory of problem behavior in accounting for problem drinking. The last section looked at driving par terns and frequency of driving and drinking. The questionnaire was supervised by the researcher or assistant in the classroom. I'he student was free not to participate; however, less than Pk% of the group chose to decline. The schools sampled were from Western Montana The stratified random sample was drawn from approximately half of each grade and the total size of the sample was 1,208, The tool was administered in the Spring of 1983. DEFINITIONS Alcohol misusers-students who reported drunkenness at least six times in the past year and/or negative consequences two or more time in the past year in at least three of the five areas considered. Weekly heavy drinkers-students who drink at least once a week and at least 5 drinks per typical drinking occasion Imore than 2.7 oa. F.thanoli. Seldom drinkers ISDI•students who reported drinking about once a year. tkcasional drinkers IUUhstudents who reported drinkingat least once or twice a month. Frequent drinkers IFUl-students who reported drinking at least weekly. Frequent drinking driver IFDDI•students who reported on a weekly basis driving after drinking at least two drinks or more Occasional drinking driver IODDI-students who reported one to three times a month driving after drinking two drinks or more. Seldom drinking driver ISUUI students who reported once in the last three month> driving after drinking two drinks or more. Never drinking driver INUUI-students who repon have never driven after twu drink, or mora DRIVING BEHAVIOR The report on this section is focused on students in Grades 10-12 as this group is the more frequent driver. The research questions that examined driving under the influence of alcohol was worded "driving after drinking two drinks or more;" I he increased vulnerability of drivets under 18 towards crash involvement with alcohol at that level was demonstrated by both Carlson 119721 and Zylman 119731. Frequency of Drinking and Driving Driving a car is a taken for granted activity of student.: in grades 10 12. tvinety six per cent report they drive a car and seventy-three percent drive during both in weekends and the weekdays. Within the past month most students in this sample report car driv Frequency of Attendance at Meetings 10 ' 6~, 6-I 91 TIMN 321484 _ _
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Conclusion This paper has discussed the characteristics of parent and children in the context of alcohol abuse. It should be clear that these characteristics are not restricted to the alcohol crontext. It is proposed that the characteristics reviewed may apply to any abusive context, whether it be physical abuse, psychological abuse, sex- ual abuse, food abuse, drug abuse or whatever. The abuse must be perceived and understood as a symptom of a dysfunctional system. In such systems, there are no single causes or cures. There are no saints or victims in such.systems, only players in the family game. It is the goal of preventior~ and treatment to help families change the rules of the family game so that the symptomatic behaviours become unnecessary. It should also be clear that there needs to be much more theoretical and em- pirical work in these areas. It is hoped that some of the ideas expressed in this paper will trigger research based on the new epistemology of family systems theory. REFERENCE NOTES Carr, R.A.11981). Peer Counselling Project. Faculty of Education, University of Victoria, Victoria, Canada. - Creighton, T.D.11985). Alcohol Abuse: The Professional as enabler or therapist? Proceedings of the Presentor's Conference, Faculty of Social Welfare, University of Calgary, Canada: University of Calgary Press. Pascual-Leone, J. (1969). Cognitive development and cognitive style. Unpublish- ed doctorat dissertation, University of Geneva, Switzerland. Skirrow, 1. (1984). Design considerations of a multi-faceted adolescent primary prevention program. Paper presented at the 30th International Institute on the Prevention and Treatment of Alcoholism, Athens, Greece. Skirrow, J. & Nutter, C.119841. Evaluation of a multi-faceted alcohol primary preven- tion program. Paper presented at the 30th International Institution on the Preven- tion and Treatment of Alcoholism. Athens, Greece. Yip, R.11985). A Critical look at children of alcoholics from a child development perspective. Paper presented at the 34th International Congress on Alcoholism and Drug Dependence. Calgary, AB, Canada August 4-10, 1985. REFERENCES Bames, H.L & Olson, D.H. (1985). Parent-adolescent communication and the cir- cumplex model. Child Development, 56, 438-447. Bateson, G. 119711. The cybernetics of self: A theory of alcoholism. Psychiatry, 34,1,1•18. Bateson, G.119721. Steps to an ecology of mind. San Francisco: Chandler Publishing. Baumrind, D. (1974). Current patterns of parental authority. Developmental Psychology Monograph, 4. Belsky, J. & Isabella, R.H.119851. Marital and parent-child relationships in family of Origin and marital change following the birth of a baby: A retrospective analysis. Child Development, 56, 342-349. Black,C. (1979). Children of alcoholics. Alcohol, Health and Research World, 4, l, 23-27. Bowen, M(1974(. Alcoholism as viewed through family systems theory and family Psychotherapy. Annals of the New York Academy of Sciences, 233, 115-122. Bowen, M. (1976). Theory in the practice of psychotherapy. In Guerin. P.J. Jr. (Ed.). Family Therapy: Theory and practice. New York: Garner Press, Inc. Brenner, A. I19851. Wednesday's Child. Psychology Today, 19, 5, 46-50. Case, R.11985). Intellectual development: Birth to adulthood. New York: Academic Press. Dornbusch, S.M., Carlsmith, J.M., Bushwall, S.J., Ritter, P.L Liederman, H., Hastorf, A.H. & Gross. R.T. 11985). Single parents, extended households, and the control of adolescents. Child Development, 56. 326-341. Elkind, D. (1974). How the mind grows. Two paths of mental development. In: Children and Adolescents. (Second Edition). New York: Oxford University Press. Pp• 58-73. Elkind, D. 119811. The hurried child. Reading, Massachusetts: Addison-Wesley. Elkind, D. (1984). All grown up & no place to go. Reading Massachusetts: Addison. Wesley. Garmezy, N. 119831. Stressors of childhood.ln Garmezy, N. & Rutter, M. (Eds.): Stress, coping, and development in children. New York: McGraw-Hill. Pp. 43-84. Grotevant, H.D. & Cooper, C.R. Patterns of interaction in family relationships and the development of identity exploration in adolescence. Child Development, 56, 415.428. Harter, S. U983i. Developmental perspectives on the self-system. In Mussen. P.H. (Ed.): Handbook of child psychology. (Fourth Editionl Volume IV, Chapter 4. New York: Wiley. Pp. 275-385. Hartman, A. & Laird, J. (1983). Family-centred social work practice. New York: The Free Press. Hebb, D.O. (1972). Textbook of psychology. Third Edition Philadelphia; Sanders. Lerner, R. (19811- What's it like? Growing up in an alcoholic home. Focus on Alcohol and Drug Issues, 4 (6), 12-15. Lerner, R. & Naiditch, R. (1979• 1983). Chemical dependency prevention programs. St. Paul, Minnesota: Children Are People, Inc. Maccoby, E.E. & Martin, J.A. (1983). Socialization in the context of the family: Parent-child interaction. In Mussen, P.H. (Ed.): Handbook of child psychology (Fourth Editionl. Volume IV, Chapter 1. New York: Wiley. Pp. i-l01. MacKinnon, L, Parry, A. & Black, R. (1984). Strategies of family therapy: The relationship to styles of family functioning. The Journal of Strategic and Systemic Therapies, 3 (3), 6-22. Minuchin, P. (1985). Families and individual development: Provocations from the field of family therapy. Child Development, 56, 289 302. Minuchin, S. (19741. Families and family therapy. Cambridge: Harvard Universi• ty Press. Palazzoli, S.M., Boscolo, L, Cecchin, G. & Prata, G.11978). Paradox and counter• paradox. New York: Jason Aaronson. Palazzoli, S.M., Boscolo, L, Cecchin, G. & Pratra, G. 11980). Hypothesizing. Circulatory-Neutrality: Three guidelines for the conductor of the session. Family Process, 19. 301-345. Pascual-Leone, J.119701. A mathematical model for the transition rule In Piaget's developmental stages. Acta Psychologica, 32 (3), 1-345. Piaget, J.119591. The language and thought of the child. (Third Edition) London: Routledge & Kegan Paul. Piaget, J. 11963). The origins of intelligence in children. New York: Norton Piaget, J. 119831. Piaget's theory. In Mussen, P.H. (Ed.): Handbook of child psychology. (Fourth Edition). Volume 1, Chapter 3. New York: Wiley. Pp. 103-128. Quigg, C. (19851. Elementary particles and forces. Scientific American, 252 (41, 84-95. Rutter, M. & Garimezy, N.11983). Developmental psychopathology. In Mussen, P.H. (Ed.l: Handbook of child psychology. (Fourth Edition). Volume IV, Chapter 10. New York: Wiley. Pp. 775-912. Tomm. K. I1984ai. One perspective on the Milan systemic approach. Part I: Over view of development, theory and practice. Journal of Marital and Family Therapy, 10 (2). 113-125. Tomm. K. (1984b1. One perspective on the Milan systemic approach. Part II: Description of session format, interviewing style and interventions. Journal of Marital and Family Therapy, 10 131, 253•271. Watzlawick, P., Beavin, J.H. & Jackson, D.D. (1967). Pragmatics of human com- munication. New York: Norton. Wegscheider, S.119811. Another Chance: Hope and health for the alcoholic family. Palo-Alto: Science and Behaviour Books. Witkin, H.A., Dyk, R.B., Faterson, H.F., Goodenough. D.R. & Karp, S.A. (19621. Psychological differentiation. New York: Wiley. Woititz, J.11983I. Adult Children of alcoholics. Hollywood, Florida: Health Com- munications. Wynne, L.C., Rycoff. I., Day, J. & Hirsch, S.11958). Pseudo-mutuality in the fami• ly of schizophrenics. Psychiatry. 21, 205-220. TIMN 321490 97
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'1'able 1 Mean Index of the Gross and Microscopic Change in the Postmortem Brain of SDAT Patients with Patients With Alcoholic Dementia GROSS CHANGES MICROSCOPIC CHANGES INDEX OF INDEX OF AFFLICTION BY TYPE OF BRA ATROPHY NT, SD, GVB NEUROPATHOLOGY PATIENTS I~ WEIG}1T FRONTAL PARIETAL HIPPOCAMPAL (g) R.H. L.H. NEO CORTEX NEO'CORTEX FORMATION ALCOHOLIC DEMENTIA 1215.5 1.5 1.4 1.2 1.3 2.6 x age: 72.7 ALZHEIMER DISEASE 1181.5 1.4 1.2 1.1 1.3 2.5 x age: 75•75 INDEX 0€ SEVERITY OF BRAIN PATHOLOGY: 0 no pathology 1 marked pathology 2 severe pathology 3 very severe pathology Table 2 P•aluea for correlations between the postmortem rating scales for both Alcoholic Dementia and Alzheimer Dementia together. Factor BRAIN ATROPHY MICROSCOPIC CHANGES RIGHT . LEFT FRONTAL PARIETAL actor HEMISPHERE HEMISPHERE NEOCORTEX NEOCORTe:X RIGHT ir 9~^^ HEMISPHERE ~ ® LEFT < HEMISPHERE -0.42* FRONT L u NEOCORTEX -0.13 -0.15 E PARIETAL R ;x!3 HEOCORTEX -0.27 0.49f -0.06 BIPPOCAMPA ~~ FORMATION 0.44• -0.29 -0.26 0.08 •p<0.05 CLINICAL AND ULTRASONIC STUDY ON ALCOHOLIC LIVER DISEASE T wmDA Clinical and ultrasonic study on alcoholic liver disease Joseph, et al. reported the bright echo patterns of the liver different from normal one and consistent of minute, compact and diffuse bright spots. The liver showing such ultrasonic findings is generally called the "bright liver" and includes some histological specificities. Their typical case is a relationship between the histological fatty liver and the "bright liver" : The author; et al. did clinical and pathological study on the liver disease patients who showed bright liver by ultrasonic examination, especially in its relationship with the fatty live; the results of which will be reported. I. Subject and Method 1) Subject Total 137 liver disease patients were examined who were hospitalized in Osaka City University school of medicine, histologically diagnosed by a liver biopsy with the laparoscope, and examined by ulttasonography. The alcoholic liver disease patients in the habit of excessive alcoholic drinkings more than 80 grms/day for past 10 years were designated as excessive alcoholic drinkers. 2) Method (1) Ultrasonic (US) Findings Ultrasonic examination was generally conducted immediately before the laparoscopic examination, and the US findings observed during the US examination and the photograms were retrospectively evaluated by plural US examiners. The ultrasonic findings were examined mainly on the following 4 items in a close relationship with the fatty liveti and each of them was classified into three stages scored 0 to 2, and an aggregate of their scores was evaluated as the fatty liver scores a) Brightness The bright echo patterns of the liver consistent of minute, compact and diffuse bright spots offered by Joseph, et al. were classified into three levels of score 0: normal echo level, score I: mild echo level and score 2: significant echo level. b1 UK Contrast The right robe of the liver and the right kidney were shown in a same display, and the echo level of the liver parenchyma was compared with the cortical echo level of the kidney. Their comparative liver/kidney contrast was scored as 0: normal level, 1: dearly higher level and 2: significantly higtler level of the liver parenchyma respectively. c) Vascular blurring The degree of the vascular blurring in the liver was classified into 3 levels of score 0: no findings, score 1: obvious findings, and score 2: significant findings di Deep attenuation The US findings occupied with fine and high level echo on around the surface of the liver wnile noted deep attenuation were devided into 3 stages (Table 11. (2) Histological examination The histological examination was conducted mainly on the 2 points of fatty infiltration and fibrosis. TIMN 321494 101
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TABLE 1 HOSPITAL-RELATED STATISTICS: 1982/83 AREA CATCHMENT AREA POPULATION TAAL N HOSPITAL BEDS TOTAL N OF SEPARATIONS SEPARATIONS PER BED BEDS PER 1,000 SEPARATIONS PER 1,000 TOWN A 16,000 90 2,151 23.9 5.6 134.4 TOWN B 45,000 142 4,067 28.6 3.2 90.4 TOWN C N/A+ 94 2,037 21.7 N/A N/A PROVINCE OF ONTARIO 8,715,800 46,228++ 1,290,206++ 27.9 5.3 148.0 Notes: + Hospital staff have not completed an assessment of the hospital's catchment area. The psychiatric unit serves all of the County, a population of 56,355. ++ Rehabilitation figures are excluded from the totals. Sources: These data are provided by the three (3) town hospitals and from Hospital Statistics 1982/83, Ministry of Health, Ontario. i TABLE 2 ALCOHOL SALES AND ALCOHOL-RELATED HOSPITAL STATISTICS: 1982/83 AREA N OF SEPARATIONS ALCOHOL-RELATED ALCOHOL-RELATED SEPARATIONS AS PERCENTAGE OF TOTAL SEPARATIONS SALES OF ALCOHOL IN LITRES OF ABSOLUTE ALCOHOL TOTAL POPULATION AGED 15+ SALES RATE IN LITRES OF ABSOLUTE ALCOHOL PER PERSON 15 YEARS OF AGE AND OVER TOWN A 62 2.9% 128,623.8 6,788 18.9 TOWN B 63 1.5% 125,745.3 8,347 15.1 TOWN C 92 4.5% 113,832.5 5,735 19.8 PROVINCE 0F ONTARIO 12,344+ 0.96%+ 73,630,957.4 6,839,600 10.8 Note: + This figure is incomplete, as data for alcoholic poisoning, alcoholic pellagra, alcoholic gastritis, alcoholic cardiomyopathy, alcoholic dependence, and alcoholic polyneuropathy are not available. However, the data for liver cirrhosis include non-alcoholic liver cirrhosis so that this will inflate the restricted amount. Sources: These data are compiled from the three town hospitals; Hospital Statistics 1982/83, Ministry of Health, Ontario; Brewers Retail, operated by Brewers are ousing Company Limited; the Liquor Control Board of Ontario and Statistics Canada. TIMN 321503 110
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CANADIAN ADDICTIONS FOUNDATION: PRESENT CHALLENGES AND FUTURE THRUSTS G. Ross Ramsey HISTORY AND CONTRIBUTIONS Ihe Canadian Coundl on Alcoholism began in 1054 througN a meeting between H. David Archibald, Executive Director. Addiction Research Foundation (Ontario): I. A. Calder. Director, Bureau of Alcoholism for Saskatchewan: M. Ross A4ounce. F.xecutive Director: Committee on Alcoholism for Manitoba; George Riddell. represen- ting E. D. McRae, Executive Director, Alcoholism Foundation of British Columbia; and J. George Strachan. Executive Director, Alcoholism Foundation of Afberta. fhe initial functions of the Council included: IU '1o facilitate relationships with various departments of the Federal Government: 121 fo facilitate relationships and develop policies In relation to other national organizations in health, welfare and other fields related to the work of the Cana dian Council and its members: - t3f 7o cooperate in matters of research programming; 141 7o plan and develop materials applicable for distribution on a Canadian-wide basis: 151 1o investigate the possibility of receiving and distributing funds from Canadian businesses, industries and other sources: - 101 to assist, on request, in the development of adequate programs on alcoholism in the various provinces in Canada. _ Ihe Council met annually until 1962, when it was federally chartered as the Cana than Foundation on Alcoholism with assistance from legal counsel of the Federal Department of National Health and Weifare As a result of the growing impact of other drug addictions and the public demand for greater assistance in coping with these dependencv trends, the name of the organization was changed to the Cana dian Foundation on Alcohol and Drug Dependencies; then in 1979, shortened to the Canadian Addictions Foundation 1CAFi. I hroughout its formative years. CAF's essential contribution was that by virtue of it+ existence a focal point was created for individuals and organizations desirous of confronting addiction-related problems in Canada. Each year, through annual conferences, and latterly through regional symposia, cot kaKues could congreQate sharing knowledge and experience and unite within one prolessional association. 'ihis national contribution dovetailed and reinforced in dividual jurisdictional developments whereby provincial and territorial governments , responded rt~ the growth of drug addiction problems by establishing official addic tion a>•eric es. utilizing Foundation, Crown Corporation or Government 1)epanment structures. ~ tkher notable CAF contributions include: Ill The advocacy of positions on relevant social policy issues demonstrating c:.Af leadership: 121 lhe expansion of membership categories and the adoption of postal nomina tion and election procedures to promote participation in the affairs of the Foun dation from a wide array of individuals and ancillary-related organiiations: i3i l he establishment of Speciai fnterest Sections, which appeal to professionals employed in treatment, prevention or evaluation and research capacities: and. allow colleagues to gathc•r/share information and work on project% of mutual interest; 14t 1 he creation of regional chapters permitting and encouraging participation in prolects on a local level: I51 'i he publication of a newsletter providing information on current addiction related matters and encouraging communication between the Board and its membership: inl fhV coordinatiun of local initiatives into a National Drug Awarenc:,ti Week desig.n ed to fotu> pubhc attentiun on addictionrelated i+.ues• - i7t I'he organiiatton of a resource di,lributnr,htp whereby CAI members could purchase printed matter and audio visual material at discount priets: 181 I he eo spnn.sorship of svmpn.ia focusing on topics or programs of current in terest to addiction prolessionals i()t 1 he productiun and distribution of a I)irectorv of 5ervices which rrcirrdvd a description and location of many addiction-related agencies throughout Canada. PAST AND CURRENT CHALLENGES FACED BY CAF (Af's contributionti to tfn• addictions field in Canada has been hard won. Non 6overnmental Organizations INGA)i traditionally fact• many similar problems in Canada. CAF's experience can be categorized into four major headings. fhe,e arc: Ftnancial Challenue>. Volunteer Limitations, Structural Problems and Accountabili ty Priorities. - Financial Challenges Perhaps the most complex problems faced by CAF can be categorized as financial. From its inception, CAF has had limited financial resources to the point that con• vening a meeting of its Board of Directors is a ma(or challenge. For example, in 1981, with an annual budget of SOS,DOQ CAF faced a financial challenge of a S20,000 deficit. Realizing that it costs between S12.000 to SI5.000 to convene a meeting of the Board of Directors. one begins to appreciate the sorrowful state of resources provided to this national organization. lack of available monies has forct•d CAI to survive on a predominantly volunteer basis fhis has precluded the recruitment of a permanent staff which can devote full-time energies to the objectives of the organii.ation. In addition. lack of monies has served to limit participation in the affairs of thc loundation largely to those people who enjoy the suppon of an employer willing to reimburse travel and ac• commodation expenses. Finaily, lack of funds contributed to the adoption of a"hat in hand" attitude, whereby staff and volunteers spend a ma{ority of their energies in crisis management attempting to access resources as opposed to producing products, Volunteer Limitations CAl has fortunately accessed the energies of many volunteers livinyl In various provincial and territorial jurisdtctions throughout Canada. While it is true that volunteers have meant the survival of CAF, it is also true that volunteers alone are unable to mana,<e and expand the programs and services of this national organira tion. Without the adoption of a long-range plan, inconsistency is the by-product of rapidly changing volunteers. In addition, many volunteers have limited personal financial resources to pay their own travel and work-related expenses. As indicated above, this has led to a circumstance wherein the majority of Board positions are accessible to individuals who have tht• support of organizations which can pay these expen.ses and donate the individual's time to CAh matters. Such a circumstance has perpetrated a perception that CAF is an "old boys club" which is not sensitive to general membership needs. Funher: it suggests that certain constituencies: specifical ly. representatives of lurisdictional addiction agencies, have had more influence on the organi•ration, i.e. the golden rule ... he who has the gold makes the rule. Volunteers, despite stronr commitment, have to take care of their own personal needs and are not always available to ensure that the ongoing commitments of CAF are met. In addition. numerous administrative matters monopolize CAf volunteers and thereby hinder them from taking a long term planning perspective which can ensure the expansion and growth of the orQanization. Administrative matters, including budgeting, conference organiiation and planning, constitutional and bvlaw reviews and standing committees, are but a few of the routine re quirements draining the energies of these people. It is clear that while CAF has employed some capablc- personnel and attracted the volunteer services of many outstanding individuala the routine demands and growth rc•quirement, of this national or>',ani/.ation has far outweighed available resourct•s. If (:AF were simph• to continu< with part time pt•ntmnel and volunteers function- inf; solely within the rolt of a Rnard, it is conceivable that this organintinn could cease to survivv amid thc increasing expectations and demand, of its membership and the community at large. Structural Problems Structural problems include g,coy;r.tphtcai disperx•ment of Board members, short appointments of ext.utitt• ofh~er> ton to two vc•ar termsi and the participation ot official addiction agrntrt•s. t:Al intendt-d to b, , national ort;aniiItion with rrprc.rntan:'es lmm sua to sea, fhc vast geography ot c;anada coupled tcith scarce financial re,•sourco frustrated the un,:ani.atum in it> attempts to be national because it was impossibi..- tn reirnburx cxprnk-~ fur participants frum remotc areas in thc eountry. I his funher compound •d the perspective that the Buard of (;AI was only available to a xrle.t group of p~nplr front across Canada. I he short term of uffi.r for Directors and executive officers frustrated team building and tht adopum of consistent plans. t 1n,:c an individual bt•comra comfortable and knowiedl;vablc in tht, rule and duties nf hia her uUi:c• he she is required to resign. A new individual is eleaed, appointed, and the process of orientation repeats itselt. I he rapid chany:e of senior stafl and the short terms of office for officials contributed tu CAl's shonterm problem solving perspective and hindered the development and adoption of a IonQterm plan focusing on a resolution of fundamental challenges frustrating the gruwth of this national organization. An additional challenge surfaced as a result of the funding support received by t;At. With a small membership Irc linitiallv SlO.tun, now 525.UU, and a modest Rl TIMN 321474
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TABLE 3 ALCOHOL-RELATED SEPARATIONS AND THEIR DIAGNOSES: 1982/83 AREA N OF ALCOHOL- N OF ALCOHOL- N OF NON- TOTAL N N OF % OF TOTAL RELATED RELATED ; ALCOHOL- OF UNSPECIFIED DIAGNOSES SEPARATIONS DIAGNOSES RELATED DIAGNOSES DIAGNOSES UNSPECIFIED FOR THESE DIAGNOSES SEPARATIONS FOR THESE SEPARATIONS TOWN A 62 77 130 207 26 12.6% TOWN B 63 67 82 149 13 8.7% TOWN C 92 101 160 261 27 10.3% Sources: These figures are derived from data provided by the three town hospitals. TABLE 4 COMPARATIVE RATES OF ALCOHOL-RELATED PROBLEMS: 1982/83 AREA SALES RATE IN LITRES OF ABSOLUTE ALCOHOL PER PERSON 15 YEARS OF AGE & OVER RATE OF ALCOHOL-RELATED CHARGES BY POLICE PER 1,000 AGED 15 & OVER CATCHMENT AREA POPULATION 15 YEARS OF AGE & OVER RATE OF ALCOHOL- RELATED SEPARATIONS PER 1,000 AGED 15 & OVER IN THE CATCHMENT AREA TOWN A 18.9 17.5 12,305 4.7 TOWN B 15.1 35.9 34,605 1.8 TOWN C 19.8 37.0 N/A 2.1++ PROVINCE OF ONTARIO 10.8 31.4+ 6,658,875 1.8 Notes: + 1981/82 Data ++ In order to calculate this rate, we assumed the catchment area population for the hospital to be the same as the catchment area population for the psychiatry ward. However, this rate will be an underestimate, since this psychiatry ward is the only one in the county and thus has the county population as its catchment area population, whereas this hospital is not the only one in the county and thus has a smaller catchment area population. Sources: These rates are derived from data provided by the three town hospitals, the three town police departments, the Brewers Retail operated by Brewers Warehousing Company, the Liquor Control Board of Ontario, Statistics Canada and Hospital Statistics 1982/83, Ministry of Health, Ontario. 04 111
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TABLE Patient Age Reason for Admission JL 31 Court order GP JM 30 33 Court order Financial and family concerns. Patient Age Reason For Admission DY 28 Concern about quantity of drug use Duration Drug Use 13 yea s SUMMARY OF TEN PATIENTS Mental Psychosocial Status History No primary Divorced. 4 psychopathology arrests - drug possession, theft. Disci- plinary action in Army. 16 years Antisocial School dropout. behavior since 3 divorces. childhood. Arrests for auto theft, fraud, burglary, drug possession. IWprisoned, armed robbery. Family Treatment History Outcome 19 years No primary School dropout. Alcoholism psychopathology Marital separ- ation. 3 arrests - assault Disciplinary action in Army. SUMMARY OF TEN PATIENTS Duration Mental Drug Use Status 16 years No primary psychopathology T4 34 Expressed need 21 years No primary to stop drugs psychopathology 37 Material losses 18 years No primary psychopathology EB 42 Seeking halfway 22 years No primary house placement psychopathology Blatant disregard for rules. Disci- plinary dis- charge after 4 days in pro- gram. Insight lacking. Compliant. Minor rules infractions. Lacked insight and motivation. Uncooperative. Disciplinary discharge after 25 days in pro- gram. Psychosocial History Family History Treatment Outcome School dropout Alcoholism Lacked insight 2 divorces. 8 and motivation. arrests-drunk Uncooperative. driving, Left program assault, after 16 days. robbery. Disciplinary actions in Army. School dropout Lacked insight. 7 arrests - Arrogant, robbery, grandiose in larceny, group. Poor assault, drug compliance with sales. Unit rules. School dropout. Alcoholism, Completed pro- Marital separa- drug abuse gram satisfac- tion. Burglary. torily. AWOL in Army. School dropout Lacked insight. truancy Compliant. Isolated, wary. One episode marijuana use. TIMN 321500 107
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therapc•utic usefulness, ahd to come to grips with the problems of illicit supply and demand. The W HO Executive Board, having discussed this matter, adopted resolu tion f.B73.R1 l and. in paragraph 2131, requested the Director•General_"to give priority to efforts to implement the guidelines for the control of narcotic and psychotropic substances in the context of international treaties and in the spirit of resolution WHA33.27 and to support the enhancement of the capacities of Member States to prevent drug abuse and control its consequences : The guidelines are being widely circulated. Country visits by an interdisciplinary team which will also include representatives of other United Nations agendes, have been planned. It has long been recognized that attention should be devqted to the education of health care professionals for improving prescription, delivery and utilization of psychoactive substances. WHO, in collaboration with the authorities of the Union of Soviet Socialist Republics, organized a meeting in Moscow. from 8 to 13 Oc tober 1984, to discuss activities which could be undertaken to improve prescrip• tion, delivery and utilization practices regarding psychoactive drugs. Educational programmes for physicians and other health workers, and other measures were recommended, as well as close cooperation in this endeavour with medical educa. tional institutions, medical associations, the pharmaceutical industry and others. The group reviewed the chapters prepared for a possible publication on improving the use of psychoactive drugs-educating the professionals. It is planned to have this available for presentation to the seventy-seventh session of the Executive Board in January 1986. The assessment of therapeutic usefulness of psychotropk substances was discussed at a meeting convened in Oslo from I to 5 October 1984. The aim of the meeting was to consider the ways in which data on therapeutic usefulness could be col lected and assessed along with data on abuse and the associated public health and social problems. The Organization needs such data as a basis on which to make its recommendations for control under the 1971 Convention. The group discussed methods of assessment of therapeutic usefulness, including assessment of therapeut'k efficacy and drug utilization, and made recommendations about WHO's work on the assessment of benefitrisk ratios of psychoactive drugs. 5. Conclusions This paper has not attempted to provide a comprehensive overview of substance abuse prevention. Not only would it be impossible to encompass such a wide frame of reference within the boundaries of a single short , but it is also beyond the com- petence of this author to undertake a task which presumes so much wisdom. in• stead, as the reader will have seen, a decision has been made to concentrate on three basic themes prohibition or moderation; combined or separate approach: na tional and international efforts- These three themes are all important to the history of substance abuse prevention. If a line of development emerges from the mixed experience of the past, then it is linked to changes within these three areas. Equally, they may lead towards some conclusions which have sufficient strength to apply to the wider field from which these themes have been drawn. The first and most important theme is that substance abuse problems are serious enough and pervasive enough to warrant action being taken to alleviate them; that treatment of doubtful efficacy but undoubtedly expensive, is not in itself a cost effective solution; that prevention sttategies, whilst requiring much more and much dearer planning, do seem to point the way towards practical benefits In other words, that lack of consensus is no impediment to a commitment to continue If this paper has helped at least to clarify the terms in which the battles have to be fought, then it has been worthwhile. the second theme is that specific problems are likely to require specific solutions. No review of the many courses of action available could fail to identify that each presumes a priority hit-list of problems to be confronted and that it is not always the same items that appear at the top of everybody's list. Devising preventive strategies involves making decisions about priorities. These decisions are likely to be influenced both by the severity of the problems under attack and by the estimated effectiveness of the proposed plan of campaign. Both these factors need to be considered simultaneously and modest but attainable impact upon particular problems may be a great deal more important than rousing battle cries about universal scourges and endless misery. 7he third theme, which has to run beside the previous one, is that, although specific solutions must be sought for specific problems. it is important not to lose sig,ht of the global perspectives. Substance abuse is not just the affair of one district or one, region or even one country. It is the worlds problem and has to be confronted with as much of an integrated approach as possible Differences between countries, between regions, even between districts are important and will exert influence upon the way that strategies are interpreted for that district, region or country. But beyond the particular, there is a general truth and the inability of some treaters, researchers, educators or social planners to look beyond their own backyard is bound in the end to limit the effectiveness of preventive strategies in a serious and unace countable way. This paper is arguing for particularity but against parochialism. 78 I he fourth theme concerns individual responsibility. We commonly feel dwarfed by talk of government committees, international treaties or a concourse of "ex• perts': Many individuals, including those active in helping alcoholics and drug ad. dicts feel that prevention Is too remote a concern for themselves and turn back hurriedly to attend to the casualties. Despite the complexity of effective preven tion, the individual is not powerless over his own environment. A group of in• terested individuals can influence the level of problems in their neighbourhood and indeed they are likely to be all the more effective because they are close to local customs and attitudes. Such an approach requires real cooperation. There are those, seeking to advance their own arguments, who wish to exclude others from the debate. To exclude doctors, or to exclude non-doctors; to exclude recovered addicts or to include only recovered addicts; to exclude the beverage trade, or to silence the neo-prohibitionist; to pour millions into education or to shut up health education as a tokenistic claptrap; to impose draconian laws or to clear the way for a free market economy; to ban advertising; to ban private clinics; to ban WHO; to ban, finally, all psychoactive substances. The public health perspective is not necessarily the overriding force in human af fairs, just as the expansion of commercial interests is not necessarily hostile to the benefit of the majority of mankind. Frequently, conflicts arise as much from a lack of understanding as from genuinely irreconcilable points of view. That is not to say that preventive action will not yield clashes. It will. We are not advocating a blurring of distinctions, a blind eye being turned to legitimate and important dif ferences. What we are advocating is a continuation of the debate. Not as an alter- native to action, but as an integral part of the action. It is probably true that national efforts will stand or fall by the degree of interna• tional commitment to them that is forthcoming, in terms of advice and support. It is not, of course, the function of international bodies to tell countries what they must and must not do. This is as true in the area of alcohol, drugs and tobacco as it is in any other. What they can do is to assemble previous relevant experience from countries that have, one way or another, attempted to Introduce national policies and programmes. They can then draw up guidelines from those examples and, through appropriate advice and support, assist those countries that request It. It is important to recognize, however, that some countries may well choose not to develop preventive policies at all and that others may choose to develop them without seeking advice from international organizations. In maintaining their ability to res• pond to a range of different requests from different countries, but mindful of the danger inherent in clinging to concepts that are rusting away through lack of use, international organizations can legitimately act in two ways. They can, through their advocacy role, encourage countries to develop their own national preventive policies; and they can, in promoting appropriate technology, offer advice that will enable countries that do decide to act, to make their policies as effective as possible. It is important to recognize that this involves a wide distribution of support. Even within WHO, it will involve contributions from major programme areas other than those traditionally associated with substance abuse. Health education and health economics are two obvious examples, but there are others. Thus, beyond WHO, there are other agencies within the United Nations family that will also represent their own perspective in the provision of international support for this important eftort. The public health perspective is vital to the process of helping countries develop effective policies, but it is not the only relevant perspective. It will not always be within ministries of health that the final touches will be put to national policies, which must after all, by definition, be comprehensive. What is certain is that WHO can and must give a lead, both globally and regional- ly. It can give a lead through the coordination of international efforL It can give a lead through the active promotion of relevant concerns, both in its own program• mes and in its relationship with Member States. In doing so, It can benefit from the accumulated experience of past efforts. It can acknowledge that it is no longer possible to draw false comfort from the idea of being in a phase of transition from a concept of disease prevention to one of sociai control. Such an interpretation simply does not fit the facts. The time has come to try to combine the best of both worlds. There is, in a real sense, no alternative If WHO does not take this lead, then the world can look forward to further increases in substance abuse and to ever-mounting casualty rates from that awful battlefield until health for all by the year 2000 becomes a very hollow toast indeed. REFERENCES In preparing this paper, extensive use was made of existing WHO documents and publications. These key sources include: WHO Technical Report Series, No. 650. 1980 Walsh. && Grant, M. Public health implications of alcohol production and trade Geneva, World Health Organization, 1985 (WHO Offset Publication No. 881 Mosez 1 Alcohol policies in national health and development planning: Report on the TechnKal Discussions at the Thirtyfifth World Health Assembly. Geneva. World Health OrganiutDn, 1985 IWHO Offset Publication No. 891. World Health Organization. Alcohol policies. Copenhagen IWHO Regional Publications. F.uro pean Series, No. 181 Iin pressl. Document A38/INEDOC.l4. Document EB75/iNF.DOCJI. 7ongue. A., The Combined or Comprehensive Approach to Alcohol and DrugRelated Pro blems (unpublished WHO document MH'PAD!85.101. iQ26 WHO Advis.ory Group Mtg, London, Feb. 1981. Report iunpublished WHO doc MNH/81. TIMN 321471
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FI R 2 100%. 23% 24 e/. Frequer2t Setdom 19% OCCASSIonOMy FIGURE 3 100o/1 Gra 50 "/s ~Ti 33 % Never Driver Declined Never 17% Dnnks Declined in N •Ii TAtLE 1 soclat Conteat for Ortrtttn9 irades 10-12 IIOst of ee ~Sa.eTt~s Fre.quentlL i 20 26 ~T16666 35 At Teenage Oartief .Aln others are 9rinttng and your 7earents or otner aoults are not Bresent At ho.e on specfal occaSions sYcA ai birth- 20 45 16 20 days. noltdays suca as TRLntsglvtng Orlvfng around or sitting 31 3s 19 15 in a car at night At Atnner at Ss.e nltn Se 35 5 2 rlta the fa.tty At ylaces Mxre teenagers - ' Mng around fie. tne:r 35 33 16 17 parents or otner aoolu ar! Ilot pre{CRt At a teenage party exn otMrs are drtnttng anA 40 40 11 9 .ne. your parents or other aAuits yom tno. arc Bresent durtng ur after a sawoi ectlvlty sucn as a 9anCe or rootDail 9- eeee 39 31 16 14 your parents or other aautu you tnar 6n Mt present or aart 6n yon Alone--.nen ne one else 77 20 2 1 is arouua Arnt .f he.r erut y t.r n r...na hr w•narnS strula..cr • .0000 r. •.S2 4f Suu.. 1.-7R1 21 ML1.. atur *=9•_="~• br...+ m.lf ~t irpwnt// Aett t rear - 16 22 ]7 7l a 2 .•2R 2/ 1. 2/ 1 1 . .• IN 7iC-- .7 2tl 22 7 0 o •• 111 Tau 1 1M1~ir. S er . y A...nt e~ S.. . Ner Orvnt 1.. 2 +s twre +, t.ns 7tr- IT 7Lr 7t7 Y el 11 11 2. IO 20 . 24 2. 1. 1 !1 te 32 13 21 20 2. tl !9 7e 10 f Yr1Y/ry .M Br1.IM b Gr.M er.me w.w le li Ttl TT/ Gr.a 12 TTI .a u 41 1Y.6111 a w 2a &[. (t.2171 71 11 S/ 1J TI..Nwu 1.•t151 27 1. 7L T.In . e.H 2Y•1051 29 1f 36 1-t TlanJweL l.•161 IS 21 57 ttlrlnc.Kt • -eG00 sr. • -.25 T/Mt s .H.IM U C.n H Swr .x.11r M•M Or.es 10-1t 4.++L Yrer S .r aen s*?.Inl ~fi7 rM =7 0® 20 SBO 2f Yoo u Y•a1 r•.JS 3t~MrluKe . .o00G 34 1-2 Ia.S TM. 7 r.. t..rRi att rnt -T[T ` R 7 i 0 u S 1 iL 20 7 a 7. S2 Y• 24, .• 171 Y• 76 erenq p rpeer irwpl< srt..+. .f ureNenS c...<+ lo-u ireW.q .1 R.nr irwe< u L.+t 1... rw uLL f0u ITT ITT 7TT PT .onr t0 SS .1 n Oncr 21 it tu 12 2-S tlrs 2S 2U a e 6.rwnn~s 17 a . 1 . . 1.0 . . lis Y • 272 , . 27. -.1C stMlrlt.ue • .8000 Passenger with Drunk Driver Grades 10-12 (Time Interval In Lost Three Months) 35% Never 4 Ride Declined from Drunk Driver des 10-12 me Interval In Lost Three Months ) 93 TIMN 321486
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CHILDREN OF ALCOHOLICS: A SYSTEMS APPROACH Terence D. Cre{ghton The consequences of growing up in a home in which one or both parents is alcoholic are currently receiving a great deal of clinical interest leg. Black, 1979; Lerner, 1981; Wegscheider, 1981; Woititz, 1983). However, as Yip 11985) has pointed out, many of the characteristics of children of alcoholics are no different from charaderisiics of children whose development Is disturbed for some other'reason. This paper will examine the more general family conditions which lead both to alcohol abuse and to the pattern of behaviours observed in dysfunctioning children. In contrast to approaches which focus exclusively on either the child, the alcoholic or alcohol, this paper will adopt a family systems approach to the topic (eg. Minuchin, 19851. Characteristics of Alcoholic Families The term "alcoholic families" refers to a family condition in which one or both parents are abusing alcohol. In understanding the genesis of such families, the ideas of Bowen 11974, 1976) have been useful. In particular, the concept of'Ylifferentia tion of self' has helped to explain the intergenerational, interpersonal and intraper sonal phenomena observed in alcoholic families. Individuals with low levels of differentiation are said to be "fused" : They have main- tained unresolved emotional ties to their family of origin which hamper their abili- ty to manage intimacy and closeness in their interpersonal relations. Such people are unable to distinguish between the feeling process and the intellectual process. Their lives are dominated by their emotions, and their self-definition is always depen- dent on the here and-now reactions of others. They are unable to construct a "solid self' because the intellectual processes necessary to do so-Piaget's "refiective abstrac tion'=are overridden by their emotions. The resulting "pseudo-self' is created by emotional pressure and can be modified by emotional pressure. Bowen 11976) writes: The pseudo-self is composed of a vast assortment of principles, bellefs, philosophies and knowledge acquired because it is required or considered right by the group. Since the principles are acquired under pressure, they are random and incon- sistent with one anothe; without the individual's being aware of the discrepancy. Pseudo-self is appended onto the self, in contrast to the solid self which is in- corporated into self after careful, logical reasoning. (p. 68) Accotding to Bowen (1974), couples meet at the same level of differentiation, although they may have adopted different strategies for coping with stress. In families which will become alcoholic, the couple is undifferentiated from their family of origin, which is itself undifferlentiated and somewhat dysfunctional, and the fact that both blame their parents for their current problems is one of the major aspects of their relationship they may have in common. These couples usually have their first child early in their marriage, before they have resolved the issues relating to the family of origin (usually around acceptance) and their "coupleness" (Tetterington, per- sonai communication). The birth of their child brings to a head the problems each spouse has in intimacy and distance regulation (Belsky & Isabella, 1985) and sets in motion family processes designed to give each spouse a more definite sense of self than would otherwise be possible. These processes, which create emotional distance, include a conflictual marriage, creating dys- function in one spouse leg. alcoholismi. and projecting the emotional immaturity of the couple on to one or more children. (Bowen, 1976). Thus, they recreate a similar context to the one they thought they were escaping from through marriage, a context with which they are familiar. Bateson 119721 explains this characteristic of "hubns when he writes: "But a tendency to verify the unpleasant by seeking repeated experience of it is a common human trait. It is perhaps what Freud called the "death instinct": ( p. 3273281• Such family systems have been described as enmeshed (Minuchin, f9741, chaotically or rigidly enmeshed ieg. Barnes & Olsen, 19851 or pseudomutual (Wynne, et ai, 1960). Because of the fusion, the sense of self for each spouse is dependent on each other. There are four features of "the family game" (eg. Palazzoli, et al, 1978( which are common in alcoholic families: - 1. Since acceptance and rejection are central issues in people whose sense of self is determined by others, such relationships are characterized by a lack of clear definition of the relationship. If the relationship were made dear, one or both spouses would receive messages of rejection which could not be tolerated. Each must avoid, at all costs, being in a "one-down" position. 2. Although the definition of the relationship must remain unclear, members of the family system attempt to impose their definition of relationships on each other. This results in an escalating pattern of symmetrical maneuvers to avoid a clear definition of relationship or to stay "equal" with each other. leg. Bateson, 1971, 1972). Symmetry is defined mathematically when the solution to a set of equations remains the same even though a characteristic of the system they describe is altered lOuigg. 19851• In other words, the behaviour of one member of the family system is countered by another member, leaving the system of relationships unchanged. Communication patterns, all of which must include information about relationship definition, are characterized by paradox (double• bind), dis-qualification and disconfirmation (Watzlawick, et al, 1967). Self- disconfirmation ("pay no attention to how I define relationships, because I am in an altered state") is a technique effectively employed by the alcoholic member of such families (Palazzoli, et ai, 1978). But, in alcoholic family systems, each person must disqualify his own definition of the relationship before the other has the chance to do it. (Therapists often pay attention to only one level of a disqualificatory communication-where two levels of the same communica- tion contradict-and therefore invoke "denial" as a characteristic of the alcoholic and his family). Only by selfdisqualification can communication about rela- tionships occur without changing the relationship and without leaving oneself vulnerable. 3. No member of the family system can leave the field, since to do so would define the relationship. So the family struggle will continue over time, across distance and generations. 4. As the parental system becomes symtomatic, anxiety Increases. The two•person system immediately seeks stability by forming a triangle with one or more children in a system of overt and covert alliances and coalitions (Bowen, 1976). There is a tendency in the literature on children of alcoholics to focus on the triangulated child as the innocent victim of parental alcoholism, or, as has been suggested above, parental emotional immaturity. Such a view sees problems as residing in the individuals. For example, "he is an alcoholic, she is depressed, and the child is angry": However, in a family system, problems are better understood if they are seen as problems of relationships, rather than problems or a disease process residing in individuals IHartman & Laird, 1983). In family systems, the roles and behaviours each member of the family adopts Is designed not only to reduce their own stress, but also to reduce the stress of the whole family system by maintaining homeostasis of the family system.(Palazzoli, et ai, 1978; Tomm, 1984a) (It is important In alcoholic fatltilies that change be minimized, since change implies a risk of relational defini- tion). The paradoxes ("I am in the system because you care and worry about me, but I am out of the system because I am in an altered state") and disqualifications by the use of alcohol are examples of how such behaviours avoid change in the family's definition of relationships. So, too, are the roles often adopted by children in alcoholic families leg, family scapegoat, family switchboard, family caretaker, family pioneer, family distractor, family joker, family organizer-Hartman & Laird, 1985). Each of these roles serves not only to make up the deficiencies in the system which are necessary to maintain family functioning and stability, but also they serve as ways of disqualifying self or other, thereby maintaining the family game For exam- ple, many of these roles involve the child taking on adult responsibility. This en• sures that such responsibilities will be taken care of, but, more importantly, serves to disqualify both the adults and the child ("You are inadequate as parents because I have to do your job, but you can't take me seriously in this role because I'm just a child"). All behaviour in family systems, including alcoholic behaviour, is best understood in terms of the communication it makes about the state or nature of relationships in the family (Tetterington, personal communication; Watzlawick, et al, 1967). It is important to view the children, no matter how young, not as vic• tims, but as active participants in the family game, albeit unaware of their role. Types of Parenting in Stressed Families The struggle between family members which Is characteristic of the family game produces both interpersonal and intrapersonal stress. Both types of stress reduce the degree of individual differentiation possible (Bowen, 1974). Furthermore, as will be argued in more detail later, poorly differentiated individuals are more vulnerable to stress. The cumulative effects of personal and situational stress in parents have impact on their patterns of child rearing, which have predictable outcomes in children (Elkind, 1981, 1984; Yip, 1985). Stress promotes egocentric thought lElkind, 19811. Stressed/fused people are preoc- cupied with their own management of emotions, their own ways of thinking, with their own views of the world. They tend to perceive others using a kind of sym- bolic shorthand. They see others as they expect to see them, rather than how they are. Because so much of their mental energy is tied up with their own problems and needs, not much thought goes into an accurate perception of others. There is often a mindless acceptance of stereotypes about others. For example, they may believe that "all kids are bad" : This belief not only may create a self-fulftlling pro, hecy, it may also lead to acceptance of "bad" behaviour in their child as being "normal" and not subject to correction. Egocentric parents also misinterpret the 94 TIMN 321487 _...e.~
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Table 4 Age and sex distribution of 27 patients of excessive alcoholic drinker ( ) : Bright Liver Age Male Fe.ale Total 10-19 1 (1) 0 (0) 1 (1) 20-29 30-39 1 (0) 6 (1) 2 (2) 1 (0) 3 (2) 7 (1) 40^49 7 (3) 0 (0) 7 (3) 50-59 5 (2) 0 (0) 5 (2) 60-69 3 (1) 1 (0) 4 (1) Total 23 (8) 4 (2) 27 (10) 4 Table 6 Histological findings and US findings bright t l T not bright L M H a o Fatty infiltration (+) 4 4 7 2 17 Fatty infiltration (-) 95 11 14 120 Total 99 38 137 L : F.L. Score 1.2. M : F.L. Score 3.4.5. H : F.L. Score 6- Table 7 Table 5 Fatty Liver Score of fatty infiltrated liver Fatty Liver Score 0 1 2 3 4 5 6 7 Total L 4 2 2 3 1 0 1 0 13 Patty Iafiltration M 0 0 0 1 0 2 0 0 3 H 0 0 0 0 0 0 0 1 1 History of the Bright Liver without fatty infiltration ( ) : excessive alcoholic drinker NSRH 1/7 (1) 14 % AH 4/10 (2) 40 % CIH 6/21 (3) 29% CAH 7/43 (1) 16 % early 2/16 (0) 6 % LC rel I developped 3/27 (2) 11 % Others 3 /l3 (1) 23 % COCAINE USE IN THE UNITED STATES ELECTRONICS IN- DUSTRY AND SOME BEHAVIORAL TREATMENT APPROACHES DESIGNED TO TREAT COCAINE ADDICTION Kathleen R O'Connel4 Ph. D. The media has given widespread attention in the past several years to the topic of cocaine abuse and addiction in the United States. Although the exact incidence of cocaine addiction is not known, certainly it is agreed to be widespread. The rate of alcoholism in the United States is conservatively estimated at I person in 10. I would say that the rate of cocaine addiction is very dose to that. However, we are talking about overiapping populations here, as people who are addicted to cocaine often develop a serious problem with alcohol, culminating in many cases in alcoholism. It Is interesting to note that 92% of the people that I treat with co- caine addiction are adult children of alcoholics. It is further interesting to note that 70% of that population marries an adult child of an alcoholic So there is a tremen- dous overlap between and among the addictions. And because of that, and because of some of the genetic research, I take the philosophy that when we re talking about cocaine addiction we're really talking about addictive disease. I'm going to focus in this paper on cocaine use in the electronics industry because it is an interesting microcosmic look at what is going in the macrocosm of the United States in generai. I would like to say in opening that certainly there are plenty of people in the electronics industry who do not have problems with co- caine. Howeve>; distressingly many do. As a matter of fact, of the 440 people that I have treated over the past 5 years in the electronics industry I have requested that they estimate the number of colleagues working side by side with them that also have problems. The estimates range from 40 to 70%. That is to say that 40 to 70% of the colleagues of the people that I treat who have cocaine problems also have cocaine problems. These people are all working side by sEde And we are talking about companies that are losing large amounts of money to this pro- blem. It is for this reason that the companies are beginning to attend to the pro blem and to develop treatment programs and mechanisms for referral for these employees. It is also frightening to note that of the 440 people in the electronics industry that I have treated for cocaine addiction, 25% are in the quality control area. That Is to say that these 25% are responsible for the quality of the product that is produced that is going out to the public In some cases, because these companies have large Federal contracts, we are talking about products that could involve national safety or public safety issues. Some of these people have high level classified clearances because of the sensitive nature of the work they are involved in. So the implica• tions in terms of public health and public safety for the United States are serious. This is why I have come out and publicly begun to speak about this topic, and furthermore, I have included a chapter in my book entitled "Cocaine in the Elec• tronics Industry". My book is coming out in September and the book is entiUed "End of the Line: Quitting Cocaine:' It is intended as a behavioral treatment guide and a self-help guide for people who have problems with cocaine. And it is also for their families who may be distressed and wonder how to get the family member or loved one into treatment It is intended as a self•help guide for many people. Currently I am also working on another project that is for doctors and therapists in order to help them work with cocaine patients better. This project is entitled "Behavioral Assessment, Diagnosis and Treatment of Cocaine Addiction:' Although there is considerable overlap between cocaine and alcoholism problems because cocaine and alcohol go together like red beans and rice-which is an expression that I learned at grad school at Tulane in New Orleans, Louisiana- at the same time there are s4me separate treatment issues which are relevant to the cocaine addicted population alone. That is to say that some treatment modalities are effective for cocaine addicts both, and some treatment modalities are more effective for cocaine addicts than for alcoholics. I am not sure of all the reasons for this. Some of the reasons I think have to do with the fact that there is a certain personality type often attracted to the use of cocaine. The popula. tion that I treat is mainly professional and executive people, and most of these people are very ambitious, driven and control-oriented people. They k 103 TIMN 321496
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we therefore now have an additional variable that needs controlling. The observed daily variation is by no means a minor variation. Using the obtained averages, the rats' mean daily consumption of water was 35.69g. Thus, on average, a bottle needed refilling every two weeks. Using the linear regression equation and limits of 600 and 100g for extremes of the fulless of the water bottle, a varia• tion in daily consumption, spread over the aforesaid two weeks, amounts to an approximately 25% variation either side of the mean. This is by no means a trivial variation. Indeed, what the animals are subjected to amounts to an exogenously induced biorhythmic variation, which, in extreme cases, may be equivalent to in- termittent fasting. It may be surmised that additionally there may alV be concomittent changes in the concentration of free fatty acid in the plasma (cf. Barrett, 1964). Consequently, not only our attitude to choice selection experiments may need revis- ing, but also our attitude to biorhythm orientated experiments, as well as those focussing on catabolic metabolism. REFERENCES Anon 11972) Learning laws repealed. Nature, Lond. (235) 366-367. Barrett, A.M. (1964) Adventitious factors affecting the concentration of free fatty acid in the plasma of rats Br. J. Pharmac. Chemother. (22) 577-584. Forsander, O.A. (1967) Self-selection. In: Maickel, R.R. (Ed.) Biochemical factors in alcoholism. Pergamon, Hew York. Pp 7-16. Goodrick, C.L (1972) End bottle preferences of inbred mice during alcohol preference and fluid intake multiple-bottle test procedures. Psychon. Sci. (28) 185-187. Modell, W. and Lansing, A. (1968) Drugs. Time-Life International (Nederland). Richtey C.P. (1941) Alcohol as a food. CL JI. Stud. Alcohol. (1) 650-662. Sandor, S.; Checiu, M.; Fazakas-Todea, 1. and Garban, Z. (1984) Experimental ap• proach to the alcohol embryo- and fetopathy. In: Tittma; H: G. (Ed.) Advanced con- cepts in alcoholism. Pergamon, Oxford. Pp 13-34. Schardein, J.L (1977) Drugs as teratogens. CRC, Cleveland, Ohia Tittma , H.-G. (1973) Some ef fects of alcohol, presented during the pre-natal period, on the development and behaviour of rats. Ph.D. thesis, Queen's University, Belfast. Tttmar, H:G.(1974) Alcohol intoxication: a method for obtaining increased ethanol intake in gravid rats. IRCS Med. Sci. (2) 1079. Tittmar, H.-G. (1984) Some effects of alcohol, presented during the pre-natal period, on the development and behaviour of rats. In: Tittmar, H: G. (Ed.) Advanced con. cepts in alcoholism. Pergamon, Oxford. Pp 39-59. Tittmar, H.-G. and Coleman, E(1985) Individual variability in alcohol taste threshold estimation. Presented at the 34th I.C.A.A. Congress, Calgary. TIMN 321507 114
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Simb Alcoholics Anonymous does not do research on alcohoiistt or, lur that matter, orl our own processes of recovery, the survey and analysis is intended only to give usgeneral information about our fellowship. It has been confined to macroscopic obser vations and properties, studied only to the extent necessary to give us such informa tion, which we share here with you. DISCUSSION. The number of individual returns from A.A. members in each of the surveys is as follows Figure I Surveys of Alcoholics Monys,aus Year of Nepor[ed Membership survey of US/Can. Rroups Sire of Saaple 1968 170,U00 11,355 1971 210,000 7,194 - 1974 331,O0u 13,467 1977 404,000 15,Ib3 1980 47b,000 2~.,95D 1983 550,U0U 7,611* *Although the 1983 sample was (deliberately) smaller it was obtair.ed for the first time aaording to a stratified random sampling scheme wtilch provides more reliable estimates of characteristics of the sampled population than previous surveys. However the con- sistency of characteristics and trends of the 1983 survey with the previous surveys con fimu that the previous sampl ing methods were in fact adequate for our purposes There were eight strata conesponding to eight regions into which the United States and Canada are divided for A.A. purposes, two in Canada and the remainder in the U.S. The sampled population is, necessarily, that of alcoholics who attend A.A. meetings We have not attempted to follow the progress of sober A.A. members who no longer attend meetings. In the uncorrected sample there is obviously a bias toward members that attend meetings frequently, but this bias has a minor effect on raw estimates of other characteristics of the population and when desired can be removed through the use of "frequency of meeting attendance" which is determined by the questionnaire. In what follows results quoted for the sample have not been corrected for fmquency of attendance while those quoted for the population have been. It is important to note that the numbers for reported membership in Figure I are not determined by the survey, but are those on record at the General Service Office of Alcoholics Anonymous in New York City. These are simply as reported by the 36,000 A.A. groups in the United States and Canada that have registered at that office. There are many reasons why these numbers do not reflect all the individuals currently active in Alcoholics Anonymous, and other reasons why double counting may occvc They certainly do not include all those who have been active in A.A. in the past. They are simply the only definable and countable membership numbers that we have. Distribution of Sobriety at Meetings In Alcoholics Anonymous the word "sobriety" is taken to mean total and uninterrupted abstinence from any alcoholic beverage, and is measured in units of time. An important characteristic of the population is the distribution of sobriety among those attending meetings. This property has been remarkably stable over the fifteen years of the survey; a fact that can be demonstrated in many different ways. Surveys prior to 1983 have shown the existence of three regimes with the following approximate characteristics: i• A randomly selected member of the population with less than a year's sobriety has an approximate 40% chance of remaining sober another year. 2. A randomly selected member with I to 5 years sobriety has an approximate 80% chance of remaining sober and active in the fellowship another year. 3 A randomly selected member with more than five years sobriety has an approx. imate 90% chance of remaining sober another year. Fsgure 2 Distribution of Sobriety Sobriety (yrs.) 1983 survey Predicted te.s than 1 382 3dZ 1 - 2 142 142 2 - 3 lo2 )u2 3-4 72 82 4 - 5 52 b2 > 5 262 242 f 89 Confidence limits on these estimates are undoubtedly rather widc. Using these to predict the distribution of sobriety in the 1983 sample gives the com parison shown in Figure 2. In constructing this comparison a growth rate of 8% per year for the population is assumed, and the frequency of attendance at meetings is assumed to be independent of sobriety. Correcting for the latter factor would improve the agreement somewhat. This suggests that the dynamics of the A.A. process insofar as recovery is concerned have not changed markedly, at least through 1983. Similar comparisons made durin}; the analysis of earlier surveys have this kind of consistency. Women in A.A. The percentage of women in the sample was 30%-a slight, probably insignificant declinc from 1980. Figure 3 shows the trend of this characteristic, which seems at least for the moment to be essentially constant. When corrected for the effect of the frequency of attendance at meetings, the inferred result for the population is also 30%. This percentage is essentially constant with age except at ages greater than 50 where the percentage of women begins a decline toward about 20%, and ages less than 25 where the percentage of women begins to tend upward toward about 40%. Age Distzibution in A.A. It is well known that the incidence of alcoholism In young people has been increasing. An age bracket that we use to epitomize "young people' is thirty years of age or less. Figure 4 shows the percentage of our sample in this bracket, 20%, in comparison with Previous surveys. However because young people tend to be in earlier stages of their sobriety and to go to more meetings, this percentage of the sample corrects to 18% of the population. Examination of the eight strata of the survey shows significant variation of the percen- tage of young people: from 13% in Eastern Canada (Ontarfo, Quebec and the maritime provinces) to 30% in the West Central region of the United States, a region containing Minnesota, Iowa, Nebraska, the Dakotas, Montana and Wyoming. Figure 4 also shows that the percentage of young people was about constant from 1968 through 1974, but then began a sharp inaease It would be expected that the phenomenon of recovery in A.A. by young people would somewhat lag the appearance of an in crease in problem drinking among that group. The Figure also shows that about 3% of the sample were alcoholics under 21 years of age These reported an average sobriety of about 9 months. Ftgure 5 is a graph of the age distribution of the population sampled: that is, it embodies the correction for frequency of attendance at meetings Drug Addiction Among Alcoholics A factor of increasing importance in the membership of Alcoholics Anonymous is the addiction of many to drugs as well. Only the 1980 and 1983 surveys examined this point, and only in the most general way. The question was "were you addicted to any drugs other than alcohol?" The result in 1983, cor cted for frequency of attendance, was 30% overall, as com- pared to 24% in 1980. The regional variation was from 35% I West Central and Pacific regions of the United States) to 27% (Westem Canadai• This attribute has a very strong dependence on age and on sex. Forty percent (40%( of women claimed drug addiction as opposed to 27% of men. Figure 6 shows the dependence on age in the form of a graph of percentage of each age that claims drug addiction, versus age The range is from about 10% at age 60 to 80% at age 18. Other Attributes The survey examined a number of other questions. The last to be reported here relates to the factors that led the members to A.A. In response to the question asking for the two most important factors Ifrnm a list of 15137% cited another A.A. member while 31% cited counsellors and rehabs. These numbers in 1977 were 44% and 19% respeo- tively. This is evidently another characteristic undergoing substantial change When corrected for frequency of attendance and plotted as the ratio of those citing A.A. members to those citing counsellors and rehabs I Figure 71 this phenomenon shows a strong age dependence, with rehabs and counsellors assuming greater importance below age 25. RELIABILITY. The difference between sample and population averages Is usually not significant. For example, Figure 8 shows the relative constancy of the frequency of attendance at meetings as a function of age except for young people The confidence limits of the various averages vary widely. The sample is so large that population averages like the percentage of women or young people have very narrow confidence limits. The stratified sampling scheme is overdesigned for that purpose. However there are underiying assumptions regarding, for example, ambiguity of the individual responses, the consistency of reporting of membership from the eight regions, TIMN 321482
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ing 22-30 days out of the month. It is not uncommon for students to drive under the influence of alcohol. See Figure 1. Forty-five percent report driving after two drinks or more: eleven percent have done this on a weekly basis. The primary motives listed for driving after drinking were lack of alternative transportation and feeling that one was the Less drunk of the crowd that was driving. Frequently the comment was "1 was in better shape than the others;' Car as a Drinking Context The popularity of the car as the place for drinking can be seen on Table 1, Social Con- text for Drinking; only 31 percent say they never drink while driving or sitting in a car at night. There is a significant positive relationship betweer the amount of beer drunk by those who report the car as a drinking context. See Table 2; Forty-seven percent of those who drink 7 cans of beer on each drinking occasion say their drink. ing context is the car most of the time. Nusbaumer and Zusman (1981( suggest that the more alcohol is consrmed, the greater the possibility of risk-taking behavior in the car. In terms of motive for drinking, drinking drivers were significantly more likely IGamma =-.36) to say their reason was to "get drunk or very high." fhe iniluence of the car is demonstrated again in terms of source for obtaining alcohol. The heavy drinker is more likely Isignificance =.00001 to get his alcohol from a gas station than is any other student. See Table 3, place Alcohol Obtained by Amount of Beer Drunk. With the exception of those who drink less than one can, the gas station ranks second only to friends as the most frequent alcohol source. Students At Risk For Dtunk Driving Studies show that senior high students who drive under the influence of alcohol were more likely to be male, to be in the 12th grade, to drink hard llquo; and to have gotten drunk more frequently (Lowman, 1983). These characteristics are present in the stu. dent drunk driver See Table 4, Drinking Driving by Grade Those who report themselves as more frequently driving under the influence are more likely to drink not only beer frequently (r = 52) but hard liquor often (r =.40) as well as to be drunk more fre quentiy in the past year (r =.431. The student who drives under the influence is often drinking in an unsupervised social setting such as teenage parties w-tthoat adults (r =.44), the car Ir = 521, teenage hangouts Ir =:46) and school activities without adults Ir =-.451. Being male is positively related (Gamma = 32) to drunk driving. Young drivers are more at risk than adults to be involved in motor vehicle accidents, and even low amounts of alcohol consumption were found by Voas and Mouklen (1981) to exaggerate this difference. By inspection of Table 5 it is apparent that at least seventy percent of the heavy drinkers are also drivers. Itis not surprising to know this group was also more apt (Gamma =.48) than non-drinkers to have had an acddent. It is dear that the frequent drinking driver in Montana's Grades 10-12 is a heavy alcohol user and as such is a serious potential hararYl to himself and others. Consequences of Drinking and Driving There is a strong relationship (r =.30) between driving after two drinks or more and having trouble with police because of drinking. Seventy percent of the students in Grades 10-12 have never been in police trouble for this reason. In contrast, thirty percent of the weekly drinking drivers have had trouble with the police Family trouble due to alcohol is strongly related (r =-.30) to drunk driving as well. The data on Table 6 reports that sixty percent of frequent drinking drivers have had family trouble due to alcohol in contrasY to less than thirty percent of those who never drive after two drinks or more. Frequency of Riding With Drunk Drivers The data in Figure 2 shows that only 35% have not been with a drunk driver. Who are the passengers in the high school student's car? Bacon and Jones (1968f found that drinkers tend to ride around with their drinking comrades. There is a signiFicant and strongly positive Isignificance .0000 and r=.43) relationship between frequency of driving after two drinks or more and being a passenger in the past three months in a car or motorcycle driven by a friend who has had two or more drinks. Eighty-eight percent of frequent drinking drivers are at least monthly passengers with drunk friends who are driving. How frequently is a ride turned down for this reason? See Figure 3, where 17 percent of the respondents in grades 10-12 said they had dedined rides from drunk drivers Frequency of drinking is a significant (chi square =.00001 indicator of this behavior Over half of the frequent drinkers have never turned down a ride of a drunk driver. Only 33 percent of the sample said the driver never drinks. The choice of being a passenger with a drinking driver is certainly a common dilemma for high school students in Missoula County. For those who had turned down a ride in the last three months, the number of rides most frequently declined was one. CONCLUSION The profile of the drinking driver as a heavy drinke>; drinking away from home, being male, and having drinking comrades IBacon and Jones, 1968) was confirmed in the sample Numerous authorities IDouglas, 1982) indicate that once problematic drinking habits are in place, prevention of drunk driving through rational educational methods 92 is unlikely. Control and rreatment are the primary svawgies for traffic safety with pro blem drinkers Frequent drinkers are more likely than others to be drunk drivers. It would be useful for students in the upper grades to role play turning down a ride from a drunk driver. This practical exercise would be especially important to males, who are more frequent• ly passengers with drunk drivers It is necessary to teach the dangers that can be deriv ed itam drunk driving to the driver and others Stricter guidelines from parents regarding the use of alcohol and the automobile would also help Intervention and control measures are necessary. Intensification of police patrols in the area known to be frequented by drunk driving teenagers, organized parental chauffering, and transportation by school bus to and from extra curricular activities have been put forward at the National erevention planners level ILowman, 1981/1982) as methods to help with this problem. SUMMARY Before any significant reduction in the alcohol-related traffic accidents are made, a long term commitment must be made (GAO, 1979). Montana is beginning a vigorous state effort and Western Montana in specific has made a decision to direct resources towards the drinking-driver problems. Teachers, parents and law enforcement people are already involved in the problem of student drinking and driving. Changing attitudes towards driving and drinking; coordination of enforcement, prosecution, adjudication, educa. tion and treatment functions; and generating community support for comprehensive programs has (ust begun. The data presented through this report demonstrates such efforts are necessary and need to be vigorously pursued. BIBLIOGRAPHY Bacon, iVl. and M.g Jones Teenage Drinking, New York: Thomas Y. Cromwell Ca 1968. Carlson, WL Alcohol Usage of the Night Time Driver, journal of Safety Research, 1972, 411). DeLuca, J.R. Fourth Special Report on Alcohol Health, National Institute on Alcohol Abuse and Alcoholism. US. Printing Office: Washington, D.C., 1981. Donrtovan, J. E and R. Jessar Pdolescent Problem Drinking journal of Studies on Alcohol, 1978, 39: 1506-1524. Douglas, R.L Youth, Alcohol and Traffic Accidents. In Special population Issues, Na• tional Institute for Alcohol Abuse and Alcoholism, U.S. Printing Office: Washington, D.C., 1982. General Accounting Office, Fatal Accident Reporting System 1980, U.S. Printing Office: Washington, DC 1981. Lassey, M. and J.E. Carl.son. Drinking Among Rural Youth: the Dynamics of parental and Peer Influence The International journal of the Addictions, 1980, 15 (I), 61-75. Lowman, C. Drinking and Driving Among Youth. Alcohol and Research Owrld, 1983, 7 (2), 4b49. Lowman, G U.S. Teenage Alcohol Use in Unsupervised Social Settings. Alcohol Health and Research World, 1981/1982, 6 12): 46-52. Nusbaumer, M.E and M.E. Zusman. Auto, Alcohol ad Adolescence: Forgotten Con- cerns and Overlooked Linkages, Journal of Drug Education, 1981, 11 (2(, 167-179. Voas, R.& and Moulden, J. Historical Trends in Alcohol Use and Driving by Young Americans, In: WechieC led.) Minimum-Drinking laws: An Evaluation. Lexington, MA: Lexington Books, 1980. Zylman, R. Youth, Alcohol and olluslon lnvolvement journal of Safety Research, 1973, 5 (21, 48•72. 21% S.Idom 11 /e Frpuent w% occassmonally 55•/. r Neve FIGURE I FreQuency o, Driving Afte: Two tkinkz or Nora ; Grad.s 10-12 (Time Intervol In Lost Three Months) t TIMN 321485 _~
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A CHRISTIAN PERSPECTIVE THE CHRISTIAN MOTIVATION, HISTORY AND CONTEMPORARY RESPONSE. Kenneth Lawton Traditionally, religious attitudes have been presented in the context of a historic summary of the Scriptures. This paper presupposes that the Old Testamenfcon- tains Hebrew scriptures which, with the Torah, have more stgnificance for the Jew than for the Christian. Of course, Jesus grew up in the Hebrew culture and had received instruction in both the Scriptures and the tradition. We must also note that he knew the proverbs and teaching, having been trained to have a moderate, temperate view with an ingrained knowledge of the dangers of strong drink. He would be familiar with the tragic and sordid stories of drunkenness recorded in the ancient scriptures. One of the most comprehensive studies of Biblical teaching was written in the 19th. Century-The Temperance Bible Commentary, 5th. Edition 1980-by Dr. Frederick Richard Lees and others, 530 pages of closely argued text. Many modern scholars and commentators approach the texts referring to wine in a more super- ficial way, and ignore the older study. In most cases it is impossible by the use of the Hebrew or Greek to distinguish between the alcoholic "old" wine and the "new" wine which was basically fresh juice and non-alcoholic. When most Christians discuss alcohol and the Bible, they frequently quote the New Testa- ment, picking out the wedding feast at Cana, the Last Supper and Paul's advice to Timothy. Much of this comment and the inferences from it are, I believe, both inaccurate and mischievous. The Cana everft is not necessarily a"nature miracle" or a conjuring trick. No responsible person-least of all one worthy of the name "the great physician"- would produce 64 gallons of highly intoxicating liquor for people who had already had enough. In any case, a careful reading of the text shows that what Jesus did was to tell them to fill the jars with water and give them that to drink-it was the drinker who asked, "why have you kept the best wine to the last" and the phrase "the water that had been tumed into wine" is no more than an editorial comment. If the wine in question was fresh new wine, its alcohol content would be minimal anyway. Was the Last Supper a passover meal with unleavened bread? If so, there would be no over indulgence and the wine could have been unfermented juice. Paul's advice to Timothy, "Take a little wine for thy stomach's sake" Is good advice if it is interpreted as new wine, or fresh juice; it is thoroughly bad advice if it is to be interpreted as alcoholic liquor. However, it is not my purpose to quote specific texts or to indulge in textual exegesis, but to present the Christian position. The Christian position, at its best, is not based on texts. but on the whole life of Jesus as presented in the Scriptures and as experienced in the living reality of the risen ChrisL The New Testament Jesus was one deeply moved by suffering who proclaimed by word and deed Good News and healing for the poor, the sick and the captive. A Greek word 4rsA.c-Yxvijot3mt describes Christ's inner'gut' reaction to the hungry, the frustrated, lost, tired multitude, the blind, the leper and the bereaved. His heart went out to them because of their need. They moved his heart and his stomach. In the modem society, the addict is the leper, the lost, the sick and there is bereave ment in the family. To turn to Paul's interpretation of the Christian attitude, as in his letter to the Corinthians, where he describes Faith, Hope and Love, he concludes that the greatest of these is Love. The Christian love to which this, and the comprehen sive New Testament picture testifies, is , not to be confused with , much more popular in our secular society today. is the sacrificial, costly love for the unlovely and undeserving. The specific Christian ethic is the situational social ethic which makes personal, individual demands. For the Christian God is not vindictive or judgmental in his dealings with his children and the followers of )esus must not be either. Forgiveness for the tran- sgressor is unlimited, if the sufferer will sincerely repent and "turn around" to adopt new values and follow a healthy, caring life, living for others and not for the self. The Divine imperative by which Christians live is a call to a sharing in the ministry of Christ, living a life of service. The Christian doctrine of Ministry, too often interpreted as applying only to the ordained Priest, is in historical fact and modem practice a Ministry of all believers. All Christians are called to minister to (Le. to serve, understand, heal and save) all in trouble, mental and physical. The sick, poor, weak and addicted (not necessari- ly the addicted poor, weak and sick) are a clear priority for Christian concern. Christian service and therapy is not judgemental and there is no question of the deserving and undeserving. It is a response to need wherever it is found. Love for the unlovable. Commissioner Harry Williams, physician, surgeon and Salva• tion Army officer, once said you need to be an alcoholic, a saint or a dedicated loving Christian to live with the vomit of the alcoholic. There is therefore an extra element and motivation within the mind and heart of the Christian therapist. Thus, the key to the Christian perspective is not to be found in the systematic study of the Scriptures, but in Christ's compassionate counselling. The Christian's experience of the saving power of the living Christ inspires Christian action. It is in this context that Christians have been responding to the plight of addicts for centuries, Both the concern about alcohol and drug abuse, the redemption of the sufferer and early models of therapy have the same motive. Similar motives and concern have guided those who have advocated legislative control, or have been committed to Moral Suasion. Christian leaders discouraged drunkenness and promoted an ascetic life long before there were any distilleries in Europe. By the time of the Reformation Luther and Calvin preached against drinking. Indeed Luther prayed to God that he might destroy the beer brewing business, saying there was enough barley destroyed in the breweries to feed the poor. The Reformed Church in Switzerland denounced excessive drinking and habitual drunkenness. The Rev. John Wesley in the 18th. Century most clearly illustrates the Christian concern for both prevention and healing. His Primitive Physic was an early treatise on medicine and one of the first attempts to set down cheap, safe and easy medicines, easy to be applied by plain, unlettered men. He even advocated electrifying as a proper therapeutic technique. Wesley expected Christians to avoid evil of every kind and called on his followers to avoid drunkenness, the buying or selling of spirituous liquors, or drinking them-except in cases of extreme necessity. His argument was based on the Christian commitment to love one's neighbour-thus you are not to gain by hurting anyone else or sell anything that can damage their health. Other examples can be given of Quakers, Baptists, Catholics and others who have abstained themselves so as not to cause their brothers or sisters to stumble. The influence of the Catholic Pioneers and Capuchin fathers is especially significant. The Salvation Army commitment to "saving" the addicted and the International Blue Cross (originally a Swiss Lutheran initiative) have for more than a hundred years provided what is now the longest unbroken work with and for those with alcohol impaired lives. Mention should be made of the "World's Women's Christian Temperance Union" founded in the U.S.A. in 1883. The movement of Christian women to campaign against alcohol use arose out of the experiences of alcohol abuse in families. To- day it has activities and members in about 70 countries. Members wear a white ribbon badge. Christian missionaries met together as far back as 1888 to combat the liquor trade. An Overseas (Missionary) Temperance Council was active in Britain early in the century. Then the Churches in the U.K. formed an ecumenical Temperance Council in 1915, The Swedish Churches came together to work through a joint commit- tee, the Temperance Movement of the Christian Churches of Sweden, DKSN. Many other countries have now established united councils, the latest initiative being in South Africa, where the first church consultation on alcohol and drug dependency took place in February. The initial statement, Declaration of Intent, recommends that the Churches appoint representatives to a Standing Commit- tee on Alcoholism and Drug Dependency, for the purpose of implementing and co-ordinating a plan for action related to advertising, representations to appropriate authorities on matters concerning control and legislation and to engage in a pro- gramme of education, including refresher courses for ministers and lay training courses. Co-operation in the provision of rehabilitation resources are also recom- mended. Representatives of the national Christian temperance organisations in Europe, together with the United Methodist Church in America, formed a World Chris- tian Temperance Federation in 1960 and today, the International Christian Federa- tion for the Prevention of Alcoholism and Drug Addiction, held its first world consultation at Lake Junaluska in 1980, attended by representatives from 25 coun- tries and 30 Churches. The constitution adopted at this consultation states its aims and purposes as: a. To promote world-wide education and remedial work through churches, teaching the wisdom of sobriety. b. To be agency for drawing together Christian concern related to alcohol and drug abuse-sharing research, educational work and experience, c. To be the agency whereby informed Christian thought and experiences is 98 TIMN 321491 z
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motives of children, attributing to the child feelings and desires that are only characteristics of aduits An infant who screams during the night may be seen by an egocentric parent as trying to "get even" or "challenge" the parent. Of course, infants don't have such concepts, and the misinterpretation of the infant's behaviour by the parent (i.e- the changing of what should be a complementary relationship into a symmetrical one-Bateson, 1972( often leads to inappropriate, or even abus- ing, parental behaviout Parents who are egocentric are not sensitive to the child's developmental agenda. This leads to inconsistent (Lerner, 1981) and inappropriate (Elkind, 1981) parent• child interactions. A perceptive parent will anticipate andespond appropriately to the child's behaviour. Egocentric parents lack the sensitivity to the interplay of their behaviour with the child's. Children learn about the world by discovering regularity in the contingencies between their actions and the reactions of objects and people (Piaget, 1963). Inconsistent parenting makes learning more difficult. Inappropriate parenting in which the child is forced to grow up too fast, too soon, is a major source of stress for the child (Elkind, 1981). Stressed parents provide less care for their children and spend less time interacting with them (Maccoby & Martin, 1983). Woititz (1983) has argued that this results in children who are informationally impoverished. They grow up lacking an infor- mation base-a constricted context of familiarity and a limited range of skill for even that context. In stressed families, parental style is more often authoritarian (Baumrind, 1971), with increased tendencies of parents to blame, command, complain, critici-ze, disagree and impute guilt to others (Maccoby & Martin, 1983). Parental interactions with their children are often aversive Furthermort; there is a breakdown of family organiza- tion and routine, which decreases the predictability of events for all family members and increases their stress. A stressed family system creates positive feedback'loops Stressed parents create stress for the child. A stressed child has more trouble learning about and adapting to the environment. This creates more stress for the parents. And the cycle pro- pagates itself. The Effects of Family Stress on Children The child in an alcoholic family is stressed not only because of egocentric paren- ting, but also because of the triangulation which occurs when the parentsystem's emotional immaturity blurs the distinction between the parent sub-system and the Child sub-system (Minuchin, 1974). The child's self becomes fused to that of the parents-Bowen's (1976) "multigenerational transnission process': More specific effects of stress are dependent on the developmental stage of the child. In children, cognitive, soda] and emotional growth generally occurs through a process of hierarchical intergratlon (Elkind, 1974, 1984). Such a process requires pressure. free time and consistent adult models who have clear standards. It is conflictual, time-consuming and laborious, requiring reflective abstraction (Piaget, 1983) of a variety of social experiences which are integrated into a consistent, integrated defini• tion of self. As Bowen (1976) writes: "The solid self is made up of dearly defined beliefs, opinions, convictions and life principles. These are incorporated into self from one's own life experiences, by a process of intellectual reasoning and the careful consideration of the alter- natives involved in the choice. In making the choice, one becomes responsible for the self and consequences. Each belief and principle is consutent with all the others, and self will take action on the principles even in situations of high anxiety and duress" (p. 68). People with a high level of self-definition are able to look at situations with a single Perspective that includes themself and others. This integrated perspective helps them to manage stress effectively [Elkind, 1984). In a stressed/fused child, the development of self-identity occurs through a process of substitution (Elkind, 1984). Feelings; thoughts and beliefs are simply copied from others and are not constructed by the child into a stable system. This results in Bowen's °pseudo-self' (Bowen, 1976), or, more descriptively, Elkind's "patchwork selP" (Elkind, 1984). The patchwork self is more vulnerable to stress, concerned more with immediate, rather than future situations and events, and more other- directed. Although their pre•occupation with managing their feelings may seem to be egocentric (in the narcissistic sense-Bowen, 1974), in fact, because their sense of self is dependent on others views of them, they appear to be more giving and selfsacriifircing of themselves. However; their selfsacrifice and other-directedness is usually inappropriate and ineffective because of their egocentrism (in the sense of being unable to take another's perspective-Piaget, 1959). That is, the self-sacrifice doesn't get them out of their dilemma. Only by creating a new, expanded perspec• tive can they escape the stress. Some of the roles children take on in stressed families are added to the patchwork self as simultaneous attempts to manage personal stress, stabilize the family system through symmetrical maneuvering and as ways of getting parental attention. In ctraotically-enmeshed systems (Barnes & Olsen, 1985), the roles are glued on more pennanently to the patchwork self as the child's way of introducing predictability 95 and order into the system. In the multigenerational transmission process iBowen, 1976), the rigid role the child has adopted for the family context is maintained by creating a similar family context in the next generation (e.g. children of alcoholics marrying alcoholics). Children under stress have less mental energy to bring to bear on the developmen• tal tasks facing then at each stage of development. In alcoholic/stressed family systems, the birth of the first child often initiates the "family game" characteristic of poorly differentiated systems. So the child will experience stress at all stages of develop- ment. However, the degree of anxiety in the parental sub-system may wax and wane as part of the symmetry between the couple. In a process similar to that described by Batesen (1971), each spouse can only show they are in control of the relationship if they produce emotional distance. But, if they create distance, have they really won, or have they lost because they avoided the provocation? The only way to find out is to create emotional closeness. This cycle of marital conflict, in which nobody can leave the field, is accompanied by various symp• t,oms during conflict (eg. alcoholism) and remissions during periods of closeness. The cycles may also vary in the intensity of stress created, and this stress may reach a maximum during a particular developmental stage of the child, with specific developmental consequences. Increased stress may also be associated with cognitive impoverishment. Although stressed children will probably advance through the stages of cognitive develop• ment (Piaget, 1983) at a rate similar to non-stressed children, their cognitive struc• tures will not be as enriched (Case, 1985, Pascual-Leone, 1969, 1970). Increased stress is associated with a decrease in exploratory activity (Hebb, 1972). Stressed children would tolerate and be curious about a decreased range of "optimally discre• pant" stimuli. They may also be more field-dependent (Witkin et at, 1962). Stressed children may show an increased tendency to develop epistemologles which are simplistic, linear; and in which external forces are seen as responsible for one's behaviour (These characteristics, which can continue through adulthood, may pose two problems for the therapist: first, clients with linear epistemologies will tend to understand only simple, blaming causes; second, their ability to process therapeutic information will be reduced because of the decreased range of optimally-discrepant stimuli to which they will attend). Not all children are equally affected in an alcoholic family system, nor will each child exhibit the same constellation of symptoms. Each child will adopt strategies which serve to reduce personal stress, and which stabilize the system. Bowen (1976) argues that if the triangulated child (often determined by birth position) can ab- sorb all the parental emotionality, other children in the family may not be affected by the parental fusion. Other factors exist, although the research data is sparse. Studies of resilient children under stress (Garmezy, 1983) identify sex of child (males more vulnerable), temperament (flexible, non-anxious or irritable less vulnerable) and support figures in the environment as factors which may convey protection from the family stress. The importance of the opportunity to play has also been em- phasized (Elkind, 1981). If the degree of parental emotionality does not overwhelm the entire family system, non-triangulated children (for whatever reason) may be left alone, and will develop normal social, emotional and cognitive skills through the normal peer interactions inherent in play. Play is also the perfect antidote to stress. Adult Children of Alcoholics "The individual who did not complete the process of constructing a sense of self and identity as an adolescent may persist in this quest as an adult. In this type of individual, energy that might be spent in the joys of everyday life, in the pleasures of family, work, and recreation, is spent instead upon what seems an unending quest for self•defination:" (Elkind, 1984, p. 164) Because of their relative lack of cognitive and emotional development, such people often have linear, blaming views of the world (blame the parents, blame the bottie, etc). They may often develop distance-regulating strategies in their interpersonal relationships which have been described as characteristic of adult children of alcoholics (Woititz, 1983). Through Bowen's (1976) concept of multigeneration transmission process, the child of an alcoholic reconstructs the relational contexts and struggles in their generation. They choose partners at similar levels of differentiation (Bowen, 1974, 1976) and with similar, linear epistemologies ("there is only one cause for my problems"), and begin the pro• cess of family stress in a new generation. Bowen (1974, 1976) and Palazzoli, et al, (1978) argue that it takes three generations of this process to create an alcoholic or schizophrenic, both of which are symptoms of the disqualification process inherent in symmetrical, fused family systems. Treatment The most important implication of the present conceptualization for treatment is that treatment for children or adult children of alcoholics be based on a systemic epistemology by the therapist. Treatment approaches which attempt to shift the burden of guilt from the child to the parent or bottle are inappropriate, and only serve to reinforce the family game One variant of such programmes is that which pro• vides alcohol and drug information, as if the "problem" could be solved If only TIMN 321488
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COLLECTING AND REPORTING ALCOHOL-RELATED MORBIDI- TY STATISTICS Norman Gfesbrech4 Gerry Conroy and Honey Fisher Introduction Morbidity data on alcohol-related complications can be usecafor planning, preven- tion, education and research. In order to effectively manage and reduce alcohol- related problems, one needs to be able to accurately measure their extenG Statistical indicators of alcohol-related morbidity are obtained primarily from reporting systems of major health and social institutions such as hospitals and police departments. These statistics, examined over time, are useful in that one can conclude from trend data whether or not the detected incidence of a disease is increasing, decreasing or holding steady. Alcohol-related hospital morbidity statistics have various research and educational uses, Including estimating the prevalence of alcoholism, documenting shifts in the importance placed on alcohol-specific ailments and the types of institutional responses to them, and in addressing questions about the correlations among availability, rate of consumption and damage (Ibpham, 1970; Makela et al., 1981: chapter 3; Giesbrecht et al., 1983). Howeve5 due to a variety of complications these data are typically neither accurate nor comprehensive indicators of the actual volume c3lype of alcohol- related problems (Makela et al. 1981). Nonetheless, this does not'fender these data worthless. Rather, it means that other factors enter into the process of collecting and reporting data which can deflate or inflate the extent of alcohol's role in mor- bidity (GIesbrecht et al., 1983: ix•xi). Since much of our research and decision-making is based on these data, it is impor- tant to question just how valid these data actually are. Accordingly, the aim of the present study is to explore the nature and quality of hospital morbidity data and examine the artifact that enters into the collection and reporting of these data and consequently influences their validity. The study focuses on three small towns located in southern Ontarfq and draws on a body of cross-sectional and temporal aggregated statistics, primary data from two general population surveys (Giesbrecht et al., 1984), as well as data derived from interviews with professionals. Four questions are considered here: 1) What is the nature of alcohol-related morbidity data and how are these data generated? 2) Is there covariation between hospital alcohol-related morbidity and other risk indicators such as the data on sales of alcohol and police data on alcohol-related incidents? 3) How can these patterns and variations be explained? 4) On the basis of this investigation, can one draw conclusions about the utility of these data for planning medical facility needs? Another source of information was the senior medical records staff person in each of the three town hospitals each of whom was contacted and asked the following questions: 01: To help with coding, do you consult with doctors regarding diagnoses? 02:Do doctors know about the ICD Codes at your hospital? 03:How many people are involved in coding? 04:Do these coders have training and, if so, where did they receive it? Q.5:Are there inside or outside procedures for checking coding? What are these procedures? How often are these procedures used and on what percentage of files? 06:What version of ICD are you currently using? 07: Are there any problem areas in coding about which you would like to comment? Results and Discussion Validity of Alcohol-Related Hospital Morbidity and Police Data The literature on hospital morbidity statistics discusses several factors which con- found the simple relationship between an alcohol-related event resulting in a hospital admission and the record that appears in official hospital statistics. These factors may complicate or undermine the utility of the statistics but, as indicated above, they do not render the statistics worthless for certain research questions or prac- tical applications. Chart I provides a general overview of the major contingencies that influence the validity of hospital data. The confounding sources involve one or more of the following four components: I) diagnostic bias arising from cultural mores and social pressures; 2) the medical practitioners' training, orientation and workload; 3) classificatory policies and instruments; 4) information transfer and in- formation conversion. CNART I AlC0N0t-RELATED EYENTS IND CDNDITIDNS AND DEFICIAC HoSPITAt HECORDS: A SCHEMI OF atVOF INTERYENING CDNT -N:ENCIES Event cr Condition Method Some of the data analyzed in this paper are taken from our larger tri-community research project entitled the Ontario Prevention Study. Since the field component of this study is still underway and reporting of results may confound the implemen- tation of the intervention or the postintervention survey, we have not identified the three small southern Ontario towns, and instead have labelled them as Towns A, B and C. The collected information encompasses data from population surveys, alcohol sales, hospital and police records and interviews with hospital and police staff. Hospital records were examined in the three communities and data on overall ad- mission rates as well as alcohol-specific diagnoses were gathered. Aggregate, rather than individual, data were collected on age, sex, month of discharge; length of stay and diagnosis. Data for the most recent five years were obtained, but for the sake of simplicity, only the one-year period from May 1, 1982 to Apri131, 1983 is reported in the tables. Data were collected by type of offence from the monthly crime and traffic reports submitted by the local police departments to Statistics Canada. In addition to such alcohol-specific offences as Liquor Control Act offences and drinking and driving offences, data on offences such as property damage and violent acts were collected. Data regarding local consumption of alcohol were available in the sales reports from the Liquor Control Board of Ontario (LCBO) for spirits, wine and fmj:orted beeti and from the Brewers Warehousing Company Limited for domestic beec In the former; information by beverage categories was converted to absolute alcohol by volume using conversion factors based on analyses by the LCBO chemists. For domestic beer, a conversion of just under 5% was used to compensate for the sale of lighter alcoholic beers. Regular beer in Canada has 5% alcohol by volume while lighter alcoholic beers have between 25% and 45% alcohol by volume Patient enterl SeriouSness Hospital hosaital - - - - - - - - of other _ _ _ _ - - facilities atinentsor ----- and conditions services Practitioner's skills, Practitioner's Status and tratning, wartload, - - - - and coaruntty influence of orientation biases re alcohol the patient abuse Practitio~ner's Diagnoses of knoyledge of - - - - - - Priwry and the patient's secondary drinking history ailments Classiftcation_ infor.ation transfer; gutdelioes, - - - - - -training & knorledge fornt, procedures of staff; clarity of diagnosis; access to doctor Dffsctial Record TIMN 321501 108 ~
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The rank order of these three percentages is similar to the rank order of the rate of alcohol sales in litres of absolute alcohol per person aged 15 and older. Town C is highest with an annual rate of 19.8 litres per adult, followed by A with 18.9, and then B with 15.1. All three rates are substantially above the provincial rate. It should be noted that, while the data indicate that percentages line up in the same order as the consumption rates, when a monthly time period Is used, this is not true. From month to month the number of alcohol-related separations rise or fall by large amounts which do not parallel the fluctuations in the monthly rate of consumption of alcohol. Due to the small numbers involved for monthly alcohol-related separations in these towns, random variations from month to month, and the lag one would expect between heavy consuniption and certain chronic consequences, it is not surprising to find that the monthly patterns of these two data sets are not parallel. The yearly variation in alcohol-related separations and rate of sales of alcohol for each town was less than the variation among the towns. Therefore, we assume that the variation among the towns for the year 1982-83 is representative of re- cent years. Table 3 provides information on alcohol-related separations and diagnoses for each town. As columns 1 and 2 of this table indicate, the number of alcohol-related diagnoses are slightly higher than the number of alcohol-related separations. Col. umn 3 indicates the diagnoses in addition to the alcohol-specific ones that appear in connection with these separations. In all three towns, nonaicohol•retated diagnoses are greater in number than the alcohol-related ones by at least a ratio of 1.22:1 (Town B) and up to 1.68:1 (Town A). Overall, for the separations under consideration, Town B has the lowest total number of diagnoses (149) and Town C the highest (261). When the percentage of unspecified diagnoses as discussed earlier is used as the criterion, it appears that the margin of error is considerable: there are from 8.7% to 12.6% of the total diagnoses that are not specified. In Table 4, the three main data sets are compared: the hospital data and alcohol sales data already discussed, and the police statistics. It appears that there is some agreement in the rank order of the towns across the indicators, but the congruence is by no means perfect. For example, Town C has the highest rate of alcohol sales per person 15 years of age and over, and Town B has the lowest. The rates of alcohol-related• hospital separations have A with the highest and B with the lowest rate. For alcohol-related police charges, Town C has the highest rate and A has the lowest. In the course of our field work in Town B, it was drawn to our attention that the police force had stepped up its pursuit of offenders for some time. This change in enforcement practices could have influenced our data, in that one might have expected Town B to have had a lower police charge rate than Town A, according to sales data. Because of the complications in defining the catchment area of the hospitals, we might consider comparing another risk indicator, alcohol-related separations as a percentage of total separations as in Table 2. The congruence of rank order by risk indicators of alcohol problems is thus improved. Town C has the highest rate of sales, rate of alcohol-related separations and percentage of alcohol-related diagnoses; Town B has the lowest rate of sales, rate of alcohol-related separations and percentage of alcohol-related diagnoses. In addition, preliminary findings from the surveys of males in Towns B and C indicate a higher rate of self-reported consumption and larger proportion of heavy consumers in C compared with B (Glesbrecht et al., 1984). The data presented in these tables suggest that certain indicators of alcohol-related problems in a community covary with consumption rate or the rate of alcohol sales. These findings provide further support for the conclusion drawn from Plant and Pirie's study (1979) that the average rate of consumption covaries with the rate of heavy consumption and alcohol-related complications such as hospitaliza- tions with alcohol-specific diagnoses. This rank order relationship across several data sets is also expected from the theory and findings on the positive reiation- ship between alcohol sales and alcohol-related consequences (Bruun et al., 1975; Popham et al., 19781. Alcohol-related morbidity data provide an indirect and incomplete indication of the physical health complications of heavy drinking. Hospital-based data show a much lower volume of alcohol-related discharges than would be expected from: 1) the availability hypothesis; 2) epidemiological studies of causes of death among heavy drinkers and the general population; and 3) accounts of emergency room clientele and their presenting conditions. There are likely a number of factors which contribute to the suspected deflation of the role of alcohol in hospital mor- bidity statistics and these were noted in the opening sections of this paper. In conclusion, if one is willing to accept the caveats and make the assumptions noted above, hospital data on alcohol-related diagnoses may be useful for educa• tion, prevention, planning and research purposes. These data should not, however, be used independently. Other data bases, such as sales of alcohol, self-reported consumption from surveys or police reports on alcohol-related incidents are cor- roborating sources of evidence for estimating the number of heavy drinkers or alcohol-related complications in a community. For communities wishing to assess their services including medical facilities, they would be advised not only to con- sider the volume of alcohol-related diagnoses, but the size of the population at risk for alcohol-related health and public order complications. The rate of sales of alcohol is a good indicator of the aggregate volume of cases that one might expect; and survey information, whether self-reported or from key informants, can provide data on the type of incidents and the socio-demographic characteristics of heavy drinkers. REFERENCES Bruun, Kettil; Griffith Edwards; Martti lumio; Klaus Makela; Lynn Pan; Robert E. Aopham; Rotin Room; Wolfgang Schmidt; Ole-Jorgen Skog; Pekka Sulkunen ana Esa Osterberg: Alcohol Control Policies in Public Health Perspective. (The Finnish Foundation of Alcohol Studies;, Vol. 25) Helsinki: Forssa. 1975 Giesbrecht, Norman; Monique Cahannes; Jacek Moskalewicz; Esa Osterberg and Robin Room (eds.) Consequences of Drinking: Trends in Alcohol Problem Statistics in Seven Countries. Toronto: Addiction Research Foundation. 1983 Giesbrecht, Norman; Gerry Conroy and Mary Lynne Hobbs: "Level of Consump- tion and Alcohol-Related Problems: Preliminary Results from a Census of Males in Two Southern Ontario Communities:' Presented at the Alcohol Epidemiology Section, International Council on Alcohol and Addictions, Edinburgh, Scotland, June 4-8, 1984. Honkanen, Risto: Alcohol Involvement in Accidents: The Role of Alcohol in In- juries Treated at Emergency Stations. Helsinki: Department of Public Health, Science, University of Helsinki. 1976 de Lint, Jan and Wolfgang Schmidt: "Alcoholism and Mortality" In: Biology of Alcoholism, Chapter & Edited by B. Kissin and H. Begleiter. New York: Plenum Publishing Company. 1976 Makela, Klaus; Robin Room; Eric Single; Pekka Sulkunen and Brendan Walsh with Richard Bunce; Monique Cahannes; Tracy Cameron; Norman Giesbrecht; Jan de Lint; Hannu Makinen; Patricia Morgan; James Mosher, Jacek Moskalewicz; Richard Muller Esa Osterberg; Ignacy Wald and Dermot Walsh: Alcohol Society and the State: Volume 1, A Comparative Study of Alcohol-Control: Toronto: Addiction Research Foundation. 1981 Marshman, Joan A.; Rod D. Fraser; Paul W. Humphries; Camille Lambert; Douglas W Macdonald; Alan C. Ogbome; James G. Rankin; Sarah J. Saunders and Wolfgang Schmidt: The Treatment of Alcoholics: An Ontario Perspective. (The Report of the Task Force on Treatment Services for Alcoholics.) Toronto: Addiction Research Foun• dation. 1978 Murphy, H.B.M.: "Hidden Barriers to the Diagnosis and Treatment of Alcoholism and Other Alcohol Misuse:' Journal of Studies on Alcohol, Vol. 41, No. 5: 417-428. 1980 Plant, Martin A. and Fiona Pirie: "Self Reported Alcohol Consumption and Alcohol- Related Problems: A Study in Four Scottish Towns' Social Psychiatry, Vol. 14: 65-73. 1979 lbpham, Robert E.: "Indirect Methods of Alcoholism Prevalence Methods: A Critical Evaluation" In: Alcohol and Alcoholism, Chapter 39, Edited by R. E. Popham. Toronto: University of Toronto Press. 1970 Popham, Robert E.; Wolfgang Schmidt and Jan de Lint: "The Prevention of Hazar dous Drinking: Implications of Research on the Effects of Government Control Measures" In: Drinking. Edited by J. A. Ewing and B. A. Rouse. Chicago: Nelson Hall. 1978 Popham, Robert E.; Wolfgang Schmidt and Stephen Israelstam: "Heavy Alcohol Con- sumption and Physical Health Problems: A Review of the Epidemiologic,Evidence:' In: Research Advances in Alcohol and Drug Problems, Volume 8. Chapter 5. Edited by R. Smart; H. Cappell;, F. Glaser; Y. Israel; H. Kalant; W. Schmidt and E. Sellers. New York: Plenum Publishing Company. 1984 Room, Robin: "Improving Indicators of Alcohol-Related Problems" Paper presented at the Informal Consultation on Alcohol Statistics, Geneva, October 28-29, 1982, World Health Organization, MNH/82.49. 1982 Schmidt, Wolfgang and Reginald Smart: "Admissions of Alcoholics without Psychosis to Mental Institutions, and the Estimated Prevalence of Alcoholism in Ontario, 1948-1955:" Canadian Journal of Public Health (October): 431-435. 1959 Skinner, Harvey A.; Stephen Holt and Yedy Israel: "Early Identification of Alcohol Abuse: Critical Issues and Psychosocial Indicators for a Composite Index:' Cana• dian Medical Association Journai. Vol. 124: 1141-1152. 1981 Wodd Health Organization: International Classification of Diseases, 1975 (Ninth) Revision, Volumes I and 2. Geneva: World Health Organization. 1977-78 TIMN 321505 112
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A COMPARISON OF PSYCHOTROPIC DRUG USE BETWEEN THE GENERAL POPULATION AND CLIENTS OF HEALTH AND SOCIAL SERVICE AGENCIES Brian Rush, Marg Simmons, Carol Timney and Jennifer Evans Introduction 6 Of 1,434 mailed questionnaires,3 a total of 1,016 (70.9%) were returned. The small number of unusable returns brought the total down to 989 questionnaires (69%) that were completed and usable for data analysis. The demographic characteristics of respondents were initially inspected to ascer- tain their comparability with census population data for the Regional Municipali- ty of Durham. The data were subsequently weighted to adjust for an overrepresentation of females and underrepresentation of persons aged 18-24. After the weighting, other sample characteristics (e.g., household size, marital status) remained comparable to known population parameters. The weighting procedure strengthens generalizations from the survey sample to the general popula- tion of the region. The statistical weighting, however, increases the sample size for data analysis to 996 cases. Of the weighted cases, 50.3% were male. In terms of age, 19.8% were between 18-24, 43.4% were between 25-44, 26.3% were between 45-64 and 10.4% were over 65. Estimates of the prevalence of prescription psychotropic drug use in the general population vary considerably depending, for example, on the time period over which survey respondents report their use and the particular drugs included as psychotropic medication (1). Despite varying estimates of the overall prevalence of psychotropic drug use, some consistent patterns are evident when the epidemiology of use is examined. For example, consistent findings emerge with respect to the increasing use of psychotropic drugs among older people and among females (2). Age and sex differences are particularly consistent for the usage of minor tranquilizers and sleeping pills. Some studies have examined the prevalence of prescription psychotropic drug use among client populations of health and social service agencies. Such research is intended to stimulate more routine case-finding procedures for drug depen- dent persons among agency clientele, and encourage more effective communica- tion between the drug user's physician and personnel of other community agencies who are assisting the same individual (e.g., his/her probation officer, welfare worker, mental health counsellor). There is some evidence that the extent of psychotropic drug use among the client population of social agencies is above average. In 1980, about 33.48 of Quebecers between the ages of 20 and 64 who were eligible for social aid, received at least one prescription for a"psychotrope"I and 18.6% received at least one prescrip- tion for a sedative-hypnotic in 1980 (3). A women's hostel in northern Ontario reported 95% of their clients taking tranquilizers or hypnotics on entry (4). Multiple drug use and parallel prescribing from two or more physicians has been well documented among clientele of a vocational rehabilitation centre (5). High rates of psychotropic drug use have been observed in institutional services for the mentally handicapped (6) and the mentally ill (7,8) and among patients admitted to medical and surgical wards of general hospitals (9). Issues of medical advice and supervision, the risk of drug dependence, and the speciai needs of high risk groups were factors which prompted this study of psychotropiq drug use among the general population in the Regional Municipali- ty of Durham in Ontario. Also of interest was the prevalence and pattern of use of these same drugs among clients/patients already in contact with the health and social service system in the region. Both aspects of this study were conducted in the context of a comprehensive need assessment for drug treatment services (10). Method General Population Sample Subjects were those responding to a population survey conducted in the fall of 1982 in the Regional Municipality of Durham in Ontario, Canada. The survey queried individuals on their alcohol and drug use and various issues related to the treatment of addictions. The survey sampling was accomplished by a multi-stage, multi-modal, stratified random sampling design.2 In the first stage, 2,326 telephone numbers were ran- domly selected from published directory listings, stratified into urban/rural telephone exchanges. During a telephone interview with persons at residential households, one Individual was randomly selected according to the Kish method, as described by Groves and Kahn (11). Of the 2,326 telephone numbers selected, 1,690 (72.7%) connected to residential households. Of these 1,690 connected cails, 1,461 (86.4%) agreed to the respondent selection procedure. In the final stage of the survey implementation, each potential survey participant that had been identified by telephone, received the survey materials by mail. Reminder cards were mailed to these individuals after a two-week interval. A second mailing for non-respondents was undertaken three weeks later. A numbered, business reply postcard was employed to guarantee respondent anonymity while at the same time identifying survey non-respondents. Agency Clientele Sample The strategy for this aspect of the study was to screen, on a prospective basis, clients/patients attending several health and social services in the Durham region. Local agencies and hospitals were selected in a purposive rather than random fashion. Agencies were selected which: (a) provided a good cross-section of the health and social service network in the region and, (b) were willing to comply with the procedures for the survey administration. Fifteen agencies and hospitals participated in the study. Days of the week for administering the questionnaire were randomly selected for each service and the agency or hospital staff were instructed to administer the instrument to all clients/patients who presented for assistance on these days. A quota of 50 clients was sought from each service. Where possible, clients com- pleted the questionnaire without aid of a staff member. Questionnaires were return- ed in a sealed envelope to a staff member, or to a box in the reception area. A small number of questionnaires were completed on home visits and returned by mail. As with the population survey, the agency survey was administered in the fall of 1982. Since agencies and hospitals were not selected randomly, and since the number of clients selected at each agency was not proportional to the size of its overall population, generalizations to the total client population in the region are limited. These restrictions in making strong generalizations to the overall agency popula- tion of the region are due to the sampling methodology but were necessary given the resource limitations of the project. Of 750 potential agency respondents, completed questionnaires were obtained from 344 clients (45.9%). Approximately half the sample (54.1%) was drawn from various social services,13.3% from mental health agencies, and about a third 132.6%) from area hospitals or medical services (see Table i). Fifty-four percent of the sample was male. In terms of age, 22.2% were between 18-24, 50.3% were bet- ween 25-44, 18. 1% were between 45 and 64, and 9.4% were over 65. Thus, the agency sample and the sample from the general population were similar in their age and sex distributions. This facilitates comparisons between the two study populations. RESULTS AND DISCUSSION (a) Psychotropic drug-use Table 2 shows the number and percentage of respondents reporting psychotropic drug use in the last two weeks for the general population and agency clientele. The estimated percentages of the Durham population using minor tranquilizers, sleeping pills, amphetamines and anti-depressants were 5.2%, 2.3%, 1.9% and 1.5%, respectively. Of the general population, 0.4% reported the use of major tranquilizers. In contrast to these findings from the general population, considerably higher percentages of users were found for all drug categories among the agency TIMN 321510 117
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related to the WHO and expressed in the concerns of the World Church. e Consultation and Seminar in Bangalore. 1982, helped co-ordinate studies from ndinavla, Ghana and India for the World Council of Churches in preparation the Assembly at Vancouver. In October this year, the Second World Con- tion and Conference will be held in Kenya, at Limuru, to draw together con- med Christians from around the world in a meeting with African Christians an attempt to focus on the Churches' responsibility and methodology in i rehabilitation work and prevention programmes. The World Council ot Churches Sixth Assembly, meeting in Vancouver in 1983, called upon the Churches to give guidance in personal Christian lifestyle, in order to counter the appeals and attractions of alcohol, tobacco and addictive drugs. At the same time, the Church has been called to pursue the analysis of and the struggle against social, political and economic conditions which underly this global problem. HRONIC ALCOHOLISM-PREDISPOSING FACTOR TO ZHEIMER DISEASE? CORRELATION BETWEEN SYMP MATOLOGY, ELECTROPHYSIOLOGICAL FINDINGS AND OSTMORTEM NEUROPATHOLOGY. KT. Ciesielski and S. Xontela "The Pathology of Mind" (1879) Maudsley noted chronic alcoholism as a fac- leading to a clinical picture which "... resembles not a little in mental symp• ms ... the last stage of senile dementia". In spite of a different initial onset, the inical symptomatology of the gradually deteriorating chronic alcoholic, admit- ed to the mental institution, is barely differentiated from advanced senile dementia-Alzheimer type (SDAT). Cases of Alcoholic Dementia with global mory and abstraction deficit constitute a considerable subgroup of the general nic alcoholic population, most of which show a certain degree of long term itive deficits. What specific relationship exists therefore between those cases hich develop an alcoholic dementia and those with SDAT? ecent electrophysiolog(ca1 findings shed light on this subject. These findings sup- rt a greater affinity of symptoms of alcohol mental deficiency with those of AT than with symptoms of normal aging (Potjesz & Begleiter, 1982). For ex• pie, chronic alcoholics present delayed central conduction velocities similar 0 the senile demented (Harkins, Lenhardt, 1980), as opposed to elderly people, who have basically ftormal brain stem potentials (Fujikawa, Weber, 1977; Rowe, 19781. Chronic alcoholics and subjects with SDAT have also severely reduced amplitudes of visual evoked potentials (Beck et al., 1978; Laurian et al., 1977), as crompared to normal elderly controls (Porjesz et al., 1980; Dustman et al., 1977). These differences both for alcoholics or Alzheimer patients compared with nor• mal controls are very significant in more central (parietal) brain areas, but less noticeable in occipital regions (Dustman et al., 1979). We have observed this padetal preponderance in seemingly intact chronic alcoholics, recording cognitive potentials (N2-P3) to visual template matching task (Ciesielski et al., in press). The most sensitive measure of alcohol induced brain deficits was severely reduced amplitude of P3 component. Earlier potentials (up 0 150 msec peak latency) appear to be relatively preserved. Considering the relationship of P3 component to acquisition and consolidation in memory func- tions (Gomer et al., 1978; Adam & Collins, 1978) and hippocampal origin of P3 (Halgren et al., 1980) we suggested that the alcohol related deficit, indicated by P3, lies primarily within the hippocampal formation. It is worth noting that other researchers also reported most striking differences in wave form, amplitude and latency of P3 in pathological dementive brain aging (Goodin et al., 1978; Syn• dulko et al., 1982). In other words most chronic alcoholics, even the seemingly intact ones, present initial stage of similar electrophysiological indicators as do Patients with Senile Dementia Alzheimer type. The similarities of clinical and electrophysiological deficits of Alcoholic Demen- 1 tia and SDAT suggest a possible compatible similarity in the neuropathological 4. Pattern underlying these two psychiatric entities. That is, the established rela- s bonship between the hippocampus, the P3 component and the memory func- tions, and the recent hypothesis about hippocampal origin of SDAT (Ba11 et al., 1985) appears to indicate a hippocampal deficit as the focal point of neuropathology both in Alcoholic Dementia and in SDAT. METHOD As Part of a prospective electrophysiological and neuropathological study ten cases Of Alcoholic Dementia (average age 70.0/+8.0) and sixteen cases of SDAT (average age 75 + 5.91 were subjected to postmortem microscopic brain examination. 99 Twenty-three of these patients were investigated during life and met the DSM III criteria for the clinical diagnosis of Dementia associated with Alcoholism (10 cases) or SDAT (13 cases). No other dementing disorder was present. Gross and microscopic changes in the brain were assessed subjectively with reference to averaged senile brain conditions of mentally preserved humans. Brains fixed in formalin were weighted, and degree of brain atrophy assessed. Transverse sec• tions of the cerebral hemisphere were made at I cm intervals. At least 10 slides per brain were prepared to determine the severity of neuronal affliction by neurofibrillary tangles (NT), neuritic plaques (NP), and granulovacuolar bodies (GVB). Four degrees of severity of brain atrophy (occurrence of NT, NP and GVB) were subjectively estimated and described in the autopsy reports. Severity ratings ranged from 0- no pathology, I - marked pathology (at least 6-10 times more frequent occurance of NT, NP and GVB, than in healthy senile brains Ball), 1984, 2 - severe pathology, to 3• very severe pathology. The transverse section submitted for microscopic examination (routine Bodian preparation) included: inferior aspect of the frontal lobe, parietal cortex, hippocam. pus including a portion of the parahippocampal gyrus and the adjacent occipito- temporal gyrus, mamillary bodies and cerebellum. Following the conclusion from our electrophysiological study on chronic alcoholics (Ciesielski et al., in press( and most recent suggestions about localization of alcohol•induced and Alzheimer• related brain pathology (Por)esz, Begleiter, 1981; Ball et al., 1985) we selected frontal, parietal and hippocampal sections as the focus of neuropathological analysis. RESULTS A multivariate analysis of variance revealed no differences between the Alcoholic Dementia and SDAT patients on any combination of the variables presented in Table 1. Brain weight of both demented groups was within the normal range for elderly brain ((1350g ± 10%] according to Terry, 1980). The neuronal afflic• tion by NT, SP and GVB presented a similar pattern of distribution in both tested groups with a considerably more severe rate of lesions in the hippocampal for• mation than in the frontal [(t=5.5, p<0.001)] or in the parietal [(t=5.6, p<0.001)] neocortex. There were no significant differences between the neuropathological changes in the frontal and parietal cortex [(t=0.8, p>0.4)]. The bivariate correlations (Pearson Product Moment) between all five measures is presented in Table 2. A significant positive correlation was found between the rate of hippocampal pathology (NT, NP, GVB) and the cerebral atrophy mainly in the right hemisphere (r=0.44, p<0.05), suggesting that more severe degree of hippocampal lesions will result in more severe right cerebral atrophy. Respec• tively, more severe lesions in the parietal cortex will be related to the left hemisphere atrophy (r=0.49, p<0.05). Significant inverse correlation between left cerebral atrophy and right cerebral atrophy (r=-0.42, p<0.05) indicates a tendency for atrophy to occur differentially In the right and left SDAT brain. COMMENTS The pattern of lesions observed primarily within the hippocampus and to a lesser degree in the parietal and frontal neocortex have been found to be similar for both TIMN 321492 J
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the child understood the effects of alcohol, or, if only the parent would stop drink ing. The "problem' is not the symptom! The "problem" is the system of enmesh- ed, symmetric, undifferentiated relationships which resist effective solutions because of the high level of anxiety present in the system. The linear epistetnology of such systems is quick to seek simple, blaming solutions, a trait which exerts seductive pressure on the therapist to provide such solutions. For example, the presence of an "alcoholic" in the system makes it easy for the therapist to focus on alcohol as being the problem. Howeve, any changes which obtain will be countered by maneuvers throughout the family system to resist change Linear, single-cause ap. proaches to the problem may well be iatrogenir, that is, they will do more harm than good. • The A.A. programme has often been employed in the treatrttent of alcoholism. Follow- ing Bateson (1971), the present formulation attributes the success of that programme to the paradox it creates, in which the symmetry of the client is turned from the family or bottle to the treatment programme itself. (The challenge to the alcoholic is to prove that A.A. is wrong when it argues "Once an alcoholic always an alcoholic"). Twelve Step programmes for children may be successful for similar reasons. They may also be successful because they avoid drawing a therapist into the family game In general, however, such programmes must be employed with care, as children lack the emotional, intellectual and experiential resources to make such self-help groups effective in overcoming each child's linear epistemology. A major goal for treatment is to reduce the anxiety of the family system and the family members. Bowen (1976) argues that, even in a highly charged emotional system characterized by a high degree of fusion, a reduction in anxiety will make a difference. Traditional approaches to treatment which try to increase anxiety, for example by provoking a crisis, in an attempt to speed the process of "hitting bot- tom"; may well be counter-productive Therapeutic approaches which emphasize the neutrality of the therapist and positive connotations of behaviour teg as employed by the Milan Team-Palozzoli, et al, 1978, 1980) may well be effective because they serve to reduce the anxiety of the family system, allowing each member to achieve an expanded perspective of the problem. Alcoholic family systems will exert powerful attempts to force the therapist to align with family members as part of the symmetric maneuvers characteristic of the family game. The seeming vulnerability of children is especially effective at creating such alliances with helpers (therapists, teachers, etc.). To be effective, helpers must avoid such alliances and maintain their neutrality with the family system 1Palazzoli, et al, 1980; Creighton, 1985)• a) Treatment for the Child The overall goal for treatment programs directed only at the child is to give the child the opportunity to explore new and different relational processes (con- textsi than are experienced at home, and new skills to apply in these new contexts. Most importantly, the child should learn to create non-pathological contexts, to disrupt the multigenerational process. Traditional programs often attempt to change the child's self concept by simply attempting to substitute one version of self-concept for another. It is important to recognize that self-concept is relationally-determined and is usually situation- specific (although generalization certainly occurs)• A child from an alcoholic family may legitimatly have low self-esteem. The process for determining self concept has led to an appropriate outcome in that context. Rather than trying to change the child's self-erteem in that context (eg. "Its not your fault, its your parents or the bottle'), the goal should be to provide different contexts in which the child can develop a positive self-concept. Otherwise, in patchwork fashion, the child will simply adopt a different role and level of self-esteem in the therapeutic context. By giving the child the time and varied social experiences in which the development of a positive "solid-self" can occur, the child will ultimately learn to reconstruct relationships which yield positive experiences for all. School based programs have been shown to be successful in the treatment of stressed children (Brenne, 1985; Garmezy, 1983; Rutter & Garmezy, 1983). Components of such programs include: - encouraging differentiation of self by having children respond to situations by thinking, not feeling. - teaching children how to make friends, understand others' feelings (perspective. taking), express affection, anger and other normal emotion in normal ways- - providing children with solid friendships with children their own age which gives them a source of affection outside their own family. - providing children with significant, predictable relationships with adult role models. - providing children with positive experiences at school which enhance the child's values and competencies. The best programs will be the most natural. Rather than identifying and segregating a group called "children of alcoholics and laying on a treatment program designed to accomplish the above objectives (eg. Lerner & Naiditch, 1979-19831, programs should encourage friendships with "normal" children, and allow the benefits of friendship (cognitive, social and emotional develop- ment) to accrue over time during normal play. These "normal" experiences will reduce the child's anxiety associated with a major area of life f school and friendships), and foster self-growth through integration (Elkind, 1984(, providing a buffer against stress and anxiety. Specific information on stress management may also be useful (Elkind, 1984). Peer Support Groups of the type described by Carr (1981) may be a vehide for such programs. As has been mentioned, changing one member of the family system will ultimate- ly change all members, because of the characteristics of systems (Hartman & Laird, 1983). Sometimes, the changes will be beneficial to all. However, the treated child, as the youngest member of the family may return home each night to be met by symmetrical counter-maneuvers from other family members, Thus, we should expect the child to maintain many coping mechanisms which work in the home situation. The goal is to expand the child's perspectives and to provide additional coping responses for other contexts, not necessarily to change behaviour in the home context. b) Family Therapy Therapy for the entire family system is preferred, although often not possible. The principles and methods of the Milan Associates (Palazzoli, et al, 1978, 1980; Tomm, 1984a,b) appear appropriate for the treatment of families characterized by lack of differentiation, symmetry and high levels of anxiety leg. Creighton, 1985; Mackinnon, et al, 1984). Prevention The overall goal of prevention is to help people see that they are part of a system (a world, a nation, a community, a family, etc.) and to understand how their behaviour and that of others can affect the system, both positively and negatively. Prevention efforts should counter the helplessness often experienced by individuals in systems and emphasize the idea that each individual can and does make a difference. The ultimate preventative strategy is the creation of a society which emphasizes differentiation of self. Approaches at the global level could include the elimination of superpower symmetry as a model for human relations and the banning of nuclear weapons as a means of reducing global anxiety. At the societal level, the negative effects of the media outlined by Elkind 11981, 1984) which include negative role modeling and the creation of stress by giving children exposure to adult issues, should be controlled. The school system, which is a major source of stress for children and which does little to foster individual development because of its size (Elkind, 1981, 1984) could be changed, especially by making schools smaller and by enhancing the teacher-pupil ratio. Preventative approaches aimed at enhancing individuals' self efficacy, such as AADAC's Media Campaign ("Make the most of a good thing Make the most of you") have been shown to have impact (Skirrow, 1984; Skirrow & Nutter, 1984). Of all opportunities for prevention, however, probably the best understood are those relating to family processes (eg. Harter, 1983). Parental style should be authoritative (Baumrind, 1971). This pattern of parenting includes the following elements: 1. Expectation for mature behaviour from child and clear standard setting 2. Firm enforcement of rules and standards, using commands and sanctions when necessary 3. Encouragement of the child's independence and individuality 4. Open communication between parents and children, with parents listening to children's point of view, as well as expressing their own; encouragement of verbal give-and-take 5. Recognition of rights of both parents and children" (Maccoby & Martin, 1983, pp. 461 Studies reviewed by Dornbusch, et al (19851, Harter (1983), Maccoby & Martin 11983) and others all show that this pattern of parenting leads to high levels of self-esteem and self-differentiation in children. Similar suggestions for parenting are given by Elkind (1984). Of particular importance is the sharing of perspectives achiev- ed by open communication patterns as outlined in point #4 above (Grotevant & Cooper, 1985), as it facilitates systemic thinking in children. Parents should maintain the boundary between the parental sub-system and the child sub-system (Minuchin, 1974) as much as possible. Children need the oppor, tunity to learn in the "natural social laboratory" of peers and siblings without parental influence. Children should be given the opportunity to resolve their own social and emotional problems as much as possible Parental Interference prevents the child from reasoning the solution to the problem, and contributes to the formulation of the patchwork self. Parents should ensure that their children have time to grow. Elkind (1981, 1984) has discussed the many ways in which children are forced to grow up too fast, too soon, and the consequences of such pressure. Parents need to be sensitive to their child's developmental needs and to provide their child with lots of opportuni- ty for self-directed play. TIMN 321489 ~ ~ 96
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al Fatty infiltration The intralobular fatty infiltrations more than 50%, 30-50% and 10-30% were designated as (H118h level, (M)iddle level, and (Lbw level respectively. b) l.iver fibrosis The degree of fibrosis was classified into 4levels of score 0: without fibraus pylepfilebectas~ score 1: fibrous pylephlebectasis without bridging fibrosis, and score 2: with bridging fibrosis, and score 3: ciirhosLs of the liver. II. Results s 1) Amoung the 1371iver disease patients, 24 cases were excessive alcoholic drinkers drinking more than 80 grins for past 10 years and more When the silbjects who show• ed the fatty liver scores more than 2 are called "bright liver" for example, such "bright liver" subjects are 38 cases among the 1371iver disease patients who were histological- ly diagnosed by a liver biopsy with the laparoscope (Table 2). 2) The "bright liver" was noted in 10 cases of 27 excessive alcoholic drinkers, and also in 28 cases of non-alcoholic drinkers (Fig. 1). 3) Table 3 indicates the distribution by ages and sexes of "bright liver" patients. Females were 15 cases and males were 23 cases, and 8 cases of them were excessive alcoholic drinkers 4) Among total 137 liver disease patients, excessive alcoholic drinkers were 27 cases as in the Table 4 showing their distribution by ages and sexes. The 23 of the 27 cases were males and 8 (35 %) of them showed the "bright liver". 5) The histological examination was performed on the 137 liver disease patients. Some fatty infiltration was noted in the 17 cases, 11 of which showed the "bright liver" by US examination. 6) The degree of the fatty infiltration and fatty liver scores were examined on the 17 cases who showed the fatty infiltration as seen in Table 5. In the patients with high levels of fatty infiltration, the fatty liver scores were also high levels. On the other hand, there were 4 cases noted who showed the fatty tiver score "0" with the mild fatty infiltration. Three of these 4 cases have been diagnosed as the macro nodular cirrhosis by the laparoscope 7) Table 6 shows the existence of fatty infiltration and the bright levels listed on the total 137 cases. Among the 120 cases who were not noted the fatty infiltration, "not bright" findings were obtained from the 95 cases (79 %), whereas other 25 cases showed the bright liver by US examination in spite of no fatty infiltration observed. 8) Fatty liver scores were compared with the levels of fatty infiltration on the 22 ex- cessive alcoholic drinkers as shown in Fig. 2. Even in the alcoholic liver disease pa. tients, there were the subjects who could not histologically observed the fazty infiltration, though they had high fatty liver scores. 9) Table 7 shows the pathological findings on the subjects who showed "bright liver" by US examination while the fatty infiltration was not histologically noted. In the acute hepatitis, 3 of the 4 subjects who had the "bright liver" were severe hepatitis patients. In the alcoholic liver disease, the "bright liver" was noted in 3 subjects of chronic inac- tive hepatitis (CIH(. III. Conclusion 1. The "bright echo patterns" offered by Joseph, et al. were examined on the 4 points of 1) brlghtness, 2) UK contrast, 3) vascular blurring and 4) deep attenuation by scor- ing their degrees for more objective diagnosis of the photograms by means of the fatty liver scores. 2. In the patients who had the "bright liver"; howeve>; there were the subjects who showed histological figures not the fatty infiltration. The same tendency was observed in the alcoholic liver disease patients 3. To the contrary, the subJects who had the histologically mild fatty infiltration but their fatty liver score was 0 by US examination were the patients of the histologically macro nodular cirrhosis. (NOTES: The slides of the photographs of the bright liver echo and the fatty infiltrated tissues will be offered at the congress.) Fig. 1 excessive alcobolic drinker 27 cases aon drinker 113 cases 10 28 (Bright Liver) s 102 Fig. 2 Fatty Liver Score of excessive alcoholic drinker No. of Cases Fatty Liver Sco 2 7 0 6 4 1 3 2 2 Fatty L 1 1 infiltration M 1 1 H Table 1 Fatty Liver Score no finding abnor.al re.arkably abnor.al A) Brightness 0 1 2 B) L/K contrast 0 1 2 C) Vascular blurring 0 1 2 D) Deep attenuation 0 1 2 (A) + (B) + (C) + (D) -F.L.S. Table 2 Case of study Liver biopsy 137 cases Excessive alcoholic drinker 27 cases Bright liver 38 cases Table 3 Age and sex distribution of 38 patients with Bright Liver ( ) : excessive alcoholic drinker Age Mate Fe 10-19 2 (1) 1 20-29 5 (0) 3 38(2) 30^-39 5 (1) 2 40^49 6 (3) 4 50--59 3 (2) 5 (0) 8 (2) i 60^~69 2 (1) 0 (0) 2 (1) Total 2 3 (8) 1 5 (2) 3 8 (1 0) TIMN 321495 3
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What color do I think of when I hear the word "discipline"? Why? What texture do I think of when I hear the word "discipline'? Why? What shape do I think of when I hear the word "discipline"? Why? What taste do I think of when I hear the word "discipline"? Why? What sensation do I think of when I hear the word "discipline"? Why? What are some of the things in my life that I must discipline myself to do? What is hard about disciplining myself? Topic 7: Insight What color am I when I am understanding? Why? What sound am I when I am understanding? Why? What smell am I when I am understanding? Why? What texture am I when I am understanding? Why? What shape am I when I am understanding? Why? What sensation am i when I am understanding? Why? What things about me do I wish people knew? Why? What things about me do I wish no one knew? Why? How can I get to know myself better? What are some of the ways I can get to know how other people are feeling before they tell me? Topic 8: Blame Amends Do things usually seem to be someone else's fault rather than my own? Why? Why not? What color am I when I blame someone else for my behaviors? Why? What sound am I when I blame someone else for my behavior? Why? What shape am I when I blame someone else for my behavior? Why? What sensation am I when I blame someone else for my behaviors? Why? What texture am I when I blame someone else for my behavior? Why? What smell am I when I blame someone else for my behavior? Why? How can I take responsibility for myself? What things am I responsible for in my life? Is it hard for me to make amends to myself for the things I have done to hurt myself? W hy? W hy not? Do I feel as if I should make amends to those I have hurt? Why? Why not? Is it hard for me to make amends to those I have hurt? Why? Why not? Is it important for me to make amends to those I have hurt? Why? Why not? Is It hard for me to apologize when I am wrong? Why? Why not? Where do I go when I need to think about the wrong things I have done to myself and others? What color am I when I apologize? Why? What sound am I when I apologize? Why? What smell am I when I apologize? Why? What texture am I when I apologize? Why? What sensation am I when I apologize? Why? What taste am I when I apologize? Why? Topic 9: Courage Judgement Am I a courageous person? Why? Why not? When I am courageous what sound am I? Why? When I am courageous what color am I? Why? When I am courageous what texture am I? Why? When I am courageous what smell am I? Why? When I am courageous what sensation am I? Why? When I am courageous what shape am I? Why? Does it take courage not to use alcohol/drugs? How do I keep a supply of courage on hand in order to say no to alcohol/drugs? Why do I judge people? How do I judge people? Topic 10: Peace of mind Why is peace of mind so important to our recovery? What color am I when I am peaceful? Why? What shape am I when I am peaceful? What texture am I when I am peaceful? Why? What sensation am I when I am peaceful? Why? What sound am I when I am peaceful? Why? What smell am I when I am peaceful? Why? How can I find peace within myself? Where can I go to find peace? Can other people offer me peace and solace? Topic 11: Meditation What is meditation? Should I learn how to meditate? Will meditation help me? What things will I do difierently to relax, rather than use drugs/alcohol? What color am I when I am stressed? Why? What sound am I when I am stressed? Why? What shape am I when I am stressed? Why? What sensation am I when I am stressed? Why? What taste am I when I am stressed? Why? What texture am I when I am stressed? Why? Topic 12: Assist How can I help my friends understand my need to not drink/drug? What kinds of assistance will I need in order to stay strong? What color are my friends as a group? Why? What sound are my friends as a group? Why? What texture are my friends as a group? Why? What smell are my friends as a group? Why? What shape are my friends as a group? Why? Who assists me the most in my attempts to stay drug free? Why? TIMN 321525 ~ 132 I
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TABLE 1. Nu:rber and percentage of clients from specific agencies and general agency category. Social Services: General Welfare Assistance Salvation Araiy John Howard Society Probation and Parole Family Counselling Service Senior Citizens Centre Legal Aid Mental Health Services: Outpatient, Psychiatric Service Adult Protective Services Norkerl Day Treatment Program/Drop-in Medical Services: Outpatient Medical Centre Inpatient General Hospital inpatient General Hospital Inpatient General Hospital Inpatient General Hospital TOTAL Nunber of Clients Percentage of Total Sample . 34 9.9 15 4.4 52 15.1 22 6.4 33 9.6 7 2.0 23 6.7 186 54.1 20 5.8 17 4.9 9 2.6 46 13.3 25 7.3 16 4.7 14 4.1 27 7.8 30 8.7 112 32.6 344 100.0 TABLE 2. Mumber and percentage of respondents reporting psychotropic drug use in last two weeks by study sample and drug category. Drug Category Minor Tranquilizers IYJor Tranquilizers A.phatatsines Mti-depressants - sleeping pills Study Saegle General Population (n.996)s n S Agency Clientele (n.344)t n Z tActyal sauple size fluctuates slightly due to missing observations for soae categories. clientele. The difference was greatest for major tranquilizels (.4% compared to 8.0%). For the other drug categories, reported use was generally three to five times more prevalent. Table 3 shows that the higher prevalence of drug use among agency clientele was not limited to any one particular kind of community service. Rates of use for clients of all agency categories-social, mental health and medical-were higher than the general population for all drug categories. There were, however, some significant differences across the types of agencies, the most notable being the substantially higher rate of use of minor and major tranquilizers, anti-depressants and sleeping pills among clients of the mental health services. 118 The association between reported psychotropic drug use and sex is shown in Table 4, for both study samples. For the general population, a statistically signifi• cant relationship between reported drug use and sex was evident only for anti• depressants. Although the sex differences in the use of minor tranquilizers and sleeping pills were not statistically significant, they were reasonably large and in the expected direction. The female to male ratios for minor tranquilizers and sleeping pills were 1.7:1 and 1.6:1, respectively. Females accounted for just over 60% of all users of drugs in these two categories. Compared to the general population, both male and female clients had higher rates of use of drugs in all of the psychotropic drug categories. However, the sex differences in rates of use of minor tranquilizers, sleeping pills and TAaLE 3. Mueber and percenUge of retpondentt reportfng pSychetrdpic drug uie sn past tw reeki r1tASn a9ency clientele saeple. by drug category and type of agency. Social Services (n•186)s onn augr.y 5 0 s Minor Tranyuilizers Ma,)nr Tranqufllzers Aqbetaanes Mtl-depressants Sleepinp Dills Type of Agency Mental Mealth servfces (n•46)s s Medical Services (n•112)t s Stat. Sign.s 24 13.2 18 39.1 17 15.3 Pf.001 14 7.7 11 24.4 2 1.8 p s.001 23 12.6 1 2.2 2 1.0 p5 .001 11 6.0 12 26.7 5 4.5 p s.001 16 8.8 7 15.2 10 9.0 Ms tACtual u.le s fluttwtes slightly dee ta rissing Gbservations for so.e drvg categortes~le 'SUbstbcal slgnlfiGnce ras assessed ritL a cRl-square test. anti-depressants were clearly absent among agency clientele. For amphetamines, the sex differences in use reversed between the two populations. Whereas, In the general population, males had a slightly higher rate of use of amphetamines, the rate of use by the females among the agency clientele was about three times that of men. The data in Table 5 illustrate the expected, positive association between age and the use of psychotropic drugs in the general population. A statistically significant association was observed between age and the use of minor tranquilizers (p<.001), major tranquilizers (p<.05j and sleeping pills (p<.001), with persons of older age being more likely to take these drugs. A significant association was also observed between age and the use of amphetamines (p<.01). For these drugs, younger persons were more frequent users. As with the previous data concerning sex differences, the association of drug use with age was much reduced among the agency clientele. Although the higher rates of use among the agency clientele were observed for all drugs, at all age levels, there was a disproportionate increase in use among young clients. Thus, there was no statistically significant age difference in the use of minor tranquilizers, major tranquilizers or sleeping pills although a clear trend remains for the former. The strength and direction of the association between age and the use of am* phetamines was similar to that observed in the general population. Table 6 provides insight into the multiple use of psychotropic drugsin both study populations. In the general population, 8.2% reported the use of a drug in at least TIMN 321511 - _.~
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TAaLE 4. Number and percentage of respondents reporting psychotropic drug use in the last tw weeks by sea, drug category and study saeqle. Drug Category Ma1es n xa Eenales Stat. Sign.' s Minor Trenqutl/zert General Population 19 3.9 31 6.5 MS Agency Clientele 31 17.3 25 16.7 MS Ma7or Tranquilizers General Population 1 .2 3 .5 MS Agency Clientele 11 6.2 13 8.7 KS Mqhetawines: General Population 14 2.8 5 1.1 MS Agency Clientele 7 3.9 18 12.0 p 1.01 Anti-depressants: beneral Populatioa 0 0.0 14 3.0 p 5.001 Agency Clientele 15 8.4 10 6.7 MS Sleeping Pills: 6eneral Population 9 . 1.8 14 2.9 MS Agency Clientele 15 8.4 15 10.0 MS 'Statisticai significance of the sea difference ritkin each saaple, assessed with a chi-s0uare test. - - - -_- TAaIE 5. Number and percentage of respondents reporting psychotropic drug use in the last t.e Yeeks by age. drug category and study sasple. AZ Sut. 18=24 2544 45=6a 65+ sign.' Orug Category n i o S n z n t Minor Tranquilizers general Population 2 1.0 19 4.5 17 6.7 13 6.7 ps.001 Agency Clientele 8 11.4 26 16.2 15 26.3 6 26.3 MS Ma,1or Tranquilizers General Population 0 0.0 2 .4 0 0.0 2 0.0 ps.05 Agency Clientele 3 4,3 14 8.8 3 5.4 2 5.4 MS Aaqbeta.ines: 6enerai Population 9 4.7 7 1.8 2 .9 0 .9 p-.0l Agency Clientele 11 15.7 10 6.3 1 1.8 1 1.8 ps.01 Anti-depressants: General Population 0 0.0 8 1.9 3 1.2 2 1.2 M5 Agency Clientele 6 8.6 12 7.S 3 5.4 3 5.4 MS Sleeping Pills: 6enen1 Population 0 0.0 6 1.3 8 1.2 8 8.8 pt.001 ` Agency Clientele 7 10.0 10 6.3 5 8.a 6 20.0 MS 'Statistical significance of the age differnce vftbin each saeple, rs assessed rith a chi-sqwre test. one of the psychotropic categories and only a further 14 respondents (1.4%) used more than one such substance. By comparison, 18.6% of the agency clientele 119 reported the use of one psychotropic drug and a further 12.8% used more than one drug. Three or more of these drugs had been used by 4.4% of the clients in the past two weeks. (b) Additional data concerning minor tranquilizer use Given the concerns surrounding the extensive use and potential abuse of minor tranquilizers, such as diazepam, additional analyses were undertaken concern- ing minor tranquilizer use. Information concerning the duration and frequency of use, compliance to doctors advice and reported reasons for taking the drugs were requested from both study samples. Participants in both samples were also asked about their frequency of alcohol use. The actual name of the drugs being used was requested only in the population survey, where diazepam accounted for 43.8% of the minor tranquilizers reported. Of the remaining tranquilizers cited (e.g., Librium, Ativan, Serax), no one drug predominated; however, benzodiazepines were specified in another 35.2% of cases. TAaLE 6. Number and percentage of respondents reporting aultiple psychotropic drug use in the last two reeks by the nwnber of drug categories reported and study saeple. Study Saniple General Population Agency Clientele Number of Drugs n S n S 0 901 90.5 236 68.6 1 81 8.2 64 18.6 2 13 1.3 29 8.4 3 0 0.0 10 2.9 4 1 .1 4 1.2 5 --- 0 0.0 --- ----- 1 0.3 --- ----- Total 996 100.0 344 100.0 As noted previously (Table 2), the overall prevalence of use of minor tranquilizers in relation to the total study population varied considerably between the two samples-5.2% versus 17.4% for the population and agency samples, respective- ly. In the general population, 1.6% reported taking a minor tranquilizer on a dai- ly basis and had been using the drug(s) for one year or more. In comparison, 4.7% of the agency sample reported such long-term, daily use. The percentage of long-term daily users varied considerably across the various kinds of community services-social services (1.1 %), mental health services (10.9%) and medical ser vices (8.0%). Some research has considered four months rather than twelve months of regular use as a criterion for "long-term" use with a high risk of drug dependency le.g. 12,13). In the population survey, 2.0% of adults reported taking a minor tran• quilizer on a daily basis and had been using the drug(s) for four months or more. In comparison, 6.7% of the agency sample reported four months, daily use. The prevalence of four months, daily use across the different types of agencies was 3.2%, 15.2%, and 8.9% for social, mental health and medical services, respectively. Table 7 shows a comparison of the duration and frequency of minor tranquilizer use, among users in both study groups. With respect to duration of use, there was no statistically significant difference between the two samples, although there was a trend for a longer duration of use in the general population. In terms of frequency of use, there was a non-significant trend for more, non-daily use in the general population and more daily use in the agency population. For frequency X duration, there was no statistically significant difference between the two populations. There was a trend for a higher proportion of users in the general population to be using for 12 months or longer but on a non-daily, sporadic basis. There was no large difference in the proportion of users in the two popula• tions who were long-term (i.e. 12 months) daily users. The proportion of users who had been taking the drugs for over one year and who reported daily drug- taking was 34.0% and 30.2% for the general population and agency population, respectively. If a four month rather than twelve month criterion for long-term daily use is applied, then these respective percentages are 42.6% and 43.4%. Data in Table 7 also compare the minor tranquilizer users in the two groups on TIMN 321512
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accumulation in the body. The limbic system of the brain is a major target area of the drug. There it produces alteration of deep-seated structures that control emotion, pleasure, endocrine function, and memory storage. PROGRAM DESCRIPTION The Drug Dependence Treatment Unit of the Atlanta Veterans Administration Medical Center is a 16-bed inpatient section within a 490-bed general medical and swgical hospital. It is located on the same floor as a 32-bed Alcoholism Treatment Unit, and both of these are open units. Staffing is multidisciplinary, including psychiatry, internal medical, psychology, social work service, recreational and occupational therapy and nursing. Patients are drawn from six southeastern states (Georgia, Alabama, Florida, North Carolina, South Carolina and Tennessee); all are veterans of the United States military services with honorable or general discharges. More than 99% of the patients are male, aged 18 years or olde>; and the ratio of black to white admissions ts approx- imately equal. Many are unemployed, many have legal problems, and there is a con- sidetable range of psychopatlwlogy among these veterans Signibcarrt personality disotders are common. Most patients report disruption within their families and generally chaotic living conditions A majority have alcoholism or other drug dependencies in their ancestry The program provides inpatient treatment from an eclectic and pragmatic standpoint, recognizing that behavioral consequences rather than the desire to relinquish drugs most often bring the patient to treatment A drug-free atmosphere is provided in which the patients are encouraged to change behavior and attitudes. The maximum length of stay is six weeks. The mainstays of treatment are group therapy, Narcotics Anonymous, Alcoholics Anonymous, and special groups for adult children of alcoholics. Other supportive ser- vices are provided; e.g, medical, dental, and recreational services. All admissions are voluntary. There is an outpatient treatment program affiliated with the Drug Dependence Treat- ment Unit to provide followup counseling and support services. METHOD Ten consecutive patients admitted to the drug rehabilitation program between 15 Oc- tober and 20 November 1984, with histories of combined alcohol, cocaine and mari- juana abuse, were evaluated with emphasis upon behavioral issues and treatment outcotrte TABLE Patients using drugs other than alcohol, cocaine and marijuana were not considered for the study. Patients were examined and evaluated by an experienced drug unit physician as a prere quisite to admission to the drug rehabilitation program. This evaluation included a drug-use history, a complete medical history and physical examination, and a mental status assess- ment Following admission, a thorough assessment of patient needs, leading to formula• tion of a treatment plan, was done by a treatment coordinator with input from the multidisciplinary staff. Reassessment and modification of treatment planning were done periodically. The results of these evaluations and the treatment outcomes are summarized in the accompanying table DISCUSSION Consideration of the pharmacological and physiological effects of alcohol, cocaine and rnanluana, within the context of the behavioral consequences demonstrated by a group of patients using these drugs in combination supports the premises that the consequences are predictable, are often antisocial, and they are principally the result of disinhibition by alcohol, intense central nervous system (cortical) stimulation by cocaine, and en• during impairment of intellectual performance by marijuana. While these drugs evoke some unique responses, they also reenforce each other, par- ticularly with regard to production of anxiety and confusion, as well as impairment of insight and judgtnent Treatment efforts; largely educational, are obviously complicated by the persistence of cannabinoids in the brain. REFERENCES 1. Gold MS: 800-Cocaine New York, Bantam Books, 1984. 2. Washton, AM, Gold, MS, 3bttash, ALC: Survey of 500 Callers to a National Co caine Helpline Psychosomatics 25: 771-775, 1984. 3- Wilford, BB: Drug Abuse. Chicago, American Medical Association, 1981. 4. Cocaine Toronto, Alcoholism and Drug Addiction Research Foundation, 1980. 5 Hofmann, FG: A Handbook on Drug and Alcohol Abuse: The Biomedical Aspects. New York, Oxford University Press, 1975(?). 6. Manual on Alcoholism, ed 3. Chicago, American Medical Association, 197Z 7. Nahas, GG: Current Status of Marijuana Research.lAMA 242: 2775-2778, 1979. SUlRiARY OF TEN PATIENTS Patient Age Reason for Admission Duration Drug Use Mental Status TW 27 Desire to stop drug use. 9 years No primary psychopathology BK 32 Financial 17 years No primary psychopathology LJ 29 Court order 15 years Antisocial behavior since- childhood. 4 suicide attempts Psychosocial Family Treatment History History Outcome Arrests - dis- - Compliant, orderly conduct, Completed driving under inpatient influence. program satis- Disciplinary factorily. actions in Army Left outpatient counseling after 1 month. Truancy. Divor- Alcoholism, Compliant. ce. Discipli- drug abuse Lacked motiva- nary actions in tions. One Navy. episode marijuana use. Left pro- gram after 35 days. _ School dropout Alcoholism Compliant. Poor 2 divorces. group participa- Imprisoned for tion. Persistent burglary, viola- denial of tion of proba- alcoholism. tion. Discipli- nary actions in Marine Corps. 106 I I 1 I I I 1 I I { I t i TIMN 321499 ~
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Table 4: CRIMINAL JUSTICE AMO ILLEGAL DRUGS IN aESTERN-EUROPE I I enforced treatment I special I p olice I suspects I convicted drug I I I prisons for I re corded I registered I offenders { { {drug addictsl drug I by the I total/per 100.000 { { { enly I ef I 1 fenoes/ 00.000 I I pelice/ 100.000 I I I I { { e f the I of the I I I { population I population I ~ I C I I 1982 I 1960 I I fRG I - { yes I 102 I 90 I 1982: IIIi { { I I I 17.105 28 I Austria { if there is enough reason to suspect I - I 103 I 61 I 1981: I I that soaebody is abusing drugs, he I I I I 2.443 32 I I aay be subjected to a eedical I I I I ~ I eaaeination and if he is assessed I I I I { I to be addicted to drugs, treatment { { I I I I can be carried through (f 8, 9, 10 I I I I + { Narcotics Lav) ( I I I I Switzerland I Art. 19a V Narcotics Lar: the court I yes { { eay order institutionalization and I 1 { treatment if sosebody is suspected { I I to be addicted to drugs I 1 188 1 - 1 1982: I I I 7.676 121 I France I Art. 626-1 Narcotics Lau: Drug I - I 41 I 21 I 1981: { I users .ay be subjected to treatment I I I I 7.972 i5 { { by order of the court or the public I { { { ( { prosecutor's office { I I I I Belgiu I - I - I - I - I 1977: I I I I ~ I I 516 5,3 I yes I 10 ( 27 I 1980: I 1981: 281 I I I I 775 1,4 1 0,5/100.000 { Netherlands { I yes I 58 { 42 { 1981: I Assterdae 1.1.85- I I I I I I I 1.703 13 I 30.5.85: 20 I Italy Spain England I Sueden I statute concerning treatment of ( I alcoholics and drug users (1981), I { 3 2: a dru..W.ddici ay be insti- ' { tutionali:ed and treated uithout I I consent if he ay endanger his ~ { health. (s 3). I - I - I I deaths resulting froe I I drug abuse I I total/I00.000 I I I I I I I I I '11 I 1982: 383 I i 0,6/100.000 1 1981: I I 34 I I I I 0,4/300.000 ! I 1982: I 109 ~ I 1.7/100.000 I 1983: 190 I I I I I 0,4/100.000 i I I { 1984: 170 I 0,5/100.000 { _ { _ { 31 I 1982: I ca. 200 (per year) I { I I I 20.300 41 (in the eighties) ( J ) ( I 0,6/100.000 I - I 848 { 636 I 1981: I 1981: 98 ~ I I I 6.843 83 I I I ( I I I I I i I 1,2/100.000 I I I I I I I I I I TIMN 321532 139
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b) Housewives In contrast to the employed men it was not possible to identify any linear group, but rather it was evident that both high and low degress of stress, demands and social support were related to an above-average use of sedatives and analgesics. . This finding draws attention to the fact that there are problems involved in analysing drug use relating to content and method. The following explanations and hypotheses result from this: Some of the conditions and approaches/attitudes relevant to housewives were not documented or considered. Reality changed as a consequence of drug use (drifting hypothesis). Perception of reality was altered due to drug use. , The relationship between pressures and drug use is curvilinear, i.e. both a too high, and a too low degree of demands play a part. Although the first two explanations mentioned cannot be verified on the basis of the data available (cross-sectional studies), the assumption of curvilinearity holds par- tfally (i.e. both excess and shortage of demands create a risk for housewives below the age of 40, cf. figure 4a, 4b). c) Employed women in the representative sample Unlike the housewives population group, there is no cluster unaffected by stress in the employed women category. The risks for the use of analgesic and psychotropic drugs consist of an array of conditions containing aspects of a restrictive and emo- tionally taxing situation: conflicts in the professional as well as in the domestic sphere, pressures due to time and environmental factors, strain, low degrees of latitude. The types of pressure only have an effect on the use of drugs in this combination, but not individually or independentiy of the others (figure 5). Only to the factor of job latitude can a significant isolated effect be ascribed: where degrees of job latitude are low, the consumption of analgesics anad sedatives as well as the tendency to consume hypnotics, are increased (figure 61. It is relevant here that the relationship was examined controlling health complaints (disregarded in figure 6), i.e. degrees of latitude protect against drug use both in the case of minor complaints and in the case of serious complaints. Women with a greater scope available to them have a greater number and variety of opportunities and ways of coping with stresses and Fitur. I Sorlel ca.drt/ru, Feeltb coylabt. .M aru5 c.iu.ptlon !s tn trsui. .! ey~1nFN leol -- frraueerlti .f .bale srwy .i .alesr~ .wr x-!!s ae 1i.7 - ciucter Y1 Mc. .Sr e3.F ---- cluitrr I M•to ar 3f.) complaints than taking medicines, irrespective of the fact that they also suffer to a lesser degree from indisposition. Unlike the population group composed of employed men, it is conspicuous in this group that social support has no obvious effect. In our opinion this result is an indication of the dual meaning of social support for women. At home as well as at work, women are carrying out "social-relations•work" and provide support (cf. KEKUPP 1983), so that in the guise of apparent relieving and buffering there may be a hidden element of stress and commitment. d) Female administration staff For the office employees group it was possible to consider emotional demands and job-related emotional stresses and their interplay with factors of latitude from the point of view of their effect on drug use. Dealing and sympathising with others, creating a friendly Fltuie ~ Taeiel eoMleroni, co.tlalnii .wC Arut uie /n t.e trou.a ef frute clirl. -- Frry'»ucrrr ef vbolr trout M1•r90 .te Sf.: <lnttrr \ A•33 ai lf.c - cluitcr I11 n/c a=r 1F.4 .r.N m w.e F...re ele.4. ftaer F-tMe 141a,a++bli• brn*rn r~+ttt.ul baMa f(r.llnf r,N utlrrflcrtatlK • fneMli .tccrhrrt` r2 ux of Lra+Wllri.r• eentNlN fn lub 1.uwY ud ye 4uc,crn il.l•rcca+. hio lo• MtA la - ,1.3 13.a A,r lu bqA le arl wl onl ierrda dwnA. dsrnY @ltltrC 6 Surrey by the Teden7 Central Officr for lk.lth EAcstim (t9l1) bqloyed Main (t1-3o2) ' 11e7ation betxrn tr.rquiliter rre ard deprre of joh 3atitlale contrvlled fcrc social sulyort driryt Irsers (tn petcent) 34.91 0.7t 1 hlph la- h.gh ]c. job lattnFd. job 1stltWr . t !ru seci.] suppert high social support 1oy soclal suppurt hfsh social suylurt . erer ao years of ap rndrr au Tesrs of apr ra 1 J,..N. lo• b~rb le. h/iA ]at lecltudes .ah ierttWi• vrtr b le.r. sf y. aer Fr irFn af rei atmosphere, as well as subordinating oneself and setting aside one's own requirements, these are demands specifically made on female office employees. The results of the cluster and stratified analyses reveal complex relationships (figure 7(: Where the emotional demands and stresses are small, the use of drugs is likewise below average Multiple demands and conflicts resulting from the occupational as well as the domestic sphere is connected with the use of analgesics. Stress due to conflicts additionally lead to tranquilizer consumption. Emotional demands arising from the need to deal with others and having to create a friendly atmostphere do not present any risk as far as the taking of medicine provided that any other stresses occurring are only slight and that is concerned , sufficient job latitude and social support are present It can in fact be shown that the joint constellation of "dealing with others/creating a friendly atmosphere/In creased degree of latitude" actually has a protecting effect as far as the use of tranquillizers and anti-rheumatics is concerned (figure 8). Conversely, the joint occurrence of emotional demands and reduced latitude 124 TIMN 321517
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alcoholic and SDAT patients. The dependence of the cortical atrophy Iparticularly the right side) on the degree of hippocampal pathology complements the presump tion about the focal role of the hippocampal damage in these two dementias. A re• cent suggestion IBall et al., 1985) about the pathology of hippocampal formation as related to the origin of SDAT finds therefore additional support in the present data The predominant hippocampal pathology is also compatible with the elec- trophysiological correlates of hippocampal susceptibility to alcohol induced brain dysfunction I et al., in press). Additionally the present results contribute to findings revealing an association between hippocampal formation and generation of P3 com• ponent in brain evoked potentials in humans (McCarthy, 1985). The close connection of the hippocampus with basal ganglias (Heimer, Wilson, (1975) and therefore with most of the anterior and posterior association cortex via the caudate nucleus and putamen (Kunzle, 1975) could explain the widespread and complex clinical symptomatology of Alzheimer and Alcoholic dementias involving deficit of the highest cognitive functions, especially of memory, and flattening of affect. The critical role of the hippocampus in the physiology of memory has been well documented (Milner, 1965; Swanson, 1979). The supply of the hippocampus with noradrenaline-containing neurones from the nucleus locus coeruleus may explain this hippocampal•memory relation. The dorsal noradrenergic ascending bundle which arises from cells in the locus coeruleus at the dorsal pons is related to the maintenance of the cerebral notadrenalfne level, which subsequently controls (as "a reward system") the consolidation of long term memory traces (Crow,1958, Kety, 1970). Noradrenaline has also been related to the ability of selective perception of the stimulus target from the background noise, by modification of the stimulus-noise ratio (Foote et al., 19751, the function severely impaired in chronic alcoholism (Por)esz, Begleiter, 1979). A deficit of the noradrenergic (and cholinergic) system related to the neuronal loss in the hippocampus (and In the nucleus basalls of Meynert see: Rylett et al., 1983; Whitehouse et al., 1982) may well be implicated as correlate of senile and alcohol• related dementia (Crow, 1981; Robbins, 1984). We are aware of limitations in our conclusions due to simplicity of the methodology used. However the consistent compatibility of the symptomatological, elec- trophysiological and neuropathological patterns in both Alcoholic and SDAT patients reported above, encourages speculation about their close affinity. We hypothesize that in many cases the Alcoholic Dementia may represent a SDAT which might be induced or accelerated by chronic alcohol abuse. An alternative hypothesis however, may suggest consideration of SDAT not as a separate clinical entity but as a demen- ting syndrome which occurs whenever a limbic formation and, in particular the hip- pocampus, is being affected by some damaging factors such as toxic substances, viral infections etc. Frequent occurance of SDAT in conjunction with other clinical en- tities, such as amyotrophic lateral sclerosis, Parkinson disease or Creutzfeldt-Jakob disease (Hornykiewicz & Kish, 1984) would be consistent with the latter hypothesis. Dr. S Hontela, Physician in Chief, Chronic Psychogeriatric Department, Alberta Hospital Edmonton. Dr. K.T. Clesielski, Supervisor, Department of Neuropsychology, Alberta Hospital Ed• monton. ACKNOWLEDGEMENTS We wish to thank: Dr. W. Variast, Dr. D.J. Willians, Dr. P.K. Petrik and Dr. T.Y. Thay of Edmonton General Hospital, and Dr. B.W. Mielke from the Depamnent of Pathology, University of Alberta for their kind help in collecting brain autopsy data and Mr. D. Schopflocher for the statistical analysis. REFERENCES Adam, N., & Collins, G.1. 119781. Late components of the visual evoked potential in search in short•term memory. Electroencephalogr. Clin. Neurophysiol., 44, 147. Ball, M.J., Hachinski, V., Fox, A., Kirshen, A.J., Fisman, M., Blume, M., Kral, V.A., Fox, G., & Merskey, H. 11985). A new definition of Alzheimer s disease: A hippocampal dementia. The Lancet, January. Beck, E.C., Dustman, R.E., Blusewicz, T., Schenkenberg, T., & Cannon, W.G. 11978). Cerebral evoked potentials and correlated neuropsychological changes in the human brain during aging. A comparison of alcoholism and aging. In J.M. Ordy & K.R. Brizzee (Eds.), Aging sensory systems and information processing. New York, Raven, Press, 203. Ciesielski. K.T., Madden, J.S., Bligh, J.G., & Schopflocher, D. (in press). Long term brain Impairment in chronic alcoholics: N2•P3 cognitive potentials in a template mat• ching memory task. Alcohol and Alcoholism. Crow J. (19681. Cortical synapses and reinforcement. Nature, 219, 736. Crow, T.J. (1981 I. Biochemical aspects of memory. In F.C. Rose (Ed.), Metabolic disorders of the nervous system, 29, 369. Dustman, RE„ Schenkenberg. T., Lewis, EG., & Beck,1:C. (19771. The cerebral evoked potential life-span changes and twin studies. In J.E. Desmedt (Ed.), Visual evoked potentials in man: New developments. Oxford, Clarendon Press, 363- 100 Dustman, RE, Synder, W.W.. Calner, D.A., & Beck, E.C.119791. The evoked response as a measure of cerebral dysfunction. In H. Begleiter IEd.I, Evoked brain potentials and behavior, 2, New York, Plenum Press, 321. Foote, S.L, Friedman, R., & Oliver, A.P. 11975). Effects of putative neurotransmitters on neuronal activity in monkey cerebral cortex. Brain Research, 86, 229. Fuiikawa, S.M., & Weber, B.. (1977). Effects of increased stimulus rate on brain stem electric response (BER) audiometry as a function of age. J. Am. Audiol. Soc., 3, 147. Goodin, D.S., Squires, K.C., Henderson, B.H., & Starr, A.11978). Age-related varia tions in evoked potentials to auditory stimuli in normal human subjects. Electroenceph. Clin. Neurophysiol., 44, 447 Halgren, E. 11980). Endogenous potentials generated in the human hippccampal for• mation and amygdala by infrequent events. Science, 210, 803. Harkin, S.W., & Lenhardt, M. (1980). Brainstem auditory evoked potentials in the elderly. In LW. Poon (Ed.), The aging in the 1980's: Psychological issues. Washington, D.C., American Psychological Association. Heimer, L, & Wilson, R(1975). The subcortical projections of the allocortex. Similarities in the neural associations of the hippocampus, the periform cortex, and the neocortex. In M. Santini (Ed.), Golgi antennial symposium, Raven Press, New York. Hornykiewicz, 0., & Kish, S.J. (1984). Neurochemical basis of dementia in Parkin• son's disease. The Canadian Journal of Neurological Sciences, 11(1), 185. Kety, S.S. (1970j. The biogenic amines and the central nervous system their possible roles in arousal emotion and learning. In F.O. Schmidt (Ed.), The neurosciences se cond study program, 324, Rockefeller University Press, New York. Kunzle, H. (1975). Bilateral projections from precentral motor cortex to the putamen and other parts of the basal ganglia: An autoradiographic study in Macaca fascicularis. Brain Res., 88, 145-209. Laurian, S. (1984). Evoked potentials in the study on normal and pathological aging. In Senile Dementia: OuUook of the Futuret Alan R. Liss. Inc. New York, 305. Maudsley, H. (1879). The Pathology of Mind. (3rd ed.). London: Mackmillan, p. 486. McCarthy, G. 11985). Intracranial recordings of endogenous ERPs in Humans. Elec• troencephalogr. Clin. Neurophysiol., 61, 511. Milner, B. (1965). Visually-guided maze leaming in man: Effects of bilateral hippocampal, bilateral frontal, and unilateral cerebral lesions. Neuropsychologia, 3, 317. Porjesz, B., & Begleiter, H. (1979). Visual evoked potentials and brain dysfunction in chronic alcoholics. In H. Begleiter (Ed.), Evoked brain potentials and behavior, New York, Plenum Press. Porlesz, B, Beglelter, H., & Samuelly,1. 11980). Cognitive deficits in chronic alcoholics and elderly subjects assessed by evoked brain potentials. Acta Psychiatr. Scand, 62. Suppi., 286, 15. Porjesz, B., & Begleiter, H. (1981). Human evoked brain potentials and alcohol. Alcoholism, 5(2). Porjesz, B., & Begleiter, H. (1982). Evoked brain potential deficits In alcoholism and aging. Alcoholism, 6(l), 53. Robbins, T.W. (1984i. Cortical noradrenaline, attention and arousal. Psychological Medicine 14, 13. Rowe, J. (1978). Normal variability of the brain stem auditory evoked response in young and old adult subiects. Electroencephalogr. Clin. Neurophysiol., 44, 459. Syndulko, K., Hansch, E.C., Cohen, S.N., Pearce, J.W.,.Goldberg, Z., Montan, B., Tourtellotte, W.W., & Potvin. A.R. (1982). Long-latency event related potentials In normal aging and dementia. In J. Courjon. F. Marguiere, & M. Revol (Eds.), Clinical applications of evoked potentials in neurology, New York, Raven Press. TIMN 321493 i i , I I i I
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operators/syndicates, and suggested that strict supervision and investigation be conducted. There was low awareness of treatment and rehabilitation facilities thus refer- rals were made to government hospitals and occasionally to a government rehabilitation centec Sources of information on matters related to drug abuse were newspapers, pam- phlets, magazines, posters; the family; and friends and neighbors. 3. Attitudes and Perceptions. As to the causes of drug abuse, peer influence was ranked first, followed by personal and family problems (mainly parental negiecb. Majority of respondents considered "drug abusers as a menace to society such that they must be arrested and punished'; although there were some who thought of them as "normal and to be treated like any other person". The attitude towards the rehabilitated drug dependent was more favorable with majority in the opinion that they "should be accepted as if nothing happened in the past:' For any of the activities on control, prevention, treatment and rehabilitation, the respondents recognized the equally important role of non-government organizations and the family in the solution of drug abuse. It was generally indicated that the cooperation between the government and the community is necessary for long lasting solution. No relationship was found between attitudes/ perception and community par- ticipation. 4. Nahtree and Extent of Community Participation. A significant number of respondents in the three areas were active in their organizations, particularly in such activities as beautification, sports and recrea• tion, community meetings and spiritual/religious undertakings. For non- participation the reasons cited were absence of activities for them to engage in; lack of unity and cooperation among the members; and lack of time to spend for organizational activities. It was noted that solving the problem of drug abuse was not a main objective of any of the organizations existing in the three areas. Howevey some respondents had participated in some seminar activities on drug abuse control and prevention. Very few extended support to agencies involved in the solution of drug abuse because of busy schedule and lack of agency contact. For those gave support, the activities included personal reporting of drug abuse cases, apprehension of drug abusers, financial aid, involvement of youth in worthwhile activities and Infonnation-dissemination drives. The community (barangay) council closely identified with the captain or leader; was the most actively involved entity in the planning, implementation and evalua- tion of activities related to drug abuse control, prevention, treatment and rehabi7ita- tion. The participation of non-governmental organizations as well as the community is very low. The reasons for non-participation include the negative experience with government projects; lack of awareness regarding rights and roles as citizens; lack of motivation; and fear of involvement. B. Government and Non-government Organizations Organizational representatives make up thirty (30%) percent of the total respondents for this study. They identified the objectives of their organizations as mainly the implementation of community projecis, promotion of community welfare and maintenance of peace and ordes 1. Majority of the respondents had participated in activities related to the control and prevention of drug abuse, but hardly in the aspects of treatment, rehabilita tion, training and research believed to require professional expertise. Areas of involvement were information dissemination and coordination with law enforcers. 2. The collaboration between government and non-government organizations was average despite a noted tendency for most government organizations to limit their coordination with other government institutions. 3. The extent of participation of non-government organizations in the different activities related to drug abuse was average. 4. The extent/level of awareness of existing government programs on drug abuse in their areas was avetage However; it was generally high in terms of the nature of community participation in the different program activities, the causes and effects of drug abuse as well as the number and magnitude of drug abuse cases in their respective communities. 5. Most respondents consider the families, socio-civic and religious organizations as merely supportive of the government. 6. The attitudes and perceptions of respondents in general are positive in con- sidering the solution of the problem of drug abuse as a joint undertaking of government and non-government organizations. 7. Findings of the study also indicated the close coordination between parents and the community (barangay) council in solving drug abuse~ with the maior decisions assumed by the latter. 116 V1 In the analysis of the findings, it may be concluded that community participation in drug abuse control, prevention, treatment and rehabilitation was low. This may be due to the lack of participation in the process of decision-making since it was generally perceived that the major decisions in the community should be made by the community (barangay) officials and not the people who were limited to the implementation of plans, if at all. The collaboration of the government and the non-government organizations need further strengthening with the latter assuming a more direct and active role in the solution of the dnig abuse problem in coordination with those of the government. VII On the basis of the study, some points are presented for consideration: i. For the government and non-government organizations to provide opportunities for the people to actively participate in the decision-making processes in the community, especially in matters that directly affect their lives. 2. For the government organizations to share the decision-making, planning, im, piementing and evaluation tasks with the non-government organizations and the people particularly in drug abuse control, prevention, treatment and rehabilitation. 3. For the education/information campaigns to include a list of government and non-government programs directly concerned with drug abuse in all the com- munities; the proper attitude towards a drug abuser and a rehabilitated drug dependent; and the critical need for active community participation and the role people can play in drug abuse control, prevention, treatment and rehabilitation. 4. That an association of parents, youth and volunteers in every community be organized to be directly involved in all aspects of the drug abuse program. 5. For more recreational facilities to be established with the direct participation of the youth in the community. 6. For "paraprofessionals" and volunteers to be trained for drug abuse treatment and rehabilitation in every community. 7. For periodic meetings/consultation with all government organizations, non- government organizations and concerned groups in the community to con- solidate/coordinate all efforts in solving drug abuse. 8. For the parent-teacher association to be harnessed as a vehide for mobilizing parents to actively participate in drug abuse control, prevention, treatment and rehabilitation. 9. For participatory research to be undertaken in the communities which will include tapping and training of people in the community to conduct resear• ches on drug abuse, and feedback the results to residents for more effective ways of dealing with the problem. 10. For a broader and more in-depth study be made on community participation in drug abuse control, prevention, treatment and rehabilitation. TIMN 321509 -A
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CONDITIONS OF LEGAL DRUG USE BY HOUSEWIVES Figure 1: Interaction of stresses and latitudes (restrictiveness concept) EMPLOYED WOMEN AND MEN. RESULTS AND PROBLEMS OF A POPULATION-SURVEY S. Ellinger, w Karmaus, Projekt Frauen, Medtkamente, Prdventfon. UniversfMtskrankenhaus Eppendorf, Medizinische Soziologie, Hamburg, Federal Republic of Germany 1. INTRODUCTTON The object of this study is to ascertain what differing psychosocial conditions can explain the consumption of psychotropic and analgesic drugs in men and women aged between 20 and 63/65. The problem in question was posed firstly as a result of the finding that such substances are not taken for medical reasons, but rather ap- plied for the purpose of coping with psychosocial problems (COOPERSTOCK, LEN- NARD 1979), and secondly as a result of European and North-American studies revealing that roughly twice as many women as men use psychotropoic or analgesic drugs (COOPERSTOCK 1979, COOPERSTOCK, PARNELL 1981, BALTER et al. 1974) Empiricle results and theoretical considerations have induced us to investigate the effects on the following factors on consumption of such substances: I) stress due to working conditions 2) stress due to social intercourse ("sentimental work", STRAUSS et al. 1982) 3) job latitudes 4) social support 5) health complaints. (1) Stress due to working conditions Stress is to be understood as meaning the physical and mental demands resulting from the carrying out of one's work and from the given working conditions, in other words those features such as physical demands, time pressure, environmental pressure etc., normally taken into account in stress concepts (MASCHEWSKY 1983; NASCHOLD, TIETZE 1977). (2) Stress due to social intercourse (sentimental work) Work's emotional demands represent an aspect of the working world that has so far hardly been researched or documented, but which in our opinion bears a par- ticular relevance to the consumption of medicine. Role allocation and work alloca- tion according to the person's sex means that within the family the woman is alloted to the task of "maintaining emotional bonds and regulating friction" (ZAHLMANN- WILLENSBACHER 1979, p. 62). At work too, demands of the same kind are made on women: in their capacity as secretaries, nurses or sales assistants they are expected to extend empathy and sensibility toward their boss, doctor, patients and clients (SCHENK 1979, p. 177; STRAUSS et al. 1982). It is above all in the social professions that the person-oriented nature of the work necessitates emotional demands of this kind. This kind of work effects have been described as "burn-out-syndrome": psychosomatic complaints, depressiveness, and resignation (SHINN, MVRCH 1983, ARONSON et al. 1983). The two stress factors mentioned above do not exclude one another, but can occur simultaneously. We regard their significance as lying in the fact that they lead to drug consumption indirectly, via physical indisposition. To a certain extent a direct effect can also be assumed, whether analgesics/sedatives/hypnotics are taken as a pre-stress, precautionary, anticipatory measure, or whether they are taken as a direct means of coping with conflicts and tension. (3) Job latitudes To conceive of professional work and of housework as places where nothing but pressures are to be found, is to exclude from consideration a significant area of social reality. At the place of work there also exist degrees of latitude, alongside the pressures, and these can have the indirect effect of protecting against drug consumption (KARASEK 1979, KARMAUS 1984(; on the one hand, there may be a reduced occurence of complaints, leading to a reduced consumption; on the other, latitudes may allow for other forms of coping with complaints at the place of work. Thus a typist suffer ing from headache resorts to analgesics if she is under time pressure, whereas given other conditions she might decide to counteract her tension headache by taking a walk or doing some exercises. It is this very interaction of stresses and latitudes which is of significance icL ELL- INGER et al. 1985). LOh' IMANDS JOB LATITUDE Lm HIQi YL' .,. I 2 n )~C' I I The illustration shows in a schematic way how the working conditions are deter• mined by the interplay of latitudes and stresses, viz: In box I both latitude and stresses are only slight, and as no demands are made, a feeling of being insufficiently challenged can result. In box 2 the stresses are only slight but there is a high degree of latitude. Work is less taxing, the employee can apply his/her qualifications, and the likelihood of complaints and/or drug consumption is lessened. In box 3 the degree of latitude is small but the degree of stress is high. The work. ing situation is restrictive, strictly determined by the machine and/or internal structure of the company, and therefore inhuman. Complaints and drug con. sumption can be put into play to cope with such conditions. In box 4 both stresses and latitude are at a high level. By way of contrast to the situation depicted in box 3, the working situation here is less harmful, since the employees have the chance to come to term with the demands without com- plaints or drugs playing any part at all. (4) Social Support The conceptions of what is meant by social support are very all-embracing and vague. As far as the delimitation of latitudes is concemed it is to be understood as denoting the resources resulting out of social intercourse. It follows from this that social sup- port has totally differing meanings. For the receiver it can represent both a form of relief or a form of supervision (LANGLIE 1977). For the provider, pressure and obligation may be first in fine of importance (BELLE 1983; HOLAHAN et al. 1982). Owing to the socially predetermined allocation of male and female roles, men are to be seen as the beneficiaries here The function of social support in the use of analgetic, hypnotic, and tranquilizing drugs can be seen firstly as having the effect of "screening off" stresses, secondly as having the effect of directly lessening the individual's vulnerability, thirdly as hav- ing a buffering effect against the influence of stresses and emotional work (LAROG CO et al. 1980). Social support can however have yet another (fourth) function, namely that of being brought about as a result of complaints or for instance as a result of drug-taking. There can thus be a greater degree of social support particularly with suffering, or addicted, persons, be it in the form of care and sympathy, or in the form of supervision. These aspects show that the significance of this term is difficult to assess or at least only becomes clear when further factors are taken into account. (5) Complaints Complaints and indisposition could be seen as a necessary prerequisite for the taking of drugs. The relationship is however not as determining as that, but of a rather more manifold nature: trembling due to tranquillizers and hypnotics. Our main concem does not lie in establishing the significance of complaints. They Drugs may also been taken without complaints being present, e.g. In anticipa tion of stresses or in dealing with tension or conflict. Drugs are not always taken when complaints arise. This applies for example where protection is provided by a high degree of latitude, or where the complaints themselves form a means of expressive communication with others. Conversely, complaints can appear as a result of drug use over a long period: headache due to analgesics containing phenacetin; insomnia, depressions and 122 i i I I i i i t I I TIMN 321515
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THE CONSEQUENCES OF CHANGING SMOKING HABITS OF LUNG CANCER MORTALITIES IN 1990, 2000 AND 2010 H. Mantel, W.F. Forbes, M.lz Thompson and RW. Gibberd The association between smoking and lung cancer mortality iS well known, and suggests that different levels of smoking in a population will lead to different levels of lung cancer mortality. The future lung cancer mortality associated with dif- ferent smoking levels can be estimated quantitatively by the use of appropriate mathematical models. Such mathematical models can have three functions. They may provide a biological insight into the mechanism involved, they may provide information about the correct dose-response relationship and they can serve as a predictive tool for determining future mortality rates depending on the level of smoking. This paper describes a model with the latter function, that is, the estimation of future mortality rates on the basis of three different scenarios. The first scenario is that the cigarette consumption per person for each age and sex group will remain at 1981-85 levels. The second scenario is that average cigarette consumption per person will increase 10% per quinquennium until stabiliz- ing at 150% of the 1981-85 levels, and the third scenario is that the cigarette consumption per person will decrease 10% per quinquennium until stabilizing at 50% below the 1981-85 levels. These scenarios are selected to indicate the effect of different smoking levels and particularly to show that, because of the long latent period between exposure and the clinical manifestation of lung cancer, the effects of different smoking levels would only manifest themselves over relative- ly large periods of time. Hence, lung cancer mortalities are estimated for the years 1990, 2000 and 2010. The second scenario representing an increase of 10% per quinquennium is selected to emphasize what would happen if cigarette smoking were to increase further. Fortunately, this scenario is unlikely to be realistic for Western countries, but for developing countries it may help to illustrate the substan- tial increases in lung cancer mortalities which would be likely to occur if cigarette smoking were to increase. The third scenario is chosen to illustrate what the effects would be of a reasonably successful campaign to reduce the incidence and prevalence of cigarette smoking since a 10% reduction per five-year period does not seem to be an unrealistic goal. The analyses discuss lung cancer. although it is known that other diseases, specifical- ly heart disease and emphasema, are also affected by cigarette smoking. However, lung cancer, in countries where cigarette smoking is common among the popula- tion, represents the second largest cause of death for a number of age groups and is also becoming increasingly important for female populations in such coun- tries. It therefore deserves special attention in emphasizing the hazards of cigarette smoking, both to individuals and to public policy programs. That is, predictions of this type emphasize the importance of cigarette smoking for a major disease (lung cancer), and indicate how public policy programs, including educational campaigns and taxation, can be important in leading to significant reductions in mortality from such a disease. A number of quantitative models can be used to relate cigarette smoking with cancer mortality, including the Gompertz, Weibull and the Brown-Forbes model. Since In an earlier study, the Brown-Forbes model provided a very satisfactory fit to the relevant data in the sense that the R2 values obtained were greater than .98 and there were no patterns in the residuals from the model' 2 it is also used in the present study. The concept behind the Brown-Forbes model arose from various studies reporting deterioration with age of many physiological functions. The model relates the amount of physiological damage at a given age to the cor- responding probability of death from a related cause for an individual at that age. In order to extend this model so that lung cancer mortality can be related to cigarette consumption the following assumptions were made: First, the "damage" to the lung is distributed normally for a population at time i of particular age _, and cumulative consumption et=1 . Second, when a critical amount (above a certain cut-off level) of damage has accumulated, death from lung cancer follows. Third, the expected damage in the lung is a linear function of both age and cumulative consumption, that is the mean of distribution at age and cumulative consumption ct=1:d+d- +Yci.l, with variance - . It should be noted however, that in this model, lung cancer mortality rates are not related linearly to cigarette consumption. Fourth, the variance in the distribution of damage is constant for all ages and values of ct=i . Given that the mean of the of the distribution of physiological damage at age = and cumulative consump• tion et=i: a'+ d: +Yct:l, the probability of developing lung cancer by time = is given by where mW - 1 - 0(a + Px + ryC(zA a= cv~,0 v ,7 a (1) and # is the standard normal cumulative distribution function. It should be noted that no "sex" term is included In the model. Consequently any differences in mortality observed between the sexes will be due to differences in cigarette con• sumption. In carrying out predictions using this model, cigarette consumption data and mor- tality data are required. Such consumption and mortality data are available in some detail for recent years for the U.S. and for Canada. Since the U.S. data are more comprehensive than the Canadian data, the former have been used, although predictions for Canada would be expected to be similar. METHODOLOGICAL CONSIDERATIONS The lung cancer mortality data and smoking data for the different cohorts are listed in tables I and 2. In the calculations a number of assumptions are made which are outlined in detail in a previous publicationz. However, it should be emphasized that there is litUe doubt that standards of diagnosis of lung cancer have improved during the last 50 years and hence in order to compare death rates for different periods of time, It is necessary to adjust the reported death rates to approximately what they would have been if there had been constant standards of diagnosis. Consequently, the lung cancer mortalities were adjusted using indices of diagnostic accuracy as shown in table 3. Other indices of diagnostic accuracy, and particularly those of Doll and Peto3, were also used but the predic• tions did not alter markedly when this was done. An adjustment was also made for different tar (nicotine) deliveries of cigarettes consumed over the time period under investigation. Specifically, it was assumed that an a% change in measured sales-weighted tar delivery per cigarette (determined on a smoking machine) results in a 0.5GC% change in actual tar delivery (to the lung(; tnat is, some compensa- tion is assumed to occur. The results of these adjustments are shown in Table 4. Again, assuming different changes in actual tar deliveries, that is, 0.75a% or a%, did not change the predictions to an appreciable extent. It should also be noted that it is assumed that smoking is causally related to lung cancer; the im- plication is that it is assumed that if smoking were reduced or increased, there would be a corresponding decrease or increase In the lung cancer mortality rates, as given by equation I13- RESULTS The mortality data shown in table I and the consumption data shown in table 2 were used to estimate the parameters of the Brown-Forbes model. The con• sumption data were first transformed into cumulative constant tar cigarettes under the assumption of a 50% compensation for reductions in measured sales weighted average tar delivery per cigarette (see table 41. That is, for example a 10% reduc- tion in tar deliveries, as measured on a smoking machine, Is assumed to corres• pond to a 5% reduction in lung exposure. Using these transformed data, the parameters in the Brown-Forbes model were estimated by their maximum likelihood estimates. These estimates were then used to project future lung cancer rates under the various scenatios. Table 5 shows the projected U.S. lung cancer mortality rates for the years 1990, 2000 and 2010. The three scenarios illustrated in the table all assume that sales- weighted average tar deliveries per cigarette remain at the 1981-85 levels. Scenario I fSl I assumes that the age-sex specific consumption per person remains at the 1981-851evels. That is, it is assumed that present trends, for example, the recent increase in consumption for females in some age groups (see table 2), will not 126 TIMN 321519
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What would I change about my past if I could? Why? Do I want my life to change? Why? Why not? What kind of weather do I think of when I think of my past? My present? Why? What advice would I give another person who may be trying out my life for awhile?. Why? What would I tell this person are the good things in my life? Why? What would I tell this person are the bad things in my life? Why? What would I warn this person about my life? Why? Topic 2: Sanity Fear Power What color am I when I am normal? Why? What sound am I when I am normal? Why? What taste am I when I am normal? Why? What texture am I when I am normal? Why? What sensation am I when I am normal? Why? What color am I when I am crazy? Why? What sound am I when I am crazy? Why? What taste am I when I am crazy? Why? What texture am I when I am crazy? Why? What sensation am I when I am crazy? Why? What kind of place do I think of when I feel normal? Why? What kind of a place do I think of when I feel crazy? Why? Do I look any different when I feel normal? Why? Do I look any different when I feel crazy? Why? How do I act when I feel normal? How do I act when I feel crazy? Who are the different people caught inside of me? How do they act? Which ones are good and which ones are bad? When I am alone and afraid (even when I am in the company of other people), what color am I? Why? What sound am I? Why? What taste am I? Why? What texture am I? Why? What sensation am I? Why? What shape am 1? Why? Who are the powerful people in my life? Why? Do I feel comfortable with those people having power in my life? Why? Why not? What color is power in my life? Why? What texture Is power in my life? Why? What sound is power in my life? Why? What shape is power in my life? Why? What sensation is power in my life? Why? What taste is power in my life? Why? How can I get more power in my life? Topic 3: Trust Is it easy or hard for me to trust people? Why? How do I know I can trust someone? Trust reminds me of what kind of a day? I trust someone with my feelings and that person hurts me. When I am hurt by trusting someone, what color is trust? Why? What sound is trust? Why? What shape is trust? Why? What taste is trust? Why? What sensation is trust? Why? What texture is trust? Why? What smell is trust? Why? What kind of animal would I be if I trusted someone and I was hurt? Why? What kind of animal would I be if I trusted someone and was not hurt? Why? Can my best friends trust me? Why? Why not? 131 How do I know when someone can trust me? When someone cannot trust me? Topic 4: Anger Do I let people know when i am angry? How? What things about myself make me angry? What do I do when I am angry? Why do I get angry? What color am I when I am angry? Why? What taste am I when I am angry? Why? What shape am I when I am angry? Why? What sensation am I when I am angry? Why? What smell am I when I am angry? Why? What sound am I when I am angry? Why? Why do I get angry when other people tell me that I am wrong? How can anger be good? What kind of day do I think of when I am angry? Why? How do I feel after I have gotten angry at someone? Why? What are some ways I can express my anger without "losing it"? How have other people hurt me with their anger? How have I hurt people with my anger? Topic 5: Attributes Wrongs Honesty What are the good things about me? What color are the good things about me? Why? What sound are the good things about me? Why? What texture are the good things about me? Why? What shape are the good things about me? Why? What smell are the good things about me? Why? What sensation are the good things about me? Why? How do I feel when someone tells me that my behavior is wrong? Why? How do I want to react? Is It hard for me to be honest about admitting the wrong things that I do? Why? What color are the wrongs about me? Why? What sound are the wrong things about me? Why? What sensation are the wrong things about me? Why? What smell are the wrong things about me? Why? What texture are the wrong things about me? Why? What shape are the wrong things about me? Why? How do I benefit by being honest? Why? How do others benefit by my telling the truth? Why? How am I hurt by not being honest? Why? How are others hurt by my not being honest? Why? Topic 6: Change Self Discipline What color am I when I try to change myself? Why? What sound am I when I try to change myself? Why? What texture am I when I try to change? Why? What sensation am I when I try to change? Why? What shape am I when I try to change? Why? What smell am I when I try to change? Why? What does change involve? Do I want to change? Why? Why not? What changes can I make within myself in order to have a happier life? Can my friends help me to change? How? Can my family help me to change? How? How come some people never change the bad things about themselves? What things can I do to help me get through the stress of changing? What sound do I think of when I hear the word "discipline"? Why? TIMN 321524
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A COMMENT CONCERNING METHODOLOGY OF ALCOHOL CHOICE EXPERIMENTS H. G. TI7TMAR AND D. STEVENSON SUMMARY When conducting liquid selection tests, e$. alcohol choice, it ~ normal to negate position preference, and it is also anticipated that the liquid consumption, while not being steady from day to day, will at least be stable. Consumption of water by ad lih control rats was measured over a four week period, noting the daily consumption, as well as their daily non-consumed watec Pbtting one against the other gave rise to a negative regression. Consequently, the fuller the water bottle, the less liquid is consumed, and dai- ly drinking rate is influenced by the total liquid in the bottle. Thus, some of the daily variability in male rat liquid consumption is due to a procedural weakness, which may have been incorporated in previous choice selection experiments. It Is known that a non-gravid rat, in a self-selection experiment, will consume about 20 % of its daily liquid requirement in the form of 10 % alcohol solution (ETOH) (foisander; 1967). Spread over a day, such consumption does not necessarily pro- duce an ideal animal model for studying the effects of alcohol. Instead, various techni• ques have been established, which would modify the quantity of alcohol ingested. using intermittent fasting, 10% ETOH was presented for two hours, followed by tap water for approximately two minutes. Under these conditions, rats consumed between 40-58% of their total liquid intake in the form of ETOH. Re-expressed, ethyl alcohol consumption was shown to exceed, on days 6 and 12 of gestation, a mean of 2g/kg (TittmaS 1974). Even though the facilitated alcohol intake by the alcohol treated mothers was high, the method of administration, intermittent fasting, imposed only a temporary in- trement in alcohol consumption. Support for this conclusion came from a liquid selection test (Table 38 in Tittmar, 1973), in which these mothers expressed no preference/aversion to ETOH when compared with controls. Thus, it was conclud- ed that a transient increment of alcohol intake may be achieved by the manipula- tion of food and/or water intake The advantages of this model have been compared with those proposed by Chernoffs model (Tittma; 1984), and amount to being synonomous with Phase ll vs Phase I of the reproduction segment of the Guidelines fOr Reproduction Studies for Safety Evaluation of Drugs for Human use (Schardein, 1977). This model has successfully been adopted by Sandor et al. (1984). While there appears to be no evidence that the response for increased drinking of alcohol was not transient, it hinges nevertheless upon the results of the liquid selection test. In particular we wish to highlight here not just the validity of our liquid selection test, but that of all others! A case for taste? A case has already been made that alcohol may be seen to be a poison, as is reflected by drinking rates of rats for daily increasing concentrations of alcohol in a self selection experiment (Tittmar and Coleman, 1985). It is certain that alcohol can affect the body's water balance (e.g. Modell and Lansing, 1968), and that reduction in intake may be caused by its taste. It has been suggested by Larue lpersonal communica- tion) that rats, when presented with a bitter solution (e.g. quinine) will reduce their t0tai liquid intake, which may be artificially raised again by presenting them with tap water near the end of the liquid intake session. Certainly, as regards food selection, there appears to be a latent period before a Preference for a particular food is displayed by a rat (Anon, 1972), which, one would Presume, may also apply to the selection of liquids. Such preference, or bias, is not always substance related. Goodrick (1972) found that mice, in a 7-bottle preference tM showed a bias towards the bottles at either end. The simplest way of eliminating this Position bias, is to limit the preference selection test to two bottles. It also im- Plies that bottles require to be interchanged, such that the selection is one of substance Pre(erence and not of position preference. Given a choice, rats would not take alcohol solution in concentration much above 6% (Richter, 1941). Indeed, being forced to consume 10% ETOH, our own rats showed a peculiar posture when drinking from their bottle, turning their head backward and upward. Also noted was, that full bottles needed more licking than did so bottles that were half full. The effort required for a rat to attain liquid from a bottle should be proportional to h& where h Is the vertical height of the liquid, its densiry, and g the ac- celeration due to gravity. Given a choice of two full bottles, a rat, if governed by effort to be exerted for drinking, ought to select the alcohol solution, due to its density being less than the water's. If there is a taste aversion, then this shouid reflect in a water preference, which should become stronger as the water level decreases. Thus, taste apart, it was proposed that daily liquid consumption will be dependent on the fullness of the animal's water bottle. Consumption experiment Twenty male Wistar rats of approximately 200 days of age were moved into an experimental room, caged individually and supplied with ad lib. food and water. They were allowed a two week acclimatisation period, being kept at 21 ± 2°C and on a 12 hour light cycle with the light coming on at 7 a.m. During the ex. perimental phase, water bottles were removed after 3 p.m. for weighing, and refill• ing as required. As a matter of routine, the rats were weighed weekly. Water intake data was gathered Mondays to Fridays for four weeks. This data was plotted collectively as the daily starting weight of water and the daily consumption for each animal (16 points) and for all available data (320 points), the latter being shown below. Top: Scatterplot and regression line fit of daily fullness of water bottle with daily water intake by male Wistar rats. Bottom: Plot of residuals from above regression line fit. Of 20 rats, none showed a positive relationship, one produced no relationship two a weak negative one, and the remaining 17 showed a strong negative relationship of the kind illustrated above. The data 1320 points), being interval in nature, was correlated using Pearson's method, yielding r=-0.4891 (t=-9.998, p<0.0001)• A couple of the results were suspect. Thus, one rat (-# 12) seemed to "play" with its water bottle and, for one day, showed a 50% increase in water consumption, while another (# 101 seemed one day to have had an air lock in.its water bottle spout. Since we could only surmise these deviations, all data was retained, and the plot of residuals supports the existence of a linear relationship of the order. Y=47.68-0.034X Discussion The above scatterplot, and its associated statistics, distinctly confirms that a rat's daily water intake is dependent on the fullness of its water bottle. Just as one may wish to control for calory intake, should one not also control for hydrostatic pressure in a choice selection experiment? Given the conditions of a selection experiment, 113 TIMN 321506
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will however be taken into account as control variables in the assessment of other aitluences. order to safeguard our interpretation, refering as it does only to psychotropics and algesics, against the fact that groups consuming fewer drugs take other substances their place, we have also investigated multiple outcomes for alcohol and d)ugs. METHOD AND SAMPLE effects of the influences mentioned were considered with the reference to four ation groups and two random samples (Table I). TaOle I SaFqles, popolation and kind of tnrestiq+ttcn ~ rployrd aKn (aeerage ap. • qepretenUttve Sample of thl~+ (M • 550) a"1.5 yea•S) popnlatlcn of Yest-6erxuny house•tves (arerage a]r • (M • 1996) in 198) -~i (h • 31e) 43.3 yrars) : (lnterruw) L. eroloyed .n+mn (d.rraq. a7. 32;) 35.7 Yr.rs) Sanpir of fe•~aIe clerks v, the fe.wi< offfcr CarrrAyr .y • +0'trlnlstratlun of 3lemG.ry (h • - ..,ner5 JS.: Y•rrt) 196) In 1BCd (b • 190 (Isterrle., wrdfcal ru^fn+t,oo. q.A5tl~Mlrr +nd obSYrYAIt.M) In order to explore those relationships specific to sub•groups, the populations stated re were examined by means of cluster analyses (WISHART 1982). For the assess nt of the significance of individual factors along with a statistical control of the uence of other variables, stratified analyses with the calculation of odds-ratios were r/r¢t. 2 Svrey Yr tGe Hd<r,3 Rntnl ornw r¢m ik,1N rdren/oo (1Mt) dylore+re. (x•us) Ileietim Ytx<n tneq llicn ax .d r«l,l {yort warviled fer Jo6 l,tltu4 m/ eee Arua rrr (l) prr<tut) 3p.5t 6.t1 ksA J.9t low ktA lor tal suprort , lel ruppon, `I« kid Jn\ 1„tude o.rr ao lrarr ef ae ID.Ut ,,.JS th•,t 6sA lo- AlA Ir eclel eurport/ `ex/al eupport, t Iw ' ktA Joa lnftua< under ao Yearr ef eie rla¢re 3 el,tl.w brtveen tr,/qutltier u ,M prefturr due to ti.e f.ctorr rentrolled for Jo6 1•t,tNe. pan aM aer I. the rqrlnrea .en c.tetarr .na u..r. pe prrreetl n.c 1 i t 13.3 J3.J us W a.l t.~ Tmsvr tir prerru< tir prc+rurr t3ac tet+nu, tue pressu.r tu. pmrute tlne presrvre ti.e rrrfwrt nld In. hs{i~ 1« ktd . Io. A/A Io. S ,N• latriW. lon I,tlrudr J¢a l,t,tude 3o6 l.tltude .1tA p,tn at/an p,ln atl. r,tn H,fwt r•fv 1 Who takes more psychotropics and analgesics: men or employed women/housewifes? algesics and sedatives are used more frequently by women than by men. The erence is particularly marked between the ages of 40 to 49 years: approx. 50% the women, but only 37% of the men consumed analgesics in the three months before the survey; in the case of sedatives the figures were: 36% of the housewifes, 21% of the employed women and about 11% of the men. Lttr p Yter N.~uf~ruct .M truqu/hrrn as.q nomwbet, erel¢pea .o.n .re rn ln fow prow- of aye IIn a<rrrm) Is.T9 re+ri 3C•31 y<•rt ~p.15 pr•rs •oufr eq1¢reA Mvu• eii¢arA Iwae. rRlo3ed ./,ef snrn •rn a.<r .a.<c - -,. .wen .en 50.a)Ia5 3e.•, .o•su- eql¢>ro M•fril<f .5.6 at.a 35.e 53.5 53.0 ai " Sr.r Sr.S 3f.e af.e 55.1 al.c tr.o¢.,.I~.rr It.t lS.r 1).S }.,d f/.] 19.1 N.e I1.5 32.3 a>.- iE.} }>.g 3.2 Risks for the use of sedatives and analgesics The following is a presentation of the results of the re analysis of the four above mentioned groups: - a) Employed men 11, this population group it is evident that a marked risk is added to the cumulation of unfavourable conditions (pressures, low degree of latitude, lack of social support). The extent of perceived social support provides a significant protective function (cf. - figure 21. The time pressure factor represents a significant risk for the use of tran- r, quilizers. The analysis could not confirm an isolated protective effect of job latitude ~ 1cf figure 31. 123 a~r .c 3e•n uf efe uNrr .n .e,s ef are rrr+r< .. Rel,ttee !<tveen .n,lae.lr u •nA tAe t/tAOt¢n,i<A srre.atndea [er Anure.tera d1r1A<d int¢ t.o .ae arour, orrr en rr,n ¢r yr Int; em M 1f, idl 1a. ~tu< ~e. stres (W.tl (I^13/ (Ma 1 tnuLt•nlih (eortecud rer cust OS_Sg.rt . S.a . p•.3r 3ot u.t AS Yll 1M Ir. •Ntv Alky flMf IL•!Si (bt0) (NSi) Ou•Spure . ,.33 / r•.i/ rtrat. . eri,teo. e<:.ern t.np.a.:er ... .nd tar Irunntoaird urr»tnar, ror h¢..e.,.es +iadrd i.,e t.r sr v¢.rs ..wr .e t<.n ot .a. 3n• i arn '). 3M i J ..~r .. .r,r. .r sr. lu. sd:~s Yd `~ lu ud,i,. n~H (.-.tl p+•ta n++.~ 1'~etp lw-I M-Sa trrk,t+•fIU IcorrrcteA rw ne.. a,-sa.rr, - r.a . r.¢.• t3n.sa+•m . .$a . TIMN 321516 A.a
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Table 3: CURRENT LEGISLATION•IN NESiERN-EUROPE I I ~ ~ related offences Ipuaisheant previdai] prtic.lars cencersing I particulars concerRSng I fer related I precedural aspects ef drug offences I procedural aspects of drug offences I effeaees I - step and search preeedures etc.- I- dismissal of drug cases, dropping charges -I i 1~ FRG ~ - ~ I a person suspected having committed a ~¢ 29 V Narcotics Lav, if the drug offence I crime according to $ 29 1 1. 4. 10, III, ~ involves only minor quantities and if the I I I I $ 30 1 Narcotics Lav eay be sent to pre- ~ drugs are for personal use only, charges ~ I trial detention, whereby the order of a may be dropped. ~ I I ~ I pre-trial detention is justified if it can I $ 31 Narcotics Law: charges may be dropped ~ I be assuaed that the suspect vill recidi- I if the suspect cooperates with the judicial I I I ~ I vates ($ 112 a I No. 2 Procedural Lav); I or police authorities and if cooperation ~ I search of premises during the night is I results in the clearing of other drug ~ I alloved in serious cases ($ 104 II ~ cases. ~ Procedural La.); telephone vires eay be ~$ 37 Narcotics Lav: a drug case can be dis- i tapped in serious drug cases. ~issed if there is reason to assume that ~ ~ the sentence will not exceed 2 years of ~ iaprisoneent and if the suspect agrees to ~ I I ~ a certain period of treatment. ~ Austria ~ public instigation or ~ imprisonment up ~ - ~ a drug case .ust be dismissed if it in- ~ ~ ~ public approval of ~ to 6 months or a ~ ~ volves possession or purchase of a quanti- ~ ~ ~ drug use ~ fine ~ ~ ty of drugs which does not exceed a ~ ~ ~ quantity habitually consumed during I week ~ a.d treataent is not indicated or if ~ ~ treatment is currently applied ($ 17 ~ Narcotics Lav) I ~Suitzerlandf Art. 19a IV Narcotics Lau: charges can be ~ ~ dropped if the offender undergoes ~ treatment, but only in drug cases defined ~ by Art. I9a Narcotics Lav I ~ France ~ public instigation to ~ 1-5 years ~ search of premises during the night ~ the public prosecutor may dismiss any cast ~ ~ ~ drug use, glorification ~ of imprisonment ~ in the case of Art. 627 Narcotics Lav. ~(principle of opportunity); a case eust be ~ ~ ~ of drug use ~ ~ Police custody can be extended up to 3 ~ dismissed if a first offender undergoes ~ ~ ~ days by order of the public prosecutor or ~ treatment (Art. 628-1). ~ the court (Art. 627-1). ~ I ~ ~ 8elgius Art. 7. $ 3 Narcotics Laa: judiciary ~ the public prosecutor's office may dismiss I ~ police may search any premises which are ~ any cases (principle of opportunity). An ~ used to produce, anufacture, keep drugs ~ offender will not be punished if he ~ ~ ~ or those preeises vhere people come ~ cooperates vith the authorities and ~ together to consume drugs. ~ cooperation results in the detection of ~ ~ other drug cases or the arrest of drug ~ ) offenders, and if the punishment ) provided by law for the actual drug ~ offence does not exceed 5 years; ~ in serious drug cases punishaent eay be ~ reduced to 6 eonths-2 years I ~ Netherlands Art. 9 Opiuevet: police hare access at any ~ the public prosecutor's office may disaiss ~ ~ j time to vehicles and preaises, where ~ any drug case (principle of opportunity) ~ ~ ~ it is knovn that drugs are kept. Appart- ~ I ~ ~ eents may be searched under these circue- ~ stances if it is ordered by a poiice ~ i officer ~ ~ Italy ~ public advertiseeent ~ 1 aonth-3 years ~ in drug cases suspects are to be detained prior to the trial I Spain ~ England a person aay be stopped and searched by ~ the public prosecutor's office ay diseiss ~ the police vithout judicial permit if ~ any drug case (principle of opportunity) ~ there is enough evidence that the suspeet ~ ~ has drugs on hia; premises ay be ~ ~ searched after obtaining a judicial ~ I permit vhicb eay be granted oa the basis ~ of inforaation on oath that there is a ~ I ) )~ ) ~ reasonable ground for suspecting ~ a drug offence ~ ( Sweden ~ illegal iaport of ' iaprison.eot ~ syringes and needles ~ up to 2 years ~ ~ or a fine ~ illegal trade in ~ imprisonment ~ syringes or needles ~ up to 1 year ~ ~ or a fine ~ ~ any drug case can be dismissed ~ ) (principle of opportunity) I ( I / 138 TIMN 321531 = _ ~
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cross addiction to alcohol. Lifestyles factors causing stress (e.g., marital, financial, legal) are also examined. The source of the drugs is determined and a check is made for multiple prescriptions being obtained through more than one physi- cian. The assessment worker also takes on a case management role and, in col- loboration with the client's physician, will try to link the client with non-chemical alternatives for stress management YM-YWCA and community college programs in assertiveness training, biofeedback and stress management are commonly utiliz- ed. In dealing with lifestyle stressors, assistance may be provided on the budgeting of household income, seeking employment alternatives and the use of leisure time. This assistance is provided by the case manager or through appropriate referral. The growing concern over the potential misuse of prescription ps~khotropic drugs has led to consideration of the means by which the health and social service delivery system should reach out and respond to the needs of people with pro- blems related to their drug-taking. In voicing this concern and planning effective community interventions, it is important to recognize that many high risk users of prescription psychotropic drugs are already in contact with the local health and social service network. The results of the survey of agency clientele clearly indicated a much higher frequency of use of psychotropic drugs across a wide cross-section of community services in the region. The high rate of drug use cut across all age and sex sub- groups. Of particular interest was the absence or reduction of the age and sex differences in the use of tranquilizers and sleeping pills that are commonly observed in the general population. Young adult males seemed to be particularly high users in this population. As much as 4.7% of the agency population reported long-term (i.e., 12 months) daily use of minor tranquilizers, a rate about three times that in the general population. Although the prevalence of use varied considerably across the two study popula- tions, the data comparing patterns of minor tranquilizer use in the two groups showed few differences. Approximately one-third of users in both populations were long-term daily users, suggesting that the risk of drug dependency among users was similar. There was an indication that minor tranquilizers in the agency population were used more often than prescribed. Although strong generalizations to the total agency population in the region are not possible due to the sampling design of the study, these results are strong enough to suggest the need for standard procedures to be employed in community agen- cies to screen for prescription drug problems among their clientele. This could be done in the context of the intake Interview and could be incorporated with brief questions concerning alcohol and Illicit drug use. The results of this study have been used to develop a comprehensive training project for staff of regional health and social service agencies, concerning the iden- tification of clients with drug problems. The general objective of the training is to ensure that health and social service professionals have the tools and skills to identify persons experiencing drug-related problems and to enlist the support of the local addiction treatment network, as well as local physicians, in assisting these persons. The key aspect of effective intervention with individuals experien- cing prescription drug problems is likely to be the coordinated effort of the physi- cian, health and social service professionals, and local addiction services, in order to present a consistent message regarding drug use, health and alternative lifestyle. Footnotes ' Sedative-hypnotics were not included in this classification of "psychotrope". 2 See Simmons et al. (31) for a more complete description of the survey methodology and sampling procedures. ' Twenty-seven questionnaires were not sent due to clerical error, thereby reducing the number of mailed questionnaires from 1,461 selected over the telephone to 1,434. References Cooperstock R, Parnell P: Research on psychotropic drug use: A review of findings and methods. Soc Sci Med 1982; 16:1179-1196. Power B, Downey W, Schnell BR: Utilization of psychotropic drugs in Saskat- chewan: 1977-1980. Can J Psychiatry 1983; 28(7):547-551. Regle de I'assurance-maladie du Quebec: Statistiques annuelles, 1980. Quebec, 1983. Bohnen E: Women and health promotion. Strategy paper for the Ontario Regional Office, Health Promotion Directorate, Health Services and Promo- tion Branch, Health and Welfare Canada, Toronto, 1980. Keller MF, Green MA: Multiple prescription drug use among rehabilitation clients referred for psychological evaluation. Rehab Counsel Bull 1981; 25(11:26-29. Tu J: A survey of psychotropic medication in mental retardation facilities. J Clin Psychiatry 1979; 40:125-128. 5. 6. 7. Frey DD, Hetherington RW, Glassman D: The use of prescription drugs in treatment of first•time psychiatric admissions to University Hospital, Saska- toon. Soc Sci Med 1978; 12(3a):169-174. 8. Edwards S, Kumar V: A survey of prescribing of psychotropic drugs in a Bir- mingham psychiatric hospital. Br J Psychiatry 1984; 145:502-507. 9. Greenblatt DJ, Shader RI, Koch-Weser J: Psychotropic drug use in the Boston area. Arch Gen Psychiat 1975; 32:518-S21. 10. Simmons M, Rush B, Finlay R, Timney C: Licit and illicit drug use in the Durham Region. (Internal Document No. 30). Toronto, Addiction Research Foundation, 1984. 11. Groves RM, Kahn RL: Surveys by telephone: A national comparison with personal interviews. Academic Press: New York, 1979. 12. Tyrer P, Rutherford D, Huggett T: Benzodiazepine withdrawal symptoms and propranolol. Lancet 1981; March 7:520-522. 13. Hopkins DR, Seithi, KBF, Mucklow, JC: Benzodiazepine withdrawal in general practice. J Roy Coll Gen Pract 1982; 32:758-762. 14. Pool JS: Consumption of prescribed drugs in Canada. (Unpublished manuscript). Ottawa: Non-medical Use of Drugs Directorate, Department of Health and Welfare, 1977. 15. Health and Welfare Canada: The health of Canadians: Report of the Canada Health Survey. Health and Welfare Canada and Statistics Canada, Catalogue 82-538E, Ottawa, June 1981. 16. Mellinger GD, Balter MB: Prevalence and patterns of use of psychotherapeutic drugs Results from a 1979 national survey of American adults. In G. Tognoni, c. Bellantuono, and M. Lader (Eds.) Epidemiology impact of Psychotropic Drugs. New York: Elsevier/North-Holland Biomedical Press, 1981. 17. Mellinger GD, Balter MB. and Uhlenhuth EH: Prevalence and correlates of the long-term regular use of anxiolytics. J Amer Med Assoc 1984; 251(7):375-379. 18. Committee on the Review of Medicines: Systematic review of the ben- zodiazepines. Br Med J 1980; 280(6218):910-9i2. 19. Murray J, Williams P, Clare A: Health and social characteristics of long-term psychotropic drug takers. Soc Sci Med 1982; 16:1595-1598. 20. Sandifer MG, Stolldorf D: Psychotropic drug prescribing in a family medicine residency program. J Fam Pract 1980; 11(7):1077-1080. 21. Skinner PT: Skills not pills: Learning to cope with anxiety symptoms. J Roy Coll Gen Pract 1984; 34:258-260. 22. Berner MS: Benzodiazepines: An overview. Ontario Med Rev 1982, April: 233-239. 23. Catalan J, Gath D, Edmonds G, Ennis J: The effects of non-prescribing of anx- iolytics in general practice. I. Controlled evaluation of psychiatric and social outcomes. Br J Psychiatry 1984; 144:593-602. TIMN 321514 121
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CRIMINAL LAW AND DRUG CONTROL-A LOOK AT WESTERN EUROPE HansJdrg Albrecht 1. Introduction Despite some differences in the degree to which drug use ant drug addiction are treated as problematic in Western Europe, It is obvious that the cirminal law approach to drug control has been strengthened since the end of the sixties. There was and there still is a unique concentration on criminalizing certain kinds of drug leaving aside the traditionally tolerated drugs deeply rooted in the Euro- pean culture such as alcohol, tobacco and medicaments. Although there is enough reason to assume that social costs in terms of health risks resulting from the abuse of tobacco and alcohol exceed by far risks resulting from illegal drugs, criminalizaiion of tobacco and alcohol Is a non-issue. But comparing death rates related to the abuse of different kinds of drugs we may conclude that illegal drugs, especially heroin, have an insignificant impact only. In Switzerland, e.g., absolute figures show that in the year 1982, 1.173 deaths were caused by the abuse of alcohol, 5.000 could be traced to be the result of the misuse of tobacco and 561 were due to the misuse of medicaments. But only 102 fatalities are related to the use of illegal drugs, a proportion of 1,5%')- These distributions can be reproduced in every industrialized country with no European country experiencing more than 0,5/100.000 drug related deaths per year. That is why there are always various problems in justifying the repressive approach to drug control which cur- rently puts forward the aim of protecting general health standards in the popula tion. In accepting this goal of criminalization of drug abuse and drug trafficking we should admit that there does not exist any rationale which might justify the discrimination between traditionally accepted or legal drugs on the one hand and non-accepted drugs on the other hand2). 2. Criminalization of drug trafficking and other drug related behaviour in Western-Europe Criminalization of drug trafficking and drug abuse in Western-Europe is a relatively new phenomenon3). If we leave aside earlier opium laws which were introduc- ed at the beginning of the century, the onset of criminal legislation covering most of the now known soft and hard drugs can be traced back to the sixties when all European states agreed with the Single Convention of 1961*. Following the lines of the Single Convention, European states adopted criminal statutes concer- ning drug trafficking and other drug related behaviour which were subjected to various and significant changes during the seventies and eighties. Since drug offences can be labelled at least partially as transnational crimes with large amounts of drugs being transferred from one country to another and in- volving offenders of various nationalities, the problem of coordination of national drug laws and cooperation between the different justice systems and police organizations arises. The need for coordination of criminal law in Western-Europe can be seen to be the result of a social and economic developmental process which is characterized by internationalization of economics, the rise of multi- and transnational corporations, mass tourism, the implementation of new communication-, information- and transportation-systems reducing distances in terms of time, in Western-Europe furthermore by attempts to ease border con- trols . The reason why the issues of unification and coordination of national penal laws in Europe became widely discussed political topics is not only due to an urgent need to make criminal justice and police investigation in the area of transna- tional crime more efficient and to tighten control, but is also based in the need for adequate legitimation of national criminal laws which today is affected by international standards, too. Discrepancies between national criminal laws in terms of punishability or the punishment provided by law or meted out by criminal courts do not only produce opportunities for offenders to switch their activities from one place to another but may also contribute to the weakening of general prevention attributable to criminal law if those laws are perceived by major segments of society to be negotiable in an internationally comparative perspec- tive and to vary along the dimension of culture and nation. The various efforts to control cultivation, trafficking and abuse of illegal drugs are based on perceptions and beliefs which indicate a quite serious and dangerous situation in Westem-Europe6). 3. Drug problems in Western-Europe But official data on drug problems do not provide a reliable and valid basis for the assessment of the magnitude of the drug problem. Data about the amount of seizured drugs, data about arrested drug offenders, mortality cases being the result of drug abuse are but of an ambivalent character. These data might be in- terpreted also to be indicators telling us something about the efficiency of drug control or the quality of different drugs or life conditions in the subculture of drugs. Reviewing the existing evidence provided by research about the drug pro- blem resulting from various European countries, we may summarize the following: 1. The spread of drug use occurred essentially in the 60ies and in the first half of the 70ies. 2. During this development the formerly metropolitan bound drug problems swept to the countryside, too. 3. The drug scene has undergone considerable changes in these periods. While in the 50ies and the 60ies opiate use was restricted to a small number of individuals, at the end of the 60ies soft drugs became an important feature of the so-called subculture of youth. The wave of soft drugs passed leaving behind hashish and marihuana as plausible recreational alternatives in the world of adolescents and young adults. But in the 70fes hard drugs, especial- ly heroin were introduced to Europe with a subculture of drugs being the consequence. 4. Among the drug addicts a shift in consumption patterns can be observed in• dicating that it is more common today to use more than one kind of drug. 5. Cocaine has become a prominent drug since the end of the 70ies. 6. Hashish and other soft drugs are continuing to play the dominant role among illicit drugs being used cuttently in Western-Europe. 7. Drug trafficking is, at least large proportions of it, part of organized crimes activities. 8. Rates of prevalence of illegal drug use are quite high, if estimated on the basis of population surveys and responses to the question whether somebody has ever used illegal drugs. Yet the core problem of addiction resp. the problem of frequent or habitual abuse of illegal drugs is restricted to a relatively small group of drug users. This hard core group should in all those countries where surveys were carried through not reach a 1%-proportion of the population segment studied. With respect to these summarized points, It may be stressed that epidemiological research (which is currently available only for a small number of countries) does suggest that the number of persons currently using or ever having used illicit drugs has stabilized in the last years. Summarizing the existing evidence (table 5) about the prevalence of drug abuse in European countries, it can be shown that there exist considerable differences among European countries, if any kind of drug abuse is counted. Nevertheless, the proportion and magnitude of extreme groups, that means, persons who inject drugs or use drugs in other ways habitually, do not differ to a significant extent. Statements about the proportion of addicts vary between 0,1% and 0,2% of the population at large. The assumption that problems of drug abuse have stabilized in recent years Is not refutable by the evidence derived from offlctal statistics showing that the number of police recorded drug offenders is increasing at the end of the 7Oies and at the beginning of the 80ies in almost all European states7. Furthermore, the evidence that international drug trafficking is part of organized crimes ac- tivities should also be regarded to be compatible with the assertion of a stabilized drug problem. Sharp increases in the number of police recorded drug offenders and the ongoing process of organization and rationalization of drug trafficking can be explained by an enormous advance in police efficiency in controlling drug trafficking and drug abuse. Efficient police control and strict enforcement of drug laws have contributed to set into effect market mechanisms which regulate distribu- tion and diffusion of illicit drugs. The take-over of drug trafficking and drug distribu. tion by organized crime may be explained by external strains which are pressing drug trafficking towards organization and rationalization. This assumption suggests that organized drug trafficking is a response to the in• creasing efficiency of police and criminal justice agencies in drug control. If the risk of detection and conviction is not very high, then a larger number of per- sons probably will commit drug offences in terms of trafficking or distribution. But if punishment is severe, if the risk of punishment is quite high, non-professionals who would be prepared to commit drug offences at a lower risk drop out of the market and if the demand for drugs continues on the same level or even increases, criminal organizations will take over which are able to calculate and minimize the risk. Organization and rationalization of drug trafficking and drug distribu- tion therefore should be seen to be an adjustment to advances in control and repression. As far as causes of drug abuse or causes of the demand for illicit drugs are con- cerned, little is known until today. But it is evident on the basis of deterrence 133 TIMN 321526
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i rJbtS I (COeflhcArlOh): J J erdi.ary dr.g .fftaces J p..isk.eat J yrivileged I peoisk.eot J aggravated cases ~ ( J prorided far J offeaces• J provided fer J ef 4ag offcnces J ( ( .rdi.ary J J prieileg.d ( J eaceptional J clrcYestances Yhich ~ J eaclude punisheent I J I drng .ffences I I drug .ffencea J J i IsetherlandsJ Art. II OpiusYet: "spft drugs': J naieue ~ if quantities less J i.Drison.ent up J ~ J ~.anufacturing, seliing, J i.Drison.eat: J than 30 g are ~ to I.anth ~ ~ J ~ procuring, transport. ~ 2 years er a ~ invelved ~ or a fine J ~ J J production, adrertiseeent, J fine J ~ possession, keeping, J I I ieDOrtleaDprt ~ eaaioue I .I J laBrisoNent: ~ J ~ i years or a J ~ J fine I I Art. 10 Opiuoats "hard drugs": J oaaiaue J J keeping, possession. Forging ~ itprisansent: J J prescriptiona alla.ing the J 4 years ar a J ~ procureeent of narcotics, J fine J ~ adetrtiae.ent J J ~.anufacturing, selling, J eaeieue I J transport, production. J ieprisnnsent: I J delivering, preparing ~ t years or a / J J fine iapert/eapart I 12 years pr a ~ J fine possession. iaport I ieprisoneent uD esport: if einor J to I year quantities fcr ~ or a fine personal use only ~ are involved J Italy ~ Art. 71 Narcotics Ea.: J J possession, pur- I 2-fi years of ~ delivering, selling narcotics ~ acquireeent of J preductiw, offering, selling, ~ J chase, selling etc. ~ i.prisan.e„t J to juveniles: if a crieinal J narcotics fur J distribution, purchase, J (see Art. 71) Bf J J organizatian is involved; if ~ personal use if ai+ar J pracuring, transport, ieport, J J ha•d drugs, if J J drug oFfenders are a•eed: ~ quantities are in- ~ eaport, transit, possession, J ~.inor quantities J J penalties are increased froe J.alved (linor quanti- ~ keeping: in the case af hard J4-15 years of ~ are involved only ( ~ one third to half of the J ties corresDOnd to J drugs: ~ ieprisonoent ~(5 72) ( ( regular punishaent J those doses, vhica J in the case of soft drugs: j 2-i yenrs of if large quantsties are invol- ~ addicts consume per ~ J ieprisontent J J J ved: penalties are increased J day) J offering opportunities to J 3-10 years of ~ in the case of minor J 1-4 years of J froa half up to tvo third of J J consuee drugs J ieprisonaent J@uantities of J ieprisoneent I the regular punisheent (oaai- J J J ~ suft drugs ~ J.. i.Drisoneent 25 years) ~ J in the case of organized drug J J trafficking: einioue ieprison- J J oent: 15 years ~ J if the crioinal organization ~ ~ has tore than 10 oeebers or if ~ J Besbers of the organization ~ ~ are araed: ainieua itDrison- J I J J J J J aent: 20 years ~ Spain I Art. 344 pe.al Code: cultiva- J if nareotics are distributed I possession of J I tion, produetion, eanufac- ~ J J ~ atoeg juveniles, in school: or J narcotics uitn the J J turing, trafficking, passes- universities, in oilitary ~ intent of personal ~ f sion, encouraging, supporting, J J J J caaps, in prisons, if drug ~ use onlf J J facilitating the consutption: - J J J J trafficking is part of any J ) ( in the c e of a cotics hicb ( i eonths-f years ( ) 9 organized eri.e activity o if ~ J J bring uponserious haro to J of ieprisanaent ( ( ) large quantities are involved: ) ~ ~ health and life: ~ , J J in the case of dangerous sub- J J J in a11 other cases: J I.onth-f .onths J J J stances: 6-12 years of iopri- J 1 I I of iaprieaneent J I' I sonaent J J J J J J ) in all other cases: I eontn- J ~ I ~ I I I` years of i.prisament J England J possessioe: hard drugs J oanioue J (class A) J iepriseneent: J . ( 7 years or a J ( fine J soft drugs (class 0) J oasieue J ~ ieprisoneent: ( J 5 years or a J J fin J soft drugs (class C) J ranious J J ioprison.ent: J J 2 years or a J J fine ~ .anufactu•ing, productiono J aaaieue ~ trafficking, possession of ~ ieprisoneent: ~ narcotics ith the intent of J 14 years or a . ' trafficling (class A) J fine I (alass 0) I aaeieuo J J iaprisoneent: J J 14 years or a J J fine J (class C) J aaaia~e J J i.prison.ent: I / 5 years nr a J ( fine J cultivation of Cannahis J. J J i.prisoneent: 1 I ia years or a I J fine J consueption of opiates. J eatieue J frequenting places here J i.prisen.eat: J epiates are consuaed, posses- J 14 years pr a J sion of npiuo-pipas and sther J fine I opiue related utensils J Methadone-heroin- prograeees TIMN 321529 136 ~
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go in for the use of cocaine to enhance their sense of power and control in the beginn- ing. Because in the beginning of its use cocaine often gives people the illusion that they have more power and control, this appears at first blush to be a perfect drug for a person who is driven, ambitious and control-oriented. However; quite soon the per- son is actually producing less work, although they are continuing with the illusion that they are actually being very productive. In many cases, people who have problems with cocaine are working 80 hour weeks but yet producing only 25 hours of product. So in an industry like the electronics industry in the United States, which is high prenure, and time and goal oriented, the use of cocaine has become popular because it gives the illusion to people that they are producing to a greater degree And perhaps in the beginning they are-but not for long. Soon they begin to produFe less for the same number of hours and people around them begin to notice that something is wrong, but they are not quite sure what Companies are beginning to notice that their produc- tivity has gone downhilL For medium range electronics companies-that is to say com- panies of 400 to 800 employees-they are noticing a difference in the balance sheet. It ts not unusual for these companies to come to me for consultation and to indicate that they have lost $2 million last year they estimate and loss of productivity secondary to cocaine addicted employees. That is to say they are paying for these 80 hour work weeks when they are actually getting 25 hours of product in return for 80 hours of pay. So the companies are becoming increasingly concerned. As a result of this I find myself doing a lot of educational and consultative work with management at the com• panies. In a number of cases it is the management who also has problems with cocaine and work place interventions are required. So there a number of strategies that I have developed in order to deal with this type of problem. One of the strategies I call the "work place interventlon': This has been very successful in getting companies to participate on a corporate level in identifying cocaine addicted employees and getting them to treatment. Over the past 20 years we have developed the family intervention in the alcohol field. In Pxamining that model I have taken some aspects of it and applied it to the cocaine addicted corporate setting and I call this the "work place intervention": Many times this is the only way to get corporate executives into treatment who very badly need treatment. That is to say that I work with some of the other executives around them who are concemed about their problems and sometimes family members as well, and strategize a meeting with the person, similar to a family intervention meeting, at the work site with the goal of getting this person into treatment Sometimes It is the company president or vice president or chairman of the board. Because of this it is a very delicate situation and needs to be handled in a sensitive way. Howevei: I find that when these people are approached in a sen- sitive, caring, yet confmntative wag utilizing the (acts of the situation and citing behaviors, that they are amenable to treatment Often they are amenable to outpatient treatment because they have not yet lost all of their resources. That is to say they still have their )ob and their family, and they have those as motivations to keep them in treatment on an out-patient basis. The second strategy that 1 often employ with corporations, along with all of the other strategies, is to educate them about urine testing programs. Laboratory tests to detect the presence of cocaine can be very useful if they are used along with treatment methodologies and referral methodologies which get a person help Urine testing alone and other security measures alone, like sniffing dogs and undercover agents, for exam- ple, can cause harm if utilized without the proper guidance and treatment If utilized alone they set up a climate of paranoia and lack of trust which accentuates the paranoia already present in a company where people are using cocaine, as paranoia is one of the primary effects of the drug cocaine So I encoutage people to consder regular screening for new employees utilizing very high quality screening where they can measure the presence of cocaine up to 30 days. And I encourage randomized checking on existing employees with the normal kind of testing that can measure cocaine up to 4 or 5 d2ys in the body. I encourage careful monitoring of these tests to make sure that it is the actual patient who is giving the specimen and not someone else s specimen which occurs often in these situations where proper monitoring is not present But once again, I would like to stress that laboratory testing and security measures must be taken together with a full program and a multi-phasic approach in order to be successful. The next approach that I employ in this multi-phasic regimen is education with super- visors on identification and referral of people who have problems on the joh There needs to be an amnesty period of 30 to 60 days where an employee can report that they have a problem and that they need help or treatment without bein