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

Date: 10 Aug 1985 (est.)
Length: 560 pages
TIMN0321379-TIMN0321938
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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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