Public Policy Update

When the World Health Organization released its 2002 "Reducing Risks: Promoting Healthy Lifestyles" report, those who treat substance use and other mental health disorders were probably not surprised by the data. The report characterized causes of disability by illness category, and alcohol use was second only to unipolar depression among 15- to 44-year-olds in the United States and Canada. Survey data collected by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) indicate that fully 30 percent of the U.S. adult population uses alcohol in a manner that places them at risk for physical, mental health and social problems, and 25 percent of that population would meet diagnostic criteria for current abuse or dependence.

What may be surprising is how much of this heavy drinking goes undetected. A 2003 New England Journal of Medicine study reported that patients with alcohol dependence received recommended standards of care, including assessment and referral, only 10 percent of the time. Based on that and other similar studies, NIAAA Director T.K. Li, MD, decided that when Mark Willenbring, MD, became the new director of the NIAAA Division of Treatment and Recovery Research, a top priority of his would be to re-evaluate and revise the division's screening guide for clinicians. The resulting 2005 edition "Helping Patients Who Drink Too Much: A Clinician's Guide" was designed to broaden the target audience and provide a simpler screening method.

A single question

The last edition of the guidelines, released in 2003, focused on primary-care practitioners, but Willenbring--a psychiatrist by training who brought a "many hands make light work" philosophy with him to NIAAA--determined that expanding the clinician base to include mental health providers would be essential. Why? Substance use disorders, primarily alcohol use disorders, are more prevalent in patients with other mental health problems than in the general population, and many mental health patients do not regularly see primary-care providers.

Indeed, two surveys conducted by the Practice Directorate (in fall 2002 and fall 2003), using its Internet-based survey system PracticeNet, found that about a quarter of patients seen by participating psychologists had either a current or past substance use problem. However, only half of those patients were assigned a substance use diagnosis--suggesting that assessing for diagnosis alone may not be sufficient in capturing the number of patients with problems. Clinicians who had obtained continuing education in substance abuse during the past year were more likely to have ever discussed substance use with their clients and to be treating someone identified as having a substance use problem. For more PracticeNet results, or to participate, go to www.apapracticenet.net.

Willenbring decided that the NIAAA guide must make it easier for clinicians to screen patients. The 2003 edition relied on a time-tested instrument, the Alcohol Use Disorders Identification Test, and heavily structured interviews. While those methods were true to the science in that they had been evaluated for sensitivity in rigorous clinical trials, they were somewhat impractical to administer in the real world.

"It's not realistic to expect busy practitioners to recall and administer structured weighted questions in detail, and requiring use of an elaborate instrument severely limits the numbers of people actually willing to do it," says Willenbring.

By examining a range of published epidemiologic and treatment research as well as NIAAA's own National Epidemiologic Survey on Alcohol Use and Related Conditions, Willenbring and his colleagues chose to pare the screening down to a single question with follow-up as required.

"We settled on a single question focused on whether any heavy drinking days had occurred in the prior 12 months, since virtually everyone with alcohol-related disorders at least occasionally engaged in heavy drinking," Willenbring says. His NIAAA colleagues, APA members Harold Perl, PhD, and Bob Huebner, PhD, who worked on the revision with Willenbring, say the decision was a good call.

"The 2005 edition achieves a good balance between the 'real' and the 'ideal' as is often the case in trying to accommodate research in evidence-based practice," says Huebner.

Perl adds that the guide will help clinicians overcome the barriers that keep them from identifying and helping people with drinking problems.

"This single question can be key in revealing the hidden and unmet treatment needs of our patients," he explains.

Expanded reach

In addition to offering a step-by-step approach to providing brief interventions for nondependent drinkers, the new guidelines also provide advice on how to deal with a dependence patient who refuses or fails to follow up with a referral or who fails to respond to a behavioral treatment program. For the first time, medications for treating alcohol dependence are covered as well. Future products related to the new guide will include patient-education materials and continuing education for professionals who take an online instruction planned for NIAAA's Web site.

APA's Science Policy Office will be working with NIAAA and APA's professional development staff to disseminate the new guidelines.

"The field of psychology has provided important leadership in researching and treating substance use disorders, and APA is in an ideal position to help us get these new guidelines into the hands of those who can really use them," says Willenbring.

Geoff Mumford is APA's director for science policy.

Further Reading

For a copy of the guidelines, go to www.niaaa.nih.gov/publications/Practitioner/guide.pdf.