Alcohol and the Physically Impaired: Special Focus

DOCUMENT RESUME

ED 313 827 EC 221 343

AUTHOR Boros, Alexander, Ed. TITLE Alcohol and the Physically Impaired: Special Focus. INSTITUTION National Inst. on Alcohol Abuse and Alcoholism (DHRS), Rockville, Md. REPORT NO ADM-89-151 PUB DATE 89 NOTE 101p. AVAILABLE FROMSuperintendent of Docments, Mail Stop: SSOM, U.S. Government Printing Office, Washington, DC 20402-9375 ($8.00 per year; $4.00 single copy). PUB TYPE Collected Works Serials (022) Reports Descriptive (141) -- Guides - Non-Classroom Use (055) JOURNAL CIT Alcohol Health & Research World; v13 n2 1989

EDRS PRICE MF01/PC05 Plus Postage. DESCRIPTORS *Alcohol Abuse; *Alcoholism; Blindness; College Students; Disease Incidence; Epilepsy; *rtioloTi; Higher Education; *Intervention; *Physical Disabilities; Physical Therapy; *Rehabilitation; Research Projects; Visual Impairments IDENTIFIERS Arthritis; Head Injuries; Spinal Cord Injuries

ABSTRACT The articles in this special issue explore the connections between the dual disabilities of alcohol abuse and physical impairment, and reflect progress made in exploring the causes and treatments of alcohol abuse a,nrig the physically impaired. Selected articles include: "Results of a Model Intervention Program for Physically Impaired Persons" (Sharon Schaschl and Dennis Straw); "Alcohol .'buse and Traumatic Brain Injury" (Gregory Jones); "Alcohol Abuse ano persons Who Are Plind: Treatment Considerations" (Michael Nelipovich and Elmer Buss); "Treatment of Alcohol Abuse in Persons with Recent Spinal Cord Injuries" (Allen Heinemann et al.); "Intervention with Visually Impaired Children of Alcoholics" (Christine Saulnier); "Double Trouble: Alcohol and Other Drug Use among Orthopedically Impaired College Students" (Dennis Moore and Harvey Siegal); "Arthritic Disease and Alcohol Abuse" (David Nashel); "Epilepsy, Seizures, and Alcohol" (Michael Stoll); "Alcohol and Othei Drug Abuse by the Physically Impaired: A Challenge for Rehabilitation Educators" (Bobby Groer); "Epidemiologic Bulletin No. 21: Alcohol-Related Morb,dity among the Disabled: The Medicare Experience 1985" (Mary Dufour et al.); "Highlights from the 1987 National Drug and Alcoholism Treatment Unit Survey (NDATUS)" (Joan Harris and James Colliver); and "A New Agenda for Alcohol Research: Tie Institute of Medicine Reports on Causes and Consequences -A Summary." (JDD)

* * * * * * * * * * * * * * * * * * * * * * * * ** * ..{. * * * * * * * * * * * * * * * * * * * * * ** * * * * * * * * * * * * * * * * * * * * * Reproductions supplied by EDRF are the best that can be made * from the original document. ********************************************************,************** RECEIVED JuL 0 1989 Volume 13 Number 2 NALNIL 1989 National Institute on Alcohol Abuse and lete,Aworm Alcoholism

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/itumulagasXat Alcohol lesellzhWorklSPECIAL FOCUS Alcohol- and the Physically Impaired

From the Editors 99

Facing the Challenge 101 ALEXANDER BORGS

Alcohol Abuse and Traumatic Brain Injury 104 GREGORY A. JONES

Reatment of Alcohol Abuse in Persons with Recent Spinal 110 Cord Injuries ALLEN W. HEINEMANN, MATTHEW DOLL, AND SIDNEY SCHNOLL

Double Trouble: Alcohol and Other Drug Use 118 PAGE III Among Orthopedically Impaired College Students DENNIS MOORE AND HARVEY SIEGAL

Arthritic Disease and Alcohol Abuse 124 DAVID J. NASHEL

Alcohol Abuse and Persons Who Are Blind: Treatment 128 Considerations MICHAEL NELIPOVICh AND El MER BUSS

Intervention with Visually Impaired Children of Alcoholics 132 CHRISTINE SAULNIER

PAGE 104 Epilepsy, Seizures, and Alcohol 138 MICHAEL J. STOIL

Alcohol and Other Drug Abuse by the Physically Impaired: 144 A Challenge for Rehabilitation Educators BOBBY G. GREER

Results of a Model intervention Program for Physically 150 Impaired Persons SHARON SCHASCHL AND DENNIS SERA ?'

PAGE 118

97 California Responds: Changing livatment Systems Through 154 Advocacy for the Disabled JOHN DE MIRANDA AND LINDA CHERRY

Epidemiologic Bulletin No. 21: 158 Alcohol-Related Morbidity Among the Disabled: The Medicare Experience 1985 MARY C. DUFOUR. DARRYL BERTOLUCCI, CAROL COWELL. FREDERICK S. STINSON, AND JOHN NOBLE

Readers' Exchange: Hearing-Impaired AlcoholicsAn Underserved 162 PAGE 12{ Community GLADYS A. KEARNS Alcoholism and Bullous Changes of the Lungs 166 SIDNEY L. CRAMER

Departments: Occupational Arena: 'Keating Patients with 168 Alcohol-Related TraumaA Report from the ARUS Symposium International Perspectives: Alcohol-Related Trauma in 174 M "cico Special Populations: NIAAA Suppor, for Studies on 176 PAGE US Hispanic-Americans

Research Reports: Highlights from the 1987 National Drug and Alcoholism 178 Treatment Unit Survey (NDATUS) JOAN R. HARRIS AND JAMES D. COLLIVER A New Agenda for Alcohol Research: 183 The Institute of Medicine Reports on Causes and ConsequencesA Summary

PAGE. 183

NI ALCOHOL HEALTH & RESEARCH WORLD FROM THE EDITORS In 1980, Alcohol Health & Re- leagues, that alcohol abuse often nier describes the important. of search World presented an issue develops before physical impair- this interaction to an inpatient pro- that focused on persons with both ment and that physical impairment gram for the visually impaired, and physical impairments and alcohol- is the result of accidents related to de Miranda and Cherry describe related problems. At that time, alcohol abuse, is perhaps the mos' how shared interests and activism most research on physical impair- dramatic. These authors state that among the two groups of profes- ment and alcohol abuse centered onif alcohol abuse was a problem sionals have resulted in a statewide documenting the relationship be- before physical impairment, it is effort in California. tween those two conditions. Much likely to continue to be a problem. One crucial factor remains un- progress has been made since then The need to address alcohol abuse changed when comparing 1980 to in exploring the causes and the while treating the physically im- 1989: the enthusiasm and dedica- treatments of alcohol abuse among paired becomes crucial to patient tion of the inaividuals involved in the physically impaired. recovery. diagnosing, treating, and preventing The articles in this issue reflect At the same time, the psychologi-alcohol-related problems among the this progress and explore the con- cal and practical problems of the physically impaired. The editors of nections between the twat disabili- physically impaired must be ad- Alcohol Health & Research World, ties of alcohol abuse and physical dressed in any number of settings ifincluding Guest Editor Alexander impairment. Some of these connec- alcoholism treatment is to succeed. Boros, were delighted with the re- tions are subtlesuch as that be- Treatment centers, inpatient units, sponse to the development of this tween alcohol abuse and arthritis, and self-help groups, in meeting theissue of the journal. We hope that as described by Nashel, and that special needs of the physically im- some of this enthusiasm is trans- between alcohol abuse and epilepsy, paired, can be most effective in mitted to the reader along with the as described by Stoil. Other connec-helping their alcohol-dependent research results, clinical observations are dramaticthe finding, clients. Examples and practical tions, and experience-based recom- expressed by Moore and Siegal, guidance to meet these needs are mendations that comprise this Jones, and Heinemann and co, provided in the articles by Saulnier, Special Focus issue. Schaschl and Straw, Jones, Neli- povich and Buss, and Heinemann and colleagues. Many of the authors in this issue believe that current levels of exper- tise can be expanded through increased interaction between physical rehabilitation specialists and their colleagues in the field of alcoholism and other addiction treatment. Greer, for example, suggests that this type of interaction should be part of the curriculum for training rehabilitation professionals. Saul-

- VoL. 13, No.2, 1969 99 &tout GORDIS,M.D.,Director, National EDITORIAL ADVISORY BOARD Alcohol Health & Research World Institute on Alcohol Abuse and Alcoholism (ISSN 0090-838X) isaquarterly produced KENNETHR.WARREN, PH.D., Director, Office THOMAS E BABOR, PH 0./UntVerSay of ozler contract by the National Institute on of Scientific Affairs, Nation, Institute on Connecticut Hefoth Center/Department of Alcohol Abuse and A', aholism (NIAAA). Alcohol Abuse and Alcoholism Psychiatry/Farmington, CT Terry Freeman is the Project Officer. The PETER BELL, B.A./Minnesota Institute on Secretary of Health and Humaa Services has CATE TIMMERMAN. Editor Black Chemical Abuse/Minneapolis, MN determined that the publication of this Eve N. SHAPIRO, Managing Editor HOWARD DIANE, PH D./Research Institute on periodical is necessary in the transaction of ANN M. BRADLEY, Associate Editor Alcoholism/State University of New York/ the public business required by law of this JOHNJ.DOR1A, Associate Editor Buffala NY Department. Use of funds for printing this MICHAEL J. STOIL, PH D., Special Focus Fuom E. BLOOM, M.D./Scripps Clinic and periodical has been approved by the Director Editor Research Foundation/La Jolla, CA of the Office of Management and Budget BEATRICE B. KF-SSLF.R. Copy Editor WILLIAMBurvNsKt. PH.D./NationalAssocia- through September 30, 1989. Opinions MARY S. MOYNIHAN. Copy Editor tion of State Alcoholism and Drug Abuse expressed in con:ributed articles do not ALEXANDER M. TUCKER, An Director Directors/Washington, DC necessarily reflect the views of NIAAA. The MAURA GAFFNEY, Editorial Assistant RAUL CAETAND PHD./Medical Re- U.S. Government does not endorse or favor search Institute of San Francisco/Berkeley, any specific commercial product or com- CA modity. Trade or proprietary names appear- ABOUT THE COVER RICHARD A. DEITRIC H, PH D./University of ing in this publication are used only because Colorado School of Medicine/Denver, CO they are considered essential in the context The International Smbol of A< was JEROME A. HALLAN, DR.P.H./ Healthare of the studies reported herein. adopted in 1969 at Rehabilitation International's Administration/Oregon State University/ Manuscripts concerning research, treat- 11th Woild Congress on Rehabilitation of the Corvallis, OR ment, or prevents a of alcoholism and DisabledIt is used throughout the world and it RICHARD JESSOR. PH.D. /University of Colo- alcohol problems are solicited and should be functions on two levels The symbol indicates rado Institute of Behavior Science/Boulder, sent to the Editor,Alcohol Health & Re- to persons who are physically impaired that a CO search World,c/o CSR, Incorporated, Suite building or a facility iS accessible to them and. THic-ILti LI, M.D./Indiana University 600, 1400 Eye Street, NW., Washington, DC on a broader level, it IS an emblematic reminder School of Medicine/Indianapolis, IN 20005.Electronic submission on 5 I/4-inch that while person, with physical impairments CHARLES S. LIEBER, M.D. /Mt. Sinai School diskettes is acceptable Unless otherwise should he recc,gnized as having Special needs of Medicine/ VA Medical Center/New York, noted ii the text, all material appearing in they ?.. e invoked in the same day-to-dal, NY this magazine is in the public domain and activities as are person, without SUlh JANE BENNER LORENZ, B.A./National Federa- may be reproduced without permission. impairments tion of Prents for Drug-Free Youth/ Citation of the source is apprt dated It IN hoped that the ,)mbol will continue to Deerfield, IL Subscriptions and changes of address he used to increase the awareness of the general ALBERT B. LoweNens, M.D./New York should be sent to the Superintendent of public of the problems that ideological and Medical College/Westchester County Medi- Documents, Mail Stop: SSOM, U.S. Gov- architectural barriers present to ph) sicalk cal Center/Valhalla, NY ernment Printing Office, Washington, DC impaired persons DONALD C. MARTIN, PH D./University of 20402-9375. Subscriptions are $8 per year or Washington Department of Biostatistics/ $10 if mailed to a foreign address Single Seattle, WA copies arcisvallabieat $4 ($5 to a foreign ELLEN R. MOREHOUSE.A.C.S.W./Student address, These prices are subject to change Assistance Services/ White Plains, NY without notice PAUL M. ROMAN, PH.D./University of Geer gia Institute for Behavioral Research/ Athens, GA ROBERT J. SOKOL, M.D./ Wayne State Univer- sity School of Medicine/ Hutzel Hospital/ Detroit, MI LAWRENCE WALL 4C K, DR.?.H./Untversttyof California School of Public Health/Pacific Institute for Research and Evaluation/ Berkeley, CA JOSEPH WESTERMEYER,M.D.,PH D./ University of Minnesota/Minneapolis. MN SHARON C. WILSNACK, PH D./ University of North Dakota School of Medicine/Grand Forks. ND

100 ALCOHOL. HEALTH & RESEARCH WORLD Buddy and Ruth from Incurably Iturnapta, (Temple University Press) © Bernard F Stehle. 1985 Facing the Challenge

ALEXANDER BOROS, PH.D. derstanding problems of individuals The special winter 1980- abled alcoholic" to refer to an alco-with physical impairments and 1981 issue ofAlcohol holic who had the additional dis- alcohol- or other drug-related Health & Research World ability of a mental or physical problems. These contributions used the tern~ "multidis- impairment. That issue focused or emphasize the importance of un- recognizing and treating the multi- derstanding what makes this ALEXANDER BOROS. PH D., is profes- disabled and announced a new population special. The legal and sor of sociology at Kent State Uni- disability initiative by the National psychosocial aspects of intervention versity and founder and director of Institute on Alcohol Abuse and among people with physical impair- the Addiction Intervention with the Alcoholism (NIAAA). The treatments pose challenges to be faced Disabled Project. Dr. Boros served ment and prevention specialists by treatment and prevention as Guest Luritor of this Special were expected to follow the exam- specialists. Focus issue ofAlcohol Health & ples cited in those pioneering The Rehabilitation Act of 1973, Research World.Comr.ents on this articles and to continue to ad- section 504 (Public I :.w 93-122), article should be addressed to the vance knowledge of this unique identifies a "handicapped" person author at the Department of Soci- population. as anyone with a physical or mental ology, Kent State University, Kent, The articles in this issue provide disability that limits substantially Ohio 44242. new insights into treating and un- one or more of such major life

VoL. 13, Na 2, 1909 101 Facing the Challenge

activities as walking, seeing, hear- have a 20-percent rate of alcohol or abilities may contribute to continuing, speaking, working, or learning.other drug abusea rate twice as ation of alcohol or other drug Today, the terms "physically im- high as that among able-bodied abuse after an individual becomes paired" and "disabled" are pre- adults. Kirshbaum'F csiimate is physically impaired (Boros 1983): ferred to the term "handicapped" supported by the findings of an that was employed in the 504 regu- article included in this issue, the The physically impaired person is lations. Physical impairments, ac- Epidemiologic Bulletin No. 21. handicapped in adjusting to a cording to section 504, may include Several authors represented in social and material world de- blindness, cancer, cerebral palsy, this issue have documented that a signed for normal persons. deafness or hearing impairment, majority of physically impaired Most home-bound persons with diabetes, epilepsy, heart disease, individuals with alcohol- or other physical impairments face bore- multiple sclerosis, muscular dystro- drug-related problems appear to dom and a lack of challenging phy, orthopedic impairment, per- show evidence of such problems activities. ceptual impairments, and spina before the onset of impairment; a In addition to normal daily bifida. Mental or emotional illness large percentage of these individ- stress, physically impaired pc.- and mental retardation also are uals became physically impaired as sons must cope with frustrations described as impairments in the a result of trauma that is caused by linked to the impairment and, in legislation. abuse of alcohol or other drugs. A some cases, with chronic pain. An estimated 16 percent of our minority of physically impaired Many unemployed or underem- society is physically or mentally individuals develop alcohol or other ployed persons with physical im- impaired (Bowe 1978). According todrug abuse following onset of impairments lack adequate income Kirshbaum (1979), clinical evidence pairment. A number of stressful or resources to pay for services reveals that the physically impaired circ:_mstances associated with dis- that they require.

BARRIERS TO ALCOHOLISM TREATMENT ENCOUNTERED BY PERSONSWITH PHYSICAL IMPAIRMENTS

he following barriers to alga- sympathies among alcoholism job-related incentives to seek 1 ment for the disabled have counselors is not conducive to treatment. been reported in the literature the necessary confrontation of The local community network (Boros 1983): the physically im paired client's of alcohol and other drug abuse denial of alcoholism. service providers may be per- Police and courts often respond ceived as disjointed and inacces- Programs for disabled alco- inappropriately to physically sible by persons with physical holics ere few and still color- impaired pet** arrested for impairments, particularly when atoti; standanlized maid alcohol- or other drug-related such impairments impede nego- that can easily be indtated has offenses, sending them home tiation of bureaucratic hurdles emerged. rather than to treatment. to obtaining treatment. 'Vestment acftvitiel need to be ilea** Ind recovery facilities Professional literature fails to paced at a slower rate for clients often cannot provide transporta- address adequately the unique who require more time for tion for orthopedically impaired treatment problems facing phys- mobility andixernunicatina, cliezrts. ically impaired alcoholics. inclu ding *is Who are %Allies often may be less de- blind, deaf, sintintellectuelly *siding of treatment for the The above 10 generalized barriers impaked, pirssically linpaired rev a- reflect experiences of those seek- Sometallitatallailities are not berth* they would be for an ing treatment serves for alco- ace**. talatiaOtit in wheel- atiobodial relative. holics and other drug abusers. chairs* hitlioieiho use othc Individnift with severe impair- Such barriers vary significantly aids In wi.lkina ments frequently lack employ- within each community. The prevalence of misplaced ment and therefore lack -ALEXANDER BOROS. PH.D.

102 ALCOHOL HEALTH & RESEARCH WORLD Persons with severe impairments Progress in the field of alcohol fully from these gains achiesed in often have easy access to addic- and other drug abuse has occurred the addiction field. Withfc.vexcep- tive prescription drugs. Too often,without much attention to the tions, intensive inpatient treatment the physically impaired per- unique needs of persons with physi- programs do not meet the needs of son mixes prescribed drugs cal impairments. The advent of the physically impaired clients. Further- with alcohol, resulting in dire Alcoholics Anonymous self-help more, prevention curriculums for consequences. program in 1935 gave suffering special education departments to Physically impaired persons face alcoholics a boost in morale use in educating high-risk disabled a double stigma for the impair- through peer group resources youth often receive priority for ment and for alcohol or other (Kurtz 1979), but not all Alcoholics State funds earmarked for the en- drug abuse. They often sense Anonymous or other self-help tire physically impaired at-risk pop- societal rejection when deprived groups effectively respond to mobil-ulation; adults with physical of jobs, recreation, and services. ity needs or communication needs impairments and alcohol-related When physical impairment al- of persons with physical impair- problems rarely are targeted for ready has made a person feel less ments. Nearly 50 years ago, the special support by government than complete, admitting to alco- Center of Alcohol Studies and the agencies. hol or other drug abuse often is Quarterly Journal of Studies on Great gains have been made in another blow to self-esteem. Alcoholwere organized to promote the addiction field, but people with Persons with physical impairment thedevelopment of a professional major life-limiting impairments may present strong rationaliza- body of research-based knowledge continue to be undertreated and tions for drinking. It is difficult on alcoholism, and in 1949, profes- undercounted. This special focus to convince such individuals that sionals interested in problems of issue ofAlcohol Health & Research sobriety offers a rewarding a'iter- addiction were brought together for Worldreminds us that the challenge native to life's problems escape the first time with the creation of of making treatment and prevention through use of alcohol or other the North American Association of accessible and responsive to people drugs may appear to be satisfy- Alcoholism Program (Strachan with physical impairments is a chal- ing, at least in the short run. 1971). Prior to the mid-1970s, how- lenge that faces us all. ever, research literature rarely ad- These circumstances vary among dressed the problems of alcohol cr REFERENCES individuals and types of impair- other drug abusers who had con- SOROS, A Physically disabled alcoholics: ment; nevertheless, their existence comitant physical impairments, and The latest challenge In: Cleminshaw, H.K , supports the argument that persons professional associations in the and "fruit, E B., eds. Alcoholism. New with physical impairment are at Perspectives. Akron, OH: Center for Urban alcohol research and treatment Studies, 1983. pp 35-46. relatively high risk for alcohol or fields offered minimal coverage of other drug dependence. physical impairment-related con- BOWE,F Handicapping America: Barriers to Disabled People New York. Harper and One of the challenges facing cerns at annual and regional Row, 1978. professionals in the addiction field meetings. HEWIErr. A.G Governmental responses to is to understand why alcohol and Slowly, the condemnation of alcoholism in North America. In: Pittman, other drug abusers with physical alcoholism as a moral weakness has D J , ed. Alcoholism. New York: Harper impairments tend to be under- been replaced with the growing and Row, 1967 pp 223-246. treated. Some of the barriers to acceptance of alcoholism as a dis- KIRSHdAUM, H 15 to 3007o of 21,000 disabled alcoholism treatment encountered ease. The use of social therapies in in California area called abusers. Arise, May by persons with physical impair- the treatment of alcoholic patients 1979, p 38. ments are identified in the accom- was another breakthrough (Root Kuirrz. E Not God. A History of Alcoholics panying sidebar and in articles 1967). Government involvement in Anonymous. Hazelden, MN Hazelden included in this issue. In general, a financing and planning services for Education Services, 1979. review of the literature shows that alcoholics provided needed re- Roar, L.E Social therapies in the treatment alcohol and other drug abuse inter- of alcoholics In. Pittman, D.J , ed. Alco- sources to specialty populations holism New York: Harper and Row, 1967. vention programs are less accessible (Hewlett 1967) and to the develop- pp. 142-156. to those with physical impairments ment of school-based prevention STRAC HAN, G T Practical Alcoholism Pro- than they are to able-bodied programs. Persons with physical gramming. Vancouver, Canada- Mitchell persons. impairments have not benefited Press, 1971.

Vol. 13, No. 2, 190 193 1/4 -1414111 4s 0, i 41 4, V , 4 I 1 I l. e I GREGORY A. Jos (Galbraith et al. 1976; Rutherford 1977; Brismar et al. 1983; Parkinson et al. 1985). In the most recent study The role of alcohol and other drug abuse in trau- of head-injured patients at a North American trauma center, 67 percent matic brain injury is well of those tested for blood alcohol levels documented, with an incidence of intoxication at injury of showed evidence of alcohol use and more than one-half (51 percent) were approximately 50 percent. Because of intoxicated, using a definition of 100 cognitive, behavioral, and functional mg/100 ml (100 mg/dl) (Sparadeo c'eficits, brain injury survivors pose and Gill, in press). This is consistent unique challenges to the alcoholism with a Swedish study showing a 58- treatment field. percent rate of intoxication among HEAD INJURY AND ALCOHOL ABUSE those tested (Brismar et al. 1983). In a study of neuropsychological Alcohol consumption is a strong deficits in alcoholics, psychometric predisposing actor in traumatic bra injury (Kerr et al. 1971; Field 1976; test performance was significantly lower among head-injured alcoholics Parkinson et al. 1985). In studies than among those who had not ape- addressing head injury and alcohol rienced head injuries (Hillivm and use specifically, elevated blood alcohol Holm 1986). Both groups scored levels were present in more than 40 lower than the general population on percent of the patients seen in emer- most test items. Results of the study gency rooms or admitted to hospitals also suggest that the incidence of head because of traumatic head injury injury in alcoholics is two to four GREGORY A JONES is in °gram times higher than in the general doe( for for ( helm( al health at the population. V Inland National Centel oi Lor etto, Other studies have documented the Mollie sofa role of alcohol and other drug abuse

* t , : Richard Rush Brain Injury

in traumatic brain injury. Alterman culty seeing the relationship between and llarter (1985) found the risk for Many brain injury their behavior and the resulting conse- head injury in patients with familial quences and may experience confu- alcoholism to be almost twice that of survivors...are sion or frustration in their attempt to patient: without such histor:,. In a more easily distracted understand situations. study of 75 severely brain-injured Impairment of abstract reasoning patients (Ibbis et al. 1982), 51 had by extraneous stimuli The ability to integrate information histories of alcohol abuse and 29 had and to reason ir tvabstract are vital histories of illicit drug use. The num- and have a reduced skills in our "information age." Un- ber of patients using both alcohol and abilfty to concentrate fortunately, many brain injury survi- other drugs was not specified. Spara- vors experience a reduction in these deo and Gill (i t press) found that 25 and focus. skills and a corresponding increase in percent of their sample had alcohol concrete thought. In assessment, these histories documented in their medical that alcohol and other drug abuse problems are sometimes detected in records. A recent Nrvey of brain professionals acquaint themselves with proverb interpretation tasks, where injur, rehabilitation programs around the unique problems these clients clients may be unable to move be and the country reported that approxi- present. The following discussion of the concrete content of a simple say- mately 55 percent of patients had 'he more common consequences of ing to its more abstract meaning some alcohol or other drug abuse nead injury is drawn from general (Lezak 1983). problems before the brain injury and knowledge in the field of brain injury Deficits of attention and concen- 40 percent had abuse problems de- rehabilitation. For more Detailed in- trationMany brain injury survivors scribed as moderate to severe (NHIF formation, the reader is directed to have difficulty attending to complex 1988). Levin arc' _olleagues (1982), Edelstein tasks. They are more easily distracted and Couture (1984), Lezak (1978a, by extraneous stimuli and have a PSYCHOSOCIAL CONSEQUENCES OF 1978b, 1983), and Brooks (1984). reduced ability to concentrate and HEAD INJURY focus. Traumatic brain injury can mean Impairment of memory Post- Inappropriate social behavior many lcng -term psychological and traumatic amnesia is one of the most Problems with impulsiveness and common consequees of head injury. behavioral difficulties. Because every disinhibition are common among Mead injury is differelit, it is impos- For many survivors, memory for survivors of traumatic brain injury. sible to predict the exact outcome for events and conditions prior to their They may giggle or make inappro- the survivor. While generalizations r ut injury is generally intact w!ile short- priate comments; they may interact in be made, it is important that treat- term memory for recent everts is a rude or aggressive man, T. Excessive ment professionals and other con- disrupted. In practical terms, this flirting or more overt sexual gestures cerned persons note that individuals means that brain injury survivors are sometimes observed. Some survi- may present few problems or a combi- might remember the events of their vors become withdrawn and isolated; high school prom in great detail but nation of b..--veral problems. Some others demon ra. behavior that is deficits following head injury are "orget what was served for breakfast self-centered and perceived as imma- painfully obvious; others are ex- this morning. Some survivors may try ture. They may have a low tolerance tremely subtle and become evident to fill in the gaps with confabulation, for stress and be easily frustrated. a usually sincere attempt to mask only during intensive clinical evalua- Changes :n mood and affectSome tion (Lezak 1978b). Alcohol ar.,, other memory deficits that is sometimes brain injury survivors experience drug abuse professionals working with misinterpreted :is dishonesty. Impair- c' anges in emotional responses. Af- head :njury survivors commonly deal ment of recent memory makes it diffi-rect may T.. some flat or blunted with w;tht ctients who appear to function cult for many survivors to retain little expression of either joy or sad- normally in most settings but who are information and gentralize new learn- ness. Emotions may become labile, unable to understand the concepts of ing from one setting to another. with broad swings of mood. Anger, alcohol or other drug addiction or to Decreased self - awareness and along with feelings of profound grief, benefit from traditional treatment insightMany survivors of traumatic may be accompanied by a clinical modalities. brain injury experience a reduced depression. lb work effectively with survivors capacity for insight, self-monitoring, Language and communication of traumatic injury, it is vital and awareness. They may have diffi- deficitsDamage to the brain may

106 I ALCOHOL HEALTH & RESEARCH WORLD result in oral-motor problems, such as and communities must face the issue tionary time and boredom, 2) in- slurring of speech and difficulty form-of the reintegration of survivors crewed enabling from family and ing words (dysarthria). Of a more who may have experienced pro- friends, 3) uncertainty over the ability serious nature are deficits of compre- found changes their abilities and to return to work or to funcLan effec- hension or language disorders known personalities. tively at work, and 4) physical limita- as aphasia. The brain injury survivor There is a high incidence of divorce tions and posttraumatic mood may not understand everything heard following head injury. Reports of change. All of these factors can be and may not be able to find the wordsdepression and somatic disorders found among most brain injury or formulate the sentences necessary among spouses or children of survi- survivors. to respond. These problems may vors are common. Many survivors While anecdotal reports are numer- result in increased frustration or con experience social_ isolation and ous, there are few data on the inci- fusion for survivors and concerned marginalization a result of their dence of alcohol and other drug persons alike. injuriev; peer relationships and sup- abuse after brain injury. In one of the Sensory deficitsThere is a high port systems are often radically first attempts to document postinjury incidence of visual-perceptual prob- altered. use patterns, Sparadeo and Gill (1988) lems following head injury; reading found that 54 percent of the survivors and writing abilities may be impaired. ALCOHOL AND OTHER DRUG ABUSE they surveyed had returned to alcohol Tinnitus (ringing in the ears) or other FOLLOWING HEAD INJURY use after completion of rehabilitation. disorders may affect hearing. Vv nen the complex variable of alcohol This was in spite of the fact that the Goal-fotmulation and problem- or other drug abuse is considered majority had been injured in motor solving di/fiat/tiesUnrealistic or within the context of the social reinte- vehicle accidents while under the undefined goals are common among gration of brain injury survivors, the influence of alcohol or other drugs. brain injury survivors. When they do potential for serious problems seems The two major factors influencing have clear and reasonable objectives, clear. Given that the population as a abstinence in the remaining 46 percent many survivors have a reduced ability whole has a high rate of documented were the presence of a seizure disorder to solve problems and to achieve their alcohol abuse prior to injury (and or placement in long-term, supervised goals without sufficient structure and that alcohol abuse is a key factor in living situations. support. Voaltionalleducational problems Psychosocial CLINICAL CONSIDERATIONS FOR ALCOHOL Because of the permanence of brain AND OITIER DRUG ABUSE PROFESSIONALS damage and the long-term nature of and functional Brain injury survivors present unique its consequences, few head ink-ry consequences of brain problems for counselors and other survivors are able to return to their professionals because the psychosocial premorbud (prcinjury) level of voca- injury complicate the and functional consequences of brain tional educational placement. injury complicate the already difficult Those who have survived mild injuriesalready difficult tasks tasks of evaluation and treatment. often retain the cognitive skills neces- of evaluation and Given what is known about traumatic sary to return to work but may experi- brain injury and alcohol abuse, it is ence reduced tolerance for stress and treatment. likely that most professionals will increased fatigue. occasionally encounter brain injury 'piped on the family and commu- the etiology of brain injury), it is survivors; those practicing in urban nityThe functional impairments reasonable to suggest that alcohol areas or among minority populations from traumatic brain injury, though consumption following injury would should give special attention to the serious, do not usually require that also be a problem. This is especially incidence and consequences of brain survivor., be institutionalized. In their so, considering that the great majority injury. Cognitive and neurobehavioral study of severely brain-injured pa- of brain injury survivors are dis- problems may have an impact on the tients, -MIAs and colleagues (1982) charged into the community, where following areas of practice: reported that 72 percent had beer alcohol and other drugs are readily Assessment and diagnosisMemo- discharged to return home; the rate of accessible. Reilly and colleagues (1986)ry deficits tend to make brain injury community discharge is even higher have identified four factors that in- survivors poor historians, and subjec- among survivors of m....ierate and crease the risk of alcohol abuse after tive reports of alcohol or other drug mild injuries. As a result, families traumatic injury: 1) increased discre- use patterns may be inaccurate. Im-

VoL. 13, Na 2, 1N9 107 Brain Injury

and either providing necessary services paired insight may keep survivors or mat ing appropriate referrals. Ef- from recognizing that their use pat- Effective case fective case management usually re- terns are problematic. Because many mild head injuries go unreported management usually quires an interdisciplinary approach involving social workers, psycholo- (Hil lbom and Holm 1986), it is rec- requires an gists, occupational and physical thera- ommended that evaluators inquire pists, vocational counselors, and about previous accidents or injuries. interdisciplinary specialists in community reentry. Pro- A simple question such as "Have you fessionals must acquaint themselves ever been knocked unconscious?" approach. with available programs, since refer- may be helpful in a preliminary rals to economic or housing assistance screening for possible head injury havioral difficulties of survivors, such programs and consultation with medi- status. as impulsiveness and disinhibition, cal or public health professionals may Because brain injury survivors may cause conflict or tension in group be necessary. Services for spouses or sometimes have difficulty with ab- sessions, reducing the effectiveness of families of clients also should be con- stract thought and more complex the sessions. Rather than receiving sidered, because the dual problems of concepts, brig or complicated assess- support and affirmation from group disability and alcohol or other drug ment tool: may be ineffective. Con- members, brain injury survivors may abuse put intense pressure on family sideration should be given to the use be stigmatized or characterized as systems. of a brief diagnostic tool suchasthe disruptive. These problems also may Ftriurte Mammon's CAGE Questionnaire (Ewing 1984). be experienced in meetings of self- Utilization of data from neuropsycho- help groups, such as Alcoholics The outlook for future development logical or rehabilitation evaluations is Anonymous, where significant neuro- in the area of alcohol or other drug also suggested. behavioral problems attributable to abuse and brain injury is mixed but Changes in functional abilities are head injury may be viewed as "char- hopeful. There remains a troubling often the most reliable and measur- acter defects." avoidance of the problem on the part able symptoms of alcohol or other In the case of brain injury rehabili- of clinicians who provide acute care to drug abuse by head injury survivors. tation, the prevailing behavioral model brain injured persons. In a recent and Once the practitioner has determined of intervention relies on achieving quite revealing survey of 154 trauma that such changes are not the result of positive long-term outcomes through centers in 43 States, only 55.2 percent other medical conditions and can be a series of short-term goals (Goldstein regularly measured blood alcohol associated with known incidents of and Ruthven 1983; Wood 1987). This levels upon admission (Soderstrom consumption, decreasing skills or approach may h.: more effective with and Cowley 1987). In a retrospective increasing patterns of maladaptive inpatients than with alcohol- or other chart review of 379 trauma patients behavior may provide observable drug-abusing outpatients who live in seen in the emergency room of an diagnostic criteria for alcohol abuse. community settings where factors urban teaching hospital, Chang and For the survivor, these declines in influencing behavior cannot be as Astrachan (1987) found that al- functional ability can be devastating, easily monitored. though 43 patients were suspected or limiting involvement in rehabilitation known to have used alcohol or other or vocational programming. Threaten- In a manual examining methods of drugs, none was referred for further ing to discontinue essential services counseling head injury survivors in evaluation. may motivate the Drain injury survi- the community, Blanchard (1984) Rehabilitation providers, on the vor to respond to intervention. emphasizes the need for practitioners other hand, have responded to the Intervention and treatmentInsight-to understand the cognitive and be- problem of alcohol abuse and brain oriented approaches are prevalent havioral consequences of head injury injury with a positive initiative. In among treatment models for alcohol and to rely more on such basic coun- 1987, the Prof ssional Council of the and other drug abuse (Logan et al. seling techniques as respect, authentic- National Head Injury Foundation 1987). However, the usefulness of ity, and empathy. convened a Substance Abuse Task psychodynamic approaches with brain CasemanagementAgenciesand Force. The work of this group, injury survivors is questionable be- individual practitioners serving brain though preliminary, has helped to cause of the high incidence of cogni- injury survivors who abuse alcohol or define the problem from both an tive deficits, such as impaired abstract other drugs are responsible for ad- etiological and clinical perspective and reasoning and decreased insight. Be- dressing their often complex needs to suggest potential solutions. A posi-

ALCOHOL HEALTH & RESEARCH WORLD tive finding of the task force is that 50 and other drug abuse fields merits HILLBOM. M., AND HOLM, L. Contribuucn of percent of acute and 83 percent of the further development, especially where traumatic head injury to neuropsychological deficits in alcoholics. Journal of Neurology, postacute rehabilitation programs brain injury is concerned. Pn.fession- Newtsurgery, and Psycluatry 49 1348-1353, surveyed are addressing alcohol and aLs L-1 both fields have much to learn 1986. other drug abuse within their range of from each other. KLRR, TA.; KAY, D.WK.; AND LASMAN, L.P. services (NHIF 1988). Preliminary attempts to examine Charactenstics of patients, type of accident and Better identification and interven- and integrate information from vari- mortality in a consecutive series of head injuries tion strategies for those with trau- ous fields have contributed much to admitted to a neurosurgical unit. Bnnsh Journal matic brain injury will succeed only if the effort. With additional research, of Preventive and Social Medicine 25:179-185, 1971. a corresponding initiative is under- education, and improved interdiscipli- taken within the alcohol and other nary cooperation, the outlook is LEVIN, H.S ; BENIGN, A.L.; AND GitossmArc R.G. Neurobehavioral Consequences of Closed drug abuse treatment field. Recom- hopeful. Head Injury. New York: Oxford University mendations for development of effec- Press, 1982. tive services for brain injury survivors The author thanks banns R. Sparadea Ph.D., LEZAK, M D. Living with the characterologically include improvement in the following for generously prowling information and manu- altered brain mjured patient. Journal of Clinical areas: script matenal necessary to the complenon of this Psychiatry 39:592- 598,1978a Research The number of brain article. LEZAK, M.D. Subtle sequelae of brain damage: injury survivors being served within perplexity, distractibility and fatigue. Amencan the cunt.alcohol and other drug REFERENCIN Journal of Physical Medicine 57(1):9-15, 19786. abuse treatment system is not docu- ALTERMAN, A.I , AND TARTER, R.E. Relationship LT ZAK, M.D. Neuropsycho/ogica/ Assessment. mented. Tb determine the effective- between familial alcoholism and head injury. 2nd ed. New York: Oxford University Press, ness of current programs and Journal of Studies on Akohoi 46(3)256-25F, 1983. 1985. methods, it is essential that this popu- LOGAN. S L ; McRov, R.G.; AND FREEmAN, E.M lation be profiled. While it may be BLANC-HARD, M.K. Counseling Head Irulaud Current practice approaches for treating the Patients. Albany, NY: New York State Head alcoholic client. Health and Social Won( reasonable to suppose that brain- Injury Association, 1984. 12(3):178 -186, 1987. injured persons who abuse alcohol or Pr ISMAR, B.; ENGSTROM, A.; AND RYDBERG, U National Head Injury Foundation. Professional other drugs have a high incidence of Head injury and mtoidcauon: A diagnostic and Council Substance Abuse "Risk Force. White discharge from treatment centers for therapeutic dilemma. Acta Ciunirjra Sam- Amer. Southborough, MA: NHIF, 1988. failure to meet treatment goals and dinavica 149:11-14, 1983 PARKINSON, D.; STEPHENSEN, S.; AND PHILLIPS, S ale more prone to relapse than those BROOKS, N. Closed Head lrywy: Psychological, Head injuries. A prospective, computerized without brain injuri, this has not Social and Family Consequenms Oxford. Oxford study. Canadian Journal of Surgery 28(1).79-83, been established. University Press, 1984. 1985. EducationPerhaps the greatest CHANG, G., AND AsrawcitAr.. B Identification RIR I Y. E.L.; KELLEY, IT.; AND FA1LLACE, L.A. barrier to the effective identification and disposition of trauma prtients with sub- Role of alcohol use and abuse in trauma. Ad- vances in Psychasomatic Medicine 16.17-3.. and treatment of brain injury survi- stance abuse or psycluamc illness. Connecticut Medicine 51:4-6, 1987. 1986. vors with alcohol or other dryg abuse problems is the continued lack of EDEISTEIN, BA., Awn COUTUKE, E.D Behavioral RUTHERFORD, W. DlagTIOSIe sf alcohol ingestion Ass.sprient and Rehabilitation of the Traumati- in mild 1.ead injuries. Lance. 1:1021, 1977. awareness among professionals. Medi- cally Elnim-Damagecl. New York: Plenum Press, cal and rehabilitation professiorls Soneasntom, CA., AND COWLEY. R.A A 1984. national alcohol and trauma center survey. would benefit from additional training EWING, J.A. Detecting akoholiso: the CAGE Archives of Surgery 122(9).1067-1071, 1987. in assessing alcohol and other drug questionnaire. Journal of the ,,imerican Medical SPARADEa ER., AND GILL, D. "Alcohol Use abuse. Professionals treating clients Associat,on 252(14):1. J5-1907, 1984. After Head Injury." Paper presented at the who abuse alcohol and other drugs FIELD, J H. Epidemiology of Head injury in annual conference of the Amencan Psychologi- need more information about brain England and Wales: With Fttrticular Application cal Association, Atlanta, GA, August 1988. injury and its consequences. Alcohol to Rehabilitation. Leicester; Printed for H.M. SPARADECX F.R., AND GILL. D. Effects of alcohol and other drug abuse counselors Stationary Office by Willson, 1976. use on head injury recovery. Journal of Head should be encouraged to familiarize GALBRAITH, S.; MURRAY, W R ; PATE' , A.R.; AND Ammo Rehabihtation (in press). themselves with the brain injury reha- KN`IAJONF_S, R. The Midair:ship between alco- TOBIS, J.S.; PURI. K.B ; AND SHERIDAN. J. Reha- hol and head injury and its effect on the con- bilitation of the severely brain - injured patient bilitation programs and services in scious level. Bntish Journal of Surgery their communities. Scandinawan Journal of Rehabilitation Medicine 63:128 - 130,1976. 14(2):83-88, 1982 Interdisdplinary dialogue and GOLDSTEIN. G., AND RtJVHVEN, L Rehabilitation cooperation Communication be- WOOD, R.L. Bruin limey Rehabilitation: A of the Bruin-Damaged Adult. New York: Plenum Neurobehavioral Approach. Rockville, MD: tween the rehabilitation and alcohol Press, 1983. Aspen Publishers, 1987.

Va.. 13, No. 2,1199 109 Treatment of Alcohol Abuse in Persons with Recent Spinal Cord Injuries

ALLEN W. HEINEMANN, PH.D., MATTHEW DOLL, AND SIDNEY SCHNOLL, M.D., Ph.D.

"Range-of-motion" exercises prescribed in the early stages of rehabilitation allow persons with recent spinal cord injuries to maintain flexibility and strength and to make maximum use of residual muscle function The prevalence of alcohol- can undermine the rehabilitation and 49 percent for persons who related problems in per- process by impairing the learning incur traumatic injury (Galbraith et sons with physical process and increasing morbidity. al. 1976; Fullerton et al. 1981; Gale disabilities has emerged In patients whose disabilities are et al. 1983; Frisbie and Tim 1984; as an issue in medicine and physicalthe result of traumatic injury, these Heinemann et al. in press). Im- rehabilitation. Physicians, rehabili- effects may be exacerbated. In one paired judgment resulting from tation specialists, and service pro- study, O'Donnell and colleagues intoxication appears to have been viders increasingly are aware that (1981-1982) reported a 68-percent responsible for increased risk- alcohol abuse not only can contrib-rate of alcohol or other drug use at takingthe cause of many of these ute to onset of disability, but also the time of a disabling spinal cord injuries. injury (SCI) among 54 patients on The prevalence of alcohol use a spinal cord injury unit; 68 percentand abuse following initial care for of patients also resumed drinking traumatic disability also has been during hospitalization Other re- reported in several recent studies. In r searchers have found that the rate a 1985 study of vocational rehabili- of intoxication varies between 17 tation and independent living center clients with SCI, the rate of moderate and heavy drinking reported was 46 percent, nearly twice the rate reported in the general population (Johnson 1985). The rate of

ALLEN W HEINEMANN, PH D., is director of the rehabilitation services evaluation unit at the Rehabili- tation Institute of Chicago, 448 East Ontario Street, Suite 650, Chicago, Il/'nois 60611, and associate professor in the Department of Rehabilitation Medicine at North- western University Medical School. MATTHEW DOLL, a graduate student in psychology at Illinois Institute of Technology, assisted on the project described in this article. SIDNEY SCHNOLL. M.D., is chairman of the division of substance abuse in the Medical College of Virginia (Rich- mond) and president of the Associ- ation for Medical Education and Research on Substance Abuse (AMERSA).

4s Alcohol Abuse Tteatment and SCI

alcoholic symptomatology has been treatment among persons who would be paid $20 each. The first observed to vary from 49 percent ofincur traumatic injury resulted in interview, conducted during inpa- persons with recent onset SCI NIAAA-supported research at the tient rehabilitation, reviewed drink- (Heinemann et al. 1988a) to 62 Rehabilitation Institute of Chicago, ing patterns during the 6 months percent of vocational rehabilitation a 176-bed, nonprofit hospital in theprior to injury. The second inter- facility clients (Rasmussen and Midwest Regional Spinal Cord view was conducted 6 months after De Boer 1980-1981). Injury Care System. The goal of SCI, and the third interview oc- Although there are reports on the the study was to describe the extent curred 18 months after SCI. Inter- nature and extent of alcohol abuse to which persons who had incurred views typically lasted 3 hours. among traumatic injury patients, traumatic injuries experienced Of the 103 participants, 75 con- less information is available about alcohol-related problems, recog- tinued through the third assess- traumatic injury patients who rec- nized they had problems, and then ment. They ranged in age from 16 ognize and seek treatment for acted to reduce abusive drinking. to 63 years, with an average age of alcohol-related problems. Knowl- The objectives of the study were to 28.2 years. Men comprised 75 per- edge of the factors leading to recog- assess the rate of alcohol use, prob-cent of the sample. Most of the nition and treatment for these lems resulting from drinking, per- participants were white (75 per- patients should enable rehabilita- ceived need for treatment, and cent); the others were black (15 tion professionals to assist other actual receipt of treatment for alco-percent), Hispanic (9 percent), and patients in need of similar services. hol abuse from 6 months prior to Asian (1 percent). The marital sta- If, as Marlatt and colleagues (1988) 18 months after spinal cord injury. tus of participants included those suggest, personal injury contributes A total of 168 patients admitted never married (63 percent), married to a drinker's awareness of an consecutively met inclusion criteria (26 percent), divorced (8 percent), alcohol-related problem, then the for this study,. Patients in the sam- and separated (4 percent). Educa- period following injury may be a ple were between 13 and 65 years oftion attained included less than particularly productive point at age, cognitively intact, injured dur- high school graduation (28 per- which to intervene. ing the past 12 months, and Englishcent), high school graduation or In fact, failure to intervene can speaking. Of the 154 patients for equivalent (59 percent), college threaten the entire rehabilitative whom physician permission to par- graduation (7 percent), and gradu- process. Unrecognized alcohol ticipate was obtained (90 percent ofate degree completion (7 percent). abuse may contribute to neglect of eligible patients), 103 agreed to The most frequent cause of injury self-care and, consequently, to in- participate. The participant and was a road or traffic accident (41 creased morbidity. Psychological nonparticipant groups did not dif- percent), and quadriplegia was the and social adjustmentsformida- fer in age, gender, race, injury etiol-resulting disability for 64 percent of ble enough already for persons who ogy, self-reported intoxication at the sample. incur traumatic injurymay be injury onset, marital or social sta- complicated further by alcohol tus, diagnosis, or exposure to sub- THE TYPE A DRINKER AS THE MODAL abuse. Continuation or resumption stances for which routine toxicology ALCOHOLIC SCI PATIENT of drinking following personal screening was completed (Heine- A typology devised by Glass (1980- injury also may interfere with pro- mann et ai. 1988b). 1981) highlights the potential dif- ductive physical activity by a reha- Because approximately 1 month ferences between persons with bilitation client (Heinemann et al., is needed for patients to adjust to a physical disabilities whose drinking in press). For these and other rea- rehabilitation hospital eliv;ionment problems predate injury (Type A sons, it is critical that rehabilitation and to consider favorably a request drinkers) and those whose drinking professionals understand and, to participate in a research project, problems began after injury (Type where necessary, facilitate the iden- patients were not approached aboutB drinkers). Glass asserted that tification and treatment of alcohol this study until between 4 and 6 Type B drinkers were more likely abusing clients. weeks after admission. Patients than 'type A drinkers to have favor- were told at the initial approach able rehabilitation outcomes. THE REHABILITATION INSTITUTE OF that the security of their data Applying Glass' typology to the CHICAGO STUDY would be safeguarded by a confi- Chicago sample, 65 percent of the The need to improve understanding dentiality certificate and that they sample were classified as Type A of the behaviors associated with thewere being asked to participate in dr nkers, with onset of drinking perceived need for alcoholism three interviews for which tliex problems before injury. Six percent JL t /

112 ... ALCOHOL HEALTH & RESEARCH WORLD were Type B drinkers, with onset of previously (Heinemann et al., in drinking problems after injury. The Pre-injury drinking press), evidence of valid self-reports remainder (29 percent) reported no patterns were strongly was obtained. Serum ethanol analy- drinking problems during any time sis conducted at patient's admission reriod. Drinker type was strongly related to intoxication to the acute SCI unit was in agree- related to self-reported intoxication ment with self-report in 78 percent at injury onset. at injury. of cases. Consumption without As expected, pre-injt.ry drinking intoxication or intoxication with patterns were strongly related to through to the third interview and some other substance, as well as intoxication at injury. While the those who dropped out of the studyinvalid self-report, could account overall rate of intoxication was 43 in terms of age, sex, race, marital for less than perfect agreement percent, 27 of the 49 Type A drink- status, injury etiology, quantity andbetween these measures. ers (55 percent), 1 of the 4 Type B frequency of drinking before injury, The proportion of the sample drinkers (25 percent), and 3 of the number of alcohol-related prob- that reported drinking on three or 20 nonproblem drinkers (15 per- lems, perceived need for treatment, more occasions during any of the cent) reported intoxicatiol at injury or receipt of treatment before three assessment periods was 93 onset. Type A drinkers also re- injury. However, noncontinuing percent. The proportion of the ported drinking and experiencing participants averaged less for- sample that drank on three or more alcohol-related problems at more mal education than continuing occasions during the 6 months be- assessment periods than did Type B participants. fore injury was 91 percent. That and nonproblem drinkers. For ex- proportion dropped to 53 percent ample, 55 percent of the Type A ALCOHOL CONSUMPTION PATTERNS for the 6 months after injury and drinkers reported drinking on three AMONG SCI PATIENTS increased to 67 percent during the or more occasions at each of the Alcohol consumption was quanti- next 12-month period (see Figure assessment periods, whereas only fied by asking participants to report 1). Median frequency of drinking 25 percent of the Type B drinkers the frequency and quantity of alco- for those who drank was three to and 27 percent of the nonproblem hol consumed during each of three six times per week before injury drinkers reported this pattern of time periods: 6 months before in- and one to two times per week at drinking. Although this relation- jury, 6 months after injury, and the second and third assessments. ship was statistically significant, the from 7 to 18 months after injury. Median quantity of alcohol was small number of Type B drinkers Quantity was coded as number of five drinks per drinking occasion limits the generalizability of these drinks per drinking occasion; fre- during the 6 months before injury results. quency was coded on an 8-point and four drinks per drinking occa- Relationships between demo- scale of 0 (no drinking) to 7 (binge sion during the two postinjury as- graphic variables and drinker type drinking). This measure quantifies sessment periods (see Figure 2). also were examined. No relation- drinking in a manner similar to Overall, the proportion of drink- ship was found between drinker several valid and reliable measures, ers declined from pre- to postinjury. type and age, injury etiology, level including the Drinking Classifica- However, fully two-thirds of the of injury, race, marital status, or tion Indices (Brandsma et al. 1980), sample were drinking 18 months drinking frequency and quantity the Quantity-Frequency-Variability after injury. Median consumption immediately after injury. Seventy- Index (Cahalan et al. 1969), and thealso declined from pre- to postin- one percent of the men and 47 per- National Alcohol Program Infor- jury, a finding consistent with the cent of the women were Type A mation System (NAPIS) ATC Cli- results of Frisbie and Tim (1984). drinkers who reported significantly ent Intake Form (NIAAA 1979). Nonetheless, a median of four greater drinking frequency before Because the reliability and valid- drinks one to two times each week injury than either Type B or non- ity of self-report measures used to was observed 18 months after problem drinkers. Both Type A and assess drinking and resultant prob- injury. Type B drinkers reported greater lems have been questioned, several drinking frequency during the 6- to methods were employed to substan- ALCOHOL-RELATED PROBLEMS AND 18-month postinjury period than tiate the self-reports. lbst-retest PERCEIVED NEED FOR TREATMENT did nonproblem drinkers. reliability of substance use informa-Seventy-one percent of the sample No differences were found be- tion for this sample typically reported one or more alcohol- tween participants who continued exceeded 0.90 and, as reported related problems, and 15 percent

VoL. 13, Na 2, 90 t 113 Alcohol Abuse Reaanent and SCI

reported believing they needed treatment for these problems. Figure 1 Makin Pripianny7/ WI Patients Prior to Wur s Months Pandidry, and lafsizolles PestIsenry Eleven percent reported receiving 40 treatment. Alcohol-related problems were assessed by asking participants in the Chicago study to report if they had experienced any of the following as a result of drinking: 1) loss of control over amount or strength of alcohol used; 2) problems with family; 3) problems with friends; 4) problems thinking, remembering, or controlling thoughts; 5) problems at work; 6) physical or health problems; 7) becoming overly tired; 8) becoming overly excited, agi- tated, or nervous; 9) experiencing negative moods, such as sadness, depression, helplessness, or guilt; ROM 10) sexual problems; 11) r.-Auced driving ability; 12) hallucinations; or 13) financial problems. Re- sponses to each of these categories were coded as 0 (no) or I (yes). Positive responses were summed to form an index of alcohol-related problems similar to indexes formu- lated by Donovan et al. (1983) ant+ Fillmore (1974). Figure 3 shows the proportion of the sample reporting each of 13 assessed alcohol-related problems at each assessment period. The proportion of the sample reporting one or more problems was 65 percent during the 6 months before injury; this rate dropped to 17 percent during the 6 months after injury and percent at the last assessment. On- "During this time period, did you rose to 24 percent during the fol- set of drinking problems was re- ever think that you needed help lowing year. Pre-injury alcohol- ported to be most common before regarding use of this substance?" related problems reported by at injury; only 6 percent reported Similarly, receipt of treatment was least one-quarter of the sample drinking problems for the first timeassessed by asking, "During this included loss of control over the after injury. As might be expected, time period, did you ever receive amount used (32 percent), cognitivepersons who acknowledged alcohol-any counseling of treatment for difficulties (33 percent), fatigue (35 related problems prior to injury your use of this substance?" Intoxi- percent), and driving problems (33 were far more likely to report being cation at injury onset was assessed percent). Relatively few persons intoxicated at injury onset than by asking, "Were you under the reported any of these specific prob- were persons with postinjury onset influence of alcohol or any other lems after injury. of alcohol-related problems or no drugs at the time of your injury?" The rate of self-reported drinking problerto. Findings at each assessment period problems also declined initially Perceiv:d need for treatment was are shown in Figure 4. after injury but increased to 24 assessed by asking participants, The proportion of participants

41_ _ 114 4 ALCOHOL HEALTH & RESEARCH WORLD

AIL percent immediately after injury, to none during the following year. A similar pattern was observed for actual receipt of assistance for drinking problems: 7 percent reported receiving assistance before injury; 3 percent reported receiving assistance immediately after injury; and 1 percent reported receiving assistance during the following year. Persons who thought they needed assistance but did not receive treatment were asked why they did not seek assistance. At the first assessment, changing one's mind was cited by six persons. Other reasons cited included inability to afford treatment (N.1), not knowing where to obtain treatment (N = 1), believing treatment was unavailable (N= 1), and believing that one's drinking pattern was unchangeable (N = 1). No reasons were given by persons not receiving treatment at later assessment periods.

SCI PATIENTS RECEIVING TREATMENT FOR ALCOHOL-RELATED PROBLIMS Participants receiving treatment were asked the most important reason for their seeking treatment. At the first assessment, their reasons included employer referral (N.2), referral by family (N.1), and court-ordered referral (N.1). At the second assessment, one person each cited physician referral and a desire to sty drinking as the reason for seeking treatment. One person at the third asseR,ment cited a court order as the reason for referral. The relationship between number of drinking problems and perceived need for treatment was examined at each assessment period. At the fist assessment, persons who reported no need for treatment reported a mean of 2.0 problems, whereas persons reporting a need for treat- who believed they needed assistance clined from 13 percent during the ment reported a mean of 5.7 prob- for drinking-related problems de- immediate pre-injury period to 4 lems. No significant relationship pants with pre-injury drinking problems were early onset drinkers whose drinking reflects a genetic component. The success of rehabilitation interventions that consider familial and persor.....:i inking his- ! tories are apt to be greater than 6 interventions that do not. g As with most studies, caution should be exercised in generalizing 8these observations to all persons

Ewith SCI. Participants were re- cruited from one rehabilitation

Allen Heinemann, Ph.D., meets with project members (left to right) Elizabeth Rogers, hospital, albeit with a large, diverse Matthew Doll, and Nancy Goranson. Heinemann was awarded a grant by the National catchment area. Whereas refusal to Institute on Alcohol Abuse and Alcoholism to study the prevalence of and rehabilitation participate in the study did not outcomes associated with alcohol use following spinal cord injury appear to bias the results, the ten- was found at the second and third were cited as a reason for pursuing dency of persons with less formal assessment periods. treatment. education to cease participation in Collectively, 11 percent of the Although some drinkers did stop the study may signal that individ- sample reported receiving alcohol or reduce their drinking after trau- uals who completed more years of treatment at some time, although matic injury, others dia not. This fornial education (and who most most of those receiving treatment finding supports the theory that the likely enjoyed higher socioeconomic did so before injury. The relatively acknowledgement of drinking prob-status and stronger social supports) low rate at which persons believed lems is a developmental process. As were those assessed at the third they needed treatment for drinking alcoholism treatment professionals interview. Replication of these ob- problems, despite the high preva- contend, more than a major life servations will be important to lence of drinking and alcohol- disruption appears sometimes to be generalize these results with confi- related problems, may reflect required to convince an aicotol dence to other populations. individuals at different stages of theabuser to seek treatment. Thus, Future studies should investigate addictive process (see Prochaska spinal cord injury appears to do no the extent to which early postinjury and Di Clemente 1986). Consistent more to cure drinking problems for drinking patterns continue over with the findings of Marlatt and some persons than do job loss, time. The ways in which drinking is colleagues (1988), the fact of injury divorce, and other forms of related to morbidity, vocational for persons who were intoxicated trauma. However, SCI does appear outcome, and independent living may have served to illustrate the to present an opportunity for exter- also require examination. extent of their drinking problems nal agents to intervene on behalf of and motivated them to initiate be- alcohol abusers who become THE NEED FOR ALCOHOL havior change. However, the major injured. INTERVENTION IN REHABILITATIVE reason for not pursuing treatment CARE was changing one's mind about the SCI AND THE ADDICTIVE PROCESS Several observations for enhancing need for treatment. This change in The results of this study help to the rehabilitation care of persons belief can be understood as an as- identify stages of change in addic- with recent SCI emerged as a result pect of denial or rationalization tive processes. SCI provided an of the study. First, assessment of about the severity of alcohol-related...pportunity for some persons to alcohol use and alcoholism should problems. recognize the seriousness of their be a routine part of all inpatient No one in the Chicago sample problems with alcohol and to make screenings in acute care and rehabil- who believed that treatment was changes in their drinking patterns. itation programs for persons with needed asserted that social support For most, this change was achieved traumatic injury. Responsibility for or self-initiated attempts to control without professional assistance. Yet this screening could be assumed by drinking were successful. For per- others continued to drink and to a variety of team members, includ- sons who obta led treatment, exter-drink heavily, a testament to the ing representatives from medical, nal agents (en ,loyers, courts, pernicious quality of alcohol addic- nursing, psychology, or sociai work family, and physicians) most often tion. It may be that some partici- departments.

1M ALCOHOL HEALTH RESEARCH WORLD Second, appropriate training of collaboration of alcoholism treat- the co..scious level. British Journal of Sur- medical and allied health team ment and rehabilitation medicine gery 63:128-130, 1976. members to recognize alcohol abuseprofessionals. The opportunity to GALE, J.; DD MEN, , WYLER. A., TEMKIN, N.; is essential. Alcoholism treatment profit maximally from physical AND MCCLEAN. A. Head injury in the Pacific program professionals are possible medicine and rehabilitationpro- Northwest. Neurosurgery 12:487-491, 1983. resources for providing this knowl- grams is unlikely if addiction issues GLASS, E.J. Problem drinking among the edge to physical medicine specialistsare not addressed early after blind and visually impaired. Alcohol Health and rehabilitation care providers. injury. et Research World 5:20-25, 1980-1981. Third, establishing referral net- HEINEMANN, A; DONOHUE, R.; KEEN, M.; AND works to alcohol treatment pro- SCHNOLL, S. Alcohol use by persons with Support for this project was provided by the recent spinal cord injuries. Archives of grams is necessary if potential dual National Institute on Alcohol Abuse and disabilities are to be identified and Physical Medicine and Rehabilitation Alcoholism (ROI AA07111), the National 69:619-624, 1988a. treated in a timely fashion. In addi- Institute on Disability and Rehabilitation tion, sL,Jnd communication links Research ((;00863120), the Spinal Curd HEINEMANN, A.; SCHNOLL, S.; BRANDT, M.; Research Foundation (NBO-611), and the MALTZ, R ; AND KEEN, M Toxicology screen- must be established so that alcohol- Rehabilitation Institute of Chicago. The ing in acute spinal cord injury. Alcoholism. ism treatment programs and alco- authors extend their gratitude for data Clinical and Experimental Research 12:815- holism counselors learn about the collection to Scott Allen, Anastasia Arm- 819, 1988b. special needs of patients with dis- strong, Kevin Armstrong, Michael Asher, HEINEMANN. A.W.; GORANSON, N ; GINSBURG, K.; Michael Brandt, Kyu Man Chae, Carol abilities. Accessibility needs, func- AND SCHNOLL, S. Alcohol use and activity tional abilities, and attitudes Dell'Oliver, Robert Donohue, Mark God- patterns following spinal cord injury. Reha- dard, Nancy Goranson, Debra Kiley, Brian bilitation Psychology, in press. toward persons with disabling con- Mamott, Tami McGraw, William O'Brien, ditions are some of the topics that Susan Paradise, Elizabeth Rogers, and Jon JOHNSON. D.C. "Alcohol Use by Persons with might be addressed by training Wemand. Disabilities." Unpublished manuscript, Wisconsin Department of Health and Social programs for alcoholism treatment Services, 1985. personnel. Chemical dependence REFERENCES LOWENTHAL. A., ANC ANDERSON, P. Network treatment programs designed spe- ANDERSON. P Alcoholism and the spinal development: Linking the disabled commu- cord disabled: A model program. Akohol cifically for persons with physical nity to alcoholism and drug abuse programs. Health et Research World 5:37-41, disabilities are another treatment Alcohol Health & Research World 5 '6-19, 1980-1981. alternative (Anderson 1980-1981; 1980-1981, BRAN DSMA, J M.; MAInTse- 4.0 ; AND Lowenthal and Anderson 1980- MA RLATT. G A.; BAER. J.S.; DONOVAN. D.M., WELSH, R.J. Outpatient Theutment of Alco- AND KIVLAHAN, D R. Addict:Ve behaviors: 1981; Sweeney and Foote 1982). holism: A Review and Comparative Study Etiology and treatment. In: Annual Review Finally, the findings of this study Baltimore: University Press, 1980. highlight potential hospital policy of Psychology. New York: Annual Review, CAHALAN, D , CISIN, 1.H., AND CROSSLEY, H.M Inc., 1988. pp. 223-252. issues. Policies regarding possession American Drinking Practices. A National National Institute on Alcohol Abuse and and use of alcohol and recreational Study of Drinking Behavior and Attitudes. Alcoholism. National Alcohol Program New Brunswick, NJ: Rutgers Center for or socialization programs that in- Information System (NA PIS). Washington, Alcohol Studies, 1969. corporate alcohol use need to be DC: Supt. of Does., U.S Govt. Print. Off., reexamined and perhaps reformu- DONOV,, J.E ; JESSOR, R.; AND JESSOR, L. 1979. Problem drinking in adolescence and young lated in light of studies examining O'DONNELL, J.J.; COOPER. I.E.; GESSNER, J E.; adulthood. Journal of Studies on Alcohol SHEHAN, I, AND ASHLEY. J Alcohol, drugs controlled drinking outcomes. 44:109-137, 1983 Whereas alcohol used in modera- and spinal cord injury. Alcohol Health & Fn I MORE, K.M. Drinking and problem Research World 6:27-29, 1981-1982. tion is likely to pose few problems drinking in early adulthood and middle for many patients, those who have ageAn exploratory 20-year follow-up PROCHASKA. J 0 , AND DICLEMENTE, C C. Toward a comprehensive model of change. histories of alcohol abuse may be study. Quarterly Journal of Stuch&. on In: Miller, W.R , and Heather, N., eds. Alcoholism 35:819-840, 1974. fncouraged to abuse alcohol by Theating Addictive Behaviors: Processes of policies and programs that provide FRISBIE. J.H, AND TUN. C.G. Drinking and Change. New York: Plenum, 1986. pp. 3-27. spinal cord injury. Journal of the American opportunities for alcohol consump- RASMUSSEN. G., AND DEBOER, R Alcohol and Paraplegia Society 7.71-73, 1984. tion. A case-by-case assessment of drug use among clients at a residential each patient's history and social FULLERTON, D; HARVEY, R.; KLEIN. M ; AND vocational rehabilitation facility. Alcohol needs should precede any exposure HOWELL. T. Psychiatnc disorders in patients Health et Research World 5:48-56, 1980- with spinal cord injuries. Archives of Gen- 1981. to alcohol. eral Psychiatry 28.1369-1371, 1981. Persons with addiction problems SWEENEY, T.T., AND FOOTE, J.E. Treatment of GALBRAITH, S.; MURRAY, W.; PATEL, A.; AND who incur traumatic injury have drug and alcohol abuse in spinal cord injury KNirr-JoNEs. R. The relationship between veterans. International Journal of the Addic- special needs that require close alcohol and head injury and its effects on tions 17:897-904, 1982.

VOL 13, Na 2,1189 117 AlcoholandOther Drug able AmongOrthopedicallyImUsePaired uk CollegeStudents

L Students with severe orthopedic impairments may be especially vulneraole to abusing alcohol or other drugs.

DENNIS MOORE. M.A., AND loss of mobility. At the same time, HARVEY SIEGAL, PH D. factors such as low self-esteem, social isolation, and unresolved anger may exacerbate tendencies College students are chal- toward alcohol and other drug use. lenged by opportunities Dean and col:eagues (1985), in a to experiment with illegalstudy comparing college drug use drugs and by occasions patterns between students with and when excessive drinking seems to be without disabilities, discovered few encouraged. It is reported that 70 significant differences between the to 80 percent of college students aretwo groups in frequency and types regularmonthly or more frequentof drug use. The disabled group consumers of alcohol and that only reported less alcohol consumption 10 percent report abstinence (Friendthan the nondisabled group, but and Koushki 1984; Berkowitz and illicit drug use was approximately Perkins 1986; Johnston et al. 1986- the same. The study's disabled Salt? and Elandt 1986). Approxi population of 66 students included mately 25 to 40 percent cf college 20 orthopedically impaired individ- students are reported to use mari- uals, but this subset was not differ- juana (Friend and Koushki 1984; entiated from other disabilities in Johnston et al. 1986). the analysis. Students with severe orthopedic Other studies provide contradic- impairments may be unusually tory findings. Hepner and col- vulnerable to abusing alcohol and leagues (1980-1981) reported that other drugs. Compounding the approximately 25 percent of the availability of alcohol and other clients at a rehabilitation center drugs in many college settings is theabused drugs. They also reported availability to many orthopedically that 41 percent of the prescriptions impaired students of medications received by their clients were medi- prescribed to ameliorate the effects cally unnecessary. A study of over of their disabilities. Narcotics may 250 clients at a residential rehabili- be prescribed to ameliorate pain, or tation facility reported that the antidepressants may be prescribed proportion of clients using alcohol to relieve depression associated with and other drugs was much higher than the general population figure for the same average age of 26 years DENNIS MOORE. M.A., is a certified (Rasmussen and DeBoer 1980- alcoholism counselor completing 1981). A recent study of 205 physi- doctoral studies in counseling and cally disabled adults (Meyers et al. counselor education at Indiana 1988) suggested that 16 percent of University, Bloomington, Indiana. the respondents drink beer on at HARVEY SIEGAL, PH.D., is director of least 14 days of the month and that Substance Abuse Intervention Pro- the same percentage drink at least 4 grams at the School of Medicine, beers per episode. In that same Wright State University, Dayton, sample, 25 percent of the group use Ohio. Comments on this article marijuana more than once a may be addressed to Dennis Moore month. at W.I.P./S.O.M., Wright State Possible explanations for the University, Dayton, Ohio 45401. reported tendency of physically

2t VOL. 13, Na 191! j 119 Orthopedical!y Impaired College Students impaired individuals to engage in The study was conducted at a mid- For analytic purposes, the au- alcohol and other drug use range vestern university that maintains a ti'ors created a variable to measure from self-medication to reduce positive posture toward physically th' extent of problems associated chronic pain or physical discomfort impaired persons. To maintain with Audents' list of alcohol (Sullivan and Guglielmo 1985; homogeneity in the sample, partici- and oth.a- drugs. This variable, Benedikt and Kolb 1986) to more pation as a respondent in the study described as "Problem Use," con- complex psychological rationales. was limited to students who use s:s:ed of an additive score on 18 For example, DeLoach and Greer wheelchairs for primary moh:1;ty. items similar to those included in (1981) noted that proneness to use School authorities estimated ap- the Michigan Alcoholism Screening of fantasy as a vicariou-, form of proximately 80 students with this Test. Answers to questions about experience may have unusual signif-level of orthopedic impairment werestudents having hangovers, fig,.ts, icance for nersons with physical actively enrolled during the study illness, legbag accidents, inadver- limitations; alcohol or other drug period. tent injuries, and class attendance use may be initiated as a means of A 104-item questionnaire was while "high" were among the data escaping reality or enhancing fan- devised and field tested among compiled along with reported daily tasy. In addition, Krupp (1968) orthopedically impaired college consumption patterns of nonpre- suggested that trauma associated alumni before be,ng converted to. scription drugs (see Table 1). Prob- with a disabling injury may lead self - administered computer test lem Use scores obtained from this at least temporary loss of control housed in an open computer lab. process ranged from 0 (14 respon- over use of mood-altering sub- Active recruitment of subjects in- dents) to 15 (1 :espondent), with a stances, and Prescott (1980) sug- cluded individual solicitations. A mean of 3.03 and a standard devia- gested that diminished physical total of 57 students (71.3 percent of tion of 3.35. sensation may instigate elcohol or estimated population) completed Symptoms of problem use were other drug abuse. the study; this level of participation compared with a number of inde- is perceived to have been a function pendentV3riables includira respon- of the anonymity of the question- dem age, gender, grades, housing, A SURVEY OF ALCOHOL AND DRUG USE naire and a $10 stipend offered to impairment, chronic pain level, AMONG PHY, `ALLY IMPAIRLJ respondents. attitude toward impairment, sexual STUDENTS Thirty-eight respondents (66.7 contacts, and medication. Other In light of the contradictory find- percent) reported that their impair- questionnaire components included ings on the relativelcidence of ment resulted from either a trauma the Perceived Benefit of Drinking alcohol and other drug abuse event or from another postnatal Scale (Petchers and Singer 1987) among physically impaired young condition; the remaining 19 re- and Srole's Anomia Scale (Dull people, the authors undertook an ported congenital disability. Thirty- 1983)- both_point Guttman scale examination of alcohol and other five respondents (61.4 percent) were true/false tests that have been uti- drug use among 5' college students male, and all but two were white. 1 :zed ir. pleviou- drug studies. The with orthopedic disabilities. Three Median sample age was 21 Thrill Seeking lndex-S,S scale IV basic hypotheses were posited based Approxinniely 85 percent of the (Zuckerman 1979) also was in- on the literature and clinical sample reported living away from cluded with four items adapted to observation: their families of origin while at- apply to wheelchair users. Thrill tending school, with the majority seeking scores consis'ently have Nonprescription drug use is living in dormitories or other cam- demonstrated strong correlations higher among students with phys- pus housing. with nonprescription drug use ical L.sabilities than it is among among general college populations nondisabled students. (Brennan et al. 1986; Jaffe and Alcohol and other drug choice ' For example, it was assumed from chnica. contacts and previous literature (Malec et al. Archer 1967). among students with orthopedic 1982) that the incidence of marijuana use impairments is dictated by factors among orthopedically impaired students unique to the disability.' would be greater than it was among other RESULTSTRAUMA VICTIMS DOW), \TE nauma victims tend to exhibit college students, due to bladder problems HIGH PROBLEM USE SCORES more problematic or high-risk use associated with alcohol consumption among physically impaired populations. Survey The overall alcohol and other drug than persons with congenital results indicated that this is not necessarily use levels reported among the sur- disabilities. correct. vey respondents (see Table 2) ap-

125 ALCOHOL HEALTH itzscutcw WORLD pear comparable with that of general college cohorts (Friend and Koushki 19R4; Berkowitz and Otodilloollos So Problem Ike Soots Perkins 1986; Johnston et al. 1986; Saltz and Elandt 1986). Data obtained on the Problem Use variable, nfnflnittlyely alcohol or other drug use however, produced striking results. Ike Loss of friends or other impor- Of the 11 individuals who scored 5 tant relationship due to alcohol or more on the Problem Use varia- or other drug use ble, non,.. had a congenital impair- Experienced withdrawalfrom. ment and 9 reported a trauma event habit7forinhis druP as the cause of their physical im- Snif*Onty while intoxicated or pairment. Most surprising was the realization that 8 of the 9 trauma rbladder accident victims in this group reported use intoodelied or "high" of alcohol or other drugs at the --llonigenple *Mond me use time of their disabling injury. This theta ,do" fact, combined with their high *-44440kcanimbis, barbiturate, Problem Use scores, implies thP1 , cocaine, or nar- their current alcohol-and other k=-mod *- drug-related problems predated *Wet TS Pais for each drug) their disability. Aka* cannabis, barbiturate, Similarities among the II most .,'cocaine, or ear- problematic users suggest a natu- ;. y ePhodes 0 rally occurring cohort, representing ParrAireach dra Ja 19.3 percent of the total sample. **1113.0110iin use Significantly, the results of previous studies indicate that 20 percent of This** is jatended for intra- the general college population are gtosPoompaison only. It is ori- abusers or potential abusers eittedhstaatienally toward Serious of alcohol or other drugs (Gada- or rem* symptom., of abuse to letto and Anderson 1986). As ex- discourage "false positive' .scores. pected from previous literature on ale.ol use by college students (Berkowitz and Perkins 1986; Tem- ple 1987), seven of the eight victims flosorlhoy Uspettooslitod Us% of drug-related trauma who scored relatively high on the Problem Use index were men. An unexpected finding was that the two respon- Motilhly Loss Then No dents with nontraumatic impair- SIAM or Mows Clueo pot Month Ws ments and high Froblem Use scores 10.0 were women. 64.9 WHY ARE ALCOHOL AND OTHER 5.3 87.7 DRUGS USED AT PROBLEMATIC LEVELS? 10.5 84.2 Table 3 provides Spinrmaa correla- 5.3 91.2 tion coefficients of selected varia- 7.0' 91.2 bles with Problem Use sLvres. The 3.5 96.5 variables correlate(' most highly with Problem Use were thrill seeking, sexual activity le iel (protlhlv a covariate of thrill seeking), anc 2 VOL 13, No. 2, 1989 1:1 Orthopedically Impaired College Students

scores from the Perceived Benefits of Drinking Scale. Expected predic- tor variables of medication levels, Table 3 flpoormao Come lotion Coolllolonte for Solootod Verbalise chronic pain, anomie, etiologies of disability, and attitudes toward Problem rollSeeking Samuel Perm Imd Omer la disability did not correlate with Use locket Score AM any of Orfoldng Sooty Problem Use at significant levels. Problem However, use of the chi square Use .464 .379 .329 statistical test matching the dichot- Thrill omous variables of trauma/ Seeking .526 .282 congenital etiology versus high/low Sexual Problem Use score indicated that Activity .263 trauma victims were more likely than congenitally impaired students The 016010111CIPV1141i14110011001*6t 6111 two voiebble. The =WOWo Problem to score high on Problem Use (chi UseallAlbilt, triffollialkMoOlaf0(4003, Sad lh000nrelation c square of 6.815, p< .009). Problellt l'*f014r< .0037; as Controlled for open- The use of alcohol and other drugs by the orthopedically im- plibelverffirehillsoll Woking Scale .., .048). paired college students correlated --, : 'n--- most highly with social and enpho- dant effects, rather than with any Table 4} perceived stress-reducing or analge-

sic properties. High thrill seeking, _ for example, had the highest corre- . Puma,*of Respopanls Replan. Um lation with Problem Use among this sample, irrespective of varia- 30.8 bles specific to disability-generated 7)3 consumption. These findings sug- Artfi0 badliWY:171 1.8 gest that physically impaired college Blood Illi(l'iAptiiNDr 8.8 students tend to use alcohol and 29.8 o",er drugs for reasons common to Other other college students. 47.4

MEDICATION USE AND ALCOHOL AND more education or information was receiving no medical information OTHER DRUG ABUSE necessary. This perceived lack of on how their physical impairment Amajorityof the sample (61.4 needformore information about might influence alcohol or other percent) reported use of at least one their medication was contradicted drug tolerance. prescribed drug, and 48.7 percent by the results of an exercise in cf those on medication (30 percent which respondents were provided SUMMARY of the total sample) reported use of examples of common medications The results of this study provide at least three prescribed medica- for each drug class and asked to information in three major subject tions concurrently. In fact, 14.3 report prescribed medications by areasetiologies of problem use percent of the students receiving those groups (see Table 4). In spite among students with disabilities, medication used at least five medi- of examples provided, many stu- comparisons of use between dis- cations concurrently. Estimating dents were unable to recognize the abled and nondisabled students, pharmacological effects of alcohol appropriate drug class of their med-and concerns about medication. or other drugs on multiple prescrip- ications, as eNidenced by the large The findings are intriguing in the tions is extremely difficult and sub- number of responses in the "other" support they lend to traditional ject to wide individual variation. category. theories concerning initiation of Several respondents expressed in addition to the low level of alcohol and other drug abuse. In awareness about the problems asso- information on pharmacokinetics this study, these traditional descrip- ciated with drug tolerance and po- of their current prescriptions, 43.9 tors seemed to hold ascendancy tentiation, but few respo.ided that percent of the sample reported over factors unique to physical 2;, 122 ALCOHOL HEALTH & RESEARCH WORLD impairment. Abuse of mood- factors, including understanding of tional disabilities: The center for indepen- altering drugs, including alcohol, alcohol and other drug abuse epi- dent living. Alcohol Health & Research appears to have predated disability sodes that predate impairment. As World 5(2) 11-15, 1980-1981. for the most problematic cohort in suggested by Glass (1980-1981), it JAFFE. L., AND ARCHER, R. The prediction of this study. A trauma-related disabil-is important to distinguish between drug use among college students from MMPI, MCMI, and Sensation Seeking ity correlated with greater likeli- alcohol or other drug abuse that scales. Journal of Personality Assessment hood of alcohol or other drug predates the impairment-produzing 51(2):243-253, 1987.

abuse during college than did a trauma and abuse that postdates it JOHNSTON, L.; O'MALLEY, P.; AND BACHMAN, J. congenital disability. This was espe-as a reaction to the injuries. The Drug Use Among American High School cially true if the trauma occurred relationship between use of pre- Students, College Students, and Other whit: the individual was under the scribed medication and use of non- Young Adults. National Rends Through influence of mood-altering drugs. 1985. DP.HS Pub. No. (ADM)86-1450. prescription drugs, including Washington, DC: Supt. of Docs., U.S. Govt. The incidence alcohol and alcohol, requires further elabora- Print. Off.. 1986. other drug use of this sample ap- tion, as do intervention strategies KRUPP. N. Psychiatric implications of pears comparable to use reported tailored for the physically impaired chronic and cnppling illness. Psychosomat- for high school and college student alcoholic or drug abuser.111 ics 9(2):109-113, 1968. populations. As is true in the gen- MALEC, J.; HARVEY. R.; AND CAYNER, J. eral college student population, Cannabis effect on spasticity. Archives of thrill seeking attributes, previous REFERENCES Physical Medicine and Rehabilitation 63:116-118, 1982. history of drug use, and level of BENEDIKT, R.A., AND KOLB. L.C. Preliminary sexual activity correlated with cur- findings on chronic pain and posttraumatic MEI ERS, A.; BRANCH, L. AND LEDERMAN. R. rent alcohol and other drug use stress disorder. American Journal of Psychi- Alcohol, tobacco, and cannabis use by atry !43:908- 910,1986. independently living adults with major patterns. disabling conditions. International Journal BERKOWITZ. A., AND PERKINS, W. Problem Only 16 percent of the respon- of the Addictions 23(7):671 -685, 1988. drinking among college students: A review dents thought that they were over- of recent research. Journal of American FETCHERS, M., AND SINGER, M. Perceived- medicated. However, the issue of Colfte Health 35(1):21-28, :986. Benefit-of-Drinking Scale: Approach to prescribed medication interacting screening for adolescent alcohol use. Journal BRENNAN. A.; WALFISH. S.; AND AIJBOCHON, P. of Pediatrics 110:977-981, 1987. with alcohol or other drug use was Alcohol use and abuse in college students: A raised by results indicating that 30 review of individual and personality corre- PRESCOTT, J.W. Somatosensory affectional percent of the sample were taking lates. International Journal of the Addic- deprivation (SAD) theory of drug and alco- three or more concurrently pre tions 21(4 - 5):449 -474, 1986. hol use. In: Lettieri, D.J.; Sayers, M.; and Wallenstein-Pearson, H., eds. Theories on DEAN, J.C.; Fox, A.M.; AND JENSEN. W Drug scribed drugs. Over one-third of the Drug Abuse: Selected Contemporary Per- and aicohol use by disabled and nondisabled sample (36.8 percent) reported two spectives. NIDA Monograph Series No. 30. persons: A comparative study. International DHHS Pub. No. (ADM)80-967. Rockville, or more episodes of physical illness Journal of the Addictions 20(4):629-641, MD: National Institute or Drug Abuse, following alcohol or other nonpre- 1985. scription drug use, suggestli,: the 1980. pp. 286-296. DiLOACH. C., AND GREER, B.G Adjustment RAsmussEN, G., AND DEBOFR, R. Alcohol and possibility that prescribed medica- to Severe Physical Disability: A Metamor- drug use among clients at a residential tions may potentiate effects of alco- phosis. New York: McGraw-Hill, 1981. vocational rehabilitation facility. Alcohol hol or other drug use among this DULL, R. An empirical examination of the Health & Research World 5(2):48 -56, 1980- population. This is particularly anomie theory of drug use. Journal of Drug 1981. Education 13(1):49-62, 1983. troublesome because much of the SALTZ, K. AND ELANDT, D. College student medication is used over extended FRIEND, K AND KOUSHKI, P. Student sub- drinking studies 1976-1985. Contemporary periods of time or in recurring regi- stance use: Stability and change across Drug Problems 13(1):117-159, 1986. college years. Inte, ational Journal of the mens. Alumni in the pilot study SULLIVAN. A., AND GUOLIELMO, R Chronic Au'dictions 19(5):571-575, 1984. had reported planning for evenings imperceptible pain as a cause for addiction. of drinking by discontinuing certain GADALETro, A., AND ANDERSON. D. Contin- Journal of Drug Education 15(4):381 -386, ued progress: The 1979, 1982, and 1985 1985 medications in advance; however, it college alcohol surveys. Journal of College TEMPLE, M. Alcohol use among male and is difficult to control unwanted Student Personnel 27(6):499-509, 1986. outcomes when the drug actions are female college students: Has there been a GLASS, E. Problem drinking among the blind convergence? Youth and Society 19(1\ 44-72, not understood by the person at- and visually impaired. Alcohol Health & 1987. tempting to control the drug intake. Research World 5(2):20 -25, 1980-1981. ZucxEame.N. M. Sensation Seeking: Beyond Subsequent studies should pro- HEPNER, R.; KIRSHBAUM. H.; AND LANDES, D. the Optimal Level of Arousal. Hillsdale, NJ: vide greater understanding of these Counseling substance abusers with addi- Lawrence Erlhaum Associates, 1979. f

Va. 13, Na 2, 1.1119 jid 123 Arthritis is a term used to indiLute the presence of a rheumatic condition affecting the joints. A common misconception is that arthritis represents a single illness. In fact, there are more than 100 distinct diseases that may involve the joints. Many arthritic disorders are chronic in nature, result in significant disability, and require a long- term commitment to management. lbgether, arthr'tic and other rheumatic diseases are the most widespread chronic disabling conditions. The U.S. National Center for Health Statistics estimates that nearly 31 million Americans including more than 5 million between the ages of 18 and 44 years have at least o.form of these conditions. Approximately 6 million suffer activity limitation because of arthritis or other rheumatic disease. These disabling effects are twice as common among women as among men and are especially prevalent among low-income Americans (US NCHS 1984). Clinicians know that the arthritic diseases have a variety of causes, including infection, metabolic abnormalities, and injury to the immune system. Most individual cases of arthritis can be traced to one or more of these causes without reference to the patient's use of alcoholic beverages. However, it is less widely recognized that chronic

DAVID J. NASHEL. M D., is chief of the rheumatology section of the Veterans Administration Medical Center of Washington, DC, and associate professor of medicine at Georgetown University.

3 ALcouoL Hum &RIDIZARCH WOIU.D alcohol abuse may be a predispos- The association of gout with alco- because the whiskey often is dis- ing factor for several varieties of hol abuse is highlighted by a recent tilled using old car radiators as arthritis. Further, these disorders study of patients seen in a family condensers; the lead in the connec- may be so severe and crippling that practice (Sharpe 1984). In this tions contaminates the alcohol. In in the mind of both clinician and study, the average weekly alcohol one study of gout patients admitted patient, the arthritic diseases ulti- intake of patients with gout was between 1970 and 1976 to the Vet- mately may overshadow their root found to be more than twice that oferans Administration Hospital in cause, which is the alcoholism. a matched control group. Birmingham, Alabama, 36 percent The bases for the alcohol-gout had evidence of plumbisma THE ALCOHOL-GOUT CONNECTION connection only recently have be- chronic form of lead poisoning Gout is an arthritic disease derived come clear. We now understand resulting from their consumption of from elevated levels of uric acid in that uric acid is the end product of moonshine (Halla and Ball 1982). the blood. In some patients with the breakdown of proteins consumed in the diet and that alcohol elevated uric acid levels, crystals of SPECIAL CARE IN TREATMENT OF THE causes the body to increase produc- urate form in the joints. What en- ALCOHOLIC PATIENT WITH GOUT sues is an inflammatory reaction tion of uric acid (Faller and Fox manifested by swelling, redness, 1982). At the same time, lactic Because alcohol so often is an incit- and intense painthe hallmarks ofacidproduced by the chemical ing element in the development of acute gouty arthritis. breakdown of alcohol molecules in gouty arthritis, abstinence is a cru- In the early phase of the disease, the bodyblocks the normal dis- cial part of the management of this attacks of gout are infrequent and posal of uric acid by the kidney. disorder. In an otherwise healthy of relatively short duration. With- Thus, it is not surprising that ele- individual, an acute attack of gout out treatment, a single episode mayvated uric acid levels in the blood easily is aborted through the use last from 1 to 2 weeks. With the resulting in acute attacks of gout of any one of a variety of anti- passage of time, however, gouty may follow on the heels of a drink- inflammatory medications (Schweitz flares usually become more numer- ing binge. et al. 1978). However, when the ous and the condition may evolve For many centuries, alcoholic patient has chronic alcoholism, the into one in which there is chronic beverages inadvertently have been use of these agents may pose signif- inflammation involving multiple ,ontaminated by lead. Originally, icant risks. joints. In tnis stage, gout is often this resulted from the practice of All of the commonly used anti- crippling and deforming and is storing beverages, such as brandy, inflammatory medications, includ- easily mistaken for longstanding in lead casks. This contamination ing colchicine and the nonsteroidal rheumatoid arthritis. provides another connection be- anti-inflammatory drugs employed Clinicians long have recognized tween alcohol and gout: The term in the treatment of gout, have the that acute attacks of gout often are "saturnine" gout is the designation potential to irritate the lining of the related to overindulgence in alco- for a variety of the disease that stomach. Alcohol also irritates the hol. In a classic treatise o gout, develops when the patient is a vic- gastrointestinal tract, and as a Garrod (1859) stated that: tim of lead poisoning. Saturnine result, the alcoholic patient is more gout was particularly common in likely than other patients to de- ...the use of fermented or 18th century England when port velop ulcer disease and gastritis, an alcoholic liqi:ors is the most "fortified" with brandy was a fa- irritation of the stomach lining. powerful of all the predisposing vorite drink. Both ulcers and gastritis may be causes of gout; nay so potent, Saturnine gout remains a com- associated with blood loss, and that it may ',)e a question whether mon malady to this day, particu- there is a risk of acute hemorrhage the malady would ever have been larly in the southern Unite., States when anti-inflammatory medication known to mankind had such. where the illicit production of is used incautiously to treat gout in beverages not been indulged in. "moonshine" whiskey contirues. an alcoholic patient (Nashel and (p. 260) Moonshine frequently contains lead Chandra 1982).

-t7 VOL. 13, Na 2, HO 125 Arthritic Disease

Another concern in the use of ber of disorders that may limit much to be desired. Of course. anti-inflammatory medications is blood supply to the bone. The dis- after the diagnosis has been estab- their potential effects on the pa- ruption of blood flow may result lished, further alcohol consumption tient's blood. Alcoholic patients, from a fracture, a spasm, inflam- must be discouraged. Unfortu- for a variety of reasons, are more mation of the blood vessels,or nately, by the time changes in the likely than other patients to be obstruction of the blood vessels by bone are evident by x-ray, the dis- anemic and to experience prob- small blood clots. When avascular ease is likely to have progressed to lems with blood clotting. Anti- necrosis is associated with alcohol- the point that eventual destruction inflammatory medications also ism, some investigators believe that of the joints is inevitable. tend to inhibit normal blood coagu- the vessels supplying blood to the Several snrgical techniques have lation and thus may pose an addi- bone may be obstructed by clumps been used in attempts to reestablish tional danger to patients in this riskof fat globules known as fat emboli the blood supply to the affected group. (see, for example, Jones et al. 1965 bone. However, surgery appears to Acute gouty arthritisalthough and Nixon 1983). be only partially effective even uncomfortable to the patientis Investigations of the drinking when used in the early stages of the usually self-limiting, and attacks patterns of patients with avascular disease (Lotke and Steinberg 1985). often subside even when untreated. necrosis have found that as many When pain can no longer be For this reason, it is important to as 39 percent of these individuals controlled adequately by anti- remember the old adage that the have a history of significant alcohol inflammatory medication and the cure should not be worse than the use (Jacobs 1978). Among these patient's disability becomes severe, disease. Because anti-inflammatory patients, the head of the femur reconstructive surgery with com- medications pose unique risks for the "ball" portion of the hip plete replacement of the joint may the alcoholic patient, clinicians jointis the bone most often af- be necessary. should consider alternative treat- fected. Hungerford and Zizic ment regimens. Such alternatives (1978), reporting on 26 patients ALCOHOL AS AN IMPORTANT RISK include the use of medication for diagnosed with alcohol- associated FACTOR IN DUPUYTREN'S CONTRACTURE pain relief and the local injection ofavascular necrosis of the hip, indi- Studies of the incidence of Dupuy- corticosteroid into the affected cated an average patient age of 38 tren's contracture, a disease that joint or joints. years but found 1 patient who was involves the palm of the hand and only 16 years old. Particularly that usually follows a chronic tragic was the fact that the disease AVASCULAR NECROSIS: DIFFICULTTo course, suggest an association be- DIAGNOSE ANDTo TREAT eventually affected both hip joints tween cases of this condition and a in 73 percent of the patients history of alcohol abuse. The area Avascular necrosis, also known as studied. first affected by the disease is the aseptic necrosis or osteonecrosis, is The earliest symptom of avascu- fascia, a band of fibrous tissue that another arthritic disorder associ- lar necrosis is pain when using the ated with excessive alcohol intake. lies adjacent to the tendons that involved joint. As the disease pro- pull the fingers together into a With this disease, bone cells die as gresses, however, pain may be closed position. In Dupuytren's a result of inadequate blood supply. present even when the patient is at In the early stages of avascular contracture, the fascia thickens rest. Unfortunately, there may be a and, eventually. the skin becomes necrosis, the areas most often af- delay from several months to sev- bound and fixed to this fibrous fected are the ends of the longest eral years between the onset of pain bones. The region of bone affected tissue mass. Gradually, at least and the time at which changes first some of the fingersusually the lies under the cartilage, the dense become discernible by x-ray. A fourth and fifth digitsare pulled connective tissue that forms the variety of other diagnostic proce- toward the palm and the patient smooth surface layer of bone and dures now can be used to permit can no longer fully open the hand. bears the weight of the joints. In earlier detection of the bone dis- time, the cartilage itself becomes Dupuytren's contracture often ease; among the most promising of affects both hands in a symmetrical damaged. Ultimately, arthritis de- these are computerized axial tomo- fashion. There appears to be a velops and the joints may be graphy, or CAT scan, and nuclear hereditary predisposition to devel- destroyed. magnetic resonance (NMR). opment of the disorder, and men The occurrence of avascular Even with timely diagnosis, treat- are approximately seven times more necrosis is correlated witha num- ment of avascular necrosis leaves likely to be afflicted than are

121 ALCOHOL HEAITH * REstAncs Won') women (Turek 1977). The preva- sumption, and chronic liver disease. Ar- lence of the disease gradually in- chives of Internal Medicine 147:1065-1067, Researchers also 1987. creases with age. Although Dupuytren's contrac- noted a strong BRADLOW, A , AND MOWAT, A G. Dupuytren's contracture and alcohol. Annals of the ture has been associated with such Rheumatic Diseases 45:304-307, 1986. diseases as diabetes mellitus and association between FALLER, J., AND Fox, I.H. Ethanol-Induced epilepsy, the most striking correla- the presence of hyperuncemia: Evidence for increased urate tion is with chronic alcohol abuse. production by activation of adenine nucleo- Attali and colleagues (1987), exam- Dupuytren's tide turnover. New England Journal of ining the prevalence of this contrac- contracture and Medicine 307:1598-1602, 1982. ture among hospitalized patients, GARROD, A.B. The Nature and Theatment of found the disease present in 32.5 alcohol consumption. Gout and Rheumatic Gout. London: Walton percent of patients with alcoholic and Maberly, 1859. cirrhosis, in 22 percent with other J.T., AND BALL. G.V. Saturnine gout: alcoholic liver disease, and in 28 A review of 42 patients. Seminars in Arthri- associated with relatively high levels tis and Rheumatism 11:307-314, 1982. percent with chronic alcoholism of alcohol consumption. and no liver disease. In compari- The treatment of Dupuytren's HUNGERFORD, D.S., AND ZIZIC, T.M. Alcohol- ism associated ischemic necrosis of the son, they found Dupuytren's con- contracture primarily depends on femoral head. Clinical Orthopaedics and tracture in only 6 percent of the stage of the disease in which Related Research 130:144-153, 1978. hospitalized patients with nonalco- diagnosis is made and on the rate JAcoes, B. Epidemiology of traumatic and holic liver disease and in 12 percentof progression. In the early stages, nontrauraatic osteonecrosis. Clinical Ortho- of a matched control group. The physical therapyincluding local paedics and Related Research )30:51-67, same researchers also noted a heat, exercises, and corticosteroid 1978. strong association between the injectionmay suffice. However, JONES, J.P.; ENGLEMAN, E.P.; STEINBACH, presence of Dupuytren's contractureif there is a significant functional H.L.; MURRAY, W.R.; AND RAMBO, G. Fat and total alcohol consumption deficit or if physical appearance embolization as a possible mechanism producing avascular necrosis. Arthritis and and discovered a correlation be- becomes a major concern, then Rheumatism 8:449, 1965. tween total alcohol intake and the surgery often is necessary. LCTKE, P.A., AND ST_INBERG, M.E. Osteone- severity of the contracture. crosis of the hip an i knee. Buidetin on the ARTHRITIC DISEASE AS A SIGNALFOR In another recent study (Brad low Rheumatic Diseases :5:1-8, 1985. THE POSSIBILITY OF ALCOHOLISM and Mowat 1986), 64 patients ad- NASHEL, D.J., AND CHANDRA, M. Acute gouty mitted for surgical correction of Each of the arthritic conditions arthritis: Special management considerations Dupuytren's contracture answered discussed above may result in sig- in alcoholic patients. Journal of the Amen- questions regarding their drinking nificant disability to the patient. In can Medical Association 247:58-59, 1982. history. Patients with a current or many instances, the illness can be NIXON, J.E. Avascular necrosis of bone: A maximum lifetimz average daily directly attributed to underlying review. Journal of the Royal Society of consumption of 40 grams or more alcoholism. This recognition by Medicine 76(8):681-692, 1983. of alcoholthe equivalent of ap- both physician and patient is cru- SCHWEITZ, M.C.; NASHEL, D.J.;ftND ALEPA, proximately four 10-ounce glasses cial because continued alcohol use F.P. Ibuprofen in the treatment of acute gouty arthritis. Journal of the American of beerwere classified by the may further exacerbate these dis- Medical Association 239:34-35, 1978. stuoy's authors as "heavy" drink- eases. Although most arthritis has SHARPE, C.R. A case-control study of alco- er,. Thirteen of 54 men with Du- no direct link to alcohol consump- hol consumption and drinking behavior in puytren's contracture fell into this tion, the definitive management of patients with acute gout. Canadian Medical category, compared with only 1 of these three arthritic disorders by Association Journal 131:563-567, 1984. 45 male controls without the dis- clinicians requires identification TUREK, S.L. Dupuytreh's contracture. In: ease. Among women, 2 of 10 pa- and treatment of any associated Tbrek, S.L., ed. Orthopaedics: Principles tients with contracture were alcohol abuse. and Their Application. Philadelphia: J.B. classified as "heavy" drinkers, Lippincott Company, 1977. pp. 958-964. whereas none of the 44 matched U.S. Natie,aal Center for Health Statistics. female controls reported similar REFERENCES Current estimates from the National Health Interview Survey, U.S., 1983. Vital and levels of alcohol use. These data ATTALI. P.; INK, 0.; PELLETIER, G ; VERNIER, Health Statistics, Series 10. Washington lend support to the view that Du- C.; JEAN, E; MOULTON, L, AND ETIENNE, DC: U.S. National Center for Health Statis- puytren's contracture is strongly J-P. Dupuyten's contracture, alcohol con- tics, 1984.

Vol- 13, Na 2, ne 127 Alcohol Abuse and Persons Who Are Blind Treatment Considerations

MICHAEL NELIPOVICH, RE.D., AND ELMER Buss

A1984 Wisconsin State of and adjustment to this impair- The level of a client's adjustment government survey to ment has been reached before alco- skills will affect tne ways in whict evaluate alcohol and hol abuse begins, then treatment the staff of an alcohol rehabilita- other drug abuse ser should be geared to addressing the tion facility interact with a visually vices to individuals who are blind alcohol abuse. If the visual impair- impaired client. The staff can ask or visually impaired led to the con- ment has been more recent, then whether the patient travels indepen- clusion that this is an underserved treatment should focus on helping dently and uses either a long cane population. The fact that no signif- the client to accept and adjust to or dog guide. Reatment staff, par- icant data are available concerning the visual impairment first, and ticularly in an inpatient facility, such services to this group may then on treating the alcohol abuse. also determine whether or not a indicate that persons with impaired The greatest challenge to rehabilita- client has the appropriate organiza- vision are not generally perceived tion professionals occurs when a tional skills to identify clothing. by treatment programs as a special person suffers from two or more The absence of such skills may client group. Instead, persons with disabilitiessuch as alcohol abuse impinge upon self-image in a situa- impaired vision often are perceived and vision impairmentand has tion in which self-image is already a as isolated cases remembered be- accepted neither of them. problem. The pitfall to avoid is cause of the difficulty and frustra- treating the blind patient like a Another consideration in devel- tion of trying to serve them. child during assessment. oping a treatment plan is the level The accurate assessment of ad- of the client's adjustment to the ONSET AND ADJUSTMENT SKILL ISSUES justment skills by treatment staff condition of visual impairment. All A person -.vho is blind and abuses clients, blind or sighted, who are MICHAEL NELIPOVICIL RHD., is act- alcohol should be considered duallyadmitted to alcoholism treatment ing director of the Office for the disabled. In developing a treatment programs hrve attained some level Blind of the Wisconsin Division of plan, several things are important. of independence. In assessing ad- Vocational Rehabilitation.ELMER It is important to determine, if justment skills, the goal is to deter- Buss is employed by the Office for possible, whether the vision impair-mine whether or not the client can Persons with Physical Disabilities ment or the alcohol abuse occurred travel independently, can send and of the Wisconsin Division of Com- first. Because every treatment plan receive communication by various munity Services. Comments on this must be individualized, each plan means, and can manage clothing article should be addressed to Dr. differs in part depending ca the and personal needs. Adjustment Nelipovich at the Wisconsin De- circumstances under which the skills can be measured by asking partment of Health and Social disability begins. If the visual im- specific questions about indepen- Services, I Wilson Street, Room pairment is of long standing and if dent mobility, communication tech- 830, P.O. Box 7852, Madison, Wis- an appropriate level of acceptance niques, and personal management. consin 53707.

National Eye Institute 30,

VoL. 13, Na 2, IWO 129 Persons Who Are Blind

also includes identification of the client's preferred mode of communication. During treatment, clients typically are asked to read a variety of materials that are viewed as ben- eficial to rehabilitation. Not being able to access the appropriate print can be as big a barrier to treatment as taking steps is to a person in a wheelchair or as group sessions conducted in English are to a cheat who speaks only Spanish. The sighted person's first response to the problem of communi- cating with the visually impaired often is to have material available on tape or to have a sighted person available to read. These are functional approaches, but may not be the best solutions. For example, if an alcoholism treatment client is legally blind but can use print with ple, when staff members orient the leisure time activities to determine magnification, treatment facilities visually impaired client to the treat-their accessibility to visually im- can purchase or rent the appropri- ment facility, it is wise to ask paired clients. Again, the local ate device. Alternatively, if a client whether the client has a preferred service agency can help to meet the is a braille reader, the facility can way of becoming accustomed to recreational needs of the visually provide at least a copy of the basic physical surroundings; most visu- impaired. A multitude of items are material that is already available in ally impaired people have such available for purchase, ranging braille. The objective is to assist the preferences. from braille playirg cards to modi- patient in becoming as independent Effective orientation of a blind fied table games and craft kits. The as possible and to increase choices client to the physical environment goal is to allow the blind client to in rehabilitation. of an inpatient facility includes, at participate in the mainstream of If assessment of a visually im- a minimum, familiarity with the activit:and not be isolated. The paired client's adjustment skills client's sleeping room, bathroom, closest library for the blind also can indicates that there are major gaps meeting rooms, dining room, recit- be contacted so that. the treatment in the client's ability to function ation room, and all exit locations staff may obtain the adaptive independently, alcoholism treat- When sufficient time is spent on equipment for cassette magazines ment program staff can contact the the orientation process, the client and other materials that are avail- local State or private agency that becomes comfortable with the sur- able for nonprint readers. specializes in services to the blind. roundings. The authors' experience Treatment facilities also should be suggests that a staff member or THE V/PliA.LLY IMPAIRED PERSON IN prepared to identify community another client should be designated ALCOHOLIcs ANONYMOUS resources that can provide any of as a guide for the first few days. Many counselors advocate partici- the needed services. After this period, most inpatient pation in Alcoholics Anonymous clients who are blind should ye able(AA) for long-term recovery. The to travel independently. Some indi- IA system can be most effective FAcn.rry 13suzs viduals may require more orienta- for persons who are blind if they Blindness restricts control of the tion and more guided assistance can participate fully. Many of the environment and ease of mobility. depending upon the level of their following observations on removing Clients are most responsive when adjustment skills. barriers within AA are equally valid treated respectfully and when as- Inpatient treatment facility staff for other outpatient treatment and sumptions are avoided. For exam- should evaluate recreational and recovery programs. 3

LI ALCOHOL HEALTH & Itzmutat Wo am Although AA meetings are avail- vision. It also is important to ap- playing speed saves space and cost: able 7 days a week at a wide range preciate that it is awkward for a For example, one version of The of times and locations, their acces- visually impaired person to move Big Book at 1-7/8 rpm contains six sibility to the visually impaired freely in a crowded room, and as- cassette tapes, with two sides per recovering alcoholic is limited be- sistance should be provided when cassette, and costs $25, whereas a cause of the inability to drive. Taxi- necessary. 15/16 rpm version can be recorded cabs may provide a solution but The process of socialization in anon a single cassette and can be can become expensive. If a blind AA meeting is assisted when some- made available for significantly less person in recovery wants to attend one introduces the visually im- cost. Of course, many audiotapes an AA meeting on Saturday morn- paired member to several other are prepared primarily for sighted ing and the closest one is 15 miles attendees. Members should adopt people to use in standard tape away, the stress that can result fromthe courtesy of identifying them- decks, but with limited modifica- trying to get there can compound selves when speaking and telling thetion, taped AA material can be this person's agony. 11.anspo.-tation blind person when they are depart- made much more accessible to the can make all the difference to a ing (see sidebar on personal interac-blind. visually impaired alcoholic's strug- tion with visually impaired persons). gle to become and remain sober. Many sighted people become ner- THE NEED To REACH Our If a visually impaired alcoholic is vous when addressing an individual Alcohol- and other drug-related referred to AA from treatment, the who cannot make eye contact when problems exist among the blind, referring counselor has a responsi- speaking, and this nervousness can and individuals involved in treat- bility to make the first arrange- promote a feeling of negative self- ment services should be aware of ments for transportation to the AA worth and isolation that is detri- the responsibility for serving this meeting of choice. Visually im- mental to recovery. To counter this, population. Developing the skills paired persons should go to the an oldtimer can be assigned to pro- necessary to serve this group di- rust meeting the best way possible mote introductions and stimulate rectly affects the treatment outcome and explain the need for future conversations between the visually for blind individuals with alcohol- transportation. A new visually im- impaired person and others until related problems, as suggested by paired member and AA oldtimers interactioi. occurs easily. the results of an earlier survey of immediately can begin working on It is important to provide alterna-agencies serving the blind (Nell- a list of friendly drivers. The AA tive communications to reduce the povich and Parker 1981). Sixteen oldtimers at the meeting can be barriers to full participation in counselors who participated in that made aware that lack of transporta-AAand other outpatient settingsstudy could find no employment tion may result in a serious risk of by the visually impairer' alcoholic. for any visually impaired alcohol nonattendance and eventual re- The schedule and a list of meeting abusing client. However, eight lapse. Their response is likely to be locations can be made available in counselors successfully found em- diligent assistance. braille. Taped items can be preparedployment for one-half of the visu- Additional barriers to effective with the visually impaired recover- ally impaired client population. The participation in AA meetings ining alcoholic in mind. It is wise to greater the knowledge and the more clude problems related to the envi- have audiotapes of The Big Book highly developed the skills of the ronment and to socialization. As in and Thelve Steps and Thelve Thadi- counselor, the better the prospects an inpatient treatment facility, it is tions, but tihese audiotapes are for rehabilitation of the visually important to orient the visually not labeled in braille, the blind impaired alcohol abusing clients. impaired person to the surround- alcoholic will not be able to deter- The authors strongly suggest that ingswhere entry doors are, how mine their contents. Audiotapes the professionals in alcohol and the room is shaped, how the tables used in recovery can also be tone or other drug treatment services con- and chairs typically are arranged, voice indexed for the blind, and sult with agencies serving visually where the coffee pot is, and where readers can indicate wnen one side impaired persons. la the bathrooms are located. These is over. REFERENCE are basic facts that a sighted person When audiotapes are prepared quickly determines upon entering a for the blind, the appropriate play- NELIPOVICH, M., AND PARKER.R. Comment: room, but that cannot be taken for The visually impaired substance abuser. back speed is 15/16 rpm instead of Journal ofVisual Impairments and Blind- granted for a person with impaired the standard 1-7/8 rpm. The slower ness 75:305, 1981.

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fir 4114 Intervention with Visually Impaired 4 Children of Alcoholics

CHRISTINE SAULNIER

Children of aroholics Despite the scope of the problem, (COAs) are generally treatment services for alcoholics acknowledged to be at and COAs rarely are designed spe- increased risk for devel- cifically for the visually impaired. oping alcoholism. At the same In part, this lack of special services time, the incidence of alcoholism is is due to the process of "main- higher among the disabled than streaming," in which it is assumed among the general population that the visually impaired can rely (Hepner et al. 1980-1981; Hindmanon services geared to meet the and Widem 1980-1981; Greenwood needs of the general population. 1984; Gallagher 1985; Sylvester Suggestions in the literature have 1986). Therefore, one would expect been limited to educating addiction visually impaired COAs to be at treatment professionals regarding especially increased risk. visual impairments and adding low- Peterson and Nelipovich (1983) vision aids to current alcoholism estimate that there are 40,000 visu- treatment programs to accommo- ally impaired alcoholics in the date the needs of the visually im- United States. The number of visu- paired (Glass 1980-1981; Neli- ally impaired COAs is not known. povich and Parker 1981). However, concern about the prob- On a policy level, the Compre- lem is raised by suggestions made inhensive Alcohol Abuse and Alco- a treatment group for visually im- holism Prevention, Treatment, and paired adolescent and young adult Rehabilitation Act Amendment of COAs run by the author. Four out 1979 (42 U.S.C., 1980) requires that of five members of this group use alcoholism treatment services be alcohol, and one-half of those who made available to "handicapped" use alcohol abuse it. In each case inpersons. In practice, access to alco- which the child is abusing alcohol, holism and other mental health both parents are alcoholic. Both services for those with physical parents are alcoholic in three out of disabilities has been limited for the four group members. following reasons:

CHRISTINE SAULNIER iS director of Service providers lack education social service at Quigley Memorial and training in disabilities aware- Hospital, 91 Crest Avenue, ness (Gallagher 1985). Chelsea, Massachusetts 02150. The desire to comply with the Amencan Council of the Blind 4 133 Visually Impaired Children of Alcoholics

"normalization" campaign that visual impairment. This may be a focuses - 7 how well people with The alcoholism sign of depression, or the client disabllit:...s fit into the larger soci- may simply need be reminded ety (Gallagher losS) leads some treatme.rit professionalthat others are favorably affecteu people with disabilities to mini- needs to monitor any by the appearance of a well- mize or deny genuine treatment groomed person. The author peri- needs. tendency toward odically consults with personal People with disabilities fear management instructors to decide double stigma of disability and decreased expectationswho will address these issues and to dependence on alcohol and other of visually impaired clarity whether the problem is emo- drugs and are therefore reluctant tional or skill based. to seek treatment (Boros 1980- cfients. Finally, the alcoholism treatment 1981; Hindman and Widem professional needs to monitor way 1980-1981; Lowenthal and people have some degree of sight tendency toward decreased expecta- Anderson 1980-1981). (N- clonal Society to Prevent Blind- tions of visually impaired clients. If ness 1980). If the client does not group members are expected to do This article presents strategies for request assistance, the clinician "homework," such as reading, writ- overcoming some of the difficultir should ask what specific assistance ing, or attending a meeting or ac- encountered in treating visu is needed; trying to force unneeded tivity, he visually impaired clients impaired COAs. It is based help is counterproductive. Other should be held to the same expecta- author's experience with a tre...- common mistakes include ignoring tions. As one group member said, ment group for COAs residing in a the visually impaired client and "If they all clean ashtrays [at Al- school for the visually impaired. addressing a companion, equating Anon meetings], clean ashtrays." When asked what would be the blindness with dearnc..: and show.- most important piece of informa- irgt a visually impaired person, COUNSELING THE RECENTLY IMPAIRED tion to convey -nembers insisted or loc::ing around the room rather One of the first steps in beginning that readers beade to understand than directly at the person being trea'n.ent is to dr'ermine whether that the similarities between visu- addressed. the client has only recently become ally impaired COAs and their Occasionally a client may exhibit impaired. If so, additional therapies sighted peers far outwe'gh the dif- rocking, eye poking or pressing, may need to be incorporated into ferences. While this is true, it also hard flapping, and head p >Ring. the alcoholic -t treatment to address should be noted that the problems These behaviors, known as "blind- the special emotional and physical shared by all COAs are apt to be rms," are unrelated to mental needs of the newly impaired. Con- compounded and itensified when illness aiare not indications of sultation with a vision expert is visue1 impairments are present. The pathology, althourh they may in- recommended at this stage. family alcoholism counselor's treat- crease in frequency of intensity It is important to note that the ment approach and emphasis there- when the client is under stress. use of confrontational techniques fore depend on the needs of the They are most co nmon in people may be a mistake at this time. This specific client and on whether or who a-e totally and congenitally approach, so useful for breaking not the client already has access to blind. Some -isually impaired per- through a COA's denial of family special services. sons who exhibit these behaviors alcoholism, might be psychologi- have been misdiagnosed as athistic. caLy harmful to a newly impaired T:IE N. URE OF THE IMPAIRMENT Altho-igh autism does occur amongclient whose primary need is sup- Awareness of a number of facts the blind, a diagnosis of autism port. The alcoholism treatment about the nato7e of visual impair- based solely on the occurrence of professional should assist the client ment helps health care providers to blindisms would probably be in accepting the impairment and avoid clinical misinterpretations. inaccurate. integrating it into self-concept in a First, it is important to remember Tt would also be a mistake to positive way. that visually impaired does not assume that sloppiness in self-care In addition to the loss to which necessarily mean completely blind. or dress is a permanent condition the client must adjust and to possi- Ninety percent of visually impaired or that it is necessarily related to ble related depression, the newly

4A. 134 ALCOHOL HEALTH a Itrumecu %Num impaired person faces architectural, The prevalence of denial among against discrimination is one of the attitudinal, and employment barri- COAs does nc preclude a sense of issues that sets this treatment group ers (Glass 1980-1981) that may be guilt and responsibility for the fam-apart. The stigma of family alco- initially overwhelming, decreasing ily's problems. Here, too, this con- holism, together with the negative the client's ability to cope with viction seems harder to dispel with associations of being blindfor family alcoholism and possibly evenvisually impaired COAs. Statementsexample, the stereotype of the blind increasing the risk of the client's such as "If only I'm good enough, person as a beggar (Glass 1980- own drinking. The client's aware- my dad will stop drinking" are 1981) can have a devastating ef- ness of both the li.-nitations and common among COAs; a variation iect on self-esteem, exposing the potential for compensating for that surfaced among members of visually impaired child to an even vision loss may need to be dis- the author's treatment group was higher risk of continuing the family cussed. Encouraging or arranging the belief that if they were not visu- alcoholism. Therefore, values clari- interactions with other visually ally impaired °.%)ey would be better fication sessions must focus not impaired persons will help decrease able to help their alcoholic parents. only on beliefs about alcohol con- the ( dent's sense of isolation and It is necessary to state repeatedly sumption and alcoholism but also the teas of in;lity to cope. that eliminating the client's visual on beliefs about visual impair- impairmrat would not eliminate thements and the culture's view of PROBLEMS IN TREATMENT: parent's alcoholism and that inabil- compe nce. DENIAL AND Glam. ity to cure the disease is not related For example, people may react Denial of family alcoholism is a to lack of sight. with surprise, embarrassment, an- common phenomenon among Clients sometimes insist that if ger, or even disbelief when they COAs. The problem may become they saw better, they woula be less discover that a visually impaired more complicated when the COA isof a burden to the parent. They person can see. A partially im- visually impaired. Clients some- paired COA who has been sub- times seem to interpret the adage In breaking the silencejected to such reactions may need "seeing is believing" quite literally, reassurance and support with re- disregarding information that they about family spect to the reality of his impair- have obtained through their other ment and the validity of his senses. For example, as ev;dence of alcoholism, visual self-image. alcohol abuse, hearing a parent's impairment should The specifics of each client's slurred speech seems to be less con- visual disability are open for discus- vincing than seeing the parent's not be substituted as asion in the author's group, and a unsteady gait. conscious effort is made to identify Another problem of perception istaboo topic. and accept one another's needs; that group members tend to evalu- 11group members are not necerily ate the seriousness of a parent's may even wonder if the reason the aware of one another's abilities nor drinking problem based on their parent drinks is because he or she are they particularly adept at artic- personal interactfr. s with the par- views the child as defective. Realis- ulating their own. In breaking the ent rather than on objective obser- L discussion of how the visual silence about family alcoholism, vation. Clients often discount the impairment affects tie parent's life visual impairment should not be seriousness of a drinking episode sometimes convinces group mem- substituted as a taboo topic. because it did not cause clear, im- bers that their impaired vision is As with other COAs, group mediate trouble between the alco- more of an inconvenience to them- members are enconraged La re- holic parent and other family selves than to their parents and examine their view of themselves as members"My mother and I that parental inconvenience, while unlovable. Clients need to be reas- Jidn't fight last night, so she didn't it does exist, does not cause su-ed that visual impairmerL,, and have too much to drink." ,k. con- alcoholism. other injuries, even when these are cept of alcoholism being h- "iful to secondary to alcoholism (for exam- 0,- alcoholic also seems more diffi- PROBLEMS IN TREATMENT. ple, fetal alcohol syndrome or cult to communicate to visually DISCRIMINATION AND SELF -IMAGE traunr resulting from alcohol- impaired COAs. The virtually constant struggle related ia cidents), do not make

Vat. 13, No. 2, LW 135 Visually Impaired Chilthen of Alcoholics

them unlovable, nor were they de- less support for leaving because of example, whether it may be safer to liberate acts planned by their par- a perceived need to be protected by call someone or to leave; and if ents to harm them. the parents. they leave, how they will leave, Visually impaired COAs may be Therefore, the need for indepen- where they will go, and by what even more inclined to see them- dent living should be identified route. Independent travel promoted selves as different from other COAs during the "aging out" process by the special education system is and as not capable of being helped. the time when the client makes the reinforced in consultation with the lb combat this perception and to transition from special education toorientation and mobility trainer to encourage interaction with nondis- adult services, usually between the ensure that students will not be abled peers, group members are ages of 21 and 26 (depending on exposed to further risk by taking an encouraged to join Alateen or Al- the State). The clinician can contactunfamiliar route or traveling by a Anon. The combination of special the coordinator of the education method they are not skilled in services that directly address their plan and urge that this goal be using. specific needs and traditional ser- incorporated into the transition vices for COAs seems to work well. plan. OUTREACH There is also a tendency by others After a -nference in which alco- to regard the lack of normal vision COPING WITH VIOLENCE holism counselors and disability as a "supreme catastrophe ;father The combination of overprotection rehabilitation professionals shared than] a nuisance that can be cir- and involvement in special educa- information and treatment tech- cumvented or overcome" (Selvin tion may lead the Professionals niques, Lowenthal and Anderson p. 420) and to see the visually serving the COA to a false impres- (1980-1981) suggested outreach impaired person as being incapable sion of safety regarding the physicalprocedures to identify physically of taking care of himself or herself. dangers of family alcoholism. Even impaired alcoholics and to inform All the members of the author's in a residential school setting, risk them of treatment options. Their treatment group have been sub- is not eliminatedsome children suggestions included developing a jected to annoying, damaging pity with special needs still go home to referral directory and disseminating regarding their impairment and alcoholic families. information in writing, over the their capa_ity to cope. Therefore, it is essential to review telephone, and through community The children in the author's treat-realistically the visually impaired education workshops. Supplying ment group are taught to avoid COA's vulnerability to danger and clients with information in braille accepting the negative impressions violence (Hindman 1977). Group or on tape is another possibility others may have of them. The im- members are encouraged to explore (Peterson and Nelipovich 1983). age of vision loss as a supreme their increased risk, to examine Mobility and personal manage- tragedy is discussed, challenged, coping skills they have developed in ment services may need to be pro- and emphatically denied. Group other arenas to compensate for vided to visually impaired clients, members arc cl,....ouraged to focus visual impairments, and to apply particularly for alcoholism treat- on their skills and their ability to the compensatory skills to this situ- ment in a residential setting (Glass compensate for their impairment. ation. The special eaucation system 1980-1981). They are reminded of their aca- teaches COAs how to .eek assist- Despite the importance of out- demic achievements, their home- ance, how to call a telephone oper- reach efforts designed to break making and cooKng skills, and ator, and how to call a taxicab or through denial (Bean 1988), the their success in such varied activi- the police if necessary. The author's lack of systematic inquiries de- ties as acting, mash. athletics, and group discusses the advantage of signed to identify alcohol and other overcoming negative behavior keeping emergency cab fare avail- drag abuse among persons entering patterns. able and of memorizing telephone e. rehabilitation program is a serious The tendency of others to over- numbers of friends and relatives procedural problem. Hindman and protect the visually impaired person who could come to their assistance Widen (1980 -1981) advocate the interferes with the goals of family if needed. inclusion of relevant questions dur- alcoholism treatment. In adult- Group members discuss the dan- ing the intake interview. hood, when other COAs may be ger of trying to intervene in violent It is important to note, however, extricating themselves from the situations. They are encouraged to that the alcoholism treatment pro- dysfunctional family system, the plan a course of ac :on to be fol- fessional places the special educa- visually impaired COA may receive lowed in violent situations: for tion system in a precarious position

1.36 4t. ALCOHOL HEALTH &IlitszARatWORLD when requesting that the system holism service provider should keep REFERENCES either confront a parent about fam-the agencies serving visually im- BEAN, M. Identifying and managing alcohol ily alcoholism or provide treatment paired persons informed of the problems of adolescents.Psychosomatics without parental consent (NIAAA availability of treatment and coun- 23(4):151-155, 1988. 1983). The system in this case runs seling services. Integration of Boaos, A. Alcoholism intervention for the the risk of alienating the family knowledge can occur in much the deafAlcohol Health & Research World and, as a result, perhaps having thesame way as, for example, learning 5:26-30, 1980-1981. parents withdraw the child from theto work with a client who is both CROXTON, T.; CHURCHU L. S.; AND FELLEN, P. special education program. In somealcoholic and diabetic. By asking Counseling minors without parental consent. Child Welfare 67(I):3-14, circumstances, special education for help, alcoholism service pro- 1988. officials may need to be informed viders may find willing consultants GALLAO/ ER, H. Who cares about disabled people?Social Policy about laws regarding the treatment among those who serve the special- 15(I):18-20, 1985. of minors without parental consentized needs of the visually impaired. GLAss, E. ProblPm drinking among the blind (see Croxton et al. 1988). To ensure and visually impaired.Alcohol Health & Service providers in rehabilitation Research World5(2):20-25, 1980-1981. that alcoholism awareness is part are encouraged to examine their GREENWOOD, W. Alcoholism: A complicating of the special education milieu, commitment to normalization to factor in the rehabilitation of disabled indi- arrangements must be made to ensure that it does not interfere viduals.Journal of Rehabilitation50(4):51- provide in-service training to clini- with the ability to acknowledge 52, 72, 1984. cal and educational staff. HEPNER, R.; KIRSHBAUM, H ; AND LANDES, D. Written screening policies cur- The lack of systematic Counseling substance abusers with addi- rently are being developed in the tional disabilities: The center for indepen- dentliving. Alcohol Health & Research setting of the author's treatment inquiries...to World5(2):11-17, 1980-1981. group for incorporation into the identify alcohol... HINDMAN, M. Child abuse and neglect: The students' initial evaluation. Memos alcohol connection.Alcohol Health & are sent periodically to social work-abuse among persons Research World7(3):2-7, 1977. ers and psychologists working with HINDMAN, M., AND WIDENS, P. The mulndis- visually impaired students, remind- entering a abled: Emerging response.Alcohol Health & ing them that the treatment group Research World 5(2):5-10,1980-1981. exists and that it accepts referrals. rehabill tationogram LOWENTHAL, A., AND ANDERSON, P. Network Memos are followed up in person, is a serious problem. development: Linking the disabled commu- and the clinical supervisor is asked nity to alcoholism and drug abuse programs. to heir, monitor students for alco- Alcohol Health & Research World5(2):18- alcoholism. The message of nor- 21, 1980-1981. holism treati lent needs. Cross- malization is that an impaired per- con..,:lt& on between rehabilitation National Institute on Alcohol Abuse and son is, first of all, a person, not to Alcoholism. Prevention Plus: Involving pro'essionals and alcoholism pro- be defined by his or her impair- Schools, Parents, and the Community in fessionals, suggested by Lowenthal ment. Ho;m.ver, normalization can Alcohol and Drug Education.DHHS Pub. and Anderson (1980-1981), will be become counterproductive if it No. (ADM)83-1256. Washington, DC: Supt provided through a local univer- leads to actual denial of the impair- of Docs., Govt. Pnnt. Off., 1983. sity's course on rehabilitation of ment or of problems such as alco- National Society to Prevent Blindness. persons with physical impairments. holism. Rehabilitation specialists Vision Problems in the U.S.: Facts and Figures. New York: National Society to might be asked to provide consulta- Prevent Blindness, 1930. TAKING THE FIRST PRACTICAL EPS tion to alcoholism treatment profes- NELIPOVICH, M., AND PARKER, R. The visu- The alcoholism treatment professionals when a client is referred for ally impaired substance abuser.Journal of sional can compensate for gaps in services. Alzoholism service pro- Visual Impairments and Blindness75:305, knowledf e or experience regarding viders can assess their skills and 1981. visually impaired clients by consult-capacity for providing treatment, PEransoN, J., AND NELIPOVICH, M. Alcohol- ing with specialists and taking consult with those wt o have com- ism and the visually impaired c":,ntJournal continuing education classes. Place-plementary skills, and actively seek of Visual Impairments and Blindness ment on the mailing list of agenciesto acquire new skills so that visually 77:345-347, 1983. serving visually impaired people impaired abusers of alcohol and SELV1N, H. 1-1,v to succeed at being blind. will remind the alcoholism treat- other drugs and visually impaired The New OutlookDecember:420-428, 1976. ment professional of the needs of COAs can have their therapeutic SYLVESTER, R. Treatment of the deaf alco- this population. In turn, the alco- needs addressed. holic: A review.Alcoholism Theatment Quarterly3(4):1-20, 1986, 4? Va.. 13, MA 2, 1,119 137 Epffepsy, Seizures, and Alcohol

MICHAEL J. STOIL, PH.D.

umented for centuries, seizures formerly were believed to result L F from the disease of epilepsy. Scien- tists now agree that the term epi- R,r lepsy is similar to the term cancer in if at both terms are applied ge- nerically to several conditions with differing symptoms, consequences, R T. and perhaps mechanisms. In general, epilepsy involves erratic electrical activity arising from within ev".41M-404.1 the central nervous system (CNS), R.P. including the brain. The pioneering studies of William Gordon Lennox z (Lennox 1941) and Maurice Victor ri\MAIN ki\ttA/t and colleagues (N ictor and Adams 1953; Victor and Brausch 1967) rcgw's-v'vt,/ f f 1,11\1 \I. \f" \IVVAArvi6 were particularly important in defining a relationship between alcohol use and nervous system These wavy line tracings of the electroencephalogram (EEG) show normal branwave patterns recorded from eight sites in the brain (far left), followed by the steep "spike and disorders, including epileptic sei- wave" EEG pattern associated with one type of epileptic seizure zures. This work led to identification of the potential risk for seizures resulting from alcohol child sits on a hospital hand holding his highlighting abuse and to improvements in the bed with her head marker begins to twitch spasmodi- study of possible caub.s and con- wrapped in bandages, cally. Although the student tries to trolling mechanisms for seizure matting cheerfully withcontrol the movement, the tremor phenoiliena. a visitor about her doll collection. becomes more violent and gradu- Without warning, she falls silent ally "walks up" the arm until every WHAT IS EPILEPTIC SetzuRE? and her head lolls back against the muscle below the shoulder seems toAn epileptic seizure can be defined pillow. The child remains motion- be affected. Moments later, the as the sudden disruption of normal less for several seconds and then tremor stops abruptly and the brain function due to hyperactivity recovers, resuming her conversationstudentshaken in more ways thanin one or more areas of the CNS. without interruption. onereturns to his books. Under nonseizure conditions, A college student is cramming Members of the emergency room groups of nerve cells, or neurons, late at night for a midterm exami- staff examine the pedestrian victim operate without synchronization nation, at a desk lit by a flickering of an early morning traffic acci- at any given moment, some neurons fluorescent light. He suddenly be- dent. The patient's clothes and are discharging electrochemical comes aware of a peculiar taste in breath smell strongly of spirits, andimpulses, some are resting, and his mouth, reminiscent of cherries. the patient alternately complains ofsome are priming far the next dis- As soon as the sensation passes, thehis injuries and demands a drink. charge. In primary epilepsy, seizure- Staff members are not surprised related CNS hyperactivity occurs when the patient enters into convul-when groups of neurons synchro- MICHAEL J. SMIL, PH D., served as sions that threaten to topple him nize their discharges as a single Special Focus Editor for this issue from the hospital gurney. unit. This phenomenon is known as of Alcohol Health & Research These three cases are examples ofthe seizure discharge. World. seizure phenomena. Clinically doc- The effect of CNS hyperactivity A :

13$ ALconol. HEALTH& Itzsr-tecHWORLD on brain function may be analo- M.D., professor of public health Hillbom (1980), almost one-half of gous to the effect of a flood of and neurology at Columbia Univer- 560 seizure patients admitted dur- incoming telephone calls on a tele- sity, the prevalence of epilepsy in ing 1 year to the emergency depart- phone switchboardthe receipt of the general population ranges be- ment of a hospital in Helsinki, incoming messages beyond the tween 6 and 10 cases per 1,000. In Finland, had been intoxicated switchboard's capacity causes the other words, as many as 1 person within 12 hours of the incident. lines to cross and calls to become per 100 experiences epileptic sei- Similarly, a study of 566 patients in disconnected, placed on hold, or zures sometime during his or her a detoxification unit in the United switched to the wrong party. A life. Epilepsy is slightly more preva- States showed that nearly one-third similar "communications" snarl lent among men than among evidenced seizure symptoms at the within the CNS translates into a women, and more than one-half of time of admission (Gerson and variety of clinical results, depend- all cases involve onset after the 18th Karabell 1979). ing on the site in the nervous sys- birthday (Hauser 1988). CNS hyperactivity is involved in tem where the seizure originates. Neurologists divide epilepsy into both "alcoholic epilepsy" and pri- Although many laymen think of two categories. Symptomatic epi- mary epilepsy. Nevertheless, clinical epilepsy as limited to the spectacu- lepsy is associated with known studies have demonstrated that the iar general convulsions and black- origins, including tumors, infec- diagnostic tool known as an elec- outs of the tonic-clonic or grand tions, and injury to the nervous troencephalograph (EEG) can dis- h,a1 seizure, epilepsy also produces system. Primary epilepsy has no tinguish between the brain wave such diverse phenomena as the clearly identifiable cause other than patterns of epileptic patients and 90 simple partial seizure in which the genetic predisposition. Most cases percent of all other patients admit- patient is aware of the convulsions of recurrent epileptic seizure involveted for alcohol-related seizures and the nonconvulsive complex primary epilepsy. (Hauser et al. 1982; Deisenhammer partial seizure associated with hal- In some instancesas in the et al. 1984; Vossler and Browne lucinations and memory lapses. example of the overworked student 1988). This distinction and the Virtually anyone may experience cited earliera specific seizure failure of most patients with an epileptic seizure, given the right episode can be associated with pre- alcohol-related seizures to develop combination of conditions. Accord-cipitating conditions including sleepother epileptic svrJilts suggest ing to Lennox (1960), individuals deprivation or exposure to a flicker- that "rum fits" are different from vary in their predisposition to sei- ing light source. It is not clear, primary epilepsy. zures. For some people with a low however, why the conditions that Findings on the prevalence of the seizure threshold, in infection or a precipitate seizures differ among relationship between alcohol use mild head injury may be enough to seizure-prone people or why behav- and seizures raise important scien- trigger the occurrence of seizures. ior as universal as the act of falling tific questions because beverage These individuals are most likely to asleep occasionally triggers convul- alcohol or ethanol is essentially a be diagnosed with primary epilepsy.sions. Many aspects of primary CNS depressant. In addition, Other people seem to have a high epilepsy remain a mystery. ethanol has been perceived and seizure threshold and are more occasionally prescribed as an anti- resistant to precipitating factors. ALCOHOL AND PRECIPITATIO convulsant. One therefore might The results of recent experiments OF SEIZURE postulate that alcohol reduces hy- demonstrate that at least some pre- Clinicians long have observed that peractivity and makes seizures less disposition toward seizure is geneti-alcoholic beverages play a rule in likely. For this reason, scientists and cally inherited--for example, triggering seizures (Buchan 1800; clinicians specializing in the ner- scientists have selectively bred Gowers 1893). Seizures following vous system are investigating the seizure-prone and seizure-resistant intoxication are known as "rum specific mechanisms involved when animals (see, for example, Mishra fits," "withdrawal seizures," or "al- seizures are associated et al. 1988). Other experiments havecoholic epilepsy," as distinguished abuse. demonstrated that seizures can be from primary epilepsy. initiated deliberately through a An estimated 20 to 25 percert of THE WITHDRAWAL HYPOTHESIS AT THE "kindling" process of CNS stimula-newly diagnosed adult cases of 1988 ALCOHOL AND SEIZURES tion (see, for example, Mucha and epilepsy have no risk factors other SYMPOSIUM Pinel 1979 and Freeman 1981). than a history of alcohol abuse In September 1988, an international According to W. Allen Hauser, (Hauser et al. 1988). According to symposium on alcohol and seizures 4, Vol.. 13, Na 2.,1999 139 Epilepsy, Seizures, and Alcohol

or long-term alterations associated convulsant action of alcohol on the was held in Arlington, Virginia, with alcohol use. Others are exam- body. Pinel concluded that this under joint sponsorship of the ining alcohol-related effects on tolerance is an adaptation to one I American Epilepsy Society and the neuron receptors and ion channelsthe effects of alcohol on the Epilepsy Foundation of America. nerve cell structures directly in- bodythat is, the anticonvulsant Tiventy-nine distinguished speakers volved in receiving, transmitting, activity that prevents or dampens and 18 poste: session presenters and inhibiting electrochemical im- seizuresrather than an adaptation from 7 countries exchanged re- pulses. A third group is investigat- to alcohol's presence in the body. search results and working hypothe-ing the possibility that alcohol Robert J De Lorenzo, M.D., ses on the basic mechanisms and changes the body's ability to main- Ph.D., professor of neurology at clinical management of alcohol- tain a supply of nutrients to the the Medical College of Virginia, related seizure. Many of the de- neurons. summarized for symposium attend- scribed studies reflected NIAAA's Diamond cautioned against as- ees the state of the art in searching support of research exploring the suming that any seizures produced for the cause of alcohol-related possible origins of alcohol-related by withdrawal must be related to epileptic seizure at the level of the seizure within the complex inter- the body's adaptation to alcohol. individual neuron (De Lorenzo action of the neuron with its He reminded symposium attendees 1988). Focusing his remarks on environment. that withdrawal and associated success in observing alcohol-related Ivan Diamond, NI.D., Ph.D., seizures alternatively may result changes in neurotransmitters professor of neurology at the from CNS reaction to indirect ef- chemicals that activate neuron University of California at San fects of alcohol consumption. Sup- receptors and ion channels Francisco, provided symposium port for Diamond's warning was De Lorenzo stated: attendees with an overview of the provided in a presentation by John issue (Diamond 1984. According toP.J. Pinel, Ph.D., professor of Mil neurobiology over the last 10 Diamond, most scientists believe psychology at the University of years...we've gone from not that the phenomenon of withdrawal examining the role of neurotrans- rather than the act of consuming mitters at all to 'v focus on the the drug alcohol itself is th.s prime Experimental individual neurotransmitter to culprit in alcohol-related seizures. overall changes in the neurotrans- Until recently, it was thought that observations at the mission process. In effect, we're such phenomena as alcohol depen- cellular level may going from "the receptor of the dence, tolerance to the drug's ef- month" to deciding that every- fects, and withdrawal take place explain why seizure thing is related to excitability. We only after long-term alcohol abuse. now must look at unifying con- ...can Recent experiments, however, indi- phenomena cepts: which observed changes cate that these alcohol dependence occur following an mean something significant? phenomena may be observed at the When 50 [cellular] receptors [for cellular level following a single isolated drinking neurotransmitters] change value drinking occasion. Such experimen- in response to alcohol with- tal observations at the cellular level binge. drawal, does that mean that all may explain why seizure phenom- 50 are related to alcohol with- ena, similar to those observed in British Columbia (Pinel et al. drawal or only that some of them some drug addicts who are experi- 1988). Pinel and colleagues studied are related? encing withdrawal, can occur fol- the effects of administering alcohol lowing an isolated drinking binge. prior to kindled (artificially in- Other symposium attendees agreed Diamond noted that the search duced) seizures compared with the with DeLorenzo's prescription of for biochemical processes involved effects of administering alcohol integrating separate research find- in seizure generation during with- following seizures. Their findings ings into unifying concepts. They drawal from alcohol focuses on revealed that timing of the adminis- acknowledged that years of work three elements of the CNS. Some tration of alcohol relative to the lie ahead in trying to determine scientists are examining the mem- inducement of seizures was critical which of the many observed CNS brane of the neuron itself for rapid to producing tolerance to the anti- changes following exposure to alco-

------149 ALCOHOL HLALTH £ RJSLAICH WORLD hol are most important in defining the view that alcohol withdrawal is alcohol withdrawal at the cellular not the culprit in alcohol-related Patients...who level and in explaining how with- seizure (Koppel et al. 1988), others drawal may precipitate seizures. argue that more than one replica- control their seizures tion of the Ns research is necessary Is THE WITHDRAWAL HYPOTHESIS through medication Corm Ecr? before discarding the alcohol withdrawal explanation for alcohol- should be advised of Within the past year, some re- related seizure. Roger P. Simon, searchers have challenged the as- M.D., wrote in a recent editorial in the risks...from sumption that alcohol withdrawal isThe New England Journal of the mechanism responsible for Medicine: the indirect effects of alcohol-related seizure. One of the drinking. most sophisticated examinations of The issue of whether alcohol- the alcohol withdrawal hypothesis related seizures are caused by seizure-prone patients who used has been presented by Stephen K.C. alcohol itself or by alcohol with- alcohol at nonabusive levels and Ng, M.D., Ph.D., assistant profes- drawal cannot be considered found that 20 percent reported sor of public health and pediatrics, settled.. . . [T]hat seizures Ind his colleagues at Columbia some increase in seizures "the occur as a direct effect of alcoholmorning after." Similarly, Johnson University. Using a combination of use and that they occur as a man-(1985) reported that 12 percent of clinical studies and statistical find- ifestation of alcohol withdrawal ings from computer modeling tech- primary epilepsy seizures "were may not be mutually exclusive probably precipitated by ethanol in niques, Ng and his colleagues propositions (Simon 1988, patients who could not be said to questioned the validity of alcohol p. 716). have a major drinking problem." withdrawal as the source of seizures Controlled experiments conducted for the following reasons: %SYS FOR SEIZURE AMONG EPILEPTICS WHO DRINK with low doses of alcohol, however, The withdrawal hypothesis is have not verified any increase in incompatible with the drinking Almost 50 years ago, Lennox (1941) seizure activity among patients with history of most patients admittedaffirmed that epileptic patients are primary epilepsy (Hauser et al. for alcohol-related seizures. Only neither more nor less likely than 1988). a minority of these patients had other populations to abuse alcohol. Epileptics who drink to intoxica- reduced consumption sufficiently Although comprehensive data are tion encounter higher risks, in part to produce withdrawal prior to I- ...King, more recent surveys often because of the indirect effects of the onset of seizures. confirm that the drinking patterns alcohol consumption on manage- of individuals with priraary epi- Computer modeling found that ment of their condition. As noted lepsy are similar to the prevailing the time lapse between cessation by Simon (1988), an evening of drinking patterns of their culture of drinking and onset of seizures drinking may provoke a seizure (Hoeppener et al. 1983). An excep- did not suppol t the withdrawal through alteration of the normal tion to this general rule is provided hypothesis and that 16 percent of sleep routine. Intoxication may by Johnson (1985), who interviewed alcohol-related seizures occurred result in failure to maintain anti- primary epileptics in the Welling- after 2 weeks of sobriety. convulsant medication used in the ton, New Zealand, metropolitan Computer modeling found that treatment of epilepsy (Johnson area. Johnson stated that 20 per- seizure onset was more likely to 1985). The interaction of alcohol cent of epileptics reported drinking be related to the level of drinking with drugs used in treating epilepsy the equivalent of 80 grams or more than to withdrawal (Ng et al. may reduce the effectiveness of 1988). of pure ethanol per day compared medication, increase the rate at with 6 percent of the general New which medication used by the Ng and his colleagues raised the Zealand population. body, or produce potentially dan- possibility that alcohol has a dose- Studies of epileptics who occa- gerous side effects. Finally, intoxi- dependent relationship with seizuressionally drink alcoholic beverages cation is a major risk factor for and that seizures may result from indicate that seizure occurrence accidental injuries that may trigger direct toxic effects of the drug. may be associated with their drink- epileptic seizures. Although some clinicians supporting. Mattson (1988) surveyed 112 Should a physician counsel absti-

Va. 13, Na 2, 190 141 Epilepsy, Seizures, and Alcohol

nence to a patient with primary related seizure rather than pri- International Symposium in Alcohol and epilepsy? In practice, a survey of a mary epilepsy. Seizures, Arlington, V,.girna, September 29- sample of clinicians throughout 30, 1988. Europe conducted by th, Epilepsy REFERENCES JOHNSON, R. Alcohol and fits. British Jour- nal of Addiction 80:227-232, 1985. Centre of the Netherlands iiidicated BucHAN.W. Domestic Medicine. 17th ed. that national culture influences the London: A. Strahan, 1800. KOPPEL, B.; DARAS, M.; GROSSINGER, B.; LIZARDI, E.; AND TUCHMAN, A. "Seizures in type of advice that is given: Physi- DEISFNHAMMER, E.; KLINGER, D.; AND City Hospital Alcoholic Patients." Unpub- cians in wine-producing and -con- TRAGNER, H. Epileptic seizures in alcoholism lished paper presented in a poster session to suming nations were less likely than and diagnostic value of El',G after sleep deprivation. Epilepsia 25:126-530, 1984. the International Symposium on Alcohol physicians in northern Europe to and Seizures, Arlington, Virginia, September urge Ipileptic patients to abstain DELoanNzc. R.I. "Models of Excitability: 29-30, 1988. from alcohol use (Hoeppener 1988). Receptors and Transmitters." Presentation to the Panel on Basis, M....lianisms of Alcohol LENNiox, W.G. Alcohol and epilepsy. Quar- Daring informal discussions, Amer- and Seizure, International Symposium on terly Journal of Studies on Alcohol 2:1-11, ican physicians attending the inter- Alcohol and Seizures, Arlington, Virginia, 1941. national symposium on alcohol and September 29-30, 1988. LENNOX, W.G. Epilepsy and Related Disor- seizures were divided on the justifi- DIAMOND, I. "Models of Investigation of ders. Boston: Little, Brown, & Co., 1960. cation of complete abstinence for Seizures Associated with Alcohol." Presen- MATTSON. R. "Effect of Alcohol on Seizures patients with epilepsymany held tation to the Panel on Basic Mechanisms of in Patients with Epilepsy." Presentation to Alcohol and Seizures, International Sympo- the Panel on Classification -aid Diagnosis of the view that any additional risk for sium on Alcohol and Seizures, Arlington, Syndromes, International Symposium on seizure or for reduced effectiveness Virginia, September 29-30, 1988. Alcohol and Seizures, Arlington, Virginia, of anticonvulsant medication is FREEMAN, F.G. Effects of ethanol on the September 29-30, 1988. unacceptable. development of kindled seizures in rat amyg- MISHRA, P.K.; DAILEY, J.W.; REIOEL, C.E.; At a minimum, patients with dala. Journal of Studies on Alcohol 42:500- AND JOBE, P.C. Brain norepinephnne and primary epilepsy who control their 507, 1981. convulsions in the genetically epilepsy-prone rat: Sex-dependent response to Ro 4-1284 seizures through medication should GERSON, I.M., AND KARABELL, S. The use of treatment. Life Sciences 42:1131-1137, 1988. be advised of the risks to seizure electroencephalogram in patients admitted control from the indirect effects of for alcohol abuse with seizures. Clinical MUCHA, R.F., AND FINEL, J.P.J. Increased Electroencephalography 10:40-49, 1979. susceptibility to kindled seizures following a drinking behavior, as cited by single injection of alcohol. Journal of Stud- Simon (1988) and Johnson GOWERS, W.R. A Manual of Diseases of the Nervous System. Vol. 2. London: J & A ies on Alcohol 40:258-271, 1979. (1985). Patients also should be Churchill, 1893. NG, S.K.C.; HAUSER, W.A.; Bausr, J.C.M.; monitored carefully for symptoms HAUSER, W.A. "Alcohol and Epilepsy: The AND SUSSER, M. Alcohol consumption and of alcohol abuse because of the Frequency of the Problem." Presentation to withdrawal in new-onset seizures. New potentially serious consequences the Panel on Clinical Overview, International England Journal of Medicine 319:666-673, of intoxication. Symposium on Alcohol and Seizures, 1988. It may be wise for patients with Arlington, Virginia, September 29-30, 1988 PINEL. J.P J ; MANA. M.; AND Ktm.C.K. primary epilepsy to carry identifica- HAUSER, W.A.; NG, S.K.C.; AND BRUST, "Effect-Dependent Tolerance to Ethanol's tion that would help hospital J.C.M. Alcohol, seizures, ana epilepsy. Anticonvulsant Effect on Kindled Seizures." emergency room staff to make an Epilepsia 29(Suppl. 2):S66-S77, 1988. Presentation to the Panel on Basic Mecha- HAUSER, W.A.; RICH. S.; NICOLOSI, A.; AND nisms of Alcohol and Seizure, International appropriate diagnosis. Although Symposium on Alcohol and Seizures, most cases of alcohol-related sei- ANDERSON, V.E. Electroencephalographic findings in patients with ethanol withdrawal Arlington, Virginia, September 29-30, 1988. zure can be distinguished from seizures. Electroencephalography and Clini- Sis46,4R.P. Alcohol and seizures. New En- primary epilepsy through the use of cal Neurophysiology 52:64, 1982. gland Journal of Medicine 319:715-716, an EEG and family history (Deisen- HILLsom, M.E. Occurrence of cerebral 1988. hammer et al. 1984), the pressures seizures provoked by alcohol abuse. Epilcp- VICTOR, M., AND ADAMS, R.D. The effects of of time and caseload may delay sia 21:459-466, 1980. alcohol on the nervous system. Proceedings these procedures'1the emergency HOEPPENER. R.J. ; KUYER, A.; AND VAN DER of the Association for Research in Nervous room setting. When a patient is LUDT, P.J.M. Epilepsy and alcohol: The and Mental Disease 32:525-573, 1953. unable to respond to family history Influence of social alcohol intake on seizures VICTOR. M., AND BRAUSCH, C. The role of questions, it is possible that clini- and treatment in epilepsy. Ep:!Posia 24.459- abstinence in the genesis of alcoholic epi- 47!, 1983. lepsy. Eprlepsia 8:1-20, 196'. cians may prefer to withhold long- term anticonvulsant medication in HOEPPENER. R.J. "The Effect of Social VOSSLER, D., AND BROWNE, T.R. Absence of Alcohol Use on Seizures in Patients with EEG photoparoxysmal responses in alcohol the belief that the convulsive Epilepsy." Presentation to the Panel on withdrawal patients treated with benzodiaz,e- patient is displaying alcohol- Classification and Diagnosis of Syndromes, pines. Neurology 38(Suppl. 1):404, 1988.

142 ALCOHOL. HEALTH & RESEARCH WORLD )

TheNational Institute on Alcohol Abuse and Alcoholism, announces the public availability of ETOH The Alcohol and Alcohol Problems Science Database NIAAA cordially invites you to preview the database at the Institute's Scientific Exhibit during the following events:

Annual Meeting of the National Association of State Alcohol and Drug Abuse Directors June 3-7, 1989 Westin Cypress Creek Fort Lauderdale, Florida

10th Annual Meeting of the Research Society on Alcoholism June 10- 15,1989 Beaver Creek Resort Vail, Colorado

97th Annual Convention of the American Psychological Association August 11-15, 1989 New Orleans Convention Center New Orleans, Louisiana

41t Annual Scientific Assembly of the American Aeademy of Family Physician, September 18-21, 1989 Los Angeles Convention Center Los Anc1,-s, California

1 17th Annual Meeting of the American Public Health Association October 22-26, 1989 Chicago Hilton and Towers Chicago, Illinois Alcohol and Other Drug Abuse by the Physically Impaired A Challenge for Rehabilitation Educators

BOBBY G. GREER, PH.D.

Alcohol and other drug ally are described in terms of such abuse is a problem pairings as brain injury with con- among some clients vulsive disorders, cerebral palsy with physical impair- with speech problems, and low ments (Anderson 1980-1981; Boos back injury with a learning disabil- 1980-1981; Greer 1986), although ity. Physically impaired clients with the scope of the problem is not alcohol or other drug problems known precisely (Hindman and often are described in training ma- Widem 1980-1981; Greer 1986). terials as having one primary dis- Thurer and Rogers (1984) found ability and almost never as having that 53 percent of a sample of phys-long-term dependence on alcohol ically impaired clients rater' help or other drugs. with alcohol or other drug prob- This article examines possible lems as a "substantial need" or explanations for the lack of discus- "great need" among the physically sion of alcohol and other drug impaired. problems in most counselor training The lack of services to meet this programs. It also presents some need can be traced in part to the strategies to rectify this omission. training received by rehabilitation counselors, who often are taught to AN APPROPRIATE INTERVENTION ROLE expect that their future clients will FOR REHABILITATION COUNSELORS have only one disability. When In the author's view, four general multiple disabilities are discussed in guidelines on the appropriate role rehabilitation education, they usu- of the rehabilitation counselor in intervention for alcohol and other drug abuse can be inferred from the BOBBY G. GREER, PH.D.,is professor ethical standards and principles of of Counseling and Personnel Serv- the profession (as discussed in the ices at Memphis State University accompanying sidebar): and director of the vocational evaluation unit. Comments should be 1) The rehabilitation counselor addressed to Professor Greer at who knows that a client abuses Memphis State University, Mem- alcohol or other drugs, and that phis, Tennessee 38152. the abuse may interfere with the University of Nevada

T. _.A.,' 144 5 ALCOHOL. HEALTH & RESEARCH WORLD ...... ,C, , .

...

--- VOL. 13, Na 2,1 US A Challenge for Rehabilitation Educators

client's rehabilitation program, and if the client's persistent client drug abuse in which direct is professionally obligated to abuse of alcohol or other drugs confrontation by the rehabilitation bring this fact to the client's will seriously impair potential counselor may not be indicated. attention. The counselor should benefits from rehabilitation Diazepam (Valium), for example, apprise the client of all available services, the counselor may ter- can be abused (Hepner et al. 1980- intervention options. minate services to the client. 1981), and a counselor may have 2) The rehabilitation counselor Services should be terminated reason to believe that a client is should make alcohol or other only after reasonable effort to receiving and/or using diazepam drug abuse intervention a part secure the client's compliance beyond appronriate therapeutic of the Individual Written Reha- has failed. Upon termination, limits. In such situations, the coun- bilitation Plan, if the client the counselor is obligated to selor would, without delay, confer consents. refer the client elsewhere. with the rehabilitation agency's 3) The client has a right to refuse medical consultant. If the patient is any suggested intervention. The abuse of drugs prescribed byfound to be abusing a drug that is 4) If the client refuses intervention a physician is a specific area of prescribed within therapeutic limits,

PROFESSIONAL ETHICSAND ALCOHOL AND DRUG ABUSE IN REHABILITATION COUNSELING

"[low far should a rehabilita- tation, and be dependent in- Rehabilitation Education 1988) tion counselor go in identify- stead, should the rehabilitation states: ing a client who has an alcohol or counselor persistently encourage Rehabilitation counselors shall other drug abuse problem in addi- him to "maximize his poten- respect the integrity and protect tion to ..me or more physical im- tial?" The goal of "maldng" the welfare of people and pairments? Some authors assert the client as independent as a. pups with whom they work. that any intervention goes beyond possible contains inherent con- The primary obligation of reha- appropriate roles and duties. For tradictions if the client is deni-d bilitation counselors is their example, one of the major intro- the freedom to choose not to be clients, defined as people with ductory textbooks in vocational independent. Professional and disabilities who are directly rehabilitation states: medical approaches toward receiving services from a reha- Paternalism can often be con- disabled persons emphasize bilitation counselor..(p. 67). fused with caring. What the changing the client. Disabled counselor knows is best for the persons ... are opposed to Since the ultimate objective of the client can get in the way of true client change as the primary rehabilitation counselor is the respect of the client's autonomy focus (Rubin and Roessler 1987, total rehabilitation of the client, and independence. If a client pp. 117 -1881. this canon implies that the coun- with emphysema, knowing full selor has a professional obligation well the dangers of smoking, to confront an alcoholic client decides not to give up ciga- Although this concept compli- regarding the abuse and to de- rettes, should the counselor cates the answer to how far a velop a strategy for dealing with respect that decision or attempt counselor should go in dealing the problem. When the counselor to change it? If a client who with a client's abuse of alcohol or is responsible for the development received a $.1 million settlement other drugs, there are ethical of an Individual Written Rehabili- from the automobile accident standards in the profession that tation Plan (IWRP) for a client that landed him in the rehabili. support an activist role. One who abuses alcohol or other tation center decided to forego canon incorporated in the Profes- drugs, the intervention strategy the arduous task of extended sional Ethics for Rehabilitation can become an integral part of the physical and vocational rehabili- Counselors (National Council on IWRP. BOBBY G. GREER, PH.D.

146 ALCOHOL HEALTH & RESEARCH WOIU.D the medical consultant, not the (1986). The other exception is of casework ex-?riences in existing counselor, would decide what brief discussion of the impact of courses and fieldwork. Such experi- action to take. Similarly, if it is alcohol and other drug problems onences could be modeled after those suspected that the client is receiving the development of the rehabilita- developed for education in other a larger than therapeutic dose of a tion plan for disabled clients incor- health professions (ADAMHA psychoactive medication, the medi- porated in the training materials for !986). This approach would incor- cal consultant would intervene; the the Preliminary Diagnostic Ques- porate four basic elements: counselor is bound by professional tionnaire or PDQ (Moriarty 1982). ethics to avoid confrontation with The PDQ, a preliminary screening integration of relevant alcohol the client on the issue of the prac- tool, has two questions dealing with and other drug abuse content into tices of the treating physician. client abuse of alcohol and other existing courses and seminars drugs. inclusion of alcohol and other CURRICULUM ISSUES IN REHABILITATION To improve coverage of alcohol 'rug abuse program facilities in COUNSELOR EDUCATION and other drug issues in rehabilita- clinical experiences involving The traditional model for graduate tion counselor education, profes- practicum and internship sites programs in rehabilitation counsel- sionals in the field need to address exposure durin,Y fieldwork to such ing was established in the mid-1950sthe paucity of literature on this self-help groups as Alcoholics (Wright 1980). Although aspects oftopic. Specific topics that may be Anonymous, Al-Anon, and Nar- this model still are debated, most included are definition of terms, cotics Anonymous curriculums closely resemble a epidemiology, social and family participation in client experiences model proposed in 1956 (Graves et effects, client education needs, including role playing and video- al. 1987; Wright 1987; Walker and pharmacology and pathology, and taping (see Spickard et al. 1989) Myers 1988). This course work legal and ethical issues (NIAAA as well as exercises designed to typically consists of 1) an introduc- 1985). Thc AID Bulletin,' a quar- clarify the students' own values tion to vocational rehabilitation, terly newsletter about alcohol and concerning alcohol and other 2) medical aspects of rehabilitation,other drug abuse among persons drug use. These experiences also 3) psychosocial adjustment to dis- with disabilities, is particularly could include simulations de- abling conditions, 4) assessments in useful. Another potential resource signed to explore approaches to vocational rehabilitation, 5) coun- is the bibliography of materials confronting the manipulative seling technique and practice, related specifically to alcohol and client. 6) occupation information and other drug abuse among the career developrn 7) current top- phrically/intellectually impairea, EDUCATION To DISPEL HARMFUL ics in rehabnation w. taught asavailable from the National Clear- ATTITUDES a seminar), 8) an internship experi- inghouse for Alcohol and Drug The process of educating rehabilita- ence, and 9' electives. Info.mation (NCADI 1987). Grad- tion c, 'unselors on issues relating to As noted earlier, publications uate students in rehabilitation alcohol ai,: ter drug abuse used in this curriculum tend to cation should be encouraged to among clients with physical impair- avoid the topic of multiple disabili- contribute to the literature on alco- ments is complicated by the preva- ties, including the pairing of physi- hol and other drug use among the lence of potentially harmful cal impairment with alcohol or disabled by conducting research on attitudes and beliefs among coun- other drug dependence. Only one the topic. selors.tiAltudes that could be ad- text on psychosocial adjustment to Another necessary component of dressed during the education of disability, for example, mentions curriculum revision is the inclusion rehabilitation counselors include alcohol and other drug abuse (Vash the following: ' TheAID Bulletinpublishes feature articles, 1981). lino sign;ficant publications announcements, and notices of new pro- stand as exceptions to the general grams that would be helpful and informative having expectations that are lower rule of omitting alcohol and other for both faculty and students rehabilita- than they should be for clients drug abuse from teaching materials tion counseling programs. The acronym AID with alcohol-related problems used in the rehabilitation education stands for Addiction Interventior. with the the belief that "mourning" be- Disabled. Further information cn the AID curriculum. One of these is the Bulletin can be obtained from .'1..cander haviors or the lack of "normal- computer-generated simulation Boras, Ph.D., Department of Sociology, ity" justify client abuse of program developed by Chubon Kent State University, Kent, Ohio 44242. alcohol

Vol- 13, Na 2, 14119 147 A Challenge for Rehabilitation Educators

misplaced sympathy that can be drink excessively. If the prevalence manipulated by an alcohol abus- The need to confront of alcohol and other drug use is ing client similar among rehabilitation coun- acceptance of abuse of alcohol or student counselors selor trainees, it is possible that other drugs as the norm based on about their attitudes their attitudes toward alcohol or the counselor's own problematic other drug use among their future use. ...presents a clients may tend to be permissive. chcgenge to The need to confront student Iivo indei,endent studies (Allen et counselors about their attitudes al. 1982; Goodyear . >83) have doc- rehabilitation toward alcohol or other drug use umented a marked negative attitude presents a challenge to rehabilita- among rehabilitation counselors educators. tion educators. Such student atti- toward clients with alcohol-related tudes dry from condemnation of problems. One of the most omi- so, I would drink myself into obliv- any use of alcohol or other drugs to nous findings of both studies is ion too!" permissive tolerance of clearly ex- that many counselors considered Another confounding factor is cessive use, with most counselors' the rehabilitation potential of the ability of many disabled clients attitudes falling somewhere between such clients to be minimal or to manipulate nondisabled persons these extremes. Either extreme is nonexistent. and to play on their sympathy. Vashcounterproductive in interacting A second factor influencing per- (1981) states that some tendency with a disabled person who is abus- ceptions of rehabilitation personnel toward manipulation is necessary ing alcohol or other drugs. toward alcohol or other d-ug abuse for persons wi.h severe imps: .-rents An NIAAA curriculum guidefor behavior is the "require' for to function effectively. However, alcohol and other drug abuse edu- mour ling" identified by Wrigk' Cireer and colleagues (in press) cite cation for pediatricians suggests (1983). This "requirement" implies a case in which a disabled individ- including in the curriculum a dis- that persons with physical impair- ual applied much of his skill at cussion of the abusing health pro- ments are dewed by most nondis- generating sympathy to the procure-fessional and the effects of such abled individuals as being in a statement of drugs. Many nondisabled abuse on the professional's judg- o: loss. In this state, the Hidividual counselors and counselor trainees ment, lear,ng, decisions, and over- is expected to "mourn" the loss by view disabled personsespecially all professional productivitl exhibiting such behaviors as denial, those disabled from birthas being (NIAAA 1985). Although this ap- depression, and lack of motivation. naive, innocent, and free from the proach could be adopted for reha- Some nondisabled individuals in- vices of so-called "normal" people. bilitation professionais, the NIAAA clude alcohol or other drug abuse If a manipulative client works with curriculum guide notes that discus- as a mourning behavior that may a counselor who holds such an sion of suc:1 issues in a course beexpectedof a physically im- attitude, the results can beex- format tends to be "impersonal, paired person. tremely counterproductive. generalized, or intellectualized" Del oach and Greer (198i) iden- The counselor's attitudes toward (P. 33). tify "deification of normality" as a his or her own me of alcohol or Another workable solution to the similar phenomeno:in which the other drugs may further complicate problem may be inviting students to absence of impairment is perceived the issue. Because there are few discuss with the instructor, outside by the nondisabled as the only data documenting the nature and of class, their own concerns about desirable state of existence. When prevalence of counselor attitudes their use or abuse of alcohol and an indi 'dual adopts this rigid toward alcohol and other druguse, other drugs. Also, students with belief, all manner of maladaptive data from other health professions academic or personal problems may behaviorincluding alcohol and may provide insight. The results of be provf '.1 an opportunity to (-:- other drug abuseis justified by recent surveys ind:cate that as many plore the possibility of alcohol or the physically impaired client's lack as 95 percent of medical students other drug use as a contributing of "normality." Awareness of an use alcohol and 53 percent have factor to these prelims. alcohol problem in a disabled indi- used other drugs (NIAAA 1985, Another apc roacn that may en- vidual thus may ..)ke the reac- p. 33). This same source indicates courage examination of attitudes tion, "If I "ere that poor so-and- that 10 percent of such students t.)ward alcohol and other drug use

14 is to supplement lass sessions with GREER, B G , ROBERTS. R , AND MAY, G , EDS National Institute on Alcohol Abuse and aud;nvisual material.. One cur- A stt.dy of substance abuse in a vocational Alcoholism, Pediatric Minimal Knowledge riculum for health professionals evaluation samrile. Journal of Rehabilitation and Skills. The First Step in Developing a (in press) Curriculum in Alcohol and Other Drugs for (Liepman et al. 1986) offers a com- Pediatricians DHHS Pub. No (ADM)281- HEPNLR, R.; KIRSCHRAUM, H ; AND LANDES, D prehensive appendix of videotapes 85 -0014 Rockville, MD: the Institute, 1985. Counseling substam, abusers with addi- ana films designed to stimulate tional disabilities: The center for Indepen- RUBIN, S E , AND ROESSLER, R.T. Foundations such exploration. dent living. Alcohol Health & Research of the Vocational Rehabilitation Process 3d All student counselors need to be World 5(2) 11-15, 1980-1981. ed Austin, TX. Pro-Ed, 1987 exposed to the issue of clients who HINDMAN, M , ANL) WIDEM, P Special issue. SPICKARD, A , JOHNSON, N.P.; AND BURGER, C abuse alcohol or other drugs: The The multidisabled. Alcohol Health & Re- Learning through experience. Interviewing profession can do no less than search World 5(2):5-10, 1980-1981. real(?) patients. Alcohol Health & Research World 13:36-39, 1989 make the effort to shape the views LIEPMAN, M.R , ANDERSON, R C.; AND THURER, S., AND Roc.5. E.S. The mental of future counselors according to FISHER, W., EDS Family Medicine Curricu- health needs of physically disabled persons: lum Glad- to Substance Abuse. Kansas City, facts rather than myths about the Their perspective. Rehabilitation Psychology MO: The Society of Teachers of Family 29(4):239-248, 1984. issue. Medicine, 1986. VASH. C L. The Psychology of Disability. MoiciAirry, I B. Raining Manual for the REFERENCES New York- Springer Publishing, 1981. Administration of the Prelim:T. iry Diagnos- Alcohol, Drug Abuse and Mental Health tic Questionnaire. Morgantown, WV West WALKER. M ,L., AND MYERS, R W A counter- Adr nration (ADAMHA) Consensus Virginia Rehabilitation Training Institute, proposal: Definer- the qualified rehabilita- Stateyents from the Conference on Alcohol, 1982. tion professional. Rehabilitation Education Drugs, and Primary Care Physician Educa- 2(1):49-57, 1986. tion: Issues, Roles, and Responsibilities, National Clearinghouse for Alcohol and Drug Information (NCADI). NCADI Up- WRIGHT, B Physical Disability: A Psycho- November 12-15, 1905; Rancho Mirage, logical Appioach New York: Harper & Row, California. Fockville, Maryland: National date Alcohol and Other Drugs and the 1983 Institute on Alcohol Abuse and Alcoholism, Phystrallyantellectually-impaired. Rock- 1986. ville, MD he Clearinghouse, 1987. WRIGHT. G.N Total Rehabilitation. New York Little, Brown and Company, 1980. ALLEN, H.A.; PETERSON, 1 ; AND KEATING. G National Council on Rehabilitation Educa- Attitudes t.. counselors toward the alcoholic tion. Code of professional ethics for rehabil- WRIGHT, G.N., ED Special Issue: Research on Rehabilitation Counseling Bulletin itation counselors. Rehabilitation Education professional rehabilitation competencies 26(3):162-164, 1982 2(1) 65-74, 1988. Rehabilitation Counseling Bulletin 3I(2):1987 ANDERSON, P Alcoholism andle spinal cord disabled: A model program Alcohol Health & Research World 5(2):37-41, ;980- 1981. New from NIAAA

BOROS, A. AILJ1,2;ISM intervention for the deaf. Alcohol Health & Research World ALCOHOL AND COGNITION 5_1:26-30, 1 -1981. A Summary of Findings on the Relationship CHUBON. R A. Genesis II A computer-based case management simulation Rehabilitation Between Alcohol and Cognitive Impaient Counseling Bulletin 30(I):25-32, 1986

DELOACH, CP ,AND GREER, B G. Adjustment Chronic heavy drinking adversely affects the brain.Alcohol-induced to Seveir Physical Disability. A Met4mor- cognitive impairment may detract from the potential benefits of treatment phosis. New York McGraw-Hill, 1981 for many patients. Read about this treatment concern in the most recent Alcohol Alert GOODYEAR, ItPatterns of counselors' atti- bulletin, "Alcohol and Cognition," wliich addresses. tudes toward (inability groups Rehr,'" ihta- lion Counseling Bulletin 26(3) 181-186, Cognitive impaethent in the first weeks of abstinence 1983 Excessive alcohol use and malnutrition as possible contributors to cognitive deficiency GRAVES, W.; COFFEY, D , HAFBCK. R., AND Cognitive impairment reversibility STUDE, E NCRE position paper. Definition Identifying cognitive deficiency and tailoring treatment to the individual of the qualified reh- oli,:qtion professional Rehabilitation Education 1(:):1-7, 1987 Alcohol Alert is a timely information bulletin that relates research findings to the practical concerns of clinicians and other ticatment professionals. To GREER, B.O Substance abuse among people receive "Alcohol and Cognition" and future Alcohol Alert bulletins, send with disabilities: A problem of too much your name and address to Alcohol Alert Update, c/o CSR, Inc., Suite 600, accessibility. Journal of Rehabilitation 1400 Eye Street, N.W , Washington, D.C. 20(X)5 52:34-38, 1986.

VOL. 13, Ni 2, 19119 149 Results ofaModel Intervention Program for Physically ImpairedPersons

SHARON SCHASCHL, R.N., B.S.N., AND DENNIS STRAW, C.C.D.P.

For many persons with dependence evaluation, interven- family and friends, don't acknowl- disabilities, alcohol and tion, and treatment. edge or address the impaired per- other drug dependence son's use of alcohol and other impc,.es far greater limita- OBSERVATIONS ON PERPETUATING d7ugs. Well-meaning caretakers and tions than their physical impair- FACTORS loved ones may even encourage use ment. The problems created by Factors that perpetuate alcohol andof alcohol and other drugs due to alcoaol and other drug dependence other drug dependence among the misperception that the alcohol frequently are attributed tc the those with physical impairments helps the impaired person to social- physical impairment, and a ,treat include the negative attitudes that ize, to experience pleasure or happi- deal of time, energy, and money other people exhibit toward both ness, and possibly even to feel may be spent treating the "syrti;,- physical impairment and alcohol "equal" with more able-bodied toms" rather than the disease of and other drug dependence, the people. These well-meaning care- dependence. Failure to address scarcity of knowledge and skills to takers may even see that alcohol alcohol and other drug dependence treat the dual problems of alcohol and oth,r drug abuse is self- adequately may prevent successful and other drug dependence and destructive, but they don't want to rehabilitation and adjustment to physical impairment, and the scar- deny the disabled person the indi- disability, lead to increased medical city of specialized treatment pro- vidual "right" to elect to use the complications of the physical im- grams for this group. alcohol and other drugs. pairment, and interfere with prog- Among these, the negative atti- There is often an erroneous as- ress toward independent living. tudes commonly held toward both sumption that all of the problems For this reason, disabled persons physical impairment and alcohol experienced by people with physical require access to alcohol and other and other drug dependence may be impairments are rel%ted p.imarily drug abuse prevention efforts and the most difficult to overcome. to the impairment. Yet, persons to early alcohol and other drug Physically impaired persons often who are abusing alcohol and other are perceived as hopeless, helpless, drugswhether physically impaired tragile, and sick. "'Physical impair- arnotfanction well below their SHARON SCHASCHL, R.N., B.S.N., is ment" is commonly equated with potential and may experience prob- program coordinator of the Chemi- "illness," fostering the beliefs that lems in any or all of the following cal Dependency/Physical Disability physically impaired persons are areas of their lives: physical, emo- Program at Abbott Northwestern incapable of assuming responsibil- tional, spiritual, social, sexual, Hospital/Sister Kenny Institute and ity for themselves, require repeated family relationships, legal, voca- a CertiPd Chemical Dependency hospitalizations, and must depend tional, and financial. These prob- Practitione- DENNIS STRAW, on medication to function. lems may be manifested by frequent C. C. D. P, consultant to the pro- In addition, a person who is health problems and/or hospitaliza- gram. Comments may be addressed physically impaired may face added tions, low self-est ., poor to either coauthor at the Abbott stigma and may not receive help personal hygiene, uependent Northwestern Hospital Chemical that is needed because he or she lifestyle/living arrangements, asso- Dependency Theatment Ce,iter, 1800 ,Iso is abusing alcohol and/or ciation primarily with alcohol and 1st Avenue South, Minneapolis, other drugs. Sometimes, health careother drug users lack of motiva- Minnesota 5403. providers and counselors, and alsc tion, significant personality

150 ALCGHOL HELTH & RESEARCH WORLD changes, memory deficits, depres- Abbott Northwestern Hospital's home health care agency schedules sion, rejection, of beliefs that once alcohol and other drug dependence certified nursing assistants for 2- to were important, isolation from treatment center. 3-hour periods in the morning and family and friends, and Involve- Pi the community, alcohol and evening. Nursing care, treatments, ment in unhealthy relationships. other drug dependence treatment medications, and any Additional The affected person may become a staff of Abbott Northwestern Hos- assistance throughout the day are victim or a perpetrator of sexual pital conduct workshops to increa provided by the regular nursing abuse or inappropriate sexual awareness and to provide direction staff members. Physical therapy behavior, suicide attempts, arrests, in identifying and referring physi- and occupational therapy are or- incarceration, loss of driver's li- cally impaired clients with alcohol de7ed only if necessary to maintain cense or public transportation privi-or other drt.6 dependence. The the patient's level of functioning. leges, unemp'oyment, failure in staff members also provic...- consul- The Chemical Dependency/ school, and lack of vocational in- tation for community program Physical Disability Program coordi- volvement and may have difficulty development. nator and program consultant meeting basic financial obligations. On the physical rehabilitation provide individual counseling and Problems and events such as these units and in the Chronic Pain Reha- support to patients and their fami- may be attributed to the physical bilitation Program at Abbott lies for physical impairment and impairment, when in fact alcohol Northwestern Hospital/Sister dependency issues and, with two and other drug use may be a signif-Kenny Institute, members of the other professionals, lead a weekly icant contributing factor. program staff provide evaluations peer support group for recovering Recognizing all of the factors of alcohol and other drug depen- physically impaired persons. The that perpetuate alcohol and other dency for patients and consultation staff of the Chemical Dependency/ drug dependence among those with and education for patients, staff Physical Disability Program offers physical impairmentsthe conse- and families of patients. assistance to counseling and medi- quences of negative attitudes com- In the alcohol and other drug cal staff to address the problems of bined with the lack of knowledge, dept.adence treatment center, physical impairment in the context skills, and specialized treatment members of the program staff of treating the primary illness of approachescalls out for the devel-coordinate a physical disability alcohol and other drug dependency. opment of model intervention component integrated with Abbott Program staff members also assist programs. Northwestern Hospital's established in formulating aftercare plans that Chemical Dependency Treatment address needs of physically im- A MODEL INTRaViNTION PROGRAM FOR Program. The premise for establish- paired, alcohol-dependent clients. PHYSICALLY hIPAHUID PERSONS ing the disability component is that The program staff members are In 1983, Abbott Northwestern the clients may have unresolved available for followup consulta- Hospital/Sister Kenny Institute in social, psychological, and medical tions, education, and awareness Minneapolis, Minnesota, imple- problems associated with their training to reintegrate the 1...ysi- mented the Chemical Dependency/ physical impairments and that these cally impaired person into the Physical Disability Program, problems need to be addressed to community. designed to meet the specialized facilitate treatment of continued An important element of the needs of physically impaired per- alcohol or other drug dependence. Chemical Dependency/Physical sons. The program staff members Physically impaired patients now Disability Program is the weekly include a program coordinator, whocomprise 5 to 10 percent of the support group led by four profes- is a Certified Chemical Dependencytotal patient population in the alco- sionals who are experienced in Practitioner (CCDP) and an experi-hol and other drug dependence counseling those with alcohol and enced physical rehabilitation nurse, treatment center. Patients with other drug dependency as well as and a program consultant, who is a physical impairments are expected physical impairments. The group CCDP and is disabled and recover- to participate with able-bodied first met in August 1983 with one ing from alcohol and other drug patients in all scheduled program member and three facilitators. At- dependency. The work of the pro- activities. Program adaptations tendance steadily increased and a gram staff affects three distinct have been made to accommodate consistent weekly attendance of 20 areas: the Minneapolis community, physical limitations to assure full participants has been maintained the physical rehabilitation units andparticipation. For those patients over the past year. There currently Chron; Pain Rehabilitation Pro- requiring personal care services, are 17 active core members, 6 of gram at Sister Kenny Institute, and Abbott Northwestern Hospital's whom received treatment at other

VOL. 13, Na 2, 19119 151 Model Intervention Program

facilities. Length of membership cal Dependency/Physical Disability were experiencing problems related ranges from 2 months to 3 years. Program from its inception throughto their alcohol and other drug use Sobriety represented is 2 months to early 1988 revealed that three pri- long before the onset of their physi- 13 years. Although nearly 50 per- mary diagnosesspinal cord injury,cal impairment. As shown in Figure cent of the members are between 30brain injury, and chronic pain l, statistics from the first 5 years of and 40 years old, the age range of accounted for more than one-half the program indicate that, of the 88 the group is from 20 to 60 years, of all diagnoses. Spinal cord injury clients with onset of disability after with an average of approximately was the most prevalent, represent- the 10th birthday, 72 clients (80 34 years. ing one-fourth of the sampk. In percent) were dependent on alcohol The group generates discussion contrast, patients with sensory im- or other drugs prior to the onset of about disability Issues that do not pairment accounted for less than 7 their disability. Alcohol or other apply for regular treatment group percent of the total number of pa- drugs contributed to the disabling meetings. Each member is encour- tients admitted. Persons with hear- injury or illness of f ,ents (73 aged to relate personal concerns. ing impairments usually are referredpercent of all clientvith later on- The peer support Ild diverse expe- to other specialized programs. set disability). rience of the group members pro- There is a widespread belief that Among the 24 patients in the vide fertile ground for personal physical impairment causes alcohol program who were congenitally growth and creative thinking as and other drug dependency. For disabled and dependent on alcohol members begin to integrate into an persons whose disabilities were the or other drugs, the majority had able-bodied society. result of a traumatic injury, several been receiving prescribed medica- studies (Anderson 1980-1981; tions with mood-altering effects DEMOGRA"HY AND ONSET O'Donnell et al. 1981-1982; since childhood and lived in pro- CHARACTERISTICS OF THE PATIENT Sweeney and Foote 1982; Heine- tective environments in which their POPULATION mann 1986) indicate that the major- alcohol and other drug use was An analysis by primary diagnosis ofity were involved in alcohol- or controlled and external stressors the patients admitted to the Chemi- other drug-related accidents and were minimized. When these pa-

04-

152 ALCOHOL HEALTH & RESEARCH WORLD tients left the home environment up rate of 62 percent admittecly is frustrated when, in contrast to their and attempted to enter fully into anlow, but results obtained from self- expectations, they find understand- able-bodied society, external stres- reports of former clients are con- ing of their feelings relating to their sors increased. They may have in- sistent v.' h observations gleaned physical impairment and support creased their alcohol or other drug from leading group sessions in the for achieving a lifestyle free of alco- use in an attempt to cope with the Chemical Dependency/Physical hol and other drugs. Commitment increased stress. Disability Program. to the program comes with partici- The majority of the program PhysLally impaired patients o. pating in the grolp and being participants have become depen- ten resist participating in the group, willing to address the physical im- dent on alcohol, usually in combi- and most have had to be required pairment and beginning to identify nation with marijuana or other to attend initially. Denial is evident with the group aswhole. illicit drugs. Prescription medica- when severely disabled patients Those persons who choose to tions frequently are used as well. refuse to attend the group, stating, remain free of alcohol and other "I've already adjusted to my dis- drugs and to become actively in- OUTCOMES: THE CRUCIAL ROLE OF THEability," "I'm not like those people,"volved in a recovery program gain SUPPORT GROUP "It depresses me to be around those self-esteem and self-responsibility 3edon successful followup of 69people,' or "Wnat right do you and begin the process of accepting patients admitted through Februaryhave to label me 'disabled'?" Those their disabilities. They are experi- 1988, there appears to be a direct persons who do readily attend the encing better health and developing correlation between those persons group for the first time frequently alternative means of managing who stay active in the disability expect support for use of alcohol chronic pain, sleep disorders, spas- support group and those who re- and other drugs; they expect others ticity, and stress. New social experi- port complete abstinence from to "understand" that their physical ences are replacing isolation, and alcohol and unprescribed drugs forimmirment "justifies" their use of healthy relationships are replacing a minimum of 6 months after ad- alcohol and other thugs. These abusive, dependent ones. Many are mission (see Figure 2). The follow- patients are often disappointed and developing more independent lifestyles/living situations, are becoming involved in vocational- Figure 2 easrapsolassiallalimmellas illis-41111+at di impart Snow avocational activities, and are , resolving financial and legal difficulties. The first 5 years of our program have been a formidable challenge and tremendous learning experi- iturapOtt *vows' slid. ence. We would like to thank those 043) mittrahraina$ persors who have allowed us to be a part of their recoveries.

REFERENCES

ANDERSON, P Alcoholism and the spinal cord disabled. A model program Alcohol is Health & Research World 5(2) 37-41, 1980- 1981. HEINEMANN, A W Substance abuse and disability An update. Rehatnlital, in Report June3-5, 1986.

O'DONNLI 1 ,1.1 , CLX)P1R, 1 E , GRESSNER, J.E.; SHEHAN, I; Ai) ASH1 EY, J Alcohol, drugs, and spinal cord injury Alcohol Adttiente+ Knosat.to Abotittralte+ *Kw to Health & Research World 6(2) 27-29, 1981- 10188 haras months sitar have 1982 admission *aped admission relapsed SWEENEN. TT., AND FOOTE, J.E Treatment of drug and alcohol abuse in spinal cord injury veterans Intgrnatwaul Journal of the Addic- tions ' n5).897-954, 1982

Vol.. 13, Na 2, 19$9 153 `I orniaesonds Changing Treatment Systems Through Advocacy for the Disabled

Advocates of institutional change fog physically impaired persons with alcohol and other drug problems have had a significant impact on local services and State policy in California during the past 10 years

JOHN DE MIRANDA, ED M., dvocates for institu- and education. Events in California AND LINDA CHERRY tional change can have during the past 10 years demon- a major effect on pro- strate how individuals working gum accessibility and through coalitions at the cemmu- the creation of quality alcohol and nity level can have significant im- drug abuse services :1,1- persons pact on local services and State with disabilities. Although institu- policy. tionalized treatment sysi ems often appear lethargi: in r:,,N.Iting the THE DISAFILITY SUBSTANCE ABUSE needs of the physically impaired, TASK FORCE such systems can be invigorated The acknowledged patriarch of the through a process of activism, doc- alcohol, drug, and disability move- umentation of existing problems, ment in California is Pete Ander-

154 f; ALCOHOL HEALTH & RESEARCH WORLD son. While working in the Veterans To remedy what he saw as the chasers of treatment services in the Administration (VA) hospital sys- unjust exclusion from alcohol and Nation, recently required all new tem during the 1970s, Anderson drug abuse services of people with programs to be fully accessible to became concerned about the dis- disabilities, Anderson and others persons with physical impairments abled veterans who experienced founded the Disability Substance (County of Los Angeles 1988). All serious, unaddressed problems with Abuse lb_sk Force. He and Alan Los Angeles County alcohol service alcohol and other drugs. His uneas-Lowenthal, associate professor of delivery contracts now include spe- iness with the status quo extended community psychology at Califor- cific language mandating that each to the publicly funded recovery nia State University-Long Beach, program prepare and annually up- system, wnich then appeared to be also established programs at date a plan for increasing the acces- largely unaware of the needs of Lowenthal's institution to provide sibility of its services to disabled persons with mobility and sensory educational workshops, technical persons. These plans must include a impairments. Anderson's frustra- assistance, and legislative advocacy separate report on services to hear- tion was fueled by difficulties he (Lowenthal and Anderson 1980- ing impaired clients. In addition, encountered in attempting to con- 1981). all programs funded by Los Angeles vince both the VA and the Califor- County must maintain participant Lacking significant funding, the nia Department of Alcohol and 72!ictration forms that include iden- Disability Substance Abuse Task Drug Problems that services were tification of clients with disabilities Force initially relied on the volun- grossly inaccessible to this commu- other than alcoholism, including teer efforts of its membership, in- nity. He recalls: sensory and mobility impairment, kind donations from community- developmental disabilities, and based programs, and occasional It was a struggle to bring in AA mentally disabling conditions. government support. Anderson and NA [Alcoholics Anonymous In 1987, neighboring Orange describes this period as the "touch- and Narcotics Anonymous]. The County convened a Disabled Access and-go years" because of the diffi- professional staff were very reluc- Coordinating Committee to ensure culties encountered in sustaining tant to introduce significant alcohol treatment program compli- interest in the issue. The problems change into the program because ance with section 504 of the Reha- were exacerbated by the lack of change involved risk-taking. bilitation Act of 1973. Activities of . . . widespread awareness of the provi- Similarly, patients were not the committee included a needs sions of section 504 of the Reha- really encouraged to leave the assessment and facilities survey that bilitation Act of 1973 among facility and to learn to live in the produced a series of recommenda- community-based alcohol treatment community. The program's exter- tions to improve access_lity programs. This legislation states nal activities might include "roll- throughout the alcohol abuse ser- that individuals cannot be denied ing" across the street to a store of vices system. Susan Zepeda Ph.D., admission to a federally funded a once-a-week bus excursion to a deputy director of county alcohol- program on the basis of a disability. museum. I was considered a tron- ism services, notes that the commit- Full compliance often requires con- blemaker because I believed the tee's recommendation to develop a siderable financial expenditure for patients ought to be living in the southern California regional data- architectural modifications, com- community and taking a bus base of disabled service recipients is once a week to visit the hospital! ixation devices, sign language a first step toward the creation of interpreters, and other resources. (personal communication, regional services: September 1, 1988) These initial difficulties gradually were overcome during the 1980s, In this age of fewer dollars, it's JOHN DE MIRANDA. ED M., is direct9r and the Disability Substance Abuse difficult for one county to sup- of the California Alcohol, Drug, Task Forcesince renamed the port a special residential program and Disability Study. LINDA CHERRYCongress on Chemical Dependency for the deaf [client with alcohol is director of the Bay Area Project and Disabilityis now an effective problems], for example. How- on Disability and Chemical Depen- advocate for accessibility of treat- ever, when a consortium of dency. Comments should be ad- ment services throughout southern counties cooperates and pools dressed to the authors at Peninsula California. In part through the resource,,t becomes quite feasi- Health Concepts, 2165 Bunker Hill efforts of the coalition, the Los ble to create reality from our Drive, San Mateo, California Angeles County Office of Alcohol dreams (personal communica- 94402. Programs, one of the largest pur- tion, September 20, 1988).

Vol. 13, Na 2, 1989 15! California Responds

CDCD AND 'ME BAY AREA PROJECT Up to 50 percent of responding county caucuses to nurture the Inspired by Anderson's example, alcohol and other drag service development of local advocacy Jim Bouquin, director of the Dis- programs prohibited use of one initiatives, and workshops focusing ability Resource Center at Stanford or more medicationsrequiredfor on alcohol and other drug abuse University, organit.ed anad hoc control of a physical disability. prevention among young people volunteer task force in the San Among responding disability wit'i disabilities. Unexpectedly, the Francisco Bay area. Bouquin hoped service agencies, only 17 percent Bay Area Project ke.o generated a to create a nztwork of individuals conducted the equivalent of an tremendous outpouring of support and agencies that would document in-depth assessment of alcohol and curiosity among professionals, the need for appropriate treatment and other drug use during the clients, and government officials. services for the disabled in the area intake process. Among those expressing an interest and otherwise reinforce the percep- Only 15 percent of responding were peop.e with so-called "hidden tion that ch-mge was needed. The disability service agencies offered disabilities," such as epilepsy and resulting northern California coun- information on alcohol and other milder forms of mobility and sen- terpart to the Disability Substance drug abuse to their clients. sory impairment. A second year of Abuse Task Force is known as the funding now is being sought for Coalition on Disability and Chemi- A second objective of the Bay projects derived from the Bay Area cal Disability (CDCD). Area Project was to provide techni- Project's final recommendations. With financial support from two cal assistance that encourages crea- local foundations anu a county tive coordination, cross-training THE CALIFORNIA ALCOHOL. DRUk., AND government, CDCD and a local between professional staff from the DISABILITY STUDY independent living center under- alcohol and other drug fields and The State of California recently tookdyear-long effort in three the disability professionals, and charged a special permanent over- counties, known as the Bay Area networking among alcohol, drug, sight commission to investigate Project on Disabilities and Chemi- and disability programs (CDCD criticism that the State Department cal Dependency, to document the 1988). In response to a need cited of Alcohol and Drug Programs has incidence and prevalence of alcohol by many teachers of special educa- not provided adequate services for and other drug proh:ems amohg , n, the Bay Area Project also the disabled. In 1987, the commis- adults with disabilities within a supported plans to develop targeted sion convened a public hearing for metropolitan population of more prevention materials for use with the purpose of ". . . determining than 2 million. During the spring disabled young people who may be if methods of enforcing the current and summer of 1988, the bay Area at high risk for developing alcohol Federal and State mandates for Project survey of public-sector alco-and other drug dependencies. program access and non-discrim- hol and other drug abuse service The Bay Area Project culminated ination are effective, identifying agencies received responses from 60 in a conference that included con- the size of the disabled, alcohol- percent of the identified potential current cross-training sessions, abusing population, and determin- respondents; 54 percent of identi- .011 fiod disability service agencies also responded to the survey. Among the Figural Promo ral INr1f1o>0oo>rl Ohio'( by AlJihe., for the 1111. Nam Allsoltai. owl Other Brugarlsted Problem survey findings reported by Cherry (1988) were the following: Of the survey area's estimated Perceived Social Injustice 62,927 individuals with disabili- System Advocacy ties who may have experienced a a problem with alcohol or other External Documentation drugs, only 334 (0.53 percent) (The Bay Area Project)

were served by the responding Internal Documentation agencies during the most recent (CALADDS) reporting year. Consensus Sign language interpreters were a available in only 13 percent of the System Change responding alcohol and other drug service programs.

156 ALCOHOL. HEALTH & RESEARCH WORLD 6, ing if there are adequate methods Programs during the summer of cate professionals in alcohol and of coordinating information and 1989. At tins writing, it is expected other drug abuse treatment resulted referrals to ensure the delivery of that the final report will include in a network of advocates with'n services" (N. Shappell, personal recommendations to improve and the service delivery system. To j is- communication, May 1987). expand alcohol and other drug tify institutional change, however, In its report to the Governor treatment and prevention services policymakers needed concrete docu- (N. Shappell, personal communica-statewide. mentation of the scope of the prob- tion, May 1987), the commission The core of the CALADDS lem and the potential need for asserted that alcohol and other needs assessment and documenta- services. Initially, advocates and drug abuse among people with tion process is a series of key in- philanthropies volunteered to pro- disabilities is more widespread than formant surveys of disability service vide re,ources for documentation. is commonly believed. Although programs throughout the St ate. These resources generated the data the commission acknowledged that Program directors have been asked that were used extensively in the lifornia has enacted ample legis- to describe the alcohol and other findings of the State oversight com- lath:. designed to ensure access to drug problems of their clients. in- mission. In response to these find- publicly fvrid.?,d programs and facil-cluding difficulties experienced in ings, the State Department of ities by the disabled, the report interacting with alcohol and other Alcohol and Drug Programs com- indicated that neither the letter nor drug abuse recovery services. A missioned CALADDS, a study the spirit of these laws has been Subset of agencies has been selected whose resources come from the honored. As a result, the commis- to administer a questionnaire di- public sector. sion reported that there may be rectls' to clients that will generate The next step, following "inter- 500,000 disabled Californians with data about levels of alcohol and nal" documentation of needs by alcohol- or other drug-related im- ether drug use, experiences in ac- CAL ADDS, may be to develop pairment who are unable to obtain cessing recovery programs, and the consensus among advocates and treatment. perceived relationship between alco- policymakers on the nature of the Responding to these alleged defi- hol and other drug use and the changes that will improve access. It ciencies, the California Depark inz.nt development of disability. is hoped that this consensus will of Alcohol and Drug Programs CALADDS also includes an lead to implementationr'stem contracted with the Coalition on unusual "street outreach" compo- changes that will make the alcohol Disability and Chernkm1 Depen- nent that will attempt to determine and other drug abuse service system dency to undertake an assessment the needs of homeless disabled accessible to individuals with of treatment needs among Califor- individuals who experience alcohol disabilities. nians with disabilities. This I-year or other drug problems. Feld- REFERENCES project, the California Alcohol, workers operating in selected urban Drug, and Disability Study areas will conduct structured inter- CIILRRY, L. Final Report Bay Area Project on Disabilities and Chemical Dependency. (CALADDS), is a joint effort of views with homeless disabled peo- San Mateo Coalition on Disability and experts from the fields of disability, ple to provide data useful for the Chemical Dependency, 1988. alcohol and other drug service de- design of specific approaches to Coalition on Disability and Chemical Dis- livery, survey research methodology,serve this population. ability The Seed Newsletter San Mateo the and service delivery to hearing- Coalition, 1988. THE PROCESS OF STATEWIDE impaired and developmentally dis- County of Los Angeles, Department of INSTITUTIONAL CHANGE. abled persons. Health Services, Office of Alcohol Pro- CALADDS focuses on accuratelyJim Bouquin, founder and presi- grams 1987-88 Los Angeles County Plan documenting architectural, attitudi-dent of the CDCD, recently sug- for Alcohol-Related Services,os Angeles the County, 1988 nal, and institutional barriers to gested a diagram that outlines the recovery, primarily for individuals process followed by advocates of LA/WI N'HAI . A , AND ANDI RSON, P Network development Linking the disabled commu- with mobility or sensory impair- institutional change for disabled nity to alcoholism and drug abuse programs ment. The re :.earchers also are inpersons with alcohol and other 4lcohol Health & Research 14-brld 5(2) 18- vestigating and documenting the drug problems (see Figure I). In 21,1980-1981. needs of the developmentally chal- California, the process began with SHAPE .I i, N Correspondence to the Hon. lenged and the mentally drabled a few individuals who perceived George Deukmejian, Governor of Califor- with dual diagnoses. The study inequity in access to recovery ser- ma, from the Commission on California findings will be reported to the vices. Organizing and collaborating State Government Organization and Econ- omy, May 1987 Department of Alcohol and Drug to Increase awareness and to edu-

Vot. 13, No. 2, 191 157 t EPIDEMIOLOGIC BULLETINNO. 21 Alcohol-Related Morbidity Among the Disabled The Medicare Experience 1985

MAKI' C. DL:FOUR, M.D., M.P.H., DARRYL BERTOLUCCI, M.A., CAROL COWELL, WA., FREDERICK S. STINSON, PH.D., JOHN NOBLE, B.A.

For a variety of reasons, There have been few national Each record in the NHDS de- alcohol-related problems data collection efforts regarding the scribes a hospital episode for an among the physically im- number of alcohol-related hospital- individual patient. The following paired have been largely izations among it dividuals with items are provided for each hospi- ignored. The problems of alcohol additional disabilities. This bulletin talization (or discharge): and other drug abuse among peopleexamines the alcohol-related mor- with additional disabilities are oftenbidity for disabled Medicare enroll- age, sex, race, marital status, and overlooked or ignored. The health ees for 1985. TWo national data sets length of stay for the patient care provider community may fail were used in this study: one to de- size and regional location of the to recognize the signs of alcohol scribe the alcohol-related hospital- hospital abuse or may look the other way. ization experience of the U.S. as many as seven diagnostic codes general population in 1985 and the and four procedure codes describ- MARY C. DUFOUR, M.D., M.P.H., is other to describe, for the same year, ing the patient's diagnosis ant! chief of the Epidemiology Branch the hospitalization experience of treatment. of the Division of Biometry and those individuals who are disabled Epidemiology, NIAAA. DARRYL Medicare enrollees. The NHDS allows space for coding BERTOLUCCI. M.A., is a mathemati- from one to seven diagnostic catego- cal statistician with the Division of THE NATIONAL HOSPITAL ries on a discharge record. "First- Biometry and Epidemiology, DISCHARGESURVEY listed" refers to the diagnostic NIAAA. CAROL COWELL. B.A., is a The first data set is the National category mentioned first on the statistician with the Office of Fi- Hospital Discharge Survey (NHDS) record. This code is presumed to be nancing and Coverage Policy, Na- of the National Center for Health the principal diagnosisthe main tional Institute on Drug Abuse. Statistics (NCHS). Public use reason for the hospital admission. FREDERICK S. STINSON, PH D., is a NHDS tapes for 1985 were used in "All-listed" refers to diagnostic cate- senior analyst with the Alcohol this study. The NHDS randomly gories mentioned any place on the Epidemiologic Data System samples discharges from non- discharge record, with or without (AEDS). JOHN NOBLE, B.A., is the Federal hospitals with six or more any all-listed set of diagnoses. It is Deputy Director, Divisio.i of Biom- beds and an average length of stay important to keep in mind that the etry and Epidemiology, NIAAA. under 30 days (i.e., short-stay hos- NHDS tabulates discharges rather For additional information, pitals). The hospital sample is strat- than patients. Fo; example, if 10 please contact Dr. Stinson at Alco- ified by size and geographic region discharges are recorded for a given hol Epidemiologic Data System, of the United States, and appropri- rrignosis, this record may reflect CSR, Incorporated, Suite 600, 1400ate weights are provided to calcu- hospitalizations for 10 separate pa- Eye Street, NW, Washington, DC late national estimates (NCHS tients or one individual hospitalized 200J5. Telephone: (202) 842-7600. 1970). for the same problem 10 times.

Is. ALCOHOL HEALTH & RESEARCH WORLD MEDICARE PROVIDER ANALYSIS AND REVIEW FILE The Health Care Financing Admin- DIAGNOSTIC CATEGORIES USED IN THE istration's (HCFA) Medicare Pro- MORBIDT/Y STUDY vider Analysis and Review (MEDPAR) file is the source of the Forthis studt &tailed codes alcoholic gastritis [535.3] Medicare hospital inpatient data hem .11sefirtersterforitaassf. pellagra [265.2] employed in this study. Information fleatiOn'OP*41*-9* Revision, available in this file includes: age, ablkidrifindaintinet nese re- anomie liver Disease and sex, first-listed diagnosis and up to cot d oste Orlin following Unhook four additional diagnoses, length of nut* i ed Categories:' stay, eligibility (aged or disabled), Alcoholic Cirrhosis of the liver and reimbursement data. The data Aid dinik alcOholic fatty liver [571.0] file used in this study is the 1985 aloolgOdiltinwel delirium acme alcoholic hepatitis [571.1] MEDPAR file for the disabled. 120i* alcoholic cirrhosis of liver Disaoled individuals who are listed aloobritainneititayndoome [511.21 in this file are those who meet the 1291.11: aicohobc liver damage, unspeci- criteria for the Social Security Dis- other alcoholic dementia 1291.21 fied (571.31 ability Insurance Program (Lubitz alcohol Withdrawal hallucinosis and Pine 1986). Although this data (291.31- ammo*, odits Spedtlel set in no way captures the entire idiosyncratic slcolsol intoxica- Whboit Menden of Alcohol population of disabled persons tion 1291.41 chronic hepatitis [571.4] under 65 in the United States, it alcoadic_ jealousy [291.5] billary cirrhosis [571.6] includes those so seriously disabled other specified alcoholic psy- other chronic non-alcoholic liver that they cannot work. One partic- diosii 091.8] disease [571.8] ular strength of the Medicare data unspecified alcoholic,ychosis portal hypertension [572.31 set is that it is population based (291-91 (rather than a sample). Also, al- Cirrbods, Unspecified Without though it resembles the NHDS in Alcohol Dependence Syndrome Meador of Alcohol tabulating discharges rather than acute alcoholic intoxication cirrhosis of liver with mention patients, another strength is that [303.0] of alcohol [571.5] the Medicare data provide patient other and unspecified alcohol unspecified chronic liver disease identifiers that can be used to ac- dependence [303.9] without mention of alcohol count for multiple hospital episodes alcoholic polyneuropathy [571.9] involving the same patient. In 1985, [357.5] there were nearly 3 million disabled alcoholic cardiomyopathy Nondependent Abuse of Alcohol Medicare enrollees (HCFA 1988). [425.5] alcohol abuse [305.0] In general, NIAAA publications on the NHDS provide data on four age groups: 14-24 years, 25-44 years, 45-64 years, and 65 years and older. However, since over 70 on the International Classification lion discharges (excluding newborn percent of disabled Medicare enroll-of Diseases' lists of alcohol-related infants) from short-stay hospitals. ees are between 45 and 64 years of disorders (CPHA 1978). The ac- In nearly 600,000 (1.7 percent) of age (HCFA 1988), NHDS discharge companying sidebar provides addi- these, the principal or first-listed rates for patients ages 45-64 were tional details on methods. diagnosis was alcohol related. In used in this study for comparison order to take population differences with the disabled MEDPAR hospi- RESULTN: A DOUBLING OF RISK FOR into account, this type of informa- tal discharge records. ALCOHOL-RELATED DIAGNOSES AMONG tion is more meaningfully expressed For the purposes of this study, 1 HE DISABLED as rates. In 1985, the discharge rate the discharge records information According to the NHDS, in 1985 for any diagnosis was 1,479 per was translated into categories basedthere were approximate:y 35.1 mil- 10,000 population age 14 and older

Vox.. 13, Na 2, 19119 159 t; Epidemiologic Bulletin

(NIAAA, in press). Table 1 lists . . discharge rates for several common, Table 1Diseiserges from UAL likort-litay itomitals, DM well-known conditions in order to provide a frame of reference for the Firsitisisd Diagnosis Rates/10,000 Population discussion that follows. Any diagnosis 1478.9 Figure 1 illustrates that the Alcohol-Mated' 31.2 alcohol-related discharge rates were FOr11811391wIthdeliveries fiCO-V271 2 dramatically higher for the disabled 314.8 than for the general population as Fractures, aN WM(800-8293 47.6 represented by the NHDS. For most Haan Mack (souls myucarcird alcohol-related diagnoses, discharge intarclion-4101 31.8 rates for the physically impaired Gallstones Ichoislithimis.5741 20.0 sample are more than double those Lung cancer (malignant neoplasm of trachea, in the NHDS. The pattern of bronchus, and lung-182, 197.0, 197.3) 13.3 alcohol-related diagnoses among Ras Ply 10,000 paps on ago 14 and oldst 2RIM per 10.000 tycoon. the disabled mirrors closely that of sconcetido* Gnat for Himithtatiari Sc,,1988 the population as a whole. The va't

Quick Facts FROM NIAAA

For persons interested in up-to-date informationon AL c e by use of a modem with and computer the scope and consequences of alcohol use Ind abuse, terminal Cr microcomputer, and the NationalInstitute on Alcohol Abuse and Luse cif u.se, with online table of contents and index, Alcoholism provides an electronic bulletin board help screens, an iwrittenuser's manual available system called Quick Facts.The system currently provides access to over 60 tables of data on alcohol UseQI41(kFacis immediately by establishing thecor-

consumption, drinking patterns, alcohol-related rect modem settings (8 data bits,I stop hit, no parity. morbidity and mortality, other consequences of fail duplex or no local echo, and 24(X) or 12(X) o: 300 alcohol abuse, and utilization and costs of alcohol baudtransmissionspeed)andby calling 202 -289- treatment. The information available through Qua k 4112 Fac tsis updated periodically and the scope of QuickFacts isa serviceofthe Alcohol Epi- coverage is constantly growing demiologic Data System, a contract operated for QuickFac is offers the following features NIAAA's Division of Biometry and Epidemiology by CSR, Incorporate.. For more information about Qui( k No feeforsubscription oraccess, Fa(is orfor assistance when using thesystem, contact Online availability 21hours each day (24 hours on Fred Stinson at 202-842-7600 weekends),

160 Al COHOI HEA I TH & RESEARCH WORLD t) related morbidity listed in the U.S. Govt Print Off , 1988.

Clearly, a significant NHDS. Therefore, when only first- LUBITZ, 3,AND PINE,P Health care use by listed diagnoses are examined, Medicare's disabled enrolleesHealth Care amount of alcohol-related morbidity in short- Financing Review7(4):19-31, 1986. alcohol-related stay hospitals is underestimated National Center for Health Statistics. Devel- substantially. This underestimation opment of the design of the NCHS Hospital morbidity exists in theundoubtedly holds true for the Discharge Survey.vital and Health Statis- MEDPAR data as well. Thus, the tics.Series 2, No. 39, PHS Pub. No. 1000 disabled community. Washington, DC: Supt. of Docs., U.S. Govt. true magnitude of alcohol-related Print. Off., 1970. morbidity among the disabled is National Center for Health Statistics.Sum- quite likely to be even more pro - majority of first-listed alcohol- mary. National Hospital Discharge Survey, related diagnoses for both groups no "nced than reported in this 1985.NCHS advance data No. 127, Septem- study. II ber 25, 1986 fell into the category of alcohol dependence syndrome followed by National Institute on Alcohol Abuse and REFERENCES Alcoholism. U S. Alcohol Epidemiologic all cirrhosis. Data Reference Manual, Vol. 4:Alcohol- The results of this study are strik- Commission on Professional and Hospital Related Morbidity Among Short-Stay Com- ing. Clearly, a significant amount Activities (CPHA).The International Classi- muhity Hospital Discharges, United States, of alcohol-related morbidity exists fication of Diseases,9th Revision,Clinical 1979- 1985..npress. Modification, Vol. 1, Diseases Tabular List STINSON,ES ,AND WILLIAMS,G.D.Surveil- in the disabled community. Pre- Ann Arbor, MI. CPHA, 1978 vious research (Stinson and Wil- lance Report #4: Alcohol-Related Morbidity liams 1986) has shown that first- Health Care Financing Administration. Among Short-Stay Community Hospital Annual MEDICARE Program Statistics: Discharges, United States, 1979-1984.Wash- listed diagnoses account for a little MedicareEnrollment,1985. HCFA Pub. No. ington, DC. Alcohol Epidemiologic Data more than half of all the alcohol- 03266. Washington, DC: Supt. of Docs., System, 1986.

My alcohol-related diagnosis

59.1 Alcohol dependence syndrome

, AN chronic liver disease and Medicare/Disabled NHDS/Ages 45-64 A;cohotie cirrhosis

Cintosis, other specified without mention of alcohol

Cirrhosis, tinspedied without mention of alcohol

10 20 30 40 50 60 Rats per 10,000 Population

VOL.13, No. 2, 1919 161 te; READERS' EXCHANGE

HEARING-IMPALRED the constant interaction with people from morning to ALCOHOLICSAN bedtimeleft me exhausted ar_i

UNDERSERVFB frequently frustrated.. . . COMMUNITY What is the explanation for this lack In the United States, more i'lan 20 of awareness and the relative absence million people suffer from in- of measures to meet the needs of paired hearing (Wentzel 1936; U.S. hearing-impaired and deaf alco- Bureau of the Census 1987). How holics? And how can these problems many of 0 em have the dual prob- be corrected? Ian of alcoholism and hearing loss? Exact data are not available; how- SOCIETAL %SPONSE TO HEARING a conservative estima,z, based IMPAIRMENT on the National Council on Alco- Hearing impairmentthe most com- holism's assumptions about the mon sensory lunitition in the United prevalence of alcoholism in the gen- States (U.S. Bureau of the Census eral population, suggests that at 1987)is a broad teem embracing least 600,000 men and women ape- degrees c,f loss from mildly "hard of 'ence this doable burden. hearing" to profoundly deaf. The loss Given the state of the art of alco- is measured in decibels (dB) that de- holism treatment services, how many scribe the ability of an individual to hearing-impaired persons can expect hear sound, as depicted in Table 1. to find help for their alcohol-related The "profound loss" category in- problems? Resources available to cludes persons who are deaf as well as hearing people, from Alcoholics some in whom residual hearing is Anonymous (AA) to professional retained. Deaf persons are those for treatment facilities, are fraught with whom the sense of hearing is non- barriers for those who cannot hear. functional for the ordinary purposes The resources depend on communi- of life. Deafn,ss refers to both the cation among individuals, communi- congenitally deaf and the adventi- cation between individuals and a tiously deafthose in whom the sense group, or the "simple' act of listen- of hearing has become nonfunctional ing to a film or talking on the tele- through illness or accident. phone. A variety of organic and erviron- mental factors may be involved in Four years ago, my brother at- hearing loss. As a consequence, hear- tendx1 AA meetings many times a ing impairment includes various com- week for four months. . . . Me] binations of middle-ear dysfunction, didn't drink for four months but inner-ear dysfunction, bone dysfunc- he didn't hear a word that was tion, and nerve damage. These condi- said in meetings. My brother went tions are expressed in the quantitative bazk to drinking and is still drink- and qualitative differences in hearing ing. .. . loss and in the responses and equip- 2 [U]sing standard treatment methods [of a 28-day inpatient treatment program], I had to GIADys A. Kt 4RNS IS executive director struggle with the grou4:ssioris in of the Union County Counril on order to follow my fellow pa- Alcoholism, 300 North .4venue E., tients, and part or the strategy Westfield, New Jersey 07090.

162 ALCOHOL IL, 11.4 & RESEARCH WORLD IIMMEMIMIL . Jr

z Readers' Exchange

acceptance of special needs, and reduce the probability of a positive treatment outcome. Alcoholism treatment service providers forge a critical link in the service delivery and recovery chain for the hearing-impaired alcoholic (Wentzel 1986). Unfortunately, this role is not adoptei effectively by many treatment service providers. Alcoholism service providers are not immune to ina( cu- rate perceptions concerning hearing loss. The varieties and degrees of hearing impairment and the effect of a given loss upon an individual re- ment required to address the loss or, This inaccurate perception about the main unexplored areas for most pro- when possible, to enhance and am- nature of hearing :z.pairrhent may viders. When alcoholism treatment plify sound. When the condition or result in the failure to respond to the providers succeed in penetrating the the circumstances do nc permit en- needs of hearing-impaired persol-s, barrier of self-protection raised by the hancemeat or amplificatior of sound, compared with the responses offered hearing-impaired alcoholic, neither a hearing-impaired individual may to those whose disabilities are more the alcoholism treatment service sys- attempt to rely on sign language, readily observed and understood tem nor the network of service deliv- interpretation, or lipreading. Without (Buss 1985). ery for the hearing impaired offers these aids, a hearing-impaired person On an individual level, insensitivity many resources designed to help inter- is consigned either to loneliness or to to the special needs of hearing- vention with the client. As a result, a a ceaseless struggle to function in a impaired persons may translat° into a hearing-impaired alcoholism client world where verbal conanumcation is negative self-perception. may fall through the gaps in a service the common method of social delivery system (New Jersey Task bonding. .. .It really hurts when a friend Force 1986). According to one recov- A general assumption in the hear- ge,s angry at having to repeat ering author: ing and speaking world is that all something for the 100th time and hearing impairments other than ,ro- rolls his head or his eyes upward; I . . .the biggest stumbling block found deafness fit under the generic hate setting them get as frustrated to recc -ry hinged on something umbrella of "hard of hearing." All as I am. .. . everyone missed: the real emotional hard of hearing people often are per- acceptance of my hearing loss. ceived as similarly afflicted and Such experiences inadvertently may Outwardly I handled my hearing similarly able to cope with the envi- impart a sense of social stigma. loss in. . .a manner that did not ronment. In effect, hearing-impaired Hearing-impaired persons may with- give evidence to the profound deaf- individuals are viewed r no different craw from the hearing world or deny ness that I have.. . .I successfully from those who hear. the exist: we of a hearing loss. These hid behind this "mask" for 38 behaviors at the last lay the ground- years. I now realize that my intense . I wear two hearing aids (only work for isolation, and it has been fight '- be "normal" and my suc- since I was 20 or so; I wouldn't do suggested that a high level of frustra- cess in so doing was the real "de- it as a kid for fear of en'b-rass- tion may increase he incidence of nial" in my life. The professionals ment) but so many do not under- alcohol abuse among the hearing- missed in not steering me towards stand [that] they are just aids. They impaire.. population (Harris 1982). the acceptance of my hearing logs don't make us hear like otherpeo- and the limitations it places on me. ple. People expect that those of us Tin Roo.: OF SFJOICE NOVIDFAS using hearing aids should be able to Isolation and denial of an impairment As for life after treatmentprofes- hear like they do! It is so very frus- are patterns familiar to the alcoholism sionals must recognize 1 v hearing trating and more so trying to ex- treatment community. lleatment loss isolates us from people, and po- plain , . . that I only hear better professionals recognize that these ple are the key to one's success in with them than I do without them traits decrease the likelihood of identi- Alcoholics Anonywous (Jestrrger and [that] I still miss a lot! fying problems, minimize a client's 1988).

164 t*-1 ALCOHOL HEALTH & RESEARCH WORLD In 1984, the governing body of holic. First, hearing-impaired people understand the nature, causes, com- Union County, New Jersey, contracted must continue t3 work as activists, plications, and possible remedies of for a survey on the appropriateness, exercising leadership in raising and hearing loss" (Stone 1987). Member- availability, and accessibility of alco- maintaining social awareness of the ship in such self-help groups may holism and related treatment services issue of alcohol-related problems assist hearing-impaired persons to for county residents with mental and among their population. Second, develop the confidence to insist upon physical disabilities. Through the end society must respond to the dual dis- a response to their needs. of data collection in June 1986, a ability cf hearing impairment and

total of 14 alcoholism treatment pro- alcoholism with the same caring con- .. .TI; biggest problem I have grams and 15 agencies serving the cern directed toward other impaired now is that although I have this needs of hearing-impaired people werepopulations. Finally, it is essential that wonderful auditory trainer, people reviewed under the administration of service providers responsible for inter- don't like to use it and it is very the author. Virtually all of the general vention among alcoholics and inter- humiliating to ask/explain to the observations on the barriers co treat- vention among the hearing-impaired members of the AA group about ment were confirmed by the survey population move vigorously toward it.. . . A few times I got rude results. No treatment program or mutual education to spur the develop- remarks about the mike and blew disability service agency in this rela- ment of necessary services and up and told them I don't like it

tiwly weaithy jurisdiction or more resources. either. . .but I want to stay than a half mil:ion population was Among human service providers sober too.. . .They don't have to prepared to offer the resources neces- and an increasing number of clini- use it but just pass it to the next sary for treatment of hearing-impairedcians, 't is a truism that recovery is one who is willing to share with alcoholics. most effective when the client be- me. Specialists who serve hearing- comes an active and knowledgeable impaired people also face lirge gaps partner in the treatment plan. Active Sensitivity to such problems is in information and resource; related participation recently was demon- needed by communities that design to the deaf alcoholic. The Inyth that strated when deaf students at Gal- and fund programs to serve people hearing loss "explains" alcohol depen-laudet University in Washington, DC, with alcohol-related problems. Several dence is pervasive within the commu- successfully protested the appointment years ago, for example, the lack of nity of service providers for the of a hearing president and obtained community-based treatment resources hearing impaired, and such providers the appointment of a qualified deaf was cited as a contributing factor to may fail to recognize alcohol-related president for the national university the suicide of a young hearing- problems among their clients. The for the deaf. Society's response to the impaired alcoholic. The attention same denial that a hearing person Gallaudet students' action was imme- focused by the incident enabled Paul uses to mask alcoholism can be read- diate. Television, radio, and newsprint Rothfeld, executive director of Cape ily applied by a hearing-impaired provided thoughtful, comprehensive Cod Alcoholism Intervention and person to mask a dual problem, espe- coverage during the week-long debate Rehabilit.;:ion Unit, Inc., to found the cially if alcoholism and hearing loss between students and 0-university Stephen Miller House in Pocasset, arrceived as deviant social charac-board of trustees. As a result, many Massachusetts, as a memorial to thir tenstics. In those rare cases in which apeople became sensitized to the sec- tragedy. Now funded by the State o'. specialist on hearing loss identifies ond class status that unwittingly may assachusetts, the Stephen Miller and attempts to meet the needs engen-be ascribed to hearing-impaired program focuses jointly on the prob- dered by a dual problem, the specialistpeople. lems of hearing impairment and alco- often may experience a sense of help- A less dramatic approach to self- holism while offering information and lessness. Resources are difficult to help leadership among hearing- counseling to the families of its clients :btain for someone who cannot hear impaired persons is provided by Self and to the deaf community through- group situation, who cannot use Help for Hard of Hearing People, out the region ( Rothfeld 1980). the telephone, or who cannot hear at (SHHH), based i i Bethesda, The process of sensitizing com- all. Maryland. According to founder and munities to the ..ids of hearing- executive director Howard E. Stone, impaired alcoholics does not require CORRECONG THE PROBLEM "SHHH was founded based on the the spark of tragedy. Alcoholism Three types of activities must be un- conviction that little progress can be Intervention for the Disabled (AID) is dertaken to correct the absence of made until both those who can hear a further example of social action in services for the hearing-impaired alco-well and those who cannot better the design of a helping mechanism.

VOL. No. 2, 1939 165 Readers' Exchange

Founded by Alex Boros of Kent State to an unfamiliar location without the KELLER, H. The Cory of My Life. New Y:Alc. University, AID now publishes a use of your ears! Service providers Doubleday, 1:54. quarterly newsletter for national distri- should view meeting such require- New Jersey 'Disk Force on Alcoholism and the bution. lbpics covered in the newslet- ments as a prime determinant of Hearing Impaired "Report to the New Jersey ter include practical, state-of-the-art successful program outcome for Division of Alcoholism." Unpublished report, information for consumers and pro- hearing-impaired alcoholics. June 1986. viders of alcoholism and other addic- Above all, treatment service pro- ROTHFELD, P Alcoholism treatment for the deaf: tion services. viders need untinstanding. People Specialized services for special people. CAFr. Arlington, VA: H/P Publishing Co., 1980. Although individuals and groups suffering froTri hearing loss are shut may work for change, the agencies out from spoken language, our major Srorge, H E. Invisible handicap. Baltimore Sun, Dec. 29, 1987. and institutions responsible for serv- means of communication. Language ing people struggling with alcoholism is a critical component of psychoso- U.S. Bureau of the Census. Stattsncal Abstnacl of and with hearing loss must acknowl- the Uruted States 19. 108th ed. Washington, cial development because of its role as DC: U.S. Bureau of the Cerkas, 1987. 'able edge institutional needs for special- a bearer of culture, a transmitter of 174, p. 108. ized, reciprocal education. Such information, and the primary means WENTZEL, C An outline for working with the education may include sensitivity of presenting a. self -image to the hearing unpaired in an inpatient substance abuse training for both types of service world. Spoken language conveys treatment program. AID 'ern 8(1)'' -6, 1986. providers. At a minimum, education moods, needs, and many other shared IML must address the myths and biases experiences among people. When that affect service delivery to hearing- language acquisition if prevent' d by ALCOHOLISM AND impaired alcoholics. early, profound hearing loss or when BULLOUS CHANGES In addition to education, alcohol- communication is diminished by later OF ism treatment services must develop onset of hearing impairment, hearing- THE LUNGS awareness of the need to match spe- impaired people are distanced and feel cial equipment and services to specific clis...ace from their fellows (Harris Some pulmonary patients are types of hearing loss. All hard-of- 1!82). Helen Keller's emphasis on her diagnosed with bullous hearing or deaf people cannot be hearing loss over her blindness ex- changes of the lungs. This expected to benefit from the listening pressed the sense of distance when she diagnosis refers to the pres- potential supplied by a given piece of said that blindness separated her from ence of blisters, known as localized equipment or communication tech- things but deafness separated her pneumatoceles or bullous formations. nique. Louder, for example, is not from people (Keller 1954). Some of Textbooks ci cribe the origin of the necessarily better. Hearing aids help this separation must be closed bullous ch Angts as obstruction of the some individuals but not all. Personal through understanding if alcoholism bronchioles, the narrowest portions of hearing aids, even when effective for services are to provide genuine recov- the bronchial tube. According to this one-to-one communication, may ery for hearing-impaired people. XI view, air can be trapped within ob- require reinforcement by auxiliary structed bronchioles, resu!ting in the formation of Msters within the lung. equipment for us' in groups, includ- Quoted passages in this article are excerpted ing AA meetings (Cutler 1985). from letters received try the author in response to The following alternative hypothesis Reatment facility operations also the publication of a recent article (Kim /987). to explain bullous changes of the may be affected by the requirements lungs is based on many years of observation of chest x-rays of alcoholic for effectively responding to hearing- REF1ENCES_ impaired alcoholics. For example, patients, including over 100 cases Buss, A. Alcohol use by persons with disabilities in which a diagnosis of billions background noie that merely distracts /irDBqletat7(1) 1-3, 1985. a client with normal hearing may changes was associated with alcohol a-r ER, W B. large Room Lsterung Systems for dependence. totally distort a message directed to a Flare of Hearing Ito* Bethesda, MD Self client with assisted hearing. Visual 114 for Hard of Hearing People, Inc., 1985 SIDNEY L. CRAMER. M.D., is a radiolo- cues that are essential to many lip- RIS, R.I. Communication and mental health gist consultant to the Veterans Home readers require good lighting. The The Deqf American 34(4) 8-12, 1982. and Hospital, Rocky Hill, Connecti- availability of alerting devices is im- JESFURGER, C A hard of hearing alcoholic finds cut. Conespondence to Dr. Cramer portant for critical functioning or recovery. Shhh Journal 9(2) 23, 1988 should be addressed to his private dangerous situations, particularly in KEARNS, G. AleChOLLSM and hearing loss' A practice at 21 Woodland Street, inpatient treatment: Think of traveling silent conspiracy? Shhh Journal 8(6)12-13, 1987 Hartford, Connecticut 06105.

166 ALCOHOL Ifd-ALTP & RESEARCH WORLD courses. Among some patients, no other significant changes in the lung occur unless complicated by infection or the presence of air or gas in the pleural cavit j. These patients often present neither symptoms nor alteration in pulmonary functionthe presence of bullous changes usually is discovered from routine chest x-rays taken for reasons other than breathing complaints. These patients can be described as Group I. A second group of patients with bullous formations also present clinical symptoms of emphysema, along with the characteristic x-ray evidence of this well-known lung disease. I have found these Group II patients in large numbers in such institutions as Veterans Administration hospitals where care is provided for chronic lung disease. These Group II patients often are pulmonary "cripples" receiving treatment with alpha 1 anti -trop; i subs itution. The Group 1 patients frequently deny a histor of alcohol consumption, but confirmation often is obtained from such other sources as relatives and friends. Through dili- gence and persistence in eliciting the history of alcohol use, over 90 percent of 100 observed cases of bullous for- X-ray photograph illustrating bullous changes mations confirmed the hypothesis. Although these observations are intriguing and potentially significant, It is hypothesized that many people diameter (as shown in Figure 1) to I believe that it will be very difficult to have a physiological susceptibility to large areas characterized by fibrosis confirm them empirically. Most indi- pulmonary effects of alcohol con- the formation of abnormal fibrous viduals who drink at problematic sumption. This population develops tissue and the absence of normal levels also smoke tobacco products; subclinical destruction of cells in the lung markings within the air sacs. bullous changes resulting from smok- lung tissue, beginning in the upper Such permanent, irreversible change,, ing pose a potential barrier to analysis lobes, in response to repeated con- can be observed in the lung tissue of of the relationship between alcohol sumption of large quantities of alco- alcoholic patients. These changes are abuse and lung disorders. Further, hol. Hyp 'hetically, this destruction not seen in chest vcaminations of unless alcohol-induced bullous continues W .1 Cie patient stops sn_Jkers or nonsn lkers without the changes can be separated om drinking alcoholic beverages. The end complication of preant or former changes affected by tobacco use, result of the cell destruction is upper alcohol abuse. specific mechanisms explaining the lobes with varying degrees of bullous My observations suggest that the relationship between alcohol and these formations, ranging from a small effects of destruction of the lung lung disorders will be difficult to lesion measuring several centimeters in tissue may take one of two possible establish. IM

VoL.13, No 2, PO 167 Occupational Arena

Treating Patients with ranked as the country's fourth lead-alcohol-related injuries and identi- Alcohol-Related Trauma ing cause of death and the leading fied promising avenues for future A Report from the ARUS cause of physician contacts Rock- study. Participants also suggested Symposium ett and Putnam 1986). ways to exploit what Douglas Victims of serious trauma find Rund, M.D., chief of emergency A 28-year-old man comes in with medical help in over 5,000 hospital medicine at 01 State University basically normal vital signs, emergency departments and 300 Hospital, termed "that brief mo- semiconscious and vomiting, trauma centers throughout the ment of care in the trauma event some cuts about his scalp and United States. It has been estimated . . . when the alcoholic trauma around his ears. He is rather that 20 to 37 percent o; adinissions victim will accept treatment for obnoxious, not a very pleasant to these acute care facilities involve alcoholism" (personal communica- character to be around, and excessive alcohol use (Roizen 1985). tion, Fulton Caldwell, Ph.D., smelling like a bottle of whiskey. According to Julian Waller, M.D., NIAAA, January 1989). One of the residents says, "Oh. of the University of Vermont's De- Chaired by Albert Lowenfels, he is just drunk." And, indeed, partment of Medicine, contacts M.D., professor of surgery at New he is drunk. But he also has a between acute care physicians and York Medical College at Valhalla, major intercranial clot. . . . victims of alcohol-related trauma the 1-day workshop featured ple- There has been an unfortunate "offer a unique window of oppor- nary sessions on diagnosis of alco- tendency to get patients in the tunity . ..if the physician helps hol dependence in injured patients; emergency room who ale drunk the patient confront the [alcohol] early management of patients with . . .and to label them. . . . probler' when the patient is no alcohol-related injuries; alcohol- If you are medically oriented, longer under the influence . . . induced physiological alterations you may have heard them called but is still hurting from injuries trauma victims; and intervention "gomers." caused by the alcohol abuse." Con-and followup for alcoholic patients. What does gomer mean? versely, failure to identify and inter-Obstacles that emergency physicians It means "get out of my emer- vene with an underlying alcohol encounter at each stage of patient gency room." disorder could result in medical care were highlighted. Soderstrcm, M.D.' mismanagement of the injury, subsequent injuries ,esulting from un- RECOGNIZING ALCO:101, DEPENDENCE Each year more than 140,000 treated alcohol abuse, or both. The World Health Organization's Americans dic from trauma, and 1 Problems that ph) -.tans encoun- in 3 incurs an injury that requires International Clasjfication of Dis- ter when addressing a j. t's eases, 9th Revision medical attention or produces tem- (ICD-9) de- injury and an underlying a ohoA scribes the outward manifestations porary disabili.:y (Committee on disorder were examined by p. of nondependent alcohol abuse as Trauma Research 1985). Trauma is pants in NIAAA's Alcohol Re!. ;archfrequent, excessive drinking suffi- Utilization System (ARUS) sympo- cient to adversely affect one's ' The source of quoted material in this sium "Post-Injury Treatment of health or social functioning (WHO article is the transcript of the June 1988 Patients with Alcohol-Related Alcohol Research Utilization System sympo- 1977). The American Psychiatric sium "Post-Injury Theatment of Patients Trauma," held in June 1988 in Association'sDiagnostic and Statis- with Alcohol- Rela!ed Thauma." A synopsis Washington, DC.' Clinicians and tical Manual of Mental Disorders, of the transcript Ls available fm, the Na- researchers who attended theARUSThird Edition, Revised(DSM-III- tional Caartnghouse for Alcohol and Drug workshop reviewed research on R) describes alcohol abuse as an Information, P.O. Box 2345, Rockville, Maryland 20857. Also avallab.'2 from the inability to stop drinking until poor clearinghouse is "4 /who? and Thauma," the The ARUS series, initiated in /980, is a health or depleted financial re- January 1989 Issue of Alcohol Alert, a forum for the assessment of knowledge and sources prevents further drinking bulletin for clinicians and allied health a limned number of high priority research (APA 1987). professionals. findings in a specific area of alcohol st idv At least intil its late stages,

168 ALCCHOL HEALTH & RESEARCH WORLD It has been estimated that 20 to 30 percent of admissions to acute care facilities involve excessive alcohol use alcohol dependence is identified to alcohol use and on a diagnosti- andpoorlysuited to administration primarily by these same manifesta- cian's interpretation of that pain an acute care setting. tions. DSM-III-R notes "marked tient's self-report. Trauma physicians suspect alco- ...impairment in social and hol dependence largely on the basis occupational functioning" (p. 172) Instruments that are used for of what theysee,which, in an acute in alcohol dependent persons. screening alcoholic patients also care setting, is less often the adverse ICD-9 describes alcohol depend- rely heavily on patient self-reports, effect of alcohol on social or occu- ence syndrome as "characterized by an assessment mechanism that has patiGnal functioning than the more behavioral and other responses" (p. been challenged (Watson et al. obvious evidence of intoxication. 198). Because few of these re- 1984; Fuller et al. 1988). In addi- However, signs of recent alcohol sponses are observable in clinical tion, according o Kathryn use ck, not justify a diagnosis of settings, the diagnosis of alcohol Magruder-Habib, of the Veterans dependence; in fact, alcoholics with dependence often relies largely on Administration Medical Center and well-developed tolerance often show patient self-report of medical, so- Duke University, most -...reening no outward manifestations of re- cial, or financial problems related instruments a-c long, cumbersome, cent alcohol use.

r Voi- 13, Na 2, 1969 169 DEPARTMENTS

Correct identification of alcohol dently is indicative of more than a dependence is further complicated Given the limitations possible alcohol-related problem. because visible signs of intoxication Given the limitations of cui rent may mimic signs of other condi- of current testing testing options, how do emergency tions. For sample, patients who options, how do care physicians diagnose alcohol are unconscious or display altered dependence? According to Wolter corsciousntcs as a result of head emergency care and to discussant Peter Fielding, injury sometimes are misdiagnosed M.D., of St. Mary's Hospital and as under the influence of alcohol. phy,icians diagnose Yale University, the question is not Similarly, patients with altered con- alcohol dependence? diagnosis but "screening and sciousness brought on by alcohol yield." "The jot a physician abuse may be misdiagnosed as vic- who is not a specialist in this area is tims of head injury. The "gomer" relatively low BAC may prevent to Know when and how to do ap- referred to by Soderstrom, of the identification of elderly alcoholics, propriate screening and to get the Maryland Institute for Emergency whose typical alcohol consumption patient into the hands of the neces- Medical Service Systems is only four drinks a day. On the sary alcohol specialist," said Waller. (MIEMSS), is one example of other hand, high BACs are cim- Waller suggested a BAC of .15 misdiagnosis. mon among teenaged alcohol without cliri =al evidence of intoxi- "Unless you actively seek out the abusers, who usually have not con- cation as indicative of high patient disease," urged Waller, "jou will sumed sufficient quantities of alco- risk of alcohol dependence. He also miss all except those individuals hol over a long enough time to be recommended several short screen- with the most flagrant, late-stage alcohol dependent. .ng instruments,' of which the most disease patterns. . .. and the only recently developed consists of only way to know how much a person However, the BAC does provide a physician with information about two questions. Cyr and Wartman has been drinking is to do a quanti- (1988) reported that a positive an- (al ive test for the drug." the amount of alcohol in a patient's system at the tame of admission swer to the question "Have you ever had a drinking problem?" was MEASURING ALCOHOLUsl, information that can prove essential predictive for 70 percent of persons The quantitative test most fre- in determining a course of treatment with alcohol-related problems. Ac- quently employed is that for blood recommendation by the U.S. College of curacy was raised to over 90 percent alcohol concentration (BAC), some- for persons who, when asked, times measured for legal reasons at Surgeons, symposium moderator Lowenfels called on conference "When was your last drink?" an- the scene if a highway accident, swered that they had consumed but routinely measured in km), attendees to recommend routine use of the BAC in all trauma centers alcohol within the past 24 hours. about 50 percent of trauma centers, and emergency departments. As W-iller noted, a positive BAC according to Soderstrorn. obviates the need to ask the second As Wailer poi"ted out, the legelly Laboratory tests that may alert question defined measui of intoxication trauma physicians to excessive alco- A!tiiough Fielding and Waller actually captures only 18 percent of hol use and to possible dependence concluded that patients who test intoxicated drivers. For this reason, in their patients include -levated positive in alcohol scieenings some States are taking action to liver function tests without obvious should be referred to alcohcl redefine the current measure of .10 explanation, elevated triglycerides cialists, the reality is that acute care milligrams of alcohol per deciliter of with relatively low cholesterol, and physicians gife priority to treating blood as evidence of intoxication. elevated blood glucose without a the immediate trauma rat he: than Measured in hospital emergency family history of diabetes or, con- to its underlying cause departments and trauma centers, versely, low blood sugar or reactive the BAC has significant limitations hypoglycemia. None of these mea- ' Other short screening mechanisms considered appropriate for use in an acute care as an indicator of possible alcohol sures is routinely applied to all setting are the A nupfer method (19d4) and dependence. According to Waller, a trauma victims, and none indepen- the CAGE method (Ewing 1984)

170 A LC OHM 11 LA I TH & RESEA RC II WEALD neuronal injury, suggested the use MANAGING ALCOHOL-RELATED studies also should be a regular of circulating hormones, or neuro- TRAUMA part of patient care. humoral markers, to predict out- The results of bath laboratory tests However, the most common sur- come in brain- injured patients. To and patient self-reports are critical gical complication among patients explore this and other areas of not only for identifying an underly-who are intoxicated precedes actual metabolic research, discussant ing alcohokehited disorder but alsosurgery, according to John Stene, David Lewis Davies, Ph.D., of the for treating those presenti:_g with M.D., Ph.D. Stene, an anesthesiol- University of Arkansas, stressed the injuries, according to Soderstrom, ogist who works with Soderstrom ne J for clinicians to coordinate who discussed early patient man- at MIEMSS, reminded symposium their research with that of basic agement, and Paul Woolf, M.D., ofattendees that alcohol potentiates scientists. Davies raised as an issue the University of Rochester Medicalanesthesia, so that when a patient isfor further exploration the possibil- Center, who discussed physiological intoxicated, the level of anesthesia ity that alcoholics are in some way alterations that may result from should be reduced. Alcoholics who at greater risk for incurring trauma: alcohol use or abuse. are not intoxicated, on the other "Is there some sort of metabolic In addition to the possible confu-hand, require much higher levels of dysfunction that predisposes them sion of head injury with intoxica- anesthesia. Stene also called atten- to higher susceptibility?" he asked. tiou, Soderstrom noted the tion to problems resulting from the Whether or not alcoholics are at difficulty with identifying intra- interaction of alcohol with other greater physiological risk for incur- abdominal injury. "To us," he said, drugs. He cautioned that most ring trauma, they are at rir,k for "if a patient appears to be intoxi- toxicology tests are crude and fail greater severity of injury. sympo- cated, that is a reason to do a peri to detect all drugs of abuse. sium presenters agreed. According toneal lavage. . . [irrigation of Other common difficulties with to Soderstrom, research findings the abdomen] or a CT [computer- treating alcoholics include cardiac 'lave disputed the widely held per- ized tomography] scan to look for and immune defense system prob- ception that persons who are internal injuries. Patients who seemlems, hypothermia, and, of course, intoxicatedand therefore relaxed to be a little drunk may have no withdrawal, Soderstrom said. Delir- are better protected against serious signs or symptoms pointing to in- ium *remens (DTs), the most criti- injury at the time of an accident ternal injuries. Some of those pa- cal form of alcohol withdrawal, has (Wailer 1987; Roizeu 1985). Waller tients may go into shock hours latera mortality rate of 4U percent it Lett also stressed that persons with high because of a fractured spleen or a untreated. Soderstrom described BACs are more likely to be alco- cracked liver." the need for emergency rooms and holics and more likely to die at the Soderstrom also noted problems trauma centers to make use of "up scene of an accident than those of thrombocytopenia (a decrease in front" indicators of persons at risk with low BACs, a pattern he noted the number of blood platelets) in and defined the presence of any to be consistent across all types of patients who have abused alcohol two of three indicators as predictive injury. "Our concern, however, is on an acute basis. With the cessa- of the need to prophylax against not with identifying alcoholism per tion of alcohol use on admission, a DTs: history of DTs or prior with- se," Waller added, "but with identi- rebound thrombocytosis (an unusu- drawal syndrome, liver cirrhosis, fying it among those who will live ally high platelet count) may occur and recent heavy drinking. and, therefote, who can benefit about I week after admission. Be- The problems encountered by from such identification and cause both conditions may produce physicians in dealing with padents intervention." surgical complications, it is impor- who have used or abused alcohol tant to monitor diligently a pa- have heightened the interest of re- IN 11.RVENING V IIh !MUM. D tient's vital signs, cardiac function, searchers in physiological altera- AIotuns and serum electrolyte levels during tions resulting from various levels "Every trauma expert must be an operative and postoperative care. of alcohol consumption. Woolf, interventionist," stated Max Schneid- Complete blood counts (with plate- who addressed the ARUS meeting er, M.D., past president of the let determinations) and coagulation on alcohol's possible effects on American Medical Society on Alco-

Vol.. 13, No. 2, 1989 7 171 DEPARTMENTS

holism and Other Drug Dependen- ted to the inpatient unit, Schneider out all departments of the hospital, cies. Schneider, who presented a said. The interventionist should alerted to patients with possible paper entitled "Intervention and furnish disliarged patients with diagnoses of alcohol dependence. Followup of the Alcoholic Itmuma specific diaoostic information, suchThe A-Team, which includes recov- Patient," lamented, ". .. because as the written comment, "Your BAC ering alcoholics, actually conducts it is really a stigmatic disease. . . was [.15], indicating the likely pres- the interventions. Nevertheless, we get the feeling [diagnosis of ence of a treatable disease." Discus- Schneider concluded, "It is the alcohol dependence] is more an sion of the diagnosis may be held physician in the trauma center, the accusation. . .. we become with the patient's family, and an physician in the emergency depart- enablers." appointment may be made for the ment, who must take the leadership Reporting on the medical student patient's retun.. On the return visit, and, historically, we have been re- education program at the Univer- the patient is counseled to the point luctant to do so." sity of California-Irvire, Schneider of referral to an alcoholism treat- added that 30 percent of the junior ment program. UPDATING KNOWLEDC.E AND ATTITUDES and senior media students are Intervention patterned after the The relationship between physician adult children of alcoholics. (This Johnson Institute model (Johnson attitudes and patient care was a figure conforms with an earlier 1986) also may be performed inan recurrent theme throughout the estimate by Waller that one-fifth to acute care setting. The Johnson ARUS workshop. In his opening one-third of all U.S. physicians model convenes family members presentation on diagnosis of alco- come from alcoholic families.) In and others significant to the alcoholism, Waller claimed that diagno- either their junior or senior yeas, holic and results in a specific plan ses are often overlooked or even the California medical students for alcoholism treatment. Schneider actively avoided because physicians work closely with the addiction cautioned that even in the busy envi- feel a ".. .sense of frustration education program, after which 3 ronment of a trauma center or emer- and futility about the disease. They percent enter treatment and 12 per- gency department, the intervention do not know what resources are cent request assistance for interven- must be conducted privately. available . . and they errone- tions with family members. Efforts For patients with whom earlier ously believe that little can be done of this sort, claimed Schneider, may intervention and prior alcoholism for me alcoholic. . . ." Waller help overcome reluctance to screen treatment have failed, reinterven- attributed some of the deficits in and refer aicohoiic patients to non is necessary, Schneider said. physician knowledge and attitudes treatment. "This is a chronic disease with to alcohol-related problems in the Schneider reviewed four types of exacerbations and remissions," he physicians' own families. interventi,,,i, including "self- noted. "The seeds arc.. sown [by Discussant Magruder-Habib intervention," which occurs only intervention] and may take weeks suggested that many physicians rarely when an injured patient sud- or months or years to grow." remain unconvinced that alcohol- denly realizes that a mood-altering Schneider emphasized that all ism is a disease at all, A position drug such as alcohol has contrib- personnel in emergency depart- that removes their responsibility to uted to the traumatic event. Al- ments and trauma centers should betreat it: "The patient does not want though initiated by the patient, knowledgeable about the processes to admit that he or she is alcoholic. self-intervention requires the medi- for intervention. Physicians, c,,un- It is a wonderful collusion. Nobody cal team to stand ready to direct theselors, nurses, clergy members, and needs to address the problem and alcoholic to appropriate therapy. social workers ". .. should be everybody comes out okayexcept, The three other forms of interven- aware that there is something that of course, in the long run." tion may be initiated productively by not only can he done, but must be Referring to recent studies of acute care physicians. One-on-one done," he said. Citing a program at physician attitudes (see, for exam- intervention by a physician, nurse, Brown University, Schneiderrecom- ple, Soderstrom 1987; Lowenfels et or counselor may be performed in mer ti-u a team approach. Brown's al. 1989), Fielding speculated that the emergency room with both am- "A Timm" consists of nurses and self declared attitudes may vary bulatory clients and persons ..:drnit- unselors who circulate thiough- substantially front actual behavior.

172 ALCOHOL HEALTH & RESEARCH WORLD "In many senses," Fielding said, to reimburse fcr medical care. Con- REFERENCES "the physician is in the same cate- siderations of this sort confound the gory as the patient, a victim of American Psychiatric Association Diagnos- decisionmaking of even the best ticand Statistical Manual of Mental Disor- something. . . wedo not intentioned emergency physicians. ders, Third Edition, Revised.Washington, understand." "What are the real solutions?" DC: the Association, 1987. Magruder-Habib called attention asked Fielding. "We have to iden- Committee on Trauma ResearchInjury in to a study in progress that examines tify where the fixed points are America: A Continuing Public Health the behavior of physicians who are . . . go to the hospital governing Problem.Washington, DC: National Acad- supplied with screening results in- bodies, the medical executive com- em; Press, 1985. dicative of likely alcoholism .1 their mittees. and ask them to draw up CYR,N ND WARTMAN, S.The effectiveness patients.' This blind study is ex- departmental guidelines, remember- of routine .,creening questions in the detec- pected to examine physician atti- tion of alcoholism.Journal of the American ing that physicians may be criti- Medical Association259:51-54, 1988. tudes and behaviors in a manner cized if they do not Identify EWING,J Detecting alcoholu,m: The CAGE that removes the possible bias of . . patients at risk. . Having iden- questionnaire.Journal of the American physician self-reports. tified patients with significant Medical Association252 1905-1907, 1984 blood alcohol levels. . .they FULLER,R.;LEE.K ,AND GORDISE. Validity need to allow the lay counseling of self-report in alcoholism rest.arch: Re.ults Even when physicians services, the paramedics, nave of a Veterans Administration cooperative the blood alcohol results on a daily study.Alcoholism: Clinical and Experimen- are kn9wledgeable basis so they can get involved with tal Research12:201-205, 1988. the physicians and take that infor- JOHNSON, V. Intervention How To Help about alcoholism and Someone Who Doesn't Waal Help.Minne- mation to the bedside. . . .I think apolis. The Johnson Institute, 1986 its treatment... we ought to be requesting that this KNUPF, R.G. Risks of drunkenness: A com- . . .topic come into the quality competing priorities parison cif frequent intoxication indices and assessment of all institutions. Then of population subgroups as to problem risks. force them to make we can get on with education for British Journal of Addiction79.185-196, patients, physicians, legislators, and 1984 difficult choices. the media." Other practical solu- LoWENEEI S.A ,SODERSTROM. C.; AND ZUSKA,J tions offered by ARUS symposium Alcohol and injury Surgical knowledge and participants included efforts to atm ides Alenhnl bionIth A peconrch Even when physicians are knowl- 13.91-92, 1989. edgeable about alcoholism and its inform the insurance industry of Rocki_r-r, I, AND PUTNAM,S Alcohol and treatment and have positive attitudes the clinical significance of alcohol testing and improved networking unintentional injury B.fyond the motor toward alcoholic patients, compet- vehicleRhode Isli nd Medical Journal ing priorities force them to make between acute care personnel and 69 419-424, 1986 community alcohol treatment difficult choices. According to one ROIZENJ. "Alcohol and Trauma." Paper resources. symposium participant, when a presented to the International Symposium diagnosis of alL3holism is incorrect, In addition to expanding and on Alcohol-Reicued Casualties, Toronto, malpractice litigation present. a refining basic, biomedical, and Canada, 1985 epidemiological investigations, formidable threat. When a BAC test SODErS, ROM, C , AND COWI EY,R A natior 1 reveals substantial alcohol involve- -,ymposium participants recom- alcohol ?nu trauma center survey, Missed mended continued Analysis of phy- opportunities, failures of rcspoosibility. ment, medical treatment may be Archives of Surgery122(9) 1067-1071, 1987 complicated by legal procedures. sician attitude , with particular attention to the specialties of sur- WAI I ER.J Injui y as di,ease.Accident And when injuries are reported as Analysis and Prevention19 !3 -20, 1987. alcohol related, insurers may refuse gery and internal medicine. Urging further research on physician atti- WATSON.C , TilI ESKJOR. C , HOODECHECI\ tudes, Waller asserted, "The payoff ScHOW,E.,PUCE! .J ;AND JAC OBS.L Do ' Kathryn Magruder-Habib, Ph.D may be will be not just better treatment for alcoholics give valid self reports?Journal of contacted concerning the study in progress at Studies on Alcohol 45.344-348,1984 our patients, but better living of the Veterans Administration Medical Center, World Health OrganizationInternational Psychiatry Service, 508 Fulton Street, Suite our own lives." Classification of Diseases, 9th Revision. Vol 116 -A Durham, North Caro'ina 27705 ANN M. BRADLEY IGeneva, Switzerland WHO, 1977

VoL. 13, Na 2, 1959 G, ti 173 DEPARTMENTS. International Perspectives

Alcohol-Related Trauma in documents the physical condition and analysis focused on the follow- Mexico of patients who may eventually ing objectives (Rosovsky 1988): become involved in criminal prose- The presumed relationship between cution_ or accident investigations. alcohol and tri..ima is an important to describe existing means of The physicians conduct clinical public health topic in Latin Amer- documenting the role that alcohol examinations of these subjects, consumption plays in accidents ica because trauma is a major cause similar to examinations performed of male mortality among several and crimes brought to the atten- at police stations. The examinations countries of the region. In Mexico, tion of medical and law enforce- include determining alcohol in- ment authorities for example, "accidents, poison- volvement in the patient's injuryor to develop and test a methodol- ings, and injuries" are the most illness. The office of the State At- frequent causes of mortality among ogy to improve evaluation of the lirney thus records probable alco- men aged 15 to 44 years (Rosovsky importance of alcohol consump- hol involvement in manyemergency tion in these cases and Garc'a 1988). Until recently, room casesbut the documenta- however, data documenting the to collect and analyze eata on tion is limited by the lack of labora- relationship between alcohol and sociodemog:aphic characteristics, tory tests that provide objective drinking patterns, and previous trauma in Latin America I. been measurement of blood alcohol con- alcohol-related problems of the scarce (Medina-Mora anc nzales centration (BAC) (Rosovsky 1988). 1988). population involved in these cases. In 1985, a research team from the During the last five years, Mexi- Mexican Institute of Psychiatry can researchers have made rapid The last of these three objectives attempted to use the records of four progress in collecting these data. was the topic of a study performed emergency hospitals to document Led by staff members of the De- at the Xoco Emergency Hospital by the scope of alcohol-related trauma partment of Epidemiologic and staff members of the Mexican Insti- experiences: in Mexico City (Mas Social Research of the Mexican tute of Psychiatry in late 1985 (Ro- Condes et al. 1986). The datasug- Institute of Psychiatry, research on sovsky and Lopez 1986). For a full gested that approximately 12 alcohol and trauma in Mexico has per- month, they interviewed every pa- cent of all cases admitted to those advanced from field tests of data tient who came to the attention of hospitals in 1983 and 1984 resulted collection techniques to interna- the onsite office of the State Attor- from arcidentc occurring under the tional collaboration that compares ncy bccausc of prc_lbabic alcol ol influence of alcohol. The case alcohol involvement in trauma in re- involvement in the presenting in- cords also indicated that approxi- Mexico City to findings obtained jury. The interviews yielded a mately 5,000 victims of intentional from California emergency rooms. wealth of information on pattern!, violence annually were admittedto of co ration, history of alcoh31- the four hospitals under the influ- USE OF STATE. ATDORNLV RECORDS ON related problems, and specific, ence of alcohol. These vicnis ALCOHOL. AND TRAUMA drinking events prior to injury, as effectively increased thea. uhol- reported by the patients. The re- According to Haydee Rosovsky of related case load of the emergency scarchers noted that most individ- the Mexican Institute of Psychiatry hospitals tc, more 'Ian one-sixth of uals in the sample were young men (1988), the earliest source of Mexi- all admissions during 1984. admitted as a result of injuries cali data on alcohol involvement in sustained in fighting and that the IMPROVING DATA COLETCDON ON trauma is the records of the State typical pattern of alcohol ccnsump- AI c °Hui-RELATED TRAI [MA Attorney in the Federal District of tion reported among those inter- Mexicoa jurisdiction similar to The epidemiologists of the Mexican viewed following fights was the District of Columbia in the Institute of Psychiatry recognized occasional binge drinkinc:, rather United States. The State Attorn y the limitations of relying on data than more frequent consumption. maintains field offices in emerg .ncy from the office of the State Attor- Rosovsky and Lopez (1986) ex- hospitals (hospitales deurgerv-ic5) ney to investigate the re' Aionship pressed concern that dependence on of the Federal District's Medic il of alcohol and trauma. Their initial physician observation to determine Services, where a resident doctor efforts to improve data collection alcohol involvement was not suffic-

174 ALC01101 HFAITH& RIENtARCH WORLD lent to identify all trauma victims month. A significant component offindings on the characteristics of whose injuries followed alcohol these data collection efforts was the trauma victims in the two coun- consumption. In their study, they adoption of a model for emergency tries. Some of these differences reported that under present condi- room data collection instituted by were gender specific: tions, a considerable nroportion or Cheryl J. Stephens Cherpitel, the admissions to an emergency Dr.P.H., of the NIAAA-sponsored In tile Mexican hospitals, the hospital and to a police station was Alcohol Research Group at Berke- ratio of all injured male patients not examined by the physician to ley, California (Rosovsky and Gar- to injured female patients report- assess the presence of alcohol: Onlycia 1988). The original Er.glish ing alcohol consumption within 6 61 percent of all patients at the language interview guide developed hours prior to the injury was emergency room and 39 percent at by Cherpitel was translated into nearly 5:1. In contrast, among the police station were examined, Spanish for use in Mexico, and the the Contra Costa sample, the and the report of alcohol consump- model's study design and analytic ratio of injured males to females tion in those cases was 7 percent at definitions have been incorporated reporting alcohol consumption the hospital and 15 percent at the in the protocols of the Mexican within 6 hours prior to the injury police station. Simultaneously, the Institute of Psychiatry's research was less than 2: I (p. 29). researchers interviewed all persons (Cherpitel and Rosovsky 1988). While female emergency room and the proportion that reported patients in California were more alcohol consumption prior to the COLLABORATION LEADING TO CROSS- than twice as likely as their Mexi- event was much higher: 18.5 per- NA1 IONAL COMPA AISON can counterparts to test positive cent at me hospital and 39 percent Adoption of the standardized Cher- on the breathalyzer (p. 28), among a the police station. pilel model and its associated data male emergency rt.am patients, In 1986, the Mexican Institute of collection techniques by researchers the injured in Mexico were more Psychiatry took a major step for- in several countries, including Mex- than twice as likely as those in- ward in data collection efforts on ico, will permit cross-national com- jured in California to test positive. alcohol and trauma by selecting parison of alcohol consumption patients for study independent of variables among emergency room Other cross-national differences the official process of case identifi- populations, using parallel methods were identified in patient self- ratinnbyrenrpcentativpcofthe and data rnlit:rtinn inctrtimprtc. reports "fthanorrrl'.! fretvency of justice system. At eight hospital Some of the first fruits of this col- alcohol consumption among emergency rooms in Mexico City, laboration were presented by Cher- trauma victimssignificantly larger investigators from the Institute pitel, of the Alcohol Research proportions of abstainers and infre- selected subjects for breath sam- Group at Berkeley, and Rosovsky, quent drinkers were found among pling and interviews at random of the Mexican Institute of Psychia-the Mexican sample than among fromalong all patients 15 years of try, at the annual meeting of the the Contra Costa sample (Cherpitel age and older admitted during a American Public Health Associa- and Rosovsky 1988, p. 12). single week. Breath samples were tion (1988). The presentation fea- The collaboration between the taken immediately after admission tured findings from parallel data Alcohol Research Group ,.t Berkeley, to obtain BAC measurement as collection efforts at emergency the Mexican Institute of Psychiatry, close in time as possible to the oc- rooms in Mexico City and Contra and investigators in other countries, currence of the presenting trauma. Costa County, California. The often aided by NIAAA, will contrib- In October 1987, similar data collaborative effort was funded in ute to further refinement of investi- lection was performed on all pa- part by NIAAA's International gative techniques. These techniques, tients 15 years of age and older and Intergovernmental Affairs in turn, yield increasingly accurate admitted to three hospital emer- Program. data on the extent of alcohol- related gency wards in the port city of Aca- Cherpitel and Rosovsky (1988) public health problems throughout pulco over the course of the entire reported significant comparative the world.

Vot 13, Na 2, 1989 175 DEPARTMENTS Special Populations

Correspondence on alcohol epi- NIAAA Support for Studies sis of the effects of acculturation demiology activities of the Mexican on !'ispanic-Arnericans and assimilation on Hisp2-ic drink- Institute of Ps),,hi ttry may be ad- Americans of Hispanic origin con- ing behavior may have applicati.m dressed to Havdee Rosovsky, stitute the fastest growing ethnic to understanding changing alcohol M.P.H., Division de Investiga- group in the United States. Num- patterns of many immigrant ciones Epidemiologicas y Sociales. bering over 14 million in 1980, the groups. Additionally, Sar nez notes Instituto Mexic-oo de Psiquiatria, Hispanic population will surpass that the stressful transition from Antiguo Camio a Xochimilco No. the black American population village life tthe complexity of 1010, Huipulco, Mexico 22 D.F., during the 1990's, according to large cities, experienced by many Mexico. some cmates. adult Hispanics, also may affect MICHAEL J. STOIL, PH D. Despite the growing numerical alcohol use. REFERENCES importance of Hispanics, little is The role of alcoholism as a cop- CHERPITEL,C.J.STEPHENS, ANDROSOVSKY, H known about patterns of alcohol ing mechanism to reduce stress is "Alcohol inptirin and Casualties. A use, abuse, and depend Ice among an explicit focus of the. rk of Comparison of U.S. and Mexico Emergency the Spanish-speaking communities. Room Populations." Paper presented at the James Neff, Ph.D., and colleagues 16th annual meeting of Lne American Public There is consensus tl di: Hispanic- ie. the Department of Psychology Health Association, Boston, MA, Noveml,,.r Americans are undcrserverl by treat- of the University of Texas Health i3 -17, 1988. ment and prevention efforts, in part Science Center at San Antonio. The

SCONDES.C.;MANRIQUE,A.;AND due to culturally based barriers DBE-supported research employs RELA,C. Detcccion de problemas rela- within tne Hispanic commurity. prospective methodology to com- cionados con el consumo de alcohol en The absence of epidemiological pare drinking patterns and motiva- cuatro hospitales de urgencias del L Salud data on the extent and consequencestions for drinking among adult Mental 9(4):10-14, 1986. of rlhol-relate l problems among Mexican-Americans, blacks, and MEDINA-MORA.M.EAND GONZALES,L Hi.punic-Am-Nicans also contrib- non-Hispanic whites A major issue Alcohol-related casuIties in Latin America. A review of the literature. ln Giesbrecht, utes to difriculties in providing r the study is the diff-rcntiation of N.; Gozales, R.; Grant, M.; Osterberg, E., appropriate services. the effects of socioeconomic status Room, R.; Rootman, 1.; and Towle, L., eds. ong its other functions, and subculture on the use of alco- Drinking and Casualties: Accidents, Poison- NIAAA's Division of Biometry and hol to relieve psychological and ing and Violence in an International Per- Epidemiology (DBE) dbects the emotional stress. In effect, the spectirLondon: Routledge, 1)88. pp. 68-83. extramural research projam in study seeks to respond to such alcohol epidemiology for the Insti- questions as whether specific drink- ROSOVSKY. H. Alr.ohol-related ca:malties and crime in Mexico: Description of reporting tute. "Extramural" research con- ing patterns, including weekend systems and results for a study In. sists of studies performed by "bilges," are influenced more by Giesbrecht, N ; Gozales, R.; Grant, M ; investigators from universities and ethnic varill-les or b!, the shared Osterberg, E.; Room, R.; Rootman, 1, and other research institutions outside value :t coworkers. Towle, L., eds. Drinking and Casualties of the Federal Clovernment. DBE- Interpretation of the findings of Accidents, Poisoning and Violence in an international Perspxtive. London awarded grants on drinking the Neff study may benefit from a P.outledge, 1988. pp 260-274 patterns in Hispanic-American second DBE-supported analysis on

ROSOVSKY. H ,AND GARCIA,G "Alcohol communities respond to the impera- patterns of alcohol use among Related Casualties iiMexico: i Comparison tive to increase knowledge of M ,icon- Americans, conducted by Between No Populations " Unpublished alcohol-related public health issues. M. Audrey Burnam of the Rand paper p: -anted to the Alcohol Epidenuol- DBE is sponsoring four investiga- Corporation in Santa Monica, Cali- ogy Symposium, Berkelei,,, California, June tions of Hispanic,!,:ohol use, 5-11, 1988 fornia. Burnam is using an existing which comprise 10 1,-ent of the data base (Hispanic Health and ROSOVSKY, H.,ANDLOPEZ, J L Violencia 3, Division's active grants. accidentes relacionados con el consumo de Nutrition Examination Survey) that alcohol er la poblacion registrada enUr, Explaining the importance of thisinciudes alcohol consumption agencia investigadora del Ministerio Publico research, DBE program officer pawl ,s of Hispanic-Americans del D.F. Salud Mental 9:72-76, 1986 David Sanchez sugge:ts that analy- (Christian et al. in press). An addi-

176 ALCOHOL HEALTH & RESEARCH WORLD pected increases in budges alloca- tions for DBE extramural research, may accelerate the pace of new rid ;findings in Clis area of alcohol epidemiology. One potential topic for new research is the identification of patterns within the Hispanic communities, including differences in alcohol-related behavic,: among Central American, South Ameri- can, Mexican, and Cuban immi- grants, and descendants of the long-established Hispanic communities of the southwestern United States. Bec use the home- lands of these distinct Hispanic communities are ....,.ociated with characteristic national patterns of alcohol use, documentation of p is differences in current use patterns imay provide important information

'. on the process through which < 7Americans in general become so- cialized to consumption of alco- tional source of comparison may beings will enable analysts to test a holic beverages. an earlier NI AAA-supported study theoretical model t. at relates Information on future opportun,1 of drinking patterns among changes in the drinking patterns of ties for DBE giant-supported inves- Mexican-Americans conducted by Puerto Ricans )n the U.S. main- tigations of Hispanic-American the Alcohol Research Center at land to gene:al celtural effects of alcohol epidemiology, including the Berkeley, California (see Caetano migration and acculturation. required application packages, may 1986-1987). A more intensive methodology be obtained by contac.mg David Variable definitions used in the employing a community sampling Sanchez at the National Institute Berkeley study have been adopted procedure to select Puerto Rican on Alcohol Abuse and Alcoholism, by Gerald Gurin, Ph.D., and col- men for structured interviews char- Room 14C -26, 5600Fishers Lane, leagues at the His; anic Research acterizes the work of Merrill Singer, Rockville, Maryland20857. Center of Fordham Universit:, in a Ph.D., and colleagues in DBE- MICHAEL J. STOIL, PH D. survey of drinking behavior, non :s,sponsored research at the University REFERENCES and problems among Puerto Rican of Connecticut at Hartford. In adults in the New York metropoli- addition to basic epidemiological CAET,,NO, R. Drinking and Hispanic- tan area. 'I as DBE-supported inform-in, the Singer study will American family life.Alcohol Health & Research Worldil(2):26-34, 1986-1987. study, performed with the help of attempt to identify he "n^tural Tempi! University's Institute of history" of drinking among ?uerto CHRISTIAN. C.; ZOBECK, T.; MALIN H.; ANC MITCHCOCK, D. Hispanic HANES: General Survel, Research, is desigred to Rican men, including family drink- description, methodological issues, and produce basic epidemiological data ing histories, beverage preferences, preliminary finrlings. In. ,..piegler, D.; 'Pa on Puc.,,. Ricans comparable to and changes in quantity and fre- D.; Aitken, S.; E nd Christian, C., eds. that generated by previous surveys quency of consumption over time. A..oh9l Use Among U.S. Ethnic Minorities. of Mexican-Americans, blacks, and Sanchez ;relieves that the recent NIAAA Research Monograph No. 18. DHHS Pub. No. (ADM)87-1435. Washing- non-Hispanic whites. In aduition, increase in interest in Hispanic ton, DC. Supt of Docs., U.S. Govt. PnnL. Gurin proposes that the study find- alcohol patterns, coupled with ex- Off , in press.

1 - 13, Na 2, 1989 177 , Highlights from the 1987 NationalDrug and AlcoholismTreatment Unit Survey(NDATUS)

JOAN R. HARRIS, PH.D. JAMES D. COLLIVER, D

I his at lc is hosed e ',Ithe tint;elltIlle,1 Abuse and Alcoholism (NIAAA) and fowling amounts and sources, llit;h1Nlas,P cati theI 9S7 Naticaial I); us; chid NDATUS is a Yolultary sure that is The data are collected in Al( °holism t secamemi ('nit St's s CI (NI) All 11 designed to oe a census of all known cooperation with the State Alcohol ; e; earl\ published In tie %ninon,' Ins01551, drug abu-e ant'' alcoholism treatment and Drug Abuse Agencies, which I ohol Abuse (mil 41e ccholism andthe facilities in the Iaits:d StatesMIN National Inmtute on 1.), at, 4InteA detailed assist in identrfying programs to he spin! shuns IS is hedidt article is based on preliminary data on surveyed, di triblitine forms to pit late, this sear and es /// /7! al ,III,1111, alcoholin treatment derived from the individual lacilitics, collecting forms porn the Notroval ( lea, L;,'',11,(tot11("11,4 1987 NDATUS The full 1957 re- and answering responder qiestiory, (mil 1)1 ht; IMoi mutual P 1) Hoc 145 port, which will include data from checking and echimg chit, ' sub Roe ks die S/!) 2/652 Pri sons ts !shalt, 1,, use both drag abuse and alcoholism the slates rata rape should «Ita 1 's nutting completed question I. reacus 1,Slins,mallilt,11 0/1,,i l 1)1,1011,0100 facilities, is scheduled to he pobli-heci In a departure from pro, roe 1)ah, S won ( SRIn ot pot we,/ Hoo I , later this yearData on clients in keys which required that tail , he St',et \41Suite WO aquto4t,,r1 2tinto treatment pertain to the point- identified by a unique Gokernmcm- pro. diem e date of Octok,r 30, 1957 issued identification number, the Bs( MAW( 'AD INFORM ihrs The purpose 01 NL. NT'clS is to 1(1'87 NDATUS S accepted the States' identify all drug attrit,e and Icoholtsm nr.sntificarton numbers andlucre The National Drug and Alcohchsm air:lent and prevention tacilities (101111110t1 of what constitutes, Treatment Unit Survey (NDATUS) throughout the nation, and to collect lot reporting piaposesIn was first ccinduohd in 1974 by the information regarding their scope, -,'tore cases multiple -site facilities National Institute on Drug Abuse unhiation, and other chant( teristics were repotted as a single unit INIDA) and has been conducted Facilities in both the public and (representing the parent orga- every 2 to 3 years since thenIn private sectors are included, miation), in other cases each ',lie was 1979, NDATUS was etypai Ito gardless of the source of tundinc reported as a separate facility include alcohol', tu as well as drug supportUnit identification and Although this,,ination may affect the abuse facilitie'since that time it ha descriptive information such as number of facilities, it has no effect been sponsored jointly by NIDA and okkr,Jship and speciali/ed programs on the total number nts re- the National Institute on Alcohol are collected from treatincnt and ported nontreatment facilitiesFrom following, a brief s ,'ction on the to- JOAN R IIARRLS, Pll I) and I S treatment urits, NDATUS also tal number of facilan s reporting, 1) COLIll LI?, PH 1) .Soiwi collects data :)',out the types of including both treatment and pre- Analysts wall the Alt Out( services provnies1, client capacity and vention units, the remainder of the Epulennoiagu Data System, census on the point-prevalence date, rcport is restricted to dta facilities CSR, m orpc, Wed client demographic characteristics, providing treatment servicc ropes

. ALCOHOL HI. ALTH & RESEARCH WORLD 0,I addre,sed lit& number, of client, in treatment, hudgetAl caraLitand Table 1 Total number of alcohol faculties repr,rting to NDATUS by facility utili/atiott rate,. number, of client, h function and facility orientation: October 30, 1987 facilitL location or en, [Hutment and ;Bally Alcohol- Combined All facilities type of treatment, client demographic function only alcohol facilities and drug characten,nc,, factlit coumInd facilities client cen,u,b. facilit location, Treatment 1,708 financial ,upport for treatment wr- 4,083 5,791 vice, 11 funding ,ource, facility Prevention/education 1,132 3,476 4 608 Other 946 2,492 oLLner,hip, intraLenou, drug uwr,In 3,43P treatn,..nt, number of client, in the 12 Number of facilities 2,132 5,360 7,492 month. ending %Lull the pout -preL a- NOTE As f:cemes may (Loon more than one function, columns do not sum to the total number of facilites SOURCE NIDA and NIAM, 1987 National Drug and Alcoholism Treatment Una Survey lence date, and number, of factinic, vor-aim and client cen,u, hL State\lore comprehen,ive info:7,1,100n including Table 2 Total numbers of allohol clients in treatment and number of drug client data LL ill tie pro, [(led in facilities according to facility orientation: October 30,1987 the 1987 main finding, report to he Alcohol- Combined All pubh,hed later tin,ear only alcohol facilities In moat caw, tabulation, of treat- facilities and drug acilities ment data are bawd on f ac dole, that ,bents 136,917 L13,696 reported either budgeted chic it ca- 350,613 pacu or actual Client, on the point- Number of treatment facilities 1,708 4,083 5,791 preL alence dateHoLLeLer table, SOURCZ NIDA and NI.AAA. 1987 National Drug and Alcoholism Treatment Uni, Survey ,,hoLL itLI unit/anon rate, are ba,ed data front facture, that reported budgeted capaL , thew table,\elude a the NDATL S ,u1Lc, the iolloLL mg client, on the point- few IaLditie, that reported actual definition, hold for I at_ ilit function, Acme date of October 31), 1987 (Them, but no hudg.Lttco capac I reatmentt unc non, refer to for- hit II D k) \ It al,o ,hould he ' hat data fot mal tortunied ,er, ice, for per min, t 1/ L InesK \II (dual item, arc netinle, 1)11\1 \\ ho ha, e ahri,ed alcoholthew mgIn the table, in , p itt the 1:1-% ice, ate dc,Igned to alter LompaI,011 of alcohol 11,2,11111(2M total number, of chi 1t, *tic phL mental it,octal fa- 111he, client,rn treatment, bud etc,L hccau trf e \ I don of function, of person, reccIL mg Ire gcted captic ILL , 1.1(.1utilliation rate h oftwiL anon, for LL Inch art, Lien) \On anon ,e;-\ ee con,,n1- facilit, orkutation on the point- item, V), etc Ilt(I R110110,1 c red to h. treatment pre, alcrice date of (ktohet 10, 1987,

I able 1 ,hoLL nurnheiof Pic Lentiomeducatior funct,oh, 1, ,ItoL it inI able Budgeted ,er\nte akohol client, on chide ac more, intended to ictluLc apacttL rebus, to the number of heti, the pomt-preLalence date of October ofit runnie the Inc Ides. e' of ncLL allocated foi ic,idconal alcohol ti:tit I 9I,7 [hie ,onkt Lic dine, L alcohoh,111 pt Thlern, and Mc merit I the [writhe' of nonic,identral onIL alcohol tuner, I HO) necanLe con,«rucnce, of olio' aLcof al, ohol client, L,ho could he ,erLed alcohol and drug cllcnt.to fable I alcohol \\ i111 ,111,1hiC 1)}1\ and ,tall I:- ItmaL be ,Len that a 1,11l1:1umber of I HI \ I \II \ I l' 1111, \ \ I) VI II \ ,ource,I he mill/mum rare refer, to ( C, 4)01 wrLe both type, of Mc proportion of hud,:.etet1 Lai/AIM I RI 11 %II \ 1 client, it, than re,trictim2 ,crL rc ma it tls,C onthe po;ni -pie\a to alcohol', client, yid% (2 112) \ in fable 2 alcoholi,rn tenordate1 \an nation of the tahlc Numeru , more at dine, are treatment Oct' III.1 I()1,11ti hoLL, that alcoholi,m Lrc dine, de\oted to treatmen, a, a fat du% ti791 LIL11111c, I 71)8 I.i11- had the ImIlict,t mill/anon rate1.13 4, function th it pl()1(11:(10111% al(A)1,()I 'or the number of c licit, LL ithin the A, ,tated in the footnote to ilk v,'I% 1Le, and 4,081 that lurti2etAl calla( it, ofI ,(4,-1, fak_ihtle, table, ft nice, ma report mole than pro, [(fed ,elL (cc, to both ding and (hi the other nand, Ill lt)11111111C(1 alco- one f unctron 1n regard to tret,'ment, alcohol client,I he,c fac dine, %Lew hol and drug taciline,, the minm.iof preLennon/.'.(lucatio,and otIrer 1,01 ,crL mg a total of 1S0,61 dt ohol ,I10)111)1 (_11C111, t: to budgeted

VOL 13, No. 2, 1989 Cj 179 Highlights of NDATUS capacity revealed a utiliration rate of 79.8, a difference of 3 6 points Table 3Nuciber of alcohol treatment facilities, number of clients in treatmont, budgeted capacity, and utilization rate by facility TREA DE110(.12 orientation: October 30,1987 CHAR 4it '7 I RISTR Number Number Budgeted Utilization Facility orientation of facilities.' of clients.' capacity rate 1 Taole 4 presents data on the demo- Alcoholism-only facilities 1,664 131,241 157,281 83.4 grarnic character', tics of alcohol Combined facilities 3,963 206,687 759,056 79.8 clientsData for clients whose sex. Total alcoholism clients race/ethnicity, or age we.: unknown 5,627 337,928 416,337 81.2 are exuded, resulting in a differing I Excludes data from facades which did nr 1 report bucketed capacity for alcohol clients SOURCE: NIA and NIAAA, 1987 National 114 and Alcoholism Treatment Unit Survey total number of clients for these c hal- mismaiP acteristics abrioarreammana Table 4 Percent distribution of alcc.01 treatment clients by aux, race/ethnicity The age distribution of alcohol and age: October 30, 1987 cheats is concentrated in the cate- Sex , race! Alcohol gories of ages 25-44 years (55.0 per- ethnicity and ape clients cent) When the ag: percentages are Male 76.3 cumulated horn younger to older, romale 23.7 57 5 percent of those in treatment on Number of clients 1 336,877 October 30. 1987. were under 35 White 71.5 years of age and 81 5 percent were Black 15.4 Hispanic under 45 years of age 9.9 Other race/ethnlcity 3.2 It may be seen. however, in Table 4 Number of cliental 3:19,992 that almost one -fourth of all alcohol Under 18 years 6.4 treatment clients on October 30, 18-20 years 6.4 1987, were female (23.7 percent) By 21-24 years 13.7 25-34 years race/ethnicity, black were somewhat 31.0 35-44 years 24.0 oventpresented in terms of their 45-54 years 11.7 composition in the general population 55-64 years 5.2 65 years and over with 15 4 percent of total alcohol 1.7 Number of cliental 327,698 treatment clientsWhile all m:nonty NC 1E: Perzrmtecais In distributions may not sum to 100 because of coo ind,n8 populations represent :d 28 5 perLcnt 1 Excludesclients for whom sex, raosiethnicity, or age was not reported of such clients. overall, almost two SOURCE: NOA and N1AAA, 1987 National Diu% .uvi Alcoholism Treatment Unit Survey thirds (71 5 percent) were white, a slightly smaller percentage than in the Table 5 Number of alcohol clients in treatment by type of care and facility genera! population location: October 30, 1987 Facility location TN Pi' of (' SRI Type of care Hospital Non' aspital Total ______v N. 'I: is( if 1110\ Inpatient/residential Medkdetoxification 4,955 s37 6,492 The "type ofare-salable relates to Social detoxification 409 3,606 4,015 RehabilratIon/recovery moatientiresidentialare with subLat- 13,906 23,833 57,739 Custodial/domiciliary 488 2,200 2.688 egones and outpanent/noniesidconal Total inpatient/residential 19,758 31.176 50,934 ire Similarlyfacility 'man( n" ie- Outpatient/nonreAlduntial 19,115 280,564 299,679 ates to ho,onal and nonhospital Lace Total inpatients and outpatients 38,873 311,740 350,613 As might he anticipated. Table fi shows that clicnts in hospitals were SOURCE NIDA and NIAAA, 1987 National Drug and Alcoholitm Treatment Unit Survey evenly split between inpatient and outpatient csr.: (5(1 8 nerc.eiand 49 2 settings as opposed to 9() 0 percent in a"--iost or slightly more than three- percent, respectively )On the other outpatient /nonresidential settings tou -ths of all st c !lents w etc in re- ham!. :.-.1Lohol clients in not hospital These same ivsults arc consonant bahlitation or iecoery programs care settings show a distribution of with a ieview of sonic of the inpa- ( e \elude detoxification), theie 10 0 pen cnt in inpatient/residential tient/residential subcategories While are cid terences in types of detoxifies's-

1110 tii,corun tit AITH & RESEARCH WORLD .... elimination of the effects of alcohol in Tab 10 Number of alcohol treatment fealties and number of clients by facility the body on a dreg-free base' : Coto Ur 30,1967 F'Aii titLo( 4.110. Foolletia, Clients health um* 842 30,946 It may be seen from Table 6 that out- , 4 ,-- , . patient fa represented 34 6 1,163 55,5(70 percent of all alcohol treatment 60 2,945 41liteihilattly facilities, but served 49 6 percent of lioiesaittleMery house 698 12,838 alcohol clients on October 30. 1987. faQYfyr 701 21,705 FINANCIAL. SI PPOR I FOR 2,004 173,912 :-' 1,-.V:-..' _---'. TRFA I %M", i SF It% 319 22,973 Alcohol treatment facilities reported 1 24 $1 71 billion in total financial support , 5,791 350,613 for alcohol services for their fiscal °R V4 filoaholos loop* monlIMpordialSo hospitals, aftdOSIOrs000takcad t `..,-..... years including October 1987 (Table 1##Vil* thilialt", 7)Private third-party payers, such as

,'`v Blue Cross/Blue Shield and HMOs, 4 ilervlasibyflundtng source ;..%vly ,,,.., provided the largest '.hare of financial aisalvIng wavy *OM Wilt Source: support for alcohol treatment services, accounting for 34.6 percent Percent Facilities reporting of such funds. When these sources are coupled with client tees, the two OVAlitsT(dietkilledkidee _ source~ account for 48.4 percent of _.1345 .023 202 2,588 Lori receipts for alcohol careState gov- 107,680 6.4 1,852 ernment funding so6R:es represent ADA*1/4- only 20 2 percent of all receipts for

10thipala 9A40 n... .a, 179 alcohol treatment

C4her Fair:if:Oda = 76,957 4.5 530 ()WNLRSHIP Tto x%U. 's I Stalskocol Gni AllhOrd fees ILIIIFS for iiiint,* 78,830 4.6 805 PrivatidoriailOnia 25,906 1.6 1,274 Of the 5.791 alcohol treatment facili- Put* #WNere (e.g.. The XX, ties that reported NDATUS. 65 5 Food Silk ; 27,778 1.6 887 percent were privately os,.ried, non- -atopTedaitZ(02., profit facrlit,es (Tahle H These CHAMPK- 145,746 8.5 1,368 facilities accounted for 57 6 percent aPrivads TN.'d Party (e.g., Fetus of alcohol clients in treatment on the Crotwalialfe *Md. HMO 592,447 34.6 2,209 point-prevalence dateFacilities (*int fees 236,531 13.8 3,727 owned by State and Local govern- Odw 64,752 3.8 927 ments accounted for higher proportion~ of alcohol clients than their rep- TOTAL 1,712,069 100.0 4,949 resentation in sheer numbers. which NOTE: Amounts* funding some coupons' may not *um total bow, of rounding. The martyr of families reporting dose not opal to total of Wiliam mooning mono funding mows Weans of fo Mau recOving suggests that these facilities had funding from roullpla tomes Luger numbers of such clients. on SOURCE. NUM and MAAA.12117 Motional Onig and Akoholion Traatmont Unit Survey. average. than those in other owner- ship categories Wm as appropriate for the facility lo- Only 4 9 percent of clients in non- CI RN I S WHO WI RI cation. One-fourth of clients in hos- hospit d settings were recek mg such IN I R 1%NOI URI pital/mpanc settings were receiving careAt the same time 116 percent medical detoxification. which rs the iris opposed to 2 I percent) of clients CommensLrate with present concern, use of medic:amr under the super,' nonhospital locationreceivedso- regarding :ire spread of AMS, treat- sion of medical personnel in a hospi- cial detoxification sery ices. wVa, h in- ment lacilities were asked t )eport tal or other 24-hour-care facCity volve the s:stein tic reduction Or the percentage of their cheats w'm

VOL. 13, Na 2. 1919 18 Highlights of NDATUS

were intravenous drug users OVERT, entered treatmentThis figure repre- particuLi point-prevalence date at the time they started treatment sent,, 4 I percent among alcohol Stai king v,ith the 1987 NDATUS, This item is relevant for. data reported client, (1-1,464 1VDUs in 350.613 however, questions regarding the in the alcohol section of the survey alcohol clients) unduplicated ,ounts of alcohol clients because of alcohol client, v'ith sec- treated in the 12-month period ending NINilif v ofCI IF S TRI' I I)IN Ila ondary drug problems October 30, 1987, have been added. P,st 12 111oNity, A iota! of 14,464 alcohol clients Data reported to NDATUS on this were reported to have been in- Histors, ally, NDATUS has collected new variable indicate that in the 12 travenous drug users at the time they client census information solely for a months ending October 30. 1987, a total of 1,430,034 alcoholism clients Table 8 Distribution of alcohol Vestment wines and clients by facility were treated at 5,582 facilities ovntemittp: October 30,1987 DAlvliNSI%If Ovnisrehip Facilities Clients State-level data on alcohol ti eatment Numbs,' Percent Number Percent facilities and clients ia treatment on Private torpolit 900 . 15.5 42,878 12.2 the point-prevalence date of October Private nonprofit 3,794 65.5 201,789 57.6 30, 1987, are shown in Table 9Cal- Stale/Local 90v..rnment 934 16.1 87,344 25.0 iforniaandNev, Yolk together ac- Federal government 183 2.8 18,402 5.2 counted for slightly more than one- fourth cifall clients in treatment at Total 8,791 100.0 350,613 100.0 the 5,791 reporting tacilthes. PotoantioNdianitulicavimay not sanin400110aNeset coundina. SOURCE: NIORaniiNkoM, 11187 WW1 Owe and Aloonallom Treatment Unit Savoy. 1111111111111MMINIMINEM., Table 9 Number of alcohol treatment facilities and number of clients In treatment by State: October 30,19J7 0: ;,. Fullness Clients State Facilities Clients Alabama 44 1,491 Nebraska 107 4,435 Alaska 30 1,293 Nevada 40 777 Arizona 75 3,814 New Hampshire 53 2,401 Manses 46 1,953 New Jersey 155 8,857 California 880 63,177 New Medco 47 4,015

Colorado 161 8,681 New York 398 36,126 C winecticut 109 3,4/1 North Carolina 98 6,331 Delaware 17 1,393 North Dakota 343 1,671 Dist. of Columbia 13 1,244 Ohio 2:1V. 12,813 Florida 197 11.783 Oklahoma 53 2,431 Georgia 52 5,932 Oregon 130 7,376 Hawaii 30 738 Pennsyl'enia 328 14,684 Idaho 28 1,332 Rhode I, ,o 41 2,760 Illinois 201 12,523 South Carolina 51 10,299 Indiana 98 5,380 South Dakota 29 1 469 Iowa 94 3,398 Tennessee 55 3,116 Kansas 74 2,596 Texas 228 5,414 Kentucky 130 5,106 Utah , 39 4,254 Lc idelana 77 5,146 Vermont 19 1,082 Maine 40 2,319 Virginia 80 7,501

Maryland 152 10,333 Washington 99 9,550 Massachusetts 166 12,1. -9 West Virginia 22 3,186 Michigan 208 12,031 Wisconsin 130 6,856 Minnesota 139 2,481 Wyoming 23 956 kilesiulppi 64 =1,935 Puerto Rico 24 3230 Missoud 94 3,976 Mr .aria 34 1,441 TOTAL 5,791 350,613

SOURCE. Nen and NIAAA, tar' Naional CNA, am Akioncasrn Treatment Unit Survey

182 ALCOHOL HEALTH & RESEARCH WORLD Nearly a decade ago, the National Institute on Alcohol Abuse and A New Agenda Alcoholism (NIAAA) asked the Iistitute of Medicine (IOM), an agency of the National for Alcohol Academy of Sciences, to review and assess the status of alcohol research. The resulting report, Alcoholism, Alcohol Abuse, and Related Prob- Research lems: Opportunities for Reseych, The Institute of Medicine Reports on provided the first comprehensive review of alcohol-related research Causes and ConsequencesA Summary for scientists, planners, policymakers, and other interested people. The pace of alcohol research has accelerated dramatically since the report was released in 1980. During that same year, as its first decath was drawing to a close, NIAAA supported a total of 167 research projects at a combined funding level of $22.2 million. By 1987, the number of NIAAA-supported research projects had increased to 387 and the total funding to $71.2 million. Because of the opportunities provided by advances in alcohol- related research since 1980, NIAAA again asked the Institute of Medicine to review new scientific knowledge,ssess current research activities, and identif!, he most promising areas to pursue over the next 5 years. This assessment will result in two reports, one addressing the causes and consequences of alcohol- related problems and the other addressing prevention and treatment. The first report, entitled Causes and Consequer.:es of Alcohol Problems: An Agdi...!:., for Research, was issued in 1987. What follows is a review of that report. The second report is scheduled to be ,ompleted in the fall 1989. The report on causes and consequences was prepared by a 10-member group of scientists, the 4 Institute of Medicine Committee

Alcohol-related research lias accelerated dramatically and made many advances over the past decade

Vol,. 13, Na 2, 1989 183 10M Report for the Study of Alcohol- Related needed for progress in prevention, panel's recommendations for future Problems, chaired by Robert treatment, and lehabiiitation. research. Straus, Ph.D., of the College of POLICY RECOMMENDATIONS Quantifying the impact of alco- Medicine of the University of hol (Chapter 3). Data on alcohol- Kentucky. 't he 1980 report emphasized the related morbidity and mortality The review contains some tech- costs associated with alcohol abu-e vary widely. For example, estimates nical terminology. As an aid to the and the need to attract scientifk of the prevalence of alcoholism in reader, a short glossary is included talent to alcohol-related research. hospitalized patient populations at the end of the summary. Limited The new report recognizes the work range from 9 to 55 percent. Such copies of the full IOM Report are of researchers whose activities meritextreme differences reflect varia- available by -Thing: Mary Dove, further support. Several policy tions in the reporting methods. One National Insite on Alcohol points are highlighted: basic difficulty 13 the lack of a trut, Abuse and Aizoho lism, Park lawn consensus on the definition of Building, Room 16C-I4, 5600 Special genetically developed (andalcoholism. Fishers Lane, Rockville, Maryland developing) onimal lines should In treatment settings, variations 20857. be made available to the alcohol in definitions give rise to differ- research community, and funding ences in diagnostic criteria. In addi- MAJOR RESEARCH QUESTIONS for this activity should be tion, a physician may be reluctant According to IOM's study of the stabilized. to enter alcohol-related problems causes and consequences of alcoilol Funding must continue for quali- on a patient's record. In other problems, "Ways in which people tative and quantitative social cases, health professionals may respond to alcohol, varied capaci- science research. Retrospective need to be alerted to the role alco- ties to drink safely, and relative data analysis or reanalysis should hol can play in the patient's illness. risks for development of alcohol- continue to be encouraged. It is not yet known, in fact, just related problems pose major ques- The value of the computerized how large a role alcohol plays tions for research, The study of abstract service provided by in muitiple-cause diseases and drinking behavior and the personal NIAAA should be enhanced with injuries. and societal consequences of a thesaurus.' Estimates of annual alcohol- alcohol use requires conceptual Diverse groups of investigators related mortality range from 69,000 approaches that accommodate should coordinate their stu.iles to 20.),000. Tne relative youth of knowledge from many biological, incorporating registered subjects the vit.tims is underscored by data behavioral, and social science om the general population on the years of hie lost. Reports for disciplines." and high-risk groups to permit 1983 estimated that an average of The report summarizes what are cost sharing and to correlate 20 years of life was lost by those termed "exciting advances in observations. who had died before age 65 from knowledge" in four areas: To interpret biological and behav- alcohol-related causes. ioral science approaches and Speciiic, quantified measures of identification of areas of cell knowledge, thought should be the full social Impact of alcoh membranes with differential sen- given to training a cadre of re- related problems are even more sitivities to alcohol searchers with the appropriate dift cult to obtain than reliable identification oi risk factors that ;-,alytic and critical skills. measures of morbidity and mortal- divide the alcoholic population Communication and coordinationity. Alcohol abuse has been esti- into subpopulations among Federal agencies interested mated to affect the families of 56 effects of the context of drinking in research on alcohol znd its million American adults. and the drinker's expectations impact on society should be An important aspect of alceol on drinking behavior and improved. abuse is its cost to society. NIAAA, consequences assisted by the Research Triangle clarification of the relationships Following its two introductory Institute, estimated that the social %)etween alcoholism and other chapters, the report presents 10 cost of alcohol abuse in the United types of psychiatric problems chapters of reviews and recommen- States was $89 billion in 1980. The dations. These 10 chapters are sum- projected estimate for 1983 was Altogether, these advances are marized below, highlighting the nearly $117 billion. linked to the increase in support for ' The Is11/1.1/1 data base is now online with The report contained the follow- alcohol research. They provide BRS Information Technologies, In" , and a ing epidemiological research refinements of the knowledge base thesaurus is being developed recommendations:

184 or) ALCOHOL HEALTH & RESEARCH WORLD study the bioiogicai and social and normal human cells to fur- test the generality of previous mechanisms leading to individual ther delineate liver- specific gene findings (possibly through recom- and group di 'ferences in suscepti- expression and to provide a pool binant DNA techniques, using bility to alcohol-related problems of cells for noninvasive clinical existing stable models) collect more extensive and accu- tests study the interactions of ethanol rate information on the prey-- measure the expression of mes- with vasopressin, opioid peptides, 'enc.. and the role of Alcohol in senger RNA or use antibodies to and thyrotrop'n-releasing hor- accidents, especial]; as alcohol estimate protein levels to clarify mone in animal groups that differ interacts with other drugs and the control of enzyme synthesis in nehavioral responses to ethanol with other variables such as age and the subunits' activities within study the effects of pharmaceuti- develop more accurate estimates cells cal agents on alcohol-seeking of the prevalence of fetal alcohol study mutant animal models behavior, on the development of syndrome that lack ore of the ethanol- alcohol tolerance, and on tenden- develop more accurate estimates metabolizing enzymes to discern cies toward alcohol dependence of alcohol's contribution to a!! their responses to and metabolism (if the results are promising, hu- causes of death and study the of ethanol and possible enzyme man studies should follow) extent to which alcohol's contri- participation in neurological evaluate gains in knowledge bution is underreported functions. about alcohol-seeking behavior develop a consensus definition for implications for humans (for and quantitative measurements of Animal models for research example, do reinforcing proper- the adverse impact of excessive (Chapter 5). Specially bred animal ties of alcohol differ between drinking on victims, especially on models are a' ailable for research on children of alcoholics and chil children and spouses of alco- alcohol-seeking behavior, on sensi- dren of nonalcoholics?) holics and on families of victims tivity to tl:e narcotic effects of use alcohol-preferring animals in of alcohol-related accidents. ethanol, on a tendency to develop studies of medical disorders asso- tolerance to ethanol, and on the ciated with chronic alcohol Biochemistry of ethanol metabo- propensity for withdrawal seizures. consumption. lism (Chapter 4). The starting point These developments confirm that for understanding individzial physi alcohol-related behavior is partly Neurosciences (Chapter 6). Un- ological responses to alcohol is the controtled by "constellations of like other psychoactive substances, study of th- enzymes that metabo- genes." ethairol does not act by binding lize ethanol. Thus far, variations in Analysis of the behavior of in- with a specific set of receptor mole- the form and the activity of one bred mice has revealed three sepa- cules in the brain. Therefore, enzyme, aldehyde dehydrogenase, rate clusters of variables in nervous neuroscientists must study the ef- have been linked with alcohol- system sensitivity to ethanol. Indi- fects of ethanol on cell membranes, relazed behavior and problems. vidual diffelences can occur in one, nn pathways for transmission of The structures of ke ;' enzymes are two, or all three of these areas. nerve impulses, and on p trticipat- known, and the DNA encoding Some researchers are using se- ing agents (e.g., calcium ions, cy- some of the subunits has been iso- lected animal models to learn whichclic AMP) within cells. Scientists lated and cloned. Studies of en- brain regions are involved in spe- are examining both vertebrate and zyme expression will be advanced cific behavioral effects of ethanol. invertebrate systems in the labora- tr.; using the DNA clones as probes In other animal studies operant tory and studying t:physiology of for new information. conditioning techniques are being alcohol-related behavior in both The IOM committee .nade used to study the reinforcing effectsexperimental animals and humans. the following related research of drinking. They are striving to relate ethanol- recommendjtions: Research in the following areas is induced changes in neural activity recommended: to observed changes in behal 'or. continue to study the genetic loc.; Acute doses of ethanol "fluidize" for alcohol dehydrogenase and study the effects of ethanc: on cell membranes; however, after aldehyde dehydrogenase to deter- reward systems in the brain in chronic ethanol treatment. the mine how these enzymes are animal groups that differ :n their membranes become more rigid. regulated alcohol-seeking behavior Restricted regions of the membrane study the hybrids of hepatomas develop new animal models to are nsitive to ethanol. A prime

Vol. 13, No. 2, 1989 165 IOM Repot t area ,..)r research is a possible rela- noamine oxidase (MAO), -.4 be a tionship between these membrane Direct methods for biological marker that differentiates effects and alcohol intoxication, these subgroups of alcoholics, be- r.linforcemet t, tolerance, or studying inherited cause MAO activity is more inhib- dependen e. ited by ethanol in Type 2 alcoholics . . . Effect ve dos o' ethanol appear tendencies use than in Type 1 alcoholics. In addi- to inilaence events in some neural DNA technologies to tion, blood platelets of alcoholics pathways in the brain. In addition, show lower levels of MAO activity rapid gain. in understanding the locate.. . specific than do those of nonalcoholics. modulating roles of ions and other markers for Other studies use recordings of agents within cells and cell mem- brain electrical activity. The electro- branes have opened new avenues in alcoholism. encephalograms (EEGs) of sons alcohol research. New techniques (but not daughters) of alcoholic are being used to study inter- males are likely to show excessive actions of ethanol with these cell ties related to ethanol reinforce- high-frequency activity. Some re- components. ment, tolerance, and withdrawal cordings of the brain activity of Research opportunities in neu :o- use brain-imaging techniques and alcoholics, sons of alcoholics, and physiology include electrophysio- electrophysiological tests in con- abstinent alcoholics have shown logical studies of brain activity in junction with neurocliemical tests reduction in the size of a brain- human subjects and to complement of blood or urine to study indi- wave component (P3) associated other studies on specific brain re- viduals in withdrawal, `sigh -risk with thought processes involved in gions. Other recommended strate- individuals prior to alcohol expo- visual or auditory perception. Some gies would integrate behavioral with sure, and individuals experiencing researchers think that these neuro- physiological findings on tolerance tolerance or dependence. logical differences may underlie and dependence. One important differences in drinking behavior. objective is to identify physiological Heritable determinants of risk Direct methods for studying in- and biochemical markers of toler- (Chapter 7). Genetics researchers are herited tendencies toward alcohol- rice an' ciependence in humans. exploring specific genetic compo- related problems use DNA 1he committee recommended the nents involved in alcoholii.m along technologies to locate genes that continued use of "sophisticated with the predisposing effects of can serve as specific markers for tools and techniques of neurophysi-environmental and experiential alcoholism. Data on the develop- ology and neurochemistry" for the factors. ment of alcohol abuse and alcohol- following research efforts: Researchers now have access to ism across generations support the sophisticated computer techniques hypothesis of a t,2netic component define the measured neural re- and multivariate statistics. Through in familial alcoholism. sponses to ethanol and their rela- factor analysis, they have found The committee made the follow- tion to human behavior (to pm that alcohol dependence and loss of ing recomme-itions for genetic the way for testing specific hy- control, social problems, personal- research: potheses about ethanol action on ity variables, family problems, the central nervous system [CNS])affective symptoms, and psychotic seek explicit definitions of clinical examine both acute and chronic symptoms require separate subtypes effects of ethanol on the CNS t assessment. conduct multilevel evaluations of three levlssiniple neurophysio- Recently, longitudinal studies of the proposed subtypes logical systems, animals, and families have enabled researchers to conduit prospective longitudinal human beings distinguish antecedents of an illness research to evaluate variables explore the effects of ethanol en from sequelae of the illness. proposed as behavioral markers learning, memory, and tolerance According to one theory, alcohol- for a predisposition to Jcoholism in simple system- having large ism takes two basic fornis: milieu assess clinical, neurobiologi:al, neurons or well-characterized limited (Type 1) and male limited and psychosocial variations neural networks (Type 2). For the Type 1 subgroup, across two or more generations to use animal strains selected for predisposing environmental factors learn about gene-environment alcohol-related behavior to pair appear to be nec,!ssary for alcoi:ol- interactions high-response with lostesponse ism to o,velop. Another study study alcohol responsesinitial groups and to study CNS activi- suggests that a CNS enzyme, mo- sensitivity, tolerance, and rein-

186 ALCOHOL HEAUfli & RV-SEARCH WORLD 9l forcementin nonjuvenile sub- gories has provided important new ments in measuring blood alcohol jects at high nsk for alcoholism insights. levels, substantial progress can be use molecular genetics, brain Social research that addresses expected soon in reporting casual- imaging, and noninvasive screen- solving alcohol-related problems ties aitd other problems related to ing for enzymes to study suscepti-gives considerable attention to pub- acute effects of alcohol consump- bility in families lic efforts. For example, the U.S. tion. In addition, researchers conduct parallel studies involving literature on the effects of changing should measure more than one cell lines from well-described the legal drinking age and on dimension of alcohol consumption, members of susceptible families, drinking- and driving countermea- such as average daily consumption. clinical profiles of subtypes, and sures is strong. in the many studies No single dimension of drinking quantitative modeling. on the effects of alcohol on driving behavior is adequate for measuring and other performance tasks requir- the risks associated with a wide Social determinants of risk ing skills and judgment, however, range of multtfactor problems. (Chsp'..m 8). Social and epidemio- knowledge gaps still exist regarding The committee made the follow- logical research has demonstrated such important matters as the ef- ing recommendations for social and that major changes occur in drink- fects of an alcohol hangcner and the epidemiological research: ing habits, both in whole popula- combined effects of alcohol and tions and within the course of fatigue. conduct both qualitative and individual lives. In additioA, the Other countries have led the way quantitative historical studies on focus of this research area has in studying drinking-related policy patterns of change and relations broadened to include alcohol- and cultural shifts. The [OM report use population sii-'ys, s*atistical related beliefs, behaviors, and var- emphasizes th° need for interna- series, and other sources to map ied problems. tional comparative studies. patterns and covariations of alco- Within this context, the commit- Social psychology in the United hol use, covering the diverse sec- tee drew attention to the need for States has been influenced by the tions of the U.S. population additional research on American psychology of thinking. This cogni- conduct longitudinal studies of wome 1, on the extent to which tive emphasis has led to research individual drinking practices and couples function as social units in showing that expectations about problems, both immediate and their chinking, on differences when alcohol consumption affect long term p onie drink in same -sex or mixed- drinking-related behaviorand conduct qualitative studies of sex groups, and on how individuals explanations of such behavior. Sim- normative and behavioral pat- influence each other's drinking. In ilarly, a cognitive approach is being terns at a given time and as addition, drinking among the gen- used to develop strategies for recov- changes occur in the course of a eral, nonethnic population of the ery and relapse prevention. In- lifetime country merits more attention, and crewed attention to studies of conduct studies of natural and sectional differences require analy- social and environmental correlates Fanned policy experiments to sis. Finally, age-oriented analyses of of heavy drinking also is indicated. learn how policy interventions drinking in the United States sug- The first IOM report called for and other social changes affect gest that different risks are encoun- studies involving "natural experi- drinking practi..es and problems. tered in different age groups. There ments," such as changes in law, is a need foi mapping out the life- policy or c:rcumstances to effect Psychopathology related to alco- time course of drinking problems. social chai.ge. Such studies stilt are hol abuse (Chapter 9). A psychiat- Emphasis on the incept:on of heavy needed. In addition. interest is ric disorder can precede, accompany, drinking may now need to be bal- growing for trend analyses and or follow alcohol abuse. The causal anced by such factors as stress or a historical studies of alcohol issues relations are unclear, and this area spouse's drinking, which may ,,ts- patterns. The IOM panel spe- of alcohol resea.ch abounds with tain heavy drinking over a period of cifically recommends th- applica- unsettles issues. Foremost among years. Research on racial and ethnic tion of qualitative historical these are the psychop lhology defi- differences in drinking recently has methods to major issues in the nitions and the psychiatric criteria been aided by nationwide surveys causes and correlates of a'cohol for alcohol dependence. of black and Hispanic populations. problems '' The committee examined a num- Identifying variations in drinking In the area of social research, ber of areas, including disorders, patterns and problems within, as measurement issues are increasingly depression, drug codependency, and well as between, major ethnic cate- important. Because of improve- withdrawal:

Vat,. 13, Na 2, 1989 9' 187 IOM Report

Antisocial personality disorder acute withdrawal period, tend to acute i.Adrawal, many patients (ASP).Individuals with ASP clear over time. Some alcoholics, compiam of persistent insomr;a report dysphoric moods (anx- however, report feeling depressed and feelings of depression or ious, unhappy), demonstrate over months or years. anxiety. impulsive behavie, rooted in It has been reported that de- Some of these symptoms may sensation-seeking attitudes, and toxified alcoholics may metabo- indicate long-lasting physiologi- tend to have poor and unstable lize some of the tricyclic cal changes, which may contrib- object relations (associations antidepressants so rapidly that ute to the risk of relapse. The with other individuals, particu- the usual therapeutic dosage may data on brain hyperexcitability larly) and a history of under- not be optimal. Future studies in that persists after ces,ation of achievement despite normal or alcoholic patients should include alcohol consumption suggest that above normal intelligence. Re- blood level measures. alcohol consumption by an absti- search on ASP as a risk factor Biological measures used in nent alcoholic may elicit for alcoholism would be ad- studies of depression in nonalco- withdrawal-like symptoms. vanced by longitudinal studies holic subjects may be of limited Research using animal models designed to identify biolog:cal, u;:e in studies of recently detoxi- is recommended to dete.mine psychosocial, environmental, fied alcoholics. This is p.irticu- whether latent hyperexcitability behavioral, and genetic variables larlv true of the dexamethasone (a tendency toward high excitabil- related to childhood conduct suppression test and studies in- ity in the brain) is associated with disorder (CCD), a history of voiving catecholamines, sero- a persistent tendency to consume which is often required for a tonin, or sleep variables. alcohol. Careful studies involving diagnosis of ASP. Another ques- Future studies of depression long-term abstinent alcoholics tion for future study is a possible and its treatment in the alcoholic would also be of interest. relationship of CCD (with or call for addressing the question Also related to hyperexcitabil- without adult ASP) to alcohol- of a separately diagnosable affec- ity is a suggested study of related aggressive or violent be- tive disorder; measuring the level ethanol-induced changes in the havior in some individuals. of cognitive function or impair- activity of gamma-aminobutyric Anxietydisorders.Although ment; probing for a family his- acid (GABA) in the brains of anxiety disorders are commonly tory of affective illness, including animal models. Gt BA is the found in association with alco- careful histories of alcohol use principal transmitter of nerve holism, very few patients appear and dependence and of depres- signals that inhibit activity of to have had anxiety symptoms sive symptomatoiogy; and assess- other nerve cells in the brain. that antedate their alcohol- ing life stmss and the adequacy Other studies could assess the related problems. of social supports. relationship between dependence Clinical studies show that anxi-Drugdependencies. The prob- severity and the electrophysiolog- ety symptoms increase during lems arising from combined use ical dimensions of long-term heavy drinking or periodically of alcohol and other drugs have abstinence. during abstinence of several changed as "drugs of choice" weeks. Interaction between alco- have changed in the general pop- The committee also made the hol dependence and the anxiety ulation. Systematic data on drug following psychiatric research disorder may complicate the use and Cependence in alcoholic recommendations: course of alcoholism and recov- patients would clarify the preva- ery; it thus merits further investi- lence and current types of drug conduct longitudinal studies to gation. aependencies and potential im- identify risk-related biological Depression.CL -leal depression pact on treatment needs. Such and environmental factors appears frequently in alcoholics, data can lead to hypotheses for compare in various settings the predominant!y in females. Depres- small-scale clinical research. results of specific psychopathol- sive symptoms in alcoholics prob- Withdrawal syndrome.The acute ogy diagnoses with assessments ably have multiple causes, ranging alcohol withdrawal syndrome based on more global or inclusive from the toxic effects of alcohol includes anxiety, agitation, irrita- observations to the presence of personality bility, and tremors, in addition to examine in various settings the disorders antedating the use of abnormalities in body tempera- distinction bctween primary and alcohol. Such symptoms, often ture, blood pressure, heart rate, secondary psychopathologies present during drinking and the and seizure threshold. After associated with alcoholism

9; AL( OHM ilk ALTO & RF-SEARCH WORLD study (in well-controlled treat- Concentrate on humans in the Examine nutrient deficiencies for ment trials as weil as in small- study of liver disease (in part tissue repair in the wake of scale laboi /tory investigations) because no experimental animals ethanol-related injury and the the subjective symptoms associ- have been found to develop a potential role of nutritional defi- ated with subacute withdrawal condition analogous to the hepa- ciencies in such medical problems and post-withdrawal recovery in titis fund in humans) and con- as fetal alcohol syndrome, liver relation to abnormalities in brain sider using magnetic resonance disease, pancreatic disease, and function and thinking described imaging (MRI), a technique that the development of cancer. in alcoholic patients after produces x-ray-like images of soft Study the mechanisms by which withdrawal. tissues, to help explain alcohol- ethanol induces hyperglycemia, inducca structural changes within ketoacidosis, and other disorders Medics; consequences of alcohol liver cells. involving fats and carbohydrates. abuse (Chapter 10). The kidneys For cancer-related alcohol re- For better insight into how alco- and the lungs eliminate only about search, use various approaches to hol consumption can disrupt 2 to 10 percent of beverage alcohol, study growth regulation, cancer- cardiac rhythms, increase hyper- ci ethanol, absorbed by the body. provoking enzyme changes in the tension, damage the heart mus- The remaining ethanol may damage liver, and tumor development in cle, and decrease cell populations both individual cells and the func- alcohol-preferring rodents. in the blood (causing clinical tioning of organs and other tissues. anemia and other blood disor- Direci cell injury by ethanol is The primary target ders), concentrate on imi..toving thought to be related to its disrup- methods for taking drinking his- tive effects on cell membranes and organs for alcohol tories, design studies to identify on structures within the cell. Tissue predisposing genetic factors, damage from ethanol is believed to injury are the liver, and develop better diagnostic result either from biochemical pancreas, heari, and techniques. changes that accompany the metab- Look more closely at alcohol's olism of ethanolin effect, the bone marrow. effects on cholesterol metabolism, body's normal process of convert- with emphasis on the cholesterol ing ethanol to other substancesor Conduct further research to ex- transported in the bloodstream in from direct effects of alcohol as a plain the apparent relationship high-density lipoprotein partic.zs. solvent. However, little is known between alcohol abuse and can- Conduct additional epidemiologi- about the primary effects of etha- cerous and precancerous condi- cal and prospective trials to nol metabolism in most tissues. tions, with possible emphasis on clarify the relationship between The primary target organs for congeners (alcoholic 'leverage alcohol use and heart disease. alcohol injury are the liver, pan- ingredients other than ethanol) Collect epidemiological details on creas, heart, and bo:Ic mut,. that may contribute to the growth alcohol-induced brain damage, Other important targets 2 .ie of tumors. especially as associated with endocrine (hormone), gastrointesti- Continue to study the effects of memory disorders. nal (digestive), and immune sys- ethanol and its metabolism on the Continue to examine the neuro- tems. Epidemiological studies biology of pancreatic funet,n logical damage to the fetus as a charting the development of result- and on the development of tech- result of alcohol and the possible ing alcohol-related disorders are niques for the detection of pan- role of nutrition in brain atrophy needed. Other research objectives creatic injury. and cognitive loss. include nutritional studies and the Examine ho.v ethanol changes Analyze the medical conse- study of cardiovascular function, gastrointestinal functions, includ- quences of alcohol consumption pulmonary function, hypertension, ing alterations in regulation of on th.., endocrine system, espe- and levels of white blood cells and the digestive pro "ess by the endo- cial:), as its hormonal functions circulating hormones as related to crine and nervous systuns, effects are complicated by interaction levels of ethanol and other drugs, of ethanol on the cells that line with other variables, including espe , tobacco. gastrointestinal organs, and the nun ition status and alcohol - The committee recommended origin of nutritional deficiencies it lated stress. specific biomedical research in a and the role that these deficien- Study in greater depth how alco- wide range of areas. Several of these cies play in the development of hol can cause atrophy of the go- recommendations are listed below. tissue injury. nads, impotence, and infertility.

VoL.13, Na 2, 1989 90 189 IOM Report

Determine the effects of chronic are especially susceptible to hu- data on lung infections. alcohol abuse on estrogen- man immunodeficiency virus kialyzc the relationship between responsive tissues and other target (HIV) infection and progressive infectious lung disease and socio- tissues in women. disease. 2) study whether alcohol economic status among alcohol Investigate the effects of plant- affects the course of the disease abusers. derived estrogens in alcoholic in individuals already infected by Conduct epidemiological and beverages. Ht V, 3) study the proportions biomedical studies about alcohol- Conduct further work on the and the interactions of T4 and T8 related birth defects. ethanol-thyroid metabolism rela- cells in alcoholics who have Study the complexities of drug- tionship and its effect on the AIDS, 4) compare infectious and-ethanol effects with each liver. diseases and tumors in alcoholic drug to learn about specific Study the specific effects of and nonalcoholic AIDS patients, interactions. chronic alcohol intake on the and 5) assess the effects of etha- Study the relationship of trau- hypothalamic-pituitary-adrenal nol on the numbers and activities matic injuries and alcohol in five axis. of natural killer (NK) lympho- types of research: 1) conduct Determine the medical effect of cytes (because of the possible role epidemiological studies on the alcohol abuse on the immune of NK cells in the immune re- role of alcohol in accidents in system in five specific areas: 1) sponse to tumors). transportation, home, work, and conduct epidemiological studies Correlate data on tobacco smok- recreational settings; 2) study the to learn whether alcohol abusers ing and alcohol drinking with me -:hanisms involved in shock

nem impulses to other nerves, first, acetaldehyde and, second, 6-WittAff muscles, or :lands. acetate. Affoldistaioden madal Cyclic AMR A "second messen- Gammaarninobatyric acid Ask** dtudtazinter- gee" cheMical that, when trig- (OARA). A substance that, ger** innomhrg aerie when transmitted through nerve Inenageinabki the recelw fibers in the brain, inhibits or napond. reduces the &kg of imptdses :Zondr 'nit that re- by other brain nerve cells. State Of-grief fol- Hepatoma A liver tumor, either Ord nide-- kileiDtbk*UtiattitkRaktive benign or cancerous. .the two dePrendost_11 toadied off by HIE Human immunodeficiency trathed in nienthand musily lasts virus, the agent thought to be a short time. Endogenous de- responsible for AIDS and preadost no-obeloui Wa- AIDSrelated syndrome. nd catriaand may be chronic. Hyperilycemkt and ketoaddosits. A depression offer kind is Related clisorden that resat dint & wben acme enough to from the body's inability to make 'treatment. metabolize carbohydrates (e.g., Deem sugar)°la a normal fashion. 1l -leimedlar dies- Messenger 111+14. Ribonuckk acid Syndrome strands that any genetic "mes- -involving sages* front the cell nucleus to the cell plasma, where they The process guide the synthesis of specific body acts on proteins. lethenol) to MorNdiot Occurrence of disease, Mortalitx 0061111111101 of death. Chemical MullAva*te statistics. Any slid*. crid by etha- deal technique capable of ana- thetwo princi- lyzing the interaction of several Pal etismrot Metabolites' are, variables at the same time.

190 ALCOHOL HEALTH & RESEARCH WORLD from bleeding during acute tively low concentrations of blood sate for the perceived alcohol ef- intoxication and in cases of alco- alcohol (BAC less than 35 mg/100 fects, personality type, and, holism; 3) evaluate the patho- ml) can disturb visual perception, possibly, heredity. physiolou of the drowning, muscle control, eye-hand coordina- The committee made the follow- intoxicated patient, to reduce tion, and visually guided movement ing recommendations for related fatalities from nonlethal levels through space. research: of blood alcohol; 4) study the Promising areas for performance effects of ethanol on bone metab-research are electrophysiological broaden the research already olism; and 5) clarify the relation- responses to visual stimuli, percep- conducted using motor vehicle ships of alcoholism and acute tual style (that is, how one driving to measure performance intoxication in burn patients. perceives the effects of one's sur- deficits induced by alcohol con- roundings), selective attention. and sumption and begin to use so- Conse pences of drinking on applied methods in human per- phisticated experimental designs performance (Chapter 11). To performance. involving many human factors to form a task, a person must coordi- Factors other than the level of test a wider spectrum c'alcohol nate several processessensory, ethanol have been found to cause effects perceptual, cognitive, and motor. variations in perception and con- simultaneously analyze the skills Alcohol impairs each of these, and trol, including beverage type, involved in machine operation by its use can result in traumatic in- expectation of an alcohol effect, a human beings, i.e., monitoring, jury. Even in healthy subjects, rela- driver's apparent effort to compen- interpretation, and intervention.

pirativet The route taken, Prevaknce and incidence. In epi- in all forms of animal life) that nerve fibers and nerve demiology, prevalence is the has had a strip of DNA from *bring about a overall occurrence of a behavior another organism inserted into or a condition (e.g., the preys- its structure. The study of the le:774 of alcoholism is low in Serotonin. Or e of the substances mews of the na some countries). Incidence is in the that transmits nerve linisialsteriOncluding the the documented occurrence of impulses. that beinvior or condition Subacute withdrawal. Withdrawal pattern:J.The patterns within a set time period and from the effects of an addictive *fining whaz is te- population (e.g., the incidence substance in which the symp- as attract Or proper of new cases of malaria in Cuba toms are less severe than in was 37 in 1970). Nomad* Patterns acute withdrawal; often occur- front behavior pat- Psychoactive substance. Any sub- ring as a lengthy phase of the =PP in stance eat affects the mind or withdrawal process following not believe is behavior. the more dramatic phase of _POW- Psychopathology. The branch of acute withdrawal. cohdftiOning. The tech- knowledge that deals with men- 8. P. Skin- Thyrotropin-releasing hormone. A tal and emotional disorders. apartictdar substance that signals the pitui- Of pun- Receptor molecules. In brain re- tary gland to release thyrotro- The behav- search, receptor molecules are pin, which then stimulates shaped is the the means through which nerve activity in the thyroid gland. cells (neurons) receive "mes- 7Hcyclk ant:dep.-amts. A family with ses*"1t the form of chemicals of drugs used to relieve depres- that released front other nave cells. sion; all have three-ring molecu- These chemical messengers are lar structures. knew* as nanotmnsmitters. Vasoptassia. A hormone produced cell Receilter moleades are in the brain that is normally an to "Ice*" to receive specific antidiuretic (inhibits urine as neurotransmittes. production) but also may be feCePtor Recombinant DNA. Deoxyribonu- involved in memory and in cleic acid (the genetic material responses to ethanol...

VOL. 13. Na 2, 1989 191 IOM Report

Social consequences of alcohol conduct research on alcohol as a behavior and/or by interfering abuse (Chapter 12). Social prob- fcctor in industrial accidents and with normal immune responses lems associated with alcohol abuse in unsound decision processes by explore systematically the assume a variety of forms and usu- professionals in the workplace alcohol-and-crime connection, ally involve several factors other study systematically occupation- including consideration of recent than alcohol. The committee ad- related exposure to chemicals that research that suggests that cul- dressed both individual conse- interact with alcohol and other tural, rather than pharmacologi- quences of drinking alcchol and psychoactive drugs. cal, factors link drunkenness with broader societal issues. Among the broader societal is- violence and crime In addressing individual issues, sLcs, the committee considered the investigate alcohol use as an ex- the committee included problems at many casualties that involve alco- planation (i.e., an excuse) for home and at work. The family hol. Recommended are prevention- domestic violence looms large as an agent for infor- oriented analyses of the role of evaluate the interaction of new mal social control of drinking and alcohol in the sequence of events drinking-and-driving regulations drinking-associated behavior. In leading to a casualty, population with the criminal justice and self-reports by drinkers, family surveys on the relationship between treatment systems problems are the most frequently drinking and accidents, emergency reexamine drinking-and-driving acknowledged type of alcohol- room and other epidemiological behavior with respect to the role fclated problem. The literature on studies of alcohol involvement in of alcohol in multiple-cause the role of drunkenness in family injurie, and case studies that con sequences violence is largely anecdotal. The trol for environmental factors in examine drinking-and-driving time has come for studies that are alcohol-related accidents. In ease- behavior with reference to risk sensitive to intimate relationships, control studies, research designs taking among young men large in scale, and comprehensive in might best seek an explanation for reexamine the relationship be- scope. how alcohol and the circumstances tween drinking and homelessness The adult children of alcoholics of the casualty are related. with reference to the rapidly movement has been a catalyst for a The impact of d, ankenness and changing homt!ess poi .lation of body of literature that calls for a drinking history on trauma survival the 1980s large research agenda. Studies in and recovery also requires further collect survey data on alcohol and this area can be based on positive study to provide guidelines to drug use, specifically about quan- as well as negative outcomes for health care systems and profession- tity consumed per drinking children, but most of the evidence als. With regard to both individual occasion points to adverse effects. and societal issues related to the study the consequences of com- consequences of drinking, the bined (simultaneous or consecu- Despite the importance of work tive) use of alcohol with tobacco, in human affairs, surprisingly little committee made the following recommendations: sedatives, marijuana, cocaine, research is being done on tne rela- caffeine, and other drugs, includ- tion between drinking and working. augment studies of the family ing over-the-counter and prescrip- The current emphasis is on the process and alcoholism with stud- tion drugs workplace as a case-finding institu- ies exploring the role of drinking investigate the effects on drinking tion. However, the sociology of and the resulting changes in a of such factors as fatigue, social alcohol and occupation deserves broad cross-section of Americar context, the "street" lore, and attention. Unanswered questions families mutual enhancement (as in smok- include the contributions of the exai.nne further the effects of ing and drinking) occupations themselves, the predis- alcohol on sexual functioning and collect more epidemiological data positions of people in those occu- reproduction, particularly in on both clinical and general pop- pations, the availability of inex- women ulations for such topics as the pensive alcohol in certain occupa- focus on alcohol issues related to events leading to emergency room tional environments, and the demo- rape and teenage pregnancy episodes involving alcohol and graphics of employees in the high- examine the possibility that alco- other drug use and combined risk occupations. In this context, hol may play a role in the trans- drug use and its consequences in the committee recommended the mission of HIV and the develop- high-usage groups. following: ment of AIDS by facilitating i.sky -TIIE EDITORS

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