World Health Organization , Regional Office for Europe / Copenhagen Management of drinking problems WHO Regional Publications, European Series, No. 32 The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this Organization, which was created in 1948, the health professions of some 165 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health problems of the countries it serves. The European Region has 31 active Member States,° and is unique in that a large proportion of them are industri- alized countries with highly advanced medical services. The European pro- gramme therefore differs from those of other regions in concentrating on the problems associated with industrial society. In its strategy for attaining the goal of "health for all by the year 2000" the Regional Office is arranging its activities in three main areas: promotion of lifestyles conducive to health; reduction of preventable conditions; and provision of care that is adequate, accessible and acceptable to all. The Region is also characterized by the large number of languages spoken by its peoples and the resulting difficulties in disseminating information to all who may need it. The Regional Office publishes in four languages- English, French, German and Russian -and applications for rights of translation into other languages are most welcome. a Albania, Austria, Belgium, Bulgaria, Czechoslovakia, Denmark, Finland, France, Federal Republic of Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Luxembourg, Malta, Monaco, Netherlands, Norway, Poland, Portugal, Romania, San Marino, Spain, Sweden, Switzerland, Turkey, USSR, United Kingdom and Yugoslavia. Management of drinking problems WHO Library Cataloguing in Publication Data Management of drinking problems (WHO regional publications. European series ; no. 32) 1.Alcohol drinking 2.Alcoholism - prevention & control 3.Community health services 5.Europe I.Series ISBN 92 890 1123 8 (LC Classification: HV 5275) ISSN 0378 -2255 World Health Organization, Regional Office for Europe l Copenhagen % WHO Regional Publications, European Series, No. 32 Management of drinking problems ICP /ADA 031 Text editing by Diana Gibson ISBN 92 890 1123 8 ISSN 0378 -2255 ©World Health Organization 1990 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for Europe applications should be made to the Regional Office for Europe, Scherfigsvej 8, DK -2100 Copenhagen 0, Denmark. The Regional Office welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this publication are those that obtained at the time the original language edition of the book was prepared. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are dis- tinguished by initial capital letters. The views expressed in this publication are those of the contributors and do not necessarily represent the decisions or the stated policy of the World Health Organization. PRINTED IN DENMARK CONTENTS Page Introduction 1 1. What we drink 5 Recorded consumption 5 Unrecorded consumption 11 Routinely collected national data 12 Ad hoc surveys 14 2. Why we drink 23 Incentives 24 Disincentives 29 Reinforcing influences 29 Moderating influences 31 3. Damage 35 National data 35 Individual data 46 Individual risk and level of consumption 59 Population -attributable risk 61 4.Resources 63 Community involvement and health promotion 66 Self -help and self -care 67 Informal care 69 Primary health care 70 General hospitals 73 Community-based programmes 74 Specialist treatment services 75 Detoxification services 75 5.Promoting health and preventing damage 77 National influences on consumption 77 Local action 86 6.Screening, case identification and assessment 91 Population screening 91 Screening for alcohol consumption 92 Measurement of psychosocial consequences 94 Self- assessment questionnaires and biological markers 100 Case identification 103 Assessment 108 7.Management 115 Prognosis and treatment of advanced alcohol problems 115 The therapeutic response 119 Working with particular population groups 128 Other potential resources 131 Organic and other problems 132 Referral 134 8.Education, training and research 137 Education and training 137 Research issues 143 References 147 Introduction In many parts of Europe alcohol consumption has increased considerably during the last 25 -30 years.Simultaneously there has been a huge increase in alcohol- related problems, which are now regarded by a number of European countries as a major public health problem, second only to cigarette smoking(1,2). Alcohol services have tended in the past to provide sophisticated specialist treatment for the few patients who either could afford to pay or lived near cities - but clearly the response to drinking and its conse- quences cannot come just from health workers. It is also quite unrealistic to expect any country to produce a group of specialists concerned solely with recognizing and treating these problems. WHO emphasizes the importance of a response embedded in the community(3)and the need for early recognition, and has also suggested ways of using reporting systems or other strategies for small -scale monitoring and evaluation (4,5).These strategies imply that early recognitionispossible, and that nipping the problem in the bud will prevent further damage. There is now increasing evidence that such strategies are justified. Nevertheless, careful evaluation of health promotion and simple inter- vention studies must continue, and more evidence of their efficacy is required. The logic and economic practicality of primary-level interven- tion is undisputed. However, more work is urgently needed to translate the rhetoric into workable, everyday activities. WHO has recently published a manual for community health workers on dealing with drug dependence and alcohol - related problems, which includes a set of guide- lines for trainers (6). This book aims to take these issues further and examine them in more detail.It is based on the reports of three working groups convened by WHO. The first group considered treatment and rehabilitation pro- grammes for alcohol abuse (7).It concluded that in most European countries alcohol- dependent people place a heavy burden on society in terms of individual suffering, harm to others and high expenditure for 1 health and social services. But it also recognized that far more wide- spread damage may be done by the much larger percentage of people with high or even moderate levels of alcohol consumption, who may never reach the stage of alcohol dependence and whose physical, mental and social problems and their repercussions on the community go unrecog- nized and untreated. In its report, this working group emphasized that the situation cannot be alleviated merely through recourse to long -term institutional care for people labelled as "alcoholics ". In addition to major efforts aimed at the prevention of alcohol -related problems, there is an outstanding need for the recognition of incipient alcohol problems and for intervention start- ing at an early stage.This work can only be undertaken with the collaboration of personnel in the primary health care services. Their willingness and ability to do it, however, is generally impeded by their lack of training and by the inadequacy of assessment and intervention techniques for use in primary health care. The second working group examined the respective roles of primary health care and specialized services in the development and implemen- tation of programmes for problem drinkers (8).It concluded that there should be a redistribution of resources, emphasizing the role of primary care in the identification and management of individuals with drinking problems.This redistribution would depend on a community and political will that could be expected only from a population enlightened as to the nature of alcohol -related problems. This in turn implied an investment in health education in order to create a background of information from which responsible attitudes towards health and health promotion could develop. In the longer term, the group thought it likely that specialist services will take on a different role. If this happens then specialist personnel will help in making the transition to a more consulta- tive and educational role, less identified with the institutional setting. The third group